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Covid 19 virus inpacts sports, NHL,Season Tix other impacts

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I have non-medical questions about resuming hockey. Has anyone gotten any feel for how the players generally feel about resuming this season on any basis? It’s really been crickets from the players as far as I know, and not a lot from the league either. Another thought or question. What if the league comes up with a plan, the NHLPA signs off but then a number of very wealthy star players say “count me out.” Is the outcome not tainted beyond all reason?

 

I have another thought that I’m completely unqualified to comment on, but just occurred to me. With all the talk of a second wave in the fall that may be worse than the first, is it possible the league is willing to drag out finishing this season through August if need be because they have doubts that there will be a 2020-21 season. Just food for thought without supporting facts either way.

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2 hours ago, remkin said:

 

Exactly right IMO. This is a tale of two diseases (probably more like 4). People who get the flu or better, and people who get really sick and might die (likely less than 1%). This is also not distributed equally in the population. Kids don't die from this (always outliers, but close to zero. People over 85 with lots of vascular disease do. Day care? No problem. Nursing home? Massive problem. Clearly it is the later that could overwhelm the system, while the former just get us to herd immunity quicker. Sure there's an in between, probably where a lot of us are. But as you mention, it is the sick people that are the issue medically. Almost the entire issue. 

 

When we are sent a patient for rule out covid, but they are generally well and low risk, the answer has been, go back home and recover. 

 

So, the fact that there appears to be a large number of asymptomatic people, if true would turn out to be a game changer. The more of them the better. (Someone wrote that at the very beginning of this thread before even the experts were saying it). Unless the current antibody tests contain a large contingent of false positives, or unless the antibodies prove unprotective (very unlikely), then there is a large number of asymptomatic, now immune people. That is a huge silent majority. That leads to the estimates of 60-100 immune patients for every positive test. 

 

But it also affects the open the lockdown calculation because as we open up, this group will grow exponentially fast. 

 

I would be keenly interested in a modeler looking at that. IF there is a massive subpopulation with immunity, and thus as the disease spreads it is really 100X more prevalent than testing has suggested, how fast to some degree of herd immunity? Has Sweden really already achieved it? WHO seems to think so. If so, then there is no question what the right way forward is. I'd think we'd want to know this. I haven't seen it yet: If the US opened up to Sweden levels, how long to herd immunity both with and without all of those apparently asymptomatic but immune people? And how many total deaths that way vs letting it play out slowly?

 

BTW, Sweden did not just throw open the gates. There were restrictions still. Since nursing homes and elderly are most vulnerable, plans to protect them make sense. Also, some degree of social distancing, no concerts or mass events, etc. 

 

Here's some of my outstanding questions (not specifically to you, rem):

 

What were the factors that led to the catastrophes that occurred in Italy, NYC, etc?  Some seem to have forgotten those actually occurred. Or maybe they don't "register" if the event has never actually been experienced close up, kind of like hurricane / tornado warnings for some?

 

How much did our extreme mitigation efforts, well, mitigate?  

 

Rem, you've noted that the primary objective of the shut down was to flatten the curve, and  I certainly understand that need.  But in addition to avoiding overwhelming the hospital system, it seems like we may gained in other ways via the delay.  How much have we learned during the shut down that might lessen the overall impact of the disease, even if the same number of people contract it, but over a longer period of time?   E.g., if remdesivir holds up, we may see a reduction in death rates from 11% to 8% for serious cases.  We've become aware of the possible impact of cytokine storms in covid-19 patients. I believe I've heard that there's anecdotal evidence that certain rheumatoid arthritis meds might be effective in treating that? I do emphasize that anecdotal evidence should always be considered with a high degree of caution.  Even learning that something as simple as turning patients on their stomachs might help in treatment.  Will what we've already learned help save lives under a flattened curve that would have otherwise been lost under an unabated, steep curve? [If so, how will that factor into the Sweden model?  They've experienced a death rate that's 3 to 6 times higher than their neighbors.  If their neighbors eventually catch up, it's clear that Sweden made the right choice.  But if the other Nordic countries have saved lives because of what they've learned while under initial lock down, that calculation becomes a bit more complex]

 

What don't we still know? (rhetorical question, lol)  I've heard concerns about a sudden rise in strokes among young people. Is there anything there, and if so, is it big enough to worry about?  

 

Have we put in place the things that will be needed to open things back up in a reasonably safe manner?  Have we got enough PPE not just for medical personnel, but to protect the population in general?  What procedures should be adopted to make opening things back up reasonably safe?  Testing: availability, accuracy, and process? How do we protect nursing homes and meat packing plants?   etc.

 

How many people have actually had the disease, and where?  That can be determined through sampling, but it needs to be randomized and from a representative slice of the population in order to get valid results.     

 

And here's the big, moral, ethical question that no one is willing to discuss but that ultimately will need to be addressed somewhere. even if we learn enough about the disease to accurately model deaths vs. economic impact, what's an acceptable balance?  Because realistically, at the end of the day it will be a balance.  We don't suffer the costs of shutting down the economy for 2 months to save 2,000 lives.  But what is the tipping point?  That's a live rail that no one is going to want to touch, lol.  

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On 5/1/2020 at 12:07 PM, remkin said:

since we've been testing the sickest people at nearly 100% for a long time now

This assumes that you've tested all the sickest people, but based on the percentage of confirmed cases to tests done--the metric which, I can't help noticing, you seem to have dismissed, Rem, though it's the one epidemiologists consider the gold standard for really knowing the extent of this disease--we lag far, far, behind the countries which are farthest in front on flattening the curve.

