175 Comments
May 25, 2023·edited May 25, 2023

I would love a tutorial on how and where to read wastewater data. Since the PHE is over, I've lost my usual data for cases/hospitalizations.

Thanks as always for the update!!

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How do we interpret the fact that hospitalizations and deaths are now lower (than 2020 and 2021), yet wastewater levels are now higher? Does this mean that in 2023, more people have covid than past years, yet they're mostly asymptomatic? And if this is true, what does this imply about transmission rates? These are important questions for "novids" (people who have never had covid).

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I'm not convinced that the hospitalizations and deaths are accurate counts. We've lost so much awareness in terms of surveillance and reporting on transmission or cases. I'm also concerned whether our at home test kits can keep pace with the virus as it mutates. Privileging wastewater levels over other metrics seems like the way to go for now, because even though wastewater tracking is scattered and underfunded it possess higher integrity than the other measures.

Big mistake ending the PHE the way we did. :(

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It would be nice if we could get more clarity on what the high baseline level for wastewater means. For instance, if someone is infected, how long do they continue to shed (poop) virus? Does the shedding window match the infectiousness window (i.e, each appx 10 days)? If so, then wastewater is a good indicator of "community transmission" (i.e. how likely am I to catch covid if I'm out and about). But if shedding occurs for months, then wastewater is an accumulation of past infectiousness, meaning it does not inform today's level of community transmission and cannot be used to assess personal risk. Do people with long covid continue to shed virus longer than people with resolved covid?

I also wonder whether vaccines result in a greater proportion of asymptomatic cases? If true, this is good news, because the person with covid doesn't end up in the hospital and/or dead. But it's also bad news, because if you don't know you have covid, you don't isolate, meaning you're out and about transmitting virus to others. Do vaccines inadvertently create a higher level of transmission?

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There was an interesting study ongoing still for the past 18 months or longer, about wastewater tracking in a major city, witha source tracked back to a specific set of restrooms in an office building, an unknown person still shedding virus particles this entire time - the speculation is that the carrier is likely asymptomatic thus still going to work and doing life as usual, but has a reservoir of virus somewhere in their body. However there have been no reports of a spike of positive tests there, maybe because test results aren't being reported or maybe because the carrier lives an isolated lifestyle... If I come across the article again, will return and edit this post to include a link. But intriguing.

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Or fecal/oral transmission for covid is negligible, making it epidemiologically (but not clinically) neutral information.

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I agree. With the lack of testing and reliable testing at that, I don’t think we can say COVID infections are decreasing.

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Key risk indicators don't have to be "accurate" per se - they just have to have enough consistency and comparability to be useful.

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There’s a hypothesis that Public Health doesn’t like, but data suggests plausible (and wastewater backs) - that our actions to fight Covid were a large part of the surge in excess deaths.

Covid was running among us unknown as early as September 2019, as late as December 2019.

There was zero action taken until March 15th, and zero excess deaths during that time period. I have yet to hear a plausible explanation on how this could be so. If people were dying of Covid in suburbs of Seattle in Jan 2020 then we should have seen a slow but steady spike in all cause mortality throughout 2020, but there’s nothing.

The moment we acted, deaths soared (unevenly too which is another oddity).

Throughout pandemic as long as we acted, we had high excess deaths.

Every time we stopped one of the measures Public Health claimed was critical and warned against it, nothing happened.

Now, that we have completely stopped doing anything - no masks, no school closures, no testing, no quarantining - excess deaths have receded.

Guess what other country did the closest to nothing? Sweden. Which has the lowest excess deaths in the world.

So it may be, the “cure” was worse than the disease. Unnecessary disruption of healthcare; terrorizing the population to increase stress, obesity, alcohol, and drug use; breaking social bonds and closing schools, it may be doing these things was a good share of why we had deaths increase only after action was taken and not before or after despite Covid being prevalent before and after.

As for the 46% saying they wear masks in a poll, that’s clearly nonsense. I have unfortunately been spending most of my time in major cancer hospitals in Cleveland and not even on the floors of patients knocking on deaths door is 46% masking.

Maybe 20% nurses, 10% physicians (it’s always the young residents if so), 5% visitors, 0% visitors.

Be spending time in hospice soon, I’m guessing low there too. Will report back.

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I'd love to see the data behind your theory, and whether or not confounders were taken into account. Many critical public health measures were stopped only after vaccines were widely available, so outcomes getting better after measures were relaxed would make sense, right? And as for excess deaths not spiking until after public health measures were taken - death is a lagging indicator, so did you consider that public health measures were taken once conditions were clocked as critical in our hospitals and health system, and deaths came after? As for COVID running rampant earlier than March 2020, that's not exactly the case. COVID was some places in late 2019, early 2020, but was not everywhere. Early COVID was less contagious than current COVID, and incubation time was longer (remember when it would take up to 14 days to test positive after exposure?). There could have been cases and excess deaths in the places that were circulating COVID before March 2020, but that wouldn't register when looking at country-wide excess death rates until the virus was truly country-wide and wreaking havoc. If you talk to people who remember what it was like on the front lines of COVID in the spring of 2020, they will tell you that it wasn't "public health measures" that nearly broke our health system, it was COVID.

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I’m going to give a point-by-point rebuttal to your comment, and if my tone is harsh – please know I’m directing it at the data, not you directly. Overall, my mindset is that I have not seen true science happening regarding Covid.

