Thursday, April 30, 2020

Should hard hit states reassess Covid-19 strategy?


Massachusetts Governor Charlie Baker announced this week an extension to his May 18 “Stay At Home" order.  The Mayors of Somerville, Cambridge and Peabody, MA ordered the wearing of masks in public places (indoor and outdoor) with fines for non-compliance of between $300 - $1000.  Is doubling down on a general population lock down strategy the right path going forward? Or does the overall strategy need review?

One can reasonably ask:  Is the strategy of generalized social distancing with increasing restriction appropriate going forward? Would it be more effective to target the virus directly where it is most insidious and deadly, focus resources there, and allow a gradual development of herd immunity in the general population?

Last week the Wall Street Journal reported over 10,000 COVID-19 associated deaths at elder care facilities. This number is likely to go up in both number and percentage terms. The WSJ has built its own database by contacting state departments of health directly because reporting from government sources was rare.   California released data this weekend indicating nearly 40% of its deaths come from nursing home and elder care facilities.  The World Health Organization (WHO) reports half of Europe's deaths from COVID-19 were from elder care facilities.

The Massachusetts Department of Public Health COVID-19 Dashboard indicates nearly 60% of the 3153 MA deaths occurred in long-term care facilities.   This percentage might rise as the definition may only indicate those that die on nursing home property not those that were released to home or died in hospitals after transfer from a nursing home. 

In Massachusetts, the 70 and older age group made up 86% of confirmed COVID-19 deaths with those 80 and older making up nearly 65%.   There have been no deaths in the 0-19 age group and 33 in total for those in age groups under 50.   Ninety-eight percent (98%) of those who died in MA, and for which a full investigation has been completed, had underlying conditions.

Anti-body testing is indicating the virus is more prevalent than was previously indicated. Massachusetts General Hospital random testing of 200 people in Chelsea, MA revealed more than 30% had antibodies to the SARS-CoV-2 virus that causes COVID-19 disease.  It is recognized that there are some technical concerns about this study’s sampling methodology, but there is a building body of evidence across the country and the world to show SARS-CoV-2 prevalence in the general population may be much more than previously indicated.

Is there an alternative to doubling down on general population social distancing? Might it be more prudent to focus on those in poor health with co-morbidities, particularly the frail elderly, and especially those in concentrated living conditions such as long-term care facilities, public housing, and dense urban high rises?

There is no doubt that people in poor health with co-morbidities, particularly elders, must be super vigilant in their personal protection until herd immunity is achieved through either vaccine or exposure in the general population.   The timeline to that goal could be more than a year away.  They will need support from their families, communities, and governments.

Specific dramatic action is needed in long-term elder care facilities.  If necessary, the National Guard should directly engage at these facilities to ensure testing, isolation, infectious disease control, hygiene, high staff to patient ratios, and other techniques are adequate to control and stop the spread of virus in these facilities and to ensure the virus is not further spread from them to hospitals or transport equipment used in the general community.   Florida created National Guard strike teams that were sent to nursing homes throughout the state in early April.

Restrictions on the general population’s movement through stay at home orders would be reduced to allow herd immunity to develop gradually while avoiding spikes that could overwhelm hospitals.  Personal hygiene techniques would continue to be encouraged.  Specific activities, such as large gatherings in concentration with close contact, that could spur a major outbreak, would continue to be discouraged.  Sampling, testing, surveillance, and contact tracing would be used to identify a particularly rapid growth in a specific location.   Hospitals and public health agencies would focus on building capacity in the event there are outbreak bursts of one kind or another, ensuring their capacity is not overwhelmed.

The initial goal to “Flatten the Curve” was reasonable given the warnings provided with imperfect data.  That strategy was successful.  But mission creep seems to have taken hold and an undeclared strategy to “stop the virus" is taking hold.  This is not achievable nor advised.  The virus is here to stay.   A vaccine is not guaranteed for this virus nor any morph that may occur going forward.  In this uncertainty a deliberate strategy of slow exposure to build herd immunity may be warranted.  Fining people for going outdoors in public without a mask would not be part of such a strategy.

