In this episode, I bring you a substantially in depth conversation with another expert physician who specializes in infectious disease and is on the front lines of treating COVID-19 patients.
Humans have a strong bias towards pessimism and the disregarding of any good news. As a result, we tend to trust bad news without question, and demand proof for good news. We apply this imbalanced approach to evidence to our peril. We should be making an effort to understand as broad of a picture as we possibly can. The goal of this episode is NOT to view the situation through rose colored glasses. In fact, you will hear explanations of the scary side of this virus here. However, we will be weighing these things against the positive developments that have occurred leading to an overall drop in the risk to our society as doctors have continued to learn and discover new and better ways to care for COVID patients.
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My concern during the entire month of May and June in choir world has been our hyper focus on one set of questions related to this pandemic. We have asked important questions about how choirs might contribute to the spread of this virus due to increased expulsion, or “super-spreading” of aerosols and droplets that may be produced when singing. This is an IMPORTANT question, but it is not the only question that we should be focused on as we consider a safe return to ensemble singing. Some critical questions that I think we are missing:
1. What do we know now that we didn’t know a month ago about viral transmission and risks to people exposed? (now that data has been collected over many months, and therapeutics have been developed and improved, the risk picture looks much less severe than it did in early March.)
2. What do we know that we didn’t a month ago about therapeutics? (discussed in episode.)
3. What do you know about the metrics being used in your area by public health officials to determine ending or changing certain gathering restrictions? (Discussed in episode.)
I addressed some of these questions in Episode 33 with Dr. Adalja from Johns Hopkins. (I address the danger of hyper-focusing in general here.) In this conversation, we were all fortunate that Dr. McKinsey was able to give us a substantial chunk of time to devote to a broader conversation related to understanding our predicament in a deeper way.
Dr. David McKinsey is a physician with Metro Infectious Disease Consultants-Kansas City. He serves as Regional Medical Director for his group. In addition he is hospital epidemiologist at Research Medical Center, Clinical Professor of Medicine at the University of Kansas, and Infectious Diseases consultant at the Stowers Institute for Medical Research. He received his medical degree from the University of Missouri-Columbia and completed an Internal Medicine residency at the University of Iowa and then an Infectious Disease fellowship at the University of Tennessee-Memphis. He is board certified in internal medicine and infectious diseases. He has served on the boards of several organizations regionally and nationally, has been actively engaged in medical research throughout his career, and has published many manuscripts and book chapters.
Just in case anyone still doubts the docs that have been on this show re the regionality of risk:
“I hesitate to make any broad statements about whether it is or is not quote ‘safe’ for kids to come back to school. When you talk about children going back to school and their safety, it really depends on the level of viral activity and the particular area that you’re talking about. What happens all too often — understandably, but sometimes misleadingly — is that we talk about the country as a whole in a unidimensional away.” Dr. Anthony Fauci
Also, some have seen the article from the British Columbia CDC posted earlier related to “no evidence of airborne spread.” Sadly, I didn’t see this until after I had done the interview with Dr. McKinsey. So I emailed him, and he confirmed that within the physicians circles, this seems well accepted. All of the latest data suggests that it is droplet transmission, not aerosol/airborne. ”Bottom line is that since the beginning of the COVID pandemic, droplet transmission has been postulated as the main means of spread and now the data are confirming this. Airborne spread would have been very bad news.” I followed up and asked if that means masked singing would be a significant increase in safety (a different angle than what we were told in webinar on May 5.) He said, “That’s exactly right. Droplets containing virus are trapped by the face mask, protecting the wearer. (And others if they wear one it’s a two way street.) In theory, with an airborne pathogen, a mask would not filter the virus (unless it was a N-95 mask) but that is not of practical importance with SARS CoV-2”
Lastly, I am really embarrassed by the sound quality of this episode. For that, I am sorry.
Some critical misunderstandings in pandemic world: (As a lay person I had to work pretty hard to wrap my head around this. I am sure some lay people already get this, but many don’t)
- Conflating, unintentionally, getting infected or exposed to SARS-Cov-2 (a virus) with being diagnosed with COVID-19 (a disease) One does not always lead to another. (CDC best estimate shows 35% infected will show no symptoms)
- Conflating, unintentionally, the Case Fatality Rate or CFR with the Infection Fatality Rate or IFR.
- Not understanding that the number you see on the news and on data tracking websites is real time info that is not at all informative or helpful. Starts as a crude number and gets refined with vetting. Many areas have seen this crude number look like 4-7% or 4-7 out of 100 are dying.
Understanding the two vetted numbers:
CFR is the higher number based on the number of people who pass away, divided by the number of people who are sick enough to seek treatment and then get diagnosed with COVID-19. That number is easier to nail down early in a pandemic when testing is not widespread for obvious reasons. The only ones factored in are the ones actively engaged with the health care system. (Though time from onset to death causes fluctuation in the rate due to the lagging indicator and differs from the reported numbers because not all reported cases are ever confirmed.)
Current overall CFR best estimate: .4% or 4 in 1000 (see number broken down by age below in attached image.)
The health care system uses this number to help plan for the allocation of resources that they can predict they will need to devote to those patients who show severe symptoms to save as many lives as possible. (ie, the much touted “having enough hospital beds, ventilators,” etc.)
IFR is the lower number that reflects all people who become exposed and infected with SARS-Cov-2 and the proportion of those people who pass away. It is a much lower number for all viruses because it includes the people who don’t get sick at all, and the ones who only have minor symptoms and don’t seek medical treatment. This number is MUCH harder to pin down, also for obvious reasons. This requires MANY data collection points from across the world to be aggregated and vetted, and it also requires the widening of the testing net to include people in the general population who would otherwise have no reason to be tested. So, a solid attempt at publishing an IFR is impossible in the early stages of a pandemic.
Seeing that current best estimate from CDC is 35% asymptomatic that puts the IFR at .26% or 2.6 in 1000 (you can find these by age below as well, simply by multiplying the CFR by .65)
This number is a better used for individuals in the community to measure the risk to themselves and their families. Because it represents how the disease statistically effects the general population. In other words, understanding the risk if they or their loved one were to be exposed to another person with the virus.
All of this must then be factored in to our best local indicators in order to assess your overall risk. Best local indicators are new hospitalization and new deaths. NOT new cases because new cases vary greatly depending on the local availability of testing. (Which is why comparing “spikes” in one country or even state to numbers somewhere else, is not productive.)
The CDC latest best risk numbers: