Beware the Siren Song

 

"First you will come to the Sirens who enchant all who come near them. If anyone unwarily draws in too close and hears the singing of the Sirens, his wife and children will never welcome him home again, for they sit in a green field and warble him to death with the sweetness of their song." – Homer, The Odyssey

Ulysses was a reluctant but skillful warrior, condemned to command a sea voyage of uncertain outcome and duration. Among his challenges was an encounter with the Sirens. In calm summer seas, the sweet, irresistible song of the Sirens lured sailors causing them to dash their ships upon the rocks.

Fortunately for Ulysses, he had advanced warning of this danger, and took the sensible precaution of packing the ears of his crew with wax and ordering them to lash him securely to the mast. Like Ulysses, we are reluctant warriors in this SARS-CoV-2 battle. We are on a journey of unknown duration. Who are our Sirens?

Our COVID-19 numbers look very good, directionally the same as I reviewed last week. Our effective reproduction rate has been less than 1.0 (virus is receding) for 20 days. New cases have dipped into the 200s and approaching levels we have not seen since last April. Test positivity rate (rough prevalence estimate) has been below 5% for three weeks. New hospitalizations are trending down, albeit more slowly than I would like. We saw no Labor Day surge. Good, good, good.

We appear to be sailing on calm seas. So why do we keep hearing from so many masking and distancing nags (myself included)? Because even though things appear to be going well now – and they are – we must remain wary of our Sirens:

• Unawareness of the experience in the global community. We have recently seen a recurrent scenario play out across the world. Early in the pandemic, a city/region/country took decisive action, achieved excellent viral control, and received accolades as a model for other to follow. Recently, as those communities have started to reopen, they have seen the virus come surging back, and have been forced to re-impose substantial economic shutdowns. A common root cause of the resurgence: indoor aggregation of people in bars, and is some cases, social gatherings in homes. To replow old ground – the nature of this virus has not changed. If we let down our guard, fail to mask and distance, begin to return to crowded environments, we will see a COVID-19 resurgence. It is worth spending some time reading about the experience of others - Quebec, Israel, London, Marseilles to name a few. All the reporting highlights on how dispiriting this experience has been to people in those communities. Having lived through one major surge in Houston – having seen the health, societal and economic impact of our surge – I think most would join me in my desire to avoid another COVID-19 crisis.

• Failure to appreciate the stealthy nature of exponential growth. Our new cases in Houston look good. Hospitalizations are flat. Why worry? Because in an immunologically naïve community – absent masking and distancing – disease will spread exponentially, and this growth is insidious early on. Here is an easy means of explaining exponential growth to others, with minimal math (you do need to multiply). Assume you have an effective R-value of 2.0. One individual will, on average, infect two others (1X2=2). Those two, in turn, will infect two others (2X2=4). It helps to get a piece of paper and write this down:
  -- 1st doubling 1X2=2
  -- 2nd doubling 2X2=4
  -- 3rd doubling 2X4=8
  etc., etc.

Continue this for a total of 10 cycles, and your answer should be 1024.

So, if you look at your numbers for each doubling, early on it does not look like a big deal. Two becomes 4, 4 becomes 8. But by the 10th doubling, 512 becomes 1024, and it feels like it is exploding. That is the nature of exponential growth – it starts slow, and accelerates. It is easy to find comfort in the early part of the growth curve; by the time the steep part is apparent, the infectious horse is out of the barn. It is too late to contain.

We should be encouraged by our current flat/declining numbers – as Quebec was – but not be lulled into complacency.

• Hope we are at or approaching "herd immunity." Herd immunity is the point at which enough of the population is immune that it becomes difficult for the virus to spread. If an infected individual walks into a place of worship, school or restaurant, and no one is immune to the virus, it will spread easily to others.

On the other hand, if many or most already have immunity, the virus has difficulty finding someone to infect, and it fades for lack of new hosts (as an aside, this effect can be mimicked by effective masking and distancing). No one is sure what percentage of the population needs to have immunity to achieve this effect, but most estimates I have seen are between 50-70%. Part of the ultimate goal of vaccination is to produce herd immunity, without a lot of people actually developing the disease.

Again, let us do some simple math.

For the purposes of this exercise, I am going to make very optimistic assumptions. Reality is probably worse.