When I say “true science”, I mean the Science outlined by Carl Sagan:

“Science invites us to let the facts in, even when they don’t conform to our preconceptions. It counsels us to carry alternative hypotheses in our heads and see which best fit the facts. It urges on us a delicate balance between no-holds-barred openness to new ideas, however heretical, and the most rigorous skeptical scrutiny of everything-new ideas and established wisdom….. When we are self-indulgent and uncritical, when we confuse hope and facts, we slide into pseudoscience and superstition”

Instead, I have seen science devolve into team sports, politically aligned, with no skepticism, no scrutiny, no self reflection. Scientists should be disinterested in outcome, of hypothesis, of results.

We should, for example, be skeptical that masks could work after finding them ineffective for 100 years. We should be skeptical that after 80 years of trying and failing to make effective ILI vaccines the fastest vaccine made in human history would actually work – those odds were huge. We should be skeptical that closing school for children has a net positive. That restricting elderly from seeing loved ones would be good for them. That pausing “elective” medicine when we have an already delicate and strained healthcare system wouldn’t create a cascading collapse.

All of the ideas put forth by the “Official PH” narrative warranted huge amounts of skepticism – that is half of science! To pause skepticism, and ask for belief and trust, is deeply troubling to me. And now that we have 3 years of data, showing just how little any of what they said mattered or could be replicated, we should be working to sift through fact and fiction so we don’t repeat these errors again.

Instead I see retconning, excuses, gaslighting, and HARKING.

>>Many critical public health measures were stopped only after vaccines were widely available, so outcomes getting better after measures were relaxed would make sense, right?”

You may be unaware of two important points, and if you primarily read Zeynep, YLE, and Topol to get Covid information, it is understandable why they wouldn’t be sharing this:

1) All Cause Mortality in almost every country, every state was higher after the vaccines rolled out. Critics of the vaccine accuse it of contributing to excess deaths, though I think the answer is much simpler – they weren’t that effective, which shouldn’t be surprising given our 80 year history of not being able to control ILI viruses with vaccines. This discredits your belief that “outcomes got better after the vaccines rolled out”, they didn’t. [1]

2) That the measures taken place had no positive effect that could be replicated. Masked places did no different than unmasked places. Countries that opened schools had the same (or often better) outcome than those that kept them closed. Lockdowns had no impact. Florida did better than California. Missouri identically to Illinois. Sweden better than the entire world.

Yes, we can find an infinite supply of observational data drudged studies that make ludicrous claims extolling how many hundreds of thousands of lives these measures saved, but non of that can be replicated. [2]

For example, if you show me a paper saying high vaccination rate lead to 80% fewer deaths, you need to explain then how Missouri, with one of the lowest vax rates in the country, fared identically to Illinois with one of the highest, especially considering PH was predicting disaster in MO [3]

“>>And as for excess deaths not spiking until after public health measures were taken - death is a lagging indicator, so did you consider that public health measures were taken once conditions were clocked as critical in our hospitals and health system, and deaths came after?”

One of the issues I have with PH is that Covid Theory is similar to Comic Book Movies. Whatever the “story” calls for, Covid is malleable to be as weak or as strong as needed to explain away the inconsistencies. One moment, Covid is so powerful a single person can sicken an entire wedding party killing multiple people in the community [4], yet when confronted by data showing it was spreading unchecked for months, now Covid has the power to just lurk in the background and not kill?

Here, you claim that PH measures were only taken once conditions were clocked as critical, but that demonstrably false. Hospitals were not overrun with Covid which caused us to react. Rather, we got spooked and preemptively closed everything down, bracing for a storm that never hit 99.99% of hospitals in the country [5], so no, it is revisionist to argue that we had to act because it was getting too bad out there.

Remember: the entire premise of Covid is that it is so contagious, so deadly, that before it hits us we needed to “flatten the curve”.

Yet unknown to us at the time, Covid was seeding among the country, and that fact was very inconvenient for PH as it contradicted the alarms they were ringing. This is why they attacked Ioannidis for showing that seroprevalence levels demonstrated Covid were higher than we knew while nothing was happening. [6]

This is one of the biggest failures of PH – that they have been uninterested in getting a true understanding of how much Covid was circulating pre March 2020. We should have been testing wastewater samples, blood banks, PCR tests sent to morgue, etc, etc.

The answer to this question is and was immensely important, and yet they seemingly didn’t want to know.

>>“Early COVID was less contagious than current COVID, and incubation time was longer (remember when it would take up to 14 days to test positive after exposure?). “

So, the less contagious version of Covid deserved to close schools and wear masks, but the more contagious version opening schools is fine?

How is the early version less contagious yet made NYC have deaths skyrocket 700% in a matter of 2 weeks? (And if the answer is population density, why wasn’t a similar catastrophe seen in London? Or Chicago?)

What about all the stories of a single person triggering a superspread event? How lucky are we that the superspreader events killing people only started after we started mass testing? [7]

>>“There could have been cases and excess deaths in the places that were circulating COVID before March 2020, but that wouldn't register when looking at country-wide excess death rates until the virus was truly country-wide and wreaking havoc. “

No, we have granular detail at county level. [8] Covid entered the country between September and December 2019. It penetrated nursing homes in suburbs by January.[9] It was in our wastewater. Our bloodbanks [10]. Yet despite it’s prevalence, there was zero uptick in all-cause mortality for at least 4 months. Then, like flipping a switch, the exact moment we took action, deaths spiked.

Which could be argued “cause or effect” back in 2020 credibly, but now we have 3 year of data to pore over showing the less you panicked, the better your outcome. All of the places designed to be “hell on earth” – Florida, Sweden, South Dakota, Africa, Iowa [11] – all the places scorned by PH did just fine (and often better than everywhere else)

>>“If you talk to people who remember what it was like on the front lines of COVID in the spring of 2020, they will tell you that it wasn't "public health measures" that nearly broke our health system, it was COVID.”

