287 Comments

I don't understand why we continue with anything other than vaccination at this point outside of particularly sensitive places (hospitals, nursing homes, etc.). Masks and social distancing make sense when there is nothing else but we're way passed that. I can't be the only person that thinks its farcical to walk into a restaurant masked, remove it at the table for an hour while talking and eating, then put it back on to leave. I mean, does the virus call a truce while we sip our beers? Was it fooled by wearing a mask at the hostess stand?

If we were a more mature people socially and politically we would drop the silly theater, mitigate as best we can with our (really quite amazing) vaccine technology, and then go about our lives.

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Additionally very, very few people are wearing masks effectively. Part of my job was training employees how to properly fit N95 masks. Achieving and maintaining a tight fit is not all that easy. Talking, coughing, even smiling behind your mask could break the fit requiring frequent adjustment. So while this type mask may be 79-90% effective when tightly fitted I’m quite sure 89-99% are not worn this way.

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To both of your points, I'm not sure how many people are wearing masks with the intent of antiviral effectiveness, rather than the intent of "I am complying with the letter of your mandate".

I'm well to the covid-hawk of the average bear, but I'm firmly in the latter camp. Triple-shotted, got (presumably) omicron a few weeks ago and it was mostly a cold... your roof, your rules, but why are we play-acting any of this?

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Feb 5, 2022·edited Feb 5, 2022

I have sourced the loosest and most comfortable scrap of fabric I could find as my “mask.” I am under zero illusion that it is a public health tool, I just don’t want to get scolded.

I’m triple vaccinated and I’ve had COVID in the last quarter, as have my spouse and infant. I’m done.

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I would guess the people wearing N95s or the like really care, the rest are just going along with it.

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Exactly. Masks work when used correctly. Virtually no one is using them correctly in any kind of consistent way, and in fairness it's probably too much to expect them to.

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Feb 5, 2022·edited Feb 5, 2022

I get this point overall, but I'm a bit suspicious about this binary view of mask efficacy and fit.

Before covid I only wore N95 masks for home improvement projects like insulating and spray painting. From this experience, I know first hand that N95 masks definitely "work" at reducing the amount of bad stuff that gets into my nose and lungs during these projects. I'm sure the fit in these cases is relatively poor and this means some bad stuff still leaks in, just not enough to irritate my lungs or make my snot turn the color of whatever I'm painting.

In a real-world fit situation, what percentage of the air that's inhaled and exhaled do you think flows through the mask material versus bypassing the filter due to bad fit?

My guess is that even with a bad fit, a very large percentage of inhaled/exhaled air gets filtered. So while personal risk is not completely eliminated with a badly fitted mask, if a large percentage of the air moves through the filter, that should still result in a lower rate of spread and less severe infections for those that do get sick.

What's wrong with my logic here?

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Feb 5, 2022·edited Feb 5, 2022

> What's wrong with my logic [re lower-but-non-zero filtering effectiveness with imperfect mask seals] here?

Nothing. But people don't understand dose-response curves and think that if one virion makes it around the mask you're going to get infected, so it needs to be perfect or you might as well not bother. In reality, the fewer virons you get exposed to, (1) the lower the chance you have of any of them managing to attach to a receptor, and (2) the lower the number of cells that will get infected before your immune system is able to counterattack, thereby reducing the severity of your infection, if any. Perfect mask seals are great! Imperfect ones are still better than nothing!

This same misunderstanding shows up in how people think about radiation exposure, too.

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I think most people can understand just fine that 10 virus particles are less infectious than 10k virus particles inhaled during a particular activity. My sense is most sentiments that get expressed as "why bother if it's not a perfect seal?" come more from them having accepted the inevitability that from a long-term perspective, there doesn't seem to be much point in reducing one's own viral exposure in a particular instance. Unlike with toxic paint fumes, I don't see much point in reducing (or even eliminating) virus exposure during one particular activity unless it's part of a long term strategy to do what it will take to meaningfully dodge infectious doses of 🦠 every day, during every activity, for, at minimum, the next few years. I'm enthusiastically vaccinated (and boosted) because that's an action that provides durable protection from severity - it's not a never-ending slow-motion whack-a-mole game.

If the virus was only in the air on leap days, sure, I could conceivably play whack-a-mole a couple times a decade. A concerted effort to play whack a mole by breathing only mostly-filtered and/or non-shared air every day for the next decade does not seem feasible or worthwhile or desirable in any way.

That's why we say things like 'Why bother?' Some admittedly use a rhetorical sleight-of-hand to project that resignedness onto the imperfect-albeit-good short term filtration effectiveness of a particular mask.

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Pre-vaccine I agree. Post vaccine I still think it's the right thing to do in certain settings with lots of vulnerable people. What I don't see is much benefit to it in general retail, restaurants, or other public spaces for vaccinated people.

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Pandemic-fetish is absolutely a real thing and I want to crush those views into tiny pieces.

GET VACCINATED AND THEN GET ON WITH IT ALL.

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This seems reasonable but it isn't where I've landed, at least for now.

For me personally, I still voluntarily always wear a good mask when indoors and I plan to until the case numbers in my area get down to the 10-20 per 100k range.

I'm retired, so it's easy for me to avoid exposure if I want to. I expect I'll eventually get covid, but I'm willing to pay a small price to try to hold it off until the hospitals in my area aren't full (eg elective surgeries are suspended right now) and maybe even until we're not rationing high efficacy treatments (maybe in a month or two?).

In my social circle of somewhat older folks, hardly anyone is socializing indoors or eating in restaurants. We do gather freely outside, where we don't wear masks or worry much about covid.

