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Saturday, June 13, 2020

COVID-19 fuels major unknowns as insurers tackle 2021 rate setting

  • Insurers face myriad challenges as they set premium rates for 2021 in the individual and small group market in the midst of the COVID-19 pandemic. The crisis is forcing payers to consider a slew of scenarios, laid out in an annual issue brief from the American Academy of Actuaries.
  • The brief notes the pandemic has fueled “significant uncertainty” in projecting claims and lists a number of scenarios, including the potential for additional waves of infection this year and next.
  • At first blush, the financial picture may seem hopeful for insurers, with deferred care outweighing the increased medical costs to treat COVID-19 patients. But the brief spells out challenges that may lead to higher spend, including a shift in coverage leading to adverse selection, deteriorating health for those delaying care and pressure on reimbursement rates as providers seek to make up for losses.
Even in the midst of a pandemic, the nation’s largest insurers have seemed cautiously optimistic about 2020, mainly due to the fact that the plunge in patient volumes has offset the increased costs to treat those infected with the novel coronavirus.
In fact, the depressed patient volumes have lead to an unprecedented descent in healthcare spending. For decades, healthcare spending has steadily ticked upward, until this spring when it took a nose dive, according to figures from the Kaiser Family Foundation.
Retrieved from Kaiser Family Foundation on June 11, 2020
Yet, the nation is long from thwarting the virus without an effective treatment or a vaccine readily available. And as states across the country lift social distancing restrictions, infections will most likely continue to rise.
Compounding the issue is the staggering drop in employment. The unemployment rate reached a record of 14.7% in April, though slightly improved to 13.3% in May as many returned to work. With job loss comes the risk of losing health insurance coverage for millions of Americans, the majority of whom receive coverage through work.
Job losses are expected to spur a shift in coverage as people who lose insurance turn to plans on the Affordable Care Act exchanges or elect COBRA. Others may be eligible for Medicaid.
For insurers, this shift can result in adverse selection for them, ending up with a member who is less healthy and costs more. However, people in the employer market tend to be viewed as healthier.
“For instance, when individuals lose coverage, they must decide whether to purchase coverage, and less-healthy people are generally thought to be more likely to purchase coverage than healthy individuals,” according to the issue brief.
On the flip side, the pandemic may motivate some to purchase insurance due to the risk of getting sick while uninsured, according to the brief.
Another scenario laid out in the paper that makes pricing more difficult is coverage for testing for the virus, which public health experts have said is key to containing and controlling future outbreaks. But who will pay for continued testing as it’s used as a public health tool is still a muddied question.
If insurers are expected to pay, outside the need for confirming as a means for diagnosis and treatment, it could pump up costs. Not to mention the potential costs if a vaccine is available.
As patients return to providers, the delayed care could have resulted in poor health, particularly those who put off cancer or other key screenings. If there is a degradation in health status for people, it will likely lead to increased per member costs.
Plus, providers are likely to pressure insurers for higher reimbursements as they seek to make up for losses experienced during the downturn toward the end of the first quarter amid mandated social distancing.
https://www.healthcaredive.com/news/covid-19-fuels-major-unknowns-as-insurers-tackle-2021-rate-setting/579634/