I’m married to front line, our friend groups are front line, and it’s sad to see some weird Mandela effect happening where people are becoming convinced that hospitals across the county were overrun with Covid spring 2020 when in fact they were empty, waiting for a surge that never came [5], and causing us to expend vast resources unnecessarily [12]

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______________

[1] https://www.mortality.org/Data/STMF - not sure how comfortable you are with pivot tables, but you could check my claim here.

[2] Consider any of the studies in this list, how many make some claim that can’t fail replication? All of them.

https://docs.google.com/spreadsheets/d/1ahaJui6Af0kGYMwHgAtnKCE6-bHbCLxnrQxuMC0kygA/edit?usp=sharing

[3] https://apnews.com/article/mo-state-wire-michael-brown-coronavirus-pandemic-health-89fa995c59397228d8d56e1ab45890ab

Yet MO and IL have identical excess death outcomes – before and after vaccination

[4] https://www.theguardian.com/us-news/2020/sep/17/maine-wedding-superspreader-event

https://www.cdc.gov/mmwr/volumes/69/wr/mm6945a5.htm

[5] https://whyy.org/articles/philly-spends-5-million-on-coronavirus-surge-hospital-that-admitted-14-patients/

https://www.reuters.com/article/us-health-coronavirus-california-hospita/california-hospitals-struggle-financially-after-preparing-for-covid-19-surge-that-never-came-idUSKBN2341NJ

https://abc7news.com/coronavirus-bay-area-nurses-healthcare-workers-pay-cuts-flatten-the-curve/6121276/

https://www.bridgemi.com/michigan-health-watch/beaumont-hospital-near-detroit-reopen-coronavirus-surge-never-came

[6] It’s crazy that this:

https://www.medrxiv.org/content/10.1101/2020.04.14.20062463v1.full.pdf

and this:

https://www.statnews.com/2020/03/17/a-fiasco-in-the-making-as-the-coronavirus-pandemic-takes-hold-we-are-making-decisions-without-reliable-data/

Lead to crazed reactions like this:

https://twitter.com/gregggonsalves/status/1239978792426274822?lang=en

And this

https://onlinelibrary.wiley.com/doi/epdf/10.1111/eci.13224

[7] https://www.poynter.org/reporting-editing/2020/heres-a-spreadsheet-of-covid-19-superspreader-events-from-around-the-world/

[8] https://wonder.cdc.gov/controller/datarequest/D76

[9] https://abcnews.go.com/US/1st-covid-19-deaths-us-year-kids-grappling/story?id=76202200

[10] https://www.npr.org/sections/coronavirus-live-updates/2020/12/01/940395651/coronavirus-was-in-u-s-weeks-earlier-than-previously-known-study-says

[11] My personal favorite hysterical condemnation of red states:

https://www.washingtonpost.com/outlook/2021/02/10/iowa-lift-all-restrictions/

[12] https://www.npr.org/2020/05/07/851712311/u-s-field-hospitals-stand-down-most-without-treating-any-covid-19-patients

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OK, I appreciate all of these footnotes but you have misread so much of the data I'm not sure where to begin, and I don't think that you are open to education. I am not a cheerleader for the "official PH" party line, because there isn't any such thing - the CDC, which should by all rights be the official source for public health data and recommendations, totally shit the bed as far as I'm concerned, and the employment and lifting of mandates was often somewhat or totally arbitrary, based more on vibes than science. But I am a public health professional that has followed the data closely and knows how to interpret different studies, so I can tell how political, un-nuanced, and misinformed your overall analysis is. How can you see hundreds of articles about the effectiveness of masks and conclude the opposite? Do you know what replicable means? And according to the data you linked, excess mortality was up in 2019 and early 2020, went down after mitigation measures were imposed, went back up during the winter of 2020, then went down significantly after vaccines were introduced, only to unfortunately go up again during the Delta and then Omicron variant waves. Now it's down again though we will likely have some degree of excess mortality for a while as the effects of COVID infection play out in contributing to other diseases. So I'm not sure how you look at the data you link and say that there was no excess mortality until mitigation measures were implemented? I'm open to evidence that disputes commonly-accepted narratives, but your data don't do that. Sweden is an interesting case study, but not nearly as conclusive of evidence as you think - this is a nuanced take on it that links to the relevant studies: https://www.nytimes.com/2023/03/30/opinion/sweden-pandemic-coronavirus.html. Absolutely nothing should be concluded from looking at Florida's data, as data there were manipulated for political purposes. One thing I'll admit I ended up wrong about - I was sure that schools staying closed was necessary to protect kids, parents, and staff. It wasn't exactly wrong to initially make that claim, but it is clear now that protracted school closings (and the move to Zoom school) had serious negative impacts on both kids and parents. If I could go back in time, I would suggest closing schools for long enough to install better ventilation inside, set up "classrooms" outside for whenever the weather allowed, and procure adequate PPE like masks and hand sanitizer for staff and students. Unfortunately, in public health, we are often operating based on our best understanding at the time, which the future might judge as inadequate. This means that we should invest much more in research and pandemic preparedness in order to learn and grow, it doesn't mean that pursuit of public health is a bad one. Anyway, I have to go back to work so can't write any more but I urge you to take a second look at some of your sources.

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I’ll give you a detailed response, but tied up next few days.

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I'm curious to know if you live in a city or in the suburbs. The experience, and effectiveness of various responses, vary dramatically.

