30 August 2022 Blog Post: Major Changes in CDC Announced, Part 2 of 2

30 August 2022 Blog Post: Major Changes in CDC Announced, Part 2 of 2

Last week, Dr. Rochelle Walensky, CDC director announced “major changes” at the agency, admitting that the storied institution has failed in its response to COVID-19 and monkeypox. She announced the changes to the CDC in a video to its 11 000 staff, most of whom are still working remotely, after commissioning a review of its pandemic response in April. This is Part 2 of 2 in our Blog Series covering these changes.

Dr. Walensky said the C.D.C.’s future depended on whether it could absorb the lessons of the last few years, during which much of the public lost trust in the agency’s ability to handle a pandemic that has killed more than 1 million Americans. “This is our watershed moment. We must pivot,” she said.

So what specifically will they do?  Dr. Walensky (who interestingly comes from an academic medical background rather than one of public health) noted that “we are responsible for some pretty dramatic, pretty public mistakes, from testing to data to communications.”

 

Data

To address her second point first, Dr. Walensky outlined a framework in which the CDC would place less emphasis on employees’ records of published scientific papers and more emphasis on quicker responses to public health issues, such as preprints. Walensky called it “data for action” rather than “data for publication.” This is an interesting pivot for an academician and one that is not without pitfalls. The process of preparing a manuscript for publication demands rigorous internal review and then is subject to external validation, accessibility of raw data and sometimes independent re-analysis. All of this strengthens the final conclusions. While this review process is time consuming, the public is left with something that has greater reliability than a preprint or a press statement. There were many times during the pandemic that the rush to get something out in the press led to wildly invalid conclusions – notably Stanford studies by Dr. Jay Bhattacharya  (link: https://pubmed.ncbi.nlm.nih.gov/33615345/) which had fundamental methodologic issues from study recruitment (done over social media), to funding source (JetBlue) and antibody test accuracy (see the following for a full accounting: https://www.the-scientist.com/news-opinion/how-not-to-do-an-antibody-survey-for-sars-cov-2-67488). While ultimately published over one year later in May of 2021 – the preprint and press releases in April of 2020 had already done their damage – suggesting that COVID-19 infection was not as bad as originally feared and had a less than 1% mortality rate.

The CDC also has a well established flagship publication, The Morbidity and Mortality Weekly Report (MMWR) which publishes public health information and recommendations that have been received by the CDC from state health departments. So Dr. Walensky’s approach to Data seems to be a bit at odds with what would actually be helpful from the CDC.

 

Communications

This is one area that the CDC can significantly improve and plan to do so by revamping its public guidance statements and making “information clear and concise and to use plain English, so that information will be easier to understand and can be issued more quickly.” This will be a clear benefit moving forward, although I think it is important to note that the CDC was essentially hamstrung by the Trump Administration during the most critical period of the pandemic. Had it not been for Dr. Nancy Messionier who communicated in clear and stark terms the gravity of the upcoming pandemic, we would have been even less prepared than we were as a country. She needed to make this statement while President Trump was on a trip to India so as to not get crossways with the Administration. She was thereafter silenced (link: https://www.businessinsider.com/cdc-official-warned-us-coronavirus-was-silenced-documentary-2020-10) and ultimately left the CDC.

But the CDC would undoubtedly benefit from improved communication – on multiple fronts from the general public, to health professionals and to local health departments. If you think the CDC website is confusing and difficult to navigate, check out that of the LA County Health Department. The CDC should require some standardization of messaging, content and structure for state and municipal health departments to coordinate information sharing. Point in fact, the CDC and LA County Health Department were so disorganized and unable to come to a consensus that I followed COVID-19 management guidelines from South Korea for the bulk of the pandemic.

 

Testing

COVID testing was (and continues to be) an absolute debacle. To address such, Dr. Walenksy has proposed that CDC’s science and laboratory sciences divisions report directly to her. While this does elevate the division within the CDC, it does little to address the critical missteps that the CDC made during the development of COVID-19 PCR testing kits. Additionally, they did not include academic or private laboratories in the development process, significantly delaying test availability. Lastly, shortages of rapid antigen tests occurred in January 2022 during the Omicron surge – to the point that our clinic was down to 10 tests at one point. None of these issues will be solved by a direct report, but perhaps such will underscore the importance of these development efforts.

