Devil and the Deep Blue Sea

I am incredibly frustrated by practically everyone's response to the pandemic.

Even places with previous existing mask mandates- including here! - largely failed to enforce them.  Now that it's nothing more than a weakly worded suggestion, you can bet your bottom dollar that the unmasked are, disproportionately, also the unvaccinated.

The right wing response?  No more masks ever! The left wing response?  You, personally, should wear a mask everywhere indoors forever, or else you're a bad person!

Is there, perhaps, a response that is not both stupid and ineffective?  Immune compromised people remain at high risk. Great!  Maybe some entity- and I'm just spitballing here, but perhaps the federal government might be in charge of this here thing? - could make sure they're provided with adequate and effective medication options?  They could use their emergency powers to do something... effective?

Nah, just kidding!  You should wear a mask or you're a bad person!  Who cares that 98% of the other people at the hardware store aren't wearing one?  You, personally, will increase others' risk by an insignificant amount (compared to what's already going on), so you, personally, are responsible for mitigating this huge societal and governmental failure!  Nobody's going to do anything to mitigate the risk for the highest-risk people; nobody's going to increase hospital staffing or make high-quality masks actually widely available or send out enough rapid tests to make one iota of difference (although looking at UK data one might reasonably wonder how much that helped).  

Right now, I get a covid-cases notice from our schools every single day.  Usually it's about 2.5% of the total students per week. The best that can be said for requiring masks in schools - which is no longer permitted here! - is that it could be worse, but it's already pretty bad.  And don't even get me started on 'mask breaks' and the ineffective wearing of masks.  (To be fair, our district did also do a lot with air quality and filtering.) 

I'm not saying, don't wear a mask to protect yourself.  Do whatever suits you best!  I am saying, this is ineffective health policy, it has done nothing to prevent an actual million deaths, and it will continue to do nothing to prevent more deaths, because the overall risk from leaving your house is so high that reducing exposure by the 2% of people actually wearing masks is stupid and ineffective.  

I think that most people are unwilling to maintain the level of precautions that would be necessary to never get covid.  (If you are, good for you.) I'm not going to call specific people out, but think of everyone you personally know who was 'just so careful' and got covid anyways at some point.  I think that if, on the whole, our society is not willing to do anything effective at a level which would be effective, why are we still pretending that individual masking at the grocery is what's going to turn the tide?  I think I want interventions to be either effective and intrusive, or neither.  I think my university 'requiring' masks of everyone is working really great as I walk by ten undergrads sitting in the hallway pretending to drink coffee.  I think this is all stupid and I would like to get off this ride, and possibly move to a desert island.

Time for the "I Told You So" sign

 Even NZ couldn't keep covid out forever (though their current outbreak of 724 cases to date is called 'a Monday' in practically any US state).

Nevertheless?  I totally told you so. 

Anxiety, Embodied

 I thought I was all ready to go for this school year, glad my kids are in school and enthusiastic about teaching.  Everything is ready to go, we have our lunch boxes, I'm doing my lectures....

Yesterday my anxiety arrived embodied in fourteen separate three-packs of masks, from three different stores.  Oops.  Apparently on multiple occasions, I took out my feelings in making sure we had enough masks. (I had meant to order maybe twenty?  Kid 1 has gym first thing and likes to wear a clean one afterwards, and Kid 3 has to leave 10 at school [no, it doesn't actually make any sense], and Kid 2 is always leaving them under the couch or whatever.) 

What am I worried about?  Schools staying open.  Schools not staying open.  Us all, inevitably, getting covid despite being vaccinated.  The FDA refusing to hurry their vaccine approval the !@#$ up despite everything being on fire.  Not finding another job.  Finding another job and moving.  The inevitable disaster this semester will be even with 95% of campus vaccinated.  My kid who lies a lot (it's normal but irritating).  Money.  My grandma.  My stubborn mother and her poor medical decision making.  EVERYTHING.

Anyhow, I have not resolved any of these issues but my family has about 80 masks now and 200 disposables to boot.

In Which I Have a Lot of Feelings

Oh, friends on the internet, it has been a MONTH. 

All the jobs I applied for rejected me with some alacrity.  I am now unsure if we are going to need to sell our house and move elsewhere before I can find another job.  I am seriously considering it.