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Suburb outside of Cleveland

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I think that explains a lot of how different our experience was. It's hard to ignore constant sirens. I do think lockdowns were necessary in big crowded cities, and they were probably extended to less inherently risky places in order to discourage migration, although I think they realized that too late. Basically every intervention was done too late.

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What city are you in?

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Really, nobody knows quite yet how exactly how wastewater levels correlate to cases, or in what range.

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founding

Great question. I think cases and hospitalizations hasn't been a very meaningful tools for some time due to little reporting of at home testing. Death data is also diminishing as reporting becomes less frequent and less widespread. Wastewater is probably the only metric with some validity but I understand that those readings are becoming more "iffy".

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I just multiply the death rate by 1000 to estimate cases. Plausible numbers so far.

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founding

The problem is that the US death rate is not reliable

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A measuring instrument doesn't have to be accurate or be a faithful "photographic" representation; it just needs to be consistent with itself, within a specified range. That's par for the course with most things that humans measure. And often the thing that we are *really* after is something quite abstract. That's certainly the case here: what we are really interested in is a concept of "risk" and the relationship of that concept to any particular indicator is a matter of subjective social consensus, which can and should evolve.

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founding

Death numbers are a good proxy for risk for me especially since cases - as you say -can only be estimated. I don’t mean to be snarky, but I don't have a lot of confidence in your estimating method. And I want more granular detail on mortality such as age, vaccine status, health etc. unfortunately even gross numbers for deaths are being reported inadequately and by a different system.

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There's enough historical data to do more - a lot more - with less. That's the whole point of data science, probability, and statistics, isn't it? To put itself out of a job? Love, your local actuary

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Thank you, thank you for reliable information when so little public information is available. It helps senior citizens make decisions re: risk assessments.

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You recommended it's good to mask up and that masking needs to increase especially in the elderly and in times of high transmission. What's disappointing and what you didn't address about masking is that perhaps the most unsafe place for all of us now, especially those of us 65 and older, is going to the doctor, dentist, clinic or hospital, since masking is no longer required, and Covid-19 waste water surveillance levels are still higher in 2023 than they were in 2020 and 2021. Would really like to see you analyze hospital/healthcare acquired infection rates in an upcoming newsletter. I suspect it will be equal to or greater than household transmission with respect to risk of infection.

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I feel bad for my patients like you, I think it’s another community failure. And increasingly you are being questioned or softly scorned. Or at least I am as I continue to work with a mask on. But if you do wear a well-fitting N95 (like 3M Aura), you will very likely be fine for a 30 minute visit, even if the patient in the room before you was filling the space with airborne viruses 🦠

Feel free to crack the door, too. Ventilation.

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Thanks for commenting on this, and for the tips. I've had a doctor take personal offense, interrupt my reason for still masking, and invalidate my 17-year-old child and I for masking. It's getting fierce out there.

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So bad. On behalf of crappy doctors everywhere, I apologize.

Hanging on the hallowed walls of Pennsylvania Hospital, our nation's first, organized by B. Franklin, are multiple portraits of legendary physicians, many of whom posed for their immortal moments sporting fat cigars and cigarettes.

When patients ask me why I'm still wearing a mask, I just say, "It's my choice." To not respect someone's choice in America still carries some taboo... unless of course you are a woman deserving full autonomy over your body, but I digress as usual...

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So good. Thanks for your reply!

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It seems like a good idea not to give a reason for masking, since you're less likely to be seen as making any sort of guarantee of safety. Less risk of lawsuits!

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Thank you very much for that very helpful information, Dr. McCormick. And, it's a comfort to know there are still healthcare providers like you that care and will continue to mask. I do have N95 3M Aura masks and wear them every time I go indoors.

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Yes, this is something the CDC should be analyzing!

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founding

I feel so fortunate that my medical providers and hospital are still requiring masks. My dental office “suggests” them and gratefully 100% of the staff continues to mask while most patients don’t while in the lobby etc.

I made my 2nd flight since 2020 and was very disappointed to be in a super small minority when it came to masking. After all this time I no longer have the time of temperament to explain to ANYONE why I continue to mask...and yes, people ask.

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I wonder if a medical office could simply charge an extra fee for failing to mask and re-invest the money to improve or maintain air quality

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There’s no quality evidence that dropping masking in hospitals has any effect on Covid transmission, so I wouldn’t worry.

Every hospital going back to normal has paid no price.

Shouldn’t be surprising because through the pandemic almost no one was wearing a fit tested single use n95 on a clean shaven face. It was all loose fitting surgical masks which are useless.

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Even since the beginning of the pandemic have we ever had good data on where the majority of cases are acquired? I've never gotten the feeling that good enough contract tracing was happening to make that determination.

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I have to tell you that I have been seeing a spike locally in Covid after a very quiet period. We have numerous parents cancelling appointments due to a positive adult in the home. This has been the most since January. This is also in the setting of greatly reduced testing, AND only rapid home tests, due to the end of the PHE and cost of PCRs, so I still suspect there is much more. Parents are not testing kids, and when I see children that have symptoms that are a little quirky and suspicious for Covid, AND, the children with symptoms and a home high risk contact, they are mostly PCR negative when the parent allows (or asks) testing.

So I am concerned that we are not detecting it, and left wondering if the vaccination status and historical illness both somehow affect the sensitivity of the use of PCR, as we have seen people that did not convert to positive via PCR for days of testing (some are really committed to getting an answer when they “know” that when the whole house is positive and they have symptoms that it MUST be covid).