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This is the first rationale I've heard from someone taking this cautious approach, in a long time, that attempts to make logical cause-and-effect sense, avoid guilt tripping others to do the same, and see the future in realistic terms. Well done.

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If a boosted person is looking to reduce their risk of getting COVID and missing a couple of days of work, throwing on a KN-95 in Target, gas stations, etc isn’t going to be of benefit when case counts are high? Genuinely curious.

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Nothing, and this is what drives me crazy about the “no more masks” line. They don’t have to be perfect. They just have to be somewhat effective, enough to help to reduce R. They are a relatively cheap and easy intervention.

As for nobody using them properly, probably depends where you are. I don’t care what people do outdoors or in huge indoor spaces like Home Depot. Indoors in the Bay Area I see 100% compliance indoors and people wearing whatever masks they have properly, along with increasing percentages of KN95s. Guess what, we also had far fewer cases this time than SoCal where compliance is much worse.

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The places where I see good compliance are places where the public mandate isn't the binding issue. Like, where even before we re-introduced our local mandate, masking was still very high either do to a private institution having the rule, or nearly everyone doing it voluntarily. Whereas in the kinds of places where people dropped masking when the government let them, masking is really poor. If people want to mask at this point, they're going to, but I'm not sure how much the government is really prepared to make them do it well.

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I agree that local culture sets actual compliance, but in places inclined to high compliance, the mandate I think obviously helps to set expectations and apply social pressure. Even if enforcement by police is virtually nonexistent, it licenses eg store workers to ask politely, with some teeth (far) behind it. (Trespass is still prosecuted and even the biggest cranks know it.) And it makes the store’s policy not a quixotic aberration but something they can shrug and point to the rule (even if they were already inclined to do it).

Laws and rules have effects beyond their enforcement, but for sure they’re not magic wands in a population who generally disagree.

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What is the point in reducing the R when every normal person is going to be exposed anyway? Why drag it out even longer?

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It reduces total penetration of each wave. It does not “drag things out”, it means fewer people in total get infected.

And everyone will not get it. The reason everyone does not get the flu every year is that the flu’s R is low to start with and its effective R fluctuates right around 1 depending on vaccines, prior immunity, climate, and behavioral factors. And prior immunity is not necessarily a large factor.

The value of mask mandates is also hugely different depending on community prevalence. At peak Omicron, wearing a good mask might have 100x the protective effect it had during a lull, simply because there are so many infectious people around.

I hope to have our local school mask mandates drop after Omicron. I dislike wearing a mask. But during a big wave I’ll put up with it.

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Right now, the main reason is healthcare system capacity. Despite the fact it poses less individual risk than previous variants, Omicron is still a major challenge due to the absolute number of hospitalizations. The major hospital system where I work - in a highly vaccinated region of the country - is having to decline transfers and admissions of very sick patients because we are at capacity.

In the near-term, there's an argument that would should continue layered NPIs to reduce R until antivirals like Paxlovid are widely available and the under-5 vaccine series' have been approved. I think the scope and extent of those NPIs is up for debate, but it's not an unreasonable position. Having Paxlovid available could make a big difference when an immunocompromised person finally gets COVID-19.

In the long-term, re-institution of NPIs may be important during surges of new variants or during the winter respiratory season. It's worth remembering that our previous 'normal' existed in a world where the circulating population of respiratory viruses/bacteria caused 2-10x less mortality (and this is assuming a fully vaccinated population). You would have seen much different social practices if the annual toll from viral PNA was 150-300k instead of 30-60k. Look at the impact that the original SARS virus had on public health in East and SE Asia.

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founding

You talk as though everyone is going to get sick exactly once in their life and then be done with it. I agree that if R was high enough that we couldn't prevent everyone from getting sick once, and if immunity was perfect enough that a vanishing fraction of people would get sick more than once, then it doesn't matter to drag it out more than just enough to avoid the worst hospital crunch.

But it looks like immunity *isn't* perfect enough to prevent people from getting reinfected. So reducing R means reducing the frequency with which people get reinfected. Getting sick once every three years rather than once every two years seems better, no?

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Two years on, we still haven't recovered or moved on from binary thinking.

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No, air is like water following the path of least resistance. While indeed some air will be filtered, much more will slip by in the gaps. To that add how much less virus needs to get by than paint mist. So sure wear a mask, I would, just don’t be misled by claims of 79-90% protection that are only achieved in a lab.

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Not disagreeing with you at all, but this spurred a thought I wanted to share. It seems like the actual brand/construction of the mask is a HUGE factor in how good you can get a good fit!

Basically the only mask out of the dozen I've tried that I can get to reliably fit is 3M Aura N95 masks from Home Depot. And I get a good fit (as defined by "won't fog my glasses") without a a lot of fiddling.

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What do you mean correctly. The except while actively eating or drinking loophole means you are wearing it correctly even if it off for long periods of time.

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Why is there no operations research on this? If the question doesn't occur to some school of public health, why doesn't a business association of bars and restaurants commission the research. For that matter, why doesn't the city health department or whoever executes venue restrictions commission such research?

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You can run randomized trials. The problem has been that even suggesting a randomized trial was very controversial until recently.

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I didn't see it get enough attention to be "controversial." :) There were never enough controversial ideas discussed.

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founding

I think the effective version of the research would have to involve sending known infected people into spaces with known uninfected people with and without masks and counting how many got infected. I don’t think challenge trials were that necessary for vaccines, which could be tested easily the other way, but for these things, challenge trials of this sort would be essential.

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Real live researchers (I'm not one) should be able to figure out the how. My guess is that masking would be done by having masked and non-masked infected people (a range of degrees and times since infection) in defined spaces and test for the detection of the virus at different distances and times that could then be modeled.