There are examples of alternative strategies. Sweden is one example. The U.S. federal system creates 50 different approaches from which to learn. Some states have targeted the vulnerable populations and used less restrictive social distancing policy in the general population with success. Florida is one example. The states being hit hardest (NY, NJ, CT, MA, LA, MI) are suffering disproportionately, yet they have some of the firmest restrictions.   The reasons for this disproportion are not yet known.  But the states' strategies may in part be at fault and demand an assessment.

I recommend the MA DPH COVID-19 Dashboard to my friends in MA who are interested in the details of impact in my home state:  https://www.mass.gov/doc/covid-19-dashboard-april-28-2020/download
  
Aside: To question state strategies is seen by some as irresponsible.   I strongly disagree.  There is comfort in conformity in dangerous times.  But that conformity can be the witches brew of poor decision making and even oppression.  It is in time of crisis and fear that courage is needed to question those in authority and vehemently encourage, not suppress, open discussion and countervailing alternative views.   There is no courage without vulnerability.   

The chant that citizens of this great republic must blindly accept and conform to the opinions and policies of government, public health officials, scientists, or doctors is, well, as FDR said, “poppycock.”   Daniel Henninger, said it best in today’s Wall Street Journal, “push back hard against the current fashion of sacrilizing the notion of certitude in science and medicine."

This is not to suggest anarchy or the chaos of the ignorant and selfish over the considered opinions of respected scientists. Coordinated action, conformity, compliance and even enforcement, are appropriate in their place and time to achieve great things.   But unquestioning compliance and conformity to power without proof, and continuous and rigorous review of evidence and efficacy, has no place in the republic.

Six states with less than 20% of the U.S. population produced nearly 70% of the COVID-19 associated deaths thus far.   The strategies and decisions of the leaders in those states should be questioned.  Deferring to their authority is absurd when, as in the Commonwealth of Massachusetts, the decision-makers own, operate, and regulate two of the worst hit long term care facilities in the state.  The death of nearly 70 veterans of the 230 living at the Commonwealth’s  Holyoke Veterans Home screams out, demanding the courage to question those in authority.

Sunday, April 19, 2020

COVID-19: Risk Assessment, Model Uncertainty, Unknown Prevalence, Unclear Mortality, Alternative Paths, and State Anomalies


The COVID-19 battle is trending favorably. There is reason to be grateful for lower death rates, less hospitalization, less ICU use, and less ventilator need than was predicted.  Those that directly engaged at great personal risk, from first responders to health care workers, deserve our thanks.  Moving forward vigilance and rigorous critical analysis is needed to understand the risk COVID-19 posed.  There is much we do not know to include:

How prevalent is it in the population?  
What is the mortality rate?
Did uncertain models overly inform and influence narrative and government policy?
What role, and to what degree, did social distancing influence cases and deaths? 
Were there alternative strategies that could have been as effective?

It is important that the nation undertake an investigation to fully understand the risks and realities of COVID-19 and assess whether or not the actions that local, state, and federal governments were in fact necessary and effective.  Shutting down the U.S. economy was an extreme action.  It is an unsustainable action that cannot become part of the standard play book for each new virus threat.  Understanding what really happened in during the pandemic is essential to ensuring future preparedness and viable strategies.

My concern is that harmful policies were taken by federal, state, and local governments that threaten our economic well being and played loose with Constitutional rights based on uncertain predictive models.  Did the governments actions stop nearly 2.2. million deaths?  Or, were the original projections simply wrong?  We do not know. We need to find out.  Our future well being may depend on it.

As the COVID-19 pandemic settles down and election season draws near some politicians are going to be patting themselves on the back for having saved thousands if not millions of lives.   If the total number of deaths by fall is approximately 60,000 President Trump can say his Administration's  actions saved between 1.44 and 2.14 million lives.  This assumes the models were correct in their predictions.  Governors can extrapolate their great success from the same numbers.  A handful of governors will have to explain to their citizens (particularly NY, NJ, MI, MA, LA, IL) why their states were negatively impacted disproportionately.  