Interestingly, this already seems to be different for monkeypox as there already is a commercially available test through LabCorp (which is our primary laboratory service provider and is contracted with Medicare and most commercial health insurance). Prior to such, any testing would need to be coordinated through the Los Angeles County Health Department which – from my experience with Zika and measles testing – is woefully under equipped for significant volumes of test material.

 

Equity

In addition to the above, the CDC will also create an equity office to make sure that its workforce is representative of the US population and better communicates public health information to all groups. This will be of great benefit as COVID-19 risks vary greatly by socioeconomic status, access to care, ethnicity, gender and age. As our preferred ways of communication change across social media and traditional media platforms, so should the CDC respond to such – meeting the public where they seek information

Further, the CDC will create an office of intergovernmental affairs to help other federal agencies and state health departments work with the agency. While I think this is helpful, I actually believe that breaking up large municipal health departments (like LA County Health which oversees a population of 10 million) into smaller, more responsive public health ‘units’ will make a bigger difference. This is one difficulty that the CDC faces having only the perspective at the top of the pyramid – they only know what information is fed to them from reporting agencies. Which needs me to my next point…

 

Shoe Leather Epidemiology

At the end of the day, the CDC needs to return to its most basic function when it comes to pandemic management – which is shoe leather epidemiology. All 3 terms are critical as investigations initiated in response to urgent public health problems must involve substantial work in the field (i.e., outside the office or laboratory). It is clear that the CDC no longer prioritizes this core function of public health.  How do we know this?  See Part 1 of this series – the vast majority of the CDC is still working remotely. None have even set foot in the office, much less at a community center, a testing center, or a mass vaccine distribution site. They need to get into the field – test and trace and, when needed, isolate. By doing so, they will have a better fundamental understanding of the numbers coming across their computer screens – what makes sense, what doesn’t fit because they have seen the pandemic – in real time.

s the New York Times points out (link: https://www.nytimes.com/2022/08/17/us/politics/cdc-rochelle-walensky-covid.html) :

 

“The agency’s massive complex outside Atlanta sits mostly empty, while employees, including Dr. Walensky, work remotely.

The actions that are being taken all strike me as actions that make sense and would make C.D.C. a more effective public health agency,” said Dr. Besser, the former C.D.C. acting director.

But he said it was hard to see how Dr. Walensky could execute wholesale changes when she only sees most of her staff at a distance. “I don’t know how you motivate and inspire culture change when people aren’t together,” he said.”

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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29 August 2022 Blog Post: Major Changes in CDC Announced, Part 1 of 2

29 August 2022 Blog Post: Major Changes in CDC Announced, Part 1 of 2

Last week, Dr. Rochelle Walensky, CDC director announced “major changes” at the agency, admitting that the storied institution has failed in its response to COVID-19 and monkeypox. She announced the changes to the CDC in a video to its 11 000 staff, most of whom are still working remotely, after commissioning a review of its pandemic response in April. 

To me, the remainder of the article is really immaterial (although I will cover it in a subsequent blog) because – stop – the CDC is still working remotely?

In fact, yes, the vast majority of the CDC continues to work remotely. As of the end of June 2020 – 5,440 workers remain fully remote, 4,467 spend at least some time working remotely, and just 2,772 workers report to work in-person.

Continuing to work exclusively from home shows either a blatant disregard or a fundamental misunderstanding of COVID risks and sets a terrible example for American workers, students and children who have resumed in person employment and learning. There are multiple layers of risk mitigation that can be performed from deploying HEPA filters, to routine testing, to strict isolation protocols when becoming ill and staggered work schedules all of which can protect an in-person workforce.

The fact that the CDC continues to work remotely, additionally, stands in stark contrast to their own recommendations. No longer do they emphasize screening nor social distancing. The quarantine rule for unvaccinated individuals is also gone. So if the agency is seeking to protect the highly vulnerable population, while simultaneously not requiring those of low or average risk to not be inconvenienced in any way shape or form to protect others, why is the CDC all still at home?

