Build Your Holiday Bubble

 

This week, we seem to be stranded in COVID-19 purgatory. In the Houston region, new community cases are slowly inching up, as are new hospitalizations. The trend is concerning enough that most TMC hospitals are dusting off their surge plans in the event our health system is once again stressed. We still do not know if we are in the early phase of another exponential growth cycle, or at a precarious equilibrium. Based on recent stressors in our community, I fear it is the former. Public schools reopened for face-to-face instruction this week in Houston and other areas, the shorter days are driving people indoors and many are experiencing mask fatigue. In addition, much of Europe is experiencing a surge rivaling the first one, and reinstituting lock-downs. Much of the US, particularly in cooler regions, is also surging. I think we must assume we are in the early phase of another regional battle with SARS-CoV-2.

I know this is demoralizing for many, especially as we approach the holiday season. Many have given up so much already. Our lives have been disrupted by the pandemic in ways large and small. Should we sacrifice time with family and close friends over the holidays as well?

For a little ray of hope, I look to the recent NBA season. The NBA created a “bubble” in Orlando, played all their games, and completed their post-season. Lots of comingling of people, plenty of close, mask-less physical contact. How many infections since the NBA resumed regular season play in August? Zero. None of us have the resources of the NBA, and we cannot replicate their bubble (they tested everyone daily and took over entire luxury hotels). However, I believe it is possible to create your own “holiday bubble” and have a relatively safe and responsible time with family. Following the lesson of the NBA, forming an effective bubble requires planning, commitment and attention to detail.

Before we dive into the details, I need to start with a couple of significant disclaimers.

First, you need to honestly assess your own risk tolerance. The only way to remain completely safe is to remain maximally isolated. If you are elderly, immunosuppressed or have a serious underlying medical condition, you need to weigh the risks of holiday celebrations against the potential benefits. Creating a holiday bubble will help to minimize those risks, but cannot eliminate them.

Second, creating a holiday bubble is possible, but it will not occur without real commitment of all participants. One weak link will breach your bubble. Half-hearted commitments will only lead to a dangerous false sense of security. If everyone is not committed, you are probably better off celebrating exclusively with members of your usual household, and not mixing with family and friends from down the street, or across the country.

With those disclaimers in mind, here is my suggested process to create your own holiday bubble. It has specific tasks that must be performed on schedule. Count backward from the day your family plans on entering your holiday bubble to establish your timeline.

Today

• Get your flu shot. This will decrease the likelihood of developing a flu-related illness around holiday time, which could disrupt your plans.
• Have a serious family conversation. Do we want to commit? Are we willing to create and maintain a safe environment? DO NOT SKIP THIS STEP. Obtaining real commitment to form your bubble is the single most important part of this process:
• Who is at high medical risk in our family? What is our risk tolerance for exposing them in a family get-together? If your risk tolerance is low, even a bubble may be too risky for you.
• Are we committed to doing the substantial work necessary to create a “holiday family bubble?”
• There is variability in how seriously people are taking precautions. Beginning two weeks before you come together, is everyone willing to rigorously adopt good viral control practices? (mask, physically distance, avoid crowds). Your bubble will only maintain its integrity if everyone is fully committed. If you have a family member that cannot commit, they cannot be safely invited to your holiday bubble.
• Have everyone print the Holiday Bubble Checklist. Or, view a Spanish version. 
• Assign a Family Bubble Commissioner, a single individual who will take responsibility for reminding bubble participants of key milestones and encouraging compliance.
• Sign a family pledge. I know this may seem a bit overboard to some, but obtaining commitment is critical.
• Agree on a location. One of the best options is a private home where everyone will come and stay. It would be ideal if the location included some outdoor space, weather permitting. Keep in mind, this will be your bubble. Once everyone arrives, you are there to stay. No excursions, no visitors. Once in the bubble, you stay in the bubble.
• If flying, order face shields or goggles to protect your eyes, which are a potential portal of entry for the virus. Consider trying to obtain N95 facemasks. Cloth masks used in combination with eye protection afford an acceptable level of safety, equivalent to the protective equipment used by health care workers during routine hospital care. An N95 combined with a face shield or goggles would provide maximal protection, and is equivalent to the equipment used by health care workers when dealing directly with known or suspected COVID-19 patients. Regarding eye protection, either a plastic face shield or eye goggles are effective. Goggles must fit snugly. Air purification in many planes is excellent, but varies based on the airline and model of aircraft.
• If flying, take a direct flight if possible.
• Check any travel restrictions for the state that you will be visiting. Note many states have restrictions and quarantine requirements. Some international destinations have testing requirements. Remember to check the regulations for the state to which you are returning after the holiday as well.

