Categories
Epidemiology Medical Economics

Should You Mandate Employee COVID-19 Vaccination?

“Individual freedom!” has been the rallying cry of a highly vocal but increasingly small minority of Americans who oppose COVID-19 vaccines. Most of these anti-vaxxers represent the intersection of ignorance, arrogance, and obstinance. But should you require them to get vaccinated if they are your employees? In a free market economy, businesses with vaccinated employees have a competitive advantage over businesses with unvaccinated employees.

COVID infection is costly

A study from the City University of New York found that the average direct medical cost of a symptomatic COVID-19 infection is $3,045. Infections that require hospitalization are considerably more expensive than those that can be managed as an outpatient. A report from CMS found that the Medicare payments for a COVID-19 hospitalization was $24,033 (this does not include co-pays that the individual is responsible for). A study in JAMA Open Network this week found that the average out-of-pocket co-pay for a COVID-19 hospitalization was $3,804. A report from the Kaiser Family Foundation found that the average cost of COVID-19 hospitalization for commercially-insured patients with pre-existing medical conditions is estimated to be $20,292 (commercially-insured patients are younger than Medicare patients, have fewer medical co-morbidities, and tend to have shorter hospital stays – all resulting in lower cost per hospitalization than Medicare patients).

In addition to direct medical costs, there is a cost of lost worker productivity during their infection. Recommendations by the CDC are persons infected with COVID-19 should not return to the workplace for at least 10 days from the onset of symptoms. Those persons who are immunocompromised or who require hospitalization for more severe COVID-19 infections should not return for 20 days. Asymptomatic persons who test positive for COVID-19 should not return to the workplace for 10 days from the date of the COVID-19 test. In total, COVID-19 absenteeism is quite costly to employers.

Unvaccinated employees cost more

Vaccines are effective in preventing COVID-19 infection. Overall, unvaccinated persons are 6.1 times more likely to test positive for COVID-19 than vaccinated persons. That means that unvaccinated persons are 6.1 times more likely to be absent from work for at least 10 days. They are 6.1 times more likely to incur the $3,045 direct medical cost of the average COVID-19 infection. The graph below shows the COVID-19 case rate per 100,000 for vaccinated and unvaccinated Americans of working age.

Vaccines are even more effective in preventing severe infection; most of the people hospitalized for COVID-19 infection are now unvaccinated. The CDC reports that unvaccinated COVID-infected persons are 12 times more likely to require hospitalization than unvaccinated persons. Preliminary data suggest that unvaccinated persons are 20-30 times more likely to require ICU admission for COVID-19 infection than vaccinated persons. The graph below shows hospitalization rates per 100,000 for vaccinated versus unvaccinated persons.

Older unvaccinated workers are even more likely to require hospitalization. The CDC reports that in August 2021, persons age 50-64 were 30 times more likely to require hospitalization if they are unvaccinated versus being vaccinated. Currently, the cost of those hospitalizations is being borne by commercial insurance companies and by Medicare. However, in the future, this will translate to higher health insurance costs and higher Medicare costs. These costs will then be transferred to employees by higher health insurance premiums and higher Medicare payroll taxes

Not only are vaccinated employees more likely to be hospitalized with COVID-19, but they are also more likely to die if they get COVID-19. In August, the overall death rate was 11.3 times higher in unvaccinated than vaccinated persons. Dead employees not only result in the cost of replacing them but they also generate life insurance payouts that then result in higher life insurance premiums for the business. The graph below shows the number of COVID-19 deaths per 100,000 in vaccinated versus unvaccinated people of working age. One implication of this graph is that it is safer for a company to hire a 70-year-old vaccinated employee than to hire a 30-year-old unvaccinated employee from a COVID-19 death risk standpoint.

 

Unvaccinated workers who are exposed to COVID-19 also incur higher lost productivity costs than vaccinated workers. Recommendations by the CDC are that unvaccinated employees exposed to COVID-19 quarantine at home for 14 days from the date of exposure. However, vaccinated employees do not need to quarantine and can continue to work as long as they wear a mask. These worker absences can be very costly to the employer who continues to pay the worker who is off work (“sick time”) and has to additionally pay someone else to do that worker’s job (often requiring expensive overtime pay). Because of the different quarantine requirements, it is far more costly to the employer if an unvaccinated employee is exposed to COVID-19 than if a vaccinated employee is exposed, even if the employee has no symptoms.

If vaccines save so much money, why don’t we just mandate them?

Vaccine misinformation has permeated the American public and has spilled over into American politics. Intuitively, one would have thought that Republicans would have been more pro-vaccine than Democrats given that Republicans historically were aligned with business and were in favor of policies that reduce business costs. Furthermore, Republicans historically opposed legislation that places constraints on the free market. Paradoxically, during the COVID-19 pandemic, Republicans have fought against vaccinations that could have lowered costs to businesses. Republicans have also introduced legislation that would prevent individual businesses from requiring employee vaccinations – even when businesses believe that having 100% employee vaccination can give them a free market competitive advantage over other businesses. As a consequence, when it comes to COVID-19 legislation, Chambers of Commerce have been aligning themselves with Democrats rather than their normal alignment with Republicans.

Most Americans are already vaccinated. As of this week, 66% of us have received at least one dose of a COVID-19 vaccine. Because many children are not eligible to be vaccinated, a better metric is the percent of adults who are vaccinated – currently 79% of Americans over age 18 have received a vaccine and 96% of Americans over age 65 have received a vaccine. The people who are vaccinated are not the ones who are vocally protesting against vaccine mandates – it is the minority of Americans who are not vaccinated that are making all of the noise. They are also the ones who are filling up our hospitals, increasing costs to employers, and increasing costs to Medicare and insurance companies. Getting these Americans vaccinated is not just good for our country’s health but it is good for our nation’s businesses. So, how to best get them vaccinated?

The mandate versus the nudge

A mandate is a directive requiring an employee to do something. A nudge is a more subtle means of influencing employee behavior without imposing a mandate. An example of a nudge applied to COVID-19 would be to make it easy for employees to get vaccinated by giving them paid time off work to get vaccinated. A nudge can be as simple as providing education about COVID-19 and vaccines in the workplace. Some employers use the nudge of paying their employees to get vaccinated and in Ohio, we have a free tuition lottery that vaccinated teenagers are automatically enrolled in. Public shaming can be a powerful nudge, for example requiring unvaccinated employees to wear masks at work but allowing vaccinated employees to work mask-free, making it clear to all who is and is not vaccinated. But perhaps one of the most effective nudges is to transfer the costs of COVID-19 to unvaccinated employees.

This was the approach taken by Delta Airlines which increased insurance premiums by $200 for unvaccinated employees. So far, 90% of Delta employees are now vaccinated and Delta projects that 95% will be vaccinated within the next month. On the other hand, United Airlines mandated vaccination and currently has 96% of its employees vaccinated with 3% having a medical/religious exemption to vaccination and only 1% of employees refusing vaccination. American Airlines and Southwest Airlines are also mandating vaccinations but their company policies are being stymied by a Texas law prohibiting businesses with headquarters in Texas from requiring vaccinations. This represents a fascinating social experiment: whether the mandate is more effective than the nudge. Over the next year, we will have an answer to this question and future economic analysis will show us which is the most cost-effective: the Delta Airlines strategy or the United Airlines strategy.

The difference between a mandate and a nudge is that a mandate eliminates choice but choice is inherent in a nudge. As a species, Americans rebel when being told what to do and are passionate about having the freedom of choice. In the song Growing Up, Bruce Springsteen said this better than anyone when he sang: When they said “sit down”, I stood up. The nudge can influence us to change our behavior without requiring us to change our behavior. But there are situations when the mandate is essential, for example, in the military on the battlefield.

When is the mandate better?

The danger of a vaccine nudge is that it may not be effective and if the business needs all of its employees to be vaccinated in order to be competitive, relying on the nudge could put the business at a competitive disadvantage. As an example, elective orthopedic hip replacement surgeries are very lucrative and are mostly performed in people over age 65. These older people have COVID phobia (which is why 96% of them have received a vaccine). The hospital that boasts that all front-line employees are vaccinated will be at a competitive advantage to attract people needing a hip replacement surgery compared to a hospital with unvaccinated nurses and doctors.

