Category Archives: Coronavirus

COVID Now: Turning Points, Vaccines, and Mutations

20 Wednesday Jan 2021

Posted by in Coronavirus, Pandemic, Vaccinations

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The pandemic outlook remains mixed, primarily due to the slow rollout of the vaccines and the appearance of new strains of the virus. Nationwide, cases and COVID deaths rose through December. Now, however, there are several good reasons for optimism.

The fall wave of the coronavirus receded in many states beginning in November, but the wave started a bit later in the eastern states, in the southern tier of states, and in California. It appears to have crested in many of those states in January, even after a post-holiday bump in new diagnoses. As of today, Johns Hopkins reports only two states with increasing trends of new cases over the past two weeks: NH and VA, while CT and WY were flat. States shaded darker green have had larger declines in new cases.

A more detailed look at WY shows something like a blip in January after the large decline that began in November. Trends in new cases have clearly improved across the nation, though somewhat later than hoped.

While the fall wave has taken many lives, we can take some solace in the continuing decline in the case fatality rate. (This is not the same as the infection mortality rate (IFR), which has also declined. The IFR is much lower, but more difficult to measure). The CFR fell by more than half from its level in the late summer. In other words, without that decline, deaths today would be running twice as high.

Some of the CFR’s decline was surely due to higher testing levels. However, better treatments are reducing the length of hospital stays for many patients, as well as ICU admittance and deaths relative to cases. Monoclonal antibodies and convalescent plasma have been effective for many patients, and now Ivermectin is showing great promise as a treatment, with a 75% reduction in mortality according to the meta-analysis at the link.

Reported or “announced” deaths remain high, but those reports are not an accurate guide to the level or trend in actual deaths as they occur. The CDC’s provisional death reports give the count of deaths by date of death (DOD), shown below. The most recent three to four weeks are very incomplete, but it appears that actual deaths by DOD may have peaked as early as mid-December, as I speculated they might last month. Another noteworthy point: by the totals we have thus far, actual deaths peaked at about 17,000 a week, or just over 2,400 a day. This is substantially less than the “announced” deaths of 4,000 or more a day we keep hearing. The key distinction is that those announced deaths were actually spread out over many prior weeks.

A useful leading indicator of actual deaths has been the percentage of ER patients presenting COVID-like illness (CLI). The purple dots in the next CDC chart show a pronounced decline in CLI over the past three weeks. This series has been subject to revisions, which makes it much less trustworthy. A less striking decline in late November subsequently disappeared. At the time, however, it seemed to foretell a decline in actual deaths by mid-December. That might actually have been the case. We shall see, but if so, it’s possible that better therapeutics are causing the apparent CLI-deaths linkage to break down.

A more recent concern is the appearance of several new virus strains around the world, particularly in the UK and South Africa. The UK strain has reached other countries and is now said to have made appearances in the U.S. The bad news is that these strains seem to be more highly transmissible. In fact, there are some predictions that they’ll account for 30% of new cases by the beginning of March. The South African strain is said to be fairly resistant to antibodies from prior infections. Thus, there is a strong possibility that these cases will be additive, and they might or might not speedily replace the established strains. The good news is that the new strains do not appear to be more lethal. The vaccines are expected to be effective against the UK strain. It’s not yet clear whether new versions of the vaccines will be required against the South African strain by next fall.

Vaccinations have been underway now for just over a month. I had hoped that by now they’d start to make a dent in the death counts, and maybe they have, but the truth is the rollout has been frustratingly slow. The first two weeks were awful, but as of today, the number of doses administered was over 14 million, or almost 46% of the doses that have been delivered. Believe it or not, that’s an huge improvement!

About 4.3% of the population had received at least one dose as of today, according to the CDC. I have no doubt that heavier reliance on the private sector will speed the “jab rate”, but rollouts in many states have been a study in ineptitude. Even worse, now a month after vaccinations began, the most vulnerable segment of the population, the elderly, has received far less than half of the doses in most states. The following table is from Phil Kerpen. Not all states are reporting vaccinations by age group, which might indicate a failure to prioritize those at the greatest risk.

It might not be fair to draw strong conclusions, but it appears WV, FL, IN, AK, and MS are performing well relative to other states in getting doses to those most at risk.

Even with the recent increase in volume, the U.S. is running far behind the usual pace of annual flu vaccinations. Each fall, those average about 50 million doses administered per month, according to Alex Tabarrok. He quotes Youyang Gu, an AI forecaster with a pretty good track record thus far, on the prospects for herd immunity and an end to the pandemic. However, he uses the term “herd immunity” as the ending share of post-infected plus vaccinated individuals in the population, which is different than the herd immunity threshold at which new cases begin to decline. Nevertheless, in Tabarrok’s words:

“… the United States will have reached herd immunity by July, with about half of the immunity coming from vaccinations and half from infections. Long before we reach herd immunity, however, the infection and death rates will fall. Gu is projecting that by March infections will be half what they are now and by May about one-tenth the current rate. The drop will catch people by surprise just like the increase. We are not good at exponentials. The economy will boom in Q2 as infections decline.”

That sounds good, but Tabarrok also quotes a CDC projection of another 100,000 deaths by February. That’s on top of the provisional death count of 340,000 thus far, which runs 3-4 weeks behind. If we have six weeks of provisionals to go before February, with actual deaths at their peak of about 17,000 per week, we’ll get to 100,000 more actual deaths by then. For what it’s worth, I think that’s pessimistic. The favorable turns already seen in cases and actual deaths, which I believe are likely to persist, should hold fatalities below that level, and the vaccinations we’ve seen thus far will help somewhat.

Long COVID: a Name For Post-Viral Syndrome

15 Friday Jan 2021

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I see references to “long COVID” or “long-haul COVID” almost every day. No, it’s not an extended COVID infection or an extra scary version of COVID. It’s about lingering or new symptoms after recovery from the infection. Reportedly, these symptoms range from fatigue or anxiety to joint pain. Sometimes they are rather unusual afflictions such as “COVID toes”, described as rashes or red spots on toes. Sebastian Rushworth notes that there is “no hard evidence that long COVID is a distinct entity”. It was essentially invented on social media by groups of individuals who connected to discuss various post-COVID symptoms. Rushworth says:

“The most common symptoms in people with long covid (defined in the study as still having symptoms after four weeks) were fatigue (98%) and intermittent headache (91%). … symptoms of long covid are extremely unspecific, so it is probable that long covid is actually a whole bunch of different things, of which I would think post-viral syndrome is likely a significant part.”

Post-viral syndrome should not be a big surprise, since COVID is, well, a virus! PVS can last for months and commonly has the following symptoms:

Those sound familiar. PVS symptoms are thought to be a consequence of the body’s effort to fight off a virus, including the lingering effects of a strong immune response and the inflammation it can induce. Such an immune response can lead to even greater problems for those with a genetic predisposition for autoimmune diseases like diabetes. It happens. But none of this is new or unique to COVID.

