Dramática baja de enfermedades por virus comunes, ¿significa máscaras para siempre?

Las máscaras y el distanciamiento físico están demostrando tener importantes beneficios extra, evitando que las personas contraigan todo tipo de enfermedades, no solo covid-19.

Pero no está claro si los protocolos valdrán la pena a largo plazo.

Maestros de la Academia New Hope en Franklin, Tennessee, estaban charlando sobre el tema. La escuela cristiana privada ha permanecido presencial durante gran parte de la pandemia, requiriendo máscaras y tratando de mantener a los alumnos separados, en la medida en que es posible con niños pequeños.

Nicole Grayson, quien enseña en cuarto grado, dijo que se dieron cuenta de algo peculiar.

“No conocemos a nadie que se haya engripado”, dijo. “A ningún estudiante que haya contraído faringitis estreptocócica”.

Y no se trata solo de algo anecdótico.

Un estudio publicado este marzo en el Journal of Hospital Medicine, dirigido por investigadores del Centro Médico de la Universidad de Vanderbilt, encontró que en 44 hospitales infantiles, el número de pacientes pediátricos hospitalizados por enfermedades respiratorias se redujo en un 62%.

Las muertes también han disminuido drásticamente en comparación con los últimos 10 años: el número de muertes por influenza en niños suele estar entre 100 y 200 por año, pero hasta ahora solo un niño ha muerto a causa de la enfermedad en el país durante la temporada de influenza 2020-21.

Los adultos tampoco se están enfermando. Las muertes por influenza esta temporada se medirán en cientos en lugar de miles. En 2018-19, una temporada de gripe moderada, se estima que murieron 34,200 estadounidenses.

Combo eficaz

No son solo las máscaras y el distanciamiento físico lo que está frenando las enfermedades transmisibles, dijo la doctora Amy Vehec, pediatra de Mercy Community Healthcare, una clínica de Tennessee que recibe fondos federales.

Que un niño tenga fiebre ahora es algo serio, los padres no están mandando a sus hijos enfermos a la escuela, agregó.

“Están quedándose en casa cuando están enfermos”, dijo Vehec. Eso incluye a los adultos que pueden sentirse enfermos.

Este aislamiento cuando alguien se siente mal podría mantenerse después de la pandemia. Pero el aislamiento, la distancia y las máscaras no funcionan para muchos niños, explicó Vehec.

Por ejemplo, los que tienen problemas del habla no ven la boca de su maestro para aprender a hablar correctamente.

“Creo que ha sido un mal necesario por la pandemia, y lo he apoyado por completo, pero ha tenido sus consecuencias”, dijo.

Y dado que las vacunas contra covid no estarán disponibles para los niños por un tiempo, puede ser otro año de cubrebocas en las escuelas.

Algunos expertos, como los investigadores que intentan mejorar las máscaras, argumentan que más sociedades deberían adoptarlas, como lo han hecho algunos países asiáticos. Pero incluso los expertos en enfermedades infecciosas como el doctor Ricardo Franco de la Universidad de Alabama-Birmingham dudan de que sea práctico.

“Soy un poco escéptico de que esta crisis sea suficiente para un cambio cultural generalizado, dado lo difícil que ha sido lograr un cambio cultural razonable en los meses anteriores”, analizó Franco.

El escenario más realista para un cambio duradero puede ser dentro de la propia atención médica.

Los médicos y enfermeras no solían usar máscaras antes de covid. El doctor Duane Harrison, quien dirige el departamento de emergencias de un hospital de HCA en las afueras de Nashville, mencionó a un colega médico que ha usado máscara desde que salió de la escuela de medicina.

“Solíamos bromear sobre esto”, dijo Harrison. “Hasta la pandemia”.

Ahora que todos usan máscaras, el departamento de Harrison ha descubierto lo mismo que muchos otros lugares de trabajo: los empleados no están diciendo que están enfermos, a menos que sea covid.

“Cuando covid termine, ésta es una práctica que la mayoría de nosotros probablemente continuaremos”, dijo Harrison. “Porque no tendremos que preocuparnos por los niños con secreción nasal y las personas mayores que no saben que están estornudando en tu cara”.

Algunos sistemas hospitalarios, incluido Nebraska Medicine, han comenzado a relajar los requisitos de uso universal de máscara para su personal. Pero incluso el personal vacunado todavía tiene que usar cubreboca cuando están con pacientes.

Intermountain Healthcare, en Utah, ha dicho que seguirá requiriendo máscara cuando se levante el mandato estatal en abril.

Pero incluso los que creen en la eficacia de las máscaras tienen dudas de que la comunidad médica las adopte en forma permanente.

“La pregunta más importante es: ¿Todos van a necesitar un descanso?”, se preguntó el doctor Joshua Barocas, quien estudia enfermedades infecciosas en la Universidad de Boston.

Funcionarios de salud pública dicen que, independientemente de lo que depare el futuro, aún no ha llegado el momento de eliminar los requisitos de las mascarillas, porque todavía hay mucha gente que vacunar contra covid.

Pero eventualmente, incluso los médicos y las enfermeras están listos para volver a mostrar sus caras sonrientes.

Esta historia es parte de una asociación que incluye Nashville Public Radio, NPR y KHN.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Dramatic Drop in Common Viruses Raises Question: Masks Forever?

Masks and physical distancing are proving to have major fringe benefits, keeping people from getting all kinds of illnesses — not just covid-19. But it’s unclear whether the protocols will be worth the pain in the long run.

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The teachers at New Hope Academy in Franklin, Tennessee, were chatting the other day. The private Christian school has met in person throughout much of the pandemic — requiring masks and trying to keep kids apart, to the degree it is possible with young children. And Nicole Grayson, who teaches fourth grade, said they realized something peculiar.

“We don’t know anybody that has gotten the flu,” she said. “I don’t know of a student that has gotten strep throat.”

It’s not just an anecdote.

A study released this month in the Journal of Hospital Medicine, led by researchers from Vanderbilt University Medical Center, found that across 44 children’s hospitals the number of pediatric patients hospitalized for respiratory illnesses is down 62%. The number of kids in the U.S. who have died of the flu this season remains in the single digits. Deaths have dropped dramatically, too, compared with the past 10 years: The number of flu deaths among children is usually between 100 and 200 per year, but so far only one child has died from the disease in the U.S. during the 2020-21 flu season.

Adults aren’t getting sick either. U.S. flu deaths this season will be measured in the hundreds instead of thousands. In 2018-19, a moderate flu season, an estimated 34,200 Americans died.

Effective Combo

It’s not just the masks and physical distancing that are tamping down communicable disease, said Dr. Amy Vehec, a pediatrician at Mercy Community Healthcare, a Tennessee clinic that gets federal funding. It’s become a serious societal faux pas to go anywhere with a fever — so parents don’t send their ailing kids to school, she said.

“They are doing a better job of staying home when they’re sick,” Vehec said. That includes adults who may feel ill.

Isolating when feeling bad could be kept up after the pandemic. But the isolation, the distance and the masks are not working for many kids, Vehec said.

Children with speech trouble aren’t seeing their teacher’s mouth to learn how to speak correctly, for instance.

“I think it has been a necessary evil because of the pandemic, and I have completely supported it, but it has had prices. It’s had consequences,” she said. “Kids’ education is suffering, among other things.”

And with covid vaccines unavailable to children for a while yet, it may be another year of masks in schools.

Some experts, like researchers trying to improve masks, argue that more societies should embrace masking — as some Asian countries have. But even infectious-disease experts like Dr. Ricardo Franco of the University of Alabama-Birmingham doubt that’s practical.

“I’m a little skeptical that this crisis will be enough for a widespread culture change, given how difficult it’s been to achieve a reasonable culture shift in the previous months,” Franco said.

The most realistic setting for lasting change may be within health care itself.

Doctors and nurses didn’t usually wear masks before covid. Dr. Duane Harrison, who directs an emergency department for an HCA hospital outside Nashville, mentioned a physician colleague who has worn a mask since he got out of medical school.

“We used to joke and clown with him about this,” Harrison said. “Until this.”