Friday, April 17, 2020

Relative percentages to understand state COVID-19 status


President Donald Trump and the White House Corona Virus Task Force released “Opening Up America Again” guidelines on April 16, 2020.  The guidelines provide “Proposed State or Regional Gating Criteria” for proceeding to each of three phases of reduced restrictions on economic and social activity.

“Core State Preparedness Responsibilities” include robust testing and contact tracing capability, adequate healthcare system capacity to include a surge capability, and a plan to protect the health and safety of critical workers, vulnerable populations (e.g. nursing homes), and other related specific requirements.

The guidelines use criteria for transitions through the three phases based on data within a state or even county or city level, as the granularity of data is now available to those levels.  The guidelines do not set dates, but rely on states satisfy criteria to transition through each phase called “Gating.”  Beyond the underpinning Core State Preparedness Responsibilities a state would make decisions about transitioning based on an observed decrease in day to day confirmed cases and  positive tests for the virus over a two week period.

This necessary plan is adequate to begin the process of transition in balancing the risk of economic collapse with public health.  Twenty-two million Americans have now lost their jobs as the result of the Covid-19 pandemic.

I keep my own databases to analyze the risk of Covid-19. I do this to satisfy my own curiosity and analytical bent, but I also feel that there is a weakness in journalism today that forces me to do my own analysis.   I have observed an overemphasis on reporting raw numbers to indicate risk and impact with an emphasis on rounded thresholds (e.g. 1000, 10,000) that make for good headlines.  This distorts impressions and understanding.   I believe a better way to understand virus risk and impact is through relative comparison of a state against other states and the national average by calculating the percentage of a state’s residents that have been tested, have tested positive, have died, and are projected to die with Covid-19.

I set up download routines from databases that are reliable and current.  The COVID Tracking Project hosted at The Atlantic has a data file that I use to track specific numbers tested, hospitalized, and deaths.  The New York Times has a database that tracks similar data, but has an excellent graphic presentation showing the increase or decrease in cases and deaths in a day over day comparison.  The University of Washington IHME database provides model projections for hospital bed and ventilator shortfalls and anticipated number of deaths through August 4th by state.

Below are some tables I created that are sorted to show different rankings by state and the national average.  I offer these tables to my blog readers in the hope that it will help them better understand the situation in their state and appreciate that all states are different. 

Wednesday, April 8, 2020

We need an exit strategy – now!


Data indicates the U.S. is achieving the goal it set out to accomplish.  The national objective was as follows:

The United States’ immediate and primary objective in response to the COVID-19 pandemic is to compress the peak of infections (commonly called “Flattening the Curve”) in order to avoid denying critical care to the afflicted as a result of insufficient hospital staffing, hospital beds, Intensive Care Unit (ICU) beds, and ventilators.  Social distancing is the primary strategy to achieve this objective.

Data tracking indicates the curve of COVID-19 illness is flattening in many countries of Europe and in the United States.  In the U.S., hospital beds, ICU beds, and ventilator capacity are meeting need and improving as the number of patients requiring these services is declining and options for treatment expand. Production of personal protective equipment and ventilators is increasing to meet need.  Care capacity to treat infected patients is increasing as hospitals reallocate resources, old hospitals and other spaces are converted to active service, field hospitals are opened, and hospital ships are deployed.

The U.S. objective stated above assumed a very high risk that healthcare capacity would be exceeded responding to the SARS-CoV-2 virus that causes Coronavirus Disease 2019 (COVID-19).  Models indicated the virus would spread wider and faster than other viruses, its symptoms would be more debilitating, and it would be more deadly than other viruses.   The models were just that – MODELS. 

Post-COVID-19 research and analysis will determine how accurate those predictive models were.  For now, gratitude is in order that the virus impact is less severe than was originally predicted.  Whether that results from our social distancing strategy, or the virus is just not as vicious as predicted, or seasonal weather change is having the same impact on SARS-2 as it does on many other viruses is fodder for another day.  For now, cautious victory can be declared, and cautious and prepared gradual rescinding of many social distancing restrictions can begin.