I rely now on Hospitalization data, which could take much longer given the population that gets hospitalized, and wastewater data which is not as readily available. It’s frustrating for us on the front lines. We ABSOLUTELY require masks for those visiting the office for illness (although the nose over mask still rules) and we all wear masks all the time but it is just not tenable to have well families mask. In the burbs masking is close to zero (but then again I don’t go out much still) but was in NYC and was impressed to see more masking there.

Please discuss air quality mitigation and please help with where and how to find good concise wastewater data!!

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Interesting thanks for these points. With prestocked antibodies and an immune system that has seen this virus, I think the most accurate timing with rapid antigen tests is about day #2 of symptoms. (Dr. Daniel Griffin recent TWiV podcast agrees)

Presymptomatic testing might be pretty low yield by now, I don’t have the numbers though.

Lots of undetected and mild cases swirling around, but once again the wastewater is reassuring overall to me

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Do you have a sense of how low the prevalence would need to be for the positive predictive value of rapid tests to take a nose dive? As far as I can tell we're already in that territory, even assuming fairly high specificity. Especially if you're asymptomatic and don't have any known exposures.

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I think you have the general concept correct, but biostatistics is not my wheelhouse ;)

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Here's my rough calculation:

1. Highest specificity rate I was able to find for rapid tests: 99.9%

2. Weekly deaths in the US: 247. If I assume a CFR of 0.001 that's a daily case rate of no more than 40,000 cases per day, which is no more than 12 cases per 100K per day.

That's a positive predictive value of less than 11%.

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Yes, I may recall last year reading some data suggesting that the PPV when asymptomatic for antigen tests is very low, 11% would not be out of that expectation. The real frustration is the “gold standard” PCR being less sensitive. We have seen that screening PCRs for travel and pre-procedure testing had not been substantially useful and when asymptomatic individuals are positive it’s unclear what that means. My very small experience is that screening for exposure is very low with PCR (I don’t recommend it with rapid Ag due to clearly poor numbers in those individuals). Once symptomatic, even so, it seems to be taking 3-5 days to convert to PCR positive- SOMETIMES. I have found that the PPV of pediatric testing low and highly variable. I cannot tell if this is due to immune status (prior infection/vaccination), or variant sensitivity of PCR. I find the lack of that data (variant sensitivity) or discussion concerning as it leaves me wondering that nobody wants to discuss it.

I am not trying to be that cynical but when it was painfully clear this was airborne in March 2020 the willingness to either consider or reveal this was very frustrating.

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Oh, and finally got on a plane to the west coast in April, and we were the ONLY masked people, in the airport and the plane. I was very surprised.

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We are getting ready to travel and our plan is to wear the masks in the airport and while boarding and deplaning. It’s not perfect, but that is our plan.

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May 27, 2023·edited May 27, 2023

You want to wear it for the whole flight too. Trust when I say that the airlines have been BSing people for years about ventilation. I travel with an Aranet CO2 monitor and the air was at its worst while flying, including first & business class, so I can only imagine coach. I've been on a dozen flights since October (restarting traveling then) and didn't remove my N95 for any of them (all long haul).

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What was the humidity level? I kinda think low humidity might be part of the issue. I think my dad caught hMPV on a flight back in March.

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I don't remember, but every flight, while inflight, the numbers were HIGH.

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High CO2 and low humidity is probably an awful combo

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thank you very much

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I was very surprised about the 47% masked in the last 7 days, but I'm not really sure what it means. I rarely mask, and I have worn one in the past 7 days when visiting medical offices and when around vulnerable people.

I am surprised you saw a lot of people masking in NYC. I rarely do. I went to a performance by a Taiwanese group this week, and many people in the audience were from Taiwan. I was surprised to only see a handful of masks there. Really no more than I would see in that same population before the pandemic! But people did skew younger there.

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Questions: Wouldn't wastewater be *the* metric right now? In the U.S., we have no reporting system that would capture real numbers of infections due to the ubiquitous use of home testing and widespread non-testing. If wastewater is still higher than in 2020 and 2021, doesn't that imply that SARS-CoV-2 is *not* nosediving? What am I missing?

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Exactly, hospitalizations and death are “nosediving,” yet individual risk of becoming infected (wastewater) is higher now than in 2021 or 2022.

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founding

You are so right. Missing nothing in my view. These reports are part of the process of "normalizing" the existence of Covid. It is there and won't go away, it is said, but we will accept fairly worthless statistics as verifying that it is much less of a problem than previously. I am sorry to see YLE extolling these numbers.

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I don't think the stats are worthless just because they aren't as voluminous. We've got over three years of historical data from all over the world, which allow us to do more with less. For instance, if you want to make a reasonable guess on number of cases from the number of deaths? Multiply by 500.

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founding

The number of deaths is no longer being reported in the same way and the continuity and comparisons are therefore suspect. And the CDC has reduced the frequency of reporting and made it harder to find. They are - as another commentator noted - “disappearing COVID”. There is no other really persuasive reason for these changes.

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All deaths get reported by cause of death, all the time, as they happen. It's hard to think of a more reliable data stream once you've got a pretty good sense of the IFR. It's no different from calculating mass from force and acceleration.

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I don't think there's ever such a thing as "the" metric for anything, ever. Even simple things like mass don't have uniform, all purpose measuring devices that work for all regions. Finding the mass of

Me

My cat

My car

The sun

An asteroid

An atom

A piece of paper

...

Are all very different processes.

Add to that, "prevalence" I'd already a proxy for something way more subjective, namely "risk." And that only matters to the extent that it informs decisions.

