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Why Veterans Are Particularly Vulnerable to the Coronavirus (COVID-19) Pandemic

 

Military personnel step out of a tent set up at the back entrance to the Holyoke Soldiers home in Holyoke, Massachusetts, on March 3, 2020. Forty-seven had died of the virus at the state-run home for veterans as of April 17. 


May 26, 2020--- Erin Clark for The Boston Globe via Getty Images

 

As the nation took a day to memorialize its military dead, those who are living are facing a deadly risk that has nothing to do with war or conflict: the coronavirus (COVID-19). Different groups face different degrees of danger from the pandemic, from the elderly who are experiencing deadly outbreaks in nursing homes to communities of color with higher infection and death rates.

 

Veterans are among the most hard-hit, with heightened health and economic threats from the pandemic. These veterans face homelessness, lack of health care, delays in receiving financial support and even death. I have spent the past 4 years studying veterans with substance use and mental health disorders who are in the criminal justice system. This work revealed gaps in health care and financial support for veterans, even though they have the best publicly funded benefits in the country.

 

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Here are 8 ways the pandemic threatens veterans:

  

1. Age and Other Vulnerabilities

In 2017, veterans’ median age was 64, their average age was 58 and 91% were male. The largest group served in the Vietnam era, where 2.8 million veterans were exposed to Agent Orange, a chemical defoliant linked to cancer. Younger veterans deployed to Iraq and Afghanistan were exposed to dust storms, oil fires and burn pits with numerous toxins, and perhaps as a consequence have high rates of asthma and other respiratory illnessesAge and respiratory illnesses are both risk factors for COVID-19 mortality. As of May 22, 2020 there have been 12,979 people under Veterans Administration (VA) care with COVID-19, of whom 1,100 have died.

 

2. Dangerous Residential Facilities

Veterans needing end-of-life care, those with cognitive disabilities or those needing substance use treatment often live in crowded VA or state-funded residential facilities.

State-funded "soldiers’ homes” are notoriously starved for money and staff. The horrific situation at the soldiers’ home in Holyoke, Massachusetts, where more than 79 veteran residents have died from a COVID-19 outbreak, illustrates the risk facing the veterans in residential homes.

 

3. Benefits Unfairly Denied

When a person transitions from active military service to become a veteran, they receive a Certificate of Discharge or Release. This certificate provides information about the circumstances of the discharge or release. It includes characterizations such as "honorable,” "other than honorable,” "bad conduct” or "dishonorable.” These are crucial distinctions, because that status determines whether the Veterans Administration will give them benefits.

 

Research shows that some veterans with discharges that limit their benefits have PTSD symptoms, military sexual trauma or other behaviors related to military stress. Veterans from Iraq and Afghanistan have disproportionately more of these negative discharges than veterans from other eras, for reasons still unclear.

 

The Veterans Administration frequently and perhaps unlawfully denies benefits to veterans with "other than honorable” discharges. Many veterans have requested upgrades to their discharge status. There is a significant backlog of these upgrade requests, and the pandemic will add to it, further delaying access to health care and other benefits.

 

4. Diminished Access to Health Care

Dental surgery, routine visits and elective surgeries at VA medical centers were postponed since March. VA hospitals are understaffed – just before the COVID-19 pandemic, the VA reported 43,000 staff vacancies out of more than 400,000 health care staff positions. Access to health care will be even more difficult when those medical centers finally reopen because they may have far fewer workers than they need. As of May 4, 2020, 2,250 VA health care workers have tested positive for COVID-19, and thousands of health care workers are under quarantine. The VA is asking doctors and nurses to come out of retirement to help understaffed hospitals.     

 

5. Mental Health May Get Worse

An average of 20 veterans die by suicide every day. A national task force is currently addressing this scourge. But many outpatient mental health programs are on hold or being held virtually. Some residential mental health facilities have closed. Under these conditions, the suicide rate for veterans may grow. Suicide hotline calls by veterans were up by 12% on March 22, just a few weeks into the crisis.