There are approximately 325 million people in the U.S. Let us assume individuals under 18 (about 75 million) cannot be infected, nor spread the virus. This is not a valid assumption, but we are being optimistic. That leaves us with a "herd" of 250 million people. If we assume the lower end of the range to reach herd immunity – 50% – 125 million people would need to be infected. The mortality rate for COVID-19 is in the range of 0.5-1.0%. We will assume the more optimistic 0.5% rate. At that rate, infection of 125 million people would result in 625,000 deaths – about three times the number of all Americans that have died so far.

There is an active debate among thoughtful and intelligent people regarding at what level we will achieve herd immunity. For an example, refer to a recent article from The Atlantic. Theories abound regarding factors that may drive the herd immunity percentage down: differential susceptibility of sub-populations, chaos theory, differential importance of cellular immunity. Perhaps our trigger is lower.

Our Siren here is the word "perhaps." However valid the theories, they are still theories and belie some actual observations of spread that occurred early in the pandemic, such as on the Diamond Princess cruise ship. Personally, I am not willing to accept the risk of larger scale death or disability when the alternative is simple – mask and distance as a bridge to the vaccine. Availability and use of an effective and safe vaccine will ensure protection, and so poses the best long-term strategy. 

Houston should pause for a moment of self-congratulation. We have pulled together as a community and done a very effective job combating SARS-CoV-2. We are in a position to begin to relax restrictions, and to incrementally resume more of our prior activities. We must all maintain our attention to proven viral control practices – masking, distancing, avoiding aggregation in crowds. We need to be thoughtful about our community priorities (I would vote for reopening schools successfully before bars).

It is time to lash ourselves to our mast, resist the allure of the Siren's song, and sail on to the end of this pandemic.

What if this is as good as it gets?

Many of you will recognize this as a movie quote. In the 1997 film “As Good as It Gets,” Jack Nicholson plays Melvin Udall, a neurotic, misanthropic character with obsessive-compulsive disorder. Early in the movie , he poses this question to a waiting room full of patients in his psychiatrist’s office.

This has been another week of good news. Our community numbers continue to improve. It looks as if we largely avoided a post-Labor Day surge. Texas Gov. Greg Abbott signed an executive order relaxing restrictions on certain services and businesses. It feels like it is time to reopen a bit.

But there is always a “but.” What about flu season? School reopening? Cold weather promoting viral spread by driving people indoors? Plenty of other nations (recently Israel, France, and the UK among others) seemed to have things well in hand, only to see second waves emerge and drive the return of restrictions. Why does our good news always need to be tempered with a warning to keep looking over our shoulder? What if this is as good as it gets?

The Houston regional numbers are unequivocally positive this week. Our calculated R(t) has been below 1.0 (virus is receding) for almost two weeks. New community cases dipped below 500 for the first time in months (our goal is less than 200 per day), and the Texas Department of State Health Services (DSHS) seems to be making real progress in correcting its well-publicized problems in reporting these data points in a timely and consistent manner. The test positivity rate for TMC-affiliated labs is 3.2%, well below our 5% goal (however, city and county positivity rates are running 4-5% higher than the TMC).

Although we ideally would like to see new admissions to TMC-affiliated hospitals declining, they are flat, and still 60% higher than the nadir in May; the fact they are not increasing is relatively good news. Moreover, hospital length of stay has improved to the point that more COVID-19 patients are being discharged than admitted, so hospital census of these patients continues to drift downward. We have ample hospital capacity. (If these monitoring concepts are unfamiliar to you, I recommend you review my prior messages).

Perhaps the best news of all, none of the numbers above reflect any Labor Day impact (although theoretically it still could still show up later this week). Thank you Houston: Masking, distancing, avoiding aggregating in crowds – it works. We cannot eradicate the virus, but we have shown we can slow its spread and decrease community viral prevelence.

The big news last week was a relaxation of restrictions in Texas. I would encourage you to read Governor Abbot’s executive order. In brief, Texas businesses, including restaurants, can operate at 75% of their total listed occupancy, including restaurants. Hair salons, barbershops, massage parlors and other personal care service businesses have no occupancy restrictions as long as their workstations are spaced at least six feet apart. Outdoor gatherings of more than 10 people still require approval of city or county government.

We want to avoid reliving our May reopening experience, which led to a very large June/July surge. Reasonable people may respectfully disagree on whether the new executive order goes too far, or not far enough. Thankfully, Houston still seems to be populated by mostly reasonable people. Those who believe the virus must be maximally controlled to avoid preventable death probably think it goes too far. Those who are concerned about protecting the economic livelihood of members of our community probably think it does not go far enough. On balance, the order is a logical, reasonable next step. It is not perfect, but perfect recommendations in the midst of a novel crisis are not a realistic expectation.

