RSV and influenza surge, primary care visits associated with earlier cancer diagnosis, and COVID-19 risks and treatments.
November 18, 2022
Happy Friday!
Today, I’ll cover what employers should know about the dramatic rise of RSV and influenza infections, new evidence that those who have regular visits with a primary care physician are less likely to be diagnosed with cancer that has already spread, and new information about Paxlovid rebound and the extra risk from each successive COVID-19 infection.
1. Both RSV and Influenza are raging
RSV (Respiratory Syncytial Virus) and “Flu” (Influenza) are both off to an early start, leading to jammed pediatric intensive care units and many parents without childcare for their sick (or healthy) children.
Here is a graph showing the amount of RSV nationally. The rates of RSV were dramatically lower during the height of the pandemic - and thus fewer people have effective immunity from a recent infection. Anyone can get RSV, but it is most dangerous for infants (especially premature infants) and those who are old or immunocompromised. Historically, RSV peaks from late December to February, but this year, like 2021, RSV is peaking earlier than usual. There is currently no vaccine for RSV, although we hope there will be a vaccine available next year for pregnant women to protect their newborns.
Source Centers for Disease Control and Prevention, 11/15/22 LINK
Influenza infections are also rising rapidly over a month earlier than usual - below is a graphic from the CDC showing this. In past years, flu vaccines can lower the risk of serious illness by 40-60%.
Source: CDC 11/15/22 LINK The line with triangles on the left shows the very high rate of influenza during fall, 2022. The orange line is last year.
The Department of Labor reports from its surveys that more parents missed work due to lack of childcare last month than any past October.
Source Bureau of Labor Statistics, November 15, 2022 LINK
The good news is that COVID-19 infections are not surging at this point, and it appears that BQ.1 and BQ.1.1, the latest Omicron variants to become dominant, have not led to large increases in hospitalizations in Europe.
Implications for employers:
- Expect more employees to miss work due to children being sick or lacking childcare
- Strongly encourage influenza vaccination - as well as COVID-19 bivalent boosters, since we don’t know how bad COVID-19 will be this winter
- Expect higher medical costs due to the RSV epidemic
2. Primary care associated with lower risk of metastatic cancer at presentation and lower risk of cancer death
Researchers from the Veterans Administration published data in JAMA Network Open showing that those who saw primary care physicians annually were 39% less likely to have metastatic cancer when they were first diagnosed. Those with annual PCP visits also were 21% less likely to die of cancer-related illness. The study included almost 250,000 veterans 40 years or older who were diagnosed with a solid (non-blood) cancer from 2004 to 2017. The researchers adjusted for other reasons for more advanced cancer, including age, race, gender, marital status, income, and education.
The results were statistically significant for all the solid tumors studied except for pancreatic cancer.
Veterans are older and far more likely to be male than the general population, but the large sample size and the careful matching suggest that regular primary care may have this benefit outside of the VA system as well.
Here is an example of what the researchers found:
Source: Qiao, et al JAMA Open Network, 11/14/22 LINK . The bar represents the portion of those newly diagnosed with that solid tumor who had metastatic disease on presentation.
Implications for employers:
- Plans that encourage (or require) being in a primary care panel could improve health.
- Employer sponsored health insurance has no cost sharing for a wellness visit with a primary care physician. Employers can encourage these visits, which are likely to be especially valuable for older employees.
3. Risk increases with each successive COVID-19 infection
Researchers in Nature Medicine reported that risk of organ damage increases with each subsequent COVID-19 infection. Those who had a second COVID-19 infection were twice as likely to die and three times as likely to be hospitalized compared to those who were never infected. This is another study that came from the Veterans Affairs electronic medical record system, and included over 440,000 who had at least one COVID-19 infection, 41,000 who had reinfection, and over 5 million who were not infected. The sample included those with a positive SARS CoV2 test between March 2020 and April 2022, and excluded those who died within 90 days of their positive test. Reinfection was a positive test at least 90 days after their first positive test, and all were followed for six months from the most recent infection.
Researchers found that even a single COVID-19 infection statistically significantly increased chances of all diseases they considered (cardiac, blood clots, diabetes, fatigue, gastrointestinal complaints, kidney disease, mental health, musculoskeletal, neurologic and pulmonary). The chances of these illnesses increased further for those with two infections, and still more for those with three or more infections.
Implications for Employers:
- This is further evidence that we should encourage vaccination and other methods (improve air quality, optional masking, work from home if ill) to decrease the chance of COVID-19 infection. Even those with mild symptoms had higher risk the more often they were infected.
4. Additional promising news on the bivalent booster
Moderna announced that a study of its US bivalent booster demonstrated robust immune response to protect against BA4/5, and laboratory tests suggested it would retain effectiveness against BQ.1, which is becoming the dominant strain in the US. This follows similar reports of laboratory immune response from Pfizer in early November. These are small but reassuring laboratory studies. I got my bivalent booster in September when it first became available.
Implication for Employers:
- The bivalent boosters were authorized by the FDA and approved by the CDC in September, and the CARES Act requires employer coverage of COVID-19 preventive medications by non-grandfathered employer sponsored health plans 15 days after such a determination.
- These boosters are currently covered by the federal government, but unless new funding is passed in the lame duck Congress, employers will pick up the tab for these vaccines and boosters beginning sometime next year.
5. Paxlovid rebound
It’s no secret that a large portion of those who could benefit from Paxlovid don’t get it. Some fret about withholding cholesterol or other medications for the five day course, and some are worried about potential rebound from Paxlovid. Joe Biden, Anthony Fauci, and CDC Director Rochelle Walensky all had widely publicized cases of Paxlovid rebound.
New data from a prospective observational study shows that Paxlovid rebound is real -but not as common as many had assumed. That’s because some who did not take Paxlovid had rebound, too.
Researchers had those with COVID-19 infections do rapid antigen tests every other day and complete diaries of their symptoms. About 1 in 7 who took Paxlovid had rebound, but almost 1 in 10 who did not take Paxlovid had rebound. Those who took Paxlovid were more likely to have symptomatic rebound, though, so would have been more likely to realize they had rebound even if they did not do testing.
Source: Pandit, et al medRxiv preprint 11/15/22 LINK
Implication for employers:
- Given that Paxlovid has been associated with a 26% decrease in Long COVID, this drug continues to be valuable for many who are diagnosed with COVID-19.
- I believe Paxlovid should be available on formularies when the federal government stops funding this medication, unless there are superior alternatives by then.
- Employers should encourage employees to talk to their providers about Paxlovid as soon as symptoms begin, as it is most effective when taken within 5 days of symptoms.
Hope all have a joyous and healthy Thanksgiving, and I will likely not post next week.
Jeff