Now that everyone wears masks, Harrison’s department has found the same thing many other workplaces have: Employees aren’t calling out sick, unless it’s covid.

“When covid’s done, this is a practice that most of us will probably continue,” Harrison said. “Because we won’t be worried about runny-nose kids and elderly people who don’t know they’re sneezing in your face.”

Some hospital systems, including Nebraska Medicine, have started to relax universal masking requirements for their staffs. But even vaccinated staffers still have to wear a mask when seeing patients. Intermountain Healthcare in Utah has signaled masks will continue to be required when a statewide mandate lifts in April.

‘Is Everyone Going to Need a Break?’

But even believers in the effectiveness of masks have their doubts about the medical community keeping it up.

“The larger question is: Is everyone going to need a break?” asked Dr. Joshua Barocas, who studies infectious diseases at Boston University.

Whatever the future holds, public health officials say, the time has not yet come to drop mask requirements as the U.S. waits for more people to get a covid vaccine. But eventually, even doctors and nurses are ready to see smiling faces again.

“I know I’m going to need to retire my masks at some point in the future,” Barocas said, “for a little bit.”

This story is part of a partnership that includes Nashville Public Radio, NPR and KHN.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Durango’s Covid ‘Cowboy’ Rounds Up Spring Break Scofflaws, Lines ’Em Up for Shots

Bartenders were pouring Old-Fashioneds at a bar with a bullet hole straight through the wood. Servers in corsets and fishnet stockings roamed the room, passing an old piano that, twice a week, fills the building with ragtime tunes.

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It was a Friday evening at the Diamond Belle Saloon on the main drag in Durango, Colorado. Outside, a man in boots, a cowboy hat and a button-down vest adorned with a U.S. marshal badge patrolled the block, eyes scanning the streets for trouble. If trouble were to appear, it would likely take the form of errant Texans.

“You can’t throw a stone around here without hitting a Texan,” recalled Scott Perez, the man in the marshal get-up.

This was the Wild West, after all: spring break 2021. And leaders of this city of about 19,000 are eager to hold covid-19 at bay with a bit of old-time law and order on mask mandates — and even a little modern vaccine science.

Perez is very familiar with this block, having staged his death several times outside the saloon during summertime gunfight performances. The former cowboy and current actor, stuntman and history buff also pretended to rob the steam train that takes tourists to the former mining town of Silverton. Now, a consortium that includes local businesses and the tourism office has hired him and a few other actors for a very specific task: to get people to obey the city’s mandate to wear their dang masks.

Early in the pandemic, some mountain towns and counties shut out visitors. These days, they’re welcoming tourists with open arms — and, in some cases, a shot in the arm.

The health department that serves Durango’s La Plata County is among those offering covid vaccines to outsiders. In neighboring San Juan County, where the sheriff was threatening to fine and tow cars with out-of-county license plates a year ago, officials are now telling visitors, “If you’re here and with us now, let’s get you vaccinated if you’re eligible,” county spokesperson DeAnne Gallegos said. Andrew Sandstrom, a spokesperson for the Gunnison County covid response, said his county is doing the same but officials are just asking that visitors receive both doses in the same place.

Liane Jollon, executive director of the health department that spans La Plata and Archuleta counties, said more than 30% of residents have gotten at least one vaccine dose, putting the counties ahead of the curve. They aren’t advertising their vaccine supply as a lure for tourists, but as long as visitors fit Colorado’s vaccine eligibility criteria, Jollon said, they aren’t turning anyone away.

The state told vaccine providers not to ask for IDs or proof of residency, to avoid creating barriers for immigrants or homeless people, said Brian Spencer, with the Colorado State Joint Information Center. By extension, though, that means spring break tourists or second-home visitors also can partake.

“While it can feel like a difficult burden to vaccinate more individuals in your jurisdiction, it also helps keep our entire community safe,” Jollon said. “We’ve had people drive up for the day from New Mexico to get a vaccine.”

Typically this time of year, visitors come in spring break waves from Texas, Oklahoma, New Mexico and Arizona. Oklahoma’s governor has refused to impose a statewide mask mandate, and the governor of Texas lifted that state’s mandate and fully reopened businesses shortly before spring break tourists began arriving in Colorado.

In La Plata County, cellphone data analyzed by the health department shows that, from the first week of March to the third, mobile devices belonging to nonresidents shot from 15% of the total to 40%, with most coming from Texas and Oklahoma.

Some of the influx started even earlier. Gunnison County, which banned visitors during last year’s spring break, has seen tourism more than rebound in the past few months. It had a jump of at least 30% in tax revenue from short-term lodging in December and January compared with the same months before the pandemic.

Coloradans fear what the visitors may leave behind.

“In many of our mountain towns, we’re starting to see a new uptick,” said Jollon. “We’re really concerned that after spring break we could see an uptick that would hurt our schools’ ability to continue to offer in-person learning options.”

Around this time 102 years ago, Durango was closing its schools and opening an emergency hospital — again — to deal with a resurgence of the 1918 flu pandemic. People were fumigating their houses with formaldehyde, and kids were jumping rope to the song “I had a little bird. Its name was Enza. I opened the window, and in-flu-Enza.”

“It was definitely bad here,” said Perez. “They had bodies stacked up, particularly the ones that died in the winter because they couldn’t dig to bury them. They couldn’t find the mortician. He was laying amongst the bodies because he died. … A lot of the ladies of the evening became nurses.”

So this time, the community wants to prevent a resurgence, but also keep the tourism dollars flowing.

Durango, which usually attracts an estimated 1.5 million visitors each year with its brick buildings, steam train and bluffs crumbling into the Animas River, initially planned to hire a private security firm to persuade out-of-towners to don masks. That’s what the town of Breckenridge did. But then Rachel Brown, executive director of Visit Durango, jokingly proposed Old West actors instead.

“I have been told that the fun and theatrical approach of the Mask Marshal program is being very well received,” Brown said. “We are glad that we chose this option over private security.”

The need for mask police puzzles Perez. “I can’t figure it out at all,” he said. “I mean, there’s so much evidence about how this helps and yet somehow it became political.”

His right-hand woman in mask compliance is Cathy Roberts, a fellow reenactor, plus an animal advocate and military veteran. She wears a red-and-black cancan dress and goes by “Miss Kitty,” after the saloon owner in the TV and radio series “Gunsmoke.”

“She can disarm anybody with charm,” said Perez. “The goal is that I disarm them with some humor.” But he’s also clear they have a second option if things go sour: a direct line to the Durango Police Department.

“And the third option is not pretty,” said Perez. To be clear, the only heat he’s packing is two rounds of Pfizer.

As the pair entered the saloon Friday night, Roberts recounted, a waitress gave her what she calls “the look.”

“That’s all they gotta do,” said Roberts, who quickly spotted the problem by the door: four people who clearly were not familiar with Durango’s mask rules. People are required to wear masks indoors, even in a bar or restaurant, unless they’re seated and eating or drinking. The women had on masks, but their noses weren’t covered. The men didn’t have masks at all.

Roberts walked up cheerfully in her red dress, greeted them, welcomed them to Durango, and offered masks that said “I [heart] Durango.” One man accepted it, she said, and put it on. The other sulked, zipping his coat up over his mouth. “I’m like, ‘Sorry, sir, it’s not over your nose,’ and he pulled it up even higher,” she recalled.

Perez hung back behind her, silent beneath his bandanna and white mustache. Technically speaking, all noses had been covered, so the pair moved on.

“Mask compliance actually is really, really high,” said Perez. “There’s a lot of people wearing masks even out on the sidewalks, where they don’t have to.”

The past few weekends, he’s mostly found himself greeting people, welcoming them to Durango, chatting about local history and then slipping in the rules about masks.

“And 99.9% of the time, that’s well received,” he said, even among the Texans, who may also go home vaccinated.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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‘I Can Breathe Again’: Older Adults Begin to Test Freedom After Covid Vaccinations

With a mix of relief and caution, older adults fully vaccinated against covid-19 are moving out into the world and resuming activities put on hold during the pandemic.