At the end of the day, keeping the viral prevelence low in Houston depends on most of the metroplex’s 7 million inhabitants making good daily decisions.

Last week I visited my father, whom I had not seen since the pre-COVID era. I drove back through the outer bands of Hurricane Sally, managing to skirt most of it. For the majority of the trip, the law mandated I keep my speed below 70 mph, and I set my cruise control at 76. However, when the rain came down hard, and my visibility was limited, I sensibly disengaged the cruise control and slowed down – not because this was mandated by regulation, but because I had appropriate situational awareness, and I was concerned about my safety, as well as the safety of my wife and others on the road.

So it is with our collaborative control of COVID-19 – we must maintain situational awareness to protect the health and safety of our family, friends and neighbors. I still think one of the best pieces of advice I have heard during this whole crisis came from Dr. Klotman very early in Houston’s pandemic experience: If you walk into a business/public gathering, and it feels like business as usual, turn around and walk out. It is probably not safe. Wherever people are aggregating, sincere efforts at appropriate distancing should be visible.

With Dr. Klotman’s advice in mind, as we start to relax restrictions, what are the pressure points to which you should remain alert? When do you need to take off the cruise control and slow down? A few thoughts, which reflect my opinion.

• Belief that this is “over” because the hospitals are not in danger of being overwhelmed. Gov. Abbott’s order has a safety valve built in: Reopening should not proceed if more than 15% of hospital capacity is consumed by patients with COVID-19. Currently TMC facilities are at about 6%, so we are in great shape. However, this is not the ideal metric, as it is a lagging indicator. Just like the patients with nascent heart disease who puts off preventive treatment and lifestyle changes until they experience a major heart attack, by the time our hospitals are filling up, it is too late. At that point we are already surging, and will continue to do so for weeks. A better leading indicator would be new community case numbers, but as we have discussed at length, this measure is still fraught with – improving – data reporting issues.

Tantalizingly, Baylor researchers are doing some fascinating work quantifying the presence of virus in wastewater. It appears virus in the upper respiratory tract is swallowed, and much of its antigenic material survives digestion and can be detected in human waste. If this pans out, it could provide a method to monitor a neighborhood, office building, dormitory, prison or nursing home by sampling wastewater. Preliminary data indicate we may be able to detect an increase in viral prevalence in advance of symptom development. A true leading indicator.

Advice: Do not get comfortable focusing on a signal metric – reading the speed limit signs alone is not enough.

• Settings with no capacity limits. The governor’s order allows a number of entities to operate at 100% capacity. Churches and places of worship are explicitly excluded from occupancy limits. As noted above, certain services (e.g. hair salons, barbershops) are able to function at full capacity if spaced appropriately. I am confident most (but not all) organizations will act responsibly and safely.

Advice: Ask yourself some key questions. Does this feel safe? Are others masked appropriately? Is my exposure to people outside of my household closer than six feet, and more prolonged than 15 minutes? Specific to houses of worship, keep in mind singing has been clearly established as a means of transmission, and probably results in spread of virus beyond the now famous six-foot limit. Also, avoid congregating before and after services.

• Bars. First of all, I want to stop to acknowledge the hardship the pandemic has placed on bar owners, who are mainly small, independent businesspeople trying to preserve their livelihood. Many have suffered major financial setbacks during this time, probably few more so than those running bars.

However, there is a reason bars have largely been closed. Congregating a high density of people in a contained indoor environment for extended periods of time with inconsistent mask usage is a perfect set up for viral spread. Add a little alcohol-induced social disinhibition, and viral spread is highly likely. Some establishments have creatively leveraged their food services to allow for table service (by order, at least 51% of sales must be attributable to food). But regardless of whether it is a “bar” or “restaurant,” a crowded indoor space is a crowded indoor space.

Advice: Ask Dr. Klotman’s question. Does this feel like business as usual? If the answer is yes – if there is not real evidence of compliance with good distancing practice – it is probably not safe.

So is this as good as it gets? Perhaps, but that is not necessarily a bad thing. Nicholson’s Melvin Udall was not “cured” of his neuroses, but he found meaning in human connection. We can continue to reclaim our lives, cautiously expand our economic activity, return to school, etc., if we all band together, maintain situational awareness and continue doing what we have proven works: Mask, distance, be wary of crowds – a reasonable price to pay to resume our lives while protecting each other.

