After years of recommending that middle-aged and older Americans consider taking low-dose aspirin to prevent a first heart attack or stroke, an influential medical task force is planning to overhaul its guidelines, based on new studies that show that the risks may greatly reduce or cancel out the benefits.
“Our message ... is if you don’t have a history of heart attack and stroke, you shouldn’t be starting on aspirin just because you reach a certain age,” said Chien-Wen Tseng, a member of the U.S. Preventive Services Task Force (USPSTF), an independent panel composed of experts in disease prevention and evidence-based medicine whose recommendations can influence medical practices and insurance coverage related to preventive measures.
The change in recommendations could potentially affect millions of people nationwide. Heart disease is the leading cause of death in the United States, killing roughly 659,000 people each year, according to the Centers for Disease Control and Prevention. Separately, strokes rank fifth among other causes of death in the U.S., with about 150,000 fatalities yearly. “Every year, an estimated 1.2 million people experience a first heart attack or stroke, so we’re talking about something pretty serious,” Tseng said.
According to the task force’s draft recommendation, a review of the latest scientific evidence found that starting to regularly take low-dose aspirin — 81 milligrams to 100 milligrams — to prevent a first heart attack or stroke may have only a “small net benefit” for people ages 40 to 59 who are at risk for cardiovascular disease. The task force emphasized that patients should make decisions about taking aspirin only in consultation with their health-care provider.
Aspirin is a blood thinner and can help head off heart attacks and strokes by preventing clots from forming in the blood vessels that lead to the heart or brain.
But taking aspirin also can cause major bleeding that can be fatal, especially in older people, said Tseng, a professor in the Department of Family Medicine and Community Health at the University of Hawai’i John A. Burns School of Medicine. That’s why, in another noteworthy change, the task force is now saying adults 60 or older shouldn’t start taking aspirin daily to lower the chances of a first heart attack or stroke, concluding that there is “no net benefit” in doing so. “At that point, the higher risk of bleeding with age actually cancels out the potential benefit of aspirin,” Tseng said.
The draft recommendations do not apply to people who have had a heart attack or stroke in the past and are now taking daily aspirin. And Tseng said people without a history of heart attack or stroke who are already taking preventive doses should not stop without consulting with their doctor.
One of the main goals of the task force’s proposed recommendations, Tseng said, is “to get people to talk with their clinicians instead of just buying a bottle off the shelf and saying, ‘I should be on aspirin.’ ”
The draft recommendation statement, which is open for public comment until Nov. 8, marks a significant change from the last update to the guidelines in 2016, which also included recommendations for using low-dose aspirin to prevent colorectal cancer. (Task force recommendations are typically revisited every five years.)
The panel previously recommended starting low-dose aspirin for the primary prevention of cardiovascular disease and colorectal cancer in people ages 50 to 59 who had an elevated chance of heart attack and stroke, as long as they weren’t at increased risk of bleeding. For older people, the task force said, the decision to start an aspirin regimen “should be an individual one.”
But after reviewing data from recent randomized, controlled trials as well as conducting simulation modeling, Tseng said the task force determined that while there is still a benefit to taking aspirin if you are at increased risk for heart attack and stroke, the benefit “is smaller than what we’ve seen before.”
“Before, when the benefit was greater, we could recommend it for people just within their age group who have high risk,” she said. “But now, because the benefit is smaller, it’s become even more clear that it’s got to be matched to the right person, and somebody’s personal values and preferences also become much more important.”
The task force also reviewed data on low-dose aspirin and colorectal cancer, but found that the latest evidence was unclear about whether the medication can have preventive benefits, and called for more research. In the meantime, the panel encourages people concerned about their colorectal cancer risk to talk with their doctors about aspirin and being screened.
If finalized, the draft recommendations on cardiovascular disease would bring the USPSTF guidelines in line with those of the American College of Cardiology (ACC) and the American Heart Association (AHA), which were updated in 2019. The ACC/AHA guidelines say that low-dose aspirin “might be considered” for primary prevention in “select” adults between the ages of 40 and 70 who aren’t at increased risk of bleeding. The guidelines also recommend against regular aspirin use in people who are older than 70.