 

6. Complications for Homeless Veterans and Those in the Justice System

An estimated 45,000 veterans are homeless on any given night, and 181,500 veterans are in prison or jail. Thousands more are under court-supervised substance use and mental health treatment in veterans treatment courts. More than half of veterans involved with the justice system have either mental health problems or substance use disorders. As residential facilities close to new participants, many veterans eligible to leave prison or jail have nowhere to go. They may stay incarcerated or become homeless.

 

Courts have moved online or ceased formal operations altogether, meaning no veteran charged with a crime can be referred to a treatment court. It is unclear whether those who were already participating in a treatment program will face delays graduating from court-supervised treatments. Further, some veterans treatment courts still require participants to take drug tests. With COVID-19 circulating, those participants must put their health at risk to travel to licensed testing facilities.

 

7. Disability Benefits Delayed

In the pandemic’s epicenter in New York, tens of thousands of veterans should have access to VA benefits because of their low income – but don’t, so far. The COVID-19 pandemic has exacerbated existing delays in finding veterans in need, filing their paperwork and waiting for decisions. Ryan Foley, an attorney in New York’s Legal Assistance Group, noted that these benefits are worth "tens of millions of dollars to veterans and their families” in the midst of a health and economic disaster. All 56 regional VA offices are closed to encourage social distancing.

 

Compensation and disability evaluations, which determine how much money veterans get, are usually done in person. Now, they are done electronically, via telehealth services in which the veteran communicates with a health care provider via computer. But getting telehealth up and running takes time, adding to the longstanding VA backlog. More than 100,000 veterans wait more than 125 days for a decision. (That is what the VA defines as a backlog – anything less than 125 days is not considered a delay on benefit claims.)

 

8. Economic Catastrophe

There are 1.2 million veteran employees in the 5 industries most severely affected by the economic fallout of the coronavirus. A very high number of post-9/11 veterans live in some of the hardest-hit communities that depend on these industries. Veterans returning from overseas will face a dire economic landscape, with far fewer opportunities to integrate into civilian life with financial security.

 

In addition, severely disabled veterans living off VA benefits were initially required to file a tax return to get stimulus checks. This initial filing requirement delayed benefits for severely disabled veterans by a month. The IRS finally changed the requirements after public outcry, given that many older and severely disabled veterans do not have access to computers or the technological skills to file electronically.

 

There are many social groups to pay attention to, with their own problems to face. With veterans, many problems they face existed long before the coronavirus arrived on U.S. shores. With the challenges posed by the situation today, veterans who were already lacking adequate benefits and resources are now in deeper trouble, and it will be harder to answer their needs.

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Kenneth Braithwaite Confirmed as Next U.S. Secretary of the NavyKenneth J. Braithwaite speaks during a dinner reception aboard the USS Iwo Jima.

Kenneth J. Braithwaite, then the U.S. ambassador to Norway, speaks during a dinner reception aboard the Wasp-class amphibious assault ship USS Iwo Jima November 15, 2018. (U.S. Navy/Mass Communication Specialist Seaman Apprentice Travis Baley)

 

May 22, 2020 --- Stars and Stripes | By Caitlin M. Kenney

 

WASHINGTON -- Kenneth Braithwaite was confirmed by the Senate in a voice vote Thursday afternoon to be the 77th Navy Secretary. Braithwaite is a 1984 graduate of the U.S. Naval Academy and served in the Navy and then Navy Reserve for 27 years. While serving as the U.S. ambassador to Norway, Trump nominated him March 2nd to be the next Navy secretary.

 

In his opening statement to members of the Senate Armed Services Committee during his nomination hearing May 7th, Braithwaite said the Navy is in "troubled waters" and listed some of the recent failings that he believes have caused a breakdown in trust in Navy leadership. His list included the Fat Leonard scandal, the 2017 collisions of the USS Fitzgerald and USS John S. McCain, as well as "judicial missteps" and the coronavirus (COVID-19) outbreak on the USS Theodore Roosevelt.

