COVID-19 news is confusing — but vaccination is still the answer

 With a recent rise of COVID-19 cases, the Delta variant and the return of certain restrictions, there is a lack of clarity in many people’s minds about breakthrough infections, vaccine efficacy, the pandemic’s trajectory and other issues. The Center for Disease Control and Prevention's (CDC) masking guidance update, driven by concern over breakthrough infections, is emblematic of this.

One of the biggest misunderstandings that persists is regarding rare breakthrough infections that occur and their importance. These rare events were always expected but perhaps poorly communicated, as no vaccine is 100 percent efficacious. Vaccines are not bug-zappers or “forcefields.”

What a vaccine does accomplish is remarkable: A vaccine primes the immune system to spring into action upon exposure to the virus and derail an infection before it has the chance to be as productive, to cause as many symptoms or to cause as much damage as it would have in the absence of this immunity. (Natural immunity also operates this way and is important.) 

The early steps of the thwarted infection are what alert the immune system to the intruder, and the aftereffects of the incident are a boost to immunity. Vaccinated people are likely going through this process frequently, especially in places where COVID-19 prevalence is high. Sometimes, if testing occurs during the right window after exposure, with sensitive PCR tests, viral genetic material will be present in a high enough quantity for a test to be positive.

As most breakthrough infections do not result in symptoms, they cannot be classified as disease and are, to the individual involved, medically insignificant. However, a positive test, even if without clinical value, will be disruptive because it is a positive test.

While there are important scientific questions regarding symptom-less breakthroughs (including how frequently it occurs, which variants are present, how much virus was present, and time post-vaccination) from a clinical perspective there is no treatment.

In the extremely rare cases in which symptoms occur — true breakthrough disease — it is crucial to realize that were it not for the immunity that existed, things would have been worse. This is very apparent with influenza vaccines, which are very good at blunting the risk for hospitalization but do not stop all infections.

The fact is that mild breakthrough infections are a vaccine success — not a short-coming.

COVID-19 has become an endemic infection much like the other four coronaviruses that cause about 25 percent of common colds. Because it is an efficiently spreading respiratory virus with a wide spectrum of symptoms and animal hosts, we will not eliminate it. It is with us. This means that we will always have some baseline level of cases, hospitalizations and deaths with season-to-season variation. The goal is not to achieve some fantastical “COVID zero” status but to deny the virus the ability to cause serious disease, with hospitalization and death on a scale that could threaten hospital capacity.

In states where vaccination rates are high, the vaccines we have in the U.S. are performing tremendously. Vaccines are taming the virus by relegating to the status of other respiratory viruses we deal with year in and year out. This was largely achieved by vaccinating those at highest risk for hospitalization.

In the U.S., tens of thousands of cases of COVID-19 occur daily. These cases are being driven by unvaccinated people spreading the more fit Delta variant of the SARS-CoV-2 virus. It is no coincidence that the states with the highest cases are the states with the lowest vaccination rates. As CDC Director Dr. Rochelle Walensky and President Biden have both stated, we are now in a “pandemic of the unvaccinated.”

Attesting to the power of the available vaccines, virtually everyone hospitalized with COVID-19 currently is unvaccinated. This is true even in states with low vaccination numbers.

The uptake of the vaccine is not uniform, however, and in those regions with substantial and high spread, breakthrough infections will be more common because it will be more likely that one run into the virus in their daily life. It makes sense for immunocompromised individuals, for whom standard vaccination doses may not be sufficient, to be vigilant and wear masks in public indoor spaces.

However, it is unclear why the pandemic of the unvaccinated impacts the behavior of the healthy, fully vaccinated. The CDC cited unpublished case studies in which Delta variant breakthrough cases on “rare occasions” in “some vaccinated people may be contagious” but that vaccinated individuals account for a “very small amount of transmission.” These findings, which would be important to publish and have peer-reviewed, prompted the CDC to shift guidance for the fully vaccinated in areas in which substantial or high levels of COVID transmission are occurring.

If vaccinated individuals account for a “very small amount of transmission” when these “rare occasions” occur, is there going to be much impact from this guidance? I believe it will have little impact on case rates.

The virus treats a vaccinated person very differently than an unvaccinated or non-immune person and, therefore, others should treat them differently because they are not the same COVID-19 threat.