 

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).

 

What if this is as good as it gets?

 

Many of you will recognize this as a movie quote. In the 1997 film “As Good as It Gets,” Jack Nicholson plays Melvin Udall, a neurotic, misanthropic character with obsessive-compulsive disorder. Early in the movie , he poses this question to a waiting room full of patients in his psychiatrist’s office.

This has been another week of good news. Our community numbers continue to improve. It looks as if we largely avoided a post-Labor Day surge. Texas Gov. Greg Abbott signed an executive order relaxing restrictions on certain services and businesses. It feels like it is time to reopen a bit.

But there is always a “but.” What about flu season? School reopening? Cold weather promoting viral spread by driving people indoors? Plenty of other nations (recently Israel, France, and the UK among others) seemed to have things well in hand, only to see second waves emerge and drive the return of restrictions. Why does our good news always need to be tempered with a warning to keep looking over our shoulder? What if this is as good as it gets?

The Houston regional numbers are unequivocally positive this week. Our calculated R(t) has been below 1.0 (virus is receding) for almost two weeks. New community cases dipped below 500 for the first time in months (our goal is less than 200 per day), and the Texas Department of State Health Services (DSHS) seems to be making real progress in correcting its well-publicized problems in reporting these data points in a timely and consistent manner. The test positivity rate for TMC-affiliated labs is 3.2%, well below our 5% goal (however, city and county positivity rates are running 4-5% higher than the TMC).

Although we ideally would like to see new admissions to TMC-affiliated hospitals declining, they are flat, and still 60% higher than the nadir in May; the fact they are not increasing is relatively good news. Moreover, hospital length of stay has improved to the point that more COVID-19 patients are being discharged than admitted, so hospital census of these patients continues to drift downward. We have ample hospital capacity. (If these monitoring concepts are unfamiliar to you, I recommend you review my prior messages).

Perhaps the best news of all, none of the numbers above reflect any Labor Day impact (although theoretically it still could still show up later this week). Thank you Houston: Masking, distancing, avoiding aggregating in crowds – it works. We cannot eradicate the virus, but we have shown we can slow its spread and decrease community viral prevelence.

The big news last week was a relaxation of restrictions in Texas. I would encourage you to read Governor Abbot’s executive order. In brief, Texas businesses, including restaurants, can operate at 75% of their total listed occupancy, including restaurants. Hair salons, barbershops, massage parlors and other personal care service businesses have no occupancy restrictions as long as their workstations are spaced at least six feet apart. Outdoor gatherings of more than 10 people still require approval of city or county government.

We want to avoid reliving our May reopening experience, which led to a very large June/July surge. Reasonable people may respectfully disagree on whether the new executive order goes too far, or not far enough. Thankfully, Houston still seems to be populated by mostly reasonable people. Those who believe the virus must be maximally controlled to avoid preventable death probably think it goes too far. Those who are concerned about protecting the economic livelihood of members of our community probably think it does not go far enough. On balance, the order is a logical, reasonable next step. It is not perfect, but perfect recommendations in the midst of a novel crisis are not a realistic expectation.

At the end of the day, keeping the viral prevelence low in Houston depends on most of the metroplex’s 7 million inhabitants making good daily decisions.

Last week I visited my father, whom I had not seen since the pre-COVID era. I drove back through the outer bands of Hurricane Sally, managing to skirt most of it. For the majority of the trip, the law mandated I keep my speed below 70 mph, and I set my cruise control at 76. However, when the rain came down hard, and my visibility was limited, I sensibly disengaged the cruise control and slowed down – not because this was mandated by regulation, but because I had appropriate situational awareness, and I was concerned about my safety, as well as the safety of my wife and others on the road.

So it is with our collaborative control of COVID-19 – we must maintain situational awareness to protect the health and safety of our family, friends and neighbors. I still think one of the best pieces of advice I have heard during this whole crisis came from Dr. Klotman very early in Houston’s pandemic experience: If you walk into a business/public gathering, and it feels like business as usual, turn around and walk out. It is probably not safe. Wherever people are aggregating, sincere efforts at appropriate distancing should be visible.

With Dr. Klotman’s advice in mind, as we start to relax restrictions, what are the pressure points to which you should remain alert? When do you need to take off the cruise control and slow down? A few thoughts, which reflect my opinion.