Two weeks (14 days) prior to holiday:

• Everyone planning to enter the holiday bubble must make extra effort to limit contact with other individuals to reduce risk of exposure.
• If your job duties permit, work from home. Self-quarantine. Important: Quarantine is more than being cautious. It means staying home and avoiding all contact with anyone outside your regular household, even if masked.
• If self-quarantine is not possible, maintain scrupulous attention to distancing and cloth masking along with hand washing/sanitizing.
• Add a plastic face-shield or goggles to your cloth mask when you are indoors and in contact with others. Note, the face shield is in addition to, not in the place of a cloth mask.
• Daily symptom and temperature monitoring. If you become symptomatic or have any fever (even low-grade), seek evaluation by a physician and tested with a PCR test (for this purpose, avoid rapid tests). If your test is positive, cancel your participation in the bubble, along with all others who live in your household.
• Decide who will be cooking during the holiday. Stock up on non-perishable food items in advance.

5-7 days prior to holiday:

• Get a diagnostic test (PCR, not a rapid test). If positive, cancel your participation in the bubble, along with all others who live in your household.
• Stock up on hand sanitizer and disinfectant wipes for travel.
• Complete your food shopping. If you plan to drive, buy travel food in advance. Purchase perishable items for your holiday meal(s). Remember, you are quarantined. Use a grocery service with touchless delivery to maintain your quarantine status.
• Recheck travel restrictions.

Traveling to the bubble:

• Drive if possible.
• Make the trip in a single day if you can do so safely.
• Bring your own travel snacks
• Limit time in -- or avoid altogether -- crowded roadside fast food restaurants, truck stops, etc. Mask and distance when out of the car. Consider adding a plastic face shield in addition to a cloth mask.
• If you must fly:
• Wear a cloth mask (or N95 for maximal protection) and a face shield or goggles. Remember, eye protection is in addition to your mask.
• While on the plane, leave your mask and face shield/goggles on as much as possible. Ideally, they should stay in place for the entire flight.
• Skip the snacks and drinks.
• Use the restroom prior to boarding.
• Limit fluid intake for 30 minutes prior to departure, and during relatively short flights (two hours and less).
• Avoid use of the airplane lavatory. If you must use the lavatory, keep your mask on, and wash your hands thoroughly.

During the holiday

• If you are confident everyone has followed the above guidance, you are relatively safe in your bubble. Continue to use common sense. Play games, eat, sing songs, throw the football. Enjoy fellowship with (bubble compliant) friends and family. After all your hard work, planning and preparation, you can relax and enjoy the holiday.
• For high-risk family members (elderly, immunosuppressed) it is probably prudent to continue to follow good masking, hand hygiene and distancing practices.

This is not easy, but what in this pandemic has been easy? Decide who is in your holiday bubble, and start the conversation today. If people are committed, begin the process as outlined above. Do not skip steps.

Let us try and spread this message. If most of us create a bubble, we can minimize the risk that the holidays will become a super-spreader event, and we can keep our loved ones safe.

Take the pledge. If you are on Twitter, post when you have committed to creating your bubble using #HolidayBubbleBCM. Encourage others to do the same.