Donald Lloyd-Jones, president of the American Heart Association, called the task force’s proposed updates a “welcome adjustment.”
“The USPSTF is appropriately updating their recommendations on aspirin for primary prevention, specifically in response to changes in the evidence,” said Lloyd-Jones, who is also chair of the Department of Preventive Medicine at Northwestern University’s Feinberg School of Medicine. “This is how science should work and should translate to clinical care.”
Amit Khera, director of the Preventive Cardiology Program at the University of Texas Southwestern Medical Center, said he hopes that health-care providers will be “more judicious” when recommending aspirin regimens and focus on those who would most benefit.
For example, aspirin may be a good choice for someone who is at high risk of cardiovascular issues and hasn’t been able to control their risk factors through other means, as long as they are at low risk for bleeding and are willing to take medicine daily, Tseng said. To assess your risk of cardiovascular disease, the task force recommends using the ACC/AHA online prediction tool.
The widely established practice of using aspirin to prevent a first heart attack or stroke stemmed from trials first done in the 1980s and 1990s, Lloyd-Jones said. “That was a time when we weren’t really focused on or doing a particularly good job of controlling things like blood pressure and cholesterol, so aspirin had room to add value in preventing heart attacks and strokes.”
But in more recent years, as the ability to reduce or manage risk factors has improved along with a greater emphasis placed on healthier living, newer studies have shown that the added value of aspirin as a primary prevention method appears to be “at best marginal and sometimes nonexistent,” Lloyd-Jones said. “We just don’t really need aspirin so much anymore.”
Khera, who was on the writing committee for the 2019 ACC/AHA cardiovascular disease primary prevention guideline, agreed. “Society changes, people change, and so the place for aspirin also changes,” he said.
Adopting a more conservative approach to using aspirin also would reinforce the message that taking the over-the-counter medicine is not without risk, experts said.
“Many people think of aspirin almost like a vitamin and that it’s benign, but that’s not true,” Khera said. “When we talk about major bleeding, we’re talking about bleeding in the brain, bleeding that needs transfusions, so not like nosebleed-type stuff.”
Experts also want the public to remember that taking aspirin is just one way to help prevent a heart attack or stroke. Other proven strategies for lowering risk include common lifestyle adjustments, such as quitting smoking, maintaining a healthy diet and getting at least 30 minutes of moderate to vigorous exercise regularly.
“All those things add value together ... and they work together synergistically,” Lloyd-Jones said. “Those are really the secrets here, and you won’t need aspirin if you’re doing those other things successfully.”
A total of 5,862 health care workers have contracted COVID-19 in New Hampshire since the pandemic began, 87 have been hospitalized and 10 have died, according to state statistics.
But that hasn’t stopped a vocal group of nurses and others in the medical industry from loudly objecting to vaccination requirements, even at the risk of losing their jobs.
The Biden Administration is requiring COVID-19 vaccinations of staff at Medicare- and Medicaid-certified facilities to protect them and patients from the virus and its more contagious Delta variant. It has also ordered the Occupational Safety and Health Administration to draft a rule requiring employers with at least 100 workers to force employees to get vaccinated or produce weekly test results showing they are virus free.
Registered nurse Terese Grinnell has been outspoken against COVID-19 vaccination mandates. She previously worked at Concord Hospital, Dartmouth Hitchcock and Concord Regional Visiting Nurse Association. She declined to state her present employer but said she works with critically ill patients.
Grinnell organizes regular protests outside Concord Hospital. She has posted photos of protests involving about a dozen people outside the hospital. Grinnell says other nurses and health care professionals join in.
She calls for the impeachment of Republican Gov. Chris Sununu. She reposted an article that compared mask mandates to the Holocaust and included a graphic of syringes formed to shape a Nazi swastika.