Maintaining social distancing to the extent it is currently in practice can cause tremendous social harm.  The “Disaster Distress Helpline” at the Substance Abuse and Mental Health Services Administration last month saw call volume increase 9 times over March 2019 and officials are warning of a national mental health crisis.   The National Suicide Prevention Lifeline set a record last month for call volume.  Those saved and sustained by addiction programs such as AA and NA are at greater risk of relapse despite attempts to move support online.  The United Nations this past weekend called for “urgent action to combat the worldwide surge in domestic violence.”

Saturday, April 4, 2020

Nursing homes need greater focus in COVID-19 battle

It is clear that age is a major factor in COVID-19 morbidity.  It is clear that underlying health status is a major factor in COVID-19 morbidity.  It appears the place one resides (SETTING) is also a major factor.  Specifically, reporting indicates nursing homes and other elder care facilities are the major setting source for COVID-19 outbreaks leading to death.  Data collection and reporting must increase immediately to identify and report the setting in which COVID-19 is contracted and immediate policy implemented to prevent and mitigate vulnerability in the short term.  In the long term, the nation must dramatically change and improve residential elder care or rethink the current model.

There are about fifteen thousand nursing homes with nearly 2 million licensed beds in the United States.   These facilities "appear" a hotbed for COVID-19 deaths.  “Appear” because there is no available repository of data to validate this hypothesis.  The Centers for Disease Control (CDC) does not release the names of nursing homes or the number of residents who have contracted COVID-19 when outbreaks occur - but it should.  There is some media and state reporting from which one can extrapolate the extent and severity of the problem.

The first such case occurred at the Life Care Center of Kirkland in King County, Washington where 81 residents, 34 staff members, and 14 visitors contracted COVID-19.  Of these cases, 23 patients and visitors died.  A more recent example is unfurling at the Commonwealth of Massachusetts’ state run Soldier’s Home in Holyoke, MA where 21 have thus far died.

At least 400 nursing homes across the country have COVID-19 outbreaks.  The number is increasing daily.  No doubt, there will be a correlation between this growth and a climbing number of deaths reported from COVID-19.

Thursday, February 6, 2020

A Trump vs Sanders contest may be needed


A general election contest may be necessary between President Donald Trump and Senator Bernie Sanders in 2020.    The United States is going through a tumultuous rejection and realignment of its political culture that may well climax with the 2020 presidential election.   Pitting the two non-party populist candidates with opposing political philosophies in a head-to-head contest will break the two major political parties and determine if the political center of American culture will be reset much further left or remain a conservative right majority.  The fight is a necessary one to conclude a rejection of two parties that are more similar than not in creating division and failing to address the interests of the American people.

Wednesday, January 1, 2020

Let’s rethink nuclear power

Nuclear power will play an essential role in the energy future of the United States and the world.  There is an increasing recognition by scientists, entrepreneurs, and policy makers that it offers unique characteristics that can provide an abundant, safe, and clean energy source indefinitely.  Despite a decline in the existing nuclear power industry, a renaissance is underway in new safe nuclear reactor designs and technologies to fuel the next century, while rapid advances in fusion power research portend a revolution to begin within the next two or three decades in the nuclear industry.  Now is a pivotal time for leadership, a national focus, the allocation of resources, and a revamping of federal and state regulatory models to accelerate development that will transform the energy portfolio of the U.S. and the world.

Many people in the United States reject nuclear power based on fear.  It is time to face that fear and reconsider nuclear power as a primary contributor to the nation’s energy portfolio.  Now is the time to reassess because there is both vulnerability and opportunity looming.   The vulnerability - existing nuclear power infrastructure is old and presently unprofitable – causing decline in a major component of our nation’s energy portfolio.  The opportunity - there is a tremendous amount of innovation taking place around modern, safe, and small fission nuclear power design that is very promising.  In addition, progress in fusion research is real and substantial, and accelerating.