29 June 2020 Blog Post: COVID-19 Update

29 June 2020 Blog Post: COVID-19 Update

It seems that a lot has gone backwards in Los Angeles County this past week. Beaches and bike paths that had been opened, are now closed for the July 4th weekends. Bars are now shut back down.

β€œTo some extent I think our luck may have run out,” said Dr. Bob Wachter, a professor and chair of the department of medicine at the University of California, San Francisco. β€œThis is faster and worse than I expected. You have to have a ton of respect for this thing. It is nasty and it just lurks and waits to stomp on you if you let your guard down for a second.”

The difficulty I am having with these sorts of quotes is that COVID-19 never stopped increasing in Los Angeles County. It was never ‘lurking’, it has always been in plain view. But, in the last week, those cases have begun to really take off (Figure 1). In the last week, case rates have increased from 13.36 daily cases per 100,000 population to 17.72 – a 32% increase.

Here’s the second sharp edge of that sword, testing has been essentially flat for the last month (Figure 2). At the end of May, there were 143.30 daily tests per 100,000. At the end of June, that rate was 151.69.(an 5.6% increase).

So here we are, more than 3 months after shelter-in-place and 17 days after having lifted restrictions. What happened? Cases have exploded.

You don’t need a degree in Epidemiology to know that it makes no sense to lift restrictions as case counts are increasing. The proof is in the numbers. It isn’t a function of our ‘luck’ having run out, our current situation is the direct result of poor public health decision making.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

Dig deeper into the health topics you care about most by signing up for our newsletter.

by submitting this form you indicate you have
read and agree to our Privacy Policy and Terms
of Use. Please contact us to for us for more
information.

24 June 2020 Blog Post: COVID-19 in Los Angeles County: Beware of Those Claiming “More Testing”

24 June 2020 Blog Post: COVID-19 in Los Angeles County: Beware of Those Claiming "More Testing"

Today I am presenting three separate graphs which will show COVID-19 case, mortality and testing rates in Los Angeles County. Hopefully these three taken together will provide perspective about the epidemic in our county.

Case rates continue to rise and are at the highest level we have ever seen. As Captain Jack Ross says in the movie A Few Good Men, “these are the facts of the case, and they are undisputed.” We are now at 13.36 new daily cases per 100,000 population on average in LA County. This is the highest rate it has been since the start of the pandemic and is now touching the upwards trendline (see Figure below).

Mortality rates continue to drop and are at their lowest rate since early April (Figure below). At 0.22 daily deaths per 100,000 population, they are now far beneath their trendline.

Testing has stalled and, in fact, rates are nearly 20% lower than they were at their height seen at the end of May (Figure below). We are now performing 137.43 daily tests per 100,000 population in Los Angeles County. At the maximum, we performed 167.38 daily tests per 100,000.

So what can we conclude?
1. We are seeing historic highs in case rates (Bad News).
2. We are performing fewer tests (Bad News).
3. Mortality rates have dropped by 50% (Good News).
Β 
That’s it – that is all we can conclude from the data that LA County Department of Public Health provides. Since the County chooses to publish only cumulative rates by age, gender, ethnicity and location any other conclusions are entirely speculative.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

Dig deeper into the health topics you care about most by signing up for our newsletter.

by submitting this form you indicate you have
read and agree to our Privacy Policy and Terms
of Use. Please contact us to for us for more
information.

21 June 2020 Blog Post: COVID-19 on School Opening

21 June 2020 Blog Post: COVID-19 on School Opening

This week I have received a number of questions about daycare and school reopening strategies. It will come as no surprise that there is essentially no guidance about such from the CDC. In fact, the CDC refers schools to their messaging for Healthcare Facilities and state that schools “may find it helpful to reference the Ten Ways Healthcare Systems Can Operate Effectively During the COVID-19 Pandemic.” Schools are most certainly not healthcare facilities.

So, once again, we are left to fend for ourselves in this pandemic. Looking to other countries for clues may be helpful but, remember, the United States is in the grips of an epidemic spread of COVID-19 at a level unlike any other county (save India and Brazil perhaps). So school reopening protocols and lessons from countries like South Korea, Germany and the UK may not be directly applicable. Even still, South Korea closed hundreds of schools in late May that had reopened days earlier β€” and postponed the opening of many others β€” after a spike in cases of coronavirus.

