COVID-19 Data Dispatch

Tag: treatment equity

  • Ending emergencies will lead to renewed health equity issues

    Ending emergencies will lead to renewed health equity issues

    The header image from a story I recently had published in Amsterdam News about declining access to COVID-19 services.

    Last week, I gave you an overview of the changes coming with the end of the federal public health emergency (PHE), highlighting some shifts in publicly available COVID-19 services and data. This week, I’d like to focus on the health equity implications of the PHE’s end.

    COVID-19 led the U.S. healthcare system to do something unprecedented: make key health services freely available to all Americans. Of course, this only applied to a few specific COVID-related items—vaccines, tests, Paxlovid—and people still had to jump through a lot of hoops to get them. But it’s still a big deal, compared to how fractured our healthcare is for everything else.

    The PHE allowed the U.S. to make those COVID-19 services free by giving the federal government authority to buy them in bulk. The federal government also provided funding to help get those vaccines, tests, and treatments to people, through programs like mass vaccination sites and mobile Paxlovid delivery. Through these programs, healthcare and public health workers got the resources to be creative about breaking down access barriers.

    Now that the emergency is ending, those extra supplies and resources are going away. COVID-19 is going to be treated like any other disease. And as a result, people who are already vulnerable to other health issues will become more at risk for COVID-19.

    I wrote about this health equity problem in a recent story for Amsterdam News, a local paper in New York City that serves the city’s Black community. The story talks about how COVID-19 services in NYC are changing with the end of the PHE, and who will be most impacted by those changes. It’s part of a larger series in the paper covering the PHE’s end.

    Most of the story is NYC-specific, but I wanted to share a few paragraphs that I think will resonate more widely:

    Jasmin Smith, a former contact tracer who lives in Brooklyn, worries that diminished public resources will contribute to increased COVID-19 spread and make it harder for people with existing health conditions to participate in common activities, like taking the subway or going to the grocery store.

    COVID-19 safety measures “make the world more open to people like myself who are COVID-conscious and people who might be immunocomprmised, disabled, chronically ill,” Smith said. “When those things go away, your world becomes smaller and smaller.”

    The ending federal public health emergency has also contributed to widespread confusion and anxiety about COVID-19 services, [said Dr. Wafaa El-Sadr, a professor of epidemiology and global health at Columbia University’s Mailman School of Public Health]. “People have so many questions about this transition,” she said, and local leaders could do more to answer these questions for New Yorkers.

    The near future of COVID-19 care in the U.S. could reflect existing health disparities for other endemic diseases, like the seasonal flu and HIV/AIDS, [said Steven Thrasher, a professor at Northwestern University and author of the book, The Viral Underclass]. For example, people with insurance and a primary care physician are more likely to get their annual flu shots, he said, while those without are more likely to face severe outcomes from the disease.

    After May 11, COVID-19 outcomes are likely to fall along similar lines. “More people have died of AIDS after there were HIV medications,” Thrasher said. “More people have died of COVID when there were vaccines in this country than before.”

    For more news and commentary on COVID-19 emergencies ending, I recommend:

  • Sources and updates, June 26

    Sources and updates, June 26

    A new chart from the CDC shows booster shot eligibility and uptake by age. Retrieved on June 26.
    • CDC report on Paxlovid distribution: A major study from the CDC’s Morbidity and Mortality Weekly Report this week: researchers at the CDC and collaborators studied the distributions of antiviral COVID-19 drugs Paxlovid and Lagevrio (also called Molnupiravir) by ZIP code, comparing ZIP codes with the CDC’s Social Vulnerability Index. More than one million prescriptions were dispensed between late December 2021 and late May 2022, the study found. But, by the end of that period, prescription rates were twice as high in low- and medium-vulnerability ZIP codes as in high-vulnerabilty ZIP codes—indicating that these antivirals are not reaching the people who most need them.
    • CDC booster shot data update: The CDC has added a new chart to its “COVID-19 Vaccinations in the United States” page, showing booster shot eligibility and uptake by age. The chart includes two rounds of boosters for seniors; according to the data, 64% of eligible seniors have received their first booster, but only 21% have received their second booster. The data are also available for download.
    • COVID-19 vaccinations among children: I also recently learned about this CDC page focused on kids’ vaccinations, including vaccination coverage by demographic factors such as poverty status, parents’ education level, and insurance. The data come from a national survey previously used to monitor flu vaccinations among children. Data are updated monthly, and don’t yet include figures for children under 5; but existing data for children ages 5-17 affirm that vaccine uptake for kids has been low so far.
    • Guide to finding government COVID-19 documents: The Digital Public Library of America has released a free ebook with an archive of over 3,000 government documents related to the pandemic response. These documents were collected by the COVID Tracking Project during its year of work, and have been meticulously categorized and indexed in true CTP fashion. CTP alum Jennifer Clyde was the project’s editor.
    • Commonwealth Fund report on improving our public health system: A new report from healthcare-focused foundation The Commonwealth Fund provides recommendations for improving the country’s public health system. It focuses on organizing local agencies, providing more funding, improving trust, and other key topics.
    • History of exposure notification apps: Jenny Wanger, whom I interviewed about COVID-19 exposure notification apps back in spring 2021, sent me this paper she wrote about the technology, which was published earlier in June. The paper provides a report of how exposure notification protocols were developed, how states used the technology, and how limited data made it difficult to assess the technology’s success.