I wish you all safe holiday season, and one filled with companionship and love.

 

(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).

 

 

Never Give Up, Never Surrender

 

Imagine a crisis in our community.  There is much about the crisis that makes it difficult.  The threat hangs over us continually; we can put it out of our minds temporarily, but it is always there in the background.  It strikes indiscriminately, causing death and disability to young and old alike.  Our best protection is defensive – everyone must modify their behavior to help keep all people safe.  As rigorously as we play defense, it does not eliminate the threat, and we yearn to go on offense.  We want an effective intervention that repels the invader, so we can return to our normal life.

SARS-CoV-2 and COVID-19?  As horrible as the global pandemic has been, and all the medical, social and economic turmoil it has wrought, I am describing the bombing of England during the Second World War.  From roughly June of 1940 to May of 1941, the English people endured a near continuous threat of death from the air.  In total, the nighttime bombings left 43,000 civilians dead, and more than three times that number wounded.  I just finished reading Erik Larson’s "The Splendid and the Vile," an excellent book that covers this period in history in a focused and engaging manner.  As I was reading, the parallels to our current crisis were unavoidable.

There are two major themes to the book.  First, in spite of the intermittent terror the population faced, life went on.  Weddings and baptisms; theater and music; the daily rhythms of work and school.  The English people endured incredible hardship, with no end in sight and the constant fear of invasion.  And life went on.

The second theme is the importance of leadership – specifically the role of Winston Churchill, who ascended to the office of prime minister during this most challenging time.

Churchill clearly had feet of clay: massive personal debt, probable over-indulgence in alcohol, odd personal boundaries (he was known to dictate correspondence to his secretary from the bathtub), quirky behaviors (he liked to wear a pink silk robe around 10 Downing Street) to name a few.  He was not perfect.

But he was a leader for that time.  He was masterful in his communication to the public: honest about the hardships faced and uncertainty of the situation, while maintaining a sense of unbridled optimism.  He dealt and managed in an environment of uncertainty (Will the U.S. enter the war? Will the Germans launch a land invasion?).  He assembled and maintained an effective leadership team.  He regularly visited sites of devastation.  He connected to, and wept with, the people.  He seemed to almost literally pick the nation up, and carry it through a horrific ordeal.

As I continue to monitor our COVID-19 metrics, and prepare to go to the polls to early vote, it is appropriate to pause and consider the importance of effective leadership.

The news out of Houston this week is a mixed bag. No one has a crystal ball, but on balance, I am discouraged by our numbers and believe we are on the cusp of another surge.  Although there is good news (the City’s test positivity rate is down to 5%), a number of our metrics are worsening.  From the TMC data, our R(t) value, after 32 days of staying below 1.0 (virus receding), snuck above 1.0 (virus is expanding).  New daily cases in the greater Houston area remain stubbornly in the 400-500 range, and the daily rate for the past three weeks is edging up (373, 394, 412).  New hospitalizations are increasing, albeit at a slow rate (0.9% daily increase) and the total census of COVID-19 patients in TMC facilities is again rising (1.3% daily).  Data from the Baylor diagnostic labs show the positivity rate increasing, along with the average viral load of specimens, a sign that the tested individuals may be more infectious.  There is increasing evidence that young adults (20s and 30s) are responsible for much of the spread.

I am afraid we will see the viral resurgence in the coming weeks, as are many regions across the world.  I hope I am wrong.  I hope the surge does not come, and if it does, that it is not as severe as we saw in July.  Let us all do what is within our power. Continue to beat the drum: mask/distance/avoid crowds.

As we prepare for a potential resurgence, and reflect on the role of leadership in crisis, I want to try to channel some of Churchill’s clear-eyed, realistic optimism.  I want us to come together, not be torn apart.  To that end, I have three specific requests of you today.

