This is a "rush" information artifact; it is fairly raw and unfinished. I don't intend to finish it, because I've gotten the value I need out of it, and it's processed enough for me to share and for others to get the gist. But feel free to take it and finish it, and let me know if you'd like me to help. Sorry it’s so long; it’s an important message, and I think the context is necessary.
Johanne and I listen to a few key experts about COVID-19, and take their analysis and advice very seriously.
One is Dr. John Campbell (PhD), via YouTube:
https://www.youtube.com/channel/UCF9IOB2TExg3QIBupFtBDxg
Another is Dr. Michael Osterholm (PhD, MPH), via CIDRAP/Osterholm podcasts:
https://www.cidrap.umn.edu/covid-19/podcasts-webinars
Dr. Osterholm, in his most recent podcast, "Episode 56: From Checkers to Chess (May 20, 2021)", said some interesting things.
By the way, a related link:
"Experts say CDC missed mark on COVID mask guidance" (CIDRAP)
https://www.cidrap.umn.edu/news-perspective/2021/05/experts-say-cdc-missed-mark-covid-mask-guidance
After Johanne and I discussed amongst ourselves, we have decided to change our personal masking policies; in particular:
We will be limiting our time in close-quarters public settings (indoors and out), and we will be wearing N95 masks, not surgical or cloth masks, until such time as it feels safer.
Outdoors in non-close-quarters situations (walking / hiking), we will not be wearing our cloth masks (to the extent local regulation permits), except that we still put them on when we approach others with masks on (out of mutual respect and solidarity), or when we feel unsafe due to the behavior of others.
For background: we are in our late 50's, we are fully vaccinated and more than two weeks past our final dose, and we live in metro Southern California, in the United States. Your mileage may vary, especially in different states and countries.
Disclaimer: This is not medical advice, please consult your doctor, your public health officials, or others you trust with your health.
The relevant bit of Dr. Osterholm's podcast is below, in an uncorrected machine transcription. He makes three main points:
1. The good vaccines are amazingly effective and a most important public health tool. However, breakthrough COVID-19 infections still happen (as expected from trials), so even if you are vaccinated, you can still get sick, and potentially very sick, and if you're frail, potentially even die, even though you are vaccinated. This is obviously more of a risk to you if you have underlying conditions that compromise your immune system (including being middle-aged or elderly).
2a. Different kinds of masks are different! A cloth mask is not as good as a surgical mask. A surgical mask is not as good as an N95 mask. A poorly fitted N95 mask is not as good as a properly fitted N95 mask. Just saying "wear a mask" is not necessarily very helpful.
2b. N95 masks are WAY WAY different. Osterholm cites studies that say if you're in close quarters with an infectious person, you have a good chance of getting sick after 15 minutes with them, if you are both not wearing masks. If you are wearing a cloth mask (and they're wearing nothing), it will give you up to 20 minutes. If you are wearing a surgical mask and they're wearing nothing, it will give you up to 30 minutes. N95s boost that to 25 HOURS. (And if you're both wearing well-fitted N95s, 2500 hours.)
(Disclaimer: I have not seen these studies, and may have misunderstood Osterholm; these are striking numbers. This is a significant part of the information artifact you are reading that is unfinished. I have the information I need for a decision already, but please do your own research to confirm, and share if you can.)
(I have ordered US-made N95s from a vendor with whom I have a chain of trust, such that I have fair confidence that the masks are as they are represented. <https://ppe-for-usa.com/N95-Face-Mask-c68319259> There are many other sources; beware of counterfeits; you'll need to establish a trust chain to the vendor you choose.)
3. Outdoor air. Osterholm doesn't wear a mask in non-close-quarters outdoor situations; however, he also cites research that shows that superspreader events can happen outdoors in close-quarter situations. Outdoor air is not a magic bullet; consider closeness and time and take appropriate precautions.
In the transcript below, point 2a is between lines of "=" characters. Scroll down or search for "====".
This is excerpted from a podcast, Osterholm Update: COVID-19, Episode 56: From Checkers to Chess, May 20, 2021.