While PVS and autoimmune diseases are very real, the unbridled panic over COVID has led to a few false claims. “COVID toes” is one of them. Moreover, the pandemic precipitated an avalanche of poor-quality academic research, rushed in an effort to produce useful findings. Some of that research is implicated in the COVID myths we’ve heard. An example discussed at the last link is the incidence of heart inflammation or myocarditis in COVID patients. This was all over the media in the months leading up to the college football season, as young athletes were said to be vulnerable. In fact, it’s incidence among COVID patients is fairly rare, and it’s not unique to COVID.

COVID can be a nasty infection, primarily for the aged and those with pre-existing conditions, including obesity. PVS is an unfortunate reality for many patients. But “long-COViD” is merely a varied collection of post-viral symptoms. Many of them are vague and usually self-diagnosed. Long COVID is, as Rushworth says, “basically whatever the person who thinks they have it says it is.” That the media has promoted long COVID and its varied manifestations as something wholly new, including a few probable “imagifestations” (to coin a term), is one more example of the “panic porn” to which we’ve been subjected during the pandemic.

Cash Flows and Hospital Woes

10 Sunday Jan 2021

Posted by in Coronavirus, Health Care

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Here’s one of the many entertaining videos made by people who want to convince you that hospitals are overrun with COVID patients (and here is another, and here, here, and here). That assertion has been made repeatedly since early in the pandemic, but as I’ve made clear on at least two occasions, the overall system has plenty of capacity. There are certainly a few hospitals at or very near capacity, but diverting patients is a long-standing practice, and other hospitals have spare capacity to handle those patients in every state. Those with short memories would do well to remember 2018 before claiming that this winter is unique in terms of available hospital beds.

An old friend with long experience as a hospital administrator claimed that I didn’t account for staffing shortfalls in my earlier posts on this topic, but in fact the statistics I presented were all based on staffed inpatient or ICU beds. Apparently, he didn’t read those posts too carefully. Moreover, it’s curious that a hospital administrator would complain so bitterly of staffing shortfalls in the wake of widespread hospital layoffs in the spring. And it’s curious that so many layoffs would accompany huge bailouts of hospital systems by the federal government, courtesy of the CARES Act.

In fairness, hospitals suffered huge declines in revenue in the spring of 2020 as elective procedures were cancelled and non-COVID patients stayed away in droves. Then hospitals faced the expense of covering their shortfalls in PPE. We know staffing was undercut when health care workers were diagnosed with COVID, but in an effort to stem the red ink, hospitals began laying-off staff anyway just as the the COVID crisis peaked in the spring. About 160,000 staffers were laid off in April and May, though more than half of those losses had been recovered as of December.

Did these layoffs lead to a noticeable shortfall in hospital capacity? It’s hard to say because bed capacity is a squishy metric. When patients are discharged, staffed beds can ratchet down because beds might be taken “off-line”. When patients are admitted, beds can be brought back on-line. ICU capacity is flexible as well, as parts of other units can be quickly modified for patients requiring intensive care. And patient ratios can be adjusted to accommodate layoffs or an influx of admissions. Since early in the fall, occupancy has been overstated for several reasons, including a new requirement that beds in use for observation of outpatients with COVID symptoms for 8 hours or more must be reported as beds occupied. However, there are hospitals claiming that COVID is stressing capacity limits, but nary a mention of the earlier layoffs.

So where are we now in terms of staffed hospital occupancy. The screen shot below is from the HHS website and represents staffed bed utilization nationwide. 29% of capacity is open, hardly a seasonal anomaly, and there are very few influenza admissions thus far this winter, which is rather unique. 37% of ICU beds are available, and COVID patients, those admitted either “for” or “with” COVID, account for less than 18% of inpatients, though again, that includes observational beds.

Next are the 25 states with the highest inpatient bed utilization as of January 7th. Rhode Island tops the list at just over 90%, and eight other states are over 80%. In terms of ICU utilization, Georgia and Alabama are very tight. California and Arizona are outliers with respect to proportions of COVID inpatients, 41% and 38%, respectively. Finally, CA, GA, AL and AZ are all near or above 50% of ICU beds occupied by COVID patients.

So some of the states reaching the peak of their fall waves are pretty tight, and there are states with large numbers of very serious cases. Nevertheless, in all states there is variation across local hospitals to serve in relief, and it is not unusual for hospitals to suffer wintertime strains on capacity.

Los Angeles County is receiving much attention for recent COViD stress placed on hospital capacity. But it is hard to square that narrative with certain statistics. For example, Don Wolt notes that the state of California reports available ICU capacity in Southern CA of zero, but LA County has reported 10% ~ 11% for weeks. And the following chart shows that LA County occupancy remains well below it’s July peak, especially after a recent downward revision from the higher level shown by the blue dashed line.

Interestingly, the friend I mentioned said I should talk with some health system CEOs about recent occupancies. He overlooked the fact that I quoted or linked to comments from some system CEOs in my earlier posts (linked above). It’s noteworthy that one of those CEOs, and this report from the KPI Institute, propose that an occupancy rate of 85% is optimal. This medical director prefers a 75% – 85% rate, depending on day of week. These authors write that there is no one “optimal” occupancy rate, but they seem to lean toward rates below 85%. This paper reports a literature search indicating ICU occupancy of 70% -75% is optimal, while noting a variety of conditions may dictate otherwise. Seasonal effects on occupancy are of course very important. In general, we can conclude that hospital utilization in most states is well within acceptable if not “optimal” levels, especially in the context of normal seasonal conditions. However, there are a few states in which some hospitals are facing tight capacity, both in total staffed beds and in their ICUs.

None of this is to minimize the challenges faced by administrators in managing hospital resources. No real crisis in hospital capacity exists currently, though hospital finances are certainly under stress. Yes, hospitals collect greater reimbursements on COVID patients via the CARES Act, but COVID patients carry high costs of care. Also, hospitals have faced steep declines in revenue from the fall-off in other care, high costs in terms of PPE, specialized equipment and medications, and probably high temporary staffing costs in light of earlier layoffs and short-term losses of staff to COVID infections. The obvious salve for many of these difficulties is cash, and the most promising source is public funding. So it’s unsurprising that executives are inclined to cry wolf about a capacity crisis. It’s a simple story and more appealing than pleading for cash, and it’s a scare story that media are eager to push.

Let’s Do “First Doses First”

06 Wednesday Jan 2021

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Both the Pfizer and the Moderna COVID vaccines require two doses, with an effectiveness of about 95%. But a single dose may have an efficacy of about 80% that is likely to last over a number of weeks without a second dose. There are varying estimates of short-term efficacy, and but see here, here, and here. The chart above is for the Pfizer vaccine (red line) relative to a control group over days since the first dose, and the efficacy grows over time relative to the control before a presumed decay ever sets in.

