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This is part of the “Advancing the Science of Cancer in Latinos: 2022 Conference Proceedings,” which summarizes findings and discussions of the 2022 Advancing the Science of Cancer in Latinos Conference on Feb. 23-25, 2022, in San Antonio, Texas.
COVID-19 Past, Present and Future
Dr. Carlos Del Rio is Distinguished Professor of Medicine, Global Health, and Epidemiology. He is also Executive Associate Dean of Emory University School of Medicine, and President-Elect of the Infectious Disease Society of America (IDSA).
The continued presence of COVID
Dr. Del Rio began by pointing out that the COVID pandemic is not over, despite gains made over the past year. At the time of his presentation, there were still two million global cases diagnosed daily, and close to 10,000 global deaths daily. Further, while there have been around six million total confirmed COVID deaths globally, the reality may be closer to 15 to 20 million due to uncounted deaths in low- and middle-income countries.
In the US alone, at the time of Dr. Del Rio’s presentation, 2,000 people per day were dying of COVID, a number which did not account for excess deaths. In these unreported COVID deaths, the US is second only to Russia. Many of those excess deaths are patients who died from diseases, like cancer, who did not get needed care during COVID. Officially, the US has passed 900,000 reported deaths, resulting in the highest death rate of all wealthy countries.
COVID among communities of color
These deaths disproportionately affect communities of color. In the Latino community, for example, cases have been 1.3 times higher than in the White population, with 3.2 times more hospitalizations and 2.3 times higher death rates. These numbers highlight the health disparities apparent in COVID, which in turn are merely indicators of greater health disparities at large.
Some of these disparities can be traced to low vaccination rates in minority communities, especially during the Omicron wave. This is largely due to a communication failure by public health officials. Vaccines were designed to prevent severe disease and death, not infection, but mixed messaging led to confusion among the public, despite the success of vaccines. A clear message detailing the overwhelming success of vaccines in preventing death and hospitalizations must be made public, especially with respect to minority populations.
Other factors have also had a greater effect on communities of color. Latinos, for example, have experienced the greatest drop in life expectancy due to COVID, with nearly three years of life expectancy lost. Minority communities of all types are also more affected by children losing one or both caregivers. In the US as a whole, 165,000 children have lost at least one caregiver.
The role of vaccines and the Omicron variant
As of Dr. Del Rio’s presentation, 64.5% of Americans were vaccinated. The rate of vaccinations increased somewhat around the time of the Omicron spike, but rates have largely plateaued. Booster rates follow a similar trend, with only 43% of those eligible having received the booster.
The Omicron variant presents very differently than the Delta variant. Omicron is 2.7 to 3.7 times more transmissible than Delta, but is more likely to cause asymptomatic infections. It is also airborne and causes different symptoms, with a smaller likelihood of lower respiratory tract infection or loss of smell but a larger likelihood of sore throat. Omicron also has many more variants and poses increased risk of reinfection.
While previous COVID infection does not seem to protect people against Omicron, most vaccines are effective, especially with a booster. Having three doses of an mRNA vaccine, for example, shows 82% vaccine effectiveness in regard to ER visits (95% CI, 79-84), and 90% vaccine effectiveness in regard to hospitalizations (95% CI, 80-94).
The future of the pandemic
Dr. Del Rio concluded by acknowledging that although the COVID pandemic will continue, the end is near. This optimism is due to the efficacy of the vaccines, the development of therapeutics, and the widespread use of diagnostic tests. That being said, it is important to continue to advocate for vaccinations and boosters, especially in those over 65. The pandemic has also revealed weaknesses in our healthcare system and infrastructure, especially when it comes to clear and understandable messaging, and vaccine hesitancy among communities of color is a big problem. A priority in public health must be to regain trust in vaccines, not only for the current pandemic, but for all future public health crises.
The Impact of COVID-19 among Latinos and NIH Initiatives to Advance Health Equity
Dr. Monica Webb Hooper is Deputy Director of the National Institute on Minority Health and Health Disparities.
Health disparities in underserved populations
Dr. Webb Hooper set out to discuss two studies designed to promote health equity in COVID-19 care, co-led by the National Institute on Minority Health & Health Disparities (NIMHD). The mission of NIMHD is to work with the NIH and the U.S. Department of Health and Human Services to advance the science of health disparities and to move closer to meaningful progress. The NIH has designated several groups as populations with health disparities, including Black Americans/African Americans, Hispanics/Latinos, American Indians/Alaska Natives, Asian Americans, Native Hawaiians and other Pacific Islanders, socioeconomically disadvantaged populations, underserved rural populations, and sexual and gender minority groups.
Health disparities in these populations are multifaceted and include higher rates of infant mortality, stroke, cancer, heart disease, diabetes, hypertension, and now COVID-19. During the pandemic, excess deaths were much higher in the Hispanic/Latino population compared to White patients. Life expectancy was severely affected as well, with Latina women showing a life expectancy loss of 2 years, and Latino men showing a loss of 3.7 years. Even among cancer patients during the pandemic, when compared to White patients, Hispanics/Latinos had a greater reduction in overall visits, were less likely to use telehealth, had greater treatment delays, and had higher rates of COVID-19 infection.
Another disparity in COVID-19 outcomes is the uptake of vaccines, which is influenced by vaccine hesitancy, a complex and nuanced issue affected by the three “C’s”: complacency, convenience, and confidence. Vaccination rates among Hispanics/Latinos have improved; however, booster rates remain alarmingly low in this population.