THE FOLLOWING IS AN UNCORRECTED MACHINE TRANSCRIPTION WITH OBVIOUS MISTAKES. Refer to audio recording for definitive statements. "Check Against Delivery / Seul le texte prononcé fait foi." This is v2021-05-22-001. Please send improved transcriptions to kaminski@istori.com.
[0:17:58]
Well I'd like to start by waking up one day and realize that this is all just a bad dream. That wouldn't be a bad place. But I know unfortunately it's not going to happen.
Let me lay out for you a picture. Something that I think we all have to look at carefully to understand anyone aspect of vaccines, mask exposures, whether it be indoor outdoor and what our end game is. I think right now we risk public health credibility. Like we haven't through the duration of this pandemic and we know it's been pretty tough and rough through many of these months, the public is taken in all this information. And the more confusing the information gets, uh the more they distrust what the message is that we're providing them.
And we heard that loud and clear this past week when CDC changed their recommendations on the use of masks. We heard those who are excited by the change and others who were very upset about it and said that it set us back not forward and it put people's lives at risk. So let me walk through vaccines, mass the protection of outdoor error. And then what is our end game And where do we go from here? And I hope that this will give some sense of where I think we're at.
If we look at vaccinations again, we continue as a country to shine. I give great credit to our biden administration, to state and local health departments, to our medical care facilities, to the many volunteer organizations, to the community clinics, to the private pharmacy companies go down the list, All the people who have made it possible for us to deliver right now on over 270 million doses of vaccine. That's just simply remarkable.
But if you look at where we're at, we still have a ways to go. And we talked last week about what has happened in the Seychelles and the fact that we had a country that had the highest reported immunization levels in the world at over 70% with one dose in the 60% plus with two doses. And these were vaccines the sign of farm vaccine from china and the Astrazeneca vaccine made in India. And there was some suggestion that maybe they weren't performing at the same level as the M. RNA vaccines were seen in this country, but they were still performing very well and yet they were in lockdown.
So this idea that there's this magic number we hit and suddenly everything stops first of all has to be right now throwing out the window. That's not the case. We can sure do a lot but we're not going to hit this herd immunity issue.
Let me just Provide some perspective while we will often use a specific percentage to describe the level of vaccination our country, such as the fact that right now 60% of all adults have at least one vaccination. You have to start to break it apart to really understand what's happening in terms of potential risk. Right now, if you look at all the population, 47.7 have had at least one dose, 37.5% are fully vaccinated, only 37.5%. If we look at the population under 12 years of age, this new group, that is now critical because of the fact that we're adding in the younger kids to this, 56.5% had a single dose, 44% are fully vaccinated with two doses or the one J. And J dose. If you look at those 18 and older, that's where the 60% comes in 60%.
As I said, have had at least one dose, 47% are fully vaccinated. And there also is good news in that uh 84.6% of our population over 65 years of age have had at least one dose, 72.8% have had both doses of the one dose of the J. and J vaccine. So why am I concerned about this?
Well, it's almost a tale of two states. If you look at what we have happened in this country, we have a number of states that are substantially below the numbers I just shared with you as an average, if you look at 10 states in the country, you'll see very, very different pictures of vaccination levels. Mississippi 32% of the population has at least one dose Louisiana 34% Alabama, 35% Wyoming, 35% Idaho 36% Tennessee 37%, 37 Arkansas, 38 Indiana 39% in South Carolina, 39%.
Note that all of those states where they're clustered in the south Or the two states in the Rocky Mountain Region.
So from that perspective, we're not going to be done for a while yet. We are going to be working really hard to get these last few percent of people vaccinated. So when we say 60% have had at least one dose, Don't count on it suddenly getting to 70% or 80%.
Now the CDC announcement on the issue with mass, they pointed out also about studies showing how well the vaccines were working such that they meant the transmission of the virus among vaccinated people should they become infected would not be a challenge and would therefore not mean you continue to need masking.
Well, I found this little confusing quite honestly. And even among my colleagues who have cited a number of studies and I say confusing not because I don't believe these vaccines are really, really powerful tools. They are, they are incredible what they are doing.
But the data that was put forward frankly was pretty obtuse. And there's actually six studies that people have cited and among those six studies, they all showed how well the vaccine worked in primary prevention remarkable.