I've heard different things about the difference HCT's could have made. I don't see much downside.

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founding

When you say “we”, are you talking about official policy or individual behavior? My policy is still not to eat in indoor restaurants, or do anything else that involves public indoor unmasked activity, when local case counts are above 20 per 100,000 per day. It’s a pretty easy policy to follow (though quite annoying in winter to have to cook every day). Do you think this is ineffective? Or a harmful strategy for an individual? I wouldn’t want to legally mandate this (except maybe with a much higher case count threshold) but I think individual actions are the vast majority of what “we” are doing now. Legal mandates are mostly gone and/or toothless in large parts of the country.

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I'm not going to tell anyone how to live their lives. But to your question I don't understand why a vaccinated, otherwise healthy and non-elderly person would self-impose those sorts of restrictions. If you're vaccinated and boosted you've done all you can.

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founding

I'm not sure what you mean by "you've done all you can", when we are specifically talking about an additional set of things to do that seem extremely effective, and not very difficult if it's just about a few weeks.

My main thinking is that I don't like getting sick, and if the choice is between voluntarily not going to restaurants and bars for a few weeks, or going and maybe getting sick and then involuntarily not going for a few weeks, the former seems better (though admittedly the calculus might be different if I lived in a place with better restaurant options).

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Where I disagree is the assumption that any one is going to avoid getting covid forever. Maybe some small number will but the vast, vast majority won't and where it happens I think it will be more luck than any particular individual efforts.

The ethical obligation IMO is really to prevent yourself from being unnecessarily hospitalized so there are beds for others who need them. If you're healthy and vaccinated you've already done way more to that end than a mask will.

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founding

At this point I'm not treating this as an ethical obligation to others, but just as a simple cost-benefit analysis for myself. I don't need to avoid getting covid forever to get the benefit of reducing the frequency with which I get covid.

I expect most people will get covid repeatedly over the course of their lives. I used to get significant colds multiple times a year, but haven't the past two years. I'd be much happier if I get them once every year or two rather than once every few months.

The relevant question is then, what behaviors reduce my frequency of respiratory infections more than they cost me in terms of present fun. I think that avoiding restaurants for a couple weeks during the height of an outbreak is on one side of that cost-benefit analysis, but during June/July and November/December I was totally happy going out and doing indoor things, and I expect to be in a few weeks again.

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100% agree. Keeping our family from getting knocked on our ass for 3-4 days (which does happen when boosted) is more annoying than wearing a KN-95 indoors when omicron is surging.

I work in tech and multiple projects have been hindered from vaccinated folks being out in Jan.

If I can avoid some of that via a KN-95 indoors, I’ll wear the mask.

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More like a few years. There’s no guarantee Covid is ever going away. They’ll always be a risk. (Unless they really developed a universal vaccine.)

Are you prepared to not do anything indoors in public for years to come?

And what about the Amazon & Fresh Direct workers? They have to work indoors with other people or we all starve.

There has to be a level of acceptable risk.

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founding

I don't understand what you're saying. Are you claiming that case counts won't get below 20 per 100,000 per day? They have been for about half of the last seven months, despite the big waves we've had. We're definitely not talking years of waiting here, just a couple weeks.

I'm saying there has to be a level of acceptable risk, but you seem to be saying the same thing, while thinking you're disagreeing with me. Are you just thinking that my level of acceptable risk, which seems like it should apply most of the time other than during acute waves, is still too high a level? I think that as long as that level only kicks in for a few weeks during bad waves, then that seems like a minor price to pay to eliminate most of my infection risk. I'm definitely not suggesting that we wait until case counts be below 1 per 100,000 per day or anything like that.

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Kenny, let’s talk about your infection risk. Presumably, you are vaccinated against covid. You are probably also boosted. I doubt that you are vaccinated against the common cold because there isn’t a vaccine and even if you are vaccinated against influenza, that vaccination isn’t hugely effective.

Your covid infection risk is probably less than half of your totally risk from respiratory diseases. Even when covid levels crater, your total respiratory disease risk will only decline somewhat.

Did you socially distance every January before covid? Was it reckless not to? Unless you think thst every modern human should distance for a month every winter, you are being more risk averse than 2019 normal. I want 2019 back and the psychological benefits will be great.

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At this point, if you're under 70ish and vaccinated, I suspect you're in more danger of norovirus from a cook who pooped and didn't wash his hands carefully, and you will be forever.

If that's the framework in which you want to make your own health risk decisions, of course you're welcome to do that.

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founding

When you say "more danger" what do you mean? It sounds like the base rate of covid infections is much higher right now than the rate of norovirus infections I've had from eating out. Maybe covid infections are a bit less bad, but they're more predictable based on case numbers.

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Post-vaccination covid sent me to bed early in a sweatshirt and sweatpants, rather than violently assaulting the toilet for two days.

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founding

That sounds right. I think the threshold of frequency of norovirus cases that would make me avoid eating out is probably a factor of ten lower than my threshold of frequency of covid cases. I don't believe those have ever been anywhere as near a tenth as common as covid cases have been the last couple weeks (but I admit I've also never had access to statistics on those).

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so you’d rather have food poisoning ten times than post vaccine covid once. i’d rather have post vaccine covid two or three times than one bad stomach bug

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I'm talking policy. Personally, being triple vaxxed, even though I'm in a statistically very vulnerable age group, I spend an evening with a group in a bar with everyone including me unmasked (obviously). I don't think masking protects me at all, (and I have "moral certainty" that I am not infectious) so I see almost zero benefits to my wearing a mask, but the costs are low, so I'm happy to go along with a local indoor mask requirement as it presumably represents other people having more confidence in the protective value of masking than I do.