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Many are making plans to see adult children and hug grandchildren they haven’t visited for months — or longer. Others are getting together with friends indoors, for the first time in a long time.

People are scheduling medical appointments that had been delayed and putting trips to destinations near and far on calendars. Simple things that felt unsafe pre-vaccination now feel possible: petting a neighbor’s dog, going for a walk in the park, stopping at a local hangout for a cup of coffee.

“I feel I can breathe again,” said Barry Dym, 78, of Lexington, Massachusetts, expressing a widely shared sense of freedom.

The rapid rollout of covid vaccines to people 65 and older makes this possible. As of Monday, nearly 49% of seniors in the U.S. had been fully vaccinated, while nearly 73% had received one dose of the Moderna or Pfizer-BioNTech vaccine. (A third vaccine, from Johnson & Johnson, became available earlier this month and requires just one dose.)

Recent guidance from the Centers for Disease Control and Prevention recognizes the protection that vaccines offer. According to the CDC, people who are fully vaccinated can meet indoors without masks, without incurring significant risk. Also, they can visit relatively safely with people who haven’t been vaccinated, so long as those individuals are healthy and gatherings remain small.

Still, with coronavirus variants circulating and 55,000 new infections reported daily, the CDC continues to recommend precautions elsewhere, such as wearing masks, staying physically distant in public and refraining from air travel.

How are older adults who’ve been fully vaccinated — a privileged group, to be sure, given the millions of seniors who’ve yet to get shots — balancing a desire to shed isolation with a need to stay safe amid a pandemic that’s not yet over? I asked several people I’ve spoken with previously about their plans and their reflections on the difficult year we’ve been through.

Mardell Reed, 80, of Pasadena, California, told me she wasn’t sure she’d get the vaccine originally, because “I was concerned about the process going so fast and drug companies maybe producing something that wasn’t up to par.” But she changed her mind “once we all started hearing from actual scientists rather than politicians.”

Now, Reed tries to educate people she knows who remain reluctant to get the shots. One of them is her 83-year-old stepsister. “No one had explained anything about the vaccines to her,” Reed told me. “I talked about all the things that would be possible — seeing her daughter, who lives up north, seeing more of her grandkids, and I think that convinced her.”

Reed used to walk in her neighborhood regularly before the pandemic but stopped when she became afraid of being around other people. Reviving that habit is a goal.

Among Reed’s other priorities in the months ahead: visiting with her daughter, grandchildren and great-grandchildren, and seeing her primary care physician, a dentist, a neurologist who’s treating nerve damage and an eye doctor. “I didn’t want to go to places where people might be sick this last year; now, it’s time for me to catch up on all that,” she said.

Harry Hutson, 73, and his wife, Mikey, 70, invited two couples to their house in Baltimore, on separate nights, after getting their second Moderna shots in February and waiting two weeks. “We’re going right into having safe dinners with people who’ve been vaccinated,” Hutson told me.

He feels a touch of lingering uncertainty, however. “While we’re 95% sure this is the right thing to do, we’re a little tentative. For a whole year, we’ve had ‘Covid is death’ engrained in us. After that, you can’t just go back to normal, just like that,” he said.

Hutson has continued working as an executive coach during the pandemic and has recently been giving talks on hope to business groups, nonprofit organizations and churches. “What I tell people is ‘You’ll help yourself by helping others.’ We’re all emerging from trauma and healing has to be a collective, not an individual, endeavor.”

On a personal note, Hutson is going through an attic full of yearbooks, letters and photos, “curating my family’s history.” He hopes to make an across-the-country road trip with his wife later this year visiting his son’s family in Madison, Wisconsin, his daughter’s family in Portland, Oregon, and his brother in Eugene, Oregon, as well as several friends.

Marian Hollingsworth, 67, of La Mesa, California, spent last spring and summer sequestered at home with her husband, Ed, 72, who had stomach cancer, focused on keeping Ed safe from the coronavirus. But his illness progressed and, in early October, Ed died at home, where the couple’s four adult children had gathered to say goodbye.

Since then, Hollingsworth’s son Morgan, 27, who lives in New York City, has stayed with his mom, keeping her company. But grief struck hard: Hollingsworth lost weight and couldn’t sleep at night despite profound fatigue. “It was like getting hit by the biggest Mack truck you could find,” she told me.

The pandemic’s resurgence in the fall and winter made adjusting to Ed’s loss “even more of a challenge,” Hollingsworth said, since she couldn’t get together with friends or get hugs — a form of contact she longed for. To this day, his clothes hang in the closet because the places she’d like to send them aren’t accepting donations.

When Hollingsworth became fully vaccinated in early March, she said, she felt for the first time that “my head was coming up above water.” Although she’s not sure, yet, how much she wants to go out and see people, she’s looking forward to simple pleasures: petting the neighbor’s dog and going on “distanced walks” with a few friends. “I’m going to be cautious until there’s more clarity about what’s really safe,” she told me.

Wilma Jenkins, 82, who lives in South Fulton, Georgia, has struggled with depression off and on for years — a challenge she’s spoken about publicly in talks to older adults. This fall and winter, isolated at home, “it’s been rough for me — it’s just been so sad,” she admitted.

Even though Jenkins describes herself as an “introvert,” she made sure she had regular social contact before the pandemic. Most days, she’d take herself out to lunch at local restaurants, chatting with the wait staff and other regular customers.

One of Jenkins’ great loves is music — the blues and jazz. A few days after we spoke, she was planning to return to her favorite nightclub, St. James Live in Atlanta, to catch a show — her first such outing since becoming fully vaccinated in mid-February.

“I’m not afraid to move back into the world, but I will continue to be masked and socially distanced and wash my hands,” she told me.

Jenkins plans to start walking outside again; go to restaurants, so long as they’re not too crowded; and resume visits with her two daughters, both physicians, who live in Atlanta and Washington, D.C. Her most ambitious goal: flying out to San Diego in late July for a celebration marking her grandson Jamal’s retirement from the Navy.

Barry Dym is haunted by an image that’s recurred often during the past year: He’s on a moving sidewalk, unable to get off, being hurried to a destination he doesn’t want to reach: old age. The image is associated with the pandemic and knee pain that has worsened, painfully, over the past six months, making walking harder.

This past year was a time of adjustment for Dym, who retired four years ago from his work as a consultant to nonprofit organizations. “One of the lessons of covid for me was I still need to feel useful and I love helping people. I realized maybe I’d pulled back too far.”

So, Dym expanded his coaching and mentoring practice — an activity he plans to continue. “Whatever I can do to help make this world better, I’m not going to stop trying,” he said.

Outside of travel plans with his wife, Franny — to the Florida Keys this spring, to the Berkshires in western Massachusetts in the summer, and perhaps to Israel in the fall — Dym said he finds himself “more curious than anything” about what lies ahead. “I really don’t know what my life will be like. I’ll have to find out.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Web Event: The Crucial Role of Home Health Workers, Unsung Heroes of the Pandemic

Even as the pandemic took a devastating toll on health care workers and older adults in the United States, many home care workers reported to work and provided vital care to vulnerable people despite the health risks to themselves and their families.

KHN and The John A. Hartford Foundation held an interactive web event to examine the crucial roles these workers have played for families during the pandemic, as well as the challenging economics of the industry for providers and consumers alike. KHN Editor-in-Chief Elisabeth Rosenthal served as moderator of the event.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Getting a Prescription to Die Remains Tricky Even as Aid-in-Dying Bills Gain Momentum

Linda Heim knew her dad didn’t plan to wait for the cancer to kill him. For decades, he’d lived in Montana, which they’d thought was one of the few places where terminally ill people could get a prescription to end their life.

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After two years of being sick, Heim’s dad got the diagnosis in 2019: stage 4 kidney cancer. His physician offered treatments that might extend his life by months. Instead, the 81-year-old asked the doctor for help dying. Heim said her parents left the appointment in their hometown of Billings with two takeaways: The legality of medically assisted death was questionable in Montana, and her father’s physician didn’t seem willing to risk his career to put that question to the test.