Sugar coating locks and loads coronavirus for infection

They say you can’t judge a book by its cover. But the human immune system does just that when it comes to finding and attacking harmful microbes such as the coronavirus. It relies on being able to recognize foreign intruders and generate antibodies to destroy them. Unfortunately, the coronavirus uses a sugary coating of molecules called glycans to camouflage itself as harmless from the defending antibodies.
Simulations on the National Science Foundation (NSF)-funded Frontera supercomputer at the Texas Advanced Computing Center (TACC) have revealed the atomic makeup of the coronavirus’s sugary shield. What’s more, simulation and modeling show that glycans also prime the coronavirus for infection by changing the shape of its spike . Scientists hope this basic research will add to the arsenal of knowledge needed to defeat the COVID-19 virus.
Sugar-like molecules called glycans coat each of the 65-odd spike proteins that adorn the coronavirus. Glycans account for about 40 percent of the spike protein by weight. The spike proteins are critical to cell infection because they lock onto the , giving the virus entry into the cell.
“You really see how effective its shield is,” said Rommie Amaro, a professor of chemistry and biochemistry at the University of California, San Diego. “That’s because you see the glycans covering the surface of the viral spike protein, which is the most exposed bit and the part that’s responsible for the initial infection in the human cell,” she said.
Amaro is a corresponding author of a study published June 12, 2020 on bioRxiv.org—an open-access repository of electronic preprints—that discovered a potential structural role of the shielding glycans that cover the SARS-CoV-2 spike protein. “You can see very clearly that from the open conformation, the spike protein has to undergo a large structural change to actually get into the human cell,” Amaro said.
But even to make an initial connection, she said that one of the pieces of the spike protein in its receptor binding domain has to lift up. “When that receptor binding domain lifts up into the open conformation, it actually lifts the important bits of the protein up over the glycan shield,” Amaro explained.
This is in contrast to the closed conformation, where the shield covers the spike protein. “Our analysis gives a potential reason why it does have to undergo these conformational changes, because if it just stays in the down position those glycans are basically going to block the binding from actually happening,” she said.
Another aspect of their study showed how shifts in the conformations of the glycans triggered changes in the spike protein structure. “One thing that really jumped out at us is that in the open conformation there are two glycans that basically prop up the protein in that open conformation,” Amaro said.
“That was really surprising to see. It’s one of the major results of our study. It suggests that the role of glycans in this case is going beyond shielding to potentially having these chemical groups actually being involved in the dynamics of the spike protein,” she added.
She likened the action of the glycan to pulling the trigger of a gun. “When that bit of the spike goes up, the finger is on the trigger of the infection machinery. That’s when it’s in its most dangerous mode—it is locked and loaded,” Amaro said. “When it gets like that, all it has to do is come up against an ACE2 receptor in the human cell, and then it’s going to bind super tightly and the cell is basically infected.”
Amaro and her colleagues use computational methods to build data-centric models of the SARS-CoV-2 virus, and then use to explore different scientific questions about the virus.
They started with various experimental datasets that revealed the structure of the virus. This included cryo-EM structures from the Jason McLellan Lab of The University of Texas at Austin; and from the lab of David Veesler at the University of Washington. “Their structures are really amazing because they give researchers a picture of what these important molecular machines actually look like,” Amaro said.
Unfortunately, even the most powerful microscopes on Earth still can’t resolve movement of the protein at the atomic scale. “What we do with computers is that we take the beautiful and wonderful and important data that they give us, but then we use methods to build in missing bits of information,” Amaro said.
What’s more, details of the glycan shielding have been too difficult for experiments to resolve. “What people really want to know, for example vaccine developers and drug developers, is what are the vulnerabilities that are present in this shield,” Amaro said.
The computer simulations allowed Amaro and colleagues to create a cohesive picture of the spike protein that includes the glycans. “The reason why the computer resources at TACC are so important is that we can’t understand what these glycans look like if we don’t use simulation,” Amaro said.
Amaro was awarded compute time on the NSF-funded Frontera supercomputer of TACC. Her team has used about 2.3 million node hours for molecular dynamics simulations and modeling , the most among any researchers using the system to study COVID-19. She used up to 4,000 nodes, or about 250,000 processing cores. Frontera—the leadership-class system in NSF’s cyberinfrastructure ecosystem—ranks as the fifth most powerful supercomputer in the world and the fastest academic system, according to November 2019 rankings of the Top500 organization.
In order to animate the dynamics of the 1.7 million atom system under study, a lot of computing power was needed, said Amaro. “That’s really where Frontera has been fantastic, because we need to sample relatively long dynamics, microsecond to millisecond timescales, to understand how this protein is actually working.”
“We’ve been able to do that with Frontera and the COVID-19 HPC Consortium,” Amaro said. “Now we’re trying to share our data with as many people as we can, because people want a dynamical understanding of what’s happening—not only with other academic groups but also with different pharmaceutical and biotech companies that are conducting neutralizing antibody development,” she said.
Basic research is making a difference in winning the war against the SARS-CoV-2 virus, Amaro explained. “The more we know about it, the more of its abilities that we’re going to be able to go after and potentially take out,” she added.
Said Amaro: “It’s of such great importance that we learn as much as we can about the virus. And then hopefully we can translate those understandings into things that will be useful either in the clinic, or the streets, for example if we’re trying to reduce transmission for what we know now about aerosols and wearing masks. All these things will be part of it. Basic research has a huge role to play in the war against COVID-19. And I’m happy to be a part of it. It’s a strength that we have Frontera and TACC in our arsenal.”
The study, “Shielding and Beyond: The Roles of Glycans in SARS-CoV-2 Spike Protein,” was published on bioRxiv.org June 12, 2020. The study authors are Lorenzo Casalino, Zied Gaieb, Abigail C. Dommer, Rommie E. Amaro of the Department of Chemistry and Biochemistry, University of California, San Diego, La Jolla, CA; and Aoife M Harbison, Carl A Fogarty, Elisa Fadda of the Department of Chemistry and Hamilton Institute, Maynooth University, Dublin, Ireland. This work was supported by NIH GM132826, NSF RAPID MCB-2032054, an award from the RCSA Research Corp., a UC San Diego Moore’s Cancer Center 2020 SARS-COV-2 seed grant, the Visible Molecular Cell Consortium, and the Irish Research Council.