 

I can't make a better argument for prudent caution than this one. This 'graph in particular points to facts which too many of those pushing so hard to reopen seem to be either forgetting or ignoring: 

Quote

The discussion around reopening often draws a distinction between “the vulnerable” and everybody else, as if our strength were not defined by our willingness to stand together. Reading Texas’s reopening plan, one would think that only the elderly are vulnerable. Yet one of the risk factors for death from Covid-19 is obesity, which affects a third of the adults in the South and the Midwest. And diabetes is a major factor in the many deaths of people who are relatively young. There is a misperception, too, that only cities are susceptible, in spite of the fact that some rural areas have been devastated. The most dangerous illusion one can have in a pandemic is that it is only happening to other people, someplace else.

 

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14 hours ago, LakeLivin said:

And here's the big, moral, ethical question that no one is willing to discuss but that ultimately will need to be addressed somewhere. even if we learn enough about the disease to accurately model deaths vs. economic impact, what's an acceptable balance?  Because realistically, at the end of the day it will be a balance.  We don't suffer the costs of shutting down the economy for 2 months to save 2,000 lives.  But what is the tipping point?  That's a live rail that no one is going to want to touch, lol.  

 

I think we've addressed that already and have a risk-reward model well in place.  Specifically, the usage of personal vehicles.  We've decided that the deaths and injuries are acceptable for the benefit.  Alternatively, we could mandate professional mass transit with private professional feeder transit. 

 

So, there are rough numbers available regarding death and serious life-altering injury that we accept.  Start there.

 

11 hours ago, cc said:

We already are likely losing more to suicide and non treated other health issue than have and Will die from this illness.

 

I'm not suicidal.  But I am concerned about my fitness, especially cardiovascular fitness.  My major form of exercise is swimming, both for the cardio and for the health of my back (history of surgery).  I can't run anymore.  Biking is OK, but all lower body, as is walking.  I do both, but really miss my swimming which is completely closed.

 

And even though I made it through the first 3 weeks eating well, the locked-in-eat-nothing-but-crap syndrome hit me at week 4 and I can't shake it because we cannot obtain things from the store via curbside pickup.  Mrs. wxray doesn't want us to cruise the isles as she has some risk and with curbside available, would rather use it.  And I support her with that.  The downside is our orders miss various healthy things and we end up subsisting on some crap.  For example: I ordered whole wheat flour and they substituted white self-rising flour.  So instead of healthy home-made wheat bread, I'm making delicious glucose-spiking pancakes.

Edited by wxray1

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18 hours ago, LakeLivin said:

 

Rem, gotta disagree with your thought above.  If the U.S. ultimately loses it's democracy it won't likely be due to an "emergency powers" power grab (although I could see that as a tool utilized in certain circumstances). It will be a much more subtle and insidious process.  Take a look at recent examples of countries that have actually seen a significant deterioration in democracy in favor of populist authoritarian regimes.  Russia, Venezuala, Turkey, and Hungary are some good examples.. Democracy was eaten out from within, not taken over.

 

Common techniques included leveraging anti-establishment sentiment and fostering "us vs. them" mentalities. Attacks on and eventual suppression of the free press. Installation of loyalists in positions of power.  A gradual usurping of power that neutralized or bypassed checks and balances built into the system,  If it happens in the US it won't be a takeover; the population would't stand for that. It will be more analogous to putting a lobster into the pot and gradually turning up the heat so it won't notice it's being cooked.

Well thought out response Lake. I really wouldn't argue with it. The only thing I'd add in favor of my point is that I was referring to something that mostly hasn't happened. Basically that this isn't bad enough to cause the total breakdown in society necessary for what people are afraid of as they watch some leader's authoritarian instincts play out. In this case, the reality of Covid is not bad enough to stop the push back on those tactics. But what I was referring to is a new epidemic that combines the infectivity of say Covid or worse, Measles, with a death rate like Ebola, not this one. My point on this one is that it is bad. It kills people and in a very novel way, but it's not bad enough for what I was suggesting. It is bad, but it is also hyped into worse. This is not the one that might do that. 

 

But if the system is overwhelmed and people all have friends and neighbors and family members dying in even more massive numbers? Again, imagine if this was just as deadly to children as to nursing home patients, and the death rate was say like SERS and around 15%. One out of every 6 people die? That's a whole different situation. That would be pure pandamonium. There would be not only an overrun of the health system's beds, but the doctors and nurses would quit after watching their colleagues all get sick and many die. N95? Hell no. Full level 4 virus suits or nothing. Talk about not having enough PPE if that's the standard? And the 15% death rate is with full ICU care. Without that, the death rate could skyrocket. 

 

I still maintain that this would lead to a breakdown in everything, and the logical government response would be totalitarianism because the alternative would be anarchy. 

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1 hour ago, wxray1 said:

 

I think we've addressed that already and have a risk-reward model well in place.  Specifically, the usage of personal vehicles.  We've decided that the deaths and injuries are acceptable for the benefit.  Alternatively, we could mandate professional mass transit with private professional feeder transit. 

 

So, there are rough numbers available regarding death and serious life-altering injury that we accept.  Start there.

 

 

I'm not suicidal.  But I am concerned about my fitness, especially cardiovascular fitness.  My major form of exercise is swimming, both for the cardio and for the health of my back (history of surgery).  I can't run anymore.  Biking is OK, but all lower body, as is walking.  I do both, but really miss my swimming which is completely closed.

 

And even though I made it through the first 3 weeks eating well, the locked-in-eat-nothing-but-crap syndrome hit me at week 4 and I can't shake it because we cannot obtain things from the store via curbside pickup.  Mrs. wxray doesn't want us to cruise the isles as she has some risk and with curbside available, would rather use it.  And I support her with that.  The downside is our orders miss various healthy things and we end up subsisting on some crap.  For example: I ordered whole wheat flour and they substituted white self-rising flour.  So instead of healthy home-made wheat bread, I'm making delicious glucose-spiking pancakes.

