460 - COVID Testing & Isolation, Loneliness & Health, Intentional Gathering

From the Literature

1)  COVID-19 Rapid Antigen Testing and Isolation

Two and a half years into this pandemic, we are anxious for a stronger evidence base for the rules and restrictions under which we have been living. For people with mild COVID-19 or asymptomatic with a positive test, the Centers for Disease Control and Prevention (CDC) recommends full isolation until day 5. For those with mild symptoms who are recovering (no fevers for 24 hours and symptoms are improving), they must wear a tight-fitting mask when around others through day 10.

The authors of a small (40 subjects) cohort study in Massachusetts evaluated a group of these patients with both rapid antigen testing (RAT) and viral culture at 6 and 14 days post symptom onset (or asymptomatic positive test). This was a healthy, young cohort, using self-testing methods so generalizability is limited. The study occurred during an Omicron BA.1 wave.

The authors found:

·       At 6 days:

o   only 75% of patients were positive by RAT

o   35% had positive cultures.

o   No one with negative RAT had positive cultures, but 50% of those with positive RAT had positive cultures.

·       At 14 days:

o   All patients were negative by RAT by the 14^th day.

o   68% of patients until day 14 had positive RAT even without symptoms.

There was no association of any of the results with patient age, time since last vaccination, or cycle threshold levels on testing (a marker of viral load).

The authors conclude that the five-day guidance to discontinue isolation results in a significant number of patients with culturable virus re-entering the population.

John’s Comments:

Early in a new epidemic/pandemic, public health agencies are expected to need to create guidance based on lower quality evidence or expert opinion. However, this pandemic has seen the development of living systematic reviews, daily updated data sites, and pragmatic ongoing controlled trials of therapies all with the purpose of more rapidly providing new evidence on which to base guidelines. The goal of simple, consistent public health messaging must be balanced against the need for guidelines based on evidence.

Reference:

·       Cosimi LA, Kelly C, Esposito S, et al. Duration of Symptoms and Association With Positive Home Rapid Antigen Test Results After Infection With SARS-CoV-2. JAMA Netw Open. 2022;5(8):e2225331. Link

·       CDC. Isolation. Centers for Disease Control and Prevention. Published August 11, 2022. Accessed August 17, 2022. Link

From the Literature and the American Heart Association (AHA)

2)  Isolation, Loneliness, and the Impact on CV and Brain Health

Social isolation is defined as the objective state of having few or infrequent social contacts.  Loneliness is perceived isolation that is distressing for the individual. Individuals can lead a relatively isolated life and not feel lonely; conversely, individuals with many social contacts may still experience loneliness. Both social isolation and loneliness denote some degree of social disconnection.

Social isolation and loneliness are common, and the risk for each appears highest for the young and the old.  Among community-dwelling adults > 65, the prevalence rates for loneliness in different surveys range from 22-47%.  Data suggest that social isolation and loneliness may have increased since the start of the COVID‐19 pandemic, particularly among young adults (18–25 years of age), older adults, women, and low‐income individuals. 

 More than 4 decades of research have documented robust evidence that lack of social connection, using measures of social isolation, is associated with increased risk of premature death from all causes, as well as other adverse health outcomes.  This data was summarized in a National Academies of Sciences, Engineering, and Medicine (NASEM) consensus study in 2020 (3^rd reference).  This study did not focus specifically on the impact of social isolation and loneliness on cardiovascular (CV) and brain health, though other studies have shown an impact on both risk of incident CV and cerebrovascular disease, as well as prognosis once disease manifests.

 This recently published statement from the AHA builds upon and extends the NASEM consensus study and seeks to (1) critically review research that examines direct associations and mediating pathways between social isolation, loneliness, and CV and brain health and (2) highlight, where available, studies of their impact on CV and brain health in special populations. 

The authors found that the evidence is most consistent for a direct association between social isolation, loneliness, and CVD and stroke mortality.  Data on the association between social isolation and loneliness with heart failure, dementia, and cognitive impairment are sparse and less robust.  Few studies have empirically tested mediating pathways between social isolation, loneliness, and CV and brain health.  Research in groups that may be at higher risk or more vulnerable to the effects of social isolation is limited.  The authors did not find any intervention studies that sought to reduce the adverse impact of social isolation or loneliness on CV or brain health outcomes.