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> though quite annoying in winter to have to cook every day

Does College Station get cold enough regularly that eating outside is impractical? SF restaurants have been doing it year-round, and while it's been a warm winter, it's not _that_ warm....

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founding

We usually only have a few days a year when the high temperature is below freezing, but probably about half of January and a few weeks of December and February have highs below 50 and lows below freezing. I think in the ten years I lived in the Bay Area there were probably a few nights below freezing, but I don't think there was a single day where the high was below freezing, the way it was here in College Station yesterday.

We spent the first half of 2021 in Austin, and there's plenty of space for outdoor dining there. We did use some of them on evenings when it was in the 40s, but not often. Outside of Austin, most Texans seem to think that the summers make outdoor dining impractical as well, so restaurants and bars outside of Austin often just don't have outdoor seating at all, or only have a tiny bit, which has been really annoying.

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Vaccination is only mildly effective at preventing the spread of omicron, which causes misery to the vaccinated and potential death to the elderly, immunocompromised, and unvaccinated.

I guess wearing a piece of thin cloth on your mouth to protect your friends, family, and neighbors is just too much of a hassle for you, but don't kid yourself that you're doing "the best you can".

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Mild or not it still has a heck of a net benefit over cost. And although the benefits are not great, the costs of masking are also extremely low. [School for young children may be an exception with quite high costs.]

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What about ventilation? We should be improving ventilation in public spaces to prevent asthma alone, but I think it could also be good for preventing COVID spread in some cases.

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author

That got cut for length but what I found is that HEPA filters are precise enough to catch Covid particles but it's unclear if they would catch them before you inhale them. One study found that they really reduced the amount of Covid particles in the air in a hospital setting so it might be useful there.

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They absolutely would catch the particles, and for that matter so do MERV13 filters. It’s the exact same concept as masks, at larger scale. This is why aircraft cabins were not a significant source of spread, despite long durations in close quarters with well-mixed air.

Masks get all the press, but filtration is the next best thing after vaccines.

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Ventilation also has the advantage of being invisible infrastructure. That makes thinks look more normal than a bunch of people wearing masks.

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Ventilation has the *disadvantage* of not being a signpost of How Much We're Taking This Seriously.

Had GWB or Mitt Romney been president in 2020, I think it's an open question how much blue-leaning metros would give a crap about masks in early 2022.

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Yes, the best thing to do re:COVID is to find ways of decreasing its partisan salience so that people start following common sense (get vaxxed, avoid sick people, live life) instead of the tribal imperative (flout adherence/non-adherence).

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Feb 5, 2022·edited Feb 5, 2022

Yes, I keep trying to persuade my all-vaccinated low risk lefty cohort that we have to start acting more normal for the political benefit that will accrue. MY has of course been making this point too.

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Unfortunately it's so invisible that nobody ever talks about it, thus outside of experts in the air quality industry, there is mass ignorance on how much it helps, and therefore we have a thousand articles about mask wars.

If the average person had any idea how much safety they could buy with a $20 box fan, some furnace filters, and a roll of duct tape, you wouldn't be able to keep them on the store shelves.

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Gosh, everyone I know that traveled by air somewhere (Florida, etc. from the NE) came home sick.

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I'd say it's likely that riding in a plane was not the riskiest activity that most travelers engaged in during their trips.

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Almost certainly right. A few months ago, I recall reading that flight attendants had a lower proportion of cases than the general public.

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Feb 5, 2022·edited Feb 5, 2022

Yes, but he said it was unclear if they caught them before you inhaled them.

If you're breathing out COVID particles 2 feet from me and the air ventilation is 20 feet away, I'm going to breathe in virus.

I'm sure it reduces infection, but how well it does seems like it's going to be incredibly implementation-specific and you're never going to know how well ventilation is implemented wherever you go.

(I still think it's a good idea)

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Nothing will save you from an extremely localized source except a well-fitted, high-quality mask: that's just facts about proximity.

But aerosolized virus can survive airborne for hours. If there's a room with stagnant air and a source of virus, a mask is insufficient: you're sitting in a soup and even an N95 won't be good enough, eventually something will get through. Someone shedding virus can infect someone clear across the room. You *have* to get the virus out of the air. Filtration is good, ventilation is better, both is best.

It is absolutely the case that clearing virus from the air will help on net, and the most important thing you can do to stop indoor transmission. Can't get infected if you can't get dosed.

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I was team ventilation right up until today, but there's been new studies that the virus does NOT hang in the air for hours. They now think it in fact loses it's ability to infect after it leaves the host in about 5 to 20 minutes.

Obviously, outdoors and open windows is still better than closed. But with a little recent googling I see that Milan has a point. I'll still ventilate, but I'm gonna' start stepping back when speaking to neighbors unmasked on the street.

https://www.theguardian.com/world/2022/jan/11/covid-loses-90-of-ability-to-infect-within-five-minutes-in-air-study

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With respect, outdoor masking was always absurd, even in March of 2020.

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100% agree, I was just pointing out that your comment read as if you thought you were rebutting Milan, but saying "filters do catch viruses" is not a rebuttal to "filters might not catch viruses before you breathe them in".

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There's nothing to rebut, and TBH he didn't even answer the question (filtration and ventilation are different things). I was just confirming the fact that HEPA works, extended it to MERV 13s as well, and gave a real-world example that wasn't a hospital setting.

I don't want people reading this thread to walk out with the impression that clean air is some expensive intervention with dubious efficacy that you will only see in high-risk medical settings.

Anybody with 30 bucks and a roll of duct tape can have clean air.