Grinnell began her activism after learning a pregnant nursing student was being required to take the inoculation in order to continue her education program.
“I have a lot of friends who are not comfortable with the injection,” she said in an interview. “They’ve seen patients with adverse reactions. It has not been out long enough, and many of us lived through COVID outbreaks in the hospital, many of us have had COVID, and it doesn’t make any sense that we would have to put something man-made into our systems and yet we’re losing our livelihoods over it.”
The U.S. Centers for Disease Control and Prevention says the vaccine is safe and effective, the benefits of receiving the vaccination, including during pregnancy, far outweigh extremely rare side effects.
The CDC also says the vaccine was thoroughly researched and tested and is subject to the most intense safety monitoring program in U.S history. It also recommends the vaccine for those who have already had the virus, saying people get better protection by being fully vaccinated.
This advice is also supported by the state Department of Health and Human Services, the American Medical Association, the American College of Obstetrics and Gynecology, the Society for Maternal-Fetal Medicine and the American Nurses Association, among others.
While the vaccine was developed rapidly, efficacy and safety protocols of clinical trials, assessment of data and Food and Drug Administration authorization and approval were followed.
The process was sped by years of experience with similar diseases, decades of research on mRNA technology used in the vaccine, early sequencing of the virus genome, clinical testing stages done in parallel rather than one at time and billions of dollars in government investment, including in manufacturing and distribution. Government red tape was also cut in some instances.
Grinnell said she and her children have taken other vaccinations, but she said she simply doesn’t believe the conventional wisdom about the importance of receiving this one.
“My intuition tells me that based on what I’ve seen and my own evidence, my own patient experiences and then my research that I’ve done, my intuition tells me there is no rational reason for me to be doing this to my body at this time,” Grinnell said.
She said this view should be accepted and medical staff shouldn’t be required to receive a vaccine as a condition of employment.
Grinnell compared her stance to that of Jehova’s Witness followers who refuse blood transfusions.
Grinnell said that, similarly, her refusal to take the vaccine is a personal decision. She rejects the notion that during a global pandemic one’s decision to remain unvaccinated affects others throughout society.
“The vaccine is 95 percent effective to reduce your symptoms, but you can still contract and you can still transmit, just as much as the unvaccinated,” she said. “So, we’re operating under a lie.”
The CDC says the risk of infection, hospitalization and death are all much lower in vaccinated people compared to the unvaccinated. Unvaccinated people remain the biggest concern.
“The greatest risk of transmission is among unvaccinated people who are much more likely to get infected, and therefore transmit the virus,” the CDC says. “Fully vaccinated people get COVID-19 (known as breakthrough infections) less often than unvaccinated people.”
Grinnell said that if she were to get the virus, she wouldn’t be a danger to her patients since she tests regularly, would stay home after a positive test or symptoms, and wears personal protection equipment that would prevent transmission of the disease.
Grinnell also said ivermectin has not been sufficiently utilized to combat the virus. Ivermectin is an anti-parasitic medication not authorized or approved by the U.S. Food and Drug Administration for use in preventing or treating COVID-19.
Shouting “Shut it down!” she and other protesters forced postponement of a September 29 meeting of the state Executive Council, which was to consider taking $27 million in federal funding to boost vaccination efforts. Sununu said the protesters exhibited “unacceptable, unruly behavior.”
Jake Leon, a spokesman for the state Health and Human Services Department, said the funding will be instrumental to ongoing statewide efforts to ensure access to the vaccine.
“This funding will also allow the Department and regional public health partners to expand our ability to make the vaccine accessible when additional vaccines are approved for a third dose for people over 65 and immunocompromised individuals, and when children 5-11 years old become eligible to receive it,” he said.
“The Department will need approval by the Executive Council and Legislative Fiscal Committee to accept and expand the funding.”
Rep. Ken Weyler, R-Kingston, recently stepped down from his role as chairman of that committee after distributing information with conspiracy theories about COVID-19, including one that the vaccine contained a “living organism with tentacles.”