Explore further
Coronavirus massive simulations completed on Frontera supercomputer

More information: Lorenzo Casalino et al. Shielding and Beyond: The Roles of Glycans in SARS-CoV-2 Spike Protein, bioRxiv (2020). DOI: 10.1101/2020.06.11.146522

https://phys.org/news/2020-06-sugar-coating-coronavirus-infection.html

COVID-19 may trigger new diabetes

Emerging evidence suggests that COVID-19 may actually trigger the onset of diabetes in healthy people and also cause severe complications of pre-existing diabetes.
A letter published today in the New England Journal of Medicine and signed by an international group of 17 leading experts involved in the CoviDiab Registry project, a collaborative international research initiative, announces the establishment of a Global Registry of new cases of diabetes in patients with COVID-19.
The Registry aims to understand the extent and the characteristics of the manifestations of diabetes in patients with COVID-19, and the best strategies for the treatment and monitoring of affected patients, during and after the pandemic.
Clinical observations so far show a bi-directional relationship between COVID-19 and diabetes. On the one hand, diabetes is associated with increased risk of COVID-19 severity and mortality. Between 20 and 30% of patients who died with COVID-19 have been reported to have diabetes. On the other hand, new-onset diabetes and atypical metabolic complications of pre-existing diabetes, including life-threatening ones, have been observed in people with COVID-19.
It is still unclear how SARS-Cov-2, the virus that causes COVID-19, impacts diabetes. Previous research has shown that ACE-2, the protein that binds to SARS-Cov-2 allowing the virus to enter , is not only located in the lungs but also in organs and tissues involved in glucose metabolism such as the pancreas, the small intestine, the fat tissue, the liver and the kidney. Researchers hypothesize that by entering these tissues, the virus may cause multiple and complex dysfunctions of glucose metabolism. It has also been known for many years that virus infections can precipitate type 1 diabetes.
Francesco Rubino, Professor of Metabolic Surgery at King’s College London and co-lead investigator of the CoviDiab Registry project, said: “Diabetes is one of the most prevalent chronic diseases and we are now realizing the consequences of the inevitable clash between two pandemics. Given the short period of human contact with this new coronavirus, the exact mechanism by which the virus influences is still unclear and we don’t know whether the acute manifestation of diabetes in these patients represent classic type 1, type 2 or possibly a new form of diabetes”.
Paul Zimmet, Professor of Diabetes at Monash University in Melbourne, Honorary President of the International Diabetes Federation and co-lead investigator in the CoviDiab Registry project said: “We don’t yet know the magnitude of the new onset diabetes in COVID-19 and if it will persist or resolve after the infection; and if so, whether or not or COVID-19 increases risk of future diabetes. By establishing this Global Registry, we are calling on the international medical community to rapidly share relevant clinical observations that can help answer these questions”.
Stephanie Amiel, Professor of Diabetes Research at King’s College London and a co-investigator of the CoviDiab Registry project said: “The registry focuses on routinely collected clinical data that will help us examine insulin secretory capacity, insulin resistance and autoimmune antibody status to understand how COVID-19 related diabetes develops, its natural history and best management. Studying COVID-19-related diabetes may uncover novel mechanisms of disease.”