But for five of those studies, they didn't even measure anything related to the possibility of secondary transmission and how it was prevented by being vaccinated. So if I was somebody in the media or the public, I might say wait a minute how you kept telling us this is what you're doing the studies for. And yet these aren't the data that are really presented here. So I'm not suggesting that that by itself should have been a reason to or not to do a change in the masking recommendations. But I think we owe it to the public to say what do we know and not know? And these studies just didn't address it. They all addressed how effective vaccines are.
I think also there was some situations where people raise questions about what do we know about the J and J vaccine in terms of breakthroughs and is the single dose going to be as good as the double dose with RNA vaccines? And there were surely some colleagues who have expressed concerns just saying well we'll have to wait and see what the data shows us. And I think that's true.
So after having pushed the change a vaccine as strongly as we have suggesting it's just like the M. RNA vaccines, I'd stay tuned. I think we very well could be seen in the near term new data which might support a need for a booster I. E. The second dose. I hope I'm wrong. And I don't want anybody to come away from this podcast saying I said you're going to have to get a second dose. But I think we need to be open to that.
And we also have to be open to the fact that these studies that I just shared with you, that we could go into great detail these six studies that have been touted as showing that there is no secondary transmission. Never really measured that. Which gives me to another point on the issue of breakthrough cases.
I worry that we along with the masking issue and vaccine are going to have a crisis some day down the road in credibility about the breakthrough data, Susthrough data is by itself very, very difficult to interpret for people, meaning that when I hear from someone that they say look at, we've given out over 115 million people have have been vaccinated and we only have 1359 breakthrough cases. That means that .01% of the people got infected after having been vaccinated. And I don't think the data can support that at all. The breakthrough data surely does. I believe support that. These are very, very good vaccines. But again, it comes back to credibility. For example, if we look at the breakthrough cases, we would definitely expect to see cases occur after vaccination, Even a 90-95% vaccination level would mean that such cases would occur.
Now. You have to be careful about taking the number of individuals who have been reported breakthrough cases and putting it over the total number of people who have been vaccinated. And then coming up with this incredibly low, low, low rate, making look like the vaccines were thousands of times better after these trials and they were during the trials. Why? Because many of the 100 15 million people who had been vaccinated had never been exposed to the virus since they've been vaccinated.
So they couldn't have been a failure or they couldn't have been a success. We can only count on the breakthroughs as it relates to the number of people who have actually been exposed and could have been infected.
But here's the second thing that I worry about. C. D. C. Today reports 1359 breakthrough cases which to many people seems like a lot. You think about the number of people vaccinated and the potential number of infections. It's not but I see people on the news channels and in the media all the time commenting about how good these numbers are inciting these numbers. I have actually heard just in the last two weeks several the experts saying and there've been no deaths associated with these. Look how much better it is. You're still going to have milder illness.
Well that's just simply not true. Among the 1359 cases that have occurred and been reported to the CDC, there either hospitalist or fatal cases, there have been 223 deaths among people were fully vaccinated. Now, right up front, we have data that supports at 42 of the 223 Reporters asymptomatic or not related to COVID-19 when they died, they may have been infected, but that was not what caused their death.
Uh, on the other hand, when you look at that number, it will shock some people in the public to see that We should be telling that story honestly. So that one day someone doesn't go and say, I just heard yesterday there have been no deaths. And now you're telling me, there's 223 tell them what we're, what we know and don't know. We should be looking at all cases whether fatal or not to better understand our variants having an impact on the success of our vaccines. And most of all stop saying that these are just all mild, mild infections.
They generally are. In fact, many of them are so mild that they will be asymptomatic infections. Many of them will occur in those over 65 1080 of the 1359 cases that have been reported to CDC when people over 65 years of age. Is that a surprise? No. Look at flu vaccines, oftentimes we will see major challenges with influenza vaccine effectiveness in the frail elderly, including those who are fully vaccinated, dying. So I only raise this not to confuse people or to make people think, oh boy, this isn't real.