  • We need more data on who’s getting Paxlovid

    We need more data on who’s getting Paxlovid

    Last week, I shared a new page from the Department of Health and Human Services (HHS), reporting statistics on COVID-19 therapeutic distribution in the U.S. The new dataset is a helpful step, but it falls far short of the information we actually need to examine who has access to COVID-19 treatments (particularly Paxlovid) and address potential health equity issues.

    The HHS dataset includes total counts of COVID-19 drugs ordered and administered in the U.S., both nationally and by state. It also includes weekly numbers of the doses available for health providers to order from the federal government (which the HHS calls “thresholds”), over the last five weeks; again, these are available nationally and by state.

    As most of the monoclonal antibodies developed for earlier variants do not provide much protection against Omicron, the majority of treatments used in the country last month were antiviral drugs Paxlovid (made by Pfizer) and Molnupiravir (made by Merck).

    Paxlovid is the most effective of the two, and the most in-demand. In recent weeks, some patients have reported difficulties with accessing this antiviral as BA.2 drives rising cases across the country. For instance, one COVID-19 Data Dispatch reader wrote to me last week to share that a family member who should’ve been eligible for Paxlovid had his prescription denied, as his pharmacy said the drug was in “limited supply.”

    In the first Omicron surge, during the winter, Paxlovid definitely was in limited supply. Then, as that surge waned, supplies improved: a Washington Post article last month reported that the federal government had plenty of doses going unused, and health leaders like COVID-19 coordinator Ashish Jha wanted to raise awareness of the antiviral with providers and patients.

    Now, as BA.2 and its subvariants drive a new surge, it’s unclear whether there are still plenty of Paxlovid doses for anyone who might need them—or whether the doses must once again be rationed for only the most vulnerable patients. If the latter is true, even if it’s true only in some states or counties hardest-hit by the Omicron variants, it’s a problem: as the U.S. seems completely unwilling to put in new safety measures, Paxlovid is an important tool to at least reduce severe disease and death. Without it, high-risk people are in an even worse position.

    As a data journalist, I would love to investigate this problem by digging into federal data to see where Paxlovid is getting used, and where there may be gaps. But the existing data are pretty sparse: the HHS has published only limited national and state-level data, with the only numbers on doses actually ordered and administered being cumulative (i.e. totals over a five-month period). There’s no information on how Paxlovid prescriptions have changed in different states or counties over time, or of whether the drug is actually reaching vulnerable people who need it.

    KHN’s Hannah Recht explained why this data gap is a problem for health providers prescribing Paxlovid, in an article earlier in May:

    Los Angeles County’s Department of Public Health has worked to ensure its 10 million residents, especially the most vulnerable, have access to treatment. When Paxlovid supply was limited in the winter, officials there made sure that pharmacies in hard-hit communities were well stocked, according to Dr. Seira Kurian, a regional health officer in the department. In April, the county launched its own telehealth service to assess residents for treatment free of charge, a model that avoids many of the hurdles that make treatment at for-profit pharmacy-based clinics difficult for uninsured, rural, or disabled patients to use.

    But without federal data, they don’t know how many county residents have gotten the pills. Real-time data would show whether a neighborhood is filling prescriptions as expected during a surge, or which communities public health workers should target for educational campaigns.