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founding

Even if someone's standing two feet away from you, it matters whether each exhale adds virus to the amount that's already floating in your vicinity, or whether the ventilation system has created a gentle pressure gradient so that each exhale just causes a temporary cloud of virus that is sucked away before the next exhale adds to it.

The HVAC system in my home is definitely not sufficient for the volume of some of the rooms - particularly in the master closet and master bathroom, there's always a huge amount of stagnant air even if the HVAC is blowing. But in a well-designed system, like an airplane cabin, you've got air intake on one side of the space and air outflow on the other (in the airplane cabin air comes in above each seat and leaves below each seat) to prevent these stagnant pockets.

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What we really need to know is how effective they are in schools. Is no one trying to figure that out?

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Well, if filters help raise test scores and MIGHT lower Covid spread that's a win / win, right?

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Yes! More research needed but I don't see any possible harm in installing filters in classrooms so let's use some of the ARP money or the $5B state tax surplus to roll out some pilot programs in Massachusetts.

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Can't hurt might help! In fact, couldn't they do a test? Where two comparable schools, one with & one without updated filtration is studied during the next variant wave and we see if there's less breakouts?

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Wow, that's amazing!

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They are perfect for schools, and some people are pushing for it. I built a DIY Corsi-Rosenthal box for my son's classroom. On a low setting, it's only ~50db at a distance of 6 feet, and pushes out 400+ cubic feet per minute or filtered air.

They have not had a COVID outbreak for the entire pandemic.

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I bought portable air filtration systems for both my wife's class (she's a teacher) and my son's class (he's in Kindergarten). I don't think most school districts have actually given this much thought.

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I talked my boss into buying air purifiers for each office at our company. Now I'm worried that won't help. Ha!

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My kid's school has made some too. Although even if our kids classes haven't had breakouts that's still anecdotal. I wish someone would really study this. But I looked around and Milan's right. There's no hard evidence that it lowers spread that I can find. Send me some links if you have any.

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Any place on Slow Boring where your could post your supplementary materials (like an annex). I'd be interested in reading it!

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The high ceilings and big windows in housing built for the middle class and up in the late 19th and early 20th century were actually an party an infection control feature. Tuberculosis was very common and the high ceilings allowed mixing of the air and therefore diluted the infectious dose. Opening windows is also very effective at diluting anything in the air.

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I've often wondered if the better results in Germany have been mostly driven by building standards and cultural norms that focus on more ventilation. When I lived there, my friends would just open up the windows in the middle of a cold winter day.

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founding

Unfortunately, in my contemporary home, the high ceilings and un-openable windows mean that the HVAC system often can't move all of the air in the space. I think a lot of recent building codes have emphasized HVAC rather than openable windows for reasons of energy efficiency and/or fire safety, but this has had a lot of downside for the pandemic. (It would probably be great if your air quality concern is forest fires and traffic emissions though.)

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Interesting.

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Came here to say this, also to bring up filtration. You cannot just talk about vaccines, masks, and distance. Buildup of aerosolized virus particles is why indoor spread is a thing.

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I thought so too. Looked into it fresh after reading Milan's article. Like him I can't find any proof. And I ALWAYS open my windows indoors, in Ubers or cabs. Plus I bought an air purifier at my home. Wife got covid. kid & I didn't. But someone's gotta' really study it. I haven't seen any other than this Japanese thing that's almost 2 years old now.

https://www.weforum.org/agenda/2020/04/coronavirus-microdroplets-talking-breathing-spread-covid-19/

Plus there's new studies saying that covid does NOT hang in the air as for hours like they first thought. Now they say it loses it's infection capabilites in 5 to 20 minutes. Here's that article. Much more recent.

https://www.theguardian.com/world/2022/jan/11/covid-loses-90-of-ability-to-infect-within-five-minutes-in-air-study

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Amen. I've managed to find exactly one restauranteur who talks publicly about their air quality --- and he was on this bandwagon pre-COVID: https://www.civilbeat.org/2021/03/covid-19-is-airborne-so-why-doesnt-hawaii-have-pandemic-air-quality-standards/

(Seriously, 24 air changes per hour? That's incredibly good ventilation.)

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So, uh, I shouldn’t be sterilizing my groceries anymore?

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Feb 5, 2022Liked by Milan Singh

First off, I want to say I can see why Matt hired you - you are a good writer and you managed to condense a lot of information into a something that was not a chore to read, so well done.

Here are a few thoughts:

In many ways I think it's useful to think of this as three pandemics and not one pandemic. That's because the three major variants have not been affected by our interventions in the same way, particularly vaccine and masking effectiveness.

Secondly, with regard to mandates, process and legitimacy matter a great deal. Austria's parliament passing a mandate into law is not the same thing as the Biden administration trolling through regulations looking for something to shoehorn into a mandate. Personally, I have no problem with mandates, but there needs to be democratic accountability and support. Two years into this we should not be relying on emergency powers and gimmicks like the OSHA ETS rule.

And since the government has done such a bad job at building credibility, any hope for a democratically-legitimate mandate is pretty much gone. And two years in, it's quite depressing to see that the same mistakes are being made that contribute to a lack of public confidence.

Given these realities, I'm basically where you are. Vaccination is the best option and that ought to be encouraged, but at the end of the day, it's a choice and if people want to roll the dice, then they can do that.

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I am so, so mad at my local authorities continuing to exercise power by declaring emergency stuff, over and over and over.

*Two years ago* we knew we had to do emergency stuff. Now we don't. We have regular-process systems to control or mitigate spread, or not. The voters control those systems. Use them.

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Yeah, totally agree!