The point is, is that I just think we have to be more clear to the public now in terms of the other area that I think is so critical is masks. This is a tough one. Uh I have been trying to nuance the mask issue of protection. What we can do should do with this since the beginning of the pandemic. Last June three I did an entire podcast and mask and science and of course my inbox was loaded with people who thought that I had betrayed the public health cause etcetera. By trying to nuance.
If you look at the A. C. G. I. H organization. This used to be called the american conference of governmental industrial hygienists. The people who really understand occupational risk, they understand the issues about inhalation related disease, how to prevent them. They put out a series of really outstanding documents on COVID-19 and what we all need to do to protect workers. But they apply also to the public.
Their COVID-19 pandemic task force published data which was an initial effort by the CDC in this case. NIOSH to look at the time to infectious dose for someone not infected with COVID-19. So meaning if I'm not infected already, what's my risk of getting infected using various types of respiratory protection devices?
================================================================
[0:31:31]
And if they look at nothing, or a face cloth covering, a surgical mask, or an N- 95 that was not fitted, or an N- 95 respirator that is face fitted. In other words, good testing. And you know what If you do nothing and two people do nothing, come together And they've swapped the same air in 15 minutes. You can easily have an infectious dose exchange between the infected and the uninfected person.
But if you look at these others, such as cloth face coverings and you have someone who has one of those on and has contact with someone who has nothing and who is infected That time to infectious dose goes up to 20 minutes. But it's only it's only 20 minutes.
If you have a surgical mask on and the receiver now is receiving that virus again from somebody doing nothing, You still get an infectious dose in 30 minutes. So if I'm at a grocery store, I'm in a location where there may be a high level of virus, I'm still vulnerable.
And it goes the other way to in terms of you know what is the source wearing and what is the receiver wearing?
Now if you get into in 95, even if you don't face fitted And you look at that is 25 hours Before you would have enough to get an infectious dose.
If you both are in fact fit tested for an N- 95, it's 2500 hours.
Now, we lump masks together all the time. Have you heard anybody try to distinguish masks to you? They put them all together, Whether it's a face cloth covering, a surgical mask, and N 95 respirator, and that's been a big disservice to the public.
================================================================
All I've heard all week is masking, masking. Masking.
That is like explaining the difference between an old model car that only has a seat belt in it and one that actually has a car that has a seat belt, has air bags, It has a collapsible body on impact, it has the fractured glass. That means the shards don't go flying as all the other safety details into it. And we're now making these two equivalent.
I can tell you that if both of them end up hitting in an animate object at three mph, probably outcome is going to be the same. But if both of them are in a head on collision at 45 mph, I just bet you the one with the seat belts, airbags, collapsible body and the shard glass are going to do a lot better than those in the car with just the seatbelt.
Now, I want to be really clear. I have continued to recommend any kind of respiratory protection that you can use. So this is not to say I'm anti mask. Some will try to do that. But please beware if you're wearing a surgical mask or face cloth covering and you're in contact with someone For 20 to 30 minutes, you can get an infectious dose and we have not concentrated in that at all.
And I think CDC has been absolutely derelict in its duty not to further explain respiratory protection by time and by the kind of respiratory protection you're using.
Part of it I think has come from the fact that intelligence recently. They didn't support the fact that aerosols were important. And these data I just shared with you are based on both inward and outward leakage of particles. It would be in the air assault level.
So I just want to point this out to you as we're having this debate about throwing your mask away or not. What are you talking about? And as we look at today, what is so important is among those individuals who have underlying immune compromised conditions, some type of immune deficiency or the frail elderly who are experienced, we call immunosenescence or reduced immune response. It becomes important what they have to be protected against and how you're going to do it. That has been missed. The environment you're in has been missed.
And so we need to have much more discussion about what mask me and we have it. So when CDC said, you know, you can stop wearing your mask if you're fully vaccinated. I believe that the vaccine is a much, much, much more potent weapon.
Then face cloth coverings of surgical masks. I don't believe it's more potent than an N 95 respirator that has been fit tested somewhat in the equivalent.
We are putting the data that I just shared with you on our website today so that you can also go look at these numbers yourself. They were generated by a group of experts. And just to point out to you that this is what we have to consider and we talk about masking.
