How widespread is the Delta variant (B.1.617.2) in the US?

Centers for Disease Control and Prevention (CDC)

, as of July 20, 2021, the SARS-CoV-2 Delta variant makes up 

The CDC estimates as of July 27, 2021, the 5 states with the highest unweighted proportion of new cases attributed to the SARS-CoV-2 Delta variant are:

How many people in the US have been vaccinated against COVID-19?

as of today, July 30, 2021, at 5:00 PM, EDT:

The 5 states with the highest percentage of population fully vaccinated are:

How many cases of COVID-19 have been confirmed in the US?

, as of today, July 30, 2021 at 4:21 PM, EDT, there have been:

The 5 states with the highest total confirmed cases are:

 California has the highest number of deaths due to COVID-19

 with 64 415 reported fatalities, followed by 

How many cases of COVID-19 have been confirmed globally?

Articles

Data from the CDC on the Delta variant and US vaccination rates and from the Johns Hopkins COVID-19 interactive map on cases and deaths in the US and worldwide.

COVID-19 Updates: Delta Variant, US Vaccinations, & Global Data as of July 30, 2021

Mepolizumab (Nucala; GlaxoSmithKline [GSK]) an anti-interleukin-5 (IL-5) monoclonal antibody, was approved today by the US Food and Drug Administration (FDA) for treatment of patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

The biologic is indicated for add-on maintenance treatment of CRSwNP in adult patients aged ≥18 years who have had inadequate response to nasal corticosteroids.

Mepolizumab is the first anti-IL-5 biologic to be approved for adults with this condition, according to a 

“More than 5 million people in the US suffer with chronic rhinosinusitis with nasal polyps and today’s approval provides these patients with the first anti-IL-5 treatment option and an alternative to surgery to help reduce symptoms of this disease, said Hal Barron, MD, chief scientific officer and president R&D, GSK, in the press statement. “GSK is committed to exploring the role of IL-5 inhibition in eosinophil-driven diseases to help address unmet needs of patients.”

CRSwNP is one of a number of inflammatory diseases caused by elevated levels of eosinophils. The related nasal polyps may be bilateral and lead to nasal obstruction, loss of smell, and facial pressure. Surgical removal is indicated in severe cases and repeat surgery is not uncommon.

FDA approval is based on data from randomized placebo-controlled phase 3 

 in which mepolizumab significantly reduced polyp size vs placebo. All SYNAPSE participants had a history of surgical removal and were in need of further intervention because of severe symptoms. There was a 57% reduction in the proportion of patients requiring surgery in the mepolizumab-treated group vs placebo and the number of patients requiring systemic corticosteroid treatment during the 52-week treatment period was also lower in the mepolizumab group.

Mepolizumab is approved for use in 3 other eosinophil-driven diseases, including 

severe eosinophilic asthma in patients aged 6 years and older and 

eosinophilic granulomatosis with polyangiitis (EGPA)

“We welcome the news that mepolizumab will now offer appropriate patients and healthcare providers a novel treatment option and alternative to surgery,” said Tonya Winder, CEO and president, Allergy and Asthma Network and president, Global Allergy and Airways Patient Platform.

FDA approval of mezopelumab follows the phase 3 SYNAPSE trial in which the anti-Il-5 monoclonal antibody reduced by 57% the need for nasal polyp surgery. 

Mezopelumab Approved by FDA for Chronic Rhinosinusitis with Nasal Polyps 

A new study on US vaccine trends finds that although overall adult vaccination rates steadily increased from 2010 to 2019, racial and ethnic disparities in uptake remained persistent during that time for critical influenza, pneumococcal, shingles, and Tdap vaccinations.

While The COVID-19 pandemic has for more than a year eclipsed focus on unequal uptake of vaccination against common vaccine-preventable diseases, the trend in vaccination against SARS-CoV-2 infection among racial and ethnic minorities has mirrored the study’s findings, according to authors.