My sisters flew in to visit - from Israel, to my parents' house, two hours away - and didn't bother to tell me they were there.  Possibly the middle sister was offended by my insistence that it is wrong to deliberately target and murder civilians with your army, and that this is true of the US *and* Israel both; she hasn't spoken to me since.  (Frankly, it's no great loss.)

My youngest sister, for reasons entirely opaque to me, is flying in, with her spouse and toddler, to stay with my cranky-old-man dad and my mom for three (?) weeks, after which they will all attend a large wedding in DC.  (After I'm there more than 12 hours with my kids, I want to murder my beloved father; this is a really bad idea.)  Truly, what could go wrong?  I haven't heard a single word from her either, so I assume she has no desire to see me.  Honestly, it's kind of like I don't have sisters, except for my mother's alternate woefulness and bitching about how I don't give a shit about people who don't give a shit about me.  (Weird, right?)

My mother has decided to fly to Israel in September to enjoy some apartheid theocracy in person, despite the really quite onerous requirements, the pandemic, and the fact that she's 70.  The last time she went there, she got so sick that she spent 3 weeks in bed and I harassed her into going to the doctor for the first time in 15 years.  And that was just dehydration and sleeplessness, probably.  Like the US, Israel has infected a bare minimum of 10% of their population and are having a nice outbreak, so that's gonna go great.  Mom is vehemently anti-medical care despite BEING A MEDICAL PROFESSIONAL so I'm sure it's gonna go great when she gets Covid in Israel.  We won't see her for two, maybe three months.  I'm a little afraid she'll die and a lot exasperated.

My cousin is supposed to get married in three months in a big city.  My 87 year old grandma has plane tickets to fly across the country.  This is an objectively terrible idea and I'm bummed about the thought the wedding won't happen, but also really afraid that it will and my grandma's gonna die.

Meanwhile, certain people here where I live, with whom I must interact, are both craaaazy and inconsistent in their crazy.  Terrified about being around unvaccinated people- unless it's their kid's teacher, that's fine.  Making their kids wear a crappy cloth mask outdoors in public- but the adults aren't wearing one indoors any more, ever.  Afraid to teach in person - but fine to go to a crowded beach and stay in a hotel.  PICK.  ONE. 

In a month, the classes I'm supposed to teach will start.  I am record amounts of depressed and unmotivated.  The children are squabbling nonstop.  I just want to run away from home.  BLAH.

Masks, Yet Again

Preface: My employer requires vaccination of all staff and students; also, we're totally gonna have a nice-sized outbreak by.... October, maybe.  I think they should make everyone wear a mask from day one, but it's not gonna happen.

 The CDC recently had a nice private slideshow (which the WaPo immediately acquired) with all kinds of 'Oh, !@#$%' data about our favorite latest variant.  Behold, my favorite 'enjoy the next six months' slide:

 

Note particularly their model assumptions about masking.  These are likely to be lower-bound estimates of effectiveness.  (Also, 'how much aerosol did I inhale' and 'will I get sick' are not the same question.  How many exposures does it take to get sick?  It depends....)  How can we figure out average effectiveness?  Someone did a great study some time ago!  (Briefly, they used soft mannequins and radiation to measure particle reception.) 

Figure 4: Exposure data for tidal breathing, expressed as a percent of aerosol exhaled with a two-sided 95% CI, plotted for different masks on the Source or Receiver. An asterisk (*) denotes significance for a p-value <0.05 using the Kruskal-Wallis one-way analysis of variance. S = Source, R = Receiver, MaxEx = Maximum Exposure, SMnat = natural fit surgical mask, SF = SecureFit Ultra fitted surgical mask, N95 = 3M N95 respirator, N95vas = 3M N95 respirator with a Vaseline seal.

Figure 5: Exposure data for cough, expressed as a percent of aerosol exhaled with a two-sided 95% CI, plotted for different masks on the Source or Receiver. An asterisk (*) denotes significance for a p-value <0.05 using the Kruskal-Wallis one-way analysis of variance. S = Source, R = Receiver, MaxEx = Maximum Exposure, SMnat = natural fit surgical mask, SF = SecureFit Ultra fitted surgical mask, N95 = 3M N95 respirator, N95vas = 3M N95 respirator with a Vaseline seal.

