Durability of COVID Vax; New Asthma Guidelines: It’s TTHealthWatch!

Allergies & Asthma

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 durability of antibodies to COVID after vaccination, new asthma guidelines, firearm deaths and injuries in the U.S., and hearing aid use.

Program notes:

0:50 Follow up to Moderna vaccine

1:49 Mean geometric titer higher than natural infection

2:49 Ramping up to teenagers

3:00 Rates of firearm deaths and injuries

4:00 Self harm about 88% of deaths outside the hospital

5:00 CDC data from electronic medical records

6:01 In context of pandemic concerning

6:30 Hearing aid ownership

7:30 Actually didn’t increase for some

8:30 PADs much less expensive

9:16 New asthma guidelines

10:16 Accessible in the guidelines

11:15 Specific stepwise recommendations

12:53 End

Transcript:

Elizabeth Tracey: New asthma management guidelines.

Rick Lange: Durability of the COVID vaccination.

Elizabeth: What are the trends in fatal and non-fatal firearm injuries in the U.S.?

Rick: And trends in hearing aid ownership in the United States.

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, why don’t we start with our COVID one this week? That’s clearly something that’s at the front of everybody’s mind. Look, these vaccines, they are on the horizon. In fact, they are in some people’s hot little hands, and the question is how durable are they? You’ll have to remind me, which journal is this published in?

Rick: This is in the New England Journal of Medicine, and Elizabeth, it’s a follow-up to the Moderna vaccine. The question on everybody’s mind is, “Well, how long does that immune response last?” So their initial study — remember that this is a two-dose vaccine and they gave it on day 1 and then 28 days later — and they followed to day 57. Well, now they follow it out 119 days.

Here is what they report. When they looked at the various types of antibodies, neutralizing antibodies and receptor-binding antibodies, it looks like the response is durable. Now, there’s a slight decline from day 57 to day 118, but that’s not terribly surprising because that’s fairly normal.

It looked like the response was both robust and durable. By the way, they looked at different age groups — those under the age of 55, those 56 to 70, and those over age 71 — and the response was durable in all three age groups.

Finally, they looked at how it compared to individuals that had actually been COVID-infected and a month and a half after their recovery from their infection had an antibody response. What they determined was the mean geometric titer of the antibodies after the vaccine were higher than in people that had actually been infected. This is the first evidence we have. Granted, it’s only in 37 individuals, but the initial data looks very promising. Oh, and by the way, they looked for were there any additional side effects from day 57 to day 119? None reported.

Elizabeth: These are all good data points and I’m really happy to hear them all. There are advantages, of course, to the Moderna vaccine. It needs only refrigeration, not this -80 kind of deep chill that the Pfizer vaccine needs. I guess one of my questions about both Moderna and Pfizer at the moment is I’ve been hearing an awful lot about, “Oops, we’re worried about the supply chain.”

Rick: Elizabeth, we’re asking individuals to ramp up to produce hundreds of millions of doses, not only for the United States but worldwide, so it’s not likely that any one company is going to be able to do that. It will be difficult, but I actually think they’re up to the task.

Elizabeth: Well, let’s also note that they’ve expanded the study populations now and they’re going to be recruiting for 12-to-18-year-olds, so I think that’s also a really good development.

Rick: Right, and that’s fairly typical for vaccine development. You test it in adults first to prove that it’s safe and efficacious, then you move it on to other populations, so testing in individuals between 12 to 18 is the next logical step.

Elizabeth: Let’s go to JAMA Internal Medicine. I found this to be rather daunting, I’m sorry to say, but as you’ve pointed out already, probably a good thing because it gives us some real numbers. This is epidemiologic trends in fatal and non-fatal firearm injuries in the U.S. between 2009 and 2017.

During this time there were just about 86,000 ED visits for non-fatal firearm injury and about 34,538 deaths each year. There was an annualized mean of 26,445 deaths that occurred outside of the hospital relative to firearms. Assault was the most common mechanism, followed by unintentional injuries, and then by intentional self-harm. Unintentional injuries were the most common non-fatal injuries and had the lowest case fatality rate.

Self-harm deaths, which comprised just under 88% of those which occurred outside the hospital, increased in all age groups in both rural and urban areas during the study period, and those were most common among people aged 55 and older. The rate of fatal assault injuries, higher in urban than in rural areas, and highest among people aged 15 to 34 years. Unsurprisingly to me because of the rates of hunting, the rates of unintentional injury were higher in rural areas.

So I think I was daunted and surprised — I guess chagrined — by just how many deaths take place relative to firearms, and not surprised but validated by the suicide data.

Rick: This is a really important study and not just because of the numbers it provides, but the fact that it was actually done. We’ve had a paucity of data on firearm injuries and deaths that have not allowed us to address this issue adequately.

We’ve done a little bit more about firearm deaths because of the CDC data — we can get that from electronic medical records and from coding — but the non-fatal assaults, they’ve been very difficult to come by. This was the first time they used the Nationwide ED Sample. This is a stratified sample of 900 to 1,000 emergency departments across the U.S., and they weighted it to provide national estimates, so now we know about fatal and non-fatal, and as you suggested, there were over 120,000 firearm injuries annually. That’s 329 per day, and for every fatal firearm injury there are two that are non-fatal.

And as you alluded to, most fatal firearm injuries are suicide and they’re successful — that is, they never make it to the hospital — and most of the other types of firearm injuries — assaults, unintentional — fortunately they don’t prove to be fatal. But by knowing the age groups and where they’re at, we can begin to address mental health issues, and safety of guns, and rules and regulations that can help as well.