Many, if not most, businesses actually welcome legislated vaccine mandates. When the mandates come from the government, then the employer does not have to take responsibility for the mandate and can tell employees “Hey, this requirement is from the government, I’m just the messenger…”. Furthermore, with government mandates, a business does not need to worry about losing employees to its competition over vaccine requirements. If only one restaurant in town mandates vaccinations, there is a danger that the serving staff may quit and go work for a different restaurant rather than get vaccinated but if the State Health Department mandates that all restaurant employees in the state get vaccinated, then those serving staff will be unable to get a job anywhere if they remain unvaccinated.

In states with a high percentage of the population vaccinated, it is easier for employers to mandate vaccination because the pool of unvaccinated employees is relatively small to begin with. The implication is that if you have employees who quit rather than getting vaccinated, there will be ample other workers out there who are vaccinated and who you can hire to replace them. Thus, it is safer for a business owner in California to mandate vaccinations than for a business owner in West Virginia. The graphic below shows the geographic variation in vaccination status.

Similarly, within each state, there are regional variations in vaccination rates that can affect the worker pool and thus the willingness of a business to invoke a vaccine mandate. For example, in Ohio, it is more feasible for a restaurant owner in Delaware County, where 68% of the population has received a vaccine, to mandate employee vaccinations than in Holmes County, where only 15% of the population has received a vaccine. The restaurant owner in Holmes County will have a difficult time finding vaccinated applicants to replace unvaccinated workers who quit because of a vaccine mandate. In the graphic below, Delaware County is the darkest shade county in the middle of the state whereas Holmes County is the lightest shade county.

Another situation where vaccine mandates may be preferable is when mandates can mitigate personal injury litigation. Ever since COVID-19 vaccines have been available to all adults, there is a risk of getting sued if a customer becomes ill or dies from a COVID infection acquired at a business. In many situations, causality can be hard to prove. For example, it can be hard for a customer to conclusively prove that he acquired COVID-19 from an infected bartender at the pub that the customer was in for 45 minutes one evening. However, hospitals may be uniquely vulnerable since patients hospitalized for several days with non-COVID-19 conditions are as a group more susceptible to having severe COVID infections and hospitals have robust epidemiology measures in place that can effectively trace disease contacts. In the future, a hospital will likely be held responsible in civil court for patients who become infected from an exposure to an unvaccinated nurse with COVID-19.

When is the nudge better?

The danger of a vaccine mandate is that some recalcitrant anti-vaxxer employees may decide to quit. For many businesses, this may actually be a good thing if those individuals have a history of being disruptive or otherwise being problem employees in the past. But in other businesses, a large number of employees quitting because of a vaccine mandate can lead to worker shortages, reduced business production, and unfavorable public relations. The wise employer will find out which employees are unlikely to get vaccinated before the employer roles out a vaccine mandate. Strategically timing a vaccine mandate after researching employee vaccination status may provide the company with a rare opportunity to eliminate undesirable employees without having to deal with a protracted human resources battle over alleged unlawful job termination.

In some businesses, particularly those with a small number of employees, relentless education will eventually sway all but the most rabid anti-vaxxers. Once all of the existing employees are vaccinated, then the business can adopt a proof of vaccination requirement for all new employees, thus getting the benefits of the mandate without losing any employees.

Sometimes, the incremental nudge can be highly effective. With the incremental nudge, employee choice is preserved but over time, the consequences of choosing to be unvaccinated become incrementally more onerous for the employee. An example is as follows:

  • Step 1: Education about COVID-19 vaccination in the workplace
  • Step 2: Paid time off to get vaccinated and recover from any vaccine-related side effects
  • Step 3: Pay an incentive of $100 to every vaccinated employee
  • Step 4: Requirement that unvaccinated employees wear masks at work but vaccinated employees are not required to wear masks
  • Step 5: Requirement that unvaccinated employees get weekly COVID-19 nasopharyngeal swab tests
  • Step 6: Requirement that unvaccinated employees get daily COVID-19 nasopharyngeal swab tests
  • Step 7: Increase health insurance premiums for unvaccinated employees by $500 per year
  • Step 8: Increase life insurance premiums for unvaccinated employees by $500 per year
  • Step 9: Mandate vaccination

By the time the employer reaches step 8, only the most hardened anti-vaxxers will remain unvaccinated. This will be a relatively small percentage of employees and will mostly be disruptive employees that the employer would like to have an excuse to get rid of anyway. Therefore, step 9 could be mandating vaccinations and then terminating those few remaining unvaccinated employees. This allows the employer to time the mandate strategically in order to selectively cull the employment roster.

The future is right around the corner

In the very near future, there will be two kinds of people: those who are vaccinated against COVID-19 and those who either have had or will have COVID-19 infection. This pandemic is different than the SARS, MERS, and Ebola outbreaks – in those outbreaks, the virus was able to be contained locally until no new infections occurred. COVID-19 today is too widespread throughout the world and has long past the time when it could be locally contained. This pandemic is also different from the 1918 influenza pandemic and the 2009 H1N1 pandemic – in those pandemics, the inciting virus eventually disappeared and was replaced by other, less deadly strains of the virus. COVID-19 does not show any signs of going away or being replaced by a less deadly coronavirus.

Thus, it appears that COVID-19 is going to be with us for a long time and unless all nations can mount a universally successful vaccination campaign, as was done with polio, COVID-19 may be with us indefinitely. But it is clear that vaccination is the only way out of a perpetual pandemic. The good news is that the number of unvaccinated people is dwindling as the tolerance of the vaccinated for those who are unvaccinated also dwindles.

October 20, 2021

Categories
Epidemiology

Why The Purveyors Of COVID Misinformation Keep Winning

Physicians and scientists keep asking why so many Americans are so gullible as to believe in many absurd claims about COVID-19 and the COVID vaccine. For those of us who are taught to be able to read and interpret an article from a medical journal, the reality, epidemiology, treatment, and prevention of the viral infection just seems so obvious. The safety and efficacy of the COVID vaccines seems so indisputable. But many Americans are convinced that COVID infections are not very serious and that the COVID vaccines are more dangerous than the infection.

So, what happened?

There is clearly more than one answer to this question but one of those answers is that the medical community has made information about scientific development inaccessible to the general public whereas the architects of COVID misinformation have made their falsifications readily available to the public. They are winning the information war.

Education level is the strongest predictor of vaccination status

The June 2021 U.S. Census Pulse Survey has a wealth of information about the demographics of COVID vaccination. Although we hear a lot about racial inequities in COVID vaccination, the strongest predictor of whether or not a person gets vaccinated is education level. The survey found that 90.8% of Americans with a college degree have received a COVID vaccine but only 68.6% of those with less than a high school degree have received a vaccination. Not only have those people with lower education levels not yet received a vaccination, they also say that they are not getting one in the future. These are not people who are reading science journals, they are getting their information from social media. They trust media celebrities more than they trust doctors to know about COVID treatment. They trust political pundits more than they trust scientists to know about the science of coronavirus infection.

Physicians and scientists all too often speak a language that people with a high school education or less do not comprehend. Sometimes, it is not so much that they are gullible to what the purveyors of COVID misinformation are saying as much as they cannot understand what scientists are saying. When we open our mouths, confidence intervals, means, medians, and probability values come out. When COVID miscreants open their mouths, dogma comes out. Scientists are boring, miscreants are charismatic. If we are going to sway these Americans to get vaccinated and wear masks, we have to communicate with them in a way that they understand.