 

 

So, in summary, if you can convince your local administration/ school board/ city council to re-institute indoor masking, that would be great, because it is (according to this one very well-conducted study) 25 times more effective at reducing respiratory droplets as just 'people who want to' wearing a mask.

Which Masks for Children?

 Nicole and Maggie asked in the comments which masks I would recommend for kids.  So, here's my opinion for schools/ daycares/ non medical settings: 

• The mask your kid will wear, which is fitted as tightly as the child will tolerate, is the best mask for your child.
• The objectively best mask is a N95; not only are they very difficult to find, but they are SO uncomfortable for many hours.  (Yes, I have personally worn them for many hours.) Your kid will likely poke at the edges and pull it out for air. 
• This makes them much less effective, oddly enough. N95 fit also starts to degrade after 5 on/off cycles, and is very poor after >10 in general, so they are probably not a great idea for children
• Cambridge masks in a size small or medium have excellent filtration and fit parameters (especially with a head strap); they are hand but not machine washable.   
• Good child-sized KN95s, assuming they were actually tested correctly, are less uncomfortable than N95s, but hard to fit closely to the face.  Again, a KN95 with any air gap is probably no better than a surgical + cloth mask.   (I have also worn KN95s for many hours.  If they're not going in and out when you breathe, they're not tight enough.)
  
• A cloth mask + a tied/tucked surgical mask (see here at the very bottom) has very good filtration properties and is relatively comfortable, plus you can swap out the surgical mask in the middle of the day; surgical masks in children's sizes are also widely available.

 What are my kids going to be wearing?  Probably just cloth masks.  Our schools do all require masks for everyone, and transmission in our schools has not been high (though it will certainly be higher in the near future- note that titre and transmission are not linearly related, however).  My concern level is low (if yours is higher that is fine!), and therefore it's not worth it to me to make them miserable.  If new data come out that are concerning, I'll re-evaluate, but that's where we are now.  

Drop your recs in the comments if you want!

P.S. The Wirecutter does recommend one actually machine washable cloth mask for kids.

Once More With Depressing Predictions

Original here, most recent here. Probably I should stop doing this; it gets more depressing over time.

Revisiting previous predictions:

Excess mortality as of July is around 700,000, with the official covid deaths just over 590,000.  Well done, US!  Keep going, we'll definitely get closer to a million (I don't think we'll quite make it...).  At the beginning I definitely didn't think the country would twiddle its collective thumbs while half a million people died AND YET here we are.

In April I said this: 

"I think that some of the places (like NZ) that have done the best containment are screwed in the absence of widespread testing - even worse off than NYC- because the moment anything reopens it will spread very fast."

Everywhere but New Zealand is basically experiencing this in real time (Australia, South Korea, Japan, China (which is almost certainly lying), Israel).  Australia is barely containable but I predict will eventually give up.  That said, at least they didn't just let one in 600 of their citizens die.  But eventually the neverending cycle of lockdown after lockdown will stop, because someone will give up/ declare it endemic/ get enough people vaccinated that the government throws up its hands.

Testing and contact tracing did not make any meaningful difference anywhere with a larger-than-Australian outbreak.  Who could have guessed.

There is, in fact, almost no surface to person transmission.

On to predictions:

On re-infections: I failed to predict the rapid emergence of more and more (and more) strains, so, oops. The reinfection rate will be well above 10% because, broadly speaking, most countries' governments fucked around and found out, so hey!  We're all gonna be exposed to something quite contagious eventually.  However, it continues to be true that mostly, people with either vaccination or previous infection get less sick.  Don't worry, in a year or two we'll have a nice resistant strain. 

"The pandemic will not be 'over' before December 2021, because even after a vaccine (likely widespread by June/July) sporadic outbreaks will continue due to low immunogenicity, waning of all immune responses over time, low uptake, and Americans' stupid refusal to continue wearing masks in public."

 YEAH SORRY ABOUT THAT HOW ABOUT DECEMBER 2022 plus sporadic outbreaks for, IDK, forever? Did anyone order a new influenza, but worse?

