Corona Virus: It's a Marathon, Not a Sprint

[malchior]

Yup. Right now I know more than a dozen people with COVID - right now. One thing that I think people underestimate is that many of us in NJ have indelible memories of early pandemic being told we were overstating things when in real-time we knew people getting sick and dying, Everyone hadn't seen it yet. A seemingly never ending cycle of sorts.

[malchior]

Something I didn't think about regarding testing + travel overlaps.

https://twitter.com/TheRealDrKendi/stat ... 7996746757

I just finished 3 overnight shifts in the pediatric ED, and have a few observations.

I saw a lot of COVID. Like every other patient had COVID. And many young children. The numbers are crazy.

What’s also crazy is the number of asymptomatic people who came to the ED to be tested for COVID for travel. Many testing sites are closed for the holiday, and people who need a PCR to travel have very few choices.

So many end up in the ED - likely sitting in a waiting room full of people with COVID, possibly getting exposed.

Then they get tested, and those who were infected in the ED will still get a negative result (because they just got exposed and wouldn’t be positive yet), board a plane, and potentially expose people on the flight and at their destination.

The lack of testing site availability on evenings, weekends and holidays are driving healthy people to ED’s where the risk of COVID exposure is high.

And the additional ED visits for people who just need testing cause an already taxed health care system to stretch even further. The taxed system then leads to lower quality care for patients who are actually ill.

Ok. I’m done. Going to sleep.

[$iljanus]

Something I didn't think about regarding testing + travel overlaps.

https://twitter.com/TheRealDrKendi/stat ... 7996746757

I just finished 3 overnight shifts in the pediatric ED, and have a few observations.

I saw a lot of COVID. Like every other patient had COVID. And many young children. The numbers are crazy.

What’s also crazy is the number of asymptomatic people who came to the ED to be tested for COVID for travel. Many testing sites are closed for the holiday, and people who need a PCR to travel have very few choices.

So many end up in the ED - likely sitting in a waiting room full of people with COVID, possibly getting exposed.

Then they get tested, and those who were infected in the ED will still get a negative result (because they just got exposed and wouldn’t be positive yet), board a plane, and potentially expose people on the flight and at their destination.

The lack of testing site availability on evenings, weekends and holidays are driving healthy people to ED’s where the risk of COVID exposure is high.

And the additional ED visits for people who just need testing cause an already taxed health care system to stretch even further. The taxed system then leads to lower quality care for patients who are actually ill.

Ok. I’m done. Going to sleep.

People who are using ERs for testing for travel vs people who are symptomatic and need to confirm having Covid so they can start early treatment should be turned away. But this is where we are unfortunately.

Testing availability is so fucked up in this country. It’s not like it’s a surprise that November and December happen to have two of the busiest travel times in the year that are back to back. It happens every fucking year so one would think that in the summer you would ramp up production and stockpile testing kits for Thanksgiving and Christmas travel.

[malchior]

New to the pandemic locally - the family doctors' practice just emailed us to let us know that they will not treat unvax-ed patients going forward. They said they need to prioritize staff and patient safety in the decision.

[El Guapo]

Smoove, Fauci just suggested that there should be a vaccine mandate to be on a flight. It's just too bad that no one thought of that until now.

[Smoove_B]

Smoove, Fauci just suggested that there should be a vaccine mandate to be on a flight. It's just too bad that no one thought of that until now.

Yeah, I'd mentioned it in my earlier rant here - and of course the Biden administration has already said it's not happening, but thanks for the great suggestion.

It's all part of the general (professional) confusion I have. People waaaaaaaaaay smarter than I am know what to do. Every once and a while they actually say it. But then...nothing.

I mean, two hours ago Biden gave an update and said "There is no federal solution. This gets solved at a state level.”

While *technically* correct, the federal government could be providing model guidance to the states and business industries impacted by COVID. They could also be ramping up education and committing to getting better data analysis. The states and whatever their specific plans are would be absolutely critical, but the feds can't just wash their hands of all-things pandemic.

[malchior]

the feds can't just wash their hands of all-things pandemic.

Yet they'll desperately continue to try to wriggle out of it.

[Smoove_B]

Sure, this is holiday backlog related, but

https://twitter.com/BNODesk/status/1475657353387298819

BREAKING: U.S. reports 472,112 new coronavirus cases as many states dump holiday backlogs

For reference:

The all-time high for average daily cases was 251,232, set in January of 2021

[LawBeefaroni]

More cases? Fewer workers available? Let's cut the quarantine recommendation down to 5 days. That'll fix things.

The US Centers for Disease Control and Prevention on Monday shortened the recommended times that people should isolate when they've tested positive for Covid-19 from 10 days to five days if they don't have symptoms -- and if they wear a mask around others for at least five more days.

[Kurth]

Smoove, Fauci just suggested that there should be a vaccine mandate to be on a flight. It's just too bad that no one thought of that until now.

Yeah, I'd mentioned it in my earlier rant here - and of course the Biden administration has already said it's not happening, but thanks for the great suggestion.

It's all part of the general (professional) confusion I have. People waaaaaaaaaay smarter than I am know what to do. Every once and a while they actually say it. But then...nothing.

I mean, two hours ago Biden gave an update and said "There is no federal solution. This gets solved at a state level.”

While *technically* correct, the federal government could be providing model guidance to the states and business industries impacted by COVID. They could also be ramping up education and committing to getting better data analysis. The states and whatever their specific plans are would be absolutely critical, but the feds can't just wash their hands of all-things pandemic.

Why is that “technically” correct? In a situation where a public health crisis — a pandemic — and our response to it is crucial to support interstate commerce, why can’t the federal government legislate a federal solution?

I know that the Supreme Court has recently taken a dull view of expansive readings of the Commerce Clause, and given the make up of the current court, such a thing would be shot down quickly, but, theoretically, why couldn’t the Commerce Clause be invoked to tackle a public health emergency that threatens commerce between the states?

If ever there were a problem that needed a federal solution, it seems like COVID (or the next pandemic that’s probably just around the corner) would be that problem.

[Smoove_B]

It's technically correct because public health law is state law - there is nothing in the Constitution covering public health. That is why we are in such a cluster f over this because each individual state is tasked with regulating public health directly. It's the difference between a Ron DeSantis and a Gavin Newsom. Or a place like the state of Ohio where the GOP legislature is to control the creation (and removal) of public health laws while their GOP governor just repeats the mantra of "personal responsibility" over and over.

To answer your question about the Commerce Clause, in short it's never been done before and its likely there would be challenges - in the same way that 27 (?) states have challenged the workplace vaccination mandate being done through OSHA.

I am firmly in the camp that we need a national solution, but I don't know how it can be (legally, Constitutionally) done given our federal/state organization.

I mean, just look at the airline industry right now. Why hasn't the federal government via the FAA mandated vaccinations for domestic flight? In conjunction with masking (which they've already mandated), you now have them doing so much more to curb spread. But the airlines said "Our profits..." and that ended that. Plus, they already came to testify that masks are pointless. Business is driving the bus (or plane) here. It's...frustrating.

[Kurth]

Totally get what you’re saying and don’t disagree that a push to regulate public health via the Commerce Clause would likely be doomed to encounter stiff resistance and ultimately fail, but I think you could make solid arguments that such a regulatory move would be prudent and pass constitutional muster.

[Smoove_B]

If ever there was an argument for it, that time is now. But actually responding during the emergency by somehow coming up with a plan that passes Constitutional challenges as currently written? I don't see it happening. I've been following what's happening on a state and local level more closely and to see public health regulations being dismantled around the country while we're all in the middle of this is absolutely gut-wrenching. It's getting to the point in some cases where my understanding of public health practice is slipping into a historical perspective - the way things were done before 2016, not how they're currently being performed now. I am genuinely questioning the legitimacy of my knowledge and experience at this point based on what is unfolding. I've said it before, these are strange times for me - personally and professionally - and I've yet to completely untangle it all.

Above and beyond all that, so many in the field are also saying this is exactly what global warming will look like when there are actionable items to examine. When cities are flooding, when there are lengthy power outages associated with heat waves stressing the electrical grid, when certain diseases are being seen year round or in new areas - the politicians are going to be pushing for a "return to normal" and doing everything they can to help business get people to work.

[UsulofDoom]

New to the pandemic locally - the family doctors' practice just emailed us to let us know that they will not treat unvax-ed patients going forward. They said they need to prioritize staff and patient safety in the decision.

Can they legally do that if they receive Medicare payments? That would be like refusing aids patients because they did not follow safe sex rules.

The vaccine does not stop you from getting or giving covid. It only will reduce the effects of having it. It will also make the vaccinated more likely spread covid since they show none or little symptoms.

Yes I am vaccinated with booster and still got covid. The only symptom I had was loss of taste and smell for 3 days with a slight sinus pressure. I only had Nyquil before bed. I was still infections to others. My health insurance sent me a in-home test for free (well its part of my monthly payment.). Yours might too.

[RunningMn9]

They certainly can here in NJ. Our pediatric practice has had a policy for at least 20 years that they will only see patients that follow the normal vaccine schedule. Don’t want your kids vaccinated? That’s fine, find another practice.

[malchior]

New to the pandemic locally - the family doctors' practice just emailed us to let us know that they will not treat unvax-ed patients going forward. They said they need to prioritize staff and patient safety in the decision.

Can they legally do that if they receive Medicare payments? That would be like refusing aids patients because they did not follow safe sex rules.

Well one has documentation and the other doesn't so that's a big difference right there. But Doctor's (at least in NJ) are generally small businesses and can refuse treatment as long as they aren't discriminating against a protected class (e.g., refusing treatment based solely on race).

[Max Peck]

Waning protection from 2 doses shows need for COVID-19 boosters, says head of Ontario's science table

Protection provided by COVID-19 vaccines against infection by the novel coronavirus has waned dramatically since the highly infectious Omicron variant started spreading across Ontario, according to data from the province's Science Advisory Table.

The data shows that while having two doses does protect against severe illness among those who contract the virus, its ability to prevent infection altogether is plummeting, said Dr. Peter Jüni, the group's scientific director.

Vaccine protection has fallen to 14.9 per cent — from nearly 90 per cent a month ago — for people who have received two doses, according to the data.

"Vaccine protection against infection is melting like snow under the sun," Jüni said in an interview on CBC News Network. "Omicron is evading the immune system.

"In reality, there is no way — if it comes to infection — to distinguish anymore between a person who is not vaccinated and a person who has received two doses."

Vaccine protection refers to the reduction in the risk of getting infected.

[El Guapo]

Waning protection from 2 doses shows need for COVID-19 boosters, says head of Ontario's science table

Is there any data on the relevance (if any) of how long ago the person received their second shot?

Mainly wondering if there's any distinction in protection between my son (who got his second shot a month ago) and my daughter (who got her second shot in August).

[Isgrimnur]

Elf on a Shelf stole my immunity!

[LawBeefaroni]

Waning protection from 2 doses shows need for COVID-19 boosters, says head of Ontario's science table

Protection provided by COVID-19 vaccines against infection by the novel coronavirus has waned dramatically since the highly infectious Omicron variant started spreading across Ontario, according to data from the province's Science Advisory Table.

The data shows that while having two doses does protect against severe illness among those who contract the virus, its ability to prevent infection altogether is plummeting, said Dr. Peter Jüni, the group's scientific director.

Vaccine protection has fallen to 14.9 per cent — from nearly 90 per cent a month ago — for people who have received two doses, according to the data.

"Vaccine protection against infection is melting like snow under the sun," Jüni said in an interview on CBC News Network. "Omicron is evading the immune system.

"In reality, there is no way — if it comes to infection — to distinguish anymore between a person who is not vaccinated and a person who has received two doses."

Vaccine protection refers to the reduction in the risk of getting infected.

Haven't we given up on protection against infection anyway? This isn't really new. The vaccine now protects against severe symptoms leading to hospitalization. Masks and other prophylactics protect against infection.

[Defiant]

There's also been some preliminary data that shows that the protection of boosters against symptomatic infection drops to 35-45% after two and a half months: https://www.popsci.com/science/booster- ... ron-drops/

Haven't we given up on protection against infection anyway? This isn't really new. The vaccine now protects against severe symptoms leading to hospitalization. Masks and other prophylactics protect against infection.

Well, I would say both masks *and* boosters (and ventilation) work together to reduce your chances of being infected (as none of them are 100% effective at stopping infection).