Sununu called for Weyler to lose his leadership role.
The governor also commented on one of Grinnell’s Facebook posts calling for him to block vaccine mandates.
Sununu says that while he doesn’t support such mandates, it is not within his power to tell private businesses what they may require of their employees.
“The government can’t infringe on the rights of a private business and tell a private entity who to hire and fire,” he said. “Even if we don’t agree, there are limits to government overreach.”
“If you believe that the government must ensure you don’t get fired from your employer, I’m sorry, but that’s not right. Having a specific job with a specific private employer is not an inalienable right of freedom.”
Pamela P. DiNapoli, a registered nurse who is executive director of the New Hampshire Nurses Association, said only a fraction of health care workers oppose COVID-19 vaccinations.
An AMA survey showed more than 96 percent of doctors have been vaccinated.The American Nurses Association reports that 88 percent of nurses in the U.S. are vaccinated.
“When you talk to the public, they might think there are a lot of nurses who have not been vaccinated,” DiNapoli said. “But in our talking to nurses, before the mandate, maybe 80 percent of the nurses had voluntarily been vaccinated, and now another 10 percent have been vaccinated, so maybe 10 percent have not been vaccinated.”
She said there has not been a significant number of nurses who have resigned rather than take the vaccine.
DiNapoli said hospitals have been providing education and training for nurses who are hesitant to receive the vaccine, or who still have questions such as the inoculation’s effect on fertility.
The CDC says there is no evidence showing that any vaccines, including COVID-19 vaccines, cause fertility problems.
Others question whether the mandate allows a facemask to be worn instead of receiving a vaccination. The answer is no.
Some want to know if they can get a religious exemption from the mandate. This would technically be possible, but only if there was a specific and verified religious prohibition, DiNapoli said. There is no “conscientious objector” exemption.
“They (hospitals) are doing individual education really encouraging understanding of the science and not the misinformation, and then the nurses are going to have a choice whether or not they are going to stay or move to another organization that maybe is not mandating the vaccine,” she said.
DiNapoli said nurses sometimes are conflicted when they see unvaccinated people come down with serious cases of the disease. The majority of the people hospitalized for COVID-19 are unvaccinated.
“You have a preventable disease, and now you’re straining my resources, you’re straining resources from people who have a heart attack, stroke, who need those beds,” she said.
Of the more than 50,000 COVID-19 cases reported in New Hampshire over the past eight months, only 3 percent involve people who were vaccinated, according to state statistics.
“The nurses who are vaccinated can’t understand those who are not vaccinated,” DiNapoli said.
She also said there is a code of ethics in nursing requiring “justice and do no harm.”
“You have by virtue of your license said that you will do no harm and we know by the science that you could potentially harm children who can’t get vaccinated and the immunocompromised,” she said.
DiNapoli said she hopes to reach people who are vaccine hesitant, but feels she doesn’t have much opportunity to change the mind of true vaccine opponents, including those in the New Hampshire Legislature, science notwithstanding.
She also acknowledged that there is already a shortage of nurses, which could be exacerbated if some nurses refuse to abide by a vaccine requirement.
There are 50,000 licensed nurses in the state, and DiNapoli said she has not heard of one who has had serious side effects.
Mindi Messmer of the New Hampshire Science and Public Health Task Force said she supports vaccination mandates for health professionals and others “based on the fact that unvaccinated individuals nationally and in New Hampshire are more likely to be infected, have higher levels of the virus in their nasal passages, and therefore transmit the virus.”
Surveys have shown a correlation between vaccination rates and political beliefs. Joe Biden supporters are more likely than Donald Trump supporters to be vaccinated, although Trump himself was vaccinated after being hospitalized with COVID-19.
“It is disconcerting that some healthcare professionals are choosing political beliefs over data to inform their choices regarding the COVID-19 vaccine,” Messmer said.