So let me just move to one last piece about, well, wait a minute. We've heard over and over again how well masks work. As I said in my piece last april have continued to nuance it exactly the same.
There have been organizations that have looked at the data around respiratory protection and one of those was actually an ongoing evaluation by the Agency for Healthcare Research and Quality dr Roger chiu And colleagues have been evaluating respiratory protection and in their most recent update where they have continued to follow this over time, they just said and I quote in their most recent report on the basis of evidence from one randomized controlled trial and to observational studies the strength of evidence for mask use versus non used for the prevention of SARS COv two in the community was previously assessed as low for a small reduction in risk for infection with any mask use.
Now some could take that is don't wear them. No, I'm saying wear it even though protection is good, It's very helpful if that is that 15, 20 minute kind of exposure and you've just taken it off the table but don't assume that because you wear something for eight hours a day and you're in a high risk setting that that's going to protect you.
So I hope that people see this more not as an indictment of masking, but more a criticism of how we have given people the gradient of protection that comes with the issue of masking And right now, vaccine with short of the N- 95 respirators is by far a much, much more powerful protective tool than his mask in and of itself.
Let me just provide a quick update on the situation of outdoor air. This is another area I think we're basically leading the public to a place that we don't want to be because we're going to see some conflicting data coming out. That then will challenge the whole notion of outdoor air.
I for one have been a very strong proponent of outdoor air and how well it works. Uh, I myself have gotten rid of my face cloth covering uh, several months ago when I was outdoors walking in a park by myself and with my partner uh, very comfortable with that. But outdoor air is not 100% guarantee that you won't have transmission.
And again, this is advice we have to give to people as a setup for what's going to happen this summer. We last summer in Minnesota, worked up an outbreak. There was associated with an outdoor concert and dance for a local community was held in July four was at a campground, rural Minnesota. The festivities lasted for three hours. The week after the gathering, there was an outbreak of covid cases which the health department worked them up.
They did a remarkable job investigating this situation and they found that the outbreak was defined as at least three cases from three different households reporting the event. These people were all standing outside. They were all basically shoulder to shoulder together in a crowded venue and singing and loud voices, et cetera. And they found when they looked at the viruses from these different individuals who are at this and who had onset just days after the event, that in fact they were all the same related virus.
Now, this clearly was an outbreak of social with an outdoor concert. The sequencing supported that a superspreading event likely occurred and that even outdoors, if you're all crowded together for a prolonged period of time, if there's a super spreader in that environment, you can have transmission.
I just point that out to you because I don't want people to get confused.
Generally speaking, outdoor air is much much safer and you can feel confident and comfortable not wearing some kind of respiratory protection in that setting.
But if you're going to a bunch of outdoor concerts this summer, you're going to some events where you're all standing together quietly in a sense, meaning you're not moving all around. You could see these kinds of events and you need to then think about what kind of respiratory protection would I take if I'm an older individual who may be at higher risk for severe disease? I'm an immune compromised individual. What should I consider into that regard?
So, to me, we also have to get our messaging right? An outdoor air, I've heard a number of people say it doesn't occur outdoors. All you do is go outdoors. That's just not true.
Let me close by. Where are we going? What's our endgame? And I think this is a huge challenge right now. This is one where we should be making decisions much as a chess master anticipates the moves down a board And I fear we've been playing this far too much. Like I played checkers with my 11 year old grandson.
We should have and could have seen that when the CDC made us change last week that governor's business owners, the public positions, health care providers in general, state health departments, we're all going to be caught in the lurch.
And that's a hell of a way to make public policy and it does not engender the support of the public now grant you that the use of respiratory protection mask, whatever you call, what are you using is obviously going to create emotional responses when you do something like this.
I was one that said, you know, we're at a place where we're not going to see in India here in the United States. Were not we've taken that off the table. We have enough people vaccinated but we could see surges occur. How does that play out there in terms what we're trying to do? What's our messaging? We want? More people vaccinated.
We have a lot of people are reluctant will buy somehow changing the masking recommendation change that. I don't think so. I don't think it's gonna make it worse. It's not going to make it better for those who are protected with the vaccine.
You know, the data do support that. That's the most important thing you can do to reduce your risk. So why not allow people to do that? The question really comes to play. So what is our next move? What is our in game? What are we trying to do?