“Currently, the biggest public health concern we are facing is the COVID-19 pandemic, for which we now have safe and effective vaccines available in the USA,” explained investigators Kosuke Kawai, ScD, Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital and Harvard Medical School and Alison Tse Kawai, ScD, RTI Health Solutions, Waltham, MA, in a 

 “Unfortunately, as we observed for vaccines against influenza, pneumococcal, shingles, and Tdap…adults from racial and ethnic minorities have had lower rates of COVID-19 vaccine uptake.”

 study authors cite the annual threat posed by influenza which is responsible for between 140 000 to 710 000 hospitalizations each year and disproportionately affects racial and ethnic minority groups and adults living in vulnerable, low-income communities. Other vaccine-preventable diseases also are often more prevalent in these populations, they assert.

Noting the lack of research on trends in vaccine coverage rates in recent years, Kawai et al sought to evaluate temporal trends in adult vaccination uptake by race/ethnicity and socioeconomic status from 2010 to 2019 for routine inoculation recommended by the Advisory Committee on Immunization Practices against influenza, pneumococcal disease, herpes zoster, and tetanus, diphtheria, and acellular pertussis (Tdap).

Study data were drawn from the National Health Interview Survey (NHIS) from 2010 to 2019 and investigators reviewed self-reported receipt of:

Adults aged 18−64 years were queried about receipt of influenza and Tdap vaccinations. Among those aged ≥65 years, receipt of influenza, Tdap, pneumococcal, and zoster vaccinations were recorded. 

Data from a total of 311 343 adults from the NHIS 2010-2019 were included. 

Socioeconomic differences in influenza vaccine uptake narrowed among adults aged 18–64 years from 2010 to 2019, possibly a result, the authors suggest, related to enactment of the Affordable  Care Act in 2014. However, racial/ethnic and socioeconomic differences in vaccine uptake persisted from 2010 to 2019 among more vulnerable adults aged ≥65 years: Black 61.4%; Hispanic 63.9%; Asian 71.9%; White 72.4%. 

Among adults aged 18−64 years but not among those aged ≥65 years, the annual increase in influenza vaccine coverage differed by household income. 

Investigators reported persistent racial/ethnic differences in pneumococcal and zoster vaccine coverage from 2010 to 2019. The magnitude of the annual increase in zoster vaccine was greater among White than Black and Hispanic individuals:

 annual increase of 3.3% ([95% CI=3.1, 3.5)

Race/ethnicity, household income, education level, and health insurance type were significantly associated with receipt of influenza, pneumococcal, Tdap, and zoster vaccinations among adults aged ≥65 years after researcher adjusted for access to health care and sociodemographic factors in the multivariable regression model.

“Although the COVID-19 pandemic is the primary public health concern at the moment, our findings also serve as a reminder of the importance of continuing to strive towards equity in immunization rates for vaccines against other vaccine-preventable diseases,” the investigators commented. In addition to building trust and vaccine confidence through community engagement, reducing cost barriers especially for adults 65 years or older and implementing provider/patient reminder and recall systems using an Immunization Information System, could narrow the disparities in immunization rates.”

Rates of routine ACIP-recommended vaccination have been persistently and significantly lower among racial and ethnic minorities over the past decade, according to new research. 

Study Finds Persistent Racial/Ethnic, Socioeconomic Disparities in Adult Vaccination Coverage 2010 - 2019

Metabolic surgery in patients with uncontrolled type 2 diabetes (T2D) is associated with greater physical health and energy level and reduced negative disease impact on daily life compared to medical therapy alone, but a new analysis of data from the Cleveland Clinic-led STAMPEDE study suggests that while physical domains of health benefit from surgical weight loss, emotional components may require greater clinical focus.

Over the 5-year course of STAMPEDE (Surgical Therapy and Medications Potentially Eradicate Diabetes Efficiently), study authors found no significant long-term differences between surgical and medical groups in measures of psychosocial and emotional quality of life. They published their findings in the 

“Chronic diseases, such as severe obesity and diabetes, can negatively affect quality of life,” said lead investigator Ali Aminian, MD, Director of Bariatric & Metabolic Institute at the Cleveland Clinic, 

. “It is important to study the effects of different treatments on the well-being of patients in their daily lives.”