 

I understand your example. You could even make it more practical by looking at maximum speed limits (we know that lowering them reduces traffic deaths).  But current "accepted" cost/ benefit ratios vary for different factors.  Consider what we spend on limiting deaths from terrorism (almost a zero tolerance policy) vs. what we spend on reducing deaths linked to air pollution. I don't have actual figures but I suspect that the cost/benefit ratio of the former is bigger than the latter by an order of magnitude.  

 

Seems like one big factor in determining "socially acceptable" cost/benefit ratios related to deaths is how the threat came about.  Seems like we're much more accepting of cost in death associated with risks that have grown gradually over a long period of time (traffic deaths, heart disease) vs. risks that more or less pop up quickly (the 9/11 terrorist attacks, covid-19).  The old "put the lobster in the pot and slowly turn up the heat" principle.

 

Just for reference, here are some estimates of U.S. deaths per year (from a very shallow google search);

 

Auto Fatalities: just under 40k

Air pollution: anywhere from 20k to over 100k

Suicide: approx 50k

Heart disease: around 650k 

Influenza: 15k - 60k

Covid-19: currently at 67k over approximately 2 months.  If the disease follows the projected normal curve we keep seeing, and we're now at the peak of the curve, seems like you'd expect another 67k deaths as it winds down.  And that's with the severe mitigation procedures we've undertaken.  

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2 hours ago, remkin said:

 Again, imagine if this was just as deadly to children as to nursing home patients, and the death rate was say like SERS and around 15%. One out of every 6 people die? That's a whole different situation. That would be pure pandamonium. There would be not only an overrun of the health system's beds, but the doctors and nurses would quit after watching their colleagues all get sick and many die. N95? Hell no. Full level 4 virus suits or nothing. Talk about not having enough PPE if that's the standard? And the 15% death rate is with full ICU care. Without that, the death rate could skyrocket.

 

I hope and pray we are not so damn short sighted this time and prepare for the future (PPEs, lockdown plans, etc).  With travel increasing, the threat of a 10%+ rate killer getting spread has grown. 

 

One thing that has to be balanced here is the "cry wolf" syndrome.  We run the risk of people ignoring social distancing when a really bad one hits.  That's why transparency of statistics is important.  And why give and take should be respected -- which in most cases I think finally is, although sometimes with a bit of emotional backlash.

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1 hour ago, LakeLivin said:

 

I understand your example. You could even make it more practical by looking at maximum speed limits (we know that lowering them reduces traffic deaths).

...

 

I pretty much agree with what you are saying, Lake.  You bring up other good examples (pollution, etc.)  And yes, there is a difference between being thrown on the coals and blackened, versus being in the warm pot of water brought to a boil.

 

You also bring up heart disease.  And as I mentioned earlier, it is a big concern of mine.  This lockdown is contraindicated for heart disease prevention!  I'm not joking when I say I'm struggling with this as the change in routine has destroyed my healthy habits.

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1 hour ago, cc said:

It remains to be seen what the impact of these mitigations actually are/were.  The stated goal was to assure our hospital system was not over whelmed.

 

Sweden followed a different path with results not dramatically different than this country.

It is definitely not known how many additional deaths will occur and what percentage of covid deaths are solely due to this disease or would have occured anyway.

Some stats.

At this points ~20% of deaths have occured in long term care populations.(13,000)  In a Canadian study I reviewed the annual %age of deaths in this population was ~12%. (This is pre covid data.)  There were 1.3 million people in LTC in the US at the time this study was conducted. 12 % is near 156,000 deaths in one year. 

 

If you look at non LTC deaths this is weighted heavily in the 80 plus population and those with pre-existing risk factors.  

 

So assuming ALL is covid driven is not taking into account statistics. 

 

This is a scientific data driven approach . And that is not opinion.

 

 

Let me start with the area we agree, it's too early to definitively know what impact the mitigation actually has had / will have proved to have had. 

 

But let me get this straight:

 

You're going to compare Sweden with the US but ignore the comparison of Sweden with it's closest neighbors, where the death rate in Sweden is anywhere from 3 to 6 times higher? :huh:  [The emoji relates to your selective choice of comparisons; it may well yet prove to be that Sweden's approach was a better one than it's neighbors]  Why wouldn't just as valid a comparison be the US and Italy?  With the conclusion being that the US was correct in taking dramatic measures sooner than Italy, and thereby avoided the catastrophe experienced by Italy?  [note that I'm not saying that would be a valid inference] 

 

You're take one Canadian study and use it to make inferences about what's currently happening in the US?  You honestly think we'd be seeing deaths sweep through nursing homes at the current rate without covid-19 infections?  :huh:

 

It has become apparent that covid-19 is most deadly in the elderly and those with concurrent conditions.  Forty percent of the US population is obese (8% severely), 10% has diabetes, and I've read that almost 50% of the US population has some form of cardiovascular disease.  If any of them are exposed to covid-19 and die, should those stats not count?  Sure, there might be some percentage that might have died anyways, but the spike in deaths gives a pretty good indication that most are covid-19 related. And on the flip side, what about home deaths from the virus that aren't caught and being reported as covid-19 related? 

 

I'm not saying you're saying this, but think about the implications of more or less just waving off covid-19 related deaths because those people had pre-existing risk factors or were elderly; can you see how some would find that morally repugnant?  

 

cc, I don't mean to be disrespectful, but selectively referencing statistics that support a preexisting opinion is not a valid, scientific, data driven approach.  

 

And for the record, I don't see our current best path forward as being all or nothing, one way or the other.  In my original post I outlined some of the things I think that need to be addressed in order to mitigate the effects of this disease going forward while trying to get our country back on it's figurative feet again.