• Vote.  Do not wait until the last minute, do it this week.  Democrats and Republicans; liberals, conservatives and libertarians; supporters of “big oil” and the Green New Deal.  “MAGA-fanatics” and “Never-Trumpers.”  Vote.  We are living in divisive and turbulent times, but the nation has seen and endured worse.  Over time – if you participate – our system will work.
• Reach out to your Churchill.  We have all suffered through the pandemic, some far more than others.  I imagine everyone at some point has experienced a degree of anxiety and uncertainty; some have felt real despair.  Stop and reflect for a moment on who has helped you through this difficult time.  It may be a co-worker, supervisor, faith-leader, family matriarch/patriarch, teacher or civic leader.  Focus especially on those who are quietly leading out of the public eye – those who lead but do not get recognition.
  
  Now recognize your Churchill.  Right now, sit down and write them an e-mail.  Tell them how important they have been in helping you through this difficult time.  Tell them how they helped you.  Better yet, write them an actual letter.
• Start a global pandemic of support.  We are battling the “R(t)” and the pernicious nature of exponential viral spread: one infects two, two infect four, four infect eight, etc.  
  
  Let us try to create exponential growth in support of each other.  Share this message with two other people and ask that they send a note of thanks to their Churchill: the person that has helped them most through this time.  Then ask that they encourage two others to do the same.  Not as a social media campaign, not as a meme, not as a hashtag. Privately, individually, sincerely.

At the risk of beating this theme to death, I will finish with Churchill:

“We shall not fail or falter; we shall not weaken or tire.  Neither the sudden shock of battle, nor the long-drawn trials of vigilance and exertion will wear us down.”
 
Stay well (and vote!)
 

(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).

 

 

 

Bears and Bulls and Bars

 

It is never a good sign when I am writing my Wednesday message on Thursday morning. My intent this week was to write about bar openings. However, events have evolved so quickly, two versions of this message are already obsolete. Instead of rehashing the recent news, I will refer you to a couple of sources if you want to dig deeper into the issue.

I am going to focus on broader questions: Is it time to reopen bars in Harris County? (No); What role should personal responsibility play in community control of the virus? (A critical one); How are we doing in our efforts to have a civil, respectful public debate? (C+, but I tend to be an easy grader).

First, a couple of references for background reading. There is an article in this morning’s Houston Chronicle that does an excellent job summarizing the issues around bar reopenings. I would recommend reading this if you were under the mistaken impression bars were already open.

If you are interested in this topic, I would also encourage you to read Gov. Greg Abbott’s actual executive order (GA-32).  It is a detailed document, which makes attempts at a degree of nuance. For example, when drinking in a bar you must remain seated. That is, unless it is a wine tasting, in which case you may stand “if in a group of six people or fewer and there is at least six feet of social distancing or engineering controls, such as partitions, between groups.”

At a very high level (please read it for yourself) the Governor’s order a) permits bars to open at 50% of total listed capacity, b) but only in counties that do not have an excessive burden of COVID-19 in hospitals and c) in a major digression from prior executive orders, requires the county judge to opt-in to the reopening decision.

So should we reopen bars? First of all, let us acknowledge at this point in the debate, most of us are either viral bulls or bears. The primary concern of the bulls is economic. Government mandated limitations on businesses create hardship and long-term damage to the social, economic, emotional and medical well-being of people. Others are viral bears. Failure to adequately mitigate the virus in communities via public health measures, including limitations on businesses, will result in preventable death and a repetitive cycle of shut downs, reopenings and surges. There is validity to both positions. I work for an organization whose explicit mission is to improve healthcare. I acknowledge my bias – I am a bear, and suspect most, but by no means all of my colleagues, are similarly inclined.

