School-Based COVID Testing; Rural Hospital Mergers

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.

This week’s topics include probiotics for ventilator-associated pneumonia, artemisinin-resistant malaria, school testing for COVID, and rural hospital mergers.

Program notes:

0:42 School-based testing for COVID

1:48 Really no difference between home isolation and school testing

2:40 Kids find it troubling not to be in school

3:05 Artemisinin resistant malaria in Uganda

4:05 Prolonged clearance time of parasite

5:05 First resistant to chloroquine

6:03 Hospital mergers in rural areas and care

7:05 Non-rehab hospitals

8:06 Standardization may improve outcomes

9:01 Probiotics for ventilator-associated pneumonia

10:05 Twice daily while in ICU

11:45 End

Transcript:

Elizabeth Tracey: Artemisinin-resistant malaria in Africa.

Rick Lange, MD: When a student comes in contact with COVID, does he need to go home?

Elizabeth: Do probiotics help to prevent ventilator-associated pneumonia?

Rick: When rural hospitals merge, does the quality of care change?

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: Rick, in keeping with our tradition, let’s start with the COVID material first — and, of course, this is extremely timely — taking a look at schools. This in The Lancet.

Rick: Right. This tries to address the question, when kids are at school and they come into contact with someone at school that is COVID-positive, what’s the best course of action? Do you send that contact home to self-isolate for 10 days? Or alternatively, can you keep them in school and daily test them for COVID? That’s what this study addressed.

They looked at school-based COVID-19 contacts — this is in England — that were normally asked to self-isolate at home and they randomized them to either doing that for 10 days or allowing them to stay in school and doing daily testing with what is known as a lateral flow device. The device is about 50% to 60% specific, but about 99.5% sensitive.

They looked at 204 different schools; 201 actually participated. What they had discovered is that in the schools in which individuals were sent home they had about 59.1 symptomatic infections per 100,000 per week. Those schools in which they allowed the students to remain in school, but tested them on a daily basis, the infection rate was about 62 per 100,000 per week. There really was no change. In fact, when they looked around at both types of schools, the infection rate was less than 2% across the board.

Elizabeth, this is great news because this implies that you don’t have to send kids home for 10 days to prevent the spread of COVID. That keeps them from attending school, which interrupts not only their life, but their parents’ life.

Elizabeth: These lateral flow assays, of course, have turned out to be incredibly practical for many different applications. I’m just wondering about the cost of this.

Rick: These are fairly inexpensive tests. There are two costs, testing for the child… but remember, at least in the U.S., the school districts get paid by whether the kids are in school or not in school. There is that cost. But really the most important cost is the educational experience of the students and also their parents that may have to take off from work to care for them if they have to remain home.

Elizabeth: Surely, and I think also the other aspect is, that kids find it very troubling not to be in school. There has been plenty of data about that since the pandemic has begun.

Rick: Yeah. It not only interrupts the educational experience, but it leads to behavioral issues as well, and then psychiatric and psychological issues. It appears that this daily testing strategy is a great alternative to sending kids home to isolate. It’s limited, again, to school exposures.

Elizabeth: Since we are talking about things that are related to the pandemic, let’s turn to the New England Journal of Medicine. This is related to the pandemic because the really daunting information that’s starting to emerge worldwide about how efforts to control both tuberculosis, drug-resistant tuberculosis, and malaria are really faltering — and HIV I would also mention — in the wake of the pandemic. Clearly, we’ve had these urgent matters on our minds, but all of these diseases are experiencing this uptick.

This study, unfortunately, is reporting a drug, artemisinin, which is the drug of choice for treating malaria-resistant strain that’s emerged in Northern Uganda. This, of course, is the organism Plasmodium falciparum.

They took a look from 2017 through only 2019, so that I’m sure that this data, if we looked at it right now, would be significantly different. They found a total of 14 of 240 patients who have received intravenous artesunate, but had also evidence of in-vivo artemisinin resistance. This is the parasite clearance half-life of greater than 5 hours, which is the test for this.

Of these 14 patients, 13 of them were infected with mutations in two specific alleles in the Kelch 13 gene. We have already known about this previously that it was involved with artemisinin resistance. Previous information has also shown that these Kelch 13 mutations have increased significantly from just shy of 4% to almost 20% in 2019.

This is extremely concerning that this has emerged in Uganda now. They do say the one little positive light here is that these two mutations may be used as markers for detection of resistant parasites.

Rick: This issue of drug-resistant malaria has been an issue, gosh, dating back to the 1950s when they were first resistant to chloroquine. Artemisinin resistance has actually been demonstrated before in the Mekong Valley and in other areas of Africa in Rwanda. This is the first time it’s been demonstrated in East Africa.

This didn’t come from other parts. This actually originated in East Africa. They noticed that by looking at genetic changes on either sides of the Kelch gene.

Fortunately, however, this artemisinin is just one drug of a 2-drug component. At this particular time yet, there is no resistance to the other drug. This 2-drug treatment of malaria is still effective, but it does lead to concern. Fortunately, there are other drugs being developed.