Edited by LakeLivin

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As with most of medicine, it comes down to a risk/benefit ratio, and a harm/benefit ratio. This can be hard enough one on one between patient and physician for a disease that has best practices fairly well established after years of peer reviewed published science. Even then data is often open to wide interpretation and things we "know" turn out to be wrong. But this is far more difficult. This involves not just the pathophysiology of the disease to attempt to establish best treatments, but it is a very novel disease that has been around too short for good science, which takes years to really do. Also, we are dealing with epidemiology and the metrics of how quickly and specifically how the disease is spread. And we are dealing with an entity (viruses) that have been very difficult to treat historically. Then, as if that's not bad enough we are dealing with the effects of a governmental lockdown the likes of which has not been done, and thus, the effects of which are not proven either. And is if all of that isn't complicated enough, there is the overlay of politics. This is a strange brew of things to consider. Yet it's what we have to do. 

 

Here are some of the things that IMO need to be considered:

 

There is a major cost to shutting down an economy and society and the regular medical system for other diseases. Not just in terms of a recession/depression, but politically, as well as mental health, depression, drug abuse, domestic violence, etc. Some of those things can last well beyond the lockdown. And shutting down important other health care such as non emergent surgeries, biopsies, and many other treatments. Failure to recognize this, is, IMO a critical error.

 

A good example that is part of Lake's point. We can eradicate traffic deaths by making the speed limit 5 MPH. Essentially no deaths And as much as it would suck, we could live with it taking forever to get somewhere. The cost might not be shutdown of all non emergent health care, or a depression. Yet we don't do that because we accept risk all the time. We don't really focus on it the same way, we just do it. 

 

We cannot eradicate this disease with even our current lockdown. The disease is still spreading even as we lock down. Curing this by slowing it will not happen unless a very effective treatment is widely available or a vaccine that works and is safe arrives. 

 

The makers of vaccines claim that a Jan 1 vaccine would be a "by far" best case. There is currently no approved vaccine for wide use for any of the corona viruses. Bill Gates widely pushes a "vaccine sooner than ever" line, and last I heard he was hinting maybe end of December. Even at current rates, we are probably near herd immunity by then.

 

Treatment is a possibility, but not likely to have major impact in the next few months. Remdesivir looks good in a drug company sponsored study. But it was not a pure cure. People who took it still died (a lot of them). The last study pre drug company study was negative. We will learn more, it looks promising, but it will take more time to get the clear answer and for it to go into wide usage. There are over 30 compounds being looked at. I've mentioned the problem with the science. A good study takes months to a year, and at least half of the positive ones still turn out to be wrong. Small observational studies (like the ones on hydroxychloroquine so far), are wrong much more than that. If there was a miracle drug amongst the ones in testing, it would be awesome, but it's a hope, and the other side of the coin is that such a drug would be so effective that if it is one of the ones that's been tried over the last few months, we'd probably know by now if it was that effective. 

 

While there is an advantage to flattening the curve (avoiding catastrophic overload of the healthcare system, perhaps getting a better treatment) there is also a cost. The cost to flattening the curve is that it also pushes the pandemic out farther and makes it last longer: the flatter, the longer. This pushes the damaging responses to this out farther and farther, compounding the damage of that side of the equation. 

 

The real question is the area under the curve. If the same number of people die in the end, then getting it over sooner is better by definition. The only thing that can affect that would be 1. Shutting it down by quarantine (not possible now). 2. Getting a vaccine before people at the end of the curve would die (very unlikely) or 3. Getting an effective treatment very soon (probably best case, but probably not soon enough, or good enough). 

 

Most of the health and economic disadvantages of the lockdown will be felt disproportionately more later, while the benefits of lockdown are seen disproportionately now. This creates a natural bias towards the now, which is lockdown.

 

Finally is the important fact that this disease is not one size fits all. This is a completely different disease in kids than it is in the elderly. It's like having a gun to your head with a couple of bullets in the chamber or none. Similar in some ways but utterly different in more important ways. The death risk is night and day. (The strokes in "young" people is an interesting issue. It is an example of a very small observational thing. There is no way to know the impact of that for sure yet. However, if it were a common thing, then common sense tells us that the death rate in young people would be much higher).  

 

Sweden....lovely Sweden. My next post will give you my most current opinion. 

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OK, let me take a shot at my latest. Of course this target is constantly moving. 

 

Before I go into it this important disclaimer:  We should be careful about opening up. Absolutely, in fact, it is the most important thing after not overrunning health care. I tend to think some say "careful" as a stand in for "never" which is not a serious discussion, but a rhetorical trick. But if one truly means "careful" then I am completely with you. We should open up but we should do it in key ways more carefully than Sweden. And in fact that is central to my opinion of what do do next. 

 

Sweden is on the far end of the spectrum outside of countries that did almost nothing, but Sweden did do things. They did some social distancing and prohibited large events and asked for more voluntarily. IMO in the end it is likely that Sweden had the right idea. But as is the case in the world, they didn't get it quite right. It will probably end up being "more" right, but far from a perfect threading of the needle. Sweden openly admitted one key mistake that led at least in part to a higher death rate. They did not protect the most vulnerable well enough. Mainly this was patients in nursing homes, who made up a disproportionately large component of their increased deaths. Many of the deaths were, in essence, front loaded, but they could have been less if they had better protected the most vulnerable and elderly in group settings.

 

And that's the key. So long as there is no miracle cure or vaccine in the next few months, we can either peak the curve or flatten it. But unless we can decrease the area under the curve, peak is better if we don't peak the peak to overwhelm the system. BUT could we lessen the area under the curve also? ie: The total number of people who die from this in the end? Yes. By focusing on protecting the most vulnerable groups, while letting the hardy groups develop immunity. 

 

So, create the profile of the most vulnerable by age and underlying conditions: obesity (how obese though), and all forms of vascular disease and diabetes. Put our efforts on keeping these people as safe as possible while opening up. That's the truly effective careful part. And that could decrease total deaths in the end. Short of a cure, it's the only way in fact.

 

The vast numbers of already infected, asymptomatic people with immunity* suggest that this can be done pretty quickly. NYC probably hit about 20% in a couple of months WITH lockdowns and empty streets. But it will go much faster now since so many more people are already passing it around. 

