Roth, Zags plan for season of uncertainty

[sonuvazag]

Gotcha.

Here: https://coronavirus.jhu.edu/data/sta...s/washington/0

WA really has been skating through this with very very few deaths so far. Never yet hit 30/day and under 10/day for the past 4 weeks.

Washington has been doing well. My point with Markburn is there was a surge in testing around June 1st when contact tracing began in earnest which would explain the rise in cases at that point. The more recent escalation in the last week is more difficult to explain away and I wouldn't expect anyone knows yet for certain if we're heading back toward more hospitalizations and deaths in the next few weeks.

[LTownZag]

Washington has been doing well. My point with Markburn is there was a surge in testing around June 1st when contact tracing began in earnest which would explain the rise in cases at that point. The more recent escalation in the last week is more difficult to explain away and I wouldn't expect anyone knows yet for certain if we're heading back toward more hospitalizations and deaths in the next few weeks.

I haven't been following WA-only stats recently, but I don't see the phenomenon you're describing.

Large surge in testing beginning Monday June8th (and then tracking the weekdays for the past 2 weeks) but no increase (or only a tiny%) increase in positive cases from the week of Jun 8-14 to the week of June 15-21.

[sonuvazag]

I haven't been following WA-only stats recently, but I don't see the phenomenon you're describing.

Large surge in testing beginning Monday June8th (and then tracking the weekdays for the past 2 weeks) but no increase (or only a tiny%) increase in positive cases from the week of Jun 8-14 to the week of June 15-21.

I was speaking a little less precisely than what you're attempting but it's also important to point out that testing can go up because infections go up, testing can go up because of a change in the protocol of who gets tested such as the implementation of contact tracing, testing can go up because of increased capacity (this is not a clear-cut issue).

There are two fairly distinctive surges in overall testing in WA, one on May 18 and one on June 9th. These two surges taken together, and considering the implementation of contact tracing started in mid-May, may explain a bit of the surge in recorded cases starting in late May, but I don't see how it could be any justification for the surge in cases continuing and getting worse over the last week. It is this most recent surge that concerns me the most and it remains to be seen if there will also be a reversal of what has been a decent trend for hospitalizations and deaths.

MDAbe and Markburn are saying this virus has already reached and killed the majority of people that are vulnerable and there's no concern if cases rise because hospitalizations and deaths are going down and will continue to do so. I'm not sure they're right, but I hope they are.

[caduceus]

MDAbe and Markburn are saying this virus has already reached and killed the majority of people that are vulnerable and there's no concern if cases rise because hospitalizations and deaths are going down and will continue to do so. I'm not sure they're right, but I hope they are.

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.

[sonuvazag]

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 agree with all this.

[Markburn1]

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.

Which has been my contention from day one. If we had focused on the most vulnerable in the beginning the numbers of deaths and hospitalizations would have been reduced to a degree. I suspect it would have been a huge mitigating factor. Instead we shut down the entire country and we will pay for it in lives and a diminishing quality of life for years to come.

[caduceus]

Wouldn't you say this chart is misleading? I see these # of cases charts almost universally. What you don't see on a consistent basis are the charts that show hospitalizations and deaths.

No, not misleading. I was talking about cases in response to it being mentioned that they were falling. The graph is accurate for its intended purpose. That's all.

Death numbers are widely available (although recent news accounts seem to suggest that some states are fudging their numbers -- intentionally or unintentionally -- regarding cause of death. I dunno anything about that).

Hospitalizations are a a bit trickier, since every state reports them differently, not to mention that initial diagnoses when someone is admitted is not always specific enough, or may change. For example, one might be admitted with shortness of breath, but discharged with something like "myocardial infarction."

[sonuvazag]

Which has been my contention from day one. If we had focused on the most vulnerable in the beginning the numbers of deaths and hospitalizations would have been reduced to a degree. I suspect it would have been a huge mitigating factor. Instead we shut down the entire country and we will pay for it in lives and a diminishing quality of life for years to come.

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.

[JPtheBeasta]

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.

It seems to me that this was not really the case because in New York, and I believe elsewhere, persons recovering from Covid were placed in nursing homes after hospital discharge. Is this a contended data point or one that is universally agreed upon?