 

Braithwaite said his top priority would be to "restore the appropriate culture" in the service. Culture is what gives an organization a sense of belonging and good order and discipline, he said. "Navy culture exists. I won't say it's broken. I think it's been tarnished," Braithwaite said. "I think the events over the last several years have helped see that occur."

 

The Navy's recent Secretaries have been embroiled in controversies in the last several months. Richard Spencer, the last Navy secretary, was fired November 24, 2019 by the U.S. Defense Secretary Mark Esper for his handling of the personnel decision of Navy SEAL Chief Petty Officer Edward Gallagher, who was acquitted of murder in 2019 but found guilty of posing in a photo with the dead body of an Islamic State fighter.

 

Spencer had gone around Esper to propose a different strategy to the White House on handling Gallagher and the Navy's review of whether Gallagher would be able to retire with his SEAL trident pin. Former acting Navy Secretary Thomas Modly resigned April 7, 2020 after disparaging comments he made to the crew of the USS Roosevelt about the aircraft carrier's former Commander, Captain Brett Crozier, were leaked online. The Navy announced that the ship had left Guam nearly 2 months after coming into port due to a coronavirus outbreak that infected more than 1,000 sailors aboard the ship.

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FAQs About COVID-19

Answers to frequently asked questions based on the latest medical research and public health data

An illustrated pattern of coronaviruses over a pattern of question marks

 

Updated May 8, 2020--- Molly Walker, Associate Editor, MedPage

 

What about mild or asymptomatic cases of COVID-19?

Asymptomatic transmission has not only been confirmed in China, but recent modeling data found that mild or asymptomatic cases that went undetected ("undocumented") accounted for 85% of total infections in the earliest stages of the outbreak. The study found these cases were less infectious on a per-contact basis, but because those individuals were not isolated, they infected more people in total.

 

The big unknown, however, is how common it may be for people to become infected but with symptoms too mild to seek treatment. Currently, detection is based on molecular testing, which is performed only on individuals who come into contact with the healthcare system. The prevalence of such mild or asymptomatic infections will not be known until an inexpensive serological test, detecting antibodies to the virus that signal previous exposure, is available for use with routine blood draws. Thus, the extent of exposure in the population may not be known for years.

 

How do you contract COVID-19?

Research points to droplet and fomite transmission, with recent data suggesting the virus can survive on surfaces such as plastic and stainless steel for up to several days. It can also survive in the air for a few hours, indicating it may also potentially be aerosol transmissible. The virus may also be transmitted through the fecal-oral route, with research suggesting some patients develop gastrointestinal symptoms, and that the virus is shed through stool. A small cohort study in China found the virus present in 2 patients' tears, indicating it might be transmissible through eye secretions.

 

How infectious is the COVID-19 coronavirus?

Research from China found a similar viral load in symptomatic and asymptomatic patients, which may suggest patients can transmit the virus whether they have mild or severe disease. Latest news from the World Health Organization (WHO) estimated the "R0" as 2.0 to 2.5, meaning infected individuals transmit it to 2+ others on average. By contrast, the R0 for measles is 12-18, while for seasonal influenza it is a little over 1.

 

How virulent is COVID-19?

According to the Journal of American Medical Association (JAMA), global mortality for COVID-19 is reported to be 4.7%, and about 1.7% of patients died in the 1st  141,000 cases in the U.S., though the authors emphasized this was not an accurate case-fatality rate due to the uncertain denominator.

 

Centers for Disease Control & Prevention (CDC) examined the 1st 4,200 U.S. cases, and found 508 (12%) of patients were hospitalized, and of those, 121 were known to be admitted to an intensive care unit (ICU), and 44 patients died. Similar to China, both hospitalization and mortality rates increased with increasing age, though this data indicated 20% of hospitalized patients and 12% of patients admitted to an ICU were ages 20-44.

 

Nine patients ages 20-44 died, though in the entire group most deaths were among adults ages 65 and older. Notably, however, mortality rates vary dramatically from one country to another, raising more questions about case-finding and record-keeping than there are answers.

 

What are early symptoms of COVID-19?