• Belief that this is “over” because the hospitals are not in danger of being overwhelmed. Gov. Abbott’s order has a safety valve built in: Reopening should not proceed if more than 15% of hospital capacity is consumed by patients with COVID-19. Currently TMC facilities are at about 6%, so we are in great shape. However, this is not the ideal metric, as it is a lagging indicator. Just like the patients with nascent heart disease who puts off preventive treatment and lifestyle changes until they experience a major heart attack, by the time our hospitals are filling up, it is too late. At that point we are already surging, and will continue to do so for weeks. A better leading indicator would be new community case numbers, but as we have discussed at length, this measure is still fraught with – improving – data reporting issues.

Tantalizingly, Baylor researchers are doing some fascinating work quantifying the presence of virus in wastewater. It appears virus in the upper respiratory tract is swallowed, and much of its antigenic material survives digestion and can be detected in human waste. If this pans out, it could provide a method to monitor a neighborhood, office building, dormitory, prison or nursing home by sampling wastewater. Preliminary data indicate we may be able to detect an increase in viral prevalence in advance of symptom development. A true leading indicator.

Advice: Do not get comfortable focusing on a signal metric – reading the speed limit signs alone is not enough.

• Settings with no capacity limits. The governor’s order allows a number of entities to operate at 100% capacity. Churches and places of worship are explicitly excluded from occupancy limits. As noted above, certain services (e.g. hair salons, barbershops) are able to function at full capacity if spaced appropriately. I am confident most (but not all) organizations will act responsibly and safely.

Advice: Ask yourself some key questions. Does this feel safe? Are others masked appropriately? Is my exposure to people outside of my household closer than six feet, and more prolonged than 15 minutes? Specific to houses of worship, keep in mind singing has been clearly established as a means of transmission, and probably results in spread of virus beyond the now famous six-foot limit. Also, avoid congregating before and after services.

• Bars. First of all, I want to stop to acknowledge the hardship the pandemic has placed on bar owners, who are mainly small, independent businesspeople trying to preserve their livelihood. Many have suffered major financial setbacks during this time, probably few more so than those running bars.

However, there is a reason bars have largely been closed. Congregating a high density of people in a contained indoor environment for extended periods of time with inconsistent mask usage is a perfect set up for viral spread. Add a little alcohol-induced social disinhibition, and viral spread is highly likely. Some establishments have creatively leveraged their food services to allow for table service (by order, at least 51% of sales must be attributable to food). But regardless of whether it is a “bar” or “restaurant,” a crowded indoor space is a crowded indoor space.

Advice: Ask Dr. Klotman’s question. Does this feel like business as usual? If the answer is yes – if there is not real evidence of compliance with good distancing practice – it is probably not safe.

So is this as good as it gets? Perhaps, but that is not necessarily a bad thing. Nicholson’s Melvin Udall was not “cured” of his neuroses, but he found meaning in human connection. We can continue to reclaim our lives, cautiously expand our economic activity, return to school, etc., if we all band together, maintain situational awareness and continue doing what we have proven works: Mask, distance, be wary of crowds – a reasonable price to pay to resume our lives while protecting each other.

 

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).

 

 

Safely Reopening Schools

It feels to me like we are approaching some sort of inflection point. Our hospitals appear to be out of danger of being overwhelmed. State leadership is signaling plans to begin to relax some restrictions, and local leadership made some cautious and preliminary steps in that direction as well. HISD has started virtual school, and is about a month away from resuming face-to-face instruction. We are making halting, careful steps to safely reclaim more of our pre-COVID-19 lives. Leaders are struggling to make responsible decisions, while continually – and very appropriately – chanting our new mantra: mask and distance, mask and distance.

Last week I reflected on balancing our pride in all we have collectively accomplished in this battle against SARS-CoV-19, with what should be a sense of humility driven by what we do not know. That theme becomes even more important as we start to make decisions to relax various restrictions. Done thoughtfully, we promote the well being of our children and encourage the economic health of those who have been impacted by the viral-induced slow-down. Done poorly, we will promote another surge, and with it significant health consequences.

Starting with the positive, the Texas Medical Center (TMC) data continues to improve. The number of new patients admitted to TMC facilities continues to trend downward, and is approaching levels seen in April and May. With fewer admissions, as existing patients are discharged (or unfortunately, expire), the census in TMC affiliated hospitals is falling. We are still a week or so away from seeing what kind of Labor Day impact we might experience, but so far, so good. This is unequivocal positive news, based on solid numbers.