A total of 54.5 percent of New Hampshire residents are fully vaccinated against the virus, 59.8 percent have received at least one dose of the vaccine, 1,497 have died of COVID-19 in the state and 700,000 have died across the nation, according to state and federal statistics.
SWANZEY CENTER — Monadnock Regional Middle/High School will transition to remote learning for the rest of the week due to an uptick in COVID cases and staffing challenges caused in part by quarantine and isolation requirements, the district announced Tuesday afternoon.
The school plans to return to in-person learning on Monday, Oct. 18, Superintendent Lisa Witte said in an email to The Sentinel. Extracurriculars are also canceled for that duration, she added.
As of Tuesday afternoon, there were 18 active cases at the middle/high school, according to the district’s online COVID case tracker. The school — which enrolls approximately 840 students in 7th through 12th grade, according to the district’s website — has reported a total of 27 cases since the academic year began Aug. 30. The district does not specify whether the cases are in staff or students.
As COVID cases have increased, Principal Lisa Spencer said staff members are exercising greater caution and getting tested when experiencing symptoms, which can put people out of work for a day or two while waiting for results. There’s been some lag in test-result turnaround, she added.
Schools across the Monadnock Region have struggled with staffing shortages, particularly finding enough substitutes during the pandemic. For Monadnock middle/high school to operate safely, the school needs to have sufficient staff members throughout the building, which Witte said is not currently possible. “We are not able to ensure adequate staffing levels at this time due to absences and/or vacancies,” she said.
All elementary schools within the Monadnock Regional School District — which covers Fitzwilliam, Gilsum, Richmond, Roxbury, Swanzey and Troy — will continue with in-person classes, according to a Facebook post from the district. But visitors will not be allowed in any school through Nov. 1 due to an increase in infections districtwide.
According to the COVID tracker, there are currently 37 cases across the district: in addition to the middle/high school cases, nine at Cutler Elementary School in West Swanzey, four at Troy Elementary School, three at Mount Caesar Elementary School in Swanzey Center, two at Emerson Elementary School in Fitzwilliam and one in the district administrative building in Swanzey Center. The district has had a total of 70 cases since the start of school.
The next three days of remote learning at the middle/high school will count toward the 180 days for the year required by the state, Witte said.
The N.H. Department of Education allows districts to offer different options of in-person, hybrid and remote learning, though State Education Commissioner Frank Edelblut has said he believes schools should only switch to remote learning if absolutely necessary.
“... We have learned throughout the past year that most students are happy and learn best during in-person instruction, which provides them with the greatest opportunities for success,” he said in a statement last Thursday, after Raymond High School decided to temporarily transition to remote learning due to a rise in COVID-19 cases.
“Remote learning should be a last resort, and should only be in place for a short period of time if found to be absolutely necessary for safety reasons,” Edelblut said.
Decisions about which learning model to employ are made at the local level, according to Kimberly Houghton, a spokeswoman for the state education department.
Next month, the N.H. State Board of Education will review a proposal that would require that all students have access to in-person instruction all year. Distance education would not meet the requirement for in-person learning, Houghton said in an email.
Monadnock Regional Middle/High School students will receive Zoom links to tune into their classes for the rest of the week. Spencer said she expects teachers to handle the next few days with the expertise they’ve gained over the course of the pandemic.
“To be honest, my staff are rock stars,” Spencer said. “They are amazing — I created a schedule, sent it out to staff, and there isn’t a doubt in my mind they will implement it with fidelity.”
A handful of speakers — half of whom were elected officials — addressed the N.H. House Special Committee on Redistricting on Tuesday night, when the body convened in Keene to seek public input as the state works to redraw New Hampshire’s political boundaries.
While those who spoke raised various points, they expressed a common desire to see districts drawn fairly and in ways that preserve commonality among the communities included in them. Rindge resident Jeff Dickler pointed specifically to his senate and executive council districts, saying that his town shares representatives with places that have different interests.
“We’re grouped with Nashua,” he said. “Now what in the heck do we have in common with Nashua? We are rural; Nashua is urban. We got reps from that area that have no clue about living in Rindge.”
