Roth, Zags plan for season of uncertainty

[Markburn1]

Focusing on the most vulnerable began when a bunch of people died at that facility in Bellevue. It doesn't get much earlier than that.

We knew from the beginning from data from Italy and China that age and comorbidities were where the increased danger was. Deaths of the elderly and the sick with the virus were orders of magnitude higher than younger, healthier people. We knew all the way back to January and February. The Kirkland outbreak was much later in the timeline.

https://www.vox.com/2020/3/12/211737...lderly-seniors

[JPtheBeasta]

We knew very early from the Italy data that the elderly and those with multiple comorbidities were being hit the hardest. It seems like it should have been common sense to keep these patients away from the elderly in nursing homes. Per the New York Times, 1/3 of deaths are nursing residents or workers despite representing 153,000 total cases (the cases have gone up; article updated May 11, 2020). This was a truly fatal error. USA Today put that number at closer to 40% of all deaths.

[MDABE80]

I suspect that is a minor contributor, but I very, very much doubt that all the really vulnerable people have been culled from Washington to affect the statistics appreciably. From what I've seen, I suspect there are two larger reasons.

The first is that long-term care facilities, nursing homes and senior living joints are really locked down. Many, if not most, are essentially in quarantine isolation with heavy restrictions on entry, more robust precautions inside, and much more testing of staff and residents (state mandated a while back).

The second reason is what BurgessEra, Esq. expressed in this thread and is smartly practicing himself -- staying home. More older and vulnerable people are sheltering, masking, etc., and they've bettered their routines over time to stay COVID free.

I do expect there are other factors. There's a reason some of these bugs are seasonal, and we know it's not just because of human behavior differences between summer and winter. Sadly, we don't know all the reasons but some are surely environmental. Multiple improvements in healthcare protocols are helping, along with keeping our providers from getting sick and spreading it around hospitals and their homes. More available PPE has contributed to that.

I. Never said ALL. Nobody in science say ALL . You know that

[sonuvazag]

We knew from the beginning from data from Italy and China that age and comorbidities were where the increased danger was. Deaths of the elderly and the sick with the virus were orders of magnitude higher than younger, healthier people. We knew all the way back to January and February. The Kirkland outbreak was much later in the timeline.

https://www.vox.com/2020/3/12/211737...lderly-seniors

My point is in the earliest moments when we were having discussions about taking measures of any kind, those discussions involved consideration of the impact on the elderly. I'm not going to argue whether or not more could have been done to be more effective in this regard, but as Caduceus stated, protection of the vulnerable wasn't something we could have done effectively instead of the lockdown, since at that point the overall level of spread was unknown.

[sonuvazag]

I. Never said ALL. Nobody in science say ALL . You know that

I hope I didn't mischaracterize your argument when I said you believe "a majority" have been culled. I feel like I understand what you're trying to say, and I do hope you're right, even if it seems implausible, at least for most parts of the country.

[zagfan24]

Seems like common sense, doesn't it? The problem is it's much more complicated than that. .... But, you cannot seal away only the elderly/vulnerable from society and have any success whatsoever.

I'm sorry, but that's just the way it is. The press and others should drop this argument as they are making the problem worse in doing so. The shut down would have been effective had we not opened up early without enough testing and tracing in place. Now we're in the second verse, but worse than the first.

Thank you. I've never heard this argument fully fleshed out. If you just isolate the "elderly and vulnerable" you first have to define those groups. What age are we talking about? Does this include obesity? Chronic illness? Pediatric illness? Can a pediatric oncologist go to the grocery store? Can her kids go to school? Can a care partner from a nursing home be around his family? His grandparents?

The other argument that people keep bringing up without statistical basis is herd immunity. I listened to an enlightening interview with a few experts on this topic, and to paraphrase from memory, it would take about 70% exposure in the population which almost necessitates having a vaccine. The idea of no lock down being akin to herd immunity just isn't that simple.

Finally, people grossly underestimate the impact of the PPE shortage on all of this. Above, sylean says:

no we are not mature.....mature human beings don't believe in fairy tales as in "nothing bad will happen if we just hide"..... and how people in the hospitals are facing furloughs because the hospitals are bankrupt....