Is wastewater surveillance useful in some circumstances, sometimes, for some decision making? Probably. Do we know exactly how it relates to prevalence in human hosts? Nope. Is it worth continuing research to answer these questions? Yes. Are there serious issues involving de-anonymozation and lack of consent with watewater surveillance? Damn right. Is that an insurmountable problem? Probably not, but it'll take some work.

I implore everyone reading this not to get too hung up on any one particular key risk indicator as being THE universally appropriate one to use. Measurement is a unique human endeavor that is much more about subjective social conventions and arbitrary consensus than people care to admit. Thar goes for whatever your favorite number may happen to be, whether it's

Wastewater

Excess deaths

Positivity rate

Cases per 100K

Deaths per 100K

Yankee candle reviews

Fevers from smart thermometers

Hospitalizations per 100K

A risk indicator can work great for a month or a year, and then we may need to retire it. That's par for the course.

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It could suggest we were panicking over nothing if Covid levels still high in wastewater and excess deaths are down regardless now that we collectively stopped caring.

This is the bookend to what John Ioannidis tried to show 3 years ago - that when we didn’t realize Covid was circulating (as demonstrated by higher than expected wastewater) there were no excess deaths. He got slammed for suggesting the cure (lockdown/hysteria) may be worse than the disease and now here we are - we stopped the hysteria, covid still here, but excess deaths back to normal.*

At the very least it’s a hypothesis worth considering.

*that may be temporary - this time last year excess deaths returned temporarily to normal again before spiking again late summer.

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I feel like it's important to avoid loaded terms like "panicking".

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I think panic is a fair and descriptive word though of what happened to us. Closing schools, now being acknowledged more and more in mainstream press as the wrong thing to do, was a result of panic - we overestimated the threat to children and impact closing schools would have on the community, for example. I'm not sure if there is a less loaded word that accurately describes that response.

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I guess I don't really see "overestimating" or even "overreacting" as "panic". We make decisions based on available and often incomplete knowledge *all the time*. Managing risk, whether through mitigation, avoidance, or transfer is -always- a net loss - it's an "overreaction" by design, often to things that haven't even happened (or may never happen). That immediately introduces a subjective element, involving values and priorities that may differ dramatically from one person to another. For instance, if I see that there's going to be a lot of UV today, and I go out and buy sunscreen, but then it turns out to rain instead - was buying sunscreen "panicking"? No. It was important to me not to get a sunburn, and I had enough money to buy sunscreen, even if I didn't ultimately need it.

I think what I'm looking for is - words that don't attempt to describe mental states, but simply describe actions in as neutral way. Panic isn't an action, per se. Does that make sense?

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Glad to see the wastewater rates are down! Great for spring social lives, and great for the health of rats living in the sewer. Mostly joking, but with zoonotic reservoirs and mutation occurring in any host, I could be serious too!

Masking is my office is about 25% of staff, and about 75% of doctors. Patients I would guess 15%.

I’m a ventilation junkie, so if you write it I’ll read it. If anyone else is a ventilation junkie, I wrote this really long deep dive a while back. The shocking part for me was how bad the CO2 levels get in my car during a morning commute. Soporific. I always open the window and wear an N95 in a Lyft (in Philly where we do that a lot). Sorry it’s so verbose:

https://mccormickmd.substack.com/p/clean-air-good-ventilation-and-co2

Makes me sad seeing all the collateral damage that has been wrought against vaccines for kids with this pandemic. The best I can counsel parents and adults is that vaccination is never risk free, but the benefits far outweigh the risks for CDC/ACIP recommended vaccines

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Hey, thanks for the link to your own Substack on ventilation. I have been tempted to get a CO2 monitor, but had no idea what to get. We have Coways in our apartment and they definitely pick up stuff, but whether it’s at the level we should have has been a total mystery. So, thanks! Oh, and I LOVED the Franklin/Adams story!

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Thanks for reading it. The CO2 monitor we have (aranet4) has become a great proxy for ventilation in our house. We check it like the thermostat... more frequently actually, and open the windows more as the ppm hits 700. That study I linked to did suggest negative cognitive performance with too much CO2, and as an integral part of acid base regulation, it likely affects other systems proportionally.

The Adams Franklin odd couple night was hilariously retold in this book I listened to as an audiobook, just in case you’re looking for a goodnight historical read someday:

An American Life by Walter Isaacson

😊

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I want you to know that, as a result of your inspiration and great information, we now have a aranet4 in house, delivered today. Easy to use, and it’s already alerting us that, while not terrible, we could definitely use improvement in our ventilation. Thank you so much!

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Excellent! I think it’s a really good vital sign for your house or general surroundings- nothing to be obsessed or alarmist about, but such an easy actionable solution most of the time… crack some windows.

Thanks for letting me know 😊

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Thanks for writing it--we are going to get one, as we are pretty sure, based on the way one of the coways revs up, that we have an air quality problem and this should help us in addressing it. Also love the book tip and will check it out!

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FYI, for the NDIR sensors H20 and C02 can cross react, so on humid days you could get higher readings. That makes them trickier as a proxy for infection risk, since the relation between humidity and infection risk is thought to be non-monotone

Another thing to watch for right now - you're not necessarily better off opening windows right now, because outdoor air quality has been really bad in much of the US. Check airnow.gov

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I've noticed both these things in the last couple days. It's helpful to have validation, so thanks!

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If only I could get any wastewater data in of all places...NYC!