[Smoove_B]

Starting to see lots of chatter about schools in NY and NJ - people wondering how on earth they're going to open on Monday after what we've been seeing in our corner of America. Someone pointed out that last year schools in NYC went virtual when the city hit a 3% test positivity rate. Right now NYC is over 20% test positivity and everyone is just shrugging their shoulders. It's pretty similar in NJ. My county has the single highest rate of new positive students and staff in the entire state (~14/1000, state average is 8/1000 and climbing).

Again, none of it makes sense until you remember that when kids are home, a significant number of parents cannot work a normal schedule. And we've all decided what's most important now.

I don't know how parents of kids in that 1-4 age range are holding it together right now.

[El Guapo]

My upstairs neighbor is a physician at a Boston hospital. His wife just told me that the National Guard is at his hospital today to help with manpower, since apparently something like half the staff called out sick today. Which seems...less than ideal.

[Smoove_B]

I've been assured it's a very mild-hospitalization

https://twitter.com/BNODesk/status/1475942873375944710

Number of Americans hospitalized with COVID-19 tops 76,000, highest since September

[Smoove_B]

https://twitter.com/BNODesk/status/1476029623276290054

NEW: 7-day average of daily coronavirus cases in the U.S. reaches 267,738, the highest since the pandemic began

[Smoove_B]

And some clear insight as to what's happening

https://twitter.com/davidalim/status/14 ... 5462150148

Really blunt discussion of trade offs to keep society running during upcoming weeks.

Fauci: "So many people — now and likely in the next few weeks — who will be infected by this wave of infections that we're getting with Omicron ... that might have a negative impact on our ability to maintain the structure of society."

@chrislhayes: "You are talking about a policy judgment in a context of tradeoffs between different consequences."

Contrasts stopping spread of Covid-19 vs having a water treatment facility have its technicians all out sick for 10 days.

Fauci nods yes and responds: "Correct."

Fauci: "Nothing is going to be 100%. And this is one of those situations when you're dealing with a very difficult situation. We often say, you don't want the perfect to be the enemy of the good."

Notes people are more like to be infectious at the start of an infection.
Fauci continued: "The CDC feels and I don't disagree with them at all, that wearing a mask is ample protection during that second half of a 10 day period, when you balance that against the importance of trying to get people back functioning in society."

When asked by @chrislhayes if CDC's guidance change was in response to the Delta Airlines letter or other big employers, Fauci pushes back.

"No, that's not so at all," Fauci said. "That was not the basis of the CDC decision."

Fauci: "We're trying to have a good balance of preserving and protecting the public health, at the same time that we don't have to have the draconian decision of shutting down the country."

Says there would be "a lot more devil advocates yelling" if the U.S. was "shut down."

You can watch it here

[stessier]

We had about half a shift's worth of people call out where I work which is 2x as many as yesterday. I had one case in my department and that person's 19 year old child is in the hospital with pneumonia+covid with O2 sats at 78% when admitted. Fun times.

[Blackhawk]

Concurrently? How can you not have known someone who's had COVID by now?

I have a very small circle of in-person acquaintances. Prior to last month, I knew zero. Now I'm at two.

[El Guapo]

FWIW covid has barely reached my circle of contacts, though omicron is starting to close in. Before this it was almost all "friends of friends", and no immediately family members. Though my wife's cousin now has it, and another friend of hers has it along with her family. So we'll see how January goes.

[Smoove_B]

I feel like multiple states and state leaders are really leaning into the "it's mild" belief that's been circulating for weeks.

https://twitter.com/MarkLevineNYC/statu ... 8572719113

Hospitalizations are rising extremely fast in NYC. On track to pass last winter’s peak in a matter of days.

This is happening at a time when the healthcare workforce is depleted and exhausted and many are themselves out with covid.

We have to do more to slow this.

I'm not picking on him here, to be clear, just using his tweet to note what's happening. "We have to do more to slow this" is what public health has been saying for months. And yet...here we are. Again.

[El Guapo]

I feel like multiple states and state leaders are really leaning into the "it's mild" belief that's been circulating for weeks.

https://twitter.com/MarkLevineNYC/statu ... 8572719113

Hospitalizations are rising extremely fast in NYC. On track to pass last winter’s peak in a matter of days.