An endemic respiratory virus is something that most of us will eventually contract. Some of us have or will get it unvaccinated in its full form, others in a mostly innocuous vaccine breakthrough version.

If we are to concern ourselves perpetually with preventing rare or very small events from happening, seeking to achieve a state of zero risk — where we become overly concerned with preventing a small proportion of the fully vaccinated from experiencing minor cold-like illnesses — then this pandemic can have no off-ramp.

The aim should always have been to guard against hospital capacity concerns and deploy COVID-19 vaccines widely, in combination with natural immunity. Now, the focus must be in addressing the clusters of the high-risk unvaccinated individuals. Hopefully, with full  Food and Drug Administration approval, with more businesses and organizations requiring a COVID-19 vaccine, and with persuasion from trusted community leaders and primary care physicians, vaccinations will rise, and the less effective substitute of masks will no longer be part of the discussion.

Amesh Adalja, M.D., is an infectious disease physician and a senior scholar at the Johns Hopkins Center for Health Security. 

https://thehill.com/opinion/healthcare/565495-covid-19-news-is-confusing-but-vaccination-is-still-the-answer

Preventing childhood obesity requires changes in parents’ and clinicians’ early-life care

 Rates of childhood obesity are at historically high levels in the U.S., yet there are few interventions that promote healthy weight gain in children from infancy to age two -- a critical period for the development and prevention of childhood obesity. A new study published in Pediatrics found that fewer infants gained excess weight when low-income pregnant women received individualized health coaching in tandem with clinicians in community health centers and public health programs systematically changing how they delivered care to women and their infants.

"Most interventions to prevent obesity in children attempt to change the behavior of the child's parent or family," explains lead author Elsie Taveras, MD, MPH, chief of the Division of General Academic Pediatrics at Massachusetts General Hospital (MGH). "But a child's health is also influenced by how well clinical and public-health systems interact with families and provide care targeted to reducing the risk of obesity."

The novel intervention, called the First 1,000 Days program, has the potential to have a much broader impact on childhood obesity because it reaches all women and infants. "We can be so much more effective at preventing childhood obesity if all obstetricians pay close attention to a woman's excess weight gain in pregnancy and if all pediatricians are trained in identifying problematic weight gain in infants, for example," says Taveras, a professor of Pediatrics at Harvard Medical School (HMS). The First 1,000 Days program is also unique in combatting obesity starting in the first trimester of pregnancy and in focusing on low-income families, who have the highest risk for childhood obesity.

The investigators compared infants' weight outcomes in women and infants who received the intervention and those who received usual care. The intervention group included 995 pregnant women in their first trimester and their infants receiving care at two community health centers affiliated with Mass General Brigham. The comparison group consisted of 650 pregnant women and their infants who received usual care at two other community health centers serving low-income patients.

The intervention had two goals: to promote the adoption of healthy behavior in the women and their infants and to make systematic changes in the clinical care the women and infants received. The systems-level component of the intervention included, for example, standardizing obesity-prevention training for pediatric clinicians and staff, close tracking of infants' weight gain, screening pregnant women for adverse health behaviors and social determinants of health, and providing educational materials and text messages to families that promoted healthy feeding and sleeping behaviors of their infants. In addition, women in the intervention group received individual support and coaching during pregnancy and the first six weeks postpartum on diet, physical activity, sleep and stress reduction.

Infants in the intervention group had 54% lower odds of being overweight at six months and 40% lower odds of being overweight at 12 months compared with infants who received usual infant care. The researchers will continue to follow the children through age two. Mothers at the intervention sites had modestly lower, but clinically insignificant, weight retention at six weeks' postpartum compared with mothers receiving usual care. But more women in the intervention group had a postpartum visit with a primary care clinician than the women who received usual care. "The first six weeks after delivery are very important for positively influencing a woman's health trajectory, so we may need a more robust intervention to achieve postpartum weight reduction," says Taveras.

Making changes in systems of care holds the promise to improve the health of all women and their babies at community health centers and public-health programs, Taveras adds. "We believe we can create a sustained reduction in childhood obesity by moving beyond simply modifying individual behaviors and risk factors, one parent at a time."

The next steps for the research are to find the best approaches to disseminate the intervention to other health systems that care for low-income families and to train frontline clinicians in how to implement the program for preventing childhood obesity into their practices.

Major funding for this research was provided by the Boston Foundation and the National Institutes of Health.

Taveras is the Conrad Taff Endowed Professor of Nutrition in the department of Pediatrics at Harvard Medical School (HMS). Other authors are Alexy Arauz-Boudreau, MD, MPH, associate director for Pediatric Population Health at MGH and assistant professor of Pediatrics at HMS; Tiffany Blake-Lamb, MD, MSc, an assistant in Obstetrics & Gynecology at MGH and instructor of Obstetrics, Gynecology and Reproductive Biology at HMS; Milton Kotelchuck, PhD, MPH, a professor of Pediatrics at HMS and senior scientist at the Center for Child & Adolescent Health Research and Policy at MGH; Sarah Matathia, MD, MPH, a family physician at MGH and an Instructor in Medicine at HMS; Meghan Perkins, MPH, senior program manager in the Division of General Pediatrics at MGH; Man Luo, MPH, a biostatistician in the Division of General Pediatrics at MGH; Sarah Price, MPH, a senior health educator in the Division of General Pediatrics at MGH; and Erika Cheng, PhD, MPA, an assistant professor of Pediatrics at Indiana University School of Medicine.

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Materials provided by Massachusetts General Hospital. Note: Content may be edited for style and length.

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Journal Reference:

1. Elsie M. Taveras, Meghan E. Perkins, Alexy Arauz Boudreau, Tiffany Blake-Lamb, Sarah Matathia, Milton Kotelchuck, Mandy Luo, Sarah N. Price, Brianna Roche, Erika R. Cheng. Twelve-Month Outcomes of the First 1000 Days Program on Infant Weight Status. Pediatrics, 2021; e2020046706 DOI: 10.1542/peds.2020-046706

https://www.sciencedaily.com/releases/2021/07/210729143414.htm

Source of DNA mutations in melanoma

 The mutations that give rise to melanoma result from a chemical conversion in DNA fueled by sunlight -- not just a DNA copying error as previously believed, reports a study by Van Andel Institute scientists published today in Science Advances.

The findings upend long-held beliefs about the mechanisms underlying the disease, reinforce the importance of prevention efforts and offer a path forward for investigating the origins of other cancer types.

"Cancers result from DNA mutations that allow defective cells to survive and invade other tissues. However, in most cases, the source of these mutations is not clear, which complicates development of therapies and prevention methods," said Gerd Pfeifer, Ph.D., a VAI professor and the study's corresponding author. "In melanoma, we've now shown that damage from sunlight primes the DNA by creating 'premutations' that then give way to full mutations during DNA replication."

Melanoma is a serious type of skin cancer that begins in pigment-producing skin cells. Although less common than other types of skin cancer, melanoma is more likely to spread and invade other tissues, which significantly reduces patient survival. Previous large-scale sequencing studies have shown that melanoma has the most DNA mutations of any cancer. Like other skin cancers, melanoma is linked to sun exposure, specifically a type of radiation called UVB. Exposure to UVB damages skin cells as well as the DNA within cells.

Most cancers are thought to begin when DNA damage directly causes a mutation that is then copied into subsequent generations of cells during normal cellular replication. In the case of melanoma, however, Pfeifer and his team found a different mechanism that produces disease-causing mutations -- the introduction of a chemical base not normally found in DNA that makes it prone to mutation.

DNA comprises four chemical bases that exist in pairs -- adenine (A) and thymine (T), and cytosine (C) and guanine (G). Different sequences of these pairs encode all of the instructions for life. In melanoma, the problem occurs when UVB radiation from the sun hits certain sequences of bases -- CC, TT, TC and CT -- causing them to chemically link together and become unstable. The resulting instability causes a chemical change to cytosine that transforms it into uracil, a chemical base found in the messenger molecule RNA but not in DNA. This change, called a "premutation," primes the DNA to mutate during normal cell replication, thereby causing alterations that underlie melanoma.

These mutations may not cause disease right away; instead, they may lay dormant for years. They also can accumulate as time goes on and a person's lifetime exposure to sunlight increases, resulting in a tough-to-treat cancer that evades many therapeutic options.