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There is actually wastewater data for NYC, but it is the opposite of user friendly--and also, as a lay user, I'm can't be sure I'm right on this. But what I did was go to the link below, then scroll down to the wastewater metric map, put in New York City, then my county, then hit the metric I want (trends). Also, when asked to comment by CDC, I've asked the CDC to put the wastewater info alongside deaths and hospitalizations. That would be US wide, but at least it's a snapshot. I do hope Dr. Jetelina will do a post on how to read waste water data and what we can learn from it, as we are right now, once again, being left in the lurch by the Feds. https://covid.cdc.gov/covid-data-tracker/?ACSTrackingID=USCDC_2145-DM105348&ACSTrackingLabel=5.11.2023%20-%20COVID-19%20Data%20Tracker%20Weekly%20Review&deliveryName=USCDC_2145-DM105348#wastewater-surveillance

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I love wastewater surveillance, but I think it's fair to say it's still learning to walk and talk, and we're going to need to be patient. It might be suitable for some bespoke parametric insurance products, but that's not something ordinary citizens really need to concern themselves with.

Same goes for CO2 meters - they're a great tool, but still in their infancy as a proxy for infection risk.

We'll get there, but it's a marathon, not a sprint, as they say.

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Jun 2, 2023·edited Jun 2, 2023

I actually found it, but they don't make it easy of course. NYC is RED. So everyone should really be masking, and most definitely aren't. The site you shared doesn't even have NYC! https://coronavirus.health.ny.gov/covid-19-wastewater-surveillance

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Hi, Erica: It actually does have NYC, and also each county within NYC, but it is definitely not easy to find. Took me three tries, I think! When you get to the wastewater metric map, where it says state or territory, you have to select "New York City," not "New York." Interestingly, BTW, on the CDC maps, while wastewater is rising, the 15 day trend is still pretty low. BUT, on the map you linked, I do see what you are saying: and this is exactly why Dr. Jetelina's assistance in how to understand these maps would be most helpful.

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It took a friend AT the CDC to point out to me that New York City was just below New York. LOL It's been a week. Either way people should be masking up!

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I empathize! I wish the CDC would show at the head of the tracker page a trend graph for wastewater like they do for hospitalizations and deaths. They’re all crude measures, and also countrywide, but at least it’s at a glance as a starting point. (I am older and higher risk, so I mask up anytime I am in an indoor setting and have never stopped doing that, and I do no indoor dining in restaurants. But understanding the trends can be helpful for deciding when private, small indoor gatherings are reasonably safe (using ventilation, eg) and also when to avoid, even if masked, places like museums.)

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Good insights. I have thought throughout that relying on one proxy is never a good idea. That said, each of us do need to use some combination of proxies to help us assess level of personal risk--and know, as best as possible, when risk is higher and we need to take additional precautions. The wastewater trend data, even in its nascent state, gives a clue, along with level of deaths and hospitalizations. The important thing is to understand the limitations, so we don’t overinterpret the results. Same goes for the CO2 monitor. Each is a helper, with flaws and attributes, but all taken together are better, I think, than being totally in the dark. That’s why I so appreciate Drs Jetelina and Bob Wachter, as well as Dr. McCormick here: they don’t oversell the usefulness of risk mitigating tools, but help us as laypersons, to understand, as best as is known, how to use them.

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Two quickies on air quality.

One, the CDC recommendations are great, but much better is the new ASHRAE standards. These typically get built into building codes. Contact you local government to push them along.

https://www.ashrae.org/technical-resources/bookstore/standards-62-1-62-2

Second, when ACH is low, as it will be in many buildings (and just about every home) for quite a while, add filtration. Four ways to do this.

Portable HEPA filters

MERV 13 HVAC filters (and put fan on "on" setting)

Corsi-Rosenthal boxes

Personal air filtration (masks!)

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I don't really see either one of them as better than the other, just different lanes. They both did a good job at staying true to their own missions.

CDC - focuses on specific target air changes per hour that are considered enough to mitigate transmission

ASHRAE - making sure that all the physical and administrative controls are in place to implement whatever a public health authority puts in place - hence the "infection risk management mode" concept (these will need to be reviewed if we ever need to start worrying about insect borne diseases which given our backdrop of climate change seems all too probable)

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CDC is just a recommendation with no teeth. Builders don't have.to build buildings with 5 ACH if they don't feel like it.

ASHRAE specs get into building codes and makes stuff happen.

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They don't *have to* get incorporated by reference. CDC guidelines sometimes do too. I don't think either of them have teeth, except to the extent that they're well respected. ASHRAE seems more focused on hardware, CDC seems more focused on how that hardware is used. Neither is better, they're complementary and it's not really productive to compare them. Better to think of how they fit together like pieces of a large puzzle.

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"Things looking good right now" but wastewater is higher than in 2020 and 2021. Mixed messaging is not helpful in a pandemic. Are you saying that it is looking good for "normal" people but for"others" like the elderly, and immunocompromised folks it doesn't look so good so, they must continue to mask and for some isolate? This is a good way to further the normalization of the pandemic by reassuring the "normals" that they don't have a lot of risk and can do whatever they want without worrying about the "others". It encourages the acceptance of disease and deaths (anticipated 100,00 - 250,000 deaths per year) in the "others" by the "normals".

However, what is not getting publicity is that "normals" still have the risk of damage to their immune system that may not become apparent until the 3thd and 4th infection because the risk of long covid or post acute covid sequelae is not a one time risk, it is a cumulative risk. This is something that you don't address.

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Excellent, thank you. I'm curious whether Novavax will offer an updated booster this Fall, and if so, how accessible will it be for those looking for an alternative to mRNA? What good is it for FDA to authorize Novavax if it's not available at your local drugstore?