The statement concluded that social isolation and loneliness appear to be independent risk factors for worse CV and brain health; however, consistency of the associations varies by outcome. There is a need to develop, implement, and test interventions to improve CV and brain health for individuals who are socially isolated or lonely.

Mark’s Comments:

I choose to highlight this paper due to its provocative premise as well as the figure below, originally from the 2^nd reference, which was included and expanded upon.  This framework proposes that social isolation and loneliness impact CV and brain health through multiple and divergent pathways, including behavioral, psychological, and physiological effects.  When we consider lifestyle interventions for individual patients, key healthy social relationships are often overlooked, and this paper serves as a reminder that their lack can have significant potential downstream health effects.  When viewed on a population scale (looking at the prevalence rates for loneliness), the positive impact of effective interventions on health could be substantial.  What if everyone had at least one buddy?!

References:

·       Cene C, et al.  Effects of Objective and Perceived Social Isolation on Cardiovascular and Brain Health: A Scientific Statement From the American Heart Association.  JAHA published ahead of print 4 August 2022.  Link

·       Hodgson S, et al.  Loneliness, social isolation, CV disease and mortality: a synthesis of the literature and conceptual framework. J R Soc Med. 2020; 113:185–192. Link

·       National Academy of Sciences Engineering and Medicine. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. The National Academies Press; 2020. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Making the Most of Our Time Together

“The first step in convening people meaningfully is committing to a bold, sharp purpose.” – Priya Parker, The Art of Gathering:  How We Meet and Why it Matters

“It’s been great meeting in person again!” a colleague enthusiastically shared recently.  “I miss the convenience and casual nature of virtual,” lamented another. The contrast was striking.  They were talking about the same meeting and coming to two very different conclusions.  I’ve found this difference of perspective is not unique, and has left me reflecting on my own recent experience.     

For me, trying to find a rhythm as we begin to create our “new normal” has been mixed bag.  I’ve recently attended both a leadership retreat and a professional conference that would not have been nearly as impactful had they been held on a virtual platform, and yet I’ve also attended recent live, virtual, and “hybrid” meetings that have felt unfocused, inefficient, ineffective, or even unnecessary.  In some cases, I’ve even felt less rather than more connected with the others in attendance at the end of the meeting.  

In her provocative book The Art of Gathering, author Priya Parker shares the following reflection:  “Why do we gather? We gather to solve problems that we can't solve on our own.  We gather to celebrate, to morn, and to mark transitions. We gather to make decisions.  We gather because we need one another. We gather to show strength. We gather to honor and acknowledge. We gather to build companies, and schools, and neighborhoods. We gather to welcome and we gather to say goodbye. .. But here's the great paradox of gathering. There are so many good reasons for coming together that often we don't know precisely why we're doing so.”

In other words, we regularly gather because we are a “gathering species” – being socially connected is coded into our DNA.  However, we also know that not all gatherings are created equal.  Consider some of your recent significant times together with colleagues, family, friends, and neighbors.  Why did you gather?  Were there explicit and mutually understood intentions for those times, or did they seem routine, even mundane?  Having a clear and commonly shared understanding of purpose can allow you to ensure the design and structure of the time together fits with the intention for which you are gathering.  Without being specific about those details and planning accordingly, there can be inadequate preparation, misaligned expectations, and the risk of squandering an opportunity not only for any connection, but for more deeply meaningful connection. 

In these challenging times, we need all the meaningful connection we can get.  So this week as you come together with others in many different settings (including both live and virtual), ask yourself not only the purpose of the gathering, but also how the process might best be structured to meet that purpose.  Then prepare yourself and the other participants so you can show up as your best selves.  As Priya Parker notes, “Gatherings consume our days and help determine the kind of world we live in.”  Let’s choose wisely and intentionally to create a world where we make the most of our time together, one gathering at a time ….

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org