First, let’s cover some basic principles of any reopening strategy. On these I think we can all agree and they do not really need to be debated (modified from World Health Organization (WHO) guidance).
1. Sick students, teachers and other staff should not come to school.
2. Schools should enforce regular hand hygeine and encourage facemasks when feasible.
3. Schools should,at a minimum, ensure daily disinfection and cleaning of school surfaces.
4. Schools should promote social distancing by staggering the beginning and end of the school day, cancelling assemblies / sports / other events that create crowds, have faculty meetings remotely, keep children’s desks to be at least 1-2 meters apart, teach and model creating space and avoiding unnecessary touching.
5. Schools should increase classroom airflow and ventilation with open windows.
6. Schools should have a remote learning option established for those children at high risk or unable to return safely to school
Β 
But here’s where things will break down given that, as a nation, we have steadfastly refused to implement the three basic pillars of any coherent public health response. Test, Trace and Isolate. But these are impossible to do at school, you say. But actually they are not.
Β 
Test, Part 1: I can already here the outcry. How are we going to test all of the children that return to school? Don’t you realize that an infected person is contagious for at least a week? Don’t you realize that infected people can spread COVID-19 without displaying any symptoms (pre-symptomatic or asymptomatic)? And yes, I do realize those things. Any feasible approach to reopening schools will require students to be tested for COVID-19 every other day. Impossible, you say…
Β 
Test, Part 2: Possible, I say. Enter batch testing and intelligent planning. This idea is simple, and feasible. By combining a group of samples, say from all the students and the teacher in one classroom, you can increase testing capacity by 20-30 fold. If anyone in the group is positive, the entire sample will come back positive. Then you can go back and test each individual in that pool. In a low population prevalence situation (such as, thankfully, California) the overwhelming majority of samples will come back negative. Now granted, nasal and cheek swabs are an arduous way of testing but saliva seems to be a particularly good way to isolate the virus. Saliva based tests will most likely be widely available by Fall.
Β 
Test, Part 3: The other efficiency gain of batch testing is that it can be replicated across other activity ‘pods.’ Say a child is part of a sports team, music group or other extracurricular activity – batch testing can also occur there. In this way, an individual might be tested across multiple batches permitting traceable movement across these pods. This leads us to our next pillar…
Β 
Trace. Presumably the movement of children will be easier to track than those of adults since, with the exception of those in the upper grades of high school, they will not be traveling independently. Some may access school through public transportation but, again, with supervised and traceable movements, close contacts should be readily identified, tested and quarantined if needed. Leading us to our final pillar…
Β 
Isolate. This step should be obvious but will place a significant burden on parents and guardians who will now be charged with keeping a child with COVID-19 home for a minimum of two weeks. While symptoms may resolve more quickly in children as compared to adults, two weeks of isolation will be necessary. Schools should have a remote learning option already established as noted above. Therefore, children in isolation after a positive test should be able to access this learning option – thereby relieving some burden on caregivers. In my own (adult) practice I formally evaluate quarantine end by administering 2 COVID-19 tests separated by 24 hours. This, while burdensome, falls in line with the recommendations of the South Korea Centers for Disease Control and would prevent a student from returning to the classroom too early.
Β 
As school districts move forward with reopening plans, no doubt they will spend significant effort communicating those strategies with which we can all agree – staggered start times, social distancing, sanitation and handwashing. However, I have little confidence that they will take the time and effort needed to implement a coherent Test, Trace and Isolate strategy. In fairness, why would they given that as a country we have been unwilling to invest in such a strategy? But, without such, schools will reopen and soon close again as cases spike.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

Dig deeper into the health topics you care about most by signing up for our newsletter.

by submitting this form you indicate you have
read and agree to our Privacy Policy and Terms
of Use. Please contact us to for us for more
information.

19 June 2020 Blog Post: What’s my risk on COVID-19

19 June 2020 Blog Post: What's my risk on COVID-19

Risk estimators are sometimes used in clinical medicine as we try to quantify a patient’s likelihood of having an event (heart attack, stroke for example) or dying of a particular disease. We also use these formulas to guide therapy, such as blood thinners in certain types of heart arrhythmias.

The ASCVD (Atherosclerotic Cardiovascular Disease) Risk Calculator estimates an individual’s 10-year risk of heart disease or stroke. It uses information on age, gender, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure lowering medication use, diabetes status, and smoking status.

A similar mortality risk calculator for COVID-19 has been suggested, spanning a 0-40 range. It was generated from cohort study data performed in Canada. As you can see from the Figure below, risk begins to increase more steeply at a value of 25. The curve is essentially flat (near zero) for values below such. As with all risk estimates, this formula will likely change over time as we learn more.

