Tag Archives: Phil Kerpen

Effective Immunity Means IF YOU CATCH IT, You Won’t Get Sick

12 Thursday Aug 2021

Posted by in Coronavirus, Uncategorized, Vaccinations

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Listen very carefully: immunity does NOT mean you won’t get COVID, though an infection is less likely. Immunity simply means your immune system will be capable of dealing with an infection successfully. This is true whether the immunity is a product of vaccination or a prior infection. Immunity means you are unlikely to have worse than mild symptoms, and you are very unlikely to be hospitalized. (My disclaimer: I am opposed to vaccine mandates, but vaccination is a good idea if you’ve never been infected.)

I emphasize this because the recent growth in case numbers has prompted all sorts of nonsensical reactions. People say, “See? The vaccines don’t work!” That is a brazenly stupid response to the facts. Even more dimwitted are claims that the vaccines are killing everyone! Yes, there are usually side effects, and the jabs carry a risk of serious complications, but it is minuscule.

Vaccine Efficacy

Right out of the gate, we must recognize that our PCR testing protocol is far too sensitive to viral remnants, so the current surge in cases is probably exaggerated by false positives, as was true last year. Second, if a large share of the population is vaccinated, then vaccinated individuals will almost certainly account for a large share of infected individuals even if they have a lower likelihood of being infected. It’s simple math, as this explanation of base rate bias shows. In fact, according to the article at the link:

“… vaccination confers an eightfold reduction in the risk of getting infected in the first place; a 25-fold reduction in risk of getting hospitalized; and a 25-fold reduction in the risk for death.”

The upshot is that if you are vaccinated, or if you have acquired immunity from previous exposure, or if you have pre-existing immunity from contact with an earlier COVID strain, you can still “catch” the virus AND you can still spread it. Both are less likely, and you don’t have as much to worry about for your own health as those having no immunity.

As for overall vaccine efficacy in preventing death, here are numbers from the UK, courtesy of Phil Kerpen:

The vertical axis is a log scale, so each successive gridline is a fatality rate 100x as large as the one below it. Obviously, as the chart title asserts, the “vaccines have made COVID-19 far less lethal.” Also, at the bottom, see the information on fatality among children under age 18: it is almost zero! This reveals the absurdity of claims that children must be masked for schools to reopen! In any case, masks offer little protection to anyone against a virus that spreads via fine aerosols. Nevertheless, many school officials are pushing unnecessary but politically expedient masking policies

Delta

Ah, but we have the so-called Delta variant, which is now dominant and said to be far more transmissible than earlier variants. Yet the Delta variant is not as dangerous as earlier strains, as this UK report demonstrates. Delta had a case fatality rate among unvaccinated individuals that was at least 40% less than the so-called Alpha variant. This is a typical pattern of virus mutation: the virus becomes less dangerous because it wants to survive, and it can only survive in the long run by NOT killing its hosts! The decline in lethality is roughly demonstrated by Kelly Brown with data on in-hospital fatality rates from Toronto, Canada:

The case numbers in the U.S. have been climbing over the past few weeks, but as epidemiologist Larry Brilliant of WHO said recently, Delta spreads so fast it essentially “runs out of candidates.” In other words, the current surge is likely to end quickly. This article in Issues & Insights shows the more benign nature of recent infections. I think a few of their charts contain biases, but the one below on all-cause mortality by age group is convincing:

The next chart from Our World In Data shows the infection fatality rate continuing its decline in the U.S. The great majority of recent infections have been of the Delta variant, which also was much less virulent in the UK than earlier variants.

Furthermore, it turns out that the vaccines are roughly as effective against Delta and other new variants as against earlier strains. And the newest “scary” variants, Kappa and Lambda, do not appear to be making strong inroads in the U.S. 

Fading Efficacy?

There have been questions about whether the effectiveness of the vaccines is waning, which is behind much of the hand-wringing about booster shots. For example, Israeli health officials are insisting that the effectiveness of vaccines is “fading”, though I’ll be surprised if there isn’t some sort of confounding influence on the data they’ve cited, such as age and co-morbidities. 

Here is a new Mayo Clinic study of so-called “breakthrough” cases in the vaccinated population in Minnesota. It essentially shows that the rate of case diagnosis among the vaccinated rose between February and July of this year (first table below, courtesy of Phil Kerpen). However, the vaccines appear only marginally less effective against hospitalization than in March (second table below).