    Yasmeen Abutaleb’s article in the Washington Post (linked above) also discusses the need for data:

    Other experts welcomed the administration’s efforts, especially as cases rise, but said simply boosting the supply wasn’t enough, noting that inequities persist in who has access to Paxlovid. People without health insurance and those who live far away from medical providers or pharmacies are among those at highest risk from covid and face some of the highest hurdles to receiving effective treatment, said Julie Morita, executive vice president of the Robert Wood Johnson Foundation.

    “It is essential that we collect and report data on who is receiving Paxlovid and other antiviral medications to swiftly pinpoint and address any disparities that emerge,” Morita said. “If done right, this can be a real turning point — but it is essential that all populations and communities have the opportunity to reap the benefits.”

    In short, if health providers like community clinics and pharmacies could see data on which communities are receiving Paxlovid prescriptions and which ones are not, they could work to fill the gaps. The existing state-by-state data (published after Recht’s article) is a helpful starting point, but still has little utility for local health officials.

    Indeed, the limited state-by-state data already suggest that some states in the Northeast, the West Coast, and the Great Lakes region are ordering and administering more Paxlovid (relative to their populations), compared to others in the Midwest and South. This is a pattern worth examining further, but it’s difficult when the data are so unspecific.

    Here’s my wishlist of Paxlovid data that would be more useful:

    • More granular geographies. State-level data is pretty useless if you run a local health clinic, or if you’re a local journalist. We need prescription information at the county level, if not even smaller regions (like census tracts or ZIP codes.)
    • Demographic data. Without data on race and ethnicity, age, or other demographic factors, it’s very difficult to determine whether Paxlovid is reaching people in an equitable way—or if access to the drug is becoming another way in which the pandemic disproportionately impacts already-marginalized groups.
    • Provider type. Along the same lines as demographic data, seeing how many Paxlovid doses are going through large pharmacies as opposed to community health centers, hospitals, or other types of healthcare providers could be a useful measure of equity.
    • Patient health conditions. People with health conditions that predispose them to severe COVID-19 symptoms (compromised immune systems, diabetes, kidney disease, etc.) are supposed to be at the front of the line for Paxlovid. We need data to see whether they are actually getting this priority treatment.

    Come on, HHS: give us the granular data!

    More federal data

  • Contracted staffing issues in Missouri reveal broader crisis in hospitals

    Contracted staffing issues in Missouri reveal broader crisis in hospitals

    Chart from the Missouri Independent story.

    Early this week, I had a big story published in The Missouri Independent, as part of the Documenting COVID-19 project’s ongoing collaboration with that nonprofit newsroom. This piece goes in-depth on the Missouri health department’s contract with SLSCO, a Texas-based construction company that expanded to provide healthcare support during the pandemic.

    While this was a local story, to me, the piece provides important insights about the type of support that is actually needed in U.S. hospitals right now: not temporary assistance, but long-term, structural change.

    The Missouri agency hired SLSCO to provide two services, with a total contract of $30 million:

    • Provide staffing support (nurses, technicians, etc.) to hospitals across the state struggling in the wake of the Delta surge.
    • Set up, staff, and operate six monoclonal antibody infusion sites where Missourians infected with the coronavirus could easily access the treatment.

    SLSCO made lofty promises to the Missouri health department, citing its ability to quickly send hundreds of workers to facilities that required assistance. But in fact, the hospital staffing assistance was marred by delays, no-shows, and high rates.

    Here are a few paragraphs from the story:

    Fewer hospitals signed on to receive staff than the Department of Health and Senior Services anticipated. Within the first few weeks, some hospitals faced no-shows, while the company’s hourly rates — up to $215 an hour for some nurses and $550 an hour for doctors — were too high for other hospitals to afford after state funds ran out, according to emails obtained by The Independent and the Documenting COVID-19 project through records requests. (Copies of SLS’ contract and emails between state agencies can be found here.)

    “153 staff requested and only 10 deployed,” wrote Alex Tuttle, the governor’s legislative budget director, after receiving a staffing report early in the contract period. “Am I reading that right?”

    From mid-August through November, just 206 staff were ultimately sent to 53 hospitals, said Lisa Cox, a spokeswoman for DHSS. The healthcare support had left by the time omicron hit in the winter.

    The monoclonal antibody infusion sites were more successful; in fact, the Missouri health department ended up redirecting funding from the staffing support to the infusion sites. The six sites served a total of 3,688 patients over a two-month period.