 

Here's a model I have not seen that is uber important: If we use the data of asymptomatic but antibody positive combined with all proven cases, we should be able to recreate the actual real, rate of spread of this disease. So, using that, and estimating the number already immune. How long would it take to get to herd immunity if we opened up at various levels? 

 

Remember the health minister of Sweden thinks they're almost there now. Even a leading Norwegian epidemiologist is now lamenting that they may have kicked the can down the road and Sweden now has massive immunity that Norway does not. 

 

So how do we let others go out there and get exposed? Ideally, mostly voluntarily. Let people choose. We ought to be able to develop a roughly accurate estimate of the risk to each person using the data that includes exposure but no disease. If you are 60-65, BMI of X, with only HTN, you're rough estimated risk is X which is considered fairly high risk. Official recommendations for you are shelter in place, and......" If you are 23, BMI of 21, no health problems, your risk is...." etc. 

 

Then those at the very highest risk (nursing home, old with major health burdens especially vascular) lock down even more. (Conveniently, the majority of the work force will not be in that risk category), while the very lowest risk patients go out and get immunity to protect the vulnerable. Seems like this should appeal to both extremes politically: on the left: from each according to their means, to each according to their needs as the young develop the immunity to protect the vulnerable. And on the right. Allow the individual to ultimately make their own choice on what risk to take.

 

Finally this. What about this second wave and flu combo in the fall? Well that is an even clearer reason to do this now. That nursing home or elderly grandparent locking down fo the next few months even harder while we get more herd immunity will be better off in October than facing the possibility of a bigger second wave if we stay locked down now and get far less immunity. Where would you rather be in October if there is another world wide wave: Sweden or Norway?

 

Yes, October will come. And with it flu. What if we have herd immunity by then vs if we don't. 

 

* the idea that the antibodies might not confer immunity is put out there over and over (including by WHO the other day) but is pretty nutty. Has anyone ever produced a single case of an individual who had proven Covid, recovered, and then got it again? Wouldn't we have seen at least a few by now with almost 3.5 million proven cases so far? Also, how would the curve ever go down if we just kept getting it over and over? It IS possible that the test has false positives or is picking up another corona virus, but I think that will be disproven quickly as more people who have had confirmed cases test positive for that same antibody almost universally. 

 

So, open up, but carefully and selectively. Selectively not only by size of event and likelihood of transmission, but even more importantly by patient risk. Go even harder at protecting the most vulnerable than we are now. Let others start things back up. Use masks, social distancing, etc, especially at first. Get our jobs and businesses back, get our economy back, stave off mass poverty, and ideally get to herd immunity as safely and quickly as possible. 

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Back to hockey...  The idea of mass gatherings may be the last thing to open.  If they plan on starting Dec 1, when the traditional winter communicable disease season starts, well, it will be "interesting".  I'm a bit concerned about my season ticket prepayments to this effort.  But, still waiting to see how this turns.

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5 hours ago, remkin said:

IMO in the end it is likely that Sweden had the right idea.

 

The difference between the U. S. and Sweden: They have 6 international airports. We have 95. 

 

Edited by top-shelf-1

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5 hours ago, cc said:

Impossible to disrespect me as this is data not cherry picked. It is a comprehensive study from 2015.  I don’t select data just to prove my suggestion.  Feel free to look at other sources.

Hah!

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8 hours ago, remkin said:

OK, let me take a shot at my latest. Of course this target is constantly moving. 

 

Before I go into it this important disclaimer:  We should be careful about opening up. Absolutely, in fact, it is the most important thing after not overrunning health care. I tend to think some say "careful" as a stand in for "never" which is not a serious discussion, but a rhetorical trick. But if one truly means "careful" then I am completely with you. We should open up but we should do it in key ways more carefully than Sweden. And in fact that is central to my opinion of what do do next. 

 

Sweden is on the far end of the spectrum outside of countries that did almost nothing, but Sweden did do things. They did some social distancing and prohibited large events and asked for more voluntarily. IMO in the end it is likely that Sweden had the right idea. But as is the case in the world, they didn't get it quite right. It will probably end up being "more" right, but far from a perfect threading of the needle. Sweden openly admitted one key mistake that led at least in part to a higher death rate. They did not protect the most vulnerable well enough. Mainly this was patients in nursing homes, who made up a disproportionately large component of their increased deaths. Many of the deaths were, in essence, front loaded, but they could have been less if they had better protected the most vulnerable and elderly in group settings.

 

And that's the key. So long as there is no miracle cure or vaccine in the next few months, we can either peak the curve or flatten it. But unless we can decrease the area under the curve, peak is better if we don't peak the peak to overwhelm the system. BUT could we lessen the area under the curve also? ie: The total number of people who die from this in the end? Yes. By focusing on protecting the most vulnerable groups, while letting the hardy groups develop immunity. 

 

So, create the profile of the most vulnerable by age and underlying conditions: obesity (how obese though), and all forms of vascular disease and diabetes. Put our efforts on keeping these people as safe as possible while opening up. That's the truly effective careful part. And that could decrease total deaths in the end. Short of a cure, it's the only way in fact.

 

The vast numbers of already infected, asymptomatic people with immunity* suggest that this can be done pretty quickly. NYC probably hit about 20% in a couple of months WITH lockdowns and empty streets. But it will go much faster now since so many more people are already passing it around. 

 

Here's a model I have not seen that is uber important: If we use the data of asymptomatic but antibody positive combined with all proven cases, we should be able to recreate the actual real, rate of spread of this disease. So, using that, and estimating the number already immune. How long would it take to get to herd immunity if we opened up at various levels? 

 

Remember the health minister of Sweden thinks they're almost there now. Even a leading Norwegian epidemiologist is now lamenting that they may have kicked the can down the road and Sweden now has massive immunity that Norway does not. 