This is happening at a time when the healthcare workforce is depleted and exhausted and many are themselves out with covid.

We have to do more to slow this.

I'm not picking on him here, to be clear, just using his tweet to note what's happening. "We have to do more to slow this" is what public health has been saying for months. And yet...here we are. Again.

Is this hospitalization spike suggestive that omicron might not be as mild as thought / hoped? Or is it more just the sheer volume of people getting infected means that even a lower severity still translates into a large number of hospitalizations?

[Smoove_B]

When you say "as mild as thought" I'm not clear of your frame of reference for that. Namely, researchers, virologists, ID doctors, etc... have been saying for the last month+ that even if Omicron was slightly less severe than Delta, the speed of spread and the number of people would overwhelm our medical response. If it's exactly as virulent as Delta, the speed of spread and number of people would overwhelm our medical response.

So when I hear "as mild as thought" I am asking if that is coming from the media reports or Johnny on the Street discussing it. Because from where I'm sitting, exactly what was predicted is currently happening - at least in our area of America.Absolutely better than without vaccinations but the number of people this is about to rip through means volume of people needing medical assistance is going to increase. In my own state all the lagging numbers (hospitalizations, ICU) are increasing significantly - as we announce ~21K new cases today. ~20% of our hospitals in the state are currently on diversion...again. But our governor is still doing absolutely nothing.

It'll be another week or so until we know about deaths, but that's already going to happen - nothing we're going to do to change that. But if we started masking mandates and doing selective shut-downs today? Encourage businesses to go remote? Confirm remote schooling for 2 weeks after winter break? That would help. Somehow push back against the 5 day no testing "back to work" guidance? Otherwise, it's just going to get worse.

Also, I already know what we're going to do.

[Defiant]

Is this hospitalization spike suggestive that omicron might not be as mild as thought / hoped? Or is it more just the sheer volume of people getting infected means that even a lower severity still translates into a large number of hospitalizations?

IIRC, there were 1-2 preliminary studies that showed that it's ~15-25% less severe (in those without immunity) than Delta (but Delta is 2x more severe than the original strain). I'll see if I can find it.

Edit: twitter thread with link to study: https://twitter.com/roby_bhatt/status/1 ... 8947980300

[El Guapo]

When you say "as mild as thought" I'm not clear of your frame of reference for that. Namely, researchers, virologists, ID doctors, etc... have been saying for the last month+ that even if Omicron was slightly less severe than Delta, the speed of spread and the number of people would overwhelm our medical response. If it's exactly as virulent as Delta, the speed of spread and number of people would overwhelm our medical response.

So when I hear "as mild as thought" I am asking if that is coming from the media reports or Johnny on the Street discussing it. Because from where I'm sitting, exactly what was predicted is currently happening - at least in our area of America.Absolutely better than without vaccinations but the number of people this is about to rip through means volume of people needing medical assistance is going to increase. In my own state all the lagging numbers (hospitalizations, ICU) are increasing significantly - as we announce ~21K new cases today. ~20% of our hospitals in the state are currently on diversion...again. But our governor is still doing absolutely nothing.

It'll be another week or so until we know about deaths, but that's already going to happen - nothing we're going to do to change that. But if we started masking mandates and doing selective shut-downs today? Encourage businesses to go remote? Confirm remote schooling for 2 weeks after winter break? That would help. Somehow push back against the 5 day no testing "back to work" guidance? Otherwise, it's just going to get worse.

Also, I already know what we're going to do.

I'm talking about the severity from the perspective "for an average individual who gets omicron vs. delta vs. "vanilla" (OG?) covid, etc., what are the odds that said individual will be hospitalized, what are the odds that they die, etc."?

My understanding from a bunch of articles is that omicron appears to be more "mild" from that individual perspective, such that any given person with it is less likely to be hospitalized than if they were infected with (say) delta. To pick random numbers, let's say a 1% chance of hospitalization with omicron vs. 2% with delta.

Of course, all accounts are that omicron is *much* more transmissible, and also that it's much more likely to result in a symptomatic infection for vaccinated people than Delta.