“My parents knew when they left there that was the end of that conversation,” said Heim, now 54. “My dad was upset and mad.”

The day after the appointment, Heim’s mother went grocery shopping. While she was gone, Heim’s dad went to the backyard and fatally shot himself. (Heim asked that her father’s name not be published due to the lingering stigma of suicide.)

About a decade earlier, in 2009, the Montana Supreme Court had, in theory, cracked open the door to sanctioned medically assisted death. The court ruled physicians could use a dying patient’s consent as a defense if charged with homicide for prescribing life-ending medication.

However, the ruling sidestepped whether terminally ill patients have a constitutional right to that aid. Whether that case made aid in dying legal in Montana has been debated ever since. “There is just no right to medical aid in dying in Montana, at least no right a patient can rely on, like in the other states,” said former state Supreme Court Justice Jim Nelson. “Every time a physician does it, the physician rolls the dice.”

Every session of the biennial Montana state legislature since then, a lawmaker has proposed a bill to formally criminalize physician-assisted death. Those who back the bills say the aid is morally wrong while opponents say criminalizing the practice would be a backstep for patients’ rights. But so far, lawmakers haven’t gained enough support to pass any legislation on the issue, though it has been close. The latest effort stalled on March 1, on a split vote.

Even the terminology to describe the practice is disputed. Some say it’s “suicide” anytime someone intentionally ends their life. Others say it’s “death with dignity” when choosing to expedite a painful end. Such debates have gone on for decades. But Montana remains the sole state stuck in a legal gray zone, even if the practice can still seem taboo in many states with clear laws. Such continued uncertainty makes it especially hard for Montana patients like Heim’s dad and their doctors to navigate what’s allowed.

“Doctors are risk-averse,” said Dr. David Orentlicher, director of the health law program at the University of Nevada-Las Vegas, who helped write clinical aid-in-dying guidelines published in the Journal of Palliative Medicine in 2016. “The fear of being sued or prosecuted is still there.”

Despite that, access to medical aid in dying is gaining momentum across the U.S. Outside Montana, eight states and the District of Columbia allow the life-ending aid — six of them since 2014. So far in 2021, legislators in at least 19 states have pushed aid-in-dying bills, most seeking to legalize the practice and some seeking to drop barriers to existing aid such as expanding which medical professionals can offer it. Many are repeat legalization efforts with some, like in New York, dating as far back as 1995. Only the Montana bill this year specifically sought to criminalize it.

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North Dakota considered legislation to legalize medically assisted death for the first time. Rep. Pamela Anderson, a Democrat from Fargo who proposed the measure after hearing from a cancer patient, said she wasn’t surprised when the bill failed in February in a 9-85 vote. The state’s medical association said it was “incompatible with the physician’s role as healer.” Angry voters called Anderson asking why she wanted to kill people.

“But I heard from just as many people that this was a good bill,” Anderson said. “There is momentum to not let this concept go away.”

Back in Montana, now retired state Supreme Court Justice Nelson said he has always regretted joining the majority in the case that allowed the practice because the narrow ruling focused on physicians’ legal defense, not patients' rights. Having watched a friend die slowly from disease, Nelson, 77, wants the choice himself if ever needed.

Despite — or because of — the court decision, some Montana doctors do today feel that they can accommodate such patient decisions. For example, Dr. Colette Kirchhoff, a hospice and palliative care physician, said until she retired from private practice last year she considered patients’ requests for life-ending drugs.

Physicians who help in such cases follow well-established guidelines set by other states, Kirchhoff said. A patient must have six months or less to live — a fact corroborated by a second physician; can’t be clinically depressed; needs to ask for the aid; and be an adult capable of making health care decisions, which is determined by the attending physician. They must also administer the life-ending medication themselves.

“You’re obviously not going to do a case that is vague or nebulous or has family discord,” Kirchhoff said. “The doctors who are prescribing have felt comfortable and that they’re doing the right thing for their patient, alleviating their suffering.” Of her few patients who qualified for a prescription, she said, none actually took the drugs. Kirchhoff noted that, in some cases, getting the prescription seemed to provide comfort to her patients — it was enough knowing they had the option if their illness became unbearable.

For the past six legislative sessions — dating to 2011 — a Montana lawmaker has proposed a bill to clarify that state law doesn't allow physician-assisted death. Republican Sen. Carl Glimm picked up that effort the past two sessions. Glimm said the current status, based on the more than decade-old court decision, sends a mixed message in a state that the Centers for Disease Control and Prevention ranks as having among the nation’s highest suicide rates. Glimm said allowing someone to end their life because of pain from a terminal illness could normalize suicide for people living with depression, which is also a form of pain.

“It’s really hard because I do sympathize with them,” Glimm said. “What it boils down to is, if you’re going to take your own life, then that’s suicide.”

Kim Callinan, president and CEO of national nonprofit Compassion & Choices, said the comparison to suicide is frustrating. “People who are seeking medical aid in dying want to live, but they are stricken with a life-ending illness,” she said.

Glimm and his bill’s supporters say that some patients could be pressured into it by family members with something to gain, and doctors could prescribe it more often than they should.

But Callinan, whose group advocates for aid in dying, said that since Oregon first legalized it in 1997, no data has shown any merit to the warnings about abuse and coercion. One study showed no evidence of heightened risk of abuse within the practice for vulnerable populations such as the elderly. But critics have said states aren’t doing enough to track the issue.

By now, Leslie Mutchler, 60, knows most of the people on all sides of the debate after years of testifying in support of protecting aid in dying. Her dad, Bob Baxter, was a plaintiff in the case that eventually led to the 2009 Montana Supreme Court decision on medically assisted death. After leukemia whittled his body for years, he died in 2008 without the option, the same day a lower court ruled in his favor.

Mutchler said she didn’t understand how complicated the Supreme Court’s ultimate ruling was until her son TJ was diagnosed with terminal metastatic pancreatic cancer in 2016.

He was 36 and lived in Billings, Montana. By then, the 6-foot-5 man had lost 125 pounds off what had been a 240-pound frame. He couldn’t keep food down and needed a feeding tube for medicine and water. TJ Mutchler wanted to have the choice his grandfather never got. But when he went to his physician and asked for aid in dying, the response was it wasn’t legal. Eventually, Mutchler found a doctor to evaluate her son and write the prescriptions for phenobarbital and amitriptyline. TJ took the drugs more than two months later and died.

“People contact me asking how to find someone and it’s difficult,” Mutchler said. “That’s why people end up taking matters into their own hands.” Research into terminally ill populations is limited, but one national study published in 2019 found the risk of someone with cancer taking their own life is four times higher than the general population.

For Roberta King, another one of Baxter’s daughters, the ongoing fight over aid in dying in Montana means she knows every other winter she’ll make the more than 200-mile round trip from her Missoula home to the state capital. King, 58, has testified against all six bills that sought to ban aid in dying following her dad’s case. She memorized a speech about how her dad became so thin after his medicine stopped working that it hurt for him to sit.

“It’s still terrible, you still have to get up there in front of everybody and they know what you’re going to say because it’s the same people doing the same thing,” King said. But skipping a hearing doesn't feel like an option. “If something were to happen to this and I didn’t try, I would never forgive myself,” she said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Covid Vaccine Hesitancy Drops Among All Americans, New Survey Shows

A new poll of attitudes toward covid vaccinations shows Americans are growing more enthusiastic about being vaccinated, with the most positive change in the past month occurring among Black Americans.

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About 55% of Black adults said they had been vaccinated or plan to be soon, up 14 percentage points from February, according to a poll released Tuesday by KFF. The rate now approaches that of Hispanics, at 61%, and whites at 64%. (Asian Americans were not polled in sufficient numbers to compare their responses with other racial and ethnic groups.)

But the poll found that 13% of respondents overall said they will “definitely not” be vaccinated, signaling that significant hurdles remain in the nation’s vaccination campaign. (KHN is the editorially independent newsroom of KFF, an endowed nonprofit organization providing national information on health issues.)

Among all groups, Republicans and white evangelical Christians were the most likely to say they will not get vaccinated, with almost 30% of each group saying they will “definitely not” get a shot.