Science is not accessible to most people

For decades, physicians and scientists have communicated results of medical and scientific research through journals. Every university professor knows that to get tenured, you have to publish. Publishing does not just mean writing a post for a blog, it means getting an article accepted in a peer-reviewed medical journal. But not all medical journals are equal. For an academic physician or scientist to get promoted, it is not only the number of articles that they publish but it is also the quality of journals that their articles are published in. That quality is most commonly measured by the impact factor which is a measurement of how often articles published in those journals are cited (referenced) in other journal articles. In other words, the more times articles from a given journal are cited by other researchers, the larger the impact factor of that journal. Therefore researchers try to get their articles published in journals with the highest impact factors. The most commonly used impact factor measurement is the journal citation reports by Clarivate. Examples are in the table below:

 

Most medical journals are funded by a combination of reader subscriptions and paid advertising (usually medication ads). Because of the requirement for paid subscriptions, the articles in these journals are inaccessible to anyone without a subscription. As examples, the New England Journal of Medicine and JAMA both cost $199/year. As a consequence, unless you are one of the privileged few who can either afford to subscribe to a lot of medical journals or are a faculty member of a university with a library that has an institutional subscription, you cannot read these journals.

This has been a criticism of academic medicine for many years. As a result, Patrick Brown, MD, PhD (inventor of the Impossible Burger) and Michael Eisen, PhD created the Public Library of Science (PLOS) that publishes 15 open-access scientific journals that are free on the internet for anyone to read. One of these is PLOS Medicine, with an impact factor of 11.069. The PLOS journals are funded by fees paid by the authors when they get an article published; these funds generally come from the authors’ research grants. Although open-access journals, such as the PLOS journals, are a great idea, they only account for a tiny fraction of all of the current medical journals.

The purveyors of misinformation don’t charge subscriptions

In contrast to scientific journals, anti-vaxxers and other producers of misinformation about COVID do not rely on paid subscriptions for the public to access their propaganda. They make it freely and widely available using social media. Furthermore, articles in scientific journal articles are full of technical terms and complicated statistics that even physicians and scientists often do not understand. In contrast, COVID misinformation is written for the masses, usually at a grade school level, so that anyone can understand it.

Physicians and scientists do not get tenure and do not get promoted based on their tweets and number of Facebook posts. The purveyors of COVID misinformation count their success by their number of Twitter followers and Facebook friends.

They are not subject to the torment of peer review

Scientific journals require that articles submitted to them by researchers be peer-reviewed. This process involves sending the manuscripts out to volunteer scientists working in the same area who read over the manuscript and critique the article based on how rigorous the experiments were, how accurate the statistics are, how correct the conclusions are, and how important the findings are. I have reviewed dozens of articles as a peer reviewer and it takes a lot of time – at least a couple of hours per article and sometimes many hours. The reviewers are generally anonymous so that the author of the article does not know who the reviewers are. Sometimes, the reviews can be extremely harsh – many people will say much more negative criticisms when they are anonymous than they would if the author knows who is doing the reviews. Sometimes, the reviewers can feel threatened by the findings of an article under review if that article refutes the reviewers own work or if it will beat out publication of competing research that the reviewer is also working on. Bitter reviews can be very discouraging, particularly to younger scientists. Nevertheless, despite often being painful to the article authors, the peer review system is the best way of ensuring that the information that ultimately gets published in medical journals is accurate.

Anti-vaxxers, anti-maskers, and other curators of COVID misinformation are not subject to peer review. They can say anything they want and if it appears in print or on the internet, then to the average lay person, it seems just as legitimate as a peer-reviewed scientific article. Twelve people are responsible for 65% of all of the COVID misinformation on the internet. These are the so-called disinformation dozen:

  1. Joseph Mercola, DO
  2. Robert F. Kennedy, Jr.
  3. Ty Bollinger
  4. Sherri Tenpenny, DO
  5. Rizza Islam
  6. Rashid Buttar, DO
  7. Erin Elizabeth
  8. Sayer Ji
  9. Kelly Brogan, MD
  10. Christiane Northrup, MD
  11. Ben Tapper
  12. Kevin Jenkins

These 12 operate businesses and organizations that financially benefit from COVID misinformation such as selling potions and “natural” remedies on-line or selling books and classes about COVID misinformation. In other words, they are professional anti-vaxxers and anti-maskers who make their living by producing COVID misinformation content. The more outrageous the claims they make on social media, the more attention they get. The more attention they get, the more stuff they sell. The more stuff they sell, the more money they make.

In contrast, scientists do not get paid anything for the articles that they publish. Indeed, many journals charge the authors of scientific articles a publication fee (especially open access journals). Furthermore, if the author of a scientific article has a conflict of interest that would result in them profiting from the publication of their experiments, then they have to publicly acknowledge that conflict of interest and the editor of the journal may not allow publication.

Five of the disinformation dozen are physicians and having “Dr.” in front of their names gives them instant credibility. So who are the Doctors of Disinformation? Joseph Mercola, DO has claimed that mobile phones cause cancer and  HIV does not cause AIDS; he has an alternative medicine business that sells tanning beds to prevent skin cancer. Sherri Tenpenny, DO famously testified to the Ohio Legislature that COVID vaccines cause people to become magnetized. Rashid Buttar, DO practices alternative medicine and uses intravenous hydrogen peroxide and EDTA to treat cancer.  Kelly Brogan, MD practices “holistic psychiatry” and advocates using coffee enemas to treat depression. Christiane Northrup, MD is a gynecologist who uses Tarot cards to diagnose disease and believes that her wisdom comes from her experiences in her previous life in Atlantis. A sixth member of the disinformation dozen, Ben Tapper, is a chiropractor who introduces himself Dr. Ben Tapper to claim legitimacy for his beliefs that face masks cause disease.

So, how do we get the truth out?

It costs a lot of money to operate a medical journal. You have to pay the editors and the staff salaries. You have to rent office space. You have to pay print and mailing expenses. To cover those costs, the journal either has to sell advertising, sell subscriptions, or charge the authors publication fees. I’ve always been a bit uncomfortable with the fact that much of the costs of our journals are paid for by medication advertisements by pharmaceutical companies that at some level seems itself like a conflict of interest. Subscription fees create a barrier for dissemination of scientific information to the general public. Charging the authors of scientific articles seems like the least bad funding mechanism. Whatever the solution, making journal articles open access for anyone to read is needed.

If if science eventually becomes freely available to everyone, the medical profession needs to beat the purveyors of COVID misinformation at their own game. If the general public gets its information about COVID from Facebook and Twitter, then we need to use these same forums for spreading information about the benefits of vaccines and masks.

As physicians, we should demand that doctors who profit from creating misinformation, such as Sherri Tenpenny, be reviewed by their state medical boards to determine if their medical licenses should be revoked. In 1998, British transplant surgeon, Dr. Andrew Wakefield, falsified research claiming that the measles, mumps, and rubella (MMR) vaccine caused autism; he was struck from the UK medical register and barred from practicing medicine ever again. Those doctors who profit from disseminating COVID misinformation should be treated the same. They are a stain on our profession.

The public also bears responsibility to advocate social media business, such as Facebook and Twitter, to ban those who profit by marketing misinformation. Just as journal editors reject articles using bad science, social media companies should reject account applications from individuals such as the disinformation dozen.

Whether you are trying to sell a product or win a political campaign, there are few things more powerful than advertising. To date, advertising about COVID has relied on public service announcements. With the approval of the Pfizer COVID vaccine, I hope that Pfizer will contract with American advertising companies to create vaccine advertisements. Advertisers know how to sell products better than doctors or scientists. I look forward to the day that Pfizer vaccine ads appear on the Fox News Channel.

September 1, 2021

Categories
Epidemiology

The Lunatic Fringe

From time to time, I get letters in response to some of my posts. In the interest in providing an equal opportunity to present opposing viewpoints, I am posting a letter responding to my recent post entitled “Anti-Vaccine Laws Are Anti-Business Laws“.

Dear Dr. Allen,

I am writing to you about your recent blog post where you said that businesses ought to be allowed to mandate vaccines for their employees. I could not disagree more. The legislation proposed in Ohio House Bill 248, introduced by Representative Jennifer Gross, will prevent businesses, schools, and hospitals from mandating their employees and students get vaccines. This bill a great idea because everybody knows that vaccines make your body become magnetic but it needs to go further. I’m tired of so many government mandates that interfere with American freedoms. I believe that this bill needs to include amendments prohibiting other intrusive mandates.