“The current conditions of this pandemic are very different from those of the last two years,” CDC epidemiologist Greta Massetti said Thursday in a briefing for reporters.  We also have a better understanding of how to protect people from being exposed to the virus, like wearing high-quality masks, testing, and improved ventilation.  This guidance acknowledges that the pandemic is not over, but also helps us move to a point where COVID-19 no longer severely disrupts our daily lives.”

Comments made, not at an in-person press conference, but via telebriefing. Most likely, from home.

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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3 August 2022 Essay: Everything You Wanted to Know About Monkeypox but Were Afraid to Ask

3 August 2022 Essay: Everything You Wanted to Know About Monkeypox but Were Afraid to Ask

With the CDC now declaring monkeypox (after New York and California had already done so) a public health emergency, now seems like a good time to discuss this infection – covering its epidemiology, routes of transmission and origin.

Monkeypox is not a new disease but can be considered at this point to be emerging / re-emerging. It was first identified in 1970 in the Democratic Republic of the Congo and was found to be caused by a virus related to smallpox. Clinically, the disease resembles smallpox but is milder. It has about a 12 day incubation period (time from exposure to development of symptoms – something which can hinder containment measures) after which patients can develop a fever, headache, muscle aches and lymph node swelling. Then, 1 to 3 days later, a rash appears on the face, chest and trunk which evolves to include vesicles and the characteristic pustules. This is like smallpox (but different from chickenpox) where all the rash lesions are in the same stage. When the rash heals it often leaves scars.

The monkey part of monkeypox is a misnomer, as rodents (especially squirrels) are believed to be the most important natural reservoirs in central and west Africa, often in proximity to tropical rainforests. During May and June of 2003 there was a cluster of 71 human monkeypox cases in the United States across six states (Wisconsin, Indiana, Illinois, Missouri, Kansas and Ohio). All of these cases had contact with an infected prairie dog which had been in contact with rodents shipped to the US from Ghana (specifically Gambian rats and deer mice). While there were no human cases identified from contact with the African rodents, monkeypox was spread from these rodents to the prairie dogs staying in the same Illinois facility. A total of 93 prairie dogs were traced from the Illinois facility to 6 states and all 71 human cases had contact with an infected prairie dog. There were no cases of human-to-human transmission. The epidemic terminated in early July of 2003.

The re-emergence of monkeypox has been predicted for some time and is related to two primary factors.  The first, and one common for many zoonoses, is the encroachment of human populations into rainforests, bringing them in closer association with rodent hosts. In fact, in 1996-1997 Medicines sans Frontiers reported an outbreak of monkeypox with over 500 cases that may have been facilitated by an ongoing war which forced many individuals to seek refuge in the forest. The second factor is the discontinuation of routine smallpox vaccination in most African countries between 1981 and 1985, after the elimination of smallpox. We know that smallpox vaccine is effective in preventing monkey pox and when breakthrough cases do occur, they are milder and have fewer pustules than unvaccinated individuals (sound familiar?).

Studies of monkeypox in the 1970s and 1980s had shown only occasional human-to-human spread of infection, and usually not beyond two generations. Now, however, the longest documented chain of transmission has risen from 2 generations in the 1980s to up to 6 to 9 successive person-to-person infections. This may be due to declining smallpox immunity or a change in the virus itself.

Monkeypox is far less infectious than smallpox. Nevertheless, human-to-human transmission can result from close contact with respiratory secretions and skin lesions of an infected person. Contact with objects, fabrics (clothing, bedding or towels) and surfaces that have been used by someone with monkeypox may also lead to viral spread. Transmission via respiratory particles usually requires prolonged face-to-face contact. Transmission can also occur via the placenta from mother to fetus or during close contact during and after birth.

Since early May 2022, monkeypox cases have been reported from countries where the disease is not endemic. In fact, most confirmed cases initially had a travel history to countries in Europe and North America, not West and Central Africa. To date the WHO has tallied over 25,000 cases of which 5,874 have been diagnosed in the last 7 days (link: https://extranet.who.int/publicemergency/#).