The new community cases is a different story – good news in that the trend is in the right direction, but concerning in we are not entirely confident in the data. Over a month ago, we started to notice some inconsistencies in the case rates. The data from the Texas Department of State Health Services (DSHS) reflected an increase in the number of people being tested, but all of our local labs – Baylor included – were seeing a decrease in testing volume.

It has now been well documented this disconnect had a good explanation. DSHS found itself responsible for an unprecedented demand to receive, organize and report testing data from hundreds of labs across the state. This was a task for which it appears they were ill equipped to manage, falling far behind in accurately assigning testing results to individual counties and municipalities. Since that time, they have upgraded technology, and are playing catch-up entering a backlog of test results. This week DSHS announced a significant overhaul of processes, data quality assurance and reporting formatting which should produce more reliable results.

As a result of DSHS data issues, when we look at the reported new cases today, the numbers include cases from June, July and August, or even earlier. The unfortunate consequence is our current new cases are probably being overstated – we are doing better than we think. Also, in retrospect, because cases were not being entered in June and July, we were in even worse shape then than we knew.

At some level, this is not as bad as it might be. We are probably doing better than we think today. We already survived June and July when the numbers were understated. However, at this inflection point, it is disturbing we do not have confidence in a major benchmark. We are trekking through the wilderness with a broken compass. We are flying a plane in poor visibility conditions with an unreliable altimeter. Are we at 5,000 feet or 500 feet? I am not a pilot, but it seems to me some precision in this metric is important, as our new case rate number will be as we make decisions to reopen schools and relax other restrictions. Again, hopefully with the DSHS changes, this problem is behind us.

So now we are contemplating the reopening of face-to-face schools, armed with incomplete and evolving information. Decision-making is relatively easy when you have all the facts. Critical decisions are much more difficult based upon incomplete or conflicting information. This is the unfortunate position in which we find ourselves. State and local governments, local school boards, and – most significantly – millions of parents are struggling to make the best decision for children across the nation. Most are showing an appropriate level of caution.

In closing, I would like to offer a few thoughts on what communities, schools and parents can do to maximize success of school reentry, and recommend some specific resources.

What can communities do?

• Mask and distance. Continue to push good viral control practices in the entire community – not just among students, teachers and parents. SARS-CoV-2 is every bit as infectious as it ever was. We are nowhere close to achieving herd immunity, either through spread of infection or vaccination. Masking and maintaining appropriate distancing (6 feet or more) is inconvenient, but a small price to pay to get our children back to school.
• Do not resume full face-to-face school until your community has a sustained low rate of disease. The new community cases should be steady – or ideally declining. New cases should be at a low enough level so health departments can realistically perform contact tracing. In Harris County, that is about 200 cases/day (we are currently at 744 per the county website). If you live in communities outside of Harris County, the consensus number seems to be somewhere between 2-8 cases per 100,000 population.

Controlling the disease through contact tracing is like rowing a leaky rowboat. If the boat has a slow leak (low disease incidence) you can bail out some water every few minutes, keep rowing and be safe. On the other hand, if the boat has a gaping hole in the hull, you can bail as fast as you can, but you are going to sink. If we are in a high prevalence environment, SARS-CoV-2 will overwhelm even the best-designed defenses, and outstrip the ability to perform contact tracing. We cannot put our children in a sinking boat.

The current lack of confidence in DSHS data – hopefully resolved – make this more difficult, but the uncertainty demands we proceed cautiously.

What can schools and school boards do?

• Refer to Baylor College of Medicine's "Guide to Reopening Schools." Baylor developed a guide to help walk school leaders through critical questions. Where will masking and distancing tend to break down? (bathrooms, cafeterias, entrances, buses). What issues are important to assess in a school's physical plant? (air flow; water systems). How do I keep teachers safe? (cloth masks and face shields). How do I manage symptomatic or exposed students and employees, and when is it safe to bring them back?
• Establish teacher/employee monitored e-mail address for COVID-19 questions and concerns. Even with the best policies and training, there will be many specific questions that arise. Establish a dedicated email address to receive these questions, and commit to a timely response. Ideally, engage an objective, third party expert panel to assist with the subset of more complex issues and novel problems. The availability of rapid and reliable answers to teacher and employee questions will help to quell the inevitable anxiety that many will experience as schools reopen.

What can parents do?