And while the poll indicated that some arguments are effective at persuading hesitant people — such as sharing that the vaccines are nearly 100% effective at preventing hospitalization and death — those messages do almost nothing to change the minds of people who have decided not to be vaccinated.

Last week, President Joe Biden announced that the United States has administered more than 100 million vaccine doses and doubled his goal, to 200 million doses, by early May. According to KFF’s poll, 32% said they had already received at least one dose, and 30% said they planned to get it as soon as possible.

The poll also showed fewer people waiting to see how others respond to the vaccines before deciding to get vaccinated themselves, with 17% saying they fall into that “wait and see” group this month — a drop from 22% in February and 31% in January.

Young adults, ages 18-29, and Black adults were most likely to be in this “wait and see” group, at 25% and 24%, respectively.

Twenty-seven percent of Republicans and 35% of white evangelical Christians said they had already received at least one dose, the poll showed. Forty-two percent of Democrats said they have been vaccinated.

But Republicans and white evangelical Christians, along with 21% of essential workers in non-health fields and 20% of rural residents, were the most likely to say they will “definitely not” get vaccinated. One in 5 Republicans said they would be more likely to get vaccinated if former President Donald Trump strongly urged them to do so.

People who said they would “definitely not” receive a vaccine were asked to identify the main reason for their decision. The most common reason, at 17%, was that the vaccines are too new and not enough information is known about their long-term effects.

But informing people in the “definitely not” camp that scientists have been working on the technology used in the vaccines for about 20 years, among other arguments, did little to change their minds. Only about 6% said hearing that argument made them more likely to get the vaccine.

The poll found that some arguments were persuasive to those who had yet to make up their minds, though. Forty-one percent said they were more likely to get the vaccine after hearing that the vaccines are nearly 100% effective at preventing hospitalization and death from covid — the most effective message KFF tested.

Some indicated they would be more likely to get vaccinated if it were easier to do while going about their daily lives — or made going about their daily lives easier.

Of those in the “wait and see” group, half said they would be more likely to get vaccinated if it were offered to them during a routine medical appointment. And 37% said they would be more likely if their employer arranged for on-site vaccinations at their workplace. Thirty-eight percent said they would be more likely if their employer offered to pay them an extra $200 to be vaccinated.

Of those who were not already vaccinated or planning to be soon, the poll showed travel restrictions could prove persuasive. About 3 in 10 said they would be more likely to get vaccinated if airlines required passengers to be vaccinated, or if the Centers for Disease Control and Prevention said vaccinated people could travel freely and, in most cases, would not need to wear masks.

Still, 7% of those who said they would “definitely not” be vaccinated said they would be more likely to do so if airlines and the CDC were to make those policy changes.

The poll also showed that, for the first time, most of those who had not been vaccinated said they have enough information to know where and when to get a vaccine. However, problems remain: About 3 in 10 said they did not know whether they were eligible in their state. Most likely to respond that way were Hispanic adults and those under age 30, making less than $40,000 annually or who do not have a college degree.

The survey was conducted March 15-22 among 1,862 adults and has a margin of error of +/-3 percentage points.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Ask KHN-PolitiFact: How Can Covid Vaccines Be Safe When They Were Developed So Fast?

The development of the first covid vaccines may have seemed to occur at a dizzying pace. After all, scientists identified a new virus and created vaccines to protect against its most severe effects within a year.

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But the research underpinning these vaccines isn’t that new at all, vaccine experts say. Some of it is decades old. This foundation, combined with technical expertise, urgency and financial resources, enabled scientists to pull off the medical marvel.

“The reason it was so fast is money and work,” said Dr. Paul Offit, director of the Vaccine Education Center at the Children’s Hospital of Philadelphia.

Leveraging mRNA: A Technique as Old as Millennials

Covid mRNA vaccines use the human body’s natural immune response to its advantage. The shot contains the recipe for making the molecule known as the spike protein, which the covid virus uses to bind to cells. Once the cell receives these instructions, it creates the protein and displays it on its surface. The immune system then spots the unknown protein and makes antibodies to fight it.

The vaccines made by the companies Pfizer-BioNTech and Moderna use this technology, which stems from research that began in the early ’90s, said Dr. Drew Weissman, a professor of medicine at the University of Pennsylvania. It has been tested against other viruses like influenza. Scientists learned from previous clinical trials and have since worked to perfect the use of mRNA, he said. Previous work on related coronaviruses like SARS helped speed the process.

Weissman and his colleague Katalin Karikó, a senior vice president of BioNTech, are credited with the breakthrough discovery that enabled these vaccines to be safe and highly effective.

“This isn’t new technology,” Weissman said.

Viral Vector Vaccines: A Health Emergency Veteran

The third vaccine being distributed in the United States to protect against severe covid-19 uses viral vector technology to generate an immune response. It contains a weakened form of a different virus that carries instructions for cells to make the spike protein found on SARS-CoV-2, the virus that causes covid. The protein appears on the cell’s surface, and the immune system creates antibodies against it.

Like the mRNA vaccines, this technology carries the code for making the spike protein to the cell, said Dr. Ruth Karron, director of the Center for Immunization Research at Johns Hopkins University.

“The truck is different,” she said, “but what’s being delivered is very similar.”

Viral vector technology has been studied since the 1970s. These vaccines have been approved for use around the world to immunize people against Japanese encephalitis. Johnson & Johnson, which uses this platform for its covid shot, also created a viral vector vaccine for Ebola after a massive outbreak of the disease in 2019 in the Democratic Republic of the Congo.

Are They Safe?

In addition to existing research, generous resources were allocated to quickly create the covid vaccines, experts said. As of Dec. 2020, the federal government spent $12.4 billion alone on Operation Warp Speed to hasten vaccine development. Drug companies partnered with the National Institutes of Health to tap into its expertise and quickly enroll trial participants.

Perhaps most important, the final clinical trials for the covid vaccines enrolled between 30,000 and nearly 45,000 participants.

“These studies are so much bigger than the studies we do for many licensed vaccines,” Karron said. Some trials for previously approved vaccines have included as few as 3,000 participants, she added.

Dr. Scott Ratzan, who runs a covid-19 vaccine communications initiative called CONVINCE USA at the City University of New York, said pushing certain information has helped assuage fears among the vaccine hesitant. These include highlighting the reality of the virus, comparing the shot’s side effects to other vaccines and showing the vaccines’ effectiveness in millions of people.

Waiting for others to get the shot first was “a fair thing” when they first rolled out, Offit said. However, after nearly 90 million people in the United States have received at least one vaccine dose with no sign of safety issues, he said, the skepticism should be fading away.

“You have your proof in terms of efficacy and safety,” Offit said. If you are still refusing, “then that’s because you’re not a skeptic anymore. You’re a cynic.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Medicamentos ya conocidos, y baratos, podrían ser clave para tratar covid

¿Podría un antidepresivo que se usa desde hace décadas ser un arma secreta contra covid? Algunos científicos creen que sí, después de que dos pequeños estudios demostraran que la fluvoxamina, que se suele recetar para el trastorno obsesivo compulsivo (TOC), evitara que los participantes desarrollaran una forma grave de la enfermedad.

Sería algo impresionante. Un tratamiento de dos semanas de este fármaco, que cuesta $10, podría reducir el número de muertes y hospitalizaciones.

El medicamento podría utilizarse para luchar contra los brotes actuales en los Estados Unidos y sería un regalo del cielo para los países de bajos ingresos que deben esperar años para recibir vacunas contra el virus.

Pero la fluvoxamina, al igual que otras medicinas que muestran su potencial contra covid, se enfrenta a obstáculos para su evaluación completa.

Las compañías farmacéuticas no tienen ningún incentivo para gastar millones en probar nuevos usos de medicamentos baratos y sin patente. Aunque resulte prometedor en los primeros ensayos, las probabilidades de que cualquier medicina ya existente proporcione un beneficio importante son escasas.

Y el entusiasmo inicial por los tratamientos contra covid que luego fracasaron “ha hecho que haya escepticismo”, dijo el doctor Jeffrey Klausner, profesor de medicina preventiva de la Universidad del Sur de California.