Why is now not time to open our bars? Our numbers are stable to improving. Our R(t) has been less than one (indicating the virus is receding) for more than two weeks. Community cases (which we want below 200 per day) seem to have stabilized between 300-500. As I have previously reviewed, I have some apprehension this number is under-reported due to Texas DSHS data reporting challenges. New daily hospitalizations (probably a more reliable, but indirect estimate of disease prevalence in the community) are 20-25% of what they were during our July surge, but seem to be trending slowly upward over the past week. At best, our monitoring metrics are at a tenuous equilibrium. At worst, we are in the early phases of exponential growth. The unfortunate reality is we will only know which condition is true – best case or worst case – looking in the rear-view mirror.

Our numbers look relatively good, but the experience around the world should drive us to act cautiously. If we are too exuberant in our path back to normalcy, we will surge again. And shut down again. Critically, we are getting ready to stress our system further. School systems and parents still need to make decisions regarding a return to face-to-face instruction. Cooler weather will drive people indoors and will probably promote viral spread. Our equilibrium can only withstand so much perturbation – let us focus on getting children back in schools before we reopen bars.

A word in support of bar owners. Many are tax-paying small business owners, with personal investment in their enterprise. They employ Houstonians. They have families to feed. They are no longer receiving any government assistance to help mitigate the impact of government-ordered restrictions on their businesses. Their expenses continue, even though their revenue has evaporated. The rent still comes due. Those of us who had the good fortune to remain employed through this crisis should be careful not to vilify those who face a choice we have not had to make – close up shop, or find a way to do business in the challenging pandemic environment.

Gov. Abbott’s executive order creates some clarity, but in Harris County is likely to stoke political debate as to next steps. Should Judge Lina Hidalgo – clearly a “bear” – opt-in or opt-out? Most of us will have an opinion heavily influenced by our bullish or bearish inclinations. There will be passionate declarations made from both extremes. What can we all do to help drive a good outcome for our community? A few thoughts:

Proprietors of bars and restaurants:

• Demonstrate to those of us who are justifiably worried about the resurgence of this disease that you are taking it seriously. Most of the business community has, and we thank you. Some clearly have not.
• Look at your space. Create visual cues like floor markings and furniture placement to encourage distancing. Require masking upon entry. Creatively use outdoor spaces. Regularly walk the floor of your business, and critically assess if your patrons are effectively distanced. Do more than meet the technical requirements imposed by restrictions; meet their intent.
• Use the opportunity to innovate. Build your take-out business. Develop home mixed drink kits. Hold virtual on-line wine tastings, pre-selling the wine. I do not pretend to understand your business, or what is required to remain profitable, but I believe it is a risky strategy – from a business and public health perspective – to tie your economic recovery to packing people into a confined space.

Patrons and the general public:

• Reward those businesses – bars included – that are doing this well, and making a sincere effort to keep the community safe. Patronize them if they appear safe. Order take out. Tip generously. Tell your friends and colleagues when you have an enjoyable COVID-responsible experience.
• Remember, no matter how carefully crafted an executive order or local mandate might be, regulation will never be enough to ensure your safety. To repeat an analogy I used a couple of weeks ago: The government tells me how fast I am allowed to drive. I make a conscious decision to slow down when visibility is poor, because I have good situational awareness, and I am concerned about the safety of those around me. The same goes for viral safety. Stay alert and aware. If you walk into any environment and people are crowded and unmasked, turn around and walk out.

Americans/Texans/Houstonians:

• In what has become an increasingly divisive environment, let us all work to take the temperature down a notch or two. I freely acknowledge as a professional working in health care, I lean towards the “keep people safe and healthy, prevent the spread of the virus” side of the debate. I am a viral bear. I hope I have empathy for those who have experienced severe economic impact from the pandemic, who are justified in their desire to see things reopen as rapidly as possible. I hope I have respect for the informed opinions of bulls. There is a tension between these worldviews. In a democracy, that tension is a good thing – it helps drive better decision-making. It helps, that is, if we are actually listening to each other. Both sides – let us concentrate on listening more, and shouting less.

Stay well.

 

 

(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).

 

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).