Unfortunately, doses are in short supply, and getting doses administered has proven to be much more difficult than expected. “First Doses First” (FDF) is a name for a vaccination strategy focusing on delivering only first doses until a sufficient number of the highly vulnerable receive one. After that, second doses can be administered, perhaps within some maximum time internal such as 8 – 12 weeks. FDF doubles the number of individuals who can be vaccinated in the short-term with a given supply of vaccine. Today, Phil Kerpen posted this update on doses delivered and administered thus far:

Dosing has caught up a little, but it’s still lagging way behind deliveries.

As Alex Tabbarok points out, FDF is superior strategy because every two doses create an average of 1.6 immune individuals (2 x 0.8) instead of just 0.95 immune individuals. His example involves a population of 300 million, a required herd immunity level of two-thirds (higher than a herd immunity threshold), and an ability to administer 100 million doses per month. Under a FDF regime, you’ve reached Tabarrok’s “herd immunity” level in two months. (This is not to imply that vaccination is the only contributor to herd immunity… far from it!) Under the two-dose regime, you only get halfway there in that time. So FDF means fewer cases, fewer deaths, shorter suspensions of individual liberty, and a faster economic recovery.

An alternative that doubles the number of doses available is Moderna’s half-dose plan. Apparently, their tests indicate that half doses are just as effective as full doses, and they are said to be in discussions with the FDA and Operation Warp Speed to implement the half-dose plan. But the disadvantage of the half-dose plan relative to FDF is that the former does not help to overcome the slow speed with which doses are being administered.

Vaccine supplies are bound to increase dramatically in coming months, and the process of dosing will no doubt accelerate as well. However, for the next month or two, FDF is too sensible to ignore. While I am not a fan of all British COVID policies, their vaccination authorities have recommended an FDF approach as well as allowing different vaccines for first and second doses.

Fauci Flubs Herd Immunity

03 Sunday Jan 2021

Posted by in Coronavirus, Herd Immunity, Public Health, Vaccinations

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Anthony Fauci has repeatedly increased his estimate of how much of the population must be vaccinated to achieve what he calls herd immunity, and he did it again in late December. This series of changes, and other mixed messages he’s delivered in the past, reveal Fauci to be a “public servant” who feels no obligation to level with the public. Instead, he crafts messages based on what he believes the public will accept, or on his sense of how the public must be manipulated. For example, by his own admission, his estimates of herd immunity have been sensitive to polling data! He reasoned that if more people reported a willingness to take a vaccine, he’d have flexibility to increase his “public” estimate of the percentage that must be vaccinated for herd immunity. Even worse, Fauci appears to lack a solid understanding of the very concept of herd immunity.

Manipulation

There is so much wrong with his reasoning on this point that it’s hard to know where to start. In the first place, why in the world would anyone think that if more people willingly vaccinate it would imply that even more must vaccinate? And if he felt that way all along it demonstrates an earlier willingness to be dishonest with the public. Of course, there was nothing scientific about it: the series of estimates was purely manipulative. It’s almost painful to consider the sort of public servant who’d engage in such mental machinations.

Immunity Is Multi-Faceted

Second, Fauci seemingly wants to convince us that herd immunity is solely dependent on vaccination. Far from it, and I’m sure he knows that, so perhaps this too was manipulative. Fauci intimates that COVID herd immunity must look something like herd immunity to the measles, which is laughable. Measles is a viral infection primarily in children, among whom there is little if any pre-immunity. The measles vaccine (MMR) is administered to young children along with occasional boosters for some individuals. Believe it or not, Fauci claims that he rationalized a requirement of 85% vaccination for COVID by discounting a 90% requirement for the measles! Really???

In fact, there is substantial acquired pre-immunity to COVID. A meaningful share of the population has long-memory, cross-reactive T-cells from earlier exposure to coronaviruses such as the common cold. Estimates range from 10% to as much as 50%. So if we stick with Fauci’s 85% herd immunity “guesstimate”, 25% pre-immunity implies that vaccinating only 60% of the population would get us to Fauci’s herd immunity goal. (Two qualifications: 1) the vaccines aren’t 100% effective, so it would take more than 60% vaccinated to offset the failure rate; 2) the pre-immune might not be identifiable at low cost, so there might be significant overlap between the pre-immune and those vaccinated.)

Conceptual Confusion

Vaccinations approaching 85% would be an extremely ambitious goal, especially if it is recommended annually or semi-annually. It would be virtually impossible without coercion. While more than 91% of children are vaccinated for measles in the U.S., it is not annual. Thus, measles does not offer an appropriate model for thinking about herd immunity to COVID. Less than half of adults get a flu shot each year, and somewhat more children.

Fauci’s reference to 85% – 90% total immunity is different from the concept of the herd immunity threshold (HIT) in standard epidemiological models. The HIT, often placed in the range of 60% – 70%, is the point at which new infections begin to decline. More infections occur above the HIT but at a diminishing rate. In the end, the total share of individuals who become immune due to exposure, pre-immunity or vaccination will be greater than the HIT. The point is, however, that reaching the HIT is a sufficient condition for cases to taper and an end to a contagion. If we use 65% as the HIT and pre-immunity of 25%, only 40% must be vaccinated to reach the HIT.

Heterogeneity

A recent innovation in epidemiological models is the recognition that there are tremendous differences between individuals in terms of transmissibility, pre-immunity, and other factors that influence the spread of a particular virus, including social and business arrangements. This kind of heterogeneity tends to reduce the effective HIT. We’ve already discussed the effect of pre-immunity. Suppose that certain individuals are much more likely to transmit the virus than others, like so-called super-spreaders. They spur the initial exponential growth of a contagion, but there are only so many of them. Once infected, no one else among the still-susceptible can spread the virus with the same force.

Researchers at the Max Planck Institute (and a number of others) have gauged the effect of introducing heterogeneity to standard epidemiological models. It is dramatic, as the following chart shows. The curves simulate a pandemic under different assumptions about the degree of heterogeneity. The peak of these curves correspond to the HIT under each assumption (R0 refers to the initial reproduction number from infected individuals to others).

Moderate heterogeneity implies a HIT of only 37%. Given pre-immunity of 25%, only an additional 12% of the population would have to be infected or vaccinated to prevent a contagion from gaining a foothold for the initial exponential stage of growth. Fauci’s herd immunity figure obviously fails to consider the effect of heterogeneity.

How Close To the HIT?

We’re not as far from HITs as Fauci might think, and a vaccination goal of 85% is absurd and unnecessary. The seasonal COVID waves we’ve experienced thus far have faded over a period of 10-12 weeks. Estimates of seroprevalence in many localities reached a range of 15% – 25% after those episodes, which probably includes some share of those with pre-immunity. To reach the likely range of a HIT, either some additional pre-immunity must have existed or the degree of heterogeneity must have been large in these populations.