So with Covid hospitalizations spiking, there would seem to be two plausible explanations: (1) that omicron isn't actually less severe for a given individual (e.g., the hospitalization rate is 2% like Delta, not 1%); or (2) that omicron is infectious enough that it is infecting twice or more as many people as Delta, such that while "only" 1% of those infected are getting hospitalized, so many people are getting it that that 1% is of a number twice as big or more.

From what I'm reading it sounds like the latter is the case - that while omicron may be less likely to lead to hospitalization than delta for an average individual, it's infecting almost everyone, so that we're winding up with many more hospitalized people.

[Smoove_B]

You've hit upon the core difficulty for this entire pandemic. Here, you're referring to individual outcomes and I'm thinking in population terms. My guidance and advice cannot address the specific nature of one person's health status. All I can say is that if we don't (1) vaccinate more people and (2) encourage masking policies and (2) encourage paid leave/support for those that are sick, collectively as a society we're in trouble.

At the end of the day, not even your doctor knows exactly how Omicron or Delta or whatever will affect you. They can guess by plugging your general demographics (age/weight/underlying health status) into a calculator and think "Oh, he's an otherwise healthy middle aged man, so he most likely won't need hospitalization" and then 4 days later you have blood clots in your legs and are now a double-amputee.

From a population perspective? Sure, the data is telling us that overall it seem to be on-par with Delta, likely not worse. But from a volume perspective, scaled across an entire population. To borrow from one of the greats: more people, more problems.

[Isgrimnur]

At the end of the day, not even your doctor knows exactly how Omicron or Delta or whatever will affect you. They can guess by plugging your general demographics (age/weight/underlying health status) into a calculator and think "Oh, he's an otherwise healthy middle aged man, so he most likely won't need hospitalization" and then 4 days later you have blood clots in your legs and are now a double-amputee.

And that's if they don't break loose and become a pulmonary embolism.

[Freyland]

It'll be another week or so until we know about deaths, but that's already going to happen - nothing we're going to do to change that. But if we started masking mandates and doing selective shut-downs today? Encourage businesses to go remote? Confirm remote schooling for 2 weeks after winter break? That would help. Somehow push back against the 5 day no testing "back to work" guidance? Otherwise, it's just going to get worse.

Also, I already know what we're going to do.

Scotch?

[Smoove_B]

Scotch?

I might need to switch to Gin for the next few months - currently, the Scotch isn't cutting it.

[RunningMn9]

I assume that what I'm about to say is in a link that Smoove posted above, or sent to me privately. But it just seems like a good time to review it.

The problem with O is that let's say you are like me. You got your two shots of Pfizer back in April, and then got boosted back in October. My risk of infection from D was pretty low. My risk of hospitalization from D was negligible (both because the vaccine would help me fight it without needing hospitalization, and because I probably would not have gotten infected in the first place). Because O evades immunity (I am now beyond the 10 weeks since my booster, and so I believe I read that the efficacy is down to like 30% now), the risk to me of being hospitalized with O is *significantly* higher than the risk of me being hospitalized with D (mostly because I probably wouldn't get D). The rates of hospitalization presume an infection, but risk has to also account for infection first.

My understanding from a bunch of articles is that omicron appears to be more "mild" from that individual perspective, such that any given person with it is less likely to be hospitalized than if they were infected with (say) delta. To pick random numbers, let's say a 1% chance of hospitalization with omicron vs. 2% with delta.

From other data we've seen here in the thread, O appears to be about 25% "less severe" than D. So if we randomly select a hospitalization rate of D as 2%, than we would expect the hospitalization rate of O to be around 1.5%?

Let's accept this for the moment, which references a study that concluded that O is 4.2 times as transmissible as D.

Let's say 1M people get delta, and 2% of them get hospitalized. That's 20k people into hospitals. Now imagine 4.2M people get omicron. That's 63k people into hospitals. With that kind of transmission, I would think that the omicron would have to be something like 75% less chance of hospitalization, right?

[LawBeefaroni]

From an individual perspective, look at it this way. With O, you're more likely to have to roll the dice. While you may have a better chance to save on that dice roll to avoid hospitalization/severe symptoms than with vaxxed Delta or unvaccinated with Alpha/Delta, it's better not to have to roll at all. For the unvaxxed, they're more likely to have to roll and have have a much harder roll.

From a population perspective, with more people rolling the dice we'll have more people failing their saving throws.