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Feb 5, 2022·edited Feb 5, 2022

If you buy "Covid Zero" doesn't make sense, and I do, then it doesn't really matter that much how good masks work. They're only a delay tactic, which is only useful in a few circumstances that mostly no longer apply (like the hospitals are full or vaccines are around the corner).

This is why the "I support mask mandates because I CARE and people are DYING" people are so incredibly frustrating. Because you're doing this "until COVID is gone" but COVID is only gone after some combination of everyone is vaccinated, exposed, or both. So all you're doing is taking the same outcome and stretching it out slightly, all the while tut-tutting at the monsters who have taken a moment to think this through. I am truly, deeply confused at why this can't be explained to so many people.

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It matters how well masks work *because* they are useful in a few circumstances — if I was going to visit my grandparents in MD I might want to know what mask to wear because I don't want to get them sick, even if I wouldn't wear a mask if I was out and about on my own.

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Feb 5, 2022·edited Feb 5, 2022

I agree, I just think that a lot of people think of it as "we need masks and vaccines" when it should be "we need vaccines, vaccines, vaccines, and also vaccines, and then we can behave normally except in a few specific circumstances where masks might be helpful".

So many I overstated it a little, I should qualify it as it doesn't matter much how masks work when thinking about the big covid picture, but it may be of interest for those few circumstances.

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Yeah I agree with that

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Yeah. Vaccines are way more important than anything. If Democrats make it seem like we're gonna' be wearing masks for the rest of our lives then we're not gonna' change any Republican or anti-vaxxers mind.

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Society is not just for the young. Society includes all of us. Your premise seems to infer that the vulnerable are not important to society.

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"delay tactic" - Thank you! I wanted to say something along these lines. All these measures of NPI effectiveness, ie masks are X% effective when worn correctly, cloth is Y%, ventilation reduced by Z%, etc.. They're only measuring effectiveness over short timespans. If covid is sticking around, everyone is exposed eventually, multiple times. Sure you can reduce the frequency of exposure, but eventually we all have to rely on our immune systems and acquired (vaccine or through infection) immunity. Nothing in Milan's summary of NPI's convinced me that any of them are long term solutions.

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Aren't delaying tactics an effective way to keep hospitals from being overwhelmed and staffing shortages from becoming too acute though?

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Yes I mentioned this in my original comment. I think if you are going to push masks you have to tie them to a specific healthcare shortage issue, not just sorta wave your hands and say "masks good because people are dying."

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Sure - flatten the curve is a worthy goal. But is that why we've been doing NPIs in most of the US for most of the pandemic? The number of times and places were overwhelmed hospitals was potentially going to happen was limited in time and space.

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I increasingly find the "overwhelmed hospitals" argument to be disingenuous. All health care has operated on an unstated triage basis since time immemorial--"you're not sick enough to invoke this level of care". Feel yucky on day 1? Stay home. Feel yucky on day 3? Go to your doctor. Doctor thinks you have the black death? Go to the ER. Etc.

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Our healthcare system has had 18 months to increase capacity. Instead, our capacity has decreased. We knew that delaying care for non-Covid stuff would mean that more people would end up in the hospital. We knew that we would have surges of people in the hospital for Covid. The answer was to increase capacity. Which we didn't do. I have problems with expecting people to make substantial changes to their lives because the healthcare industry messed up.

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What steps to increase capacity could have been taken but weren't? It takes more than 18 months to train a nurse, let alone a doctor.

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It takes more than 18 months to train a person that we consider to be a whole-profile nurse in what I might call peacetime conditions. Does it take the Navy 18 months to train a corpsman, especially a general-purpose servant in peacetime? I'm less sure.

This is one aspect in which the PRC embarrassed us in a geopolitical sense. A resident of Mali, or whatever, says: what do you mean, the US couldn't meaningfully increase their hospital capacity in twelve or eighteen months?

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Do you have problems with that expectation on a fairness/morality ground (e.g. "it's not right that people have to make substantial changes") or on practical/pragmatic grounds ("people aren't going to make these sacrifices once they see how the health care industry is operating")?

Are there specific capacity buildings policies you think we should have done and did not do that fit into the time frame of the pandemic (e.g. in the last two years)?

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I have a problem on both grounds. I think there is a fundamental immorality to expect people to stop doing things that give them pleasure and their lives meaning to help out a healthcare system that is really not doing a good job managing capacity. And that's especially true if we continue to expect people to change their behavior even when there aren't many people in the hospitals as happened where I live during both summers.

I also think you're going to run into pragmatic problems because people are tired of putting their lives on hold and if the industry they're doing this to protect doesn't seem to be able to get its act together, people are less likely to go along. It's not ridiculous for people to assume that they'd just be enabling it.

Now, part of this is because I tend to see the healthcare industry as a service industry: it's here to serve people and it accepts that human nature is not going to change much. I also tend to think that we're better off not telling people to rearrange their lives unless it's actually necessary and there are no other options.

One of the things we could have done is treat our healthcare workers better. People are more willing to work extra shifts if they've been treated well. Not laying off healthcare workers during the first lockdown would also have helped. Another thing would be to allow immigration of healthcare workers. We rely on foreign nurses and doctors. Many of our nursing home and home healthcare workers are immigrants and increasing staffing in nursing homes would take some pressure off of the hospitals. Finally, trying to figure out what tasks done by licensed staff could have been shifted to non-licensed staff or staff with a lower level of licensing could have helped improve capacity.

When we did have lulls in infections, the healthcare industry should have worked hard to get the necessary elective (ie cancer surgeries) procedures done. I had a relative in the hospital in the summer of 2021. The hospital was nearly deserted. That was when we should have been doing the urgent but not emergency stuff.