But if that’s true, why did secondary waves occur in the fall? There are a few possibilities. Of course, some areas like the upper Midwest did not experience the springtime wave. But in areas that suffered a recurrance, perhaps the antibodies acquired from infections did not remain active for as long as six months. However, other immune cells have longer memories, and re-infections have been fairly rare. Another possibility is that those having some level of pre-immunity were still able to pass live virus along to new hosts. But this vector of transmission would probably have been quite limited. Pre-immunity almost surely varies from region to region, so some areas were not as firmly above their HITs as others. It’s also possible that infections from super-spreaders were concentrated within subsets of the population even within a given region, in certain neighborhoods or among some, but not all, social or business circles. Therefore, some subsets or “sub-herds” achieved a HIT in the first wave, but it was unnecessary for other groups. In other words, sub-herds spared in the first wave might have suffered a contagion in a subsequent wave. And again, reinfections seem to have been rare. Finally, there is the possibility of a reset in the HIT in the presence of a new, more transmissible variant of the virus, as has become prevalent in the UK, but that was not the case in the fall.

Fragility

Tyler Cowen has mentioned another possible explanation: so-called “fragile” herd immunity. The idea is that any particular HIT is dependent on the structure of social relations. When social distancing is widely practiced, for example, the HIT will be lower. But if, after a contagion recedes, social distancing is relaxed, it’s possible that the HIT will take a higher value at the onset of the next seasonal wave. Perhaps this played a role in the resurgence in infections in the fall, but the HIT can be reduced via voluntary distancing. Eventually, acquired immunity and vaccinations will achieve a HIT under which distancing should be unnecessary, and heterogeneity suggests that shouldn’t be far out of reach.

Conclusion

Anthony Fauci has too often changed his public pronouncements on critical issues related to management of the COVID pandemic. Last February he said cruises were fine for the healthy and that most people should live their lives normally. Oops! Then came his opinion on the limited effectiveness of masks, then a shift to their necessity. His first position on masks has been called a “noble lie” intended to preserve supplies for health care workers. However, Fauci was probably repeating the standing consensus at that point (and still the truth) that masks are of limited value in containing airborne pathogens.

This time, Fauci admitted to changing his estimate of “herd immunity” in response to public opinion, a pathetic approach to matters of public health. What he called herd immunity was really an opinion about adequate levels of vaccination. Furthermore, he neglected to consider other forms of immunity: pre-existing and already acquired. He did not distinguish between total immunity and the herd immunity threshold that should guide any discussion of pandemic management. He also neglected the significant advances in epidemiological modeling that recognize the reality of heterogeneity in reducing the herd immunity threshold. The upshot is that far fewer vaccinations are needed to contain future waves of the pandemic than Fauci suggests.

COVID Testing: Cycle Thresholds and Coffee Grounds

19 Saturday Dec 2020

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Here’s some incredible data on PCR tests demonstrating a radically excessive lab practice that generates false positives. I’m almost tempted to say we’d do just as well using a thermometer and the coffee ground test. Open a coffee tin and take a sniff. Can you smell the distinct aroma of the grounds? If not, and if you have other common symptoms, there’s a decent chance you have an active COVID infection. That test is actually in use in some parts of the globe!

The data shown below on PCR tests are from the Rhode Island Department of a Health and the Rhode Island State Health Lab. They summarize over 5,000 positive COVID PCR tests (collected via deep nasal swabs) taken from late March through early July. The vertical axis in the chart measures the cycle threshold (Ct) value of each positive test. Ct is the number of times the RNA in a sample must be replicated before any COVID-19 (or COVID-like) RNA is detected. It might be from a live virus or perhaps a fragment of a dead virus. A positive test with a low Ct value indicates that the subject is likely infected with billions of live COVID-19 viruses, while a high Ct value indicates perhaps a handful or no live virus at all.

The range of red dots in the chart (< 28 Ct) indicates relatively low Ct values and active infections. The yellow range of dots, for which 28 < Ct <= 32, indicates possible infections, and the upper range of green dots, where Ct > 32, indicates that active infections were highly unlikely. It’s important to note that all of these tests were recorded as new COVID cases, so the range of Ct values suggest that testing in Rhode Island was unreasonably sensitive. That’s broadly true across the U.S. as well, which means that COVID cases are over-counted by perhaps 30% or more. And yet it is extremely difficult for subjects testing positive to learn their Ct values. You can ask, but you probably won’t get an answer, which is absurd and counterproductive.

Notice that the concentration of red dots diminished over time, and we know that the spring wave of the virus in the Northeast was waning as the summer approached. The share of positives tests with high Ct values increased over that time frame, however. This is borne out by the next chart, which shows the daily mean Ct of these positive tests. The chart shows that active infections became increasingly rare over that time frame both because positive tests decreased and the average Ct value rose. What we don’t know is whether labs bumped up the number of cycles or replications to which samples were subjected. Still, the trend is rather disturbing because most of the positive cases in May and the first half of June were more likely to be virus remnants than live viruses.

It’s also worth noting that COVID deaths declined in concert with the upward trend in Ct values. This is shown in the chart below (where the Ct scale is inverted). This demonstrates the truly benign nature of positive tests having high Ct values.

This is also demonstrated by the following data from a New York City academic hospital, which was posted by Andrew Bostom. It shows that a more favorable “clinical status” of COVID patients is associated with higher Ct values.

It’s astounding that the U.S. has relied so heavily on a diagnostic tool that gets so many subjects wrong. And it’s nearly impossible for subjects testing positive to obtain their Ct values. Instead, they are subject to self-quarantine for up to two weeks. Even worse, until recently there were delays in reporting the results of these tests of up to a week or more. That made them extremely unhelpful. On the other hand, the coffee ground test is fast and cheap, and it might enhance the credibility of a subsequent positive PCR test, if one is necessary … and especially if the lab won’t report the Ct value.

The PCR test has identified far too many false infections, but it wouldn’t have been quite so damaging if 1) a reasonably low maximum cycle threshold had been established; 2) test results had not been subject to such long delays; and 3) rapid retests had been available for confirmation. The cycle threshold issue is starting to receive more attention, quite belatedly, and more rapid tests have become available. As I’ve emphasized in the past, cheap, rapid tests exist. But having dithered in February and March in approving even the PCR test, the FDA has remained extremely grudging in approving newer tests, and it persists in creating obstacles to their use. The FDA needs to wake up and smell the coffee!

Harbingers of COVID Fade, But Not the Pretense for Hysteria

17 Thursday Dec 2020

Posted by in Coronavirus, Pandemic, Vaccinations

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My pre-Thanksgiving optimism about a crest in the fall wave of the coronavirus has been borne out for the Midwest and Mountain states in the U.S. These regions were the epicenter of the fall wave through October and most of November, but new cases in those states have continued to decline. Cases in a number of other states began to climb in November, however, contributing to a continuing rise in total new cases nationally. Some of these states are still in the throes of this wave, with the virus impacting subsets of the population that were relatively unscathed up till now.