[LTownZag]

No, not misleading. I was talking about cases in response to it being mentioned that they were falling. The graph is accurate for its intended purpose. That's all.

Death numbers are widely available (although recent news accounts seem to suggest that some states are fudging their numbers -- intentionally or unintentionally -- regarding cause of death. I dunno anything about that).

Hospitalizations are a a bit trickier, since every state reports them differently, not to mention that initial diagnoses when someone is admitted is not always specific enough, or may change. For example, one might be admitted with shortness of breath, but discharged with something like "myocardial infarction."

Big and important difference between "misleading" and "not measuring the thing I want to see measured".

I think the comparisons of total deaths or total confirmed cases per country are examples of this. They are accurate and not misleading, but the same comparison graphs adjusted for population size are generally more of what I (and I think most people) want measured when comparing the severity of the outbreak. The USA, for example, has almost as many people as the entire EU. If one wants to look at the scale of tragedy of the deaths from "X", look at deaths per-capita, or at least compare places with similar populations (California vs Spain, or the USA vs the EU).

[sonuvazag]

It seems to me that this was not really the case because in New York, and I believe elsewhere, persons recovering from Covid were placed in nursing homes after hospital discharge. Is this a contended data point or one that is universally agreed upon?

Mar 2 https://www.npr.org/sections/health-...-nursing-homes

Mar 10 https://www.king5.com/article/news/h...b-0a1e476f83d6

Mar 10 https://www.nytimes.com/2020/03/10/u...n-seattle.html

Mar 10 https://www.twincities.com/2020/03/1...r-coronavirus/

Mar 10 https://www.bostonglobe.com/2020/03/...amily-members/

Mar 11 https://time.com/5799096/coronavirus...homes-elderly/

If the contention is that people didn't recognize the risk to the elderly and infirm right away and implement restrictions on nursing homes right away, that is simply not the case.

[LTownZag]

Markburn says..."isn't it probable that the virus has claimed the most vulnerable and though cases are climbing for various reasons the folks that are being infected are nowhere near the danger of death and hospitalization we saw at peak?

Exactly what's happening Mark. Good call.

Around 70,000 Americans over 70yrs old have died of COVID.
Let's say another 10x that number were infected and survived.

That totals .77million people.

Let's then just then double that total, for the sake of argument, in case either death or infection has been massively higher than is known.

That extremely high estimate would be ~1.7 million Americans over 70 already killed or infected.

Such a total would represent just 5% of the 36million americans over 70.

[Markburn1]

Mar 2 https://www.npr.org/sections/health-...-nursing-homes

Mar 10 https://www.king5.com/article/news/h...b-0a1e476f83d6

Mar 10 https://www.nytimes.com/2020/03/10/u...n-seattle.html

Mar 10 https://www.twincities.com/2020/03/1...r-coronavirus/

Mar 10 https://www.bostonglobe.com/2020/03/...amily-members/

Mar 11 https://time.com/5799096/coronavirus...homes-elderly/

If the contention is that people didn't recognize the risk to the elderly and infirm right away and implement restrictions on nursing homes right away, that is simply not the case.

Every one of your links described visitors being allowed into these nursing homes. Guidelines may or may not have been followed. They were just that, guidelines. The fear of a massive spread was there but the actual reality on the ground didn't reflect what the CDC and nursing home executives were suggesting. And there were some states, most notably New York, that took the insane approach to put infected people back into these facilities when released from the hospital.

My mother is in an assisted living home. There was a decided lack of concern there and they didn't even have a plan until well after the spread of the virus was significant. They were lucky. Everything is locked down now and no visitors are allowed. They have zero infections. Once again, lucky.

[caduceus]

Which has been my contention from day one. If we had focused on the most vulnerable in the beginning the numbers of deaths and hospitalizations would have been reduced to a degree. I suspect it would have been a huge mitigating factor. Instead we shut down the entire country and we will pay for it in lives and a diminishing quality of life for years to come.

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.

[caduceus]

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.

Kirkland, but you are correct. By then it was already too late.

[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.