• Get involved. Like many other components of the educational process, active involvement of parents in their children's schools will drive better outcomes. Pay attention to communication from your school. Is there a well-articulated plan for returning to the classroom? Does it seem thoughtful and comprehensive? Is communication frequent and transparent? Based on the experience to date with colleges and universities, the re-entry process will usually go well, but some schools have challenges. Frequent and open communication between parents and school leadership will be key.
• Get educated. That is, learn the basics about COVID-19, so you can begin to separate fact from fiction and opinion. Baylor provides a free online resource that is actually geared towards K-8 science teachers. However, it also a good source of unbiased, factual and accessible COVID-19 information.
• Assess your child's unique situation. This pandemic is forcing parents to make hard decisions. Does my child learn well on-line, or do they need the face-to-face structure of the classroom? Is my home even equipped to provide a good on-line learning environment? What is impact of home-based learning on my child's social and emotional well-being? If schools are not open, how can I return to work? Parents of children with special needs will have even more complexity to work through. Involved parents who understand the unique needs of their children are really the only ones in a position to answer these questions, and strike the right balance for their child. The CDC developed a good self-assessment checklist to help guide parents, caregivers and guardians through this process.

So as we move towards in-person instruction, let's draw on lessons from our COVID-19 past. We have proven we can do the hard work of engaging entire communities to band together to control the virus. Our knowledge continues to rapidly expand. We should be humbled by a clear-eyed recognition of what we do not know, but that humility should not lead to paralysis and inaction. We can and will pull together to get our children back to school, thoughtfully and safely.

 

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).

Pride and Humility

 

It is hard to believe that we have been living our COVID-19 lives only since about last March.  It has been a shade over six months, but it seems so much longer than that.  As I pause to reflect on our shared journey over that time, the first two words that come to mind are “pride” and “humility.”  I mean pride in the positive sense: that which is earned and justified.  Humility reflects how far we yet have to go.
 
But first, the recent numbers.  There is little drama here this week, and let us all hope it stays that way.  Most of the national and state numbers are improving.  Regarding our Houston regional specific numbers, please refer to prior posts for a more complete explanation of the key TMC metrics. In short, our R(t) value (the estimate of viral infectivity) is down below 1.0 again, which is good.  New case rates in Harris and surrounding counties are slowly drifting down, albeit more slowly than anyone would like.  Recall, we want this number to be less than 200, about one fifth of its current level.   These two data points demand a word of caution:  The R(t) and new case numbers are not independent variables, and both are impacted by data reporting issues from the state.  I do not yet have confidence in the validity of these two metrics.  The reporting backlog seems to be improving, but there are still open questions as to when a new case is added into the state’s database (Date of specimen collection? Date of data entry?), and how duplicate entries are managed.
 
The TMC’s third monitoring metric – test positivity percentage – currently sits at goal at 5 percent and this is a reliable number as it is based on data directly flowing from TMC institutions.  Harris County’s positivity rate is also trending down, currently at 9.5 percent.  Test positivity rate is a very rough estimate of disease incidence in the community.  In order to reopen schools and relax other restrictions, we need to have a low disease incidence (rate of appearance of new disease) and prevalence (total amount of disease in the community at any given time).  
 
For the past couple of weeks, I have started to focus on the TMC new COVID-19 hospitalizations.  From a high of about 360 admissions per day in early July, this dropped to 88 per day two weeks ago, but inched up again last week.  It now appears to be trending back down again.  Keep your eye on this number if you are looking for a “Labor Day” effect.  Recall, viral exposure leads to a sequence of events. The virus incubates in the respiratory tract.  In at least some people it produces disease severe enough to require hospitalization.  This process from exposure to hospitalization takes on average 7-14 days.   I will be very curious to see what the new hospitalizations are on Sept. 21, and if they are rising or falling.  I predict they will be higher.  Fourteen days after Memorial Day, we saw an increase in new community cases of about 65 percent (from 285/day to 470/day), and they kept on growing from there.  New hospitalizations were not far behind.  Two weeks after July 4th, new cases increased by an almost identical percentage (64 percent from 1400/day to 2300/day). 
 
In retrospect, things started to improve from mid-July forward.  It is a shame we cannot rely on the new community cases data, as this is probably our best canary in our coronavirus coal mine, but watch the new hospitalizations.  If they are trending up, we could be headed for another disease surge.  Perhaps – hopefully – enough people have embraced masking, distancing and safe practices at this point that it will dampen the Labor Day impact.
 