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Wait, why? A family member went to the ER for heart issues (turned out to be unrelated to COVID, she went in because of the heart symptoms) and the efficiency with which the hospital took in her case was worse than one would expect if the Omicron wave wasn't in peak. One tell was that she was taken in by the national guard and not the regular staff.

So yeah - it's always triaged - but isn't that's exactly why the total load of severe illness matters?

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This is absolutely the more accurate take. We've throttled down all sorts of care during the surge and the care we are providing has been reduced in quality or efficiency to some degree.

Flattening the curve is still necessary in 2022. With Omicron and vaccines, the math driving the surge is just a bit different.

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(I do think that "NPIs don't move the needle enoguh" is a different and real concern - but that's orthogonal to whether we care about how many sick people are in the hospital.)

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Feb 5, 2022·edited Feb 5, 2022

Yeah, it's making me think I'm insane. The Public Health Official types like Fauci seemed to drag their heels on making this fairly obvious argument (even though it was universally understood in April 2020), and now it seems like they kind of acknowledge it, but quietly. And otherwise smart seemingly people in breakdowns like this one don't seem to clearly lay out the difference between how the vaccines "work" and how masks "work" - they're not even "working" in the same way. You can't even really compare them.

If you roll a six sided die and a twenty sided die 1000 times each, you're going to get a 1 on both at least once!

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I would say they do work in the same way in the sense that the point of all of these measures is to slow down and spread out the burden on the hospital system. In 2020 masks made sense to help slow the spread. Now the best thing to do is vaccinate because even if you still get a case the chances of you taking up a hospital bed becomes tiny.

But underlying both strategies is the understanding that we're all getting this at some point. That's what it seems like some people have trouble accepting. Not that almost certainly avoiding death isn't also a really awesome side effect of the vaccine, and as great an incentive to get it as I can imagine.

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COVID zero did make sense in the beginning though. Sars and Mers were defeated by these policies before they could become pandemics. And we would have far more people alive right now if we had pursued strategies similar to the Asian countries early in the pandemic.

I agree with you, the cats out of the bag. Still, the recent waves did put some hospitals over capacity so it is possible that mask policies did save lives during the delta and omnicron surges.

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I agree, there was a moment where vaccines almost defeated alpha Covid, but Delta removed the possibility. Omicron is almost a blessing, in a terrible way, because it's about the best outcome you can have if you refuse vaccines.

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Perhaps if we could have more quickly expanded those vaccines to the rest of the world it could have been defeated before Delta emerged. I hope people begin to see the need for a coordinated worldwide vaccine production system. The more infected people the more variants emerge. We are all in this together.

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Anything that reduces spread (effective R) also reduces the total percentage of the population that is infected in a given wave. Most Americans still haven’t gotten Covid and it’s not at all inevitable that they will in the short term.

And yeah, delay alone is helpful, especially with reinfection. If I asked you if you wanted a bad bout of the flu this year and maybe getting it again next year, or you just wanted to get it next year, it would be an easy choice. The idea that delay is worth absolutely nothing to people is just wrong. I’m not panicking over getting Covid, but I still don’t want to? Maybe next year there will be a better vaccine. Maybe next year it will have faded away.

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The best estimates I've seen of how many people in US have got covid up until now have been converging on around 60% or so. They've all works by taking the case numbers and applying some varying multiple to account for untested cases.

I'm triple vaxxed and I've caught about a half dozen colds, sore throats and very mild fevers since my kid started daycare this fall. Were any of them covid? I have no idea.

For me it wasn't worth the time and effort to go get tested. I can't be the only the person who's not bothering with testing.

I agree that delay has some value and it's good to point that out. I just don't put all that much value to it. Short of avoiding close contact with a person who was probably infected I can't think of a behavior that's worth changing for me, personally. I might avoid a few social situations if I didn't really want to go that much anyway. That's about it.

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Feb 5, 2022·edited Feb 5, 2022

The vaccine is excellent already and it won't fade away without most people getting it. I think that most Americans have already gotten covid, or just had it bounce off them due to vaccination. This is the process we have through.

The difference with the flu is Covid is way more infectious and it's new. So we *have to* go through the same process humanity went through with the 1918 flu, where only mass exposure kicks it down into a low background level.

If any one individual, either because they have serious health issues or because they're just super risk averse, wants to try to avoid it forever, they can go ahead and do that, but it will probably require permenent behavior changes. But as a question of policy, requiring masks for everyone is just delaying the inevitable. And if you asked me if I wanted to encounter Covid tomorrow, or hide at home for a year and then encounter it a year from now anyways, I'd say get it over with.

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You seem to be talking about everyone getting it exactly once and then being done. That doesn't seem to be how it works though. The question is *how often* you will get it, not *when* you will get it once only.

You don't have to hide at home all year - if you just pay attention to when there's a big wave, and hide at home for a week or two each year (which may well be the weeks with the worst weather anyway), you can get the majority of the benefit of hiding away at home, and also get the majority of the benefit of ignoring it.

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I think waves tend to last a lot longer than two weeks. More like months.

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True. It looks like in Brazos County, the delta wave had counts above 20 per 100,000 per day for about 10 weeks, and Omicron will likely end up being about 6 or 7 weeks at that level.

Choose a slightly higher threshold then that gets only the highest couple weeks of the wave. There's no rule that says that either you have to stay home the whole wave, or you have to go out the entire wave - cutting off the peak is the most benefit for relatively low cost.

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Both the Republicans and Democrats show their specific malfunctions with the Covid policies they adopted, or not adopted.

Republicans choose idiocy for the sake of idiocy. To adopt competent policies would be a breach of faith with the base.