In addition to fever, cough and shortness of breath, CDC now lists several other symptoms: chills, repeated shaking with chills, new loss of taste or smell, muscle aches, headache and sore throat.

 

Examining data from patients admitted in New York City, prior to respiratory symptoms, including about three-quarters presented with cough or fever, and almost 60% with shortness of breath. Gastrointestinal symptoms seem to be more common in U.S. patients, with about a quarter reporting diarrhea and 20% reporting vomiting. It appears not all patients present with symptoms, with research out of Germany in February finding patients testing positive for COVID-19 despite being afebrile and otherwise normal-seeming.

 

How is COVID-19 diagnosed?

CDC criteria for testing include hospitalized patients with symptoms of COVID-19, older symptomatic adults with chronic medical conditions and/or who are immunocompromised, and anyone who has been in close contact with a suspected or confirmed COVID-19 case within 14 days, including healthcare professionals, or anyone who has traveled to affected geographic areas within 14 days of symptom onset.

 

A patient is swabbed, then the sample is tested via reverse transcription polymerase chain reaction (RT-PCR) to determine presence of viral Ribonucleic Acid (RNA). The U.S. Food & Drug Administration (FDA) recently authorized the 1st serology test to detect Immunoglobulin M (IgM) and Immunoglobulin G (IgG) antibodies under Emergency Use Authorization, for diagnosing COVID-19 infection in combination with other clinical and lab data.

 

What are risk factors for more severe disease?

Reports from China indicate disease is much more severe in older patients, with the highest mortality rate among adults age 80+. Patients with other comorbidities are also the most at risk, with U.S. data finding hypertension and obesity were the most common chronic medical conditions among patients hospitalized with COVID-19, followed by chronic lung conditions, diabetes and cardiovascular disease.

 

Data out of New York City found obesity as a risk factor for mechanical ventilation. Patients requiring mechanical ventilation were also more likely to need vasopressors, and experienced other complications such as atrial arrhythmias and new renal replacement therapy.

 

What does severe disease look like?

JAMA detailed 21 patients from Washington state, 15 of whom needed mechanical ventilation. All 15 had acute respiratory distress syndrome, and eight developed severe Acute Respiratory Distress Syndrome (ARDS) by 72 hours. Vasopressors were used for 14 patients, though most patients did not present with evidence of shock, and 7 patients developed cardiomyopathy. Mortality among this group was 67%, 24% remained critically ill and 9.5% were discharged from the ICU, as of March 17, 2020.

 

In New York City, 33% of patients required intubation, and of these, 30% did not get supplemental oxygen, meaning they deteriorated quickly. However, U.K. research indicated a lower proportion of COVID-19 patients in the critical care unit survived compared to patients with non-COVID-19 viral pneumonia (52.1% vs 77.8%, respectively).

 

How is the disease treated?

Treatment mainly consists of supportive care, according to CDC recommendations. The most common complications of severe disease include pneumonia, hypoxemic respiratory failure/ARDS, shock, multiorgan failure. Since pneumonia is common, IV antibiotic use has been widely reported, along with supplemental oxygen, with anecdotal reports of proning and ultimately, mechanical ventilation, including some patients who receive extra corporeal membrane oxygenation (ECMO).

 

Although corticosteroids were widely used in China, the CDC generally recommends against them except in patients with steroid-responsive comorbidities such as septic shock. "Patients with MERS-CoV or influenza who were given corticosteroids were more likely to have prolonged viral replication, receive mechanical ventilation, and have higher mortality," whereas COVID-19 reports from China were uncontrolled and observational. Research indicates patients hospitalized with COVID-19 often develop blood clots, leading some international societies to call for patients to receive prophylactic anticoagulant treatment to prevent this complication.

 

What are potential therapeutic options for treating the virus?

There are currently no approved therapies to treat COVID-19. The U.S. National Institutes of Health (NIH) released treatment guidelines, which noted both insufficient clinical data to recommend for or against use of both Remdesivir and hydroxychloroquine (HCQ) and chloroquine. Specifically, the agency noted monitoring patients who receive HCQ for adverse effects, especially prolonged QTc interval. The FDA recently issued a warning about the heart risks of the drug.