"Safe sun practices are very important. In our study, 10-15 minutes of exposure to UVB light was equivalent to what a person would experience at high noon, and was sufficient to cause premutations," Pfeifer said. "While our cells have built-in safeguards to repair DNA damage, this process occasionally lets something slip by. Protecting the skin is generally the best bet when it comes to melanoma prevention."

The findings were made possible using a method developed by Pfeifer's lab called Circle Damage Sequencing, which allows scientists to "break" DNA at each point where damage occurs. They then coax the DNA into circles, which are replicated thousands of times using a technology called PCR. Once they have enough DNA, they use next-generation sequencing to identify which DNA bases are present at the breaks. Going forward, Pfeifer and colleagues plan to use this powerful technique to investigate other types of DNA damage in different kinds of cancer.

Other authors include Seung-Gi Jin, Ph.D., Dean Pettinga, Jennifer Johnson and Peipei Li, Ph.D., of VAI.

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Materials provided by Van Andel Research Institute. Note: Content may be edited for style and length.

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Journal Reference:

1. Seung-Gi Jin, Dean Pettinga, Jennifer Johnson, Peipei Li, Gerd P. Pfeifer. The major mechanism of melanoma mutations is based on deamination of cytosine in pyrimidine dimers as determined by circle damage sequencing. Science Advances, 2021; 7 (31): eabi6508 DOI: 10.1126/sciadv.abi6508

https://www.sciencedaily.com/releases/2021/07/210730142042.htm

Early COVID-19 symptoms differ among age groups

 Symptoms for early COVID-19 infection differ among age groups and between men and women, new research has found. These differences are most notable between younger age groups (16 to 59 years) compared to older age groups (60 to 80 years and over), and men have different symptoms compared to women in the early stages of COVID-19 infection.

The paper, published today in The Lancet Digital Health, and led by researchers from King's College London analyses data from the ZOE COVID Symptom Study app between April 20th to 15th October 2020. App contributors are invited to get tested as soon as they report any new symptoms, thanks to a joint initiative with the Department of Health and Social Care. The researchers modelled the early signs of COVID-19 infection and successfully detected 80% of cases when using three days of self-reported symptoms.

Researchers compared the ability to predict early signs of COVID-19 infection using current National Health Service UK diagnostic criteria and a Hierarchical Gaussian Process model, a type of machine learning.

This machine learning model was able to incorporate some characteristics about the person affected, such as age, sex, and health conditions, and showed that symptoms of early COVID-19 infection are different among various groups.

18 symptoms were examined, which had different relevance for early detection in different groups. The most important symptoms for earliest detection of COVID-19 overall included loss of smell, chest pain, persistent cough, abdominal pain, blisters on the feet, eye soreness and unusual muscle pain. However, loss of smell lost significance in people over 60 years of age and was not relevant for subjects over 80. Other early symptoms such as diarrhoea were key in older age groups (60-79 and >80). Fever, while a known symptom of disease, was not an early feature of the disease in any age group.

Men were more likely to report shortness of breath, fatigue, chills and shivers, whereas women were more likely to report loss of smell, chest pain and a persistent cough.

While these models were generated in the COVID Symptom study app, models were replicated across time suggesting they would also apply to non-app contributors. Although the models were used on the first strain of the virus and Alpha variants, the key findings suggest the symptoms of the Delta variant and subsequent variants will also differ across population groups.

Lead author, Claire Steves, Reader at King's College London said: "Its important people know the earliest symptoms are wide-ranging and may look different for each member of a family or household. Testing guidance could be updated to enable cases to be picked up earlier, especially in the face of new variants which are highly transmissible. This could include using widely available lateral flow tests for people with any of these non-core symptoms."

Dr Liane dos Santos Canas, first author from King's College London, said: "Currently, in the UK, only a few symptoms are used to recommend self-isolation and further testing. Using a larger number of symptoms and only after a few days of being unwell, using AI, we can better detect COVID-19 positive cases. We hope such a method is used to encourage more people to get tested as early as possible to minimise the risk of spread."

Dr Marc Modat, Senior Lecturer at King's College London, said: "As part of our study, we have been able to identify that the profile of symptoms due to COVID-19 differs from one group to another. This suggests that the criteria to encourage people to get tested should be personalised using individuals' information such as age. Alternatively, a larger set of symptoms could be considered, so the different manifestations of the disease across different groups are taken into account."