The first mandate that needs to go is the requirement that restaurants mandate employees have to wash their hands after using the bathroom. Why should a business require its employees to wash their hands? I saw on Facebook that washing your hands causes hand cancer – these restaurants are simply mandating that their workers get hand cancer. Before you know it, everyone is going to be running around with their hands amputated off because of hand cancer. And then if no Americans have hands any more, then who is going to keep all of the illegal immigrants out? Unbelievable! I also read in People magazine that Ashton Kutcher doesn’t take baths or showers. The doctors say that washing your hands is good hygiene but who are you going to believe, Ashton Kutcher or a bunch of doctors? I’ll take Ashton any day.

And speaking of restaurants, I’m sick and tired of seeing signs on the doors that say “No shirt, no shoes, no service”. They have no right to mandate that I wear clothes into their building. I was born naked and if that is good enough for God, then it sure ought to be good enough for these restaurants! Besides, these signs are unconstitutional. It clearly says in the second amendment that Americans have the right to bare arms. So, if we have the right to bare arms, don’t we also have the right to bare feet?

Last month, I had to have my bunions removed and when they were taking me into the operating room, all of the doctors and nurses were wearing face masks. Face masks! Can you believe it? I asked them what in the world they were doing and they said that that face masks were mandatory when they do surgery. Everyone knows that face masks give off toxic chemical fumes and prevent oxygen from getting into your brain. I didn’t want some oxygen-starved surgeon who was high on face mask chemicals operating on me! I walked right out of that operating room and decided to leave my bunions right where they are.

And another thing, there are businesses out there that are mandating that employees have driver’s licenses. I tried to get a job as a school bus driver because I heard they make good money. A few years ago, some idiot judge took away my driver’s license just because I had 17 DUIs. Not only is the government mandating that I can’t drink a few Budweisers while I’m driving but the school system is mandating that I have to have a valid driver’s license to drive a bus. I took driver’s ed back in ’67 when I was in high school so why should I have to have a driver’s license? Ridiculous.

And what about mandatory in-service training? My brother-in-law is a pilot for Delta and he tells me that Delta is mandating that he have in-service training before he can fly one of their new jets. Can you believe it? Anyone who can fly a Cessna can fly a 737. These mandatory in-service trainings need to be against the law! And don’t even get me started about mandatory staff meetings! 

And talking about airplanes, I flew to Vegas last month and at the airport, they made me go through a TSA check. It was scandalous!. They said it was to check for weapons because the government mandates that people can’t take guns onto planes anymore. When did that happen? Ohio needs a law prohibiting TSA mandates about weapons checks. What are we going to do if the plane gets taken over by a bunch of space aliens that beam onboard? How are we supposed to defend ourselves then? If TSA takes the guns from law-abiding citizens, pretty soon the only ones on the planes who have guns will be the space aliens.

I’ve also heard that tickets are mandatory to get into Ohio State University football games. This is appalling! OSU is a state-supported university and I am an Ohio taxpayer so why should I have to buy a ticket to get in to see a football game? Whats next – are they also going to mandate that you have to pay for hotdogs and beer at the concession stand too?

For years, people have been telling me that I’m a left-wing extremist on the lunatic fringe. Well, even though Ohio Representative Jennifer Gross is a Republican, I’m still glad to have her join me in the lunatic fringe!

Sincerely,

Mr. I.M. Stultus

August 26, 2021

Categories
Epidemiology

Anti-Vaccine Laws Are Anti-Business Laws

The above is a clip from the website of a restaurant in Bar Harbor, Maine. I’ll be in Bar Harbor next month and will only order food at restaurants that I feel are safe. I’ll be taking my business to this restaurant because they advertise that their staff are all vaccinated against COVID-19.

Presently, there is proposed legislation in the Ohio Statehouse (House Bill 248) that would prevent Ohio businesses from requiring their employees get COVID-19 vaccines. As a strong proponent of free markets, I think this is an incredibly bad idea.

Businesses differentiate themselves in order to gain a competitive advantage. Businesses win by advertising that they provide something that their competitors do not have and thus attracting customers who want that something. The more the government regulates what a business can or cannot do, the less freedom that business has to differentiate itself from its competitors.

A business that can attract more customers by advertising that all of its employees are vaccinated should not be restricted by excessive governmental regulations prohibiting it from requiring employee vaccination. 

As of today, 60% of all Americans have received at least one dose of a COVID-19 vaccine. 70% of Americans over age 12 have received a vaccine dose. 91% of Americans over age 65 have received a vaccine dose. Of importance to businesses, most of the remaining unvaccinated are low income Americans whereas high income Americans are largely vaccinated. A pulse survey of the U.S. Census of 3,777,136 Americans in June 2021 found that the largest percentage of Americans who either have received or plan to receive a COVID-19 vaccine were those reporting a household income > $200,000/year. The next highest percentage of vaccinated persons were those with a household income $150,000 – $200,000. The lowest percentage of vaccinated persons were those reporting an annual household income < $25,000. The majority of Americans are getting vaccinated, particularly middle income and high income American adults who are the most likely to go to a business and spend money. Many, if not most, of these American adults are going to prefer to support businesses that have taken the same steps that they have taken with vaccination in order to keep themselves, their families, and their communities safe.

Data from the recent full U.S. census shows that two-thirds of Ohio counties lost population in the past decade. Because the population of many other states is growing faster than Ohio, we will be losing one U.S. congressional seat this year. One of the most effective ways to stop this loss of population and the loss of Ohioans’ voice in the U.S. House of Representatives is to attract businesses to Ohio, particularly businesses that pay good employee salaries. Companies that already require their employees to be vaccinated against COVID-19 will find other, more business-friendly states more attractive for their new offices, new factories, and new jobs if the proposed legislation is passed. In essence, House Bill 248 says: “If you are a business that wants to require your employees to be vaccinated, do not come to Ohio.

I have a lot of reasons to promote COVID-19 vaccines. I’ve had to find ICU beds in our hospital where ICU beds did not exist in order to care for COVID patients on ventilators. I’ve had to manage physicians, nurses, and respiratory therapists who were over-worked and burned out from caring for the surge of hospitalized patients. I had 5% of my (largely elderly and immunocompromised) outpatient pulmonary practice die of COVID prior to availability of vaccines. But I also do not want to see excessive government regulations on businesses that stifles a free market economy.

If a business wants to mandate employee vaccinations because the owner believes it will give that business a competitive advantage in attracting customers or attracting more qualified employees, then let that business have the freedom to do so… whether that business be a restaurant, a grocery store, an auto dealership, a school, or a hospital.

August 16, 2021

Categories
Epidemiology Inpatient Practice

The Next Surge In COVID-19 Hospitalizations

Just when we thought it was safe to go back to the movie theater, to church, and to the grocery store… it looks like we are in for COVID, the sequel. The CDC reported that an outbreak of COVID infections in a town on Cape Cod earlier this month resulted in 469 people becoming infected, of whom 74% had previously been vaccinated. Of these vaccinated persons who developed infection, 79% had symptoms and 4 of them required hospitalization. Disturbingly, vaccinated people who developed COVID-19 had the same viral load detected in their noses as unvaccinated people who developed COVID-19.

This change in the epidemiology of the pandemic is attributed to the Delta variant, a much more contagious strain of the coronavirus that causes COVID-19. Coupling Delta with recent evidence that the SARS-CoV-2 virus is not simply transmitted by droplet spread as originally believed but can also be spread by aerosolization is a warning that we will likely see a resurgence in COVID hospitalizations in the near future. In anticipation of this, the CDC yesterday published recommendations to resume indoor masking for all people (regardless of vaccination status) in areas of the country where there is “substantial or high transmission” of COVID-19. In July 2021, there was a dramatic increase in U.S. counties with high transmission. The three figures below show the change in transmission rates over the past 4 weeks (red is high transmission and orange is substantial transmission):

This data indicates that most U.S. counties are now experiencing high transmission rates. To determine what these trends will mean in the upcoming weeks for U.S. hospitals, we can look at COVID-19 hospitalization trends. The figure below shows the number of new hospitalizations for the entire United States from August 1, 2020 through July 28, 2021. This indicates that the hospitalizations are going up but are not as high as the nationwide peak in January 2021.