De hecho, muchos científicos creen que la prematura publicidad que hizo el presidente Donald Trump de la hidroxicloroquina obstaculizó los esfuerzos para encontrar otras curas genéricas.

La Administración de Alimentos y Medicamentos (FDA) concedió el uso de emergencia del fármaco contra la malaria en marzo, y luego revocó la autorización menos de tres meses después de que la evidencia demostrara que era probable que fuera más perjudicial que beneficioso para los pacientes.

“A los médicos que queremos practicar medicina basada en la evidencia nos sentimos afectó la experiencia de la hidroxicloroquina, y lo que de verdad queremos ver son buenos estudios antes de decidir”, expresó el doctor Paul Sax, director clínico de la división de enfermedades infecciosas del Brigham and Women’s Hospital de Boston.

Y eso plantea un dilema. Hasta hace poco, los Institutos Nacionales de Salud (NIH), el mayor financiador público de investigación biomédica del mundo, han mostrado poco interés en los estudios de medicamentos reutilizables.

Y sin grandes cantidades de dinero, es difícil realizar la investigación necesaria para demostrar si los tratamientos existentes podrían funcionar contra covid.

Por ello, los esfuerzos por reutilizar los fármacos han recaído en los filántropos, algunos de ellos ubicados en el Área de la Bahía de San Francisco, en California.

“Nos estamos perdiendo los beneficios para la salud pública de los fármacos que ya tenemos porque dependemos casi por completo del capitalismo y de la industria privada para conseguir avances”, afirmó Elaine Lissner, fundadora de la Fundación Parsemus, con sede en San Francisco, que apoya la investigación sobre covid y la fluvoxamina y otros fármacos orales de bajo costo.

La reutilización es una apuesta arriesgada, pero comparada con la creación de fármacos y vacunas, el enfoque tiene claras ventajas durante una pandemia de rápida evolución. “Si funciona y lo tienes a mano, y no tienes tiempo de desarrollo”, dijo la doctora Lisa Danzig, especialista en enfermedades infecciosas que asesora a empresas, inversores, gobiernos y filántropos.

Uno de los mejores tratamientos del arsenal anti covid —el esteroide común dexametasona— es un medicamento reutilizado. Pero sólo se recomienda para pacientes hospitalizados que estén gravemente enfermos.

En abril de 2020, Danzig se sintió “muy entusiasmada” por la noticia de que un equipo dirigido por investigadores de la Universidad de California-San Francisco había identificado 69 posibles fármacos que, utilizados de forma precoz, podrían contrarrestar las infecciones por SARS-CoV-2, el virus que causa covid. “Pienso que, si podemos probar rápidamente algunos de ellos en ensayos clínicos, podremos tener respuestas para octubre”.

Sin embargo, estos estudios han tenido dificultades para ponerse en marcha. Los ensayos sólidos de tratamientos tempranos contra covid son especialmente difíciles de realizar. Los pacientes deben inscribirse a los pocos días de notar los síntomas. Y sin una infraestructura nacional de investigación, “es difícil llamar la atención de alguien para que participe en un ensayo o lo remita”, aseguró el doctor Eric Lenze, psiquiatra de la Universidad de Washington en San Luis, que el año pasado se asoció con su colega, la doctora Angela Reiersen, para llevar a cabo un ensayo de fluvoxamina en pacientes recién infectados de covid con síntomas leves.

Los participantes en ese primer estudio registraron los síntomas en un sitio web mientras tomaban comprimidos de fluvoxamina o de un placebo que se enviaban por correo a sus casas.

La fluvoxamina es uno de los fármacos más antiguos de la clase de los inhibidores selectivos de la recaptación de serotonina (ISRS). Se receta para la depresión mayor en muchos países y fue aprobado por la FDA en 1994 para tratar el TOC.

Los resultados del ensayo, publicados en noviembre en el Journal of the American Medical Association, mostraron que ninguno de los 80 pacientes tratados con fluvoxamina enfermó gravemente, mientras que seis de los 72 pacientes que tomaron pastillas de placebo empeoraron y requirieron hospitalización.

El mes pasado, otra revista especializada publicó los resultados de un estudio en el mundo real que se hizo eco de los resultados de la JAMA: Entre los 113 trabajadores de hipódromos a los que se les ofreció fluvoxamina tras contraer covid durante un brote en el Área de la Bahía, ninguno de los 65 pacientes que eligieron tomar el fármaco empeoró, mientras que seis de los 48 que rechazaron el medicamento acabaron hospitalizados, y uno murió.

Las pruebas de la fluvoxamina —que incluyen datos de células y animales que demuestran que el fármaco bloquea la inflamación perjudicial a través de una vía molecular diferente a la forma en que trata la depresión o el TOC— la sitúan “entre las terapias no probadas más prometedoras”, dijo Sax.

Está a la espera de resultados más definitivos de un ensayo nacional que lleva a cabo el equipo de la Universidad de Washington. “Basándome en años de observación de ensayos terapéuticos en enfermedades infecciosas”, comentó Sax, “muchas de estas cosas resultan ser un fracaso”.

Los estudios pequeños tienen más probabilidades de sobreestimar los efectos de un fármaco, señaló Elizabeth Ogburn, bioestadística de la Escuela de Salud Pública Bloomberg de la universidad Johns Hopkins.

Las experiencias con varios tratamientos experimentales ilustran la palabra precaución. A principios de la pandemia, algunos médicos empezaron a tratar a las personas con plasma convaleciente, es decir, sangre donada por pacientes recuperados. El entusiasmo por el plasma, que ha decaído a medida que estudios más amplios han puesto en duda su eficacia, desvió durante un tiempo los recursos para el estudio de otros fármacos, afirmó Ogburn.

La investigación sobre el fármaco para la gota, la colchicina, provocó una reacción similar. En enero, un comunicado de prensa afirmaba que el fármaco reducía las muertes por covid en un 44%, pero una vez que se publicaron los datos completos, el entusiasmo se enfrió, apuntó el doctor David Boulware, médico-científico de la Facultad de Medicina de la Universidad de Minnesota que dirigió varios ensayos con hidroxicloroquina que ayudaron a refutar el valor de ese fármaco en la lucha contra covid.

“Es difícil distinguir lo que es real de lo que no lo es”, dijo.

Dado que los NIH muestran poco interés por los genéricos, los financiadores privados han aprovechado la oportunidad. El empresario tecnológico de Silicon Valley, Steve Kirsch, puso en marcha, la primavera pasada, el Fondo de Tratamiento Temprano COVID-19 para apoyar la investigación de medicamentos prometedores.

El fondo de Kirsch ayudó a financiar el ensayo de fluvoxamina y coordinó la recaudación de la mayor parte de los $2 millones necesarios para el actual estudio nacional. Kirsch ha escrito artículos de opinión y ha intentado solicitar una autorización de uso de emergencia a la FDA.

Pero algunos han interpretado su celo como una sobrevaloración del medicamento. Los periódicos han rechazado sus artículos de opinión, Facebook ha retirado sus publicaciones y Medium ha eliminado el artículo de Kirsch titulado “La solución rápida, fácil, segura, sencilla y de bajo coste para COVID que funciona el 100% de las veces y de la que nadie quiere hablar”, y ha cerrado su cuenta.

Las afirmaciones sobre la eficacia y la seguridad de un medicamento sólo pueden hacerse tras la autorización del producto por parte de la FDA para su uso previsto, explicó Danzig, que actúa como asesor médico voluntario del fondo de Kirsch. Estas normas “no son muy conocidas por la gente del mundo de la tecnología”.

Las directrices de los organismos son lentas de cambiar, y por una buena razón, dijo Boulware. “Si algo es una directriz y no se cumple, eso es el principio de una mala práctica médica”.

En el caso de la fluvoxamina, sin embargo, Boulware considera que los datos son prometedores y espera que el ensayo más amplio pueda completarse rápidamente. “Si éste fuera el primer fármaco que aparece y no existiera la experiencia de la hidroxicloroquina, la gente lo vería de forma muy diferente”, añadió.