The formula is as follows:
Β 
(Age/10)*3
+ 2 points if male
+ 3 points if a history of Chronic Obstructive Pulmonary Disease (COPD)
+ 4 points if immune compromised
+ 4 points if a history of Diabetes Mellitus (DM)
Β 
The calculated risk from this formula is one way in which we can better identify those individuals at higher and highest risk of dying from COVID-19 infection.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

Dig deeper into the health topics you care about most by signing up for our newsletter.

by submitting this form you indicate you have
read and agree to our Privacy Policy and Terms
of Use. Please contact us to for us for more
information.

18 June 2020 Post: More Cases, More Testing?

18 June 2020 Post: More Cases, More Testing?

Don’t believe everything you read from the LA Times or from the County Health Department regarding when it comes to rising case numbers in Los Angeles County.

When asked to comment on Saturday’s report of 1,568 new COVID-19 cases and 58 related deaths (marking the fifth day in a row the county reported more than 1,200 new cases), Dr. Barbara Ferrer the LA County Health Director said the following:

β€œThe state did ask us to take a hard look at the fact that our case counts are high,” Barbara Ferrer, the L.A. County health director, said Friday. β€œBut we’ve been working with them, and we’ve shown them our data that indicates that’s really, at this point, a result of a lot of testing.”

Apparently Dr. Ferrer must be looking at different data than are published on their #COVID-19 data portal. Testing rates in Los Angeles County have declined for the past three weeks in a row (Figure 1). This is in stark contrast to testing rates in San Francisco which have almost doubled over those same three weeks. San Francisco performed on average 277.31 tests per 100,000 population a day for the week ending 6/12/2020 while Los Angeles only performed 124.33.

So no, Dr. Ferrer, it really isn’t the result of a lot of testing.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

Dig deeper into the health topics you care about most by signing up for our newsletter.

by submitting this form you indicate you have
read and agree to our Privacy Policy and Terms
of Use. Please contact us to for us for more
information.

17 June 2020 Blog Post: COVID-19 Update

17 June 2020 Blog Post: COVID-19 Update

After a brief hiatus, I have returned to watching news coverage of coronavirus. It seems that the current debate appears to be hung up on the idea of what COVID-19 metric matters. In other words, which is more important – cases, hospitalizations, ICU admissions? There seems to be some general agreement that deaths matter.

This debate reminds me of the decades long back-and-forth about blood pressure. Was it the systolic (top number) or diastolic (bottom number) that better predicted heart attacks, stroke and mortality? This debate went on and on. To the general public the answer will come as no great surprise – both matter. So I think Medicine and Epidemiology have a decent track record of tying themselves into knots over the ‘answer’ when more than one thing can be true.

I started looking a bit more closely at case and mortality rates in Santa Monica in comparison to Los Angeles County as a whole. Los Angeles County has contributed by far and away the most cases and deaths to California’s total: 73,018 cases and 2,907 deaths. Santa Monica has had 340 cases and 22 deaths to date.

I am in the process of reading Hans Roslin’s book “Factfulness” (well worth the read) and in it he gives lots of great advice about numbers and our tendency to generalize. In it he says “single numbers on their own are misleading and should make you suspicious. Always look for comparisons. Ideally divide by something.” And, further, “look for differences within groups, look for similarities across groups and do not assume that what applies for one group applies for another.”

Readers should be familiar now with my graphs of case rates which are presented as a daily number (i.e. number of cases per day) expressed as a function of 100,000 population. This daily rate is an average, smoothed over the prior 7 days to account for delays in reporting (and that fewer cases are identified over weekends, for example). So looking at Figure 1 we see that Santa Monica consistently has had fewer cases adjusted for population, and for the week ending 6/12/2020 we have about 1/3 as many as Los Angeles County as a whole: 3.97 daily cases versus 11.52 daily cases.