All projections are dicey.  Like trying to predict if Hurricane Laura will hit Houston, there is no simple model, and things can change quickly.  We all crave certainty, which no one can offer at this point.  Which brings me back to the theme of humility. But first, pride.
 
If you step back and reflect on the expansion of SARS-CoV-2 (the pathogen) and COVID-19 (the disease) related knowledge over the past 6 months, it is stunning – almost explosive.  In very rapid fashion, we – scientists and clinicians – have learned a ton about the basic genetics, lifecycle, evolution and structure of the disease.  The cellular binding receptors have been identified, and we have some understanding of the human body’s complex and variable response to infection.  We have a well-defined understanding of the course of the disease, and we have developed partially effective treatment protocols and novel drug therapies.  We are well down the path of developing multiple vaccines, while systematically assessing their safety and efficacy.  We are beginning to understand the long-term complications of the disease.  And – notably – we have accomplished this while keeping providers safe.  For all our failings, and recognizing many things could have gone better, we should be proud.  Our research and care delivery system performed admirably.
 
However, there is a consequence to this rapid growth of knowledge.  Dr. Charles Burwell, a former dean of the Harvard Medical School, in an address famously told a class of new medical students, “half of what we are going to teach you is wrong, and half is right.  Our problem is that we don’t know which half is which.”  So it goes with COVID-19 knowledge.  What we think we know today may prove wrong tomorrow.  Treatments that seem promising in case reports, case series and meta-analyses fail to demonstrate benefits in randomized controlled trials.  New basic science discoveries will drive the development of treatments not yet contemplated.  This is not a flaw in our system – it is our system working as intended and working very well.  
 
Now, humility.  SARS-CoV-2 has humbled us along the way.  As we contemplate returning children to face-to-face classrooms, one great example of how our knowledge has evolved relates to how the virus impacts children.  In the few months we have been battling this pathogen, the thinking on involvement in children has changed dramatically.  
 
When COVID-19 first appeared on the scene, the common thinking was that children were not really susceptible to infection.  They rarely contracted the disease, and if they did, it was usually mild.   
 
Very shortly thereafter, it was discovered children with COVID-19, as a delayed complication, may develop a condition resembling Kawasaki’s Disease, a rare disease of unknown etiology that results in diffuse inflammation throughout the body and is a significant cause of acquired heart disease in children.  Although still rare, COVID-19 could no longer be considered an entirely benign pediatric condition.  
 
Weeks later, the thinking evolved.  Children were contracting COVID-19, and being hospitalized, with the most severe cases unfortunately rivaling the adult experience.  However, the severe cases seemed to be mainly confined to obese adolescents.  
 
More recently, data from a sleepover camp in Georgia showed COVID-19 spreads with surprising ease among children of all ages (campers were aged six and above).
 
Finally, today.  It is clear children do contract COVID-19. The American Academy of Pediatrics summary of state reporting data on children clearly indicates children become infected with the virus (over 476,000 cases to date, almost 10 percent of the total number of documented infections).  However, thankfully, hospitalizations and death are uncommon.  The risk of spread from asymptomatic children to adults remains unsettled.
 
Now as we contemplate returning tens of millions of children to school  – an educational, emotional, social and economic imperative – think about the above evolution and how reasonable recommendations may have changed from then to now, based on what we thought we knew.  Early on, it might have been rational to reopen schools with minimal precautions.  Based on current knowledge, we need to plan cautiously, with adequate protection for children, teachers and staff.  We also must consider and manage the risk to vulnerable adults living with school age children.
 
There are other examples of how knowledge has evolved.  From “don’t wear surgical masks, we need to save them for health care workers and first responders” to “everyone should be wearing a cloth mask.”  We used to think transmission from inanimate objects was a significant risk.  It is now clear this is not a major mode of transmission (you should still wash your hands regularly, and keep them away from your face).  I will repeat.  The evolution of evidenced-based guidelines is not a flaw in our system – it is our system working as intended.
 
We need to balance these two sides of our coin: pride and humility.  By embracing both, other virtues follow.  We will have the confidence to move forward, making timely decisions with incomplete information.  We will have the maturity to change our practices and behaviors as new evidence emerges.  Importantly, we will display charity and patience with leaders in our civic, medical, educational and business communities who are acting in good faith to protect people and mitigate the impact of this novel global disaster.
 
Stay well.

James T. McDeavitt, M.D
 
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(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).