My disclaimer: COVID is obviously a nasty virus. I don’t want to get it. However, on the whole, it is not a cataclysm on the order of many pandemics of the past. In fact, excess deaths this year will add just over 10% to projections of total deaths based on a five-year average. That level puts us in line with average annual deaths of about twenty years ago. And many of those excess deaths have been caused by our overreaction to the pandemic, not by the virus itself. As my endocrinologist has said, this is the greatest overreaction in all medical history. Unfortunately, a fading pandemic does not mean we can expect an end to the undue panic, or pretense for panic, on the part of interventionists.

This post will focus largely on trends in newly diagnosed COVID cases. I have been highly critical of our testing regime and COVID case counts because the most prominent diagnostic test (PCR) falsely identifies a large number of uninfected individuals as COVID-positive. However, case numbers are widely tracked and it’s fairly easy to find information across geographies for comparison. Deflate all the numbers by 30% if you want, or by any other factor, but please indulge me because I think the trends are meaningful, even if the absolute level of cases is inflated.

I’ll start with the good news and work my way down to states in which cases are still climbing (all of the following charts are from @Humble_Analysis (PLC)). The first chart is for the Great Plains, where cases peaked a little before Thanksgiving and have continued to fall since then. That peak came about six weeks after it began in earnest and cases have faded over the last four weeks.

Next we have the Mountain states, where again, cases peaked around Thanksgiving, though Idaho saw a rebound after the holiday. You’ll see below that a number of states had a distinct drop in new cases during the week of Thanksgiving. There was somewhat of a pause in testing during that week, so the subsequent rebounds are largely due to a “catch-up” at testing sites, rather than some kind of Thanksgiving-induced spike in infections.

Back to the Mountain region, the peak came an average of about six or seven weeks into the wave, but the duration of the wave appears to have been longer in Montana and Wyoming.

Here are the Southern Plain states, where cases plateaued around Thanksgiving (though cases in Missouri have clearly declined from their peak). In this region, case counts accelerated in October after a slow climb over the summer.

The situation is somewhat similar in the Midwest. where cases have generally plateaued. There were some post-Thanksgiving rebounds in several states, especially Tennessee. The wave began a little later in this region, in mid- to late October, and it is now seven to eight weeks into the wave, on average.

Here are the Mid-Atlantic states, which may be showing signs of a peak, though North Carolina has had the greatest caseload and is still climbing. These states are about seven weeks into the wave, on average.

The Northeast also shows signs of a possible peak and is about seven weeks into the wave, except for Rhode Island, which saw an earlier onset and the most severe wave among these states.

And finally we have the South, which is defined quite broadly in PLC’s construction. It’s a mixed bag, with a few states showing signs of a peak after about seven weeks. However, cases are still climbing in several states, notably California and Florida, among a few others.

Oregon and Washington were skipped, but they appear as the Pacific NW in the following chart, along with aggregations for all the other regions. Maine is Part of the “Rural NE”, which was also skipped. The fall wave can be grouped roughly into two sets of regions: those in which waves began in late September or early October, and those where waves began in early to mid-November. The first group has moved beyond a peak or at least has plateaued. The latter group may be reaching peaks now or one hopes very soon. It seems to take about seven weeks to reach the peak of these regional waves, so a late December peak for the latter group would be consistent.

Justin Hart has a take on the duration of these waves, but he does so in terms of the share of emergency room (ER) visits in which symptoms of COVID-like illness (CLI) are presented. CLI tends to precede case counts slightly. Hart puts the duration of these waves at eight to ten weeks, but that’s a judgement call, and I might put it a bit longer using caseloads as a guide. Still, this color-coded chart from Hart is interesting.

If this sort of cyclical duration holds up, it’s consistent with the view that cases in many of the still “hot” states should be peaking this month.

Aggregate cases for the U.S. appear below. The growth rate of new cases has slowed, and the peak is likely to occur soon. However, because it combines all of the regional waves, the duration of the wave nationwide will appear to be greater than for the individual regions. COVID-attributed deaths are also plotted, but they are reported deaths, not by date of death (DOD) or actual deaths, as I sometimes call them. Deaths by DOD are available only with a lag. As always, some of the reported deaths shown below occurred weeks before their reported date. Actual deaths were still rising as of late November, and are likely still rising. However, another indicator suggests they should be close to a peak.

A leading indicator of actual deaths I’ve discussed in the past now shows a more definitive improvement than it did just after Thanksgiving, as the next chart shows. This is the CLI share discussed above. An even better predictor of COVID deaths by actual DOD is the sum of CLI and the share of ER patients presenting symptoms of influenza-like illness (ILI), but ILI has been fairly low and stable, so it isn’t contributing much to changes in trend at the moment. There has been about a three-week lead between movements in CLI+ILI and COVID deaths by DOD.

(The reason the sum, CLI+ILI, has been a better predictor than CLI alone is because for some individuals, there are similarities in the symptoms of COVID and the flu.)

The chart shows that CLI peaked right around the Thanksgiving holiday (and so did CLI+ILI), but it remained on something of a plateau through the first week of December before declining. Some of the last few days on this chart are subject to revision, but the recent trend is encouraging. Allowing for a three-week lead, this indicates that peak deaths by DOD should occur around mid-December, but we won’t know exactly until early to mid-January. To be conservative, we might say the latter half of December will mark the peak in actual deaths.

The regional COVID waves this summer and fall seem to have run their course within 10 – 12 weeks. Several former hot spots have seen cases drop since Thanksgiving after surges of six to seven weeks. However, there are several other regions with populous states where the fall wave is still close to “mid-cycle”, as it were, showing signs of possible peaks after roughly seven weeks of rising cases. The national CLI share peaked around Thanksgiving, but it did not give up much ground until early December. That suggests that actual deaths (as opposed to reported deaths), at least in some regions, will peak around the time of the winter solstice. Let’s hope it’s sooner.

Successive waves within a region seem to reach particular subsets of the population with relatively few reinfections. The 10 – 12 week cycle discussed above is sufficient to achieve an effective herd immunity within these subsets. But once again, a large share of the vulnerable, and a large share of COVID deaths, are still concentrated in the elderly, high-risk population and in care homes. The vaccine(s) currently being administered to residents of those homes are likely to hasten the decline in COVID deaths beginning sometime in January, perhaps as early as mid-month. By then, however, we should already see a decline underway as this wave of the virus finally burns itself out. As vaccines reach a larger share of the population through the winter and spring, the likelihood of additional severe waves of the virus will diminish.

Lest there be any misunderstanding, the reasons for the contagion’s fade to come have mostly to do with reaching the effective herd immunity threshold within afflicted subsets of the population (sub-herds). Social distancing certainly plays a role as well. Nearly all of that is voluntary, though it has been encouraged by panicked pronouncement by certain public officials and the media. Direct interventions or lockdown measures are in general counter-productive, however, and they create a death toll of their own. Unfortunately, the fading pandemic might not rein-in the curtailment of basic liberties we’ve witnessed this year.