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Story Source:

Materials provided by King's College London. Note: Content may be edited for style and length.

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Journal Reference:

1. Liane S Canas, Carole H Sudre, Joan Capdevila Pujol, Lorenzo Polidori, Benjamin Murray, Erika Molteni, Mark S Graham, Kerstin Klaser, Michela Antonelli, Sarah Berry, Richard Davies, Long H Nguyen, David A Drew, Jonathan Wolf, Andrew T Chan, Tim Spector, Claire J Steves, Sebastien Ourselin, Marc Modat. Early detection of COVID-19 in the UK using self-reported symptoms: a large-scale, prospective, epidemiological surveillance study. The Lancet Digital Health, 2021; DOI: 10.1016/S2589-7500(21)00131-X

https://www.sciencedaily.com/releases/2021/07/210730165439.htm

Vax Alone Won't Counter Rise of Resistant Variants: Study

 Relaxation of nonpharmaceutical interventions once vaccination of the population has reached a tipping point short of herd immunity can increase the probability of the emergence of a resistant strain that natural selection then favors, according to new findings of a modeling study published online on July 30 in Scientific Reports.

Although vaccination is the best strategy for controlling viral spread, changes in our behavior and mindset will be increasingly required to stay ahead of vaccine-resistant strains, according to the four authors of the report.

"We have become accustomed to thinking of the pandemic from the point of view of epidemiology, and advised to reduce transmission and the number of people getting sick and the death rate. As the pandemic spreads across years, there will be a new dimension to our thinking, both for policymakers and the public. And that's the evolutionary perspective," said co-author Fyodor Kondrashov, PhD, an evolutionary biologist at the Institute of Science and Technology (IST), Klosterneuburg, Austria, at a press briefing Thursday.

The coming "change of mentality" that Kondrashov foresees should reassure people that masking and social distancing even after being vaccinated aren't futile. "It decreases the possibility that a vaccine-resistant strain is running around. We're not just trying to prevent the spread, but the evolution of novel variants, which are so rare at this point that we haven't yet identified them," he said.

The study focused on evolution generically, rather than on specific variants. "We took the classical model used to study epidemiology of pandemics, the SIR [susceptible, infected, recovered] model, and we modified it to study the dynamics of rare mutations associated with emergence of a vaccine-resistant strain," Simon A. Rella, the lead author of the study and a PhD student at IST, explained at the briefing.

The researchers simulated the probability that a vaccine-resistant strain will emerge in a population of 10,000,000 individuals over 3 years, with vaccinations beginning after the first year. For eight scenarios, rates of infection, recovery, death, vaccination, and mutation and the percentage of individuals with resistant viral strains were factors in the model.

The model also simulated waves of low and high transmission, similar to the effects of large-scale interventions such as lockdowns.

Three Factors

The study showed that a trio of factors increases the probability of a vaccine-resistant strain taking hold:

• Slow rates of vaccination

• High number of infected individuals

• Faster mutation rate

These factors, Rello said, are obvious to some degree. "Every infected individual is like a mini-bioreactor, increasing the risk that mutations will appear that will endow the virus with the property of avoiding the immune system primed by a vaccine," he said.

Not as obvious, Rello added, is that when most people are vaccinated, a vaccine-resistant strain has an advantage over the original strain and spreads faster.

But we can stop it, he said. "Our model shows that if at the time a vaccine campaign is close to finishing and nonpharmacological interventions are maintained, then there's a chance to completely remove the vaccine-resistant mutations from the virus population."

In scenarios in which a resistant strain became established, resistance initially emerged after about 60% of the population had been vaccinated. That makes nonpharmaceutical interventions such as masking and social distancing vitally important. Just under 50% of the US population over the age of 12 has been fully vaccinated, according to the Centers for Disease Control and Prevention.

"Our results suggest that policymakers and individuals should consider maintaining non-pharmaceutical interventions and transmission-reducing behaviors throughout the entire vaccination period," the investigators conclude.

A "Powerful Force"

"We hope for the best, that vaccine resistance has not developed, but caution that evolution is a very powerful force, and maintaining some precautions during vaccination may help to control that evolution," said Kondrashov.

The investigators are relying on epidemiologists to determine which measures are most effective.