Florida was one of the first states to convert from moderate to high transmission over the past month. As such, Florida may be a bellwether for the rest of the country. The figure below shows the same hospitalization data but just for Florida. Hospitalizations in Florida now exceed those of January 2021, when the rest of the country was at peak numbers.

So, if hospitalizations are about to go up, what demographic of patients are likely to be hospitalized? Intuitively, one might think that hospitalizations will be mainly younger people since older Americans are considerably more likely to be vaccinated. The figure below is data from the CDC that shows that in Florida (graph on the right), more younger people are being hospitalized now than in January (yellow line). However, older people still comprise the majority of hospitalizations.

So, what should hospitals do now?

From the Massachusetts outbreak and the Florida data, we can draw several conclusions: (1) the Delta variant is more contagious than earlier variants, (2) vaccinated persons can still get infected and when they do, they have just as high of a viral load as unvaccinated persons, (3) the Delta variant is more likely to be spread by aerosolization rather than simply by droplets, (4) adult hospitalizations are increasing. With those conclusions in mind, here are some tactics that hospitals can take now:

  1. Ensure that all front-line healthcare workers are vaccinated. During the January 2021 surge, many hospitals found that healthcare workers were more likely to get infected by another healthcare worker than by an infected patient. Furthermore, if a hospitalized patient becomes infected from an unvaccinated infected healthcare worker, the hospital could face litigation vulnerability in the future.
  2. Re-institute routine admission SARS-Co-2 testing. Given that more Americans are vaccinated, it is likely that we will begin to see more asymptomatic infections in patients being admitted to the hospital for non-COVID-19 related medical/surgical conditions. These asymptomatic patients can serve as vectors to infect other patients and hospital staff.
  3. Re-institute universal masking. Last winter, nearly all hospitals in the U.S. required patients, visitors, and healthcare workers to wear face masks while in patient care areas and public areas of the hospital. Because of “anti-masking” political pressure, some hospitals have loosened masking requirements in the past few months. These hospitals need to resume universal masking.
  4. Buy more N-95 masks. Given that the Delta variant is so contagious and given that it appears to be more likely to be spread by aerosols than simply by droplets, N-95 masks are likely to be more protective than simple face masks to prevent acquisition of Delta. It is likely that frontline healthcare workers will increasingly demand access to N-95 masks.
  5. Update the surge plan. Last December, hospitals made plans for expanding ICU bed capacity and for increasing the number of non-ICU beds for the January COVID surge of inpatients. It is time to revisit those plans, both for intra-hospital care as well as inter-hospital care.

17 years ago, my family was stuck on an island in the outer banks when Hurricane Alex hit. The night before, the main road became covered by a shifting sand dune and the bridge to Hatteras Island had to be closed. A few hours before impact, the local radio announcer said “Hope for the best but prepare for the worst“. That was sound advice in 2004 and it is sound advice again in 2021.

July 31, 2021

Categories
Epidemiology

Is COVID-19 A Rural Disease In Ohio?

Over the past year, I heard repeatedly from patients, politicians, and the press about how COVID-19 was an urban disease and not a rural disease. There was a perception that small towns and farm country were not as affected as cities. Many of my patients who lived in small communities did not want to travel to Columbus for office visits because of fear of getting infected during a visit to the city. There were complaints from rural residents that they were being unnecessarily subject to social distancing penalties for what was a “big city problem” that were not relevant to them. After all, COVID-19 spreads by close contact with other people and it seemed logical that in densely populated urban areas, COVID-19 would be more prevalent. However, in analyzing data from the Ohio Department of Health, it appears that just the opposite is true.

At the core of this misperception is how epidemiological data are reported. Early on in the pandemic, we heard about total numbers of infection (“1,000 people in Columbus have been infected”). And by total numbers, it is true that cities in the United States had more cases than rural areas. But total numbers do not tell you anything about the chance you have of getting infected. Instead, the rate of infection is more important than the total number of cases.

Consider this analogy: If 100,000 lottery tickets are sold and there were 5 winning lottery tickets, the total number of winners is 5 and the rate of winning is 5 per 100,000 tickets. On the other hand if 500,000 lottery tickets are sold and there are 10 winning lottery tickets, the total number of winners is higher (10 versus 5) but the chance of winning is considerably lower (2 per 100,000 versus 5 per 100,000).

So, what is important is not the total number of infections in the city versus in the country but what the chances of getting infected are if a person lives in a city versus living in the country. The Ohio Department of Health regularly releases data on the incidence of COVID-19 infection for each zip code in Ohio. And it turns out that the zip codes where a person is most likely to become infected are in rural areas, not urban areas. In the figure below, the darkest areas are those zip codes with the highest incidence of COVID-19 since the pandemic began and the lighter areas have the lowest incidence of infection.

The next figure below shows the population density in Ohio with the dark red areas having the highest population per square mile. The dark green areas have the lowest population density with yellow and light green having a middle population density.

By superimposing these two figures, we can see where the 8 major urban areas are on the map (Cleveland, Cincinnati, Columbus, Dayton, Toledo, Akron, Canton, and Youngstown). As it turns out, the darkest zip codes are in the least populated areas of the state. In other words, you are statistically more likely to get infected with COVID-19 at a restaurant, church, or grocery store in rural Ohio than in urban Ohio.

As of June 24, 2021, there had been 1,110,000 cases of COVID-19 in Ohio. With Ohio’s total population of 11.69 million people, that makes the average rate of infection 9,495 per 100,000 population in Ohio. That is almost exactly the incidence for zip code 43203 (location of OSU East Hospital, an urban area and my practice location prior to retirement) at 9,548 per 100,000. So, where are the locations where the chances of getting infected were the highest?

It turns out that of the 15 highest incidence zip codes in Ohio, all but one are in rural communities and only 44702 (Canton) is in a medium or large city. Most of these locations are small villages of a few dozen to a few hundred people. Therefore, the concept that rural areas are “safer” from COVID-19 is not true.

The rural versus urban differences in COVID-19 infection rates are likely to be amplified in the coming months as urban communities outpace rural communities with respect to vaccinations. For example, in Cuyahoga County (location of Cleveland), 52.6% of the total population has received at least one dose of the COVID-19 vaccine. On the other hand, in Holmes County (location of Walnut Creek, the highest incidence zip code in the state), only 15.2% of the population has received a COVID-19 vaccine. In the figure below, the darker counties have the highest percentage of the population receiving at least one dose of vaccine whereas the lighter colored counties have the lowest percentage of the population vaccinated. Ohio’s largest cities are in the darker counties indicating that our urban communities are more fully vaccinated than our rural communities.

Epidemiologists will be analyzing the COVID-19 pandemic for years to come and much of what we believe to be true today will turn out to be wrong.  But at the present, no place appears to be safe from COVID. Measures to prevent infection, such as vaccination, are just as important, if not more important, in rural communities than in urban communities.

June 25, 2021

Categories
Epidemiology

An Unintended Casualty Of COVID: Tuberculosis

Currently, 2 billion people are infected with tuberculosis, about one-quarter of the world’s population. It lies dormant in most people but every year, it causes active disease in 10 million people and 1.6 million die of it. It is the number one cause of infectious disease-related death in the world. In the United States, healthcare providers are required by law to report cases of TB to health departments and the health departments in turn do contact tracing to identify and test others who could potentially have been infected. Because of this reporting requirement, we have very good epidemiological data about tuberculosis in the U.S.

Tuberculosis control in the United States has generally been a success. The number of new cases of TB per year has dropped from 84,304 in 1953 to 8,916 in 2019, a nearly 10-fold drop in cases. Because the United States total population has grown during this time period, the reduction in new cases per 100,000 population has dropped even more dramatically from 52.6 in 1953 to only 2.7 in 2019, a nearly 20-fold drop in case rates. This is a testament to the effectiveness of public health measures. Indeed, quarantining and the wearing of masks is nothing new – they have been our primary tool for controlling the spread of TB for more than a century.