A principios de este mes, CityHealth Urgent Care, que tiene dos clínicas en el Área de la Bahía y un programa nacional de telesalud, empezó a poner la fluvoxamina a disposición de los pacientes de alto riesgo para covid.

Además del estudio sobre la fluvoxamina, hay otros ensayos de reutilización de fármacos que inscriben a pacientes estadounidenses, entre ellos un ensayo de los NIH que compara anticuerpos monoclonales, interferón beta inhalable y camostat, y otros ensayos que evalúan el fármaco para la diabetes metformina o la vitamina D para el tratamiento o la prevención de covid.

Hay planes para realizar más ensayos con el apoyo de una asociación público-privada. Además, un ensayo en diferentes ubicaciones y controlado con placebo, coordinado por la Universidad McMaster de Ontario, Canadá, compara la fluvoxamina, la metformina y un antiparasitario, la ivermectina, en pacientes con covid leve.

“Creo que vamos a obtener algunas respuestas”, señaló el doctor Vikas Sukhatme, decano de la Facultad de Medicina de Emory. “Pero hubiera sido mejor tenerlas antes”.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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In His Continued Sparring With Fauci, Sen. Rand Paul Oversimplified the Science

“Sorry Dr Fauci and other fearmongers, new study shows vaccines and naturally acquired immunity DO effectively neutralize COVID variants. Good news for everyone but bureaucrats and petty tyrants!”

— Sen. Rand Paul in a tweet, March 21, 2021

That Sen. Rand Paul of Kentucky often disagrees with infectious-disease expert Dr. Anthony Fauci is well known.

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Recently, the pair clashed at a Senate hearing when Paul, a Republican, argued against mask recommendations for people who have had covid-19 or have been vaccinated against it.

At the hearing, Fauci, President Joe Biden’s chief medical adviser, pushed back against Paul’s characterization of wearing masks as “theater.” Continued caution is advised, Fauci said, as scientists study the new variants now circulating in the U.S. and other countries.

Paul, an eye doctor by training, continued the squabble a few days later, calling out Fauci in a tweet, pointing to a study that he said “shows vaccines and naturally acquired immunity DO effectively neutralize COVID variants.”

The tweet linked to a study published online at the JAMA Network, a family of specialty medical journals.

We reached out to Paul’s office for additional sources for his tweet but did not receive a reply.

So, we asked the experts: Are covid variants effectively neutralized by vaccines or natural immunity conferred on people who recover from the illness?

In short, the research cited by Paul does show good blood levels of neutralizing antibodies against at least some of the current variants following infection or vaccination. But they’re not the whole story.

Mehul S. Suthar, an author of the study Paul cited, said the results are encouraging but should not be seen as all-encompassing: “Our interpretation is that our study looks at one aspect of immune response, antibodies.”

Small Samples. Big Questions.

Neutralizing antibodies are important because they can block the ability of a virus like the one that causes covid to infect cells. But the body also has other defenses. T cells, for example, can be spurred by infection or vaccination, Suthar said, although the study was not designed to look at those.

For the study, researchers gathered blood samples from 40 people who were in the hospital with covid or had recovered from it. From the National Institutes of Health, they also received blood samples drawn from 14 people who had gotten both doses of the Moderna vaccine, said Suthar, an assistant professor at Emory University’s vaccine center.

Then they ran tests on those samples against the original SARS-CoV-2 virus and three variants, including the one dubbed B.1.1.7, which first appeared in the United Kingdom and is now circulating widely in the U.S.

They wanted to know: Did antibodies produced by being infected or vaccinated neutralize B.1.1.7?

“We are lucky with B.1.1.7 that our antibodies appear to work well against this virus,” Suthar said.

However, as with any study, there are caveats. For one thing, the results were based on a small number of samples. And the analysis did not include other variants of concern, such as the ones that emerged in South Africa and Brazil, which limits the ability to draw broad conclusions.

Finally, antibodies are just one measure of potential protection against disease. Laboratory research measuring antibodies indicates that some immunity is created by both illness and vaccination, but the strength and longevity of that protection — the effectiveness in the real world — is a separate question. That’s partly because the ideal level of neutralizing antibodies needed for protection is not known and other immune protections, such as T cells, aren’t measured.

Also, in the real world, other factors — such as the variant a person is exposed to, and the presence of other mitigating factors, including masks and good ventilation — can make a difference.

“Part of the reason that real-world data are so important is looking at the whole picture of immunity,” said Gigi Gronvall, a senior scholar at Johns Hopkins Bloomberg School of Public Health. “Also, with the level of community transmissions of disease, I would be concerned that there will be more variants that emerge.”

Nuance Matters

Paul’s tweet — taking aim at what he sees as an overcautious approach by public health experts — doesn’t capture that type of nuance, nor does it reference studies on the other emerging variants.

“Blanket assertions made by non-scientific experts are not going to help,” said Gronvall.

Dr. Jesse Goodman, professor of medicine and a specialist in infectious diseases at Georgetown University, agreed.

“It’s wrong to declare victory and say there’s no problem with variants and that everyone previously infected will be fine,” said Goodman, who served as chief scientist of the Food and Drug Administration under the Obama administration.

Viruses naturally mutate as they replicate. So it’s not surprising that the coronavirus has done so. Several variants have emerged, including home-grown ones from California and New York.

Lab tests on blood samples from vaccine trial participants in South Africa showed lower levels of neutralizing antibody production, possibly related to the variant circulating there.

How big a difference the lower levels measured in those samples make isn’t yet known.

Levels are still high and could “effectively neutralize the virus,” Fauci wrote in an editorial published Feb. 11 in JAMA.

Even so, clinical trials used to test covid vaccines before they were approved for emergency use showed lower efficacy when tested in areas where the South African variant was circulating.

“We expect vaccines and prior infection to offer significant protection against variants that are closely related,” said Goodman. “But as they become more genetically different — like the South African one — that protection could go down.”

The main goal of the vaccines is to prevent hospitalization and death, and all the vaccines in use in the U.S. appear to substantially reduce the risk of hospitalization and death from covid, according to research.

“Even if the current vaccines may not be perfect, they do appear to prevent more severe outcomes,” Goodman said.

Don’t assume, as Paul’s tweet implies, that recovering from covid or getting vaccinated means zero risk of infection.

For one thing, reinfection is rare but can occur.

Goodman pointed to a recent study conducted in Denmark showing that a small percentage (0.65%) of people who tested positive for covid in the spring fell ill again.

“People should not presume that even if they had the vaccine or were previously infected that there’s no future risk,” Goodman said.

Even though no vaccine is 100% effective, Gronvall at Hopkins said not to use that as an excuse to avoid inoculation.

“The vaccines appear to be great,” she said. “Get one when you can.”

Our Ruling

Paul is correct that the JAMA study showed vaccination or previous infection appeared, based on a small sample of people, to help neutralize the virus. However, he left out important details that make his position an oversimplification of a complicated issue.

The study considered only one variant — the one that emerged in the U.K. — and did not include an analysis of other types now circulating, or the potential for additional variants that could emerge. Also, the type of antibody studied is just one factor in protecting against disease, and just what those levels of neutralizing antibodies measured in a laboratory experiment may mean in the real world is not known.

So, for those reasons, we rate the senator’s statement Half True.