Explore further
Diabetes increases risk for poorer prognosis in COVID-19

More information: New England Journal of Medicine (2020). DOI: 10.1056/NEJMc2018688

Up to 45 percent of SARS-CoV-2 infections may be asymptomatic

An extraordinary percentage of people infected by the virus behind the ongoing deadly COVID-19 pandemic never show symptoms of the disease, according to the results of a Scripps Research analysis of public datasets on asymptomatic infections.
The findings, published in Annals of Internal Medicine, suggest that asymptomatic infections may account for as much as 45 percent of all COVID-19 cases, playing a significant role in the early and ongoing spread of COVID-19. The report highlights the need for expansive testing and contact tracing to mitigate the pandemic.
“The silent spread of the virus makes it all the more challenging to control,” says Eric Topol, MD, founder and director of the Scripps Research Translational Institute and professor of Molecular Medicine at Scripps Research. “Our review really highlights the importance of testing. It’s clear that with such a high asymptomatic rate, we need to cast a very wide net, otherwise the virus will continue to evade us.”
Together with behavioral scientist Daniel Oran, Topol collected information from testing studies on 16 diverse cohorts from around the world. These datasets—gathered via keyword searches of PubMed, bioRxiv and medRxiv, as well as Google searches of relevant news reports—included data on nursing home residents, cruise ship passengers, prison inmates and various other groups.
“What virtually all of them had in common was that a very large proportion of infected individuals had no symptoms,” says Oran. “Among more than 3,000 prison inmates in four states who tested positive for the , the figure was astronomical: 96 percent asymptomatic.”
The review further suggests that are able to transmit the virus for an extended period of time, perhaps longer than 14 days. The viral loads are very similar in people with or without symptoms, but it remains unclear whether their infectiousness is of the same magnitude. To resolve that issue, we’ll need large-scale studies that include sufficient numbers of asymptomatic people.
The authors also conclude that the absence of symptoms may not imply an absence of harm. CT scans conducted on 54 percent of 76 asymptomatic individuals on the Diamond Princess cruise ship, appear to show significant subclinical lung abnormalities raising the possibility of SARS-CoV-2 infection impacting lung function that might not be immediately apparent. The scientists say further research is needed to confirm the potential significance of this finding.
The authors also acknowledge that the lack of longitudinal data makes distinguishing between asymptomatic and presymptomatic individuals difficult. An asymptomatic individual is someone who is infected with SARS-CoV-2, but never develops symptoms of COVID-19, while a presymptomatic person is similarly infected, but will eventually develop symptoms. Longitudinal testing, which refers to repeated testing of individuals over time, would help differentiate between the two.
“Our estimate of 40 to 45 percent asymptomatic means that, if you’re unlucky enough to get infected, the probability is almost a flip of a coin on whether you’re going to have symptoms. So to protect others, we think that wearing a mask makes a lot of sense,” Oran concludes.
More information: Daniel P. Oran et al, Prevalence of Asymptomatic SARS-CoV-2 Infection, Annals of Internal Medicine (2020). DOI: 10.7326/M20-3012
https://medicalxpress.com/news/2020-06-percent-sars-cov-infections-asymptomatic.html

Should oral polio vaccine be tested to see if it helps against Covid?

