TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.
This week’s topics include household transmission of COVID, monoclonal antibodies for treatment of COVID, kindergarten preparedness and long term benefits, and active surveillance for Black men with low risk prostate cancer.
0:59 Monoclonal antibodies for treatment of COVID
1:58 Antibody prevented hospitalization in many
2:57 Cost less than hospitalization?
3:40 Kindergarten readiness
4:40 Reduction in odds of being overweight
5:40 Need resources invested in preschool
6:44 Household transmission of COVID
7:44 75% of secondary infections within 5 days
8:42 Wear a face mask even within households
10:40 55% definitive treatment in Black men
11:42 More likely to have disease progression
Elizabeth Tracey: What does what happens in kindergarten tell us about later health and social costs?
Rick Lange: Using neutralizing antibodies to treat COVID infection.
Elizabeth: Can we safely watch and wait with Black men who have low-risk prostate cancer?
Rick: And the transmission of COVID infection in households.
Elizabeth: That’s what we’re talking about this week on TT HealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: And I’m Rick Lange, President of Texas Tech University Health Sciences Center in El Paso, where I’m also Dean of the Paul L. Foster School of Medicine.
Elizabeth: And still managing, thank God, well, with this outbreak that you have in El Paso.
Rick: We’re still in a crisis mode right now with an increasing number of cases and dwindling facilities and staff to care for individuals, but we’re holding it together and working together as a community, so thanks for your thoughts, Elizabeth.
Elizabeth: Of course. Since we’re talking about COVID, then why don’t you start with one of yours? Which of your two would you like to talk about first?
Rick: Let’s talk about treatment. People fight off the infection by developing their own antibodies and can we use that immune response as a treatment for COVID infection? This was a phase II trial conducted by Eli Lilly of 452 patients that were COVID-infected that received either a placebo or one of three doses of a neutralizing antibody. It’s called a monoclonal antibody. They could give it as a single dose and so that’s what they did in these individuals as an outpatient. They had mild or moderate symptoms and they got either a placebo or one of three doses of this neutralizing antibody as a single IV infusion. Then they followed them to see whether it reduced the amount of virus in their blood, whether it improved their symptoms faster, and then whether it affected their clinical outcome, were they less likely to be hospitalized?
Those that received the antibody, and even those that didn’t, there was a rapid decline in the virus over the course of a week and a half. Over the course of 11 days, about 99.97% of the virus went away. What the neutralizing antibody was able to do is it prevented those needing to go to the hospital. About 6.3% of those that received placebo versus less than 2% of those that received the antibody ended up being hospitalized. This is evidence that providing an antibody early on, even in people that have mild to moderate disease, can improve symptoms and decrease hospital stay.
Elizabeth: So let’s mention, of course, that this is in the New England Journal of Medicine. A question that I have about this — and one that’s been brought up all over the place — is relative to cost because these things are really pretty expensive.
Rick: Yep. This doesn’t provide that information, Elizabeth. It is expensive technology. There is no question about it. When you have a medication like this, there is a risk-benefit ratio in terms of benefit, clinically, versus any risks or any safety effects — and by the way, there were none in this particular study — but also, will the cost of this drug be less than the cost of caring for individuals either hospitalized or them being out of work being symptomatic? Only future studies will determine whether that’s the case or not.
Elizabeth: Right. Then, of course, there is the aspect of needing an IV infusion, which is not really easily promulgated throughout the population either.
Rick: No. It does take an IV infusion. You can’t take these orally. By the way, this is only one of several different neutralizing antibodies being tested. Regeneron or Roche are testing another one, actually a cocktail, two antibodies together against the same spike protein, and they’re studying it in the outpatient setting as well.
Those inpatient studies on the Regeneron-Roche have been halted for a while because of the safety concerns, but this, again, I think will be one of many different treatments that we’ll be looking at in the future.
Elizabeth: Okay. Let’s turn to something that is a little different for us, this one that I served up as, “Kindergarten readiness, what does it tell us about later health and societal costs?” That’s in Pediatrics.
I like this one because it’s a longitudinal study. They took a look at 966 Canadian children. These kids were examined when they were 5 years old regarding their number knowledge and what’s called receptive vocabulary. They took a look at different factors that then predicted how well they did quite a while later, end-of-high-school grades. They found out that those kids who had good math skills in kindergarten had better end-of-high-school grades, lower dropout rates, and if they had good receptive vocabulary, they had lower anxiety sensitivity.
Kindergarten classroom engagement also was positively associated with better end-of-high-school grades and lower dropout risk, better school connectedness, lower risk of substance abuse, more physical activity, and a 65% reduction in the odds of being overweight at the age of 17. These are clearly health outcomes that we are really vested in societally because they end up affecting all of us.
The authors then conclude that this early childhood readiness forecasts a protective edge at emerging adulthood and that those who start school prepared gain a lifestyle advantage that persists throughout their lifetime. I think this points very clearly to things that we need to pay attention to because we are all vested in the outcomes over the long haul for our children.
Rick: I’m glad you chose this particular trial because it assesses not how well they do in kindergarten, but how well are they prepared for kindergarten. This early readiness for school sets the stage for how they’re going to succeed in terms of their well-being, their health, and ultimately, in their capital formation.
This means that we need to think about investing time, energy, and resources not only in school, but in things that happen before school: preschool, community engagement, parenting skills. The long-term benefit from these has immense long-term consequences.