The bulk of the vaccinated population in the U.S. received their jabs three to six months ago, and according to this report, evidence of antibodies remains strong after seven months. In addition, T-cell immunity may continue for years, as it does for those having acquired immunity from an earlier infection. 

Breakthroughs

It’s common to hear misleading reports of high numbers of “breakthrough” cases. Not only will these cases be less menacing, but the reports often exaggerate their prevalence by taking the numbers out of context. Relative to the size of the vaccinated population, breakthrough cases are about where we’d expect based on the original estimates of vaccine efficacy. This report on Massachusetts breakthrough hospitalizations and deaths confirms that the most vulnerable among the vaxed population are the same as those most vulnerable in the unvaxed population: elderly individuals with comorbidities. But even that subset is at lower risk post-vaccination. It just so happens that the elderly are more likely to have been vaccinated in the first place, which implies that the vaccinated should be over-represented in the case population.

Conclusion

The COVID-19 vaccines do what they are supposed to do: reduce the dangers associated with infection. The vaccines remain very effective in reducing the severity of infection. However, they cannot and were not engineered to prevent infection. They also pose risks, but individuals should be able to rationally assess the tradeoffs without coercion. Poor messaging from public health authorities and the crazy distortions promoted in some circles does nothing to promote public health. Furthermore, there is every reason to believe that the current case surge in Delta infections will be short-lived and have less deadly consequences than earlier variants.

CDC Makes a Bum Lead Steer: Alternate Reality vs. The Herd

16 Sunday May 2021

Posted by in Herd Immunity, Pandemic

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Jordan Schachtel enjoyed some schadenfreude last week when he tweeted:

“I am thoroughly enjoying the White House declaring COVID over and seeing the confused cultists having a nervous breakdown and demanding the continuation of COVID Mania.”

It’s quite an exaggeration to say the Biden Administration is “declaring COVID over”, however. They’re backpedaling, and while last week’s CDC announcement on masking is somewhat welcome, it reveals more idiotic thinking about almost everything COVID: the grotesquely excessive application of the precautionary principle (typical of the regulatory mindset) and the mentality of “zero COVID”. And just listen to Joe Biden’s tyrannical bluster following the CDC announcement:

“The rule is now simple: get vaccinated or wear a mask until you do.

The choice is yours.”

Is anyone really listening to this buffoon?Unfortunately, yes. But there’s no federal “rule”, unless your on federal property; it constitutes “guidance” everywhere else. I’m thankful our federalist system still receives a modicum of respect in the whole matter, and some states have chosen their own approaches (“Hooray for Florida”). Meanwhile, the state of the pandemic looks like this, courtesy of Andy Slavitt:

False Assertions

The CDC still operates under the misapprehension that kids need to wear masks, despite mountains of evidence showing children are at negligible risk and tend not to be spreaders. Here’s some evidence shared by Phil Kerpen on the risk to children:

The chart shows the fatality risk by age (deaths per 100,000), and then under the assumption of a 97% reduction in that risk due to vaccination, which is quite conservative. Given that kind of improvement, an unvaccinated 9 year-old child has about the same risk as a fully vaccinated 30 year-old!

The CDC still believes the unvaccinated must wear masks outdoors, but unless you’re packed in a tight crowd, catching the virus outdoors has about the same odds as a piano falling on your head. And the CDC insists that two shots of mRNA vaccine (Pfizer or Moderna) are necessary before going maskless, but only one shot of the Johnson and Johnson vaccine, even though J&J’s is less effective than a single mRNA jab!

Other details in the CDC announcement are worthy of ridicule, but for me the most aggravating are the agency’s implicit position that herd immunity can only be achieved through vaccination, and its “guidance” that the unvaccinated should be dealt with coercively, even if they have naturally-acquired immunity from an infection!

Tallying Immunity

Vaccination is only one of several routes to herd immunity, as I’ve noted in the past. For starters, consider that a significant share of the population has a degree of pre-existing immunity brought on by previous exposure to coronaviruses, including the common cold. That doesn’t mean they won’t catch the virus, but it does mean they’re unlikely to suffer severe symptoms or transmit a high viral load to anyone else. Others, while not strictly immune, are nevertheless unlikely to be sickened due to protections afforded by healthy vitamin D levels or because they are not obese. Children, of course, tend to be fairly impervious. Anyone who’s had a bout with the virus and survived is likely to have gained strong and long-lasting immunity, even if they were asymptomatic. And finally, there are those who’ve been vaccinated. All of these groups have little or no susceptibility to the virus for some time to come.