 

So how do we let others go out there and get exposed? Ideally, mostly voluntarily. Let people choose. We ought to be able to develop a roughly accurate estimate of the risk to each person using the data that includes exposure but no disease. If you are 60-65, BMI of X, with only HTN, you're rough estimated risk is X which is considered fairly high risk. Official recommendations for you are shelter in place, and......" If you are 23, BMI of 21, no health problems, your risk is...." etc. 

 

Then those at the very highest risk (nursing home, old with major health burdens especially vascular) lock down even more. (Conveniently, the majority of the work force will not be in that risk category), while the very lowest risk patients go out and get immunity to protect the vulnerable. Seems like this should appeal to both extremes politically: on the left: from each according to their means, to each according to their needs as the young develop the immunity to protect the vulnerable. And on the right. Allow the individual to ultimately make their own choice on what risk to take.

 

Finally this. What about this second wave and flu combo in the fall? Well that is an even clearer reason to do this now. That nursing home or elderly grandparent locking down fo the next few months even harder while we get more herd immunity will be better off in October than facing the possibility of a bigger second wave if we stay locked down now and get far less immunity. Where would you rather be in October if there is another world wide wave: Sweden or Norway?

 

Yes, October will come. And with it flu. What if we have herd immunity by then vs if we don't. 

 

* the idea that the antibodies might not confer immunity is put out there over and over (including by WHO the other day) but is pretty nutty. Has anyone ever produced a single case of an individual who had proven Covid, recovered, and then got it again? Wouldn't we have seen at least a few by now with almost 3.5 million proven cases so far? Also, how would the curve ever go down if we just kept getting it over and over? It IS possible that the test has false positives or is picking up another corona virus, but I think that will be disproven quickly as more people who have had confirmed cases test positive for that same antibody almost universally. 

 

So, open up, but carefully and selectively. Selectively not only by size of event and likelihood of transmission, but even more importantly by patient risk. Go even harder at protecting the most vulnerable than we are now. Let others start things back up. Use masks, social distancing, etc, especially at first. Get our jobs and businesses back, get our economy back, stave off mass poverty, and ideally get to herd immunity as safely and quickly as possible. 

 

Rem, given our current knowledge that sounds like a mostly reasonable, rational approach to me.  The logistics would take a little while to implement If done right (and that's after mapping out the strategy).  Setting up safeguards, PPE distribution, communication and buy in, etc.  And it would probably require additional aid for those who don't fit the young/ healthy profile that would be targeted to come back during the initial phase.  But in general, maybe we've got a way forward.  Who do we call to run it by, lol? 

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Just a clarification. While I do think it's likely that Sweden will be shown to have had the generally right approach to this (possibly outside of extremely remote island states, where severe lockdowns were an option and might work selectively (watch New Zealand)), there are four distinctions I want to make on Sweden:

 

1. They did do social distancing and closed large group events, and some other things even though they kept schools, restaurants and businesses open.

2. They did not do it perfectly. As mentioned above, they did not adequately protect their nursing home patients (nor did we though) and other very vulnerable, which caused many of their deaths.

3. Their approach is still not proven. I'm predicting (as is my want) that it will end up being proven. It could still be wrong.

4. It is also very possible that early lockdowns here were more necessary here than there. We did limit travel early, but maybe not early enough, and NYC did happen. 

 

So, maybe our best approach would have been say 2 weeks of firm early lockdowns followed by fairly quick easing with the restrictions in my plan in place. But that would have been very hard to do as NYC was happening. Looking back is just to guide us forward, not to blame. No one really knew what to do. That's been my biggest point all along. No one knew. The WHO, Fauci, the U Washington group whose projections were wildly inaccurate. The two groups my hospital paid. And many more experts. All wrong, and by a lot. That's just one thing that has made this whole thing tricky. It has moved faster than science moves. So scientists are forced to conjecture with bad data which leads to bad decisions. Nothing else to do, except to recognize that the predictions are made on shifting sands, so leaders must be open to the constant need to change the plan. And in that process to keep their eyes not just on now, but on various points in the future, which is very hard to do in the midst of pain now.

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22 minutes ago, remkin said:

Just a clarification. While I do think it's likely that Sweden will be shown to have had the generally right approach to this (possibly outside of extremely remote island states, where severe lockdowns were an option and might work selectively (watch New Zealand)), there are four distinctions I want to make on Sweden:

 

1. They did do social distancing and closed large group events, and some other things even though they kept schools, restaurants and businesses open.

2. They did not do it perfectly. As mentioned above, they did not adequately protect their nursing home patients (nor did we though) and other very vulnerable, which caused many of their deaths.

3. Their approach is still not proven. I'm predicting (as is my want) that it will end up being proven. It could still be wrong.

4. It is also very possible that early lockdowns here were more necessary here than there. We did limit travel early, but maybe not early enough, and NYC did happen. 

 

So, maybe our best approach would have been say 2 weeks of firm early lockdowns followed by fairly quick easing with the restrictions in my plan in place. But that would have been very hard to do as NYC was happening. Looking back is just to guide us forward, not to blame. No one really knew what to do. That's been my biggest point all along. No one knew. The WHO, Fauci, the U Washington group whose projections were wildly inaccurate. The two groups my hospital paid. And many more experts. All wrong, and by a lot. That's just one thing that has made this whole thing tricky. It has moved faster than science moves. So scientists are forced to conjecture with bad data which leads to bad decisions. Nothing else to do, except to recognize that the predictions are made on shifting sands, so leaders must be open to the constant need to change the plan. And in that process to keep their eyes not just on now, but on various points in the future, which is very hard to do in the midst of pain now.