Post-Script: Let’s hope the side effects of the vaccines are not particularly severe in the elderly. That’s a little uncertain, because that sub-population was not tested in very high numbers.

COVID Interventions: Costly, Deadly, and Ineffective

14 Monday Dec 2020

Posted by in Coronavirus, Liberty, Lockdowns, Public Health

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What does it take to shake people out of their statist stupor? Evidently, the sweet “logic” of universal confinement is very appealing to the prescriptive mindset of busybodies everywhere, who anxiously wag their fingers at those whom they view as insufficiently frightened. As difficult as it is for these shrieking, authoritarian curs to fathom, measures like lockdowns, restrictions on business activity, school closures, and mandates on behavior have at best a limited impact on the spread of the coronavirus, and they are enormously costly in terms of economic well-being and many dimensions of public health. Yet the storm of propaganda to the contrary continues. Media outlets routinely run scare stories, dwelling on rising case numbers but ignoring them when they fall; they emphasize inflated measures of pandemic severity; certain researchers and so-called health experts can’t learn the lessons that are plain in the data; and too many public officials feel compelled to assert presumed but unconstitutional powers. At least the World Health Organization has managed to see things clearly, but many don’t want to listen.

I’ll be the first to say I thought the federalist approach to COVID policy was commendable: allow states and local governments to craft policies appropriate to local conditions and political preferences, rather than have the federal government dictate a one-size-fits-all policy. I haven’t wavered in that assessment, but let’s just say I expected more variety. What I failed to appreciate was the extent to which state and local leaders are captive to provincial busybodies, mavens of precautionary excess, and fraudulent claims to scientific wisdom.

Of course, it should be obvious that the “knowledge problem” articulated by Friedrich Hayek is just as dangerous at low-levels of government as it is in a central Leviathan. And it’s not just a knowledge problem, but a political problem: officials become panicked because they fear bad outcomes will spell doom for their careers. Politicians are particularly prone to the hazards of “do-somethingism”, especially if they have willing, status-seeking “experts” to back them up. But as Scott Sumner says:

“When issues strongly impact society, the science no longer ‘speaks for itself’.

Well, the science is not quite as clear as the “follow-the-science” crowd would have you believe. And unfortunately, public officials have little interest in sober assessments of the unintended effects of lockdown policy.

In my last post, I presented a simple framework for thinking about the benefits and costs of lockdown measures, or non-pharmaceutical interventions (NPIs). I also emphasized the knowledge problem: even if there is some point at which NPI stringencies are “optimized”, government does not possess the knowledge to find that point. It lacks detailed information on both the costs and benefits of NPIs, but individual actors know their own tolerance for risk, and they surely have some sense of the risks they pose to others in their normal course of affairs. While voluntary precautions might be imperfect, they accomplish much of what interventionists hope will be gained via coercion. But, in an effort to “sell” NPIs to constituents and assert their authority, officials vastly over-estimate benefits of NPIs and under-estimate the costs.

NPI Stringency and COVID Outcomes

Let’s take a look at a measure of the strength of NPIs by state — the University of Oxford Stringency Index — and compare those to CDC all-cause excess deaths in each state. If it’s hard to read, try clicking on the image or turn your phone sideways. This plot covers outcomes through mid-November:

The chart doesn’t suggest any benefit to the imposition of greater restrictions, or more stringent NPIs. In fact, the truth is that people will do most of the work on their own based on perceptions of risk. That’s partly because government restrictions add little risk mitigation to what can be accomplished by voluntary social distancing and other precautions.

Here’s a similar chart with cross-country comparisons, though the data here ended in early October (I apologize for the fuzzy image):

But what about reverse causality? Maybe the imposition of stringency was a response to more severe contagions. Now that the virus has swept most of the U.S and Europe in three distinct waves, and given the variety and timing of NPIs that have been tried, it’s harder to make that argument. States like South Dakota have done fairly well with low stringency, while states like New Jersey with high stringency have fared poorly. The charts above provide multiple pair-wise examples and counter-examples of states or countries having faced hard waves with different results.

But let’s look at a few specific situations.

The countries shown above have converged somewhat over the past month: Sweden’s daily deaths have risen while the others have declined to greater or lesser degrees, but the implications for mask usage are unaltered.

And of course we have this gem, predicated on the mental gymnastics lockdown enthusiasts are fond of performing:

But seriously, it’s been a typical pattern: cases rise to a point at which officials muster the political will to impose restrictions, often well after the “exponential” phase of the wave or even the peak has passed. For the sake of argument, if we were to stipulate that lockdowns save lives, it would take time for these measures to mitigate new infections, time for some of the infected individuals to become symptomatic, and more time for diagnosis. For the lockdown arguments to be persuasive, the implementation of NPIs would have to precede the point at which the growth of cases begins to decline by a few weeks. That’s something we’ve seldom observed, but officials always seem to take credit for the inevitable decline in cases.

More informed lockdown proponents have been hanging their hats on this paper in Nature by Seth Flaxman, et al, published in July. As Philippe LeMoine has shown, however, Flaxman and his coauthors essentially assumed their result. After a fairly exhaustive analysis, Lemoine, a man who understands sophisticated mathematics, offers these damning comments:

“Their paper is a prime example of propaganda masquerading as science that weaponizes complicated mathematics to promote questionable policies. Complicated mathematics always impresses people because they don’t understand it and it makes the analysis look scientific, but often it’s used to launder totally implausible assumptions, which anyone could recognize as such if they were stated in plain language. I think it’s exactly what happened with Flaxman et al.’s paper, which has been used as a cudgel to defend lockdowns, even though it has no practical relevance whatsoever.”

The Economic Costs of Stringency

So the benefits of stringent lockdowns in terms of averting sickness and death from COVID are speculative at best. What about the costs of lockdowns? We can start with their negative impact on economic activity:

That’s a pretty bad reflection on NPI stringency. In the U.S, a 10% decline in GDP in 2020 amounts to about $2.1 trillion in lost goods and services. That’s just for starters. The many destroyed businesses and livelihoods carry an ongoing cost that could take years to fade, as this graphic on permanent business closures shows:

If you’re wondering about the distributional effects of lockdowns, here’s more bad news:

It’s possible to do many high-paying jobs from home. Not so for blue-collar workers. And distributional effects by size of enterprise are also heavily-skewed in favor of big companies. Within the retail industry, big-box stores are often designated as “essential”, while small shops and restaurants are not. The restaurant industry has been destroyed in many areas, inflicting a huge blow to owners and workers. This despite evidence from contact tracing showing that restaurants and bars account for a very small share of transmission. To add insult to injury, many restaurants invested heavily in safety measures and equipment to facilitate new, safer ways of doing business, only to be double-crossed by officials like Andrew Cuomo and Eric Garcetti, who later shut them down.