He said that with a population of about 6,000 people, Rindge should have its own representative. He noted that the town easily passed a petition article during its 2021 town meeting calling for a redistricting process free of gerrymandering.
The House committee is holding meetings in each of the state’s 10 counties to give locals a chance to weigh in on the federally required 10-year redistricting process, with plans to stop in Claremont on Wednesday and North Conway on Thursday. In November, the committee will make a recommendation on new district lines, which would then become a bill and enter the legislative process.
The 15-member committee is a bipartisan group of state representatives who are responsible for drafting the boundaries of New Hampshire’s 400 House seats and two congressional districts, using population data from the 2020 Census. Rep. Steven Smith, R-Charlestown, the committee’s vice chairman, and Rep. Lucy Weber, D-Walpole, are the two Monadnock Region lawmakers on the panel, which includes eight Republicans and seven Democrats.
Smith said pieces of information about specific concerns, such as Dickler’s, are just the sort of thing the committee is looking for as it weighs its options.
Though Tuesday’s meeting was meant to reach Cheshire County residents, some people came from other parts of the state, including Spec Bowers of Grantham, who called attention to what he described as a common misconception that state law requires all larger towns to have their own House district.
Instead, he explained, the law says that towns with populations that extend beyond a “reasonable deviation” of how many people should be represented by a single person are supposed to get their own district. With 400 seats in the House, each district covers more than 3,000 residents on average. Bowers urged the committee to be cautious about putting larger towns in their own districts.
“I have seen maps that started out by making every large town its own district,” he said. “To then fix unreasonable deviations, they had to produce large and ugly floterial districts that defeated the intent to have locally elected representatives.” A floterial district is one that groups multiple municipalities together which, on their own, are too small to be entitled to a representative.
However, representatives from Open Democracy Action, a Concord-based organization aiming to reform the influence of money in politics, were on hand during Tuesday’s meeting, and Deputy Director Brian Beihl said ignoring towns that have large enough populations to warrant being in their own district is a problem. Beihl, of Alton Bay, said that last time the state redrew district lines in 2010, Chesterfield, Hinsdale, Jaffrey, Rindge, Swanzey and Walpole were all large enough to get their own district but didn’t.
Open Democracy Action is working on a mapping project designed to get citizens’ input on what new lines should look like, and the organization’s proposals were on display in the in the lobby at the courthouse before the meeting. The project creates maps based on community assets such as school districts, heath care, emergency or municipal services, as well as community issues such as environmental contamination, poverty and substance misuse.
Keene resident Ian Burke, who is working with Open Democracy on its mapping project, said that representation is most effective when representatives are able to connect with their constituents and share their interests and experiences.
“I feel that redistricting for party and electoral advantage marginalizes actual communities in favor of shared national party affiliation,” he said. “And I think that that makes a less effective Legislature and a less effective state government.”
Meanwhile, state Sen. Jay Kahn, D–Keene, brought up several concerns he’d like the committee to consider moving forward, including one of the state’s most notorious oddly shaped district: Executive Council District 2. The district, currently represented by Cinde Warmington, D–Concord, spans from the Vermont border, to the Seacoast, encompassing communities ranging from Keene to Somersworth.
He also touched on his own senate district, noting that while he represents 15 out of Cheshire County’s 23 municipalities, the others are spread among districts 8, 9 and 12.
“The remaining eight are peeled off into three other senate districts, so there is very little influence in those other three senate districts of those towns,” Kahn said.
On the other hand, two of Cheshire House District 1’s representatives — Paul Berch, D–Westmoreland, and Cathryn Harvey, D–Chesterfield — said they were happy with the districting in their part of the state. Harvey said it’s a good example of where the districting process has not failed to take commonality into account.
“It’s not broken,” she said. “Please don’t try to fix it.”
This article has been changed to correct a point about the number of N.H. House members who represent Cheshire District 1.