Elizabeth: With regard to the COVID association, I would note that some of the technologies that are being developed relative to treatment and vaccines for COVID are also being attempted with regard to malaria, so potentially there is an upside to some of this. It’s just right now it’s extremely concerning.

Rick: And trying to keep ahead of this, use effective treatments, multi-drug therapies, and develop new drugs at the same time.

Elizabeth: Let us turn now to JAMA Network Open. Another fallout that we have seen as a result of the COVID pandemic — actually, it was underway previous to that, but really gained some momentum during it — rural hospitals being acquired and being consolidated. What happens to the quality of care when that happens?

Rick: Elizabeth, this is important because more than one-third of the U.S. community hospitals are actually located in rural areas and they are care for about 60 million people — about 20% of the U.S. population.

Because of declining populations in rural areas, the worsening economic conditions, and persistent shortage of clinicians and healthcare providers, there is an increase in mergers and acquisitions of these hospitals. There is a concern that when these rural hospitals merge, they control the market and actually quality of care can actually go down. In fact, in urban areas, there has been some evidence that that’s in fact happened. Does the same thing hold true in rural hospital mergers and acquisitions?

This is a case-controlled study where they looked at mergers of community — these are non-rehab hospitals from 2009 to 2016, 32 different states. They looked at quality of care: how did patients do when they presented for an acute heart attack, heart failure, or stroke, gastrointestinal hemorrhage, hip fracture, or pneumonia, did they have complications, and what was their overall survival?

There were 172 merged hospitals. They compared them to 266 hospitals that did not merge. What they found was that the rural hospitals that merged actually had better outcomes — in particular with regard to acute heart attacks early on — that lasted for 4 years, and then for stroke, heart failure, mortality, not initially, but 3 to 5 years after the hospitals merged.

Elizabeth: In some respects what this reminds me of is our ongoing attempts to standardize protocols so that when people come in they receive the same thing. A similar — let’s just use heart attacks as an example. The testing that takes place to establish that one is underway, or has taken place, and then discharge with anticoagulation, or whatever it is, that standardization of those things actually ends up improving outcomes. What are your thoughts about that?

Rick: Well, Elizabeth, that’s clearly the case. Even though the study demonstrated improved outcomes, it wasn’t able to dig below the surface to determine why that occurred.

Now, you’re right. It could be because of improved outcomes, they are sharing things. Maybe because they are sharing services or they are sharing clinicians, or sharing expertise. It could be because now they have more money to invest in capital expenditures. Now that we have identified that the outcomes are better, why is it and how we can capitalize upon that?

Elizabeth: I think it’s really good news though because we have already talked about many times the number of people who really only have a rural hospital as the place to seek care.

Rick: Yes, and as I mentioned, 20% of the U.S. population. The things they focused on are high-volume issues: heart attacks, heart failure, and pneumonia. These are things that affect, really, all Americans. To know the outcomes better in hospitals that have had merged or been acquired, that’s good news.

Elizabeth: It is good news. Let’s turn to JAMA now and take a look at something that’s not really good news; it’s a negative study. Does the use of probiotics in patients who are on ventilators help to reduce pneumonia in that population?

We know, of course, that pneumonia occurs frequently in people who are on ventilators. I learned a new term here — microbial dysbiosis, some disruption of one’s naturally occurring fauna during critical illness. Can probiotics help with that?

There is a tremendous amount of interest right now. We have talked about it so many times in probiotics for multiple applications. In this case, they took a look at Lactobacillus rhamnosus GG (LGG) on preventing ventilator-associated pneumonia and additional infections.

This is a really big trial. It was placebo-controlled, randomized 44 IC Us in Canada, the United States, and Saudi Arabia, with a total of 2,653 patients enrolled from October 2013 to March 2019.

They gave them enterobacterio or placebo twice daily while they were in the ICU. The bad news — as I said it’s a negative study — is that there wasn’t a beneficial impact of employing this bug. Unfortunately, 15 patients receiving the probiotics experienced the adverse event of having this organism contaminate other places.

Rick: The reason this study was done, as you said, people have microbial dysbiosis in the ICU. Their gut flora changes. This is an inflammatory state. They are in an ICU. They are oftentimes on antibiotics. The question is, does that contribute to ventilator-associated pneumonia and can we treat it with probiotics?

There were small studies that suggested it could be helpful. The meta-analysis, oh gosh, it reduces this by 20%. The best way to figure that out is do a randomized controlled trial.

This is a really well done trial, and it showed it wasn’t helpful. When you have a meta-analysis, small trials, you want to do the really good study to see whether something is effective or not. That gives you the answer. What this does is it avoids us using a probiotic that’s not really helpful. In some circumstances in a small number of people, it could actually be harmful.

Elizabeth: Indeed, it’s good to know that it’s something we don’t want to employ. It’s a little bit disappointing, however, that something so simple would not help.

Rick: Right. Some things work and some things don’t.

Elizabeth: Got to test them though. 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.