Public Health Costs of Stringency

Lives are lost due to lockdowns, but here’s a little exercise for the sake of argument: The life value implied by individual willingness-to-pay for risk reduction comes in at less than $4 million. Even if the supposed 300,000 COVID deaths had all been saved by lockdowns, that would have amounted to a value of $1.2 trillion, about half of the GDP loss indicated above. Of course, it would be outrageously generous to concede that lives saved by NPI’s have approached 300,000, so lockdowns fall far short at the very outset of any cost-benefit comparison, even if we value individual lives at far more than $4 million.

As AJ Kay says, the social and human costs go far beyond economic losses:

I cited specific examples of losses in many of these categories in an earlier post. But for the moment, instead of focusing on causes of death, take a look at this table provided by Justin Hart showing a measure of non-COVID excess deaths by age group in the far right-hand column:

The numbers here are derived by averaging deaths by age group over the previous five years and subtracting COVID deaths in each group. I believe Hart’s numbers go through November. Of greatest interest here is the fact that younger age groups, having far less risk of death from COVID than older age groups, have suffered large numbers of excess deaths NOT attributed to COVID. As Hart notes later in his thread:

These deaths are a tragic consequence of lockdowns.

Educational Costs of Stringency

Many schools have been closed to in-person instruction during the pandemic, leading to severe disruptions to the education f children. This report from the Fairfax County, VA School District is indicative, and it is extremely disheartening. The report includes the following table:

Note the deterioration for disabled students, English learners, and the economically disadvantaged. The surfeit of failing grades is especially damaging to groups already struggling in school relative to their peers, such as blacks and Hispanics. Not only has the disruption to in-person instruction been disastrous to many students and their futures; it has also yielded little benefit in mitigating the contagion. A recent study in The Lancet confirms once again that transmission is low in educational settings. Also see here and here for more evidence on that point.

Conclusion

It’s clear that the “follow-the-science” mantra as a rationale for stringent NPIs was always a fraud, as was the knee-jerk response from those who conflated lockdowns with “leadership”. Such was the wrongheaded and ultimately deadly pressure to “do something”. We can be thankful that pressure was resisted at the federal level by President Trump. The extraordinary damage inflicted by ongoing NPIs was quite foreseeable, but there is one more very ominous implication. I’ll allow J.D. Tucille to sum that up with some of the pointed quotes he provides:

“‘The first global pandemic of the digital age has accelerated the international adoption of surveillance and public security technologies, normalising new forms of widespread, overt state surveillance,’ warned Kelsey Munro and Danielle Cave of the Australian Strategic Policy Institute’s Cyber Policy Centre last month.

‘Numerous governments have used the COVID-pandemic to repress expression in violation of their obligations under human rights law,’ United Nations Special Rapporteur on Freedom of Expression David Kaye noted in July.

‘For authoritarian-minded leaders, the coronavirus crisis is offering a convenient pretext to silence critics and consolidate power,’ Human Rights Watch warned back in April.

There’s widespread agreement, then, that government officials around the world are exploiting the pandemic to expand their power and to suppress opposition. That’s the case not only among the usual suspects where authorities don’t pretend to take elections and civil liberties seriously, but also in countries that are traditionally considered ‘free.’ … It’s wildly optimistic to expect that newly acquired surveillance tools and enforcement powers will simply evaporate once COVID-19 is sent on its way. The post-pandemic new normal is almost certain to be more authoritarian than what went before.”

COVID Externalities: the Costs and Benefits of Intervention

13 Sunday Dec 2020

Posted by in Coronavirus, Public Health, Social Costs

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This post offers a simple representation of the argument against public non-pharmaceutical interventions (NPIs) to subdue the COVID-19 pandemic. The chart below features two lines, one representing the presumed life-saving benefits of lockdown measures or NPI stringency, and another representing the costs inflicted by those measures. The values on the axes here are not critical, though measures of stringency exist (e.g., the University of Oxford Stringency Index) and take values from zero to 100.

The benefits of lives saved due to NPI stringency are assigned a value on the vertical axis, as are the costs of lives lost due to deferred health care, isolation, and other stressors caused by stringency. In addition, there are the more straightforward losses caused by suspending economic activity, which should be included in costs.

One can think of the benefits curve as representing gains from forcing individuals, via lockdown measures, to internalize the external costs of risk inflicted on others. However, this curve captures only benefits incremental to those achieved through voluntary action. Thus, NPI benefits include only extra gains from coercing individuals to internalize risks, while losses from NPI stringency are captured by the cost curve.

My contention is that the benefits of stringency diminish and may in fact turn down at some point, and that costs always increase in the level of stringency. In the chart, for what it’s worth, the “optimal” level of stringency would be at a value of 2, where the difference between total benefits and total costs is maximized (and where the benefits of incremental stringency are equal to the marginal costs or losses). However, I am not convinced that the benefits of lockdown measures ever exceed costs, as they do in the chart above. That is, voluntary action may be sufficient. But if the benefits of NPIs do exceed costs, it’s likely to be only at low levels of stringency.

To the extent that people are aware of the pandemic and recognize risk, the external costs of possible infectiousness are already internalized to some degree. Moreover, there is mutual risk in most interactions, and all individuals face risks that are proportional to those to which they expose others: if your contacts are more varied and your interactions are more frequent and intimate, you face correspondingly higher risks yourself. After all, in a pandemic, an individual’s failure to exercise caution may lead to a very hard internalization of costs if an infection strikes them. This mutuality is an element absent from most situations involving externalities. And to the extent that you take voluntary precautions, you and your contacts both benefit. Nevertheless, I concede that there are individuals who face less risk themselves (the young or healthy) but who might behave recklessly, and they might not internalize all risk for which they are responsible. Yes, stringency may have benefits, but that does not mean it has net benefits.

Even if there is some meaningful point at which NPIs are “optimized”, government does not possess the knowledge required to find that point. It lacks detailed knowledge of both costs and benefits of NPIs. This is a manifestation of the “knowledge problem” articulated by Friedrich Hayek, which hampers all efforts at central planning. In contrast, individual actors know their own tolerance for risk, and they surely have some sense of the risks they create in their normal course of affairs. And again, there is a strong degree of proportionality and voluntary internalization of mutual risks.

While relying on voluntary action is economically inefficient relative to an ideal, full-information and perfectly altruistic solution, it is at least based on information that individuals possess: their own risk profile and risk preferences. In contrast, government does not possess information necessary to impose rules in an optimal way, and those rules are rife with unintended consequences and costs inflicted on individuals.

My next post will present empirical evidence of the weakness of lockdown measures in curbing the coronavirus as well as the high costs of those measures. The coronavirus is a serious infection, but it is not terribly deadly or damaging to the longer-term health of the vast majority of people. This, in and of itself, should be sufficient to demonstrate that the array of non-pharmaceutical interventions imposed in the U.S. and abroad were and are not worthwhile. People are capable of assessing risks for themselves. The externality argument, that NPIs are necessary because people do not adequately assess the risk they pose to others, relies on an authority’s ability to assess that risk, and they invariably go overboard on interventions for which they underestimate costs. COVID is not serious enough to justify a surrender of our constitutional rights, and like every concession to government authority, those rights will be difficult to recover.