Most reported cases thus far have been identified through sexual health or other health service facilities and have involved mainly, but not exclusively, men who have sex with men. Thus far, there has not been an identification of a new mechanism of monkeypox spread via sexual transmission, it remains the case that monkeypox can be transmitted through prolonged physical contact – including intimate sexual contact. As the Infectious Diseases Society of America (ISDA) has stated succinctly:

“Most concerning is that stigma and discrimination continue to help drive this outbreak. Our public health education, messaging and reporting must be clear. Monkeypox is spread by close physical contact. No one community is biologically more at risk than another. “

The smallpox vaccine, as alluded to above, is protective against monkeypox, with up to an 85% estimated efficacy if given prior to exposure. There are two available vaccines, ACAM2000 and JYNNEOS. Both are live vaccines but the JYNNEOS is non-replicating and, as such, has fewer side effects. The vaccine can also be given after monkeypox exposure but must be given within 4 days of exposure to prevent disease. Giving it between 4-14 days can reduce symptoms, but not prevent disease.

Currently, the IDSA has urged physicians to follow the “Identify, Isolate and Inform” strategy to help stop the spread of the virus. Identification occurs by recognizing the typical features of monkeypox which include fevers, muscle aches, lymph node enlargement and rash. The rash is particularly characteristic and tends to be concentrated on the face and extremities. Further, the skin eruptions are all at the same stage of development at a given time, unlike chickenpox, which has vesicular lesions that erupt at different stages. Specific procedures for sample collection in suspected monkeypox cases have been outlined by the CDC (link: https://www.cdc.gov/smallpox/lab-personnel/specimen-collection/specimen-collection-procedures.html). Cases should be reported to the local health department and then  appropriately isolated until the infectious period has passed (once rash has scabbed over and scabs have fallen off – about 2 weeks for pustules to scab and another week for the scab to fall off – in total about 3 weeks).

Lastly, in terms of treatment there are two antivirals, Tecovirimat (TPOXX) and cidofovir (Vistide), available for the treatment of monkeypox in an outbreak under CDC Expanded Access Investigational New Drug Protocol status. Additionally, Vaccines ACAM200 and JYNNEOS (also known as Imvamune or Imvanex) have been shown to be effective for post-exposure prophylaxis if given within (as noted above) 4 days of exposure.

For a balanced perspective on the future of monkeypox, the following from Dr. Nicholas Christakis is worth watching (link: https://www.youtube.com/watch?v=03cRJMpK4rA).

At its core, monkeypox does not have the same relative ease of transmission as does COVID-19 and, as such, would not be expected to generate the same volume of cases. Nevertheless, there is a long incubation and recovery period with significant discomfort associated with the infection making it a critical public health issue. Lastly, it is important to note that while we are seeing initial cases primarily among men who have sex with men, one should not get involved in the “is it a STI discussion?”. I would approach a framing of monkeypox in a manner similar to MRSA (multi-drug resistant Staphylococcus aureus) which was seen initially in hospital-acquired infection but thereafter was identified among men who have sex with men. This led to questions and assumptions about the role of sexual behavior in the outbreak. It was not long before community-acquired MRSA was noted in other communities that engage in close physical contact, including athletes where it could be spread by contaminated gym equipment and towels.

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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COVID-19 and Me an Essay by Philip M. Bretsky, MD PhD

COVID-19 and Me an Essay by Philip M. Bretsky, MD PhD

On the surface, I look like the perfect person to effectively respond to COVID-19.  My educational background includes a PhD in Epidemiology, an MPH with an emphasis on Infectious Disease, an MD, Internal Medicine training and 12 years in private practice.  I know inherently that viruses know no boundaries and the concept of a virus “jumping” from animals to humans was not new to me. The fundamental epidemiologic concepts of surveillance, data sharing, and coordination of response were ones that I was confident would be employed to identify and contain the outbreak in the United States.  But none of that happened and the American public has suffered mightily as a result.  In retrospect, it is now obvious to me why our medical system has failed each and every one of us.

My faculty advisor during my graduate studies was the preeminent virologist Dr. Robert Shope. He was the principal author of the groundbreaking 1992 publication Emerging Infections:  Microbial Threats to Health in the United States.  At the time of the publication, Dr. Shope commented “The medical community and society at large have tended to view acute infectious diseases as a problem of the past.  But that assumption is wrong.  We claimed victory too soon.”  