"Schools that re-open will have sporadic transmission events, but primary grades will not be a major driver of this... This winter will be a complete !@$!%%! disaster in terms of schools, because everyone is very bad at statistics"

 This definitely also happened.  I predict that this winter, schools will close in panic at random intervals because OMG A KID GOT SICK, but, you know, not in an effective way.  Colleges and private schools and bars will remain open but God forbid we should teach public school!

Governments will continue to do the least effective possible things (like telling vaccinated people to wear masks without enforcing it on the unvaccinated or - novel idea! - requiring masks indoors for all).  Spoiler alert: the people taking the plague seriously are already vaccinated and the other people, who are 20x more contagious, think Magical Hippo* protects them. People who contract breakthrough infections will continue to be shocked - shocked! - that you can still get sick, even though, again, that is how everything works.  (Get your damn vaccine if possible, y'all. Though I'm sure basically everyone reading this already did.)

When the pandemic started, I told many people that the 1918 pandemic lasted three years (it tailed into 1920 depending on geography).  We'll be lucky to have this one over in three years, not least because of vaccine politics, vaccine hesitance, and faster travel (and therefore faster transmission). Congratulations, everyone, it's for sure endemic, plague forever!

* It's HIPAA and it only applies to 'covered entities'.  If you don't touch a patient's billing or medical records, odds are good you're not a covered entity!

 

Grim Guesses, Round 3 (Recap, further predictions)

 Original here.

We are now well past 200,000 deaths.  I hope we will not get to half a million- maybe we'll plateau out around 400,000! - but it doesn't look good.

In April I said this: 

"I think that some of the places (like NZ) that have done the best containment are screwed in the absence of widespread testing - even worse off than NYC- because the moment anything reopens it will spread very fast."

Europe is up to 100,000 cases a day over a population roughly twice the US's.  New Zealand continues to have strong containment and minimal community spread, mainly by maintaining high levels of testing, isolation, and government response. Europe has the problem I predicted: not enough testing for actual containment, and eventually it becomes both unreasonable and impossible to keep everything closed for 18 months.  The US and European outbreaks have both become un-containable.

I heard someone say last week, "Testing describes an outbreak that has already happened."  Remember that next time you hear someone say that more testing or more contact tracing will actually prevent outbreaks.  It may help contain them temporarily, but unless you catch every single asymptomatic carrier, there is going to be untraceable community spread.

On to more depressing predictions!  I am doing a best guess on many of these numbers because I don't have time to read 100 research articles.  

We will find that there is almost no surface to person transmission (the only credible case report to date does not, in fact, demonstrate any actual surface to person transmission; elevators have poor air circulation and nobody even checked; see also the Korea call center outbreak). Reasoning: this has been going on for 7 months and the absence of evidence is not evidence of absence, but there are also excellent data documenting person to person airborne droplet transmission. 

People will continue to get sporadically reinfected, and more-serious second rounds will be found predominantly in people with a mild first infection (THAT IS HOW THE IMMUNE SYSTEM WORKS).  The actual percentages will be impossible to come by, because of technical limitations of our current test system.  I predict that no more than 1% of people with 'severe' (feverish, symptomatic) infection will get re-infected within 18 months- and probably less - and no more than 10% of people with mild/asymptomatic illness - probably less.   

The pandemic will not be 'over' before December 2021, because even after a vaccine (likely widespread by June/July) sporadic outbreaks will continue due to low immunogenicity, waning of all immune responses over time, low uptake, and Americans' stupid refusal to continue wearing masks in public.

Schools that re-open will have sporadic transmission events, but primary grades will not be a major driver of this.  Teachers will continue to infect each other at some low rate, however, and children will continue getting sick from family members.

This winter will be a complete !@$!%%! disaster in terms of schools, because everyone is very bad at statistics (and kids get colds in the winter, and cough is an extremely nonspecific symptom).

If Biden is elected, things may get less bad, but they're still going to be pretty bad.  If Tr!mp is re-elected, I'm looking to leave the country.

Colleges will mostly stay open and deal with their outbreaks, because otherwise nobody gets paid.

(As a side note, be skeptical of the 'small gatherings are driving transmission.'  Yes, they are, but mostly because there are not large gatherings.  Where are people together, breathing on each other?  Small gatherings, and colleges.  If there were no gatherings, it would be 'going to the grocery' or 'nocosomial infections' or something.  This is like saying most people who are in car accidents were driving at the time.)