The reduction in TB cases has not been linear. There was a spike in cases in 1975 that was largely related to a different surveillance case definition instituted that year and not due to an actual increase in TB in the United States. There was also an increase in cases in 1989-1992 that was primarily due to a surge in the number of people with AIDS in the U.S. But for the past decade, there has been a steady reduction in cases of TB in the U.S. by about 2-3% per year between 2010-2019. But then an unexpected thing happened in 2020. There was a 20% reduction in tuberculosis.

 

It turns out that COVID-19 has been our most powerful weapon yet in combating tuberculosis. The COVID-19 pandemic brought with it mandates of social distancing and face mask-wearing in public. These are reasonably effective means of controlling the spread of the coronavirus but they are even more effective in controlling the spread of other respiratory infections, including tuberculosis. Prior to 2020, the main indication for healthcare workers wearing N-95 masks was when caring for patients with known or suspected tuberculosis. Hospitals throughout the U.S. maintained a small number of “negative airflow” patient rooms, primarily to house patients suspected of having TB. But TB had become relatively rare to the point that most medical students do not encounter a patient with tuberculosis during their training; in 2019, there were only 150 cases of TB in the entire state of Ohio.

Most cases of tuberculosis in the U.S. occur in people who immigrated to the United States. For the past decade, foreign-born people have accounted for about 71% of the cases of TB in the United States whereas U.S.-born people have accounted for about 29% of cases. These percentages did not change in 2020 and therefore, the drop in new cases of TB cannot be attributed to reduced immigration to the United States related to COVID-19 travel bans. Furthermore, 90% of foreign-born people do not develop active TB until they have been in the United States for > 1 year, meaning they enter the U.S. with dormant (latent) TB and only go on to develop active disease years later.

Not only have the infection control measures used to slow the spread of COVID-19 been effective in reducing tuberculosis, these measures have been even more effective in reducing influenza. The graph above is from the Centers for Disease Control showing that the incidence of influenza this season (red triangles) is by far the lowest of any year in the past decade.

With 2 billion people infected, tuberculosis will not be eliminated in our lifetime. But it appears that COVID-19 has given us an unexpected step forward in our efforts to reduce TB in the United States. Tuberculosis data reporting in the rest of the world is not as robust and in the United States so it will likely be a few years until we see if the same phenomenon seen in the U.S. in 2020 will also be seen in other countries.

Hopefully, another benefit of the COVID-19 pandemic will be the accelerated study of mRNA vaccine technology that could offer hope of future vaccines effective in preventing tuberculosis. Regardless, the reduction in TB last year has been a very thin silver lining in a very large dark cloud of COVID-19.

April 17, 2021

Categories
Epidemiology

COVID-19 Vaccine Side Effects (and how to prevent them)

I’ve been working at our medical center’s COVID-19 vaccine clinics for the past couple of months. We vaccinate about 3,500 people per day at our OSU Schottenstein Center site (the basketball arena) and about 275 people per day at our hospital-based vaccine clinic. Because of the potential for allergic reactions, we have either an emergency medicine physician or a critical care physician on site to manage any reactions. After supervising thousands of vaccinations, I’ve learned a lot about the vaccine reactions that people can get.

Younger people have more side effects

COVID-19 infection is much more severe the older we get. For people over age 80, the mortality rate of the infection is about 25% but for people under age 18, the mortality rate is negligible. It is just the opposite for side effects from the COVID-19 vaccines: older people are less likely to have side effect than younger people. I’m always relieved when I look over the list of the day’s vaccination schedule and see mostly people over age 60 because I know that I’m going to have an easy day.

Sore arms

Most people (about 75%) get a sore arm after the vaccination. It doesn’t typically occur for several hours after the injection and goes away within 2 days. I liken it to a bit more soreness than flu shot but less soreness than a tetanus shot. As with most other vaccines, the COVID-19 vaccines are given intramuscularly, into the deltoid muscle in the upper arm. One simple way of minimizing arm discomfort after the vaccination is to be sure that the arm is relaxed as much as possible when the needle goes in. If the deltoid muscle is tense when you get your vaccination, you are more likely to have pain later on. If there is swelling and redness at the injection site, a cold compress can help. If there is significant pain, it is OK to take acetaminophen (Tylenol) or whatever non-steroidal anti-inflammatory drug (eg, ibuprofen or naproxen) you normally take. Do not take any medications preventively and only take them if symptoms develop. Avoid taking corticosteroid medications (eg, prednisone) to treat arm pain or swelling since steroids can reduce the body’s immune response to the vaccine. If you anticipate needing to do a lot of writing or some other activity that involves your dominant hand, then get the vaccine in the non-dominant arm.

Aches, fever, and chills

It is difficult to predict who will get muscle aches, headaches, chills, or fever after the COVID-19 vaccine. The good news is that most people do not get these side effects. In general, younger people are more likely to get them than older people and people are more likely to get them after the second dose than the first dose. People who have had COVID infection in the past are also more likely to get more vaccine side effects, especially with the first dose of a vaccine. Although the timing can vary, it is typically about 18 hours after the vaccination. It is a good idea to have acetaminophen on hand and then take it at the early signs of fever or body aches in order to prevent experiencing more severe symptoms. For most people, these side effects resolve by 36-48 hours after the injection. The important thing to know is that these symptoms are NOT an indication of an infection and are instead an expected reaction of the body’s immune system to the vaccine.

Fatigue

Many people will be tired the day of and after their vaccine. For some, this can be severe enough to stay home from work. Because of this, we tried to stagger the vaccinations for our operating room nurses and the nurses on individual nursing units since we knew that a percentage of them were likely going to call off work the next day. Similarly, if you operate a restaurant or store, try to keep all of your employees from getting vaccinated on the same day or you might find yourself having to close shop the next day. To minimize fatigue, keep hydrated and plan on an extra 1-2 hours of sleep the night after your vaccine. An afternoon nap may be in order, also.

Anaphylaxis

This is the most serious side effect of the COVID-19 vaccines and it is fortunately vary rare. This is a severe allergic reaction that can cause difficulty breathing and shock. It occurs shortly after the vaccination, within the first 30 minutes. It responds very well to epinephrine injection and we keep epinephrine on hand, just in case of anaphylaxis. In my own experience, many of the people who were initially thought to have anaphylaxis didn’t actually have it – vocal cord dysfunction and vagal reaction are common masqueraders of anaphylaxis (and far less serious). The main component of the Pfizer and Moderna vaccines that can cause severe allergy is polyethylene glycol. This is the same ingredient in the laxative, MiraLAX, and the prep used for colonoscopy, Go=lytely. If a person has not had an allergy to these ingredients in the past, then they usually do not have any problem with the COVID-19 vaccine.

Rash

Less life-threatening allergic reactions can show up with a rash or itching, rather than anaphylaxis. These reactions are also quite uncommon but can be fairly easily treated with antihistamines (eg, Benadryl). Isolated rash does not warrant a trip to the emergency department but these patients should be watched a little longer than other patients to be completely sure that they do not progress to anaphylaxis.