It’s not necessary to vaccinate everyone to achieve herd immunity, nor is it necessary to reach something like an 85% vax rate, as the fumbling Dr. Fauci has claimed. Today, almost 47% of the U.S. population has received at least one dose, or about 155 million adults. Here’s Kerpen’s vax update for May 14.

Another 33 million people have had positive diagnoses and survived, and estimates of seroprevalence would add perhaps another 30 million survivors. Some of those individuals have been vaccinated unnecessarily, however, and to avoid double counting, let’s say a total of 50 million people have survived the virus. Some 35 million children in the U.S. are under age 12. Therefore, even if we ignore pre-existing immunity, there are probably about 240 million effectively immune individuals without counting the remaining non-susceptibles. At the low end, based on a population of 330 million, U.S. immunity is now greater than 70%, and probably closer to 80%. That is more than sufficient for herd immunity, as traditionally understood.

The Herd Immunity Threshold

Here and in the following section I take a slightly deeper dive into herd immunity concepts.

Herd immunity was one of my favorite topics last year. I’m still drawn to it because it’s so misunderstood, even by public health officials with pretensions of expertise in the matter. My claim, about which I’m not alone, is that it’s unnecessary for a large majority of the population to be infected (or vaccinated) to limit the spread of a virus. That’s primarily because there is great variety in individuals’ degree of susceptibility, social connections, aerosol production, and viral load if exposed: call it heterogeneity or diversity if you like. Variation across individuals naturally limits a contagion relative to a homogeneous population.

Less than 1% of those who caught the virus died, while the others recovered and acquired immunity. The remaining subset of individuals most vulnerable to severe illness was thus reduced over time via acquired immunity or death. This is the natural dynamic that causes contagions to slow and ultimately peter out. In technical jargon, the virus reproduction rate “R” falls below a value of one. The point at which that happens is called the “herd immunity threshold” (HIT).

A population with lots of variation in susceptibility will have a lower HIT. Some have estimated a HIT in the U.S. as low as 15% -25%. Ultimately, total exposure will go much higher than the HIT, perhaps well more than doubling exposure, but the contagion recedes once the HIT is reached. So again, it’s unnecessary for anywhere near the full population to be immune to achieve herd immunity.

One wrinkle is that CIVID is now likely to have become endemic. Increased numbers of cases will re-emerge seasonally in still-susceptible individuals. That doesn’t contradict the discussion above regarding the HIT rate: subsequent waves will be quite mild by comparison with the past 14 months. But if the effectiveness of vaccines or acquired immunity wanes over time, or as healthy people age and become unhealthy, re-emergence becomes a greater risk.

Sub-Herd Immunity

A further qualification relates to so-called sub-herds. People are clustered by geographical, social, and cultural circles, so we should think of society not as a singular “herd”, but as a collection of sub-herds having limited cross-connectivity. The following charts are representations of different kinds of human networks, from Nathan D. Grawe’s review of “The Rules of Contagion, by Adam Kucharski:

Sub-herd members tend to have more degrees of separation from individuals in other sub-herds than within their own sub-herd. The most extreme example is the “broken network” (where contagions could not spread across sub-herds), but there are identifiable sub-herds in all of the examples shown above. Less average connectedness across sub-herds implies barriers to transmission and more isolated sub-herd contagions.

We’ve seen isolated spikes in cases in different geographies, and there have been spikes within geographies among sub-herds of individuals sharing commonalities such as race, religious affiliation, industry affiliation, school, or other cultural affiliation. Furthermore, transmission of COVID has been dominated by “super-spreader” events, which tend to occur within sub-herds. In fact, sub-herds are likely to be more homogeneous than the whole of society, and that means their HIT will be higher than we might naively calculate based on higher levels of aggregation.

We have seen local, state, or regional contagions peak and turn down when estimates of total incidence of infections reach the range of 15 – 25%. That appears to have been enough to reach the HIT in those geographically isolated cases. However, if those geographical contagions were also concentrated within social sub-herds, those sub-herds might have experienced much higher than 25% incidence by the time new infections peaked. Again, the HIT for sub-herds is likely to be greater than the aggregate population estimates implied, The upshot is that some sub-herds might have achieved herd immunity last year but others did not, which explains the spikes in new geographic areas and even the recurrence of spikes within geographic areas.