 

I'm thinking that even now it would take a while to develop and implement a sufficiently thorough plan.  Even if we knew then what we know now, I'm guessing that "fairly quick" at the start of this wouldn't have doable (I know that term is open to interpretation).  Logistics, PPE, training, etc.  Even now, do we have sufficient comprehensive guidelines (or stronger) in place to adequately protect our nursing homes? (actual question)  

 

One thing I would like to see before any major easing is well designed sampling using antibody tests to determine the actual spread of the disease in the US.  I think the most realistic hope for a short term development that could have a major positive impact isn't a new treatment or vaccine; it would be if there are a lot more people who had the disease and are now immune than we currently think,

 

One last comment: I'm glad you mentioned that NYC happened.  And it wasn't just NYC; pretty sure I saw that there were other US cities had to rent refrigerated trucks to store bodies after hospital morgues filled up.  Then you've got Italy, Spain, who knows what happened in China / Iran, etc.  Seems a lot of people don't recognize / forget that those actually happened as well.

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It’s a joke the Suits even talk about resuming the season. They keep floating scenarios that do not take the biggest factor into account, logistics. The players and entire support staffs, coaches etc need to quarantine for 2-3 months with no family? Right. Equipment, meals, lodging all in the NHL bubble? They’re dreaming. Inside this bubble if even one player or support staff tests positive then what? Players are not in top shape. Haven’t skated in quite a while. The mental edge gets dull. Players get hurt. Bettman needs to step up and make the call. It’s like they’re waiting for good news while Covid  continues to infect and death rates continue to increase. End the season as incomplete. No champion. Get on with working out a contingency for next season.  

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1 hour ago, raleighcaniac said:

It’s a joke the Suits even talk about resuming the season. They keep floating scenarios that do not take the biggest factor into account, logistics. The players and entire support staffs, coaches etc need to quarantine for 2-3 months with no family? Right. Equipment, meals, lodging all in the NHL bubble? They’re dreaming. Inside this bubble if even one player or support staff tests positive then what? Players are not in top shape. Haven’t skated in quite a while. The mental edge gets dull. Players get hurt. Bettman needs to step up and make the call. It’s like they’re waiting for good news while Covid  continues to infect and death rates continue to increase. End the season as incomplete. No champion. Get on with working out a contingency for next season.  

This is probably the smartest comments I have heard concerning the situation that we are in.  

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3 hours ago, raleighcaniac said:

It’s a joke the Suits even talk about resuming the season. They keep floating scenarios that do not take the biggest factor into account, logistics. The players and entire support staffs, coaches etc need to quarantine for 2-3 months with no family? Right. Equipment, meals, lodging all in the NHL bubble? They’re dreaming. Inside this bubble if even one player or support staff tests positive then what? Players are not in top shape. Haven’t skated in quite a while. The mental edge gets dull. Players get hurt. Bettman needs to step up and make the call. It’s like they’re waiting for good news while Covid  continues to infect and death rates continue to increase. End the season as incomplete. No champion. Get on with working out a contingency for next season.  

With hearing the next season might not start until December that seems to suggest to me that Bettman's completely fine with restarting the current season as late as August. So whether dumb or not I doubt we're getting any clarity for months.

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14 hours ago, raleighcaniac said:

It’s a joke the Suits even talk about resuming the season. They keep floating scenarios that do not take the biggest factor into account, logistics. The players and entire support staffs, coaches etc need to quarantine for 2-3 months with no family? Right. Equipment, meals, lodging all in the NHL bubble? They’re dreaming. Inside this bubble if even one player or support staff tests positive then what? Players are not in top shape. Haven’t skated in quite a while. The mental edge gets dull. Players get hurt. Bettman needs to step up and make the call. It’s like they’re waiting for good news while Covid  continues to infect and death rates continue to increase. End the season as incomplete. No champion. Get on with working out a contingency for next season.  

The update from the morning XM guys yesterday mentioned exactly the things you mention.  The scuttlebutt is that the players are pushing back.  I'm about to turn on this morning's show for the latest.

 

11 hours ago, legend-1 said:

With hearing the next season might not start until December that seems to suggest to me that Bettman's completely fine with restarting the current season as late as August. So whether dumb or not I doubt we're getting any clarity for months.

It seems like sports leagues world over are playing chicken and waiting for someone else to give it a try.

 

And then you have the NFL.  They are taking a "What, me worry?" attitude.  The only concession so far is no international games.  Big deal.  The NFL's continued press-on-regardless attitude is leading the way.  Of course, they don't have a lingering season to clean up.  So legend, your mention of August is interesting.  Because, well, guess what buzz starts in August?  NFL.  NFL would be more than happy to take more than their fair share.

Edited by wxray1
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We have lost playoffs before over lockouts.  It won't be the end of the world to have a season with no Cup.  It seems reasonable to me to pull the plug on 2019/2020 and shoot for some kind of normalish start for next season.  Yes, there are some trade stipulations that will affect draft choices.  Flip a coin.  Assign the draft positioning and lottery chances by the winning percentages and who was in or out of the playoffs as of when they stopped playing.   Players are spread out all over N. America and Europe.  I can't see how they can get it back on track right now.

 

Sucks for us, since I think a healthy D corps would do wonders for this team. 

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The NHL playoff thing is an interesting situation anyways. I still think it can happen because I do think that in broader society things will open back up soon and that will change the environment that the decisions are made in. New cases are absolutely coming down even in the face of a simply massive uptick in testing. 

 

The real spread of this disease is under the surface of the known stats since testing has been increasing exponentially during this data collection. New US cases is definitively going down even in the face of a huge bump in testing. But it's a wavy line down. So, any bump up, which is just part of the trip down, is hyped my the media as the next plague. New cases are down. If one factors in the number of tests, then they are substantially down. 

 

Four interesting data points:

 

1. I get the numbers for Wayne County daily. Our new cases has been declining and flat despite increased testing. For the past 10 days we've documented 1 new case per day. We had two 3 day runs of NO new cases. Then, yesterday, we logged 22 in one day!!! Good grief, call in the national guard! I don't know what accounted for the bump, but it makes no sense that we went from 10 days of one/day to that. Probably they added in 19 more from Neuse correctional. I have little doubt that a news outlet would run with a headline: Covid Cases Suddenly Jump 2200%! 