Good news right?
Β 
Seems to be until you compare average daily mortality rates – these are shown in Figure 2. For the week ending 6/12/2020, Santa Monica and Los Angeles County have essentially identical rates: 0.26 daily deaths for Los Angeles County and 0.27 for Santa Monica.
So what does this mean?
Β 
Well to return to Rosling’s basic tenets of Factfulness, Los Angeles County and Santa Monica have very different case rates. However, these two regions have essentially identical mortality rates. Said in another way, 44 cases in Los Angeles County are necessary to result in one death but only 14 cases are needed to lead to one death in Santa Monica.
Β 
Now I’m obviously not the first person to make this observation (although to be fair I have not seen this phenomenon expressed so bluntly). Johns Hopkins Coronavirus Resource Center has noted such differences in mortality rates across countries and suggests a few explanations. These include:
Β 
1. Differences in the number of people tested: With more testing, more people with milder cases are identified. This lowers the case-fatality ratio (possible but daily testing rates for Santa Monica are not published).
2. Demographics: For example, mortality tends to be higher in older populations (possible but daily counts by age are not published by Los Angeles County or Santa Monica).
3. Characteristics of the healthcare system: For example, mortality may rise as hospitals become overwhelmed and have fewer resources (theoretically possible but Santa Monica hospitals have certainly not been overwhelmed by COVID-19 cases).
4. Other factors, many of which remain unknown (a particularly unsatisfying explanation).
Β 
But I think one key point can be concluded from this analysis. Both cases and deaths matter. But, if it takes fewer cases in a particular community to result to a single death, then reduction in cases takes on a heightened urgency.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

Dig deeper into the health topics you care about most by signing up for our newsletter.

by submitting this form you indicate you have
read and agree to our Privacy Policy and Terms
of Use. Please contact us to for us for more
information.

15 June 2020 Blog Post: COVID-19 in Los Angeles County; More Clarity, More Questions

15 June 2020 Blog Post: COVID-19 in Los Angeles County: More Clarity, More Questions

Cases of COVID-19 decreased last week in Los Angeles County for the first time in five weeks (Figure 1). Before you get too excited, it decreased from 11.61 daily deaths per 100,000 population to 11.52.

Testing rates in Los Angeles County declined for the third week in a row (Figure 2). For the week ending 5/22/2020 there were 160 tests performed each day per 100,000 population. We are now down to 124.33. So we are essentially seeing the same number of cases with less testing. The exact opposite of the argument put forth to explain why we are seeing increasing case numbers in Florida, Arizona and the Carolinas.

In what is without a doubt good news, mortality rates continue to decline steeply in Los Angeles County (Figure 3). We are actually in our 5th week of decline. Mortality rates peaked the week ending 4/24/2020 at 0.45 deaths a day per 100,000 population. They are now almost half that value at 0.26.

So why are we seeing fewer deaths? The most logical explanation is that a higher proportion of cases are now being identified among younger Los Angeles residents. Of course, those data are not published by the County Health Department. Instead they only present a cumulative age distribution rather than showing change in age distribution over time. So, once again, the public is left guessing when that theory could be easily answered.

While falling mortality rates are without question good news, it is concerning that testing rates are continuing to fall in the County. We should be asking our public health officials why they are doing less testing, how they can promote more testing and why data on age distribution of cases over time is not readily available.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

Dig deeper into the health topics you care about most by signing up for our newsletter.

by submitting this form you indicate you have
read and agree to our Privacy Policy and Terms
of Use. Please contact us to for us for more
information.

14 June 2020 Blog Post: COVID-19 Accelerates in Riverside County

14 June 2020 Blog Post: COVID-19 Accelerates in Riverside County

For those of you who have followed our posts regularly, you will remember that I have been tracking COVID-19 case rates in Riverside County. I began following rates after a May 8th Board of Supervisors decision to rescind public health mandates for face coverings after the Riverside County Sheriff refused to enforce such.

Riverside County now has the second-highest number of cases and deaths statewide after Los Angeles County and their case numbers have accelerated to their highest rates thus far in the epidemic (see Figure below).

Riverside County health officials are now urging residents to remember the importance of continuing safe health practices as the county passed 10,000 confirmed coronavirus cases.
Β 
β€œThe 10,000-case figure is a stark reminder that coronavirus is still active in the community and we need to continue the health practices that previously helped us flatten the curve,” said Kim Saruwatari, director of Riverside University Health System-Public Health.
Β 
Riverside County’s COVID-19 curve has not been flat since May 15th. Two weeks after the ill conceived Board of Supervisors decision their curve has accelerated upwards.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

Dig deeper into the health topics you care about most by signing up for our newsletter.

by submitting this form you indicate you have
read and agree to our Privacy Policy and Terms
of Use. Please contact us to for us for more
information.