In a Perspective piece published in the journal Science, a small international team of researchers is suggesting that the oral polio vaccine be tested to see if it might protect people from infection by the SARS-CoV-2 virus. In their paper, Konstantin Chumakov, Christine Benn, Peter Aaby, Shyamasundaran Kottili and Robert Gallo suggest the vaccine has been found to provide some protection against other viral infections, and point out that it has been proven to be safe over many years.
Polio vaccines are, of course, vaccines that are used to prevent poliomyelitis infections. They have been in use since the 1950s. Polio vaccines come in two varieties: inactivated (administered by injection) and weakened (administered orally). Together, the two vaccines have nearly eradicated polio. They have also been found to confer some degree of immunity against other types of infections, both bacterial and viral. In their , the researchers argue for testing to see if the oral (weakened) might prove effective in preventing COVID-19 infections.
They confer some degree of immunity against other infections because they activate an , known as the first line of defense response. In contrast, immunity is conferred against certain viruses when a person is infected with it specifically, because the body produces antibodies specifically geared towards fighting it. The authors of the Perspective piece suggest that activating the first line of defense via the oral vaccine may be all some people need to ward off COVID-19 infections. They note also that recent research has shown that the SARS-CoV-2 virus can suppress the innate immune response in patients with more serious symptoms.
The authors suggest the oral vaccine as opposed to the injectable kind be tested because the injectable vaccine does not activate an innate immune response, and because it is already licensed for use in the United States, the country that has thus far been hit hardest by the pandemic. They acknowledge that there is some small risk of using the oral vaccine, as it has been found to generate circulating vaccine-derived polioviruses, a type of polio that is vaccine derived in a very small number of people, mostly children with compromised or underdeveloped immune systems. But they suggest that if it does prove to ward off coronavirus infections, the good that could come from its use would far outweigh the bad.
More information: Konstantin Chumakov et al. Can existing live vaccines prevent COVID-19?, Science (2020). DOI: 10.1126/science.abc4262
https://medicalxpress.com/news/2020-06-oral-polio-vaccine-sars-cov-.html

Medtronic to ramp up diabetes R&D on $337M Blackstone investment

Medtronic (NYSE:MDT) announces a $337M investment from funds managed by Blackstone Life Sciences (and other co-investors) aimed at supporting R&D programs in its Diabetes Group.
The capital, to be disbursed over several years, will fund four undisclosed diabetes R&D programs. If successful, Blackstone-led investors will receive low-to-mid-single-digit royalties on net sales. Additional terms remain confidential.
Medtronic will host a briefing today at 6:00 pm ET from the ADA conference to discuss the deal.
https://seekingalpha.com/news/3582829-medtronic-to-ramp-up-diabetes-r-and-d-on-337m-blackstone-investment

AstraZeneca to supply up to 400M doses of COVID vaccine at no profit

AstraZeneca (NYSE:AZN) inks an agreement with Europe’s Inclusive Vaccines Alliance, led by Germany, France, Italy and the Netherlands, under which the company will supply up to 400M doses of Oxford University’s COVID-19 vaccine, currently dubbed ADZ1222 (originally ChAdOx1 nCoV-19), beginning in late Q4 at no profit.
AZN recently signed deals in the UK, U.S. and with CEPI and Gavi the Vaccine Alliance to supply 700M doses in addition to a deal with the Serum Institute of India to supply IB doses to low- and middle-income countries.
Manufacturing costs will be offset by government funding.
A Phase 2/3 trial in the UK launched last month.
AZN’s 2020 financial guidance remains unchanged.
https://seekingalpha.com/news/3582828-astrazeneca-to-supply-up-to-400m-doses-of-covid-vaccine-no-profit