Conclusion

It’s unnecessary for 100% of the population to be vaccinated or to have pre-existing immunity. Likewise, herd immunity does not imply that no one catches the virus or that no one dies from the virus. There will be seasonal waves, though muted by the large immune share of the population. This is not something that government should try to stanch, as that would require the kind of coercion and scare tactics we’ve already seen overplayed during the pandemic. People face risks in almost everything they do, and they usually feel competent to evaluate those risks themselves. That is, until a large segment of the population allows themselves to be infantalized by public health authorities.

Joe Biden’s Fat Cooked-Goose Tax Plan

03 Saturday Apr 2021

Posted by in Fiscal policy, Taxes

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I recently wrote on this blog about the damaging impact of corporate taxes on workers, consumers, and U.S. competitiveness. Phil Kerpen tweeted the chart above showing the dramatic reduction in the distribution of corporate tax rates across the world from 1980 through 2020. Yes, yes, Joe Biden’s posture as a fair and sensible leader aside, most countries place great emphasis on their treatment of business income and their standing relative to trading partners.

Kerpen’s tweet was a response to this tweet by economist Justin Wolfers:

Apparently, Wolfers wishes to emphasize that Biden’s plan, which raises the statutory corporate rate from 21% to 28%, does not take the rate up to the level of the pre-Trump era. Fair enough, but compare Wolfers’ chart with Kerpen’s (from the Tax Foundation) and note that it would still put the U.S. in the upper part of the international distribution without even considering the increment from state corporate tax rates. Also note that the U.S. was near the top of the distribution in 1980, 2000, and 2010. In fact, the U.S. had the fourth highest corporate tax rate in the world in 2017, before Trump’s tax package took effect. Perhaps Biden’s proposed rate won’t be the fourth highest in the world, but it will certainly worsen incentives for domestic U.S. investment, the outlook for wage growth, and consumer prices.

And in the same thread, Wolfers said this:

That’s certainly true, but let’s talk about those “loopholes”. First, much of U.S. corporate income is “passed though” to the returns of individual owners, so corporate taxes understate the true rate of tax paid on corporate income. Let’s also remember that the corporate tax represents a double taxation of income, and as a matter of tax efficiency it would be beneficial to consolidate these taxes on individual returns.

Beyond those consideration, the repeal of any corporate tax deduction or credit would have its own set of pros and cons. As long as there is a separate tax on corporate income, there is an economic rationale for most so-called “loopholes”. Does Wolfers refer to research and development tax credits? Maybe he means deductions on certain forms of compensation, though it’s hard to rationalize treating any form of employee compensation as income taxable to the business. Then there are the massive tax subsidies extended for investments in renewable energy. Well, good for Wolfers if that last one is his gripe! The CARES Act of 2020 allowed publicly-traded companies to use losses in 2020( presumably induced by the pandemic) to offset income in prior years, rather than carrying them forward. Did Wolfers believe that to be inappropriate? I might object to that too, to the extent that the measure allows declining firms to use COVID to cloak inefficiencies. Does he mean the offshoring of income to avoid U.S. corporate taxes? Might that be related to relative tax rates?

In any case, Wolfers can’t possibly imagine that the U.S. is the only country allowing a variety of expenses to be deducted against corporate income, or credits against tax bills for various activities. So, a comparison of statutory tax rates is probably a good place to start in assessing the competitive thrust of tax policy. But effective tax rates can reveal much more about the full impact of tax policy. In 2011, a study showed that the U.S. had the second highest effective corporate tax rate in the world. Today, among developed countries, the OECD puts the U.S. roughly in the middle of the pack, close to Germany but higher than Canada, Mexico and Japan, and lower than the UK. This article from 2019 reaches the same conclusion, though the rankings and rates differ from the OECD’s calculations. So it’s not as if the U.S. is the only country to offer tax incentives, or “loopholes” in Wolfers’ preferred terminology.

The corporate tax hikes proposed by the Biden Administration are intended to fund the massive outlays in the so-called infrastucture bill, which of course has very little to do with real infrastructure. Both the tax and spending proposals are bad policy. So far, however, passage of the bill is not a given. Let’s hope all of the Republicans and at least one Democrat senator have the sense to vote it down, but I’m not optimistic. The best hope for resistance among Democrats is Joe Manchin of West Virginia, but even he has signaled his support. Biden’s appointment of Gayle Manchin to a key administration post couldn’t have hurt.

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.

Let’s Do “First Doses First”

06 Wednesday Jan 2021

Posted by in Coronavirus, Vaccinations

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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.

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.