First, that's a complete strawman. The lock down efforts were not about hiding out of fear. More importantly, a major factor behind flattening the curve AND hospital financial ruin was the PPE shortage. The fact that Wuhan was a major manufacturing center, combined with a depleted stockpile, combined with a poor initial response...left hospitals unable to go on with non-urgent ("elective" is often a misnomer) procedures which created a huge revenue shortfall. The PPE shortage continues to be a huge issue in our hospital and I'm sure almost everywhere. We are wearing one N95 mask for as long as possible right now...then having it cleaned until it's not wearable. It's a pretty sad state of affairs.

[caduceus]

I. Never said ALL. Nobody in science say ALL . You know that

Hah. You also know that when I said all, I didn't mean ALL!

[Zagceo]

Seems like common sense, doesn't it? The problem is it's much more complicated than that. Firstly, the knowledge we have now is way better than what we knew then, particularly in Washington (since we were the early epicenter). We didn't know anything about nursing facilities being particularly vulnerable until it was too late. By then, community transmission was widespread. Secondly, we had zero tests early on, and thus zero idea where the virus was or how prevalent. It took 3 weeks for the Feds to fix the testing kit, and they actually barred UW virology from using their own, AND they barred the Seattle Flu Study program at FHCRC (Fred Hutch) from testing for COVID in their samples from January. Thankfully, FHCRC ignored them and we very luckily found out the virus was here much earlier, and spreading in the community. I digress...

If the public had been told, as soon as we knew the size and scope of things, that everybody over 60 had to self-isolate for the foreseeable future, how do you think that would have gone over? Then you have elder care facilities (which are always, always underfunded -- even the good ones) needing PPE and isolation equipment, more sanitizer, etc. These things take weeks to implement (and longer when every other facility is competing for the same stuff -- just like the toilet paper run). By the time you get your act together, it's already spreading like wildfire.

There are many other reasons, but my fingers are tiring. But, probably the greatest reason this is difficult to implement is that it's near impossible to lock down this age group like that while you let it spread rampantly through the rest of the population. I constantly hear this argument, but never, ever from epidemiologists (except that one idiot from Sweden, who has since apologized and admitted it was a huge miscalculation that cost thousands of lives). Yes, they recommend the vulnerable take added precautions. But, you cannot seal away only the elderly/vulnerable from society and have any success whatsoever.

I'm sorry, but that's just the way it is. The press and others should drop this argument as they are making the problem worse in doing so. The shut down would have been effective had we not opened up early without enough testing and tracing in place. Now we're in the second verse, but worse than the first.

You don't take off your parachute mid-air just because it's slowed your fall.

Haven’t elderly always suffered heavy consequences from viruses in the past?

[caduceus]

Thank you. I've never heard this argument fully fleshed out. If you just isolate the "elderly and vulnerable" you first have to define those groups. What age are we talking about? Does this include obesity? Chronic illness? Pediatric illness? Can a pediatric oncologist go to the grocery store? Can her kids go to school? Can a care partner from a nursing home be around his family? His grandparents?

The other argument that people keep bringing up without statistical basis is herd immunity. I listened to an enlightening interview with a few experts on this topic, and to paraphrase from memory, it would take about 70% exposure in the population which almost necessitates having a vaccine. The idea of no lock down being akin to herd immunity just isn't that simple.

Finally, people grossly underestimate the impact of the PPE shortage on all of this. Above, sylean says:

no we are not mature.....mature human beings don't believe in fairy tales as in "nothing bad will happen if we just hide"..... and how people in the hospitals are facing furloughs because the hospitals are bankrupt....


First, that's a complete strawman. The lock down efforts were not about hiding out of fear. More importantly, a major factor behind flattening the curve AND hospital financial ruin was the PPE shortage. The fact that Wuhan was a major manufacturing center, combined with a depleted stockpile, combined with a poor initial response...left hospitals unable to go on with non-urgent ("elective" is often a misnomer) procedures which created a huge revenue shortfall. The PPE shortage continues to be a huge issue in our hospital and I'm sure almost everywhere. We are wearing one N95 mask for as long as possible right now...then having it cleaned until it's not wearable. It's a pretty sad state of affairs.

Great post, insightful. Thanks for adding.