Elizabeth: Well, no doubt, hopefully we’re going to be seeing some more of these kinds of studies that’ll further this data. Clearly right now with a pandemic continuing, we’re seeing suicidality increase, and so I absolutely am concerned about the availability of firearms to folks.

Rick: I must say I was surprised that that primarily rests in the age group over 55 years of age. I thought it was in the younger group. Again, addressing this, unfortunately it doesn’t allow us to meet the mental health needs of these individuals. There’s a lot of work to be done.

Elizabeth: Well, interestingly, I would also just note that those people aged 55 and older who choose firearms are largely men, although the proportion of women is also increasing in that group.

Let’s turn to your second one. This is in the Journal of the American Medical Association, and this is a research letter taking a look at hearing aid ownership among older adults in the U.S.

Rick: This really came to home as I was helping my mother, who is in her 80s, address her hearing problems. This is not unique to people in their 80s. It actually affects an estimated quarter of adults aged 65 to 74 years of age and more than half of adults over age 75. We’ve talked before about how the fact that hearing problems are linked to social isolation, poor psychosocial outcomes, a heightened fall risk, and even dementia.

Interestingly, they looked at the trends in hearing aid ownership among older adults in the United States from 2011 to 2018. The use of hearing aids overall increased, but it was disproportionate. The use of hearing aids increased in white individuals from 16.6% to 21%, whereas in black individuals it changed minimally, that is from 5.1% to 5.9%. Actually, when you looked at socioeconomic status, individuals that were below the 100% poverty level, hearing aid use actually decreased from 12.4% to 11%.

Where does the rubber hit the road? Well, this was likely because of the fact that hearing aids are very expensive. They cost over $2,000 and I can tell you some cost as much as $5,000 or $6,000. Secondly, people just don’t have access to them and third, there’s some stigma attached to them.

Beginning in February of 2021, the U.S. FDA has authorized a study in guidelines for the use of hearing aids that are over the counter. People now need to go to an audiologist or to an ENT specialist to get their hearing aids, to get properly fitting, and the concern was, “Well, gosh, if you let people do it on their own, will it be as good?” Well, first it lower their price and it will increase access.

The preliminary data looking at over-the-counter mechanisms for hearing aid settings have shown they actually have been helpful, and people do pick the right things for what they need. So more on this to come, but this was a very interesting study.

Elizabeth: Of course, we have been reporting about these things, these personal amplification devices, or PADs, for a few years and they are significantly less expensive than fitted hearing aids. One of the researchers here at Hopkins who talks about these says, yes, you do have to be really careful in choosing them. But he also says that they’re really only good for moderate hearing loss. If you have really a pronounced problem or your problem progresses, it’s important to get an assessment and potentially get a professional to get your hearing aid.

Rick: Absolutely. There will be some standardized recommendations about when to use these over-the-counter devices and when someone needs to see a specialist. But right now, because they’re so expensive and these specialists are only recommending FDA-regulated prescribed hearing loss products, they’re just not available. Having something available, even for mild or moderate hearing loss, is better than having nothing available.

Elizabeth: Finally, let’s stay in the Journal of the American Medical Association. This is a comprehensive look at managing asthma in adolescents and adults. This is the 2020 asthma guideline update from the National Asthma Education and Prevention Program. They did a meta-analysis of all of the studies that are out there and they chose, actually, six topics to update this year.

Those were intermittent inhaled corticosteroids, add-on, long-acting muscarinic antagonists (LAMAs) — we’ve talked about those before — fractional exhaled nitric oxide (FENO) measurement as a biomarker for asthma diagnosis, managing and monitoring response to therapy, indoor allergen mitigation strategies, safety and efficacy of subcutaneous and sublingual immunotherapy, and bronchial thermoplasty.

Wow, quite a lot of things, many of which were unknown to me, especially this fractional exhaled nitric oxide measurement. I’m not going to go through all of these things. They are definitely in the guidelines in a way that’s easily accessible.

In individuals 12 years and older with mild persistent asthma, the panel conditionally recommends either a daily low-dose ICS and as-needed short-acting beta agonist for quick-relief therapy or as-needed ICS and a short-acting beta agonist concomitantly. In those 4 years and older with mild to moderate persistent asthma, they conditionally recommend against short-term increases in ICS dose.

Lots of like slicing and dicing relative to different populations they group them in that 4-year-olds, 12-year-olds, and then finally adults. I think it’s great that they’re looking at all of this and that there are new methods relative to how do we assess this and how do we manage it?

Rick: As you noted, this is pretty comprehensive and it digs down into specifically with regard to age to offer specific recommendations. These are step-wide recommendations. That is when someone has mild asthma, can you control it with a particular agent and how do you march up for people that have asthma that’s less well-controlled? By the way, for our listeners that heard you talk about ICS, these are inhaled corticosteroids, if people aren’t familiar with them.

Having these recommendations is particularly helpful, and especially broken out by age group, and you mentioned fractional exhaled nitric oxide as a way of diagnosing asthma and also monitoring asthma. The group recommends that it not be used solely as the only way to diagnose it because there are a lot of things that affect it — things like smoking, things like obesity, other conditions as well — but it can be used as an adjunct, both for helping to establish diagnosis for the proper clinical syndrome and other testing, and also to follow as management once that’s been done as well. But very comprehensive guidelines. I think for all primary care physicians this needs to be on the shelf.

Elizabeth: And we would also just note that, for our COVID segue here, that it’s very interesting to note that people with asthma are generally not at higher risk for severe COVID-19 disease.

Rick: I’m glad you mentioned that because it was considered one of the risk factors initially, along with obesity, diabetes, hypertension, other pulmonary disease and cardiac disease. But subsequently when they looked at the data, asthma does not appear to be a risk factor for developing more severe disease or for having a mortal event as well.

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.

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