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Related to all this, Bob Wachter has put out another of his excellent tweet threads discussing the current status and how he is navigating it: https://twitter.com/Bob_Wachter/status/1660819438411866114

Two things, out of both Dr. Jetelina’s great article here and Dr. Wachter’s thread:

>The importance of wastewater: I join with all here who would be grateful for more information to understand better how to interpret that data.

>Use of rapid tests: I would be grateful for any information and advice Dr. Jetelina can offer targeted to those of us who are at high risk because of age. For example, Dr. Wachter writes: “As for other behaviors, I still test myself when I have symptoms or if I’m going to be in close contact with people I know to be vulnerable. Two negative tests 24-48 hours apart still reassure me that I don’t have Covid (or that, if I do, I’m not currently infectious).” I suspect there are many like our household whose friend groups are all “people we know to be vulnerable,” which suggests that everyone will need to test, even in the absence of symptoms, prior to gathering together. I worry that this is not feasible, all the moreso because Medicare no longer covers payment for OTC rapid tests.

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Using rapid tests may be ok for short visits to be comfortable that one is not infected, or at least, not transmitting, but there is still a problem with visits from relatives and friends who come for extended visits - days and even weeks - not just an afternoon or holiday.

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Agree. Also, for those of us who are older (we are in our 70s) and whose friend groups are our age, the best way to use rapid tests is as Drs. Jetelina and Wachter have indicated: that is, to be safest, everyone in the friend group would need to space out visits to allow for cadence rapid tests (ie over 24-48 hours) between visits. To accomplish that, we’d all have to synchronize visiting a la the Rockettes, if you see what I mean. It’s laughable, and our public health officials have just thrown in the towel on even trying to offer approaches that are feasible for older adults.

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Despite the fact that COVID is waning accross the country for now, it's especially clear that those of us over 65 need to continue masking when & wherever possible. Now that COVID no longer appears to be newsworthy, without this newsletter, I would be clueless. Thanks for your excellent work!

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Thank you so much for this update! I still wear a mask in the grocery store and a few other places and feel like the only one. I'm very interested in the recommendations on ventilation. For the lay person, what does it take to have five air changes per hour, in a home for example? In a restaurant?

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I am very surprised at the 46% of respondents stating that they have worn a mask in the past 7 days. I have not seen anyone anywhere wearing masks. I recently traveled overseas and saw at most maybe two people wearing masks at a very, very busy airport terminal, maybe 1 person on the plane had a mask on. No one wears them in stores, church etc. For reference I live in Pennsylvania.

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I was a little surprised also, but then I looked at the source of the survey, which is YouGov. I am a YouGov member and receive occasional surveys, and I think the company's typical respondents are people who are socially engaged, politically savvy and who follow current events. I would guess that 46% is accurate among YouGov surveys, but the population surveyed is not necessarily in line with the general population in the US.

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I commented above that I was also surprised by this. But any time in the past 7 days is rather vague. I have worn one when going to medical facilities and visiting older people, but don't wear one elsewhere.

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It seemed that after the public health emergency declarations were all lifted on May 11th, masking literally stopped everywhere. Beginning May 11th all hospitals, medical facilities, doctors offices here stopped the mask mandate, signs went down in literally an hour.

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Also, I traveled at the end of April, BEFORE the public health emergency declaration was lifted on May 11th, although one large medical center in my area lifted the mask mandate on April 24th.

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My concern is that you’re saying that Covid is going down, but we’ve lost a ton of data due to places stopping recording, stopping testing, stopping reporting. How can we take this reduction seriously? The numbers have gone down by an implausible amount which I can only attribute to the end of tracking and data collection.

In my community in the last couple of weeks I’m seeing cases soar. I’m watching local doctors talking about a big influx in cases. So.... how do we get good data? How do we know when there is a wave?

I would pay good money for accurate information at this point.

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Also, in the past few months I’ve known friends with Covid symptoms who test negative for everything: Covid, flu and RSV - including PCR test which is now hard to get. So why are they sick? Is there a new variant emerging that doesn’t get picked up by Covid tests which were designed to detect the original strain? And if you’re told you don’t have covid, you’re not going to seek or be offered Paxlovid.

It’s almost as if CDC is taking away all our data so they can declare victory over the pandemic when the reality is they know there is nothing much left that they can do. Which is also known as giving up.

Could an election year be coming up?

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There are lots of viruses out there. And the outdoor air quality and allergens this year really are awful, thanks to global warming.

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founding

You express my thoughts beautifully. Garbage input, garbage output. Conclusions about the prevalence and deadliness of Covid based on plummeting reported problems means virtually nothing, given the lack of enough real information on which to base the conclusions.

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Curious what you think of the COVID spike in China? Estimated to have 65 million cases per week by the end of June. Is a new variant at play? Will we be able to find out? How will it affect the world? I’m immunocompromised, so I’m still masking everywhere. The number of medical professionals telling me loudly I don’t have to wear the mask is disheartening. I’m a nurse myself and think the best approach is not to mention it. If someone is masking now, it’s likely for good reason.

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Amen to observing the mask choice someone else is making, and moving on.

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I think that they painted themselves into a corner by doing a hard lockdown, but not having a good exit strategy (including mass vaccination, with the best available vaccines). Then they reopened very quickly, rather than in phases.

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I just want to bake you cookies and give you a big ole thank you hug! Thank you for continuing to keep us updated. We live in Texas and in a big city and fingers crossed we don’t see a wave this summer! Please keep us informed. I thought your gun violence update was just as important!

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