Your point about herd immunity is spot on. I mentioned earlier that it might take years (without vaccine), or never if antibody protection doesn't last long.

One thing I'll add (since it relates to college basketball). There's a huge difference between having uber-wealthy pro leagues starting up sports and student athletes. I fear the complexities of the situation will deter the NCAA from sorting all that out into a meaningful return to competition. There are parent issues, travel issues, facility issues, referees and other staff issues. PPD. Sanitizing. Practice procedures. It's an enormous hairball of complexity. We need a damn vaccine.

[caduceus]

Haven’t elderly always suffered heavy consequences from viruses in the past?

Sure. Vaccines are a great way to make it manageable. We ain't got one this time, and it's on the higher end of contagousness.

Interestingly, the H1N1 pandemic of 1918 (Spanish flu) killed 20-29 year-olds in the greatest numbers. If nCov19 had done that instead of to the elderly, I really wonder how 2020 would have played out.

[JPtheBeasta]

NPR recently referenced a New Yorker article which found only 2 cases of child-to-parent transmission of COVID-19 in Iceland, where “extensive contact tracing” was done.

The web article is titled What Parents Can Learn From Child Care Centers That Stayed Open During Lockdowns.

[JPtheBeasta]

The number needed to achieve herd immunity depends on the reproduction number (R-value (R-naught, R-[underscore 0])

The formula is susceptible persons < 1/Ro (ie immune persons >( 1- 1/Ro ))

If the R value is 3, we need >67% of persons that are not susceptible (is are immune)
to infection to protect the rest.

If the R value is 2, we need 50%

If the R value is 1, the disease sticks around but doesn’t grow.

If R value is less than 1, we don’t need to worry about herd immunity because 1 person will infect less than one person on average and it will fizzle out on it’s own.

—

The R value can be lowered by measures to slow the spread, such as avoiding other persons or wearing a mask. COVID-19-projections.com/infections-tracker has a graph of the initial R -values versus the R-values after mitigation measures. R values are different for different populations, as seen with children, who don’t transmit the disease easily. The R value currently in many places is under 1 or very close to one. It was reassuring to me to learn that R values can change because I have seen so many different estimates for the R-value.

—

Any expert who throws out one number for herd immunity is oversimplifying the calculus, is not being forthcoming about assumptions, or has an agenda and is trying to mislead people.

[zagfan24]

The number needed to achieve herd immunity depends on the reproduction number (R-value (R-naught, R-[underscore 0])

If the R value is 3, we need >77% of persons that are not susceptible to infection To protect the rest

If the R value is 2, we need 50%

If the R value is 1, the disease sticks around but doesn’t grow.

If R value is less than 1, we don’t need to worry about herd immunity because 1 person will infect less than one person on average and it will fizzle out on it’s own.

—

The R value can be lowered by measures to slow the spread, such as avoiding other persons or wearing a mask. COVID-19-projections.com/infections-tracker has a graph of the initial R -values versus the R-values after mitigation measures. R values are different for different populations, as seen with children, who don’t transmit the disease easily. The R value currently in many places is under 1 or very close to one. It was reassuring to me to learn that R values can change because I have seen so many different estimates for the R-value.

—

Any expert who throws out one number for herd immunity is oversimplifying the calculus, is not being forthcoming about assumptions, or has an agenda and is trying to mislead people.

Thanks for the info JP. I should note that the physician and scientist I listened to were specifically estimating a herd immunity % for Covid based on their best estimate of the R value without precautions. Your additional info is helpful in adding context to this. The point seems to be more clearly that herd immunity without a vaccine or significant social precautions is quite unlikely with COVID-19.

[JPtheBeasta]

Thanks for the info JP. I should note that the physician and scientist I listened to were specifically estimating a herd immunity % for Covid based on their best estimate of the R value without precautions. Your additional info is helpful in adding context to this. The point seems to be more clearly that herd immunity without a vaccine or significant social precautions is quite unlikely with COVID-19.

My disclaimer is that I am learning a lot of this on the fly with the rest of the armchair epidemiologists out there and reserve the right to be wrong on the math or missing nuances of the calculations. I thought the above would be interesting to share, at least.

[LTownZag]

FWIW I’ve read and understand the same as you regarding the strong direct relationship between Rvalue and herd immunity critical levels.