 

NIH also said there is insufficient clinical data to recommend use of convalescent plasma or hyperimmune globulin, as well as interleukin-6 inhibitors and interleukin-1 inhibitors. The agency recommended against the use of hydroxychloroquine plus azithromycin, lopinavir/ritonavir (Kaletra) or other HIV protease inhibitors, interferons and Janus kinase inhibitors.

 

What is the status of clinical trials for these potential therapies?

Remdesivir has been available for compassionate use. An interim analysis of a formal trial from the National Institute of Allergy and Infectious Diseases including data from U.S. patients found remdesivir met its primary endpoint in severe COVID-19 patients, a significantly faster time to recovery versus controls, and trended towards a survival benefit.

 

Manufacturer Gilead Sciences also reported topline results from a phase III trial comparing 2 dosing regimens in severe cases, but without a usual-care control group, showing a trend favoring a 5- versus 10-day treatment period. Many hospitals have begun to use hydroxychloroquine or chloroquine, which is most commonly used to treat patients with malaria, as well as arthritis and systemic lupus erythematosus, although the supporting evidence is anecdotal at best.

 

The FDA has issued an Emergency Use Authorization for hydroxychloroquine held in the National Strategic Stockpile, although that does not make COVID-19 an approved indication. Latest data from the U.S. found no difference in risk of ventilation the drug in male veterans with severe COVID-19. A small case series in China found 3 of 5 patients treated with convalescent plasma were later discharged from the hospital, though questions about scaling this as a potential therapy remain.

 

Some centers have also tried anti-cytokine agents such as tocilizumab (Actemra) but evidence of benefit over standard treatment remains scant. Controlled trials with tocilizumab are now underway, including one sponsored by drug maker Genentech/Roche. Sanofi and Regeneron announced a phase II/III trial for sarilumab (Kevzara), another anti-interleukin-6 agent, for patients with severe COVID-19. The Milken Institute has collated currently ongoing trials for COVID-19 interventions on its website.

 

What are the vaccine prospects?

Several companies and public health agencies have vaccines in development, including the National Institute of Allergy and Infectious Diseases. Phase I trials with vaccines are underway, with a timeline of 12 to 18 months for a vaccine to be ready for wide-scale deployment. As of April 21, 2020 the Milken Institute counted 115 vaccine candidates in development, including 6 in phase I and 5 in phase I-II safety and efficacy studies in humans.

 

What is the prognosis for patients with COVID-19?

Older patients and those with other comorbidities are the most at risk, whereas the disease appears to be less severe among younger patients. U.S. data seems to indicate fewer children contract severe disease than adults, and hospitalization in this population is most common among infants and children with underlying conditions.  Research is starting to come from China that COVID-19 vertical transmission from mother to baby is possible, given several isolated case reports.

 

What are some potential complications of COVID-19?

Data from New York City indicated ST-segment elevation on the EKG was complex, and confirmed COVID-19 cases were complicated by ST-segment elevation, which could have indicated potential acute Medical Instability (MI).

 

Neurologic complications have been reported, with limited case reports from Italy linking COVID-19 infection to Guillain-Barré syndrome. And in China, more than 33% of confirmed COVID-19 cases had neurologic symptoms, such as acute cerebrovascular events, impaired consciousness and muscle injury, which were more common among patients who required mechanical ventilation.

 

What are the long-term sequelae of COVID-19?

It is unclear whether or how often COVID-19 survivors experience persistent pulmonary or other problems, or for how long. Many patients have remained hospitalized with the illness for weeks, out of an abundance of caution and for public health reasons.

 

Chinese Researchers pointed to cardiovascular system abnormalities in nearly 50% of a small group of Severe Acute Respiratory Syndrome (SARS) patients in a 12-year follow-up cohort, as well as 66% with high lipids and 60% with glucose metabolism problems. They suggested COVID-19 may also cause chronic damage to the cardiovascular system, as the virus has a similar structure to SARS.

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