    However, the sites could have served a lot more patients: these clinics could have treated up to 136 patients each day but peaked at about 90, with numbers often much lower, according to my analysis of data from the health department. Due to these low numbers, the state of Missouri ended up spending more than $5,600 for each patient. One monoclonal antibody expert I talked to for the piece called this an “exorbitant” cost.

    Now, I don’t mean to hate on monoclonal antibody treatments here—these drugs are truly a great way to boost the immune systems of COVID-19 patients who may be at higher risk for severe symptoms. Maggie Schaffer, a case management nurse who helped set up one of the infusion sites, told me that people who had this treatment typically are “feeling like a whole new person” within a day or two.

    However, the treatments are very expensive and inefficient; one patient’s infusion appointment can take hours. The drugs themselves cost around $2,100 per dose, about 100 times as much as one vaccine. Health departments and facilities that offer monoclonal antibodies need to focus on getting the word out to patients so that these expensive supplies aren’t wasted.

    At the same time, temporary healthcare staff can be great to help a facility out a surge—but they are not a long-term solution. In particular, nurses at a hospital may be frustrated by watching new staff come in from out of town and receive much higher pay rates; the “traveling nurse phenomenon,” as this is called, may contribute to burnout and staff leaving to go become traveling workers themselves.

    What do hospitals actually need to do to address their staffing crisis? Here are a few ideas from Tener Veenema, a nursing expert focused on health systems a professor of nursing who researches health systems and emergency preparedness at Johns Hopkins’ Bloomberg School of Public Health:

    • Higher pay and assistance with education bills.
    • Regulations on things like work hours, the number of patients one nurse can be responsible for at once.
    • Mental health assistance that nurses are actually given time and space to access.

    I’ll end the post with this quote from Veenema, which is also the last line of the story:

    “If we don’t fix the toxic work environment, this issue of mandatory overtime, inadequate staffing levels, lack of time to access mental health resources,” Veenema said, “then you’re simply shooting more new nurses out of the cannon, but into the lake where they’re going to drown.”

  • First COVID-19 antiviral pill gains authorization

    This week, an antiviral pill for COVID-19 was authorized in the U.K. The drug, made by American pharmaceutical company Merck, is the first COVID-19 treatment in pill form to gain approval by any regulatory agency.

    Some scientists have called this pill a “game-changer,” and for good reason. In Merck’s clinical trial, the drug approximately halved COVID-19 patients’ risk of hospitalization or death, compared to a placebo. The pill is designed for—and was tested on—adults who are particularly vulnerable to the virus, including seniors and those with preexisting conditions such as diabetes and heart disease.

    The pill, formally called molnupiravir, works by interfering with the coronavirus’ ability to replicate itself, stopping it from reaching further into the body and causing severe symptoms. (This STAT News article includes a video that explains the process in more detail.) Adults who show mild or moderate COVID-19 symptoms can take the pill soon after they realize they’re infected, in order to improve their chances of recovery without a hospital stay.

    In Merck’s clinical trial, patients started taking the pill five days after they began to experience COVID-19 symptoms. Each patient took four capsules, twice a day, for five days—adding up to 40 pills for a single patient.

    The U.K. government has bought almost 500,000 courses of molnupiravir. The U.S. government has brought about 1.7 million courses, and our FDA is slated to consider the pill for emergency use authorization later this month. Several other countries including France, Australia, Malaysia, and Singapore also have contracts in place to purchase the pills.

    But unlike other COVID-19 treatments and vaccines, molnupiravir may be more broadly available to people who don’t live in wealthy nations. Last week, Merck announced that it signed a voluntary licensing agreement with the Medicines Patent Pool, a public health organization backed by the United Nations that increases treatment access in over 100 low- and middle-income countries. As a result, a number of companies besides Merck will be able to manufacture and distribute their own versions of molnupiravir.

    Still, some global health advocates have criticized Merck for making a deal with the Medicines Patent Pool rather than the World Health Organization’s COVID-19 Technology Access Pool, which would provide access to a broader group of countries. The current deal leaves out some middle-income countries that are particularly poised to manufacture versions of molnupiravir, including countries like Brazil and Peru that have seen high COVID-19 death tolls.

    In short, Merck’s efforts to make its COVID-19 drug widely available are much better than anything we’ve seen from the major vaccine companies. But this is still far from the most equitable scenario.