I had really no practical exposure to an infectious disease outbreak until the 2009/2010 H1N1 “swine flu” outbreak.  At the time I had so little clinical experience I assumed that flu season was just normally that bad.  In retrospect, it did strike me as odd that so many of my cases were younger but my ignorance made this unusual and characteristic feature of H1N1 seem simply, well, usual.

Fast forward a decade.  I’m older, greyer and debatably wiser. The 2019/2020 flu season followed its usual pattern with flu cases peaking here in Los Angeles between Christmas and New Years.  However, towards the end of February, I began to see a perplexing number of flu-like illnesses that tested negative on our point of care testing.  Were these Influenza B cases?  Was it an issue with the test itself?  Or was it something else?  A recent LAC+USC study suggests that this may have indeed been COVID-19 as 5.3% of patients to their medical center who presented around that time with influenza-like illness were shown to have the novel coronavirus.

I began following the coronavirus outbreak in China in earnest beginning in mid-February.  I really began paying attention when CDC’s Dr. Nancy Messonnier stated that she expected widespread transmission of the virus in the US.  The first case in the US was reported February 27th and that week I stopped seeing patients with any acute illnesses in the office.  By mid-March, I had closed the office entirely to patients transitioning to telemedicine and a video platform for assessments.

Surveillance systems – preferably global – are the first, and perhaps most critical bulwark of a health system that can rapidly and definitively respond to a pandemic.  As Dr. Shope wrote in his landmark paper, “Surveillance can take many forms, from complex international networks involving sophisticated laboratory and epidemiological investigations, to small, community-based programs or a single astute clinician.”  

So what happened in the United States that our own surveillance system has failed miserably ?  There are many places in which blame can be reasonably placed, but our inability to effectively respond to COVID-19 has exposed the rotten core of our healthcare system, one which is too bureaucratic and top heavy to respond to shifting threats. This system has consolidated around regional hospital systems which have absorbed community based, independent primary care practices.  It has decimated rural and small town medicine under the guise of higher quality care being available in metropolitan health centers.  Health insurance companies then contract with these  large hospital entities, creating a massive administrative complex which provides zero direct patient care.

For the past 10 years, I watched as primary care physicians – our “single astute clinicians”-  have been devalued in our medical community.  As with all skilled gaslighting, this erosive process began innocently enough at the hospital level where doctors used to caring for their own inpatients were replaced by hospitalists. There simultaneously occurred mass consolidation wherein the major hospital groups acquired outpatient practices.  Inherent in these negotiations (brokered by hospital administrators and legal counsel) was the fact that primary care medicine was openly and unabashedly characterized as a  ‘loss leader.’  Its value remained only in patient recruitment, retention and referrals to hospital owned imaging centers and more profitable specialty care. As a result, the profit driven health care system that valued knee replacement over cardiovascular disease prevention left the citizens of the United States with no surveillance network.  

By 2019, for the first time ever, employed physicians exceeded independent physicians. This key component of recognizing an emerging infection, assessing the risk of such and sounding the alarm was left in the hands of hospital administrators – individuals with no formal medical training..  So what did hospitals do?  They pulled inwards – shuttering outpatient clinics, abandoning any community outreach and instead braced for an inevitable tsunami of critical illness due to COVID-19.

Our ill prepared system has failed at every turn in our pandemic response.  We have further experienced a massive failure of data sharing this in spite of  huge expenditures and profits reaped by Electronic Medical Record (EMR) vendors such as Epic. Hospital systems have touted their “patient portals” yet never bothered to seek connections with their local, regional or state health departments. Thus, in the face of a pandemic, the EMR is useless. Instead we are left filling out case report forms and FAXing them to the local health department. 

Senator Kamala Harris has described a “vacuum of leadership” in Washington DC.  This vacuum is also present in our healthcare system.  Into this empty space, the novel coronavirus has swept encountering no resistance as an hospital leadership who only months ago were busy with service lines and maximizing profits are now nowhere to be seen.  Health insurers have provided no guidance, no leadership, no innovation.  Is it any wonder that a system which wastes 25% of its healthcare expenditure has failed us when we needed it most?