"It's necessary to vaccinate as many people as fast as possible and as globally as possible and to maintain some level of nonpharmaceutical intervention to ensure rare variants have a chance to be suppressed instead of spread," concluded Kondrashov.

He's pessimistic because many countries are still having difficulty accessing vaccines, and vaccine efficacy wanes slightly over time. The authors warn that "the emergence of a partially or fully vaccine-resistant strain and its eventual establishment appears inevitable."

The worst-case scenario is familiar to population biologists: rounds of "vaccine development playing catch up in the evolutionary arms race against novel strains," the authors write.

Limitations of the study are that some parameters of the rate of evolution for vaccine-resistant strains aren't known, and in creating the model, consideration was not given to effects of increased testing, rigorous contact tracing, rates of viral genome sequencing, and travel restrictions.

Rather, the model illustrates general principals by which vaccine resistance can evolve, Kondrashov said.

Sci Rep. Published online July 30, 2021. Full text

https://www.medscape.com/viewarticle/955777

Molina sees bump in coronavirus inpatient costs as delta variant takes hold

 

• A rebound in healthcare utilization and increased COVID-19 inpatient costs weighed on Molina's bottom line for the second quarter of 2021 compared to the prior-year period, the insurer reported Thursday. Those trends led to a higher medical cost ratio of 88.4%.   
• Still, the California-based insurer posted a profit of $185 million for the quarter, down from $276 million when insurers were benefiting financially from the pandemic amid steep declines in patient care.
• The company again upped its guidance for the full year, now expecting to generate an additional $1 billion in revenue as it continues to benefit from a few tailwinds, including policy decisions that bar states from kicking Medicaid members off coverage during the duration of the COVID-19 public health emergency. 

As the healthcare sector keeps a close watch on utilization, Molina CEO Joseph Zubretsky has been cautious about predicting medical usage among members as the pandemic unfolds, though he provided some color on these trends for the second quarter. 

Molina experienced high COVID-19 inpatient-related costs early in the second quarter, which tapered off as the quarter went on. Overall, the direct costs spent on COVID-19 inpatient care for the quarter totaled $95 million. 

There were also increases in outpatient costs, which may signal a return to normal in pre-COVID utilization patterns, executives said. 

Zubretsky noted that although Molina is seeing the delta variant show up in infection rates, fewer of those cases are resulting in hospital stays. 

And for the cases that do lead to a hospital admission, the length of stay is shorter and fewer end up in the intensive care unit or on a ventilator, suggesting lower acuity, he said.  

"So while we're seeing a prevalence of delta variant COVID-related cases, the severity of those cases is a lot lower than the severity of the cases earlier the pandemic," Zubretsky said on an investor call Thursday. 

Centene, a Molina competitor, saw more members return for in-person care, which executives called pent up demand. That higher utilization, particularly among those insured with Affordable Care Act marketplace plans, spurred a second-quarter loss for Centene.  

Molina continues to see membership growth and added 1.1 million members compared with the prior-year period. That added onto the robust membership growth in the first quarter of the year thanks in part to its takeover of a Kentucky Medicaid plan. 

The large jump in members in the first quarter spurred the insurer to boost its outlook for the full year, expecting to bring in an additional $1 billion. Molina again boosted expectations Thursday, expecting to bring in another additional $1 billion in revenue. Full year revenue is now expected to exceed $26 billion.

Medicaid insurers have benefited from certain policy decisions that allow Medicaid members to keep their coverage throughout the duration of the public health emergency. As a result, insurers have reported large increases in Medicaid membership during this time. 

Plus, insurers like Molina and Centene have been able to pick up more marketplace members thanks to the special enrollment period enacted by President Joe Biden in response to fallout from the pandemic. The special enrollment period will end Aug. 15. 

Molina ended the quarter with 4.7 million members. 

https://www.healthcaredive.com/news/molina-sees-bump-in-coronavirus-inpatient-costs-as-delta-variant-takes-hold/604068/

Cerner reports $1.5B in revenue, raises full-year guidance

 

• Cerner beat Wall Street expectations on earnings and revenue in second-quarter results released Friday, reporting a topline of $1.5 billion, up almost 10% year over year, though net income plummeted as restructuring charges dragged on the health IT giant's margin.
• Management chalked the revenue growth up to Cerner's ongoing business improvement initiatives and a strengthening market presence, though the year-over-year hike was also due to the second quarter last year including the biggest hit on Cerner's business from COVID-19.
• The Kansas City, Missouri-based EHR vendor raised its full-year earnings guidance following the results, while its 2021 revenue forecasts remained unchanged. Cerner expects revenue growth in the mid-single digits, implying the majority of growth in the fourth quarter, analysts said.