Evaluating vaccine intervention strategies
Dr. Webb Hooper described a funding opportunity that addresses this very issue. This Notice of Special Interest (NOSI) is entitled Research to Address Vaccine Hesitancy, Uptake, and Implementation among Populations that Experience Health Disparities, and aims to evaluate intervention strategies to facilitate vaccine uptake in general, not only COVID-19 vaccines. The initiative focuses on populations at increased risk for morbidity and mortality due to long standing social disparities and seeks to evaluate behavioral interventions, vaccine-related communications, and interventions addressing misinformation, using multi-level and other approaches.
Rapid Acceleration of Diagnostics – Underserved Populations (RADx-UP)
The second initiative presented by Dr. Webb Hooper is the Rapid Acceleration of Diagnostics – Underserved Populations (RADx-UP) initiative. RADx-UP seeks to enhance COVID-19 testing among underserved and vulnerable populations across the U.S. by supporting a consortium of over 100 community-engaged research projects to understand factors related to testing acceptance and uptake, as well as implementation of testing interventions. The three key components of RADx-UP are testing, return-to-school, and social, ethical, and behavioral implications (SEBI) research.
There are RADx-UP participants in all 50 states, several U.S. territories, and the District of Columbia, with 57 projects focusing on Hispanic/Latino populations. This consortium involves over 100 projects, with over 1.2 million participants and over 1.3 million tests conducted. At least 48 journal articles have been published on this work with more under review.
COVID-19 testing among Hispanics/Latinos
One RADx-UP study conducted in Baltimore found that Latinxs had a 31.5% SARS-CoV-2 positivity rate, compared with 7.6% among White patients. These Latinx patients tended to be younger and have a larger household size compared with White patients who tested positive for SARS-CoV-2; over half of the Latinx patients were asymptomatic, and they spoke Spanish as their preferred language. Another study from south Texas counties with mostly Mexican-American residents found that single-parent households and households with limited English proficiency had higher relative incidence risk for COVID-19.
One of the SEBI studies supported by RADx-UP from New Jersey used surveys and interviews to confirm that public health officials should seek trusted leaders within the community to aid in addressing unanswered questions to reduce vaccine hesitancy. Still another study was an online survey looking at the use of self-testing kits. Motivation to distribute kits was found to be associated with above-average income and completion of college, while motivation to self-test after receiving a kit was found to be associated with above-average income and Hispanic ethnicity.
The future of addressing disparities in COVID-19 among underserved communities
Dr. Webb Hooper closed by noting that funding opportunities for Phase III of RADx-UP are now published, with a focus on the use of rapid diagnostic testing, partnership-driven research, and variations on messaging. She also emphasized the lessons learned about engaging underserved communities in the COVID-19 pandemic, including culturally appropriate approaches for increasing trust, the use of community advisory boards to provide key recommendations and support, the importance of community engagement, flexibility and the ability to adapt, and partnerships with community health clinics.
The Impact of COVID-19 Among Pediatric Oncology Patients
Dr. Terrie Flatt, from Children’s Mercy Hospital, presented a study on how COVID-19 impacted pediatric oncology patients. This understanding is crucial to recognizing associated complications, defining patients that are at highest risk for severe illness and delays in chemotherapy, and improving medical interventions and outcomes.
Real-time chart reviews of 54 patients diagnosed with COVID-19 were performed between March 15, 2020 and April 15, 2021 at Children’s Mercy Hospital in Kansas City, MO. This patient cohort was pre-Omicron variant, and was diagnosed via polymerase chain reaction (PCR) test or rapid-antigen test. The median age was 11.1 years (range 1-21), with 55.6% being female (n=30). Caucasian patients made up 53% (n=29) of the cohort, while Hispanic patients made up 31.5% (n=17). This was a disproportionate number of Hispanic patients, who represented approximately 15-17% of the entire oncology patient population at the hospital. The underlying cancer diagnosis was predominantly leukemia or lymphoma at 59.2% (n=32), and most patients were receiving active chemotherapy (62.9%, n=34).
Clinical presentation and outcomes of the cohort
Among the cohort, 63% (n=34) were symptomatic, with the most common presenting symptoms being fever (39%), fatigue (30%), and cough (15%). Hispanics represented a disproportionate number of symptomatic patients, however, with 83% being symptomatic, compared with 55% of non-Hispanics (P=0.068). Hispanic patients were also more likely to develop the following complications compared with non-Hispanics: transaminitis (73.3% versus 37.5%, P=0.0084), pancreatitis (22% versus 0%, P=0.044), and myelosuppression (73%, with 11/15 among Hispanics receiving active therapy).
Among those treated, chemotherapy was held in 46% of patients, although this number disproportionately represented Hispanics compared to Non-Hispanics (80% versus 25%, P=0.0011). Hospitalization occurred in 18.5% (n=10) of patients, with a median length of stay at 10.9 days (range 1-32). This was again a disproportionate representation, with 29% (n=5) of Hispanics being hospitalized compared with 17% (n=5) of non-Hispanics (P=0.256). Overall, two patients died of COVID-19 related complications, both of whom had undergone Chimeric Antigen Receptor (CAR) T-cell therapy for pre-B cell acute lymphocytic leukemia (ALL).
COVID-19, pediatric oncology, and Hispanic populations
Dr. Flatt closed by reporting the major conclusions of the study. First, pediatric cancer patients generally experienced mild illness with COVID-19. However, Hispanic patients were disproportionately affected by COVID-19 compared with other racial and ethnic groups, experienced more symptomatic illness, and more frequently had their chemotherapy doses held. The study also showed that patients with an underlying diagnosis of leukemia/lymphoma appeared to be at higher risk for severe COVID-19 related morbidities, and patients who had undergone CAR T-cell therapy that contract COIVD-19 were also at high risk for COVID-19 related morbidities and mortality. Finally, the study showed that understanding the clinical findings and outcomes among minority populations is critical to providing optimal clinical care and achieving best outcomes for all patients.