But this is the direction the United States has chosen and we are harvesting what we have sown.  We have chosen profits over people and have on our hands a massive, entirely preventable death toll. We are lucky that COVID-19 spares children. We are lucky that it does not have a 100% mortality rate like rabies, 50% like Ebola or 35% its coronavirus cousin, Middle Eastern Respiratory Virus (MERS).  While nature may abhor a vacuum, this single stranded RNA virus has thrived in ours. The next outbreak may have a high mortality rate and may preferentially infect our children. 

This could have been so much worse.

So the next time, our healthcare system had better be up to task.

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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August Newsletter

August 2022 Newsletter

Welcome to the August 2022 Newsletter for Santa Monica Primary Care. In this issue, we are going to discuss case rates in Los Angeles County and why our Health Department decided against resuming an indoor mask mandate. We will also discuss Paxlovid rebound in the context of President Biden’s SARS-CoV-2 experience.

1. COVID-19 in the US and LA County during July 2022

COVID-19 cases in our practice have continued at a steady clip of about one new case a day – which has been consistent over the past three months.

 

Nationally, the BA.5 variant has overwhelmed the  original Omicron BA.1 and BA.2 variants as well as the BA.2.12.1 and BA.4 sublineages. BA.5 now accounts for 81.9% of the variants seen as compared to 54% of the total last month. Link: https://covid.cdc.gov/covid-data-tracker/#variant-proportions 

 

Cases in Los Angeles County after our huge Omicron surge in December and January were lowest the week ending March 22nd when they were at 5.8 new daily cases per 100,000 population (note viral containment is generally defined as under 1 new daily case per 100,000). They have risen steadily since that time and now stand at 59.3 cases/100,000. Note the slow rise as compared with the sharp peak of Omicron.

Similarly, prevalence (the proportion of active cases per 100 individuals) has steadily increased over that time period.  While down as low as 0.05% in late March, the most recent prevalence estimate is 9.6%. This has risen from 8.2% the week prior.

The Health Department based their decision to forego an indoor masking mandate as hospitalizations seem to have plateaued (link: http://dashboard.publichealth.lacounty.gov/covid19_surveillance_dashboard/).

We are not seeing a reduction in incidence case rates or prevalence at this point, either in the County or in the practice as a whole

 

 

2. Paxlovid Rebound

We have covered Paxlovid rebound in prior Newsletters and, as mentioned before, Paxlovid rebound has continued to be a thorny issue. To see it occur with President Biden was not a complete surprise. In our aggregate experience, 10 of the 35 patients (28%) we have treated with Paxlovid have experienced a clinically apparent rebound.   

 

Most national estimates discuss a Paxlovid rebound rate between 10% and 40%. While patients taking Paxlovid feel better faster and the rebound infection is typically milder than the initial symptoms, it nevertheless is something to consider before starting treatment.

 

 

3. Blogs This Month

Our blog posts this month focused once again on our ongoing COVID-19 pandemic, which has changed in contour since we first began covering it in March of 2020. We specifically discussed the absurdities of the CDC’s 5 day isolation guidance in “Do As I Say, Not As I Do”.  We also covered the population dynamics of the virus as well as what some call the inevitability of acquiring the infection.

 

On The CDC ‘5 Day Rule’:

https://drbretsky.com/28-july-2022-blog-post-do-as-i-say-not-as-i-do-and-the-cdc-5-day-rule/ 

 

On Population Prevalence and the ‘Luck’ of COVID Acquisition:

https://drbretsky.com/27-july-2022-blog-post-population-prevalence-and-the-luck-of-covid-acquisition/ 

 

On The Return of Masking, Summer 2022 Edition:

https://drbretsky.com/25-july-2022-blog-post-on-the-return-of-masking-summer-2022-edition/

 

4. August’s Epidemiology Definitions

Clinical Trial: A synonym for an epidemiologic experiment which is typically conducted with the aim of evaluating which treatment for a disease is better. 

 

Placebo: A comparison group in a clinical trial intended to have no biologic effect outside of the roffer of treatment itself. The term is from the Latin “I shall please” and placebo pills typically contain sugar or other inert ingredients.

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