Cerner's revenue was depressed last year as hospitals, slammed by COVID-19, spent less on their IT and data infrastructures to prioritize the pandemic response. Leadership said they hoped hospital budgets would recover in 2021, allowing both old and new clients to invest more heavily in software — a key priority for Cerner, which continues to expand its data-as-a-service offerings as it pivots away from its legacy EHR business.

The second quarter seemed to include said about-face for Cerner's health system clients, management said.

"Volume levels are returning to pre-COVID levels and so people are feeling good about core aspects of the business on the provider side and how it's recovering from the disruption last year, but I think at the same time watching with a wary eye as the delta variant plays forward," Cerner President Don Trigg told investors on a Friday morning call.

Strong bookings in the second quarter, up 2% to almost $1.4 billion, represent a "positive inflection point" since total bookings were down overall in 2019 and 2020, CFO Mark Erceg said on the call. And Cerner has nabbed 24 new client footprints and finished 49 major go-lives so far in 2021, according to outgoing CEO Brent Shafer.

Shafer announced in May he would be stepping down once a successor is found, updating investors Friday "it's difficult to provide an exact timeline" on when that would be due to the complexity and ongoing nature of the search process.

Moving forward, Cerner leadership said their clients were showing greater interest in areas like consumer strategies, provider networks in value-based and fee-for-service arrangements and cybersecurity. The latter is of particular interest, management said, due to the lack of a market leader for cybersecurity in healthcare and a rising level of attacks.

"This is an interesting space," Trigg said. "We’re thinking a lot about it and we see organic opportunities to drive business there."

Another focus area for the four-decade-old vendor is data analytics. Cerner completed onboarding Kantar Health, a data analytics company it purchased in December for $375 million in cash as a key building block of its data monetization strategy, in the second quarter.

Analyzing that business post-close has "given us a clear view into data services ... That's an area where we'll take a hard look at where inorganic acquisition can help us move faster," Trigg said. Cerner's goal is to eventually grow into a $1 billion data business for the health and life sciences industries, executives said during J.P. Morgan's healthcare conference in January.

However, some analysts called Cerner's growth outlook for the remainder of 2021 soft. In the third quarter, the vendor expects revenue to grow 6% year over year, implying about $1.45 million in revenue, well below analyst estimates, SVB Leerink analyst Stephanie Davis said in a note on the results.

That also implies a "meaningful acceleration" in the fourth quarter, "which we view as a reach given [Cerner's] track record of single digit growth," Davis said.

Cerner's restructuring charges dragged on its margin in the second quarter. The vendor had an operating margin of 3.4%, down significantly from 11% in the second quarter last year, reflecting impacts from employee separation packages, an impairment related to sold properties and eliminating redundant products and features.

That contributed to a net income drop of 76%, to $32.7 million from a profit of $134.8 million during the same time last year.

However, the cost savings initiatives — including the severance of about 500 people, and the elimination of 300 open positions — should result in annualized savings of about $70 million for Cerner, Erceg said.

In the second quarter, Cerner's professional services division led the company's revenue drivers at $537.1 million, followed by managed services at $320.8 million, support and maintenance at $259.6 million and licensed software at $175.2 million.

Also on the call, management updated investors on the status of its beleaguered $16 billion project to create and implement a new EHR for the Department of Veterans Affairs. The VA told Congress earlier this month it wasn't scheduling any more deployments of its new Cerner EHR for six months, following recent watchdog reports highlighting snowballing spending and shoddy staff training at the record's first go-live at a VA medical center in Spokane, Washington.

The Office of the Inspector General findings "were generally not technology related," Shafer said, noting while the VA worked to finalize new governance Cerner would continue to work on predeployment. "But no further go-lives are expected until 2022," Shafer said.

Recently, the vendor has gained on renewed takeover speculation.

https://www.healthcaredive.com/news/cerner-reports-15b-in-revenue-raises-full-year-guidance/604180/