12 June 2020 Blog Post: Orange County Removing Their Masks to Spite Their Own Face

12 June 2020 Blog Post: Orange County: Removing Their Masks to Spite Their Own Face

It is, admittedly, difficult to keep up with all of the #COVID-19 news but the lunacy occurring in Orange County has the makings of a public health nightmare of their own creating.

On June 8th, Orange County’s Health Officer Dr. Nichole Quick quit her position after receiving death threats over her order for people to wear masks in public. Irate residents blasted the requirement, and the county sheriff said he wouldn’t enforce it (sound familiar Riverside County?). Dr. Clayton Chau who has now assumed Dr. Quick’s position then lifted this requirement “after taking a closer look at the state’s virus monitoring criteria.”

Here’s the scientific problem with this misguided approach, a study published this week by Renyl Zhang and colleagures from Texas A&M and Cal Tech has shown that the primary determinant in shaping the spread of COVID-19 is mandated face coverings. What a time to be on the wrong side of science and history, especially when the answer is a mouse click away.

But lets break the paper down a little bit further to understand its conclusions. First off, Dr. Zhang is in the Department of Atmospheric Sciences which is a fascinating perspective by which to study an airborne pathogen. The authors evaluated three epicenters of the disease: Wuhan, Italy and New York City. They then compared the outbreak trends in each region in the context of various mitigation measures – including mandated face coverings, social distancing, quarantine, hand sanitizing and minimizing social contacts. Their atmospheric analysis was so detailed that they concluded that winter haze conditions in Wuhan likely exacerbated viral spread because of low UV radiation and air stagnation.

Their analysis of these three massive outbreaks of COVID-19 showed that the primary determinant in shaping the trend of the pandemic was mandated face coverings. This protective measure “significantly reduces the number of infections” by blocking atomization and inhalation of virus-bearing aerosols AND contact transmission by blocking viral shedding of droplets. The unique function of face coverings accounted for significant reduction in infections in China, Italy and NYC.

Now Orange County isn’t solely to blame. One month ago Riverside County similarly decided to roll back mandated face coverings – and this has not worked out well for them. The WHO and CDC have thus far emphasized the prevention of contact transmission and largely ignored the importance of face coverings. As the authors note “clearly, integration between science and policy is crucial to formulation of effective emergency responses by policy makers and preparedness by the public for the current and future public health pandemics.”

So Orange County, somehow surgeons can manage wearing a facemask through procedures lasting 8, 12 or even 14 hours without passing out from “toxic levels of CO2.” I think mandating you wear one for a 20 minute trip to the grocery store is not a major imposition when it is the most effective means to prevent person-to-person spread of COVID-19.

Plus, it is more than a bit disingenuous to threaten a Public Health Officer’s life when she is trying to save yours.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

Dig deeper into the health topics you care about most by signing up for our newsletter.

by submitting this form you indicate you have
read and agree to our Privacy Policy and Terms
of Use. Please contact us to for us for more
information.

11 June 2020 Blog Post: Opening Up In Los Angeles County: Once Again, Misguided

11 June 2020 Blog Post: Opening Up In Los Angeles County: Once Again, Misguided

Los Angeles County health officials announced today that gyms, day camps, museums, zoos, campgrounds and various other outdoor recreation facilities will be permitted to reopen Friday, joining other parts of the state in Phase 3. Also allowed to reopen are fitness facilities, pro-league arenas and professional sports without live audiences, galleries, aquariums, RV parks and swimming pools, along with music, film and television production. Hotels, lodging and short-term rentals can also resume operations.

For those reading the fine print, today’s briefing came as Los Angeles was one of nine counties placed on a watch list by California health officials concerned about their ability to contain COVID-19 spread amid reopening plans.

Perhaps what Dr. Ferrer and the Health Department need is a little perspective before they go charging forward. In the San Francisco Bay area, there is considerable debate about “too much, too soon” as well as disproportionate COVID-19 case burdens. Our comparison graph below (Figure 1), however, shows that the City of San Francisco is in a far better position than Los Angeles to reopen. Here in Los Angeles, we have a 340% higher daily case rate than San Francisco.

Well is that because of testing? Absolutely not.
Β 
Last week, in San Francsico they performed on average over 232 tests per 100,000 population per day. In Los Angeles? 109 tests.
Β 
So one third of the number of cases with more than twice the amount of testing. And San Francisco is the city fretting.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

Dig deeper into the health topics you care about most by signing up for our newsletter.

by submitting this form you indicate you have
read and agree to our Privacy Policy and Terms
of Use. Please contact us to for us for more
information.