Well, we can try to get back to a new normal, A new normal might be. What is the influenza world? There are on average 38,000 deaths a year from influenza in this country. If you look at it, most of them are occurring in three or four months of the winter, we might get up to, you know, 456 7000 a month.
Um, if you look at what's happened relative to Covid, we're now beginning to approach the number of deaths that we might expect to see with an influenza here. Does this mean we've hit now the new normal that we're willing to accept are we gonna only, except if we get it down to zero? And then when I say, except what does that mean? Does that change the way we operate? What we do?
I'm going to share with you very briefly an article that was posted on the website of Peter salmon and Jody Lenard. I've referred to the many times on this podcast. I think there are some of the most skilled gifted experts in the world on risk communication and they published an article over the weekend called We're not all in this together anymore. CDCs unspoken adult defying message regarding mass and social distancing. This too will be linked on our website.
You can go and read the entire piece what Peter and Jody laid out was really to get to this new and world order of covid. CDC needed to reach three conclusions.
One that the residual threat unvaccinated americans pose to vaccinated americans is small enough to be acceptable. And I think the data would support that.
Number two, that the amount of morbidity mortality that result when unvaccinated americans, most of them young and healthy, are free to abandon non pharmaceutical interventions without third party policing will also be small enough to be acceptable. Well, what is the mass prevention efforts? How much have they prevented widespread hospital overcrowding, for example, is no longer like the outcome.
Number three, given the first two points continuing to recommend mps for all americans but unduly penalized, those who are vaccinated and unduly minimize those who are unvaccinated. We need to start thinking about how do we deal with people who are not going to get vaccinated? I don't want to sit by them in a restaurant. I don't want to sit by them at the theater event. Maybe immune passports are going to become something more commonly accepted.
You know, in Minnesota. Back in the 1970s, we were the first state in the country to enact clean air acts inside of our restaurants and bars. And at first he said, oh, this is going to be terrible and you know this, this is going to be a major problem, bars and restaurants will suffer immeasurably. Do you know that their business just went up Because 70% of the population that didn't smoke wanted to go to a clean error, location to eat, to drink to socialize.
Are we going to see one day that restaurants and entertainment venues and airlines and cruise ships and all these places are going to say, you know, you don't have to come with us, but if you are going to come, you have to be vaccinated.
We need to start thinking about things like that. I'm not sitting here today to say that's going to happen or necessarily should happen. That's the world we need to start planning for, what are we going to do and we're not.
So in conclusion chris and a very long answer, I hope that number one people realize these are incredible vaccines. They are highly effective. Our challenge right now is getting those who have not yet been vaccinated vaccinated.
Number two is we've got a message about these vaccines appropriately. Don't make them to be perfect. Don't make them to be without some concerns about do they fully protect the elderly or the questions we just raised. We have breakthrough cases. Yes. Well, in proportion to what we'd expect to have happened with the 90-95% effective vaccine.
Number two, we've got to start being much more direct about masking. If it's your mother or grandmother who's immunocompromised, you want to know what's the respiratory protection that she ought to use if she's going back out into the public? Stop talking about masking. I even hear the experts in neurobiology to keep talking about their masks. That doesn't give the public a definition of what they should be doing.
I do not understand after 14 months, 15 months into this pandemic. We do not have better respiratory protection for the world. Why don't we? We need that? That's a demand.
Number three is we have to understand outdoor air is great, but it's not perfect. And you need to consider that as you all celebrate this summer and large crowds. And finally, we need a game plan. What is our game plan here? What are we going for?
I believe one of the standards will use as influenza if we get to be like an influenza a year, Are we going to shut down? Are we going to keep kids out of school? Are we going to require people to wear a mask and all kinds of settings And we don't even know what those masks mean.
I think now is the time to have that grand plan discussion envision what the future will look like and don't keep making decisions that come out in the next news cycle that have tremendous implications for people both in terms of real protection and their psychology and then cause great consternation.
So I hope if nothing else in this section, you came away with the sense, it's not easy. It's complicated, but also telling the truth and just laying it out there is the best bet in the end.
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