Most Hospitals Have Ample Capacity

05 Saturday Dec 2020

Posted by in Coronavirus, Health Care

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Let’s get one thing straight: when you read that “hospitalizations have hit record highs”, as the Wall Street Journal headline blared Friday morning, they aren’t talking about total hospitalizations. They reference a far more limited set of patients: those admitted either “for” or “with” COVID. And yes, COVID admissions have increased this fall nationwide, and especially in certain hot spots (though some of those are now coming down). Admissions for respiratory illness tend to be highest in the winter months. However, overall hospital capacity utilization has been stable this fall. The same contrast holds for ICU utilization: more COVID patients, but overall occupancy rates have been fairly stable. Several factors account for these differing trends.

Admissions and Utilization

First, take a look at total staffed beds, beds occupied, and beds occupied by COVID patients (admitted “for” or “with” COVID), courtesy of Don Wolt. Notice that COVID patients occupied about 14% of all staffed beds over the past week or so, and total beds occupied are at about 70% of all staffed beds.

Is this unusual? Utilization is a little high based on the following annual averages of staffed-bed occupancy from Statista (which end in 2017, unfortunately). I don’t have a comparable utilization average for the November 30 date in recent years. However, the medical director interviewed at this link believes there is a consensus that the “optimal” capacity utilization rate for hospitals is as high as 85%! On that basis, we’re fine in the aggregate!

The chart below shows that about 21% of staffed Intensive Care Unit (ICU) beds are occupied by patients having COVID infections, and 74% of all ICU beds are occupied.

Here’s some information on the regional variation in ICU occupancy rates by COVID patients, which pretty much mirror the intensity of total beds occupied by COVID patients. Fortunately, new cases have declined recently in most of the states with high ICU occupancies.

Resolving an Apparent Contradiction

There are several factors that account for the upward trend in COVID admissions with stable total occupancy. Several links below are courtesy of AJ Kay:

  • The flu season has been remarkably light, though outpatients with symptoms of influenza-like illness (ILI) have ticked-up a bit in the past couple of weeks. Still, thus far, the light flu season has freed up hospital resources for COVID patients. Take a look at the low CDC numbers through the first nine weeks of the current flu season (from Phil Kerpen):
  • There is always flexibility in the number of staffed beds both in ICUs and otherwise. Hospitals adjust staffing levels, and beds are sometimes reassigned to ICUs or from outpatient use to inpatient use. More extreme adjustments are possible as well, as when hallways or tents are deployed for temporary beds. This tends to stabilize total bed utilization.
  • The panic about the fall wave of the virus sowed by media and public officials has no doubt “spooked” individuals into deferring care and elective procedures that might require hospitalization. This has been an unfortunate hallmark of the pandemic with terrible medical implications, but it has almost surely freed-up capacity.
  • COVID beds occupied are inflated by a failure to distinguish between patients admitted “for” COVID-like illness (CLI) and patients admitted for other reasons but who happen to test positive for COVID — patients “with” COVID (and all admissions are tested).
  • Case inflation from other kinds of admissions is amplified by false positives, which are rife. This leads to a direct reallocation of patients from “beds occupied” to “COVID beds occupied”.
  • In early October, the CDC changed its guidelines for bed counts. Out-patients presenting CLI symptoms or a positive test, and who are assigned to a bed for observation for more than eight hours, were henceforth to be included in COVID-occupied beds.
  • Also in October, the FDA approve an Emergency Use Authorization for Remdesivir as a first line treatment for COVID. That requires hospitalization, so it probably inflated COVID admissions.
  • The CDC also announced severe penalties in October for facilities which fail to meet its rather inclusive COVID reporting requirements, creating another incentive to capture any suspected COVID case in its reports.

In addition to the above, let’s not forget: early on, hospitals were given an incentive to diagnose patients with COVID, whether tested or merely “suspected”. The CARES Act authorized $175 billion dollars for hospitals for the care of COVID patients. In the spring and even now, hospitals have lost revenue due to the cancellation of many elective procedures, so the law helped replace those losses (though the distribution was highly uneven). The point is that incentives were and still are in place to diagnose COVID to the extent possible under the law (with a major assist from false-positive PCR tests).

Improved Treatment and Treatment

While more COVID patients are using beds, they are surviving their infections at a much higher rate than in the spring, according to data from FAIR Health. Moreover, the average length of their hospital stay has fallen by more than half, from 10.5 to 4.6 days. That means beds turn over more quickly, so more patients can be admitted over a week or month while maintaining a given level of hospital occupancy.

The CDC just published a report on “under-reported” hospitalization, but as AJ Kay notes, it can only be described as terrible research. Okay, propaganda is probably a better word! Biased research would be okay as well. The basic idea is to say that all non-hospitalized, symptomatic COVID patients should be counted as “under-counted” hospitalizations. We’ve entered the theater of the absurd! It’s certainly true that maxed-out hospitals must prioritize admissions based on the severity of cases. Some patients might be diverted to other facilities or sent home. Those decisions depend on professional judgement and sometimes on the basis of patient preference. But let’s not confuse beds that are unoccupied with beds that “should be occupied” if only every symptomatic COVID patient were admitted.

Regional Differences

Finally, here’s a little more information on regional variation in bed utilization from the HealthData.gov web site. The table below lists the top 25 states by staffed bed utilization at the end of November. A few states are highlighted based on my loose awareness of their status as “COVID “hot spots” this fall (and I’m sure I have overlooked a couple. Only two states were above 80% occupancy, however.

The next table shows the 25 states with the largest increase in staffed bed utilization during November. Only a handful would appear to be at all alarming based on these increases, but Missouri, for example, at the top of the list, still had 27% of beds unoccupied on November 30. Also, 21 states had decreases in bed utilization during November. Importantly, it is not unusual for hospitals to operate with this much headroom or less, which many administrators would actually prefer.

Of course, certain local markets and individual hospitals face greater capacity pressures at this point. Often, the most crimped situations are in small hospitals in underserved communities. This is exacerbated by more limited availability of staff members with school-age children at home due to school closures. Nevertheless, overall needs for beds look quite manageable, especially in view of some of the factors inflating COVID occupancy.

Conclusion

Marc Boom, President and CEO of Houston Methodist Hospital, had some enlightening comments in this article:

“Hospital capacity is incredibly fluid, as Boom explained on the call, with shifting beds and staffing adjustments an ongoing affair. He also noted that as a rule, hospitals actually try to operate as near to capacity as possible in order to maximize resources and minimize cost burdens. Boom said numbers from one year ago, June 25, 2019, show that capacity was at 95%.”

So there are ample beds available at most hospitals. A few are pinched, but resources can and should be devoted to diverting serious COVID cases to other facilities. But on the whole, the panic over hospital capacity for COVID patients is unwarranted.