 

2. Ireland locked down hard. Sweden, well we all know. Ireland's death rate per 100K people: 27.18. Sweden's: 27.19. Selective data points? Yes. But it is true though.

 

3. There were headlines that the death rate went up in states that loosened restrictions a few days ago and that could be due to loosening. This is just to point out what we're up against in the media. That is embarrassing. The time from a new case until that person's death is 8-30 days, with the average around 14-20 days. Any death from the May 1 loosening causing it, won't be seen until May 14th at the soonest. 

 

4. In the very early stages of opening up in other countries they have not seen a substantial bump in new cases yet. It's still very early though.

 

Things will open. If there's a bump, that's not the end of the world, and in a contrarian way could actually be good. There is a huge cost to this going on and on and on and on. 

 

Every week the landscape in which the NHL has to make it's decision will change. That' why I'm still thinking they have playoffs. But I am firmly in the minority if the reaction parts of online stories are any indication. Most reactors anyways, say scrap it and move on. But that's now, not in a few weeks. 

 

I think the logistics are a challenge but two things make it doable. First, where there's a will there's a way. All the talk about not being with your family? Well these guys have been locked down for months with their families. Probably seen more family than ever. Second, I don't think that families necessarily need to be excluded. They can be tested and locked down too. In many places they're locked down now anyways.

 

Finally, the kicker will be the realization that if a player gets this, for them it will almost certainly be like flu. They don't have to shut the league down if a few guys get it. The plan needs to include social distancing, masks, etc. They quarantine that guy, and move on. Might need to include a few standby minor leaguers. 

 

We have had a PA who almost certainly HAD coronavirus. Since she didn't have cough or fever, she worked 7 10 hour shifts along with nurses, and other providers. She wore a mask as did we. She distanced. No worker got covid from her. (She had complete loss of taste and smell and cared for her husband who works at Neuse Correctional and was Covid positive with fever, cough, etc.)

 

It may not happen in the end. But I'll stay with my bet.

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On 5/4/2020 at 11:41 AM, LakeLivin said:

 

I'm thinking that even now it would take a while to develop and implement a sufficiently thorough plan.  Even if we knew then what we know now, I'm guessing that "fairly quick" at the start of this wouldn't have doable (I know that term is open to interpretation).  Logistics, PPE, training, etc.  Even now, do we have sufficient comprehensive guidelines (or stronger) in place to adequately protect our nursing homes? (actual question)  

 

One thing I would like to see before any major easing is well designed sampling using antibody tests to determine the actual spread of the disease in the US.  I think the most realistic hope for a short term development that could have a major positive impact isn't a new treatment or vaccine; it would be if there are a lot more people who had the disease and are now immune than we currently think,

 

One last comment: I'm glad you mentioned that NYC happened.  And it wasn't just NYC; pretty sure I saw that there were other US cities had to rent refrigerated trucks to store bodies after hospital morgues filled up.  Then you've got Italy, Spain, who knows what happened in China / Iran, etc.  Seems a lot of people don't recognize / forget that those actually happened as well.

 

It's all the retrospectoscope on how it could have been done better. PPE is a legit point, trust me on that one. In fact, while ventilators were the focus, the real fail will be the lack of N95 masks IMO. Despite the drama of refrigerated trucks, even that wasn't the issue. The issue was someone dying without a ventilator. That never happened in NYC and it wasn't close anywhere else. Maybe that was social distancing that happened. It seems so likely. But not proven. But that was the concern. Mine too. Likely, we would have had no problem with zero lockdown outside of hot spots, especially if we protected the most vulnerable and did shut down big events, did social distancing, masks, etc. But a much shorter lockdown without question. Again, retrospectoscope. We did what made sense. It no longer does. We do know now what we didn't know then.

 

Another retrospective question is this: was it necessary for the entire country to lock down because NYC? NO. That is provable as 5 states did NO lockdown and 3 more did only regional lockdowns, and have had no more cases than the lockdown states, let alone ICU overruns. So yes, NYC, NJ, New Orleans, should have locked down longer. Most of the rest of the country should have locked down less. Again, this is in the retrospectoscope, not a criticism. The criticism is now. We have that retrospectoscope now, so moving forward and not opening would be open to fair criticism. 

 

Protecting nursing homes is a legit criticism IMO. Another not protected class. This whole thing was ushered in with a huge death toll in a nursing home in Washington. (In fact the first case in NC was a person who visited that exact nursing home in Washington). Deaths were popping up in nursing homes everywhere, including here in NC and here in Wayne County. The plan in NYC and embarrassingly here too, was to send those people back if they didn't meet hospitalization criterion. Along with the lack of N95 masks this will be seen as a big fail. But that is literally a captive population. It is one of the most fixable things, and lockdowns didn't stop it.

 

BTW the media pointing out every possible blip in the opening should be baked into the plan the same way that massive new testing is baked into the real picture of what new cases are doing. 

 

Italy and parts of Spain and probably Iran were overrun. They were right there in our faces as these decisions were being made. Again, this is why there is no criticism from me about what WAS done. My beef is what will be done now. 

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Part of showing some credibility IMO is making some predictions moving forward that can be measured. No one will be 100% right, (ask Fauci and WHO, and just about everyone who is an expert modeler of epidemics). But if predictions generally are right that should give some cred. 

 

On this watch from this point forward in: Sweden, North and South Dakota, Nebraska, Iowa, Arkansas, Oklahoma, Utah and Wyoming. If they did it right, they will start looking better than everyone else, and certainly no worse. If states who open have a bump, compare it to those that never closed as well as those that stay locked down. I think Sweden and those states will fair very well moving forward relative to others. We shall see.

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