, (NEJM, 2012) compared the efficacy for glycemic control of intensive medical therapy (IMT) alone vs IMT plus Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) in 150 obese patients with uncontrolled T2D (mean age 49 years, 66% women, mean baseline A1c 9.2%). Patients were randomized 50 to each arm and the primary endpoint was the proportion of participants with A1c ≤6%, with or without antihyperglycemic medication, at 12 months after randomization.

Metabolic surgery was superior to IMT alone for weight loss and control of A1c and results were durable at 5-year follow-up.

The current analysis of STAMPEDE focused on the long-term impact of the medical and surgical treatments on patient-reported quality of life (QoL) measures. Investigators evaluated data collected from a subset of 104 participants who were administered the RAND 36-Item Health Survey (RAND-36) and European QoL 5-Dimensions (EQ-5D-3L) generic QoL questionnaires and a diabetes-specific questionnaire at baseline and annually for 5 years after randomization. Of the 104 participants, 26 had IMT only; 41 underwent RYGB, and 37 underwent SG.

Aminian et al found that over the 5 years of follow-up, the 78 patients in the 2 surgical groups scored significantly higher on measures of physical functioning, general health perception, and energy/fatigue compared to those in the IMT arm. Measures of diabetes-related quality of life also showed greater improvement in the surgical vs IMT groups. 

Among the 26 patients in the IMT group there was no significant improvement observed from baseline in any of the QoL components included in RAND-36 and EQ-5D-3L questionnaires.

“Our findings suggest that psychological well‐being needs may require more attention in metabolic surgical patients...such as identification of psychosocial and emotional factors before surgery that can predict outcomes of surgery, as well as continuous psychosocial support after surgery.”

When investigators compared all 3 groups, they found no significant long-term differences in measures of psychological and social aspects of QoL. Multivariable analysis identified 4 independent factors associated with improved general health perception:

“Our findings suggest that psychological well‐being needs may require more attention in metabolic surgical patients,” added Aminian. “As part of our multidisciplinary approach to weight management at Cleveland Clinic, our patients have appointments with psychologists before and after surgery. The study results highlight that we may need greater emphasis on that aspect of the treatment, such as identification of psychosocial and emotional factors before surgery that can predict outcomes of surgery, as well as continuous psychosocial support after surgery.”

Five years after bariatric surgery for uncontrolled T2D patients reported improvements in physical health and QoL but measures of psychosocial wellbeing remained flat. 

In Patients with Uncontrolled T2D, Bariatric Surgery Associated with Long-term Improvement in Physical Domains, Diabetes-related QoL 

Prior to the COVID-19 pandemic, telemedicine was rarely used to see patients in the American healthcare system. It was used mostly to provide access to health care in rural communities and for those that had difficulty accessing health care.

In a survey done by the COVID-19 Healthcare Coalition, 92% of physicians averaged less than 5 telemedicine visits per week prior to the pandemic.

 Part of the hesitance then was comfort and familiarity with face-to-face clinic visits which for many clinicians was the only care delivery system they had ever used. Physicians knew how to navigate the billing world when it came to in-person patient encounters. Further, training staff and obtaining appropriate technological resources to conduct telemedicine was costly. There also were long-standing barriers that made conducting telemedicine cumbersome, including rules on services allowed over telehealth, licensing in different states, and the ability to take on new patients virtually.

With the rapid onset of the pandemic and the immediate emphasis on minimizing person-to-person spread of SARS-CoV-2, health care professionals had no choice but to switch to remote appointments. The federal government quickly eliminated many of the barriers to telemedicine, and hospitals and clinics across the United States rapidly adapted to the virtual world.

I began my medical school experience during the global pandemic and have seen firsthand the explosive increase in use of telemedicine. 