Avoidable side effects

By far, the most common symptoms we see at the time of vaccination are avoidable:

  • Vagal reactions. This is what happens when a person faints and a lot of people faint at the sight of needles, regardless of what is inside of that needle. If a person is going to develop a vagal reaction, then they will develop it even if there was nothing in the syringe. The symptoms are feeling light-headed, clammy, nauseas, and sweaty. One of the best ways to prevent a person from having a vagal reaction to a COVID-19 vaccination is to distract them by talking to them while the nurse is giving the vaccine in order to take their mind off of the vaccine. When someone does develop a vagal reaction, have them lay down, preferably with their feet elevated. If a person tells you that they faint or get dizzy every time they get a vaccine, then put them in a reclining chair before you give them the COVID-19 vaccination. Ensuring that the person is adequately hydrated is important. The most common treatments that I give out in the vaccine clinics are bottle of water.
  • Hyperventilation. Many people are afraid of vaccinations and doubly afraid of the COVID-19 vaccine. Maybe they read something written by an anti-vaxxer or maybe they heard a horror story from their neighbor about how awful the neighbor felt after their vaccination. These patients are prone to panic attacks. The symptoms are dizziness, shortness of breath, and tingling in the fingers and hands. From a physiologic standpoint, these symptoms are caused by an acute respiratory alkalosis causing the pH of the blood to rapidly rise – this is due to breathing too rapidly and too deeply. Patients who get hyperventilation after their COVID-19 vaccination need to be talked down from it – focus on slower and shallower respirations. This can be hard to do since the rapid, deep breathing is being caused by anxiety. Reassurance and having the person breath through their nose (rather than mouth) is usually all it takes. Once patients realize that the symptoms are from hyperventilation, they usually calm down. In the past, this would have been treated by breathing into a paper bag to re-circulate carbon dioxide and prevent the blood carbon dioxide from dropping too low.
  • Hypoglycemia and dehydration. This is by far and away the most common problem that I encounter at our vaccine clinic. It is also a risk factor for vagal reactions. Many people get up in the morning and go straight to the clinic to get their COVID-19 vaccine before they have breakfast. Couple an empty stomach with the fear and excitement of a vaccine and you get a bunch of queazy, dizzy vaccine recipients. Encourage people to have breakfast before their vaccine and keep up with their fluids. This can be an especially big problem when we are vaccinating college students on the weekends who stayed up late the night before drinking beer. Being dehydrated and having an empty stomach is a set-up for getting a vagal reaction
  • Grouchiness. This is another very common symptom we see in the vaccine clinic and is usually caused by hypocaffeination. Just like skipping breakfast before your vaccine is a bad idea, skipping your morning coffee can result in having a headache, feeling tired out, and having a generally bad attitude. If you are a coffee or tea drinker, have a cup before you go to the vaccine clinic.
  • Vocal cord dysfunction. In the pulmonary clinic, vocal cord dysfunction (VCD) is a common mimic of asthma. It occurs when the muscles that control the vocal cords are under excessive tension resulting in the space between the vocal cords being constricted and too narrow. This causes shortness of breath, particularly when trying to breath in (as opposed to breathing out). Some patients will say that they they feel like air is getting stuck at the top of their neck. Anxiety can precipitate vocal cord dysfunction. One of the problems with VCD is that it can not only mimic asthma but can also mimic anaphylaxis and the treatment for anaphylaxis (epinephrine) can often make the VCD worse. In our vaccine clinic, I saw a person who was their for their second dose of the COVID-19 vaccine. With the first dose, she had developed what was thought at the time to be anaphylaxis and was given epinephrine that did not help and in fact seemed to make her breathing worse. The EMS squad was called and took her to the emergency department where a particularly bright physician obtained a blood tryptase level. Anaphylaxis causes the tryptase level to be elevated and hers was normal. For her second dose, we had a nurse sit with her and provided lots of reassurance and distracting conversation. We told her to breath through her nose (which can help reduce the tension on the vocal cords). In the end, she had no problems at all after her second dose. With all that being said, VCD is never a life-threatening problem but anaphylaxis is – when in doubt about whether it is VCD or anaphylaxis, treat the persons as if it is anaphylaxis.
  • Boredom. You can always pick out the people who are in the vaccine clinic for their second dose (as opposed to their first dose). They bring a book, newspaper, or crossword puzzle. Sitting in the clinic for 15 minutes with nothing to do except look at the other people getting vaccinated can be pretty boring and that boredom can be double the amount if you have to wait 30 minutes because of a past history of severe allergies.

The COVID-19 vaccines are safe. Period. Yes, they can sometimes have annoying side effects but no one dies from the COVID vaccine whereas more than a half of a million Americans have died of COVD-19. By getting a COVID-19 vaccination, you are saving a life – if not yours, then one of your family members or someone in your community. A sore arm or fatigue for a day is a small price to pay.

April 3, 2021

Categories
Epidemiology

Who Should Be Prioritized To Receive COVID Vaccinations?

One sure way to elicit an “OK boomer” comment from anyone under age 50 is to quote the comic strip, Pogo. In the War of 1812, naval commander Oliver Hazard Perry defeated the British navy in the Battle of Lake Erie and messaged the military leadership “We have met the enemy and they are ours”. In 1970, Pogo creator, Walt Kelly, satirically paraphrased Perry’s message in an Earth Day commentary about pollution by having his character say “We have met the enemy and he is us”. A half century later, Pogo’s statement could also be applied to prioritizing COVID-19 vaccinations: “We have met the COVID special interest groups and they is us”.

When it comes to the COVID vaccine, there are two types of people, those who are not going to get it because they fear it and those who want it as well as believe that they should get it before anyone else.

When the vaccines were first authorized for use by the FDA in December 2020, each state was directed to make its own criteria for which groups of people would receive the vaccine first. The CDC and the FDA provided general recommendations but this was really a “state’s rights” issue. Most states initially approved vaccinating healthcare workers, followed by different at-risk groups.

On the surface, vaccinating healthcare workers made perfect sense – these are the people who were risking their health and their life exposing themselves by caring for patients infected with COVID. Furthermore, we need healthy healthcare workers to take care of patients hospitalized with COVID. But should all healthcare workers be prioritized ahead of the rest of the population? Across the country, hospitals developed a process for ranking their employees for who should get the vaccines in what order. Some categories of healthcare workers were easy, for example, emergency department and intensive care unit nurses. But after that, things get a bit controversial.

What about the nursing unit clerk who does not have direct contact with COVID patients but is working at a desk down the hall from sick patients? What about the primary care physician who does not care for patients in the hospital but might encounter a patient with undiagnosed COVID coming into the office with sinusitis symptoms? What about the facilities worker who might be called to do a repair in a hospital room with a COVID patient in it? What about the billing office staff who are working from home but who are essential to keeping the hospital open and running? What about healthcare professions students who are not permitted by their school administration to care for COVID patients but could encounter a patient with asymptomatic COVID infection during a clinical rotation??

Throughout the country, each of these groups of healthcare workers started lobbying that they should receive the vaccine or that they should be moved up on the prioritization list. In January, media coverage exposed hospital board members, hospital staff working from home, and health profession students who were not providing direct patient care to COVID patients. This resulted in outrage by state legislators and governors across the nation who directed that vaccine prioritization move to non-healthcare worker groups.

Many states next prioritized nursing home residents and workers. This made a lot of sense because these patients were not only at high risk of being hospitalized or dying if they got infected but because they live in confined areas close to a lot of other nursing home residents, they were more likely to get infected than people who lived independently in their own home and could isolate themselves. But what about people who live in other congregate settings such as college dorms, homeless shelters, and prisons? At the beginning of the pandemic, many prisons in the United States experienced outbreaks of COVID with large numbers of inmates and guards becoming infected. In several states, these outbreaks among prisoners were of sufficient magnitude to overwhelm hospitals to the point that it became difficult to provide care to regular citizens. In response to this experience, some states prioritized prisoners and the homeless for getting vaccinated resulting in outrage by regular tax-paying citizens.

Some states prioritized people with various diseases. This immediately created lobbying by people with one disease to be prioritized over people with other diseases. Should people with asthma be prioritized before people with COPD? Should people with type I diabetes be prioritized before people with type II diabetes? Should people with cystic fibrosis be prioritized before people with pulmonary fibrosis? In Ohio, asthma, type I diabetes, and cystic fibrosis were prioritized over the other conditions. The whole idea of lobbying is to convince governments to give something to one group instead of another group. As with all lobbying, the decisions made by states about which diseases should be prioritized first werenot often not made based on the science of epidemiology but rather based on which group could most eloquently and effectively lobby to get vaccinated first. Moreover, how do you prove that a person has a particular disease? Do they need to have a note from their doctor or do they just need to say that they have one of the diseases when they show up at the vaccination site?