Source List:

Telephone interview with Mehul S. Suthar, assistant professor at the Emory Vaccine Center, March 22, 2021

Telephone interview with Gigi Gronvall, senior scholar at Johns Hopkins Center for Health Security and associate professor in the environmental health and engineering department at Johns Hopkins Bloomberg School of Public Health, March 23, 2021

Telephone interview with Jesse Goodman, professor of medicine at Georgetown University and former chief scientist of the Food and Drug Administration, March 24, 2021

JAMA Network, “Neutralizing Antibodies Against SARS-CoV-2 Variants After Infection and Vaccination,” March 19, 2021

CNN Politics, “Masks Are Not Theater, Fauci Tells Sen. Rand Paul in Hearing Exchange,” March 18, 2021

The New England Journal of Medicine, “Neutralizing Activity of BNT162b2-Elicited Serum,” March 8, 2021

The New England Journal of Medicine, “Serum Neutralizing Activity Elicited by mRNA-1273 Vaccine,” March 17, 2021

Yale Medicine, “Comparing the COVID-19 Vaccines: How Are They Different?,” updated March 25, 2021

Fast Company, “Can I Get Covid-19 Twice? New ‘Lancet’ Study Offers Insight on Reinfection Rates,” March 22, 2021

JAMA Network, “SARS-CoV-2 Viral Variants — Tackling a Moving Target,” editorial, Feb. 11, 2021

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Scientists Seek Covid Treatment Answers in Cheap, Older Drugs

Could a decades-old antidepressant be a secret weapon against covid? A few scientists think so, after two small studies showed that fluvoxamine, typically prescribed for obsessive-compulsive disorder, prevented serious illness in all participants who took the pills soon after developing symptoms.

This story also ran on San Francisco Chronicle. It can be republished for free.

It’s an exciting notion: A $10, two-week course of this drug could reduce death and hospitalizations. The drug could be used to fight ongoing outbreaks in the United States and would be a particular godsend for lower-income countries that may have to wait years for vaccines against the virus. But fluvoxamine, as well as other old drugs showing potential against covid, face hurdles to full evaluations.

Drug companies have no incentive to spend millions to test new uses for cheap, off-patent drugs. Chances are slim that any drug, even one showing promise in early trials, would provide a major benefit. And early enthusiasm for covid treatments that later flopped has “made people gun-shy,” said Dr. Jeffrey Klausner, a professor of preventive medicine at the University of Southern California.

In particular, former President Donald Trump’s premature promotion of hydroxychloroquine likely stymied efforts to find other generic cures. The Food and Drug Administration granted emergency use of the malaria drug in March, then revoked the authorization less than three months later after evidence showed it was more likely to harm than help patients.

“We doctors who want to use evidence-based medicine feel somewhat burned by the hydroxychloroquine experience and really want to see good studies before we actually jump on the bandwagon,” said Dr. Paul Sax, clinical director of the division of infectious diseases at Brigham and Women’s Hospital in Boston.

And that poses a Catch-22. Until recently, the National Institutes of Health, the world’s largest public funder of biomedical research, has shown little interest in studies of repurposed drugs. Without big money, it’s hard to do the research needed to show whether existing treatments could work against covid.

As a result, efforts to repurpose drugs have fallen to philanthropists, some in the Bay Area. “We’re missing out on public health benefits of the drugs we already have because we’re relying almost entirely on capitalism and private industry to make advances,” said Elaine Lissner, founder of the San Francisco-based Parsemus Foundation, which is supporting covid research on fluvoxamine and other low-cost oral drugs.

Repurposing is a long shot, yet compared to creating drugs and vaccines, the approach has clear advantages during a fast-moving pandemic. “If it works and it’s on the shelf, you don’t have any development time,” said Dr. Lisa Danzig, a specialist in infectious diseases who consults with companies, investors, government and philanthropies. One of the best treatments in the covid arsenal — the common steroid dexamethasone — is a repurposed drug. But it is recommended only for hospitalized patients who are seriously ill.

Danzig was “very excited” last April by news that a team led by University of California-San Francisco researchers had identified 69 possible drugs that, when used early on, could counteract infections with SARS-CoV-2, the virus that causes covid. “I’m thinking, if we can rapidly test some of these in clinical trials, we can have answers by October.”

Yet these studies struggled to get off the ground. Solid covid trials of early treatments are particularly hard to pull off. Patients often must enroll within days of noticing symptoms. And without a national research infrastructure, “it’s hard to get anyone’s attention to participate in a trial or refer to it,” said Dr. Eric Lenze, a psychiatrist at Washington University in St. Louis who teamed with his colleague Dr. Angela Reiersen last year to conduct a trial of fluvoxamine in newly infected covid patients with mild symptoms.

Participants in that early study logged symptoms on a website while taking fluvoxamine or placebo tablets that were mailed to their homes. Fluvoxamine, sold under the brand name Luvox, is one of the oldest drugs in the selective serotonin reuptake inhibitor (SSRI) class. It is prescribed for major depression in many countries and was approved by the FDA in 1994 to treat OCD.

The results of the trial, published in November in the Journal of the American Medical Association, showed that none of the 80 fluvoxamine-treated patients became seriously ill, while six of 72 patients who took placebo pills worsened and required hospitalization.

Last month, another journal published results of a real-world study that echoed the JAMA results: Among 113 horse racetrack workers who were offered fluvoxamine after contracting covid during a Bay Area outbreak, none of the 65 patients who chose to take the drug got sicker, whereas six of 48 people who declined the drug wound up hospitalized, and one died.

The evidence for fluvoxamine — which includes cell and animal data showing that the drug blocks harmful inflammation through a molecular pathway different from the way it treats depression or OCD — puts it “among the more promising non-proven therapies,” Sax said. He is waiting for more definitive results from an ongoing national trial being conducted by the Washington University team. “Based on years of watching therapeutic trials in infectious disease,” Sax said, “a lot of these things turn out to be busts.”

Smaller studies are more likely to overestimate a drug’s effects, said Elizabeth Ogburn, a biostatistician at Johns Hopkins Bloomberg School of Public Health.

Experiences with several experimental treatments illustrate this word of caution. Earlier in the pandemic, some doctors jumped on early lab data and started treating people with convalescent plasma — blood donated by recovered patients. Enthusiasm for plasma, however, has waned somewhat as the pandemic eased and larger studies suggested it did not improve survival in hospitalized patients.

Research on the gout drug colchicine caused similar whiplash. A news release in January claimed the drug reduced covid deaths by 44%, but once the full data was released, enthusiasm cooled, said Dr. David Boulware, a physician-scientist at the University of Minnesota Medical School who led several hydroxychloroquine trials that helped disprove that drug’s value in fighting covid.

“It’s tough to weed through what’s real and what’s not,” he said.

With NIH showing little interest in generics, private funders have seized an opportunity. Silicon Valley tech entrepreneur Steve Kirsch launched the COVID-19 Early Treatment Fund last spring to support research on promising outpatient drugs.

Kirsch’s fund helped finance the published fluvoxamine trial and coordinated fundraising for most of the $2 million needed for the current nationwide study. But his zeal gave some the impression that Kirsch was hyping the drug. Newspapers have rejected his op-eds, Facebook took down his posts, and Medium removed Kirsch’s story titled “The Fast, Easy, Safe, Simple, Low-Cost Solution to COVID That Works 100% of the Time That Nobody Wants to Talk About,” and closed his account.

Claims about a drug’s efficacy and safety can be made only after authorization of the product by the FDA for its intended use, said Danzig, who serves as a volunteer medical adviser for Kirsch’s fund. These rules “are not widely known to people in the tech world.”

Agency-level guidelines are slow to change, and for good reason, Boulware said. “If something’s a guideline, and you’re not doing it, that starts to become medical malpractice.”

In the case of fluvoxamine, though, Boulware finds the data promising and hopes the larger trial can be completed quickly. “If this was the first drug that came along and there wasn’t the hydroxychloroquine experience, people would view it very differently,” he said.

Earlier this month, CityHealth Urgent Care, which has two Bay Area clinics and a national telehealth program, began making fluvoxamine available to high-risk covid patients.

Besides the fluvoxamine study, other drug repurposing trials are enrolling U.S. patients, including an NIH trial comparing monoclonal antibodies, inhalable beta interferon and camostat, and separate trials evaluating the diabetes drug metformin or vitamin D for covid treatment or prevention. Plans are underway for additional trials supported by a public-private partnership. And a multi-site, placebo-controlled trial coordinated by McMaster University in Ontario, Canada, is comparing fluvoxamine, metformin and an antiparasitic agent, ivermectin, in patients with mild covid.

“I think we’re going to get some answers,” said Dr. Vikas Sukhatme, dean of the Emory School of Medicine. “It just would have been nice to get them sooner.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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