During the first 6 months of my education, my only exposure to patients was through telemedicine. These experiences were unique to me and my classmates, exposing us to near exclusive use of telemedicine, unlike any prior class of medical students. From early on, I was navigating the different technologies involved in telehealth. I learned how to accurately chart and document telehealth appointments and understood what kind of services could be provided. These virtual visits taught me to be creative, teaching patients how to perform certain physical exam maneuvers on themselves. I discovered ways to build rapport and trust with a new patient all through a screen.

With technology, there are always unique difficulties. I learned how to prevent many troublesome issues and also developed the patience needed to work with patients through the problems that did arise. The incorporation of telehealth into my curriculum has changed my own perspectives on telehealth. I am more likely than I was before entering medical school to incorporate it into my own practice in the future.

As the world begins to open again and life begins to look more like that before the pandemic, I hope that medical schools will continue to incorporate education on telehealth into their curricula. It is important for the medical profession to keep up with new technologies, and to integrate them when and where they can be most valuable. Telehealth is a step in that direction. It is possible, after the height of the pandemic, that use of telehealth will continue to grow as an option for patients to access health care. 

It is important to train future physicians on best practices in telemedicine so that they see it as another tool in providing the best healthcare possible to our patients.

Cynthia Li has completed her first year of medical training at the Medical College of Georgia at Augusta University, Augusta, Georgia.

 The COVID-19 Healthcare Coalition Telehealth Impact Study Work Group. (2020, November 16). Telehealth Impact: Physician Survey Analysis. COVID-19 Healthcare Coalition. Published online November 16, 2020. Available at 

https://c19hcc.org/telehealth/physician-survey-analysis/

 Showalter, G. Telehealth Before and After COVID-19. Caravan Health. Published online May 7, 2020. Available at 

https://caravanhealth.com/CaravanHealth/media/Resources-Page/Telehealth_BeforeAfter_COVID19.pdf

Consider all the first year medical students introduced to patient care in 2020 via computer screens and monitors. A young telehealth native tells her story.  

New Doctors Could be Telehealth Natives 

The CDC estimates as of July 28, 2021, the 5 states with the highest unweighted proportion of new cases attributed to the SARS-CoV-2 Delta variant are:

as of today, July 27, 2021, at 5:00 PM, EDT:

, as of today, July 27, 2021 at 4:21 PM, EDT, there have been:

 with 64 272 reported fatalities, followed by 

COVID-19 Updates: Delta Variant, US Vaccinations, & Global Data as of July 28, 2021

Assessment of atherosclerotic cardiovascular disease (ASCVD) risk, the foundation of primary prevention, is a critical guide for decision-making about potential interventions, including pharmacotherapy.

The American College of Cardiology (ACC)/American Heart Association (AHA) 2019 

 emphasize the essential roles of clinician-patient discussions and a patient-centered approach to all treatment decisions whether the topic is lifestyle change or initiating medication. 

In this Guideline Topline slide show, get a concise summary of the recommended tools for evaluating patient CVD risk, refining the risk, and for placing the patient at the center of therapeutic choice. 

Slideshows

Assessment of CVD risk is the foundation of primary prevention and integral to primary care. Brush up on the fundamental tools of risk estimation from the ACC/AHA guidelines. 

Fundamentals of CVD Risk Assessment: Guideline Topline for Primary Care 

Cleveland, OH is the US city that ranks highest on measures of financial, family, and health and safety stress, according to recent data analyzed by 

. Newark, NJ leads the country in the area of work stress. At the opposite end of the stress continuum, Reno, NV ranks lowest on the composite for work stress, South Burlington, VT lowest for family stress, and Fremont, CA lowest for financial and health and safety stress. 

The COVID-19 pandemic may potentially have had a negative impact on all 41 metrics researchers  used to used to evaluate the 4 dimensions of a city's stress mentioned above. But even without the pandemic-triggered fear and anxiety, stress in US cities is ubiquitous.  

The WalletHub team compared 182 cities using a data set that ranged from COVID-19 cases and average weekly work hours to unemployment, divorce, and suicide rates.   

The highlights slide show that follows lists the 5 cities with the highest and lowest levels of stress in  9 categories. 

Cleveland ranks highest for financial and family stress; Newark ranks highest for work stress. Find out how well your metro area and your patients are coping right now.  