Elizabeth: It clearly, then, points to the need for things like high-quality daycare so that children can become exposed to a lot of these skills previously. We’ve talked about other studies that have established that even when kids get the routine childhood infections earlier, this does set them up for better school performance because they are there more often. There is, I think, all kinds of directions that we could take this data and say we really need to make this a lot more robust.
Rick: Yeah. There is more digging down to if we know that it’s not getting to kindergarten, but being ready for kindergarten, and as you said, school engagement. School engagement means self-discipline, learning to control, learning to interact, and so all these are skills that a child needs to gain before they even get to kindergarten. Elizabeth, I agree with you. Attention to these matters is incredibly important.
Elizabeth: Let’s turn to Morbidity and Mortality Weekly Report, speaking of kids and transmissions of COVID-19. What did we learn from this one?
Rick: This is a little bit shocking in terms of talking about the transmission rate. This was done in households in Tennessee and Wisconsin between April and September of this year and they systematically characterized the transmissions of COVID in households in these two areas.
What happened was they identified the index case and then they did pretty good contact tracing. They did routine testing, regardless of whether the individuals had symptoms or not, for up to 14 days to ascertain what the household transmission rate was.
They had 101 index patients and 191 enrolled household contacts that got routinely tested. 102 of those ended up being COVID-infected. The secondary transmission rate was 53%, and by the way, the index cases they looked at, they were able to look at transmission among young index cases versus older — young being less than 18, or older — the young individuals were just as likely to transmit as the older individuals even though they may have milder symptoms.
Then finally, what they determined was that 75% of the secondary infections occurred within 5 days of exposure. That means once we identify someone that’s either COVID-positive or has been exposed to somebody who’s COVID-positive, or is testing, we need to quarantine or isolate them quickly. Waiting three or four or five days for the test results to come back may be too late. They may have already infected the other individuals.
When those household contacts turned positive, about half of them had no symptoms at that particular time. Household contacts, a higher likelihood, especially if you spend a lot of time together. As soon as you suspect someone may have COVID infection or have been exposed, it’s important to isolate them as quickly as possible.
Elizabeth: More that we’re learning, of course, about all of this and it’s very concerning because much of the Northern Hemisphere is now turning into the winter months, so a good deal more confinement and close contact with each other within households.
Rick: Right. One of the things that the authors mention is because that’s the case, if there’s concern, you need to wear a face mask, even in the household right now, until it’s ascertained whether the person really is an index case or not.
Elizabeth: I would also note that something I have been paying a lot of attention to just this week has been this coincidence, the potential for coincidence of the flu and COVID-19, and the necessity for everybody to get a flu shot. But beyond that, most clinicians are calling out for, “You really need to be tested to discern which of these you have.”
Rick: You do. Now, again, the nice thing is the preventive measures that are effective for decreasing COVID are also effective for decreasing influenza infections. We have talked before in previous podcasts that in the Southern Hemisphere these measures decrease the risk of flu transmission by about 90% as well. But you’re right, the symptoms alone don’t tell whether someone has the flu or COVID, and by the way, the treatment for those is very different as well.
Elizabeth: Exactly. It’s so important to get tested. It would be great if we had some really reliable tests. I’m sorry to keep disparaging those, but let’s move on then to the Journal of the American Medical Association, looking at Black men, or African American men, and low-risk prostate cancer, and essentially whether they could be safely referred to active surveillance or watchful waiting. We use lots of different phraseologies for all of these.
They enrolled these guys, 8,726 men — 2,280 of whom were African American — and the remainder were non-Hispanic white men. These guys, as I said, all had what was considered to be low-risk prostate cancer and were referred to active surveillance. They followed them up for quite a while and they looked at this 10-year cumulative incidence of disease progression.
The 10-year cumulative incidence of disease progression in the African American men was just about 60% versus about 48% in the non-Hispanic white men. They also looked at metastasis, 1.5% versus 1.4%, receipt of definitive treatment, prostatectomy, 55% versus 41%, and all-cause mortality was essentially the same, 22.4% versus 23.5%.
So the upshot of the whole thing is that while African American men may have progression of disease and may need what’s called definitive treatment, it does not cause an increase in mortality. It seems like still a reasonable strategy to me. How about you?
Rick: I think that you’re right about the latter statement, but here is the caveat. These were all people enrolled in the VA study, so the African American men had access to active surveillance. In other words, we’re taking low-risk individuals and we are saying if you do active surveillance, follow their PSA, occasionally do biopsies when you need to, you can prevent doing unnecessary surgery — a radical prostatectomy — or unnecessary radiation, in about half the men without increasing their risk of metastasis. That’s why we do active surveillance in low-risk cancers.
But as you alluded to, African American men are more likely to have disease progression and more likely to have aggressive tumors. So we’ve been kind of caught in the middle when we say, “Maybe we need to be a little bit more aggressive in African American men, even in these low-risk cancers, so they get more radiation and surgery than the white population.” This study suggests you don’t have to do that.
The caveat though, is they have to have good active surveillance and oftentimes that’s not available across the U.S. because of the healthcare disparities. If we’re going to embrace the results of this study — and I think we should — we have to acknowledge that we can’t let the African American men fall through the cracks. The only way that this is effective is if there is active surveillance because, as this study suggests, they’re more likely to need surgery because they do have more aggressive tumors.
Elizabeth: I would note, also, that I think it behooves African American men to make sure that they come forward for these things and become educated about the need to keep on coming forward to make sure that they are engaged in active surveillance.
Rick: Yeah. Active surveillance takes both the medical side and the patient side to be actively engaged. I agree.
Elizabeth: On that note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.