Another group of citizens to be prioritized  were “essential workers”. Depending on your vantage point, more than half of employed people in the U.S. are “essential”. Where do you draw the line between grocery workers, restaurant workers, members of the military, farmers, teachers, government workers, and manufacturing workers?

The least controversial prioritization grouping was by age. The probability of being hospitalized or dying if a person becomes infected with COVID is directly related to that persons age. People < 18 years old have an exceedingly low COVID hospitalization rate and mortality rate. People > 80 years old have a 25% COVID mortality rate. By using age as a criteria, lobbying is eliminated – a lobbying group for people 60-65 years old is not going to demand that their constituency be vaccinated before people 70-75 years old. It is easy to provide proof of eligibility – all you need to do is show your driver’s license or other identification, you don’t need a letter from your doctor stating that you are 68 years old.

From a societal standpoint, vaccine prioritization should be guided by:

  1. Which people are at highest risk of death or disability if they get infected 
  2. Which people are at highest risk of creating a lot of expense if they get infected
  3. Which people cause the greatest societal disruption if they get infected
  4. Which people are most likely to get infected
  5. Which people are likely to spread the infection to others if they get infected.

The first two groups of people are the same – those who create the greatest expense are those who get hospitalized and these are the people who are most likely to die. Age is clearly a leading predictor of death and hospitalization. People older than age 85 years infected with COVID are 80 times more likely to be hospitalized and nearly 8,000 times more likely to die than people under age 18 infected with COVID.The table below from the Centers for Disease Control shows the risk of hospitalization and death from COVID infection by age.

Other strong risk factors for hospitalization and death from COVID-19 are obesity, chronic kidney disease, diabetes, and hypertension. Because there are varying degrees of obesity, hypertension, kidney disease, and diabetes, it becomes very difficult to decide where to draw the line by BMI, systolic blood pressure, creatinine level, and hemoglobin A1C.

The second and third of these groups require even more value judgement. For example, does a firefighter who has to go out on sick leave result in more social disruption than a grocery worker who has to go out on sick leave? We know that certain racial groups are more likely to become infected than others so should people belonging to one race get vaccinated before people belonging to other races?

Ultimately, nearly all of us are in a COVID vaccine special interest group and can think of some reason or another for why we should be vaccinated before the rest of the population. In many ways, this is better than the alternative of no one wanting to get vaccinated. Fortunately, the number of new cases of COVID is falling and the amount of vaccine is increasing, so soon, everyone who wants a vaccine will be able to get one. Until then, maybe we should just keep things simple and use age alone as the criteria for prioritizing vaccination.

February 25, 2021

Categories
Epidemiology

Anti-Maskers And The Company They Keep

Anti-maskers are flourishing in the era of COVID-19 but they are not new. During the 1918 influenza epidemic, the wearing of masks was mandated in many U.S. cities and “mask slackers” rebelled with one Portland, Oregon city council member arguing “Mask requirements are autocratic and unconstitutional; under no circumstances will I be muzzled like a hydrophobic dog.” The anti-maskers never went away during the past century, they’ve been quietly meeting in secret, just waiting for a new pandemic to happen so that they can once again profess the dangers of wearing masks. So, who are these anti-maskers? Most are members of a fraternity of organizations whose mission is ostensibly to protect personal liberties. Here are some of these other organizations in the fraternity of the anti-maskers:

The Anti-Hand Washing League. This secret society was created in 1848 to combat the hand washing hysteria being propagated by Dr. Ignaz Semmelweis, the physician on the lunatic fringe of medicine who had the audacity to recommend that doctors wash their hands after performing autopsies. The League’s mission is to globally eliminate hand washing in order to preserve the natural body oils of the hands. Says League president Max Saponify, “Requiring me to wash my hands after using the toilet is an infringement of my constitutional rights!

The Federation Dedicated to a Deodorant-Free World. This group has a goal of global elimination of antiperspirants and deodorants. “These chemicals are a well-known cause of armpit cancer” says Federation chairman Axilla LaPue. The Federation’s motto is that “A man should smell like a man… and a bear,… and a boar,… and a Tasmanian Devil”. Many members are also affiliated with the Anti-Bathing Guild whose motto is “Satan made soap”.

The Stogies in School Society. Formed after municipal laws against smoking in public were enacted in the early 2000’s, the Society’s mission is to preserve the rights of middle school students to smoke cigars in class. A side project of the Society is the “Spittoons in Church” project to promote legislation requiring all churches to provide spittoons in the pews for parishioners who chew tobacco during services.

The Pull My Finger Association. This organization is committed to the promotion of public flatus. The annual meeting is held in Boston every December and culminates with the group’s baked bean dinner followed by the flatus a cappella contest. Last year’s winner was the Central City Cheese Cutters with their rendition of Bob Dylan’s “Blowing in the Wind”. Afterward, the attendees went caroling in downtown Boston with their unique wordless Christmas carols.

The Anti-Vaxxers. This mainstream group opposes vaccines of all kinds. Said one anti-vaxxer: “They say vaccines prevented smallpox and polio. I don’t know anyone who ever had polio or smallpox. I think drug companies just made up those diseases so they could scare people into buying their vaccines.” Group members have determined that vaccines cause disease. “You get a flu shot and your bowels will be irregular for months… not for me!” wrote another member in a letter to the editor of the Cowtown Gazette. The group points to the Will Smith movie I Am Legend as evidence that vaccines turn normal people into flesh-eating zombies.

The Free the Snot Foundation. Dedicated to liberating oppressed nose mucus from confinement in Kleenex and handkerchiefs, the FSF is considered by some to be a terrorist group, spewing unsuspecting passersby with nasal secretions. Among the group’s more mainstream activities is the annual “Shoot the Snot” contest to see which contestant can propel sinus secretions the farthest. The current world record is held by Charlie “Booger” Snout with his 2015 performance of 15 feet, 3 inches. But a darker side of the Foundation is the rumored rite of passage for admittance that allegedly requires initiates to clandestinely launch snot over the rail of the Empire State Building creating the so-called “rhinitis rain” that the City of New York is widely known for.

The Anti-Trouser Alliance. This male-only organization seeks to overturn local ordinances requiring men to wear pants. “If God wanted us to wear them, we’d be born with pants” said the Alliance’s spokesman I. M. Stark. The Alliance’s annual project this year is the “Butts on Buses” initiative to promote the freedom to sit on public bus seats pants-free. The initiative was conceived after the enormous success of the “Butts on Banisters” project last year.

The MPH Liberation Club. This group hopes to eliminate speed limits in school zones. “Those roads were built with my tax dollars. If I want to drive 60 miles an hour in front of St. Mildred’s Elementary School, then it should be my right!” said member Phlatt N. Quash. The group also seeks to eliminate stop signs, traffic lights, and center lane lines on public roads.

The Sidewalk Turd Confederation. The Confederation’s mission is to eliminate public bathrooms. It is composed of individual groups including libertarians that want to eliminate highway rest areas in order to reduce government costs, the gas station worker’s union that objects to requiring employees to mop restroom floors, and environmentalists seeking to save trees by abolishing toilet paper. Said the Confederation’s Secretary General, P. N. Yard, “Squirrels do it, birds do it, dogs and cats do it. Don’t we have the same rights as the animals?”

The Yell “Fire” In Movie Theater Consortium. This organization’s goal is to preserve the First Amendment right to free speech. Members are encouraged to walk through maternity wards and randomly tell new parents that they have an ugly baby, to tell their mother-in-laws that her cooking is terrible, and to  shout “Shark!” at public beaches.

Anti-mask = Anti-business

The reality is that masks work. The COVID-19 virus is spread through the respiratory tract – when you cough, sneeze, or talk loudly, you exhale viruses. If you want to stop a respiratory virus from spreading, you have people wear masks to catch viruses contained in exhaled breath. Wearing masks is the fastest way to re-open stores, stadiums, bars, churches and restaurants. Anti-maskers have the confused notion that masks infringe on their human rights; the reality is that the more people wear masks, the sooner the economy recovers and jobs return. Don’t be a member of one of these fraternal organizations, wear a mask!

November 1, 2020