Stress in the US: 9 Key Measures and How Big Cities Rank  

COVID-19 Updates: Delta Variant, US Vaccinations, & Global Data as of July 27, 2021

Mandates by US health care organizations that all employees be vaccinated against COVID-19 have been few and far between since 3 vaccines were granted emergency use authorization by the Food and Drug Administration (FDA) early this year. 

Many major health systems and institutions remained hesitant, according to a report in the 

t, because the vaccines--from Pfizer, Moderna, and J&J--are not yet fully approved by the FDA, leaving the organizations open to the threat of law suits. 

One success story, cited in the Post report, could inspire confidence. Houston Methodist in March was the country's first health system to impose a coronavirus vaccination mandate. Staff protests followed, including resignation of more than 150 individuals who refused to be vaccinated. However, 97% of the Houston Methodist workforce did comply with just 2% receiving exemptions or deferrals. 

A lawsuit filed by former staff members was subsequently dismissed by a federal judge who ruled that the organization was “trying to do their business of saving lives without giving [patients] the covid-19 virus,” as reported in the Post. 

In recent days, the Department of Veterans Affairs (VA), the state of California and the city of New York all have put in place requirements for vaccination against COVID-19. The VA, which runs one of the country's largest health systems, is the first federal agency to do so.   

Frustrated by the slow down in US vaccine uptake, the alarming and steady rise in infection rates, and the dominance of the more infective and transmissible Delta variant of SARS-CoV-2, a group of 55 medical organizations became signatories to a joint statement, issued Tuesday, July 26, 2021, urging every health facility to require workers to be vaccinated. 

Organizations supporting the statement, which was organized by Ezekiel Emanuel, MD, PHD, a University of Pennsylvania bioethicist, include the American Medical Association, American Nurses Association, American Academy of Family Physicians, and American College of Physicians.  

The statement follows and for a full list of signing organizations, 

Joint Statement in Support of COVID-19 Vaccine Mandates for All Workers in Health and Long-Term Care

Due to the recent COVID-19 surge and the availability of safe and effective vaccines, our health care organizations and societies advocate that all health care and long-term care employers require their workers to receive the COVID-19 vaccine. This is the logical fulfillment of the ethical commitment of all health care workers to put patients as well as residents of long-term care facilities first and take all steps necessary to ensure their health and well-being.

Because of highly contagious variants, including the Delta variant, and significant numbers of unvaccinated people, COVID-19 cases, hospitalizations and deaths are once again rising throughout the United States. Vaccination is the primary way to put the pandemic behind us and avoid the return of stringent public health measures.

Unfortunately, many health care and long-term care personnel remain unvaccinated. As we move towards full FDA approval of the currently available vaccines, all health care workers should get vaccinated for their own health, and to protect their colleagues, families, residents of long-term care facilities and patients. This is especially necessary to protect those who are vulnerable, including unvaccinated children and the immunocompromised. Indeed, this is why many health care and long-term care organizations already require vaccinations for influenza, hepatitis B, and pertussis.

We call for all health care and long-term care employers to require their employees to be vaccinated against COVID-19.

We stand with the growing number of experts and institutions that support the requirement for universal vaccination of health workers. While we recognize some workers cannot be vaccinated because of identified medical reasons and should be exempted from a mandate, they constitute a small minority of all workers. Employers should consider any applicable state laws on a case-by-case basis.

Existing COVID-19 vaccine mandates have proven effective. Simultaneously, we recognize the historical mistrust of health care institutions, including among many in our own health care workforce. We must continue to address workers’ concerns, engage with marginalized populations, and work with trusted messengers to improve vaccine acceptance.

As the health care community leads the way in requiring vaccines for our employees, we hope all other employers across the country will follow our lead and implement effective policies to encourage vaccination. The health and safety of US workers, families, communities, and the nation depends on it.

As US vaccination rates fall and new virus case and hospitalization numbers climb, the country's leading medical organizations call for requiring any worker with patient contact to be vaccinated.   