How to reduce respiratory infection risk during the holiday season

As we prepare for our third holiday season during the pandemic, people are thinking about how to address the risk of COVID-19. Holiday events may include high-risk individuals:

• The elderly
• The very young
• Those who are immune compromised

To address these risks, I compiled common questions and included answers from experts that I trust.

1. 01

   Test or no test?

   STAT, a trusted health, medicine and life sciences news site, reports that two-thirds of the 34 infectious disease experts who responded to its survey were doing at-home rapid COVID-19 testing before their holiday gatherings. The home antigen tests are less sensitive early after infection, so it’s best to test more than once (separated by 48 hours, if you can).

   Many experts also recommend testing after such gatherings. Jeremy Faust, MD, suggests daily testing for five to six days, but others suggest testing three to four days after exposure. Anyone testing positive after a family gathering should notify other attendees so that they can test, too.

   Regardless of COVID-19 test results, if anyone has respiratory symptoms or feels sick, they should stay home. Influenza infections are quite high right now, and there is currently no home test for flu.

2. 02

   Mask or no mask?

   STAT reports that the vast majority of experts surveyed are masking in stores and crowded places; and all but one of their experts masked on planes. Some experts recommend masking in the days leading up to the holidays to avoid bringing COVID-19 or other respiratory diseases like influenza and respiratory syncytial virus (RSV) to a gathering. Epidemiologist Katelyn Jetelina reminds us that an N95, KN95 or KF94 mask is far better than other alternatives. Those who are immune compromised might want to mask when they are not eating or drinking during holiday gatherings.

   If you are traveling on a plane, train or other public conveyance, consider wearing the most protective mask that you can comfortably use. With planes at capacity, masks in the airport and on the plane will lower your risk of any respiratory infection.

3. 03

   Increase ventilation

   Opening a window in a car or a home can dramatically improve air exchange and therefore decrease risk of COVID-19, flu or RSV transmission. HEPA filters can help in the home. Some are even using portable carbon dioxide meters to determine if ventilation is adequate. Outdoor air has a carbon dioxide level of about 400 parts per million (ppm), and it’s best to ventilate to keep indoor air at about 800 ppm or less.

4. 04

   What about vaccination?

   All the experts surveyed by STAT either already had their bivalent booster or planned to get it before the holidays. I got my bivalent booster earlier this fall. But the case for excluding unvaccinated family members is not especially strong. Almost all unvaccinated people at this point have at least some antibodies from past infection. And even those who are vaccinated and boosted can bring an infection to the family gathering. Many of the experts reported all family members were vaccinated and boosted, making this a nonissue for them.

5. 05

   Where does handwashing fit in?

   Influenza and RSV can be transmitted through contact with surfaces – so handwashing and hand sanitizer remain a good idea.

For more information, you can refer to the following sources:

• Your Local Epidemiologist
• Inside Medicine
• STAT survey
• Force of Infection
• Ground Truths
• Holiday advice, Centers for Disease Control and Prevention

Using ‘nudges’ to encourage employees to participate in diabetes programs

Jessica Jones, MA, Sam Sherman, MBA, and I coauthored the article, Increasing Engagement in Diabetes Programs with Behavioral Economics, published last month in WorldAtWork. To boost program engagement, decrease risk and improve outcomes for employees with diabetes or at risk of diabetes, we suggest the following actions:

• Provide easy access to high quality, affordable programs
• Communicate the value of participation  
• Craft communications that leverage optimism bias 
• Use stories to motivate  
• Use social networks to nudge behaviors
• Appeal to intrinsic motivation to drive change

New hemophilia drug might be curative, although the price is very high

Recently, the Food and Drug Administration (FDA) approved Hemgenix (enternacogene dezaparvovec), the first treatment likely to lead to long-term remission of (or even cure) hemophilia B. Hemophilia is a rare genetic disease that usually affects only men. It is usually hereditary, although there are rare cases of spontaneous mutations. Those with severe hemophilia are unable to clot their blood, so minor injuries can lead to life-threatening bleeding. Hemophilia can also cause bleeding in joints and organs that can lead to severe disabilities or even death.

Hemgenix is given as a one-time dose and will be priced at $3.5 million per patient. The drug is an intravenous infusion of a virus that delivers genetic material to the liver, which then manufactures the missing blood clotting factor. This new drug is appropriate only for severe cases of hemophilia B (also called Factor 9 deficiency or Christmas disease), which affects about one in 19,000 males at birth. There are likely under 7,000 males in the U.S. with hemophilia B (3.7 per 100,000 males), and not all of them have severe disease.

Currently, the treatment for hemophilia B is intravenous infusion of clotting factor concentrate, which can be made from pooled human blood serum or made in a lab (recombinant). This costs, on average, over $300,000 per person per year, and can rise to over $1 million a year for those who develop an immune response to clotting factor. Lifetime treatment costs may be over $20 million for an individual. Patients who are successfully treated with Hemgenix will be able to avoid frequent medical visits for evaluation and treatment infusions; however, the drug is new, so we don’t know how long the effects will last.

This is amazing medical progress. While the price of this genetic therapy is high, it is much lower than the price of ongoing infusions. The Institute for Clinical Evaluation and Research, a nonprofit research group independent of the pharmaceutical industry, estimates that the therapy would be effectively priced at $2.9 million to $4 million per person. Most of the justification for this high cost is due to the high price of current treatments, which some policymakers feel is unjustified.

Other expensive genetic therapies likely to be approved in the coming year include treatments for hemophilia A, which is four times more common than hemophilia B, and sickle cell anemia.

Implications for employers

• Hemgenix and other genetic therapies in the pipeline will pose a serious challenge to employer-sponsored health insurance plans. Most employees with employer-provided coverage have health plans that are self-insured and a large, unexpected expense like this therapy could overwhelm efforts to effectively manage health care costs.
• Employers that purchase reinsurance can review their policies to be sure that this and other genetic therapies are covered.
• Some employers who have previously opted not to purchase reinsurance might reconsider, as unexpected “shock” claims from new genetic therapies will increase in the coming years.
• A number of insurers are offering reinsurance for specific medications, which might include such pharmaceuticals as Hemgenix, Luxturna (for hereditary blindness), and Zolgensma (for spinal muscular atrophy). Employers considering these should review coverage carefully to be sure that they are not purchasing coverage that duplicates or conflicts with existing reinsurance.

Author

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Jeff Levin-Scherz, MD

Population Health Leader, Health and Benefits, North America

Jeff is an internal medicine physician and has led WTW’s clinical response to COVID-19 and other health-related topics. He has served in leadership roles in provider organizations and a health plan and is an Assistant Professor at Harvard Chan School of Public Health.

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