Democrats choose to enact strict policies against Covid, some of dubious value, but then not bother to enforce them. Enforcing rules on people means punishing them for violating them.

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Any summary of COVID's risks that doesn't include the wildly different outcomes by age is incomplete at best, and misleading at worst.

An unvaxxed person under 30 is less likely to die from COVID than a fully vaxxed 55 year old. Policies should have adjusted to reflect this reality. But the battlefield lines had been drawn around visual signs of compliance like masking.

We'd have been much better off if the federal government would have said: "We are focused on getting those over 50 vaccinated and boosted. This disease is particularly harmful to that group. The vaccine is available for the rest of you, but our focus is on those over 50." And then respond to any policy proposal or question - masks, schools, OSHA, travel mandates, anything - with a version of that response.

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Feb 5, 2022·edited Feb 5, 2022

I honestly think such a policy would also have effectively punched the “reflexive opposition to being told or advised what to do” button that distinguishes many low-SES folks on both right and left (especially right, IMO, but that’s subjective) and gotten them to take the vaccine.

“What do you mean, prioritizing someone other than *me*?!! Well, I’ll show you, I’m making a vaccine appointment tomorrow!”

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When vaccines were in short supply, they were prioritized based on age. What does it mean to focus on those over 50 when supply is greater than demand?

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founding

It is about message discipline. It means to avoid any messaging that isn't related to the goal of getting as close to 100% vaccination for the over 50 age group. Avoid topics that are controversial around NPIs, vaccine mandates, etc. Let the CDC mention masks once, then drop it. Say schools should be open. Have a press release when the vaccine is approved for kids, then drop the topic. Until the over 50 age group is 99%+ vaccinated, don't talk about anything else.

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Back when the shot prevented infection as well as death(I believe it still helps), getting the under 55 crowd vaccinated was an important part of preventing spread to the 55+ crowd. Message discipline that undermines getting to herd immunity wouldn't have made sense before Delta. At this point it would make sense to acknowledge we won't get there thanks to vaccine hesitancy and lack of vaccine availability worldwide, and pivot to the strategy you suggest. But it wouldn't have made sense if the CDC thought there was any chance of reaching herd immunity.

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That's a little too binary. We don't really have herd immunity to measles, either, but its still worth requiring vaccines. I think it is still a message worth sending that your vaccine does help protect other people (and we are not just the nanny state minding your business for you).

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Certain places have had outbreaks recently due to declining vaccination rates, but we absolutely have had herd immunity to the Measles for some time now. The outbreaks we do have are small, Measles is in no danger of spreading to the whole society because we have herd immunity.

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OK. Bad example. I just mean that that herd immunity concept is not binary; there can be behaviors that have value in preventing infection from spreading over and above the value of the behavior to the behavior.

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Maybe the message discipline you mention is best, but I think focusing to exclusively on 50+ vaccinations is wrong. For one it would undermine the "heroic" message about vaccines and in practice potential spreaders should be vaccinated.

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It's not clear that prioritizing by age was optimal when taking account of the spread externality.

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As a practical matter, prioritizing by age lasted about a week or two as far as I can remember. Under 40, fit enough to run 30-odd miles a week, still categorized as "high risk" if I wanted to be (which I did).

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Agreed about the practical effect.

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None of y'all have zipped up a body bag and it shows. I have to tell you that 30 and 40 year olds who are unvaccinated die too.

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I agree that policy should take account of age differences, just not an age dichotomy. There is a clear difference in the costs and benefits of remote instruction v remote eating and drinking :) based in part on age. But its not just the risk the person faces but also the risk they impose to others.

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I think initially higher risk of death was prioritized (those in group homes, extended care facilities, their caregivers) but seriously, unless you think your are just going to live fast and die young -- the smart thing is to get the vaccination. Because chances are, you have parents and grandparents. Do you want to be the carrier for that virus that kills them? Because even when we vaccinate the >70's-- many of them are still vulnerable due to impaired immune systems and still die-- even after 2 shots and a booster. And of you young'uns who end up intubated and live to be extubated... your chances aren't much better post discharge. There is plenty that can still go wrong and a lot of those patients die not much later but their deaths are not Covid cause of death indicated.

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I'm not sure I understand your comment as I seem to agree with what you seem to think is a disagreement. Maybe the difference is you think I am saying prioritize ability to transmit instead of vulnerability to transmission. I only meant that both should enter the optimization function,

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One nitpick, the section on social distancing (which is a phrase I hope to soon banish from existence), references aerosol droplets as the transmission path.

Aerosols would be the better choice, to eliminate the confusion the CDC/WHO introduced to the world when they anchored themselves to droplets and surface-based transmission.

https://www.bmj.com/content/373/bmj.n913

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Indeed. The upshot is that given the long lifetime of aerosols indoors, especially when ventilation is poor, "social distancing" is not very effective (depending, of course, on the time spent indoors). Plenty of superspreader events have demonstrated this.

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Exactly. If it only means "Six Feet", then say that. If it means "no bars, no restaurants, no gyms", say that. I'm sure that in the survey showing support for Social Distancing, respondents thought it meant Six Feet.

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Feb 5, 2022Liked by Milan Singh

Spot on, Milan. Well done.

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Your data on masking is all pre-omicron. And since Omicron is the prevalent variant, you ar argument for masking policies is outdated.

You also left out border closures which I think have are the most affective. Whenever I asked my question above about mask mandates, someone inevitably points to New Zealand or South Korea or one of these other island nations that has the ability to lock their borders. They make Trump look pro open borders.

I can show you charge after chart after chart that shows the Omicron Spike is exactly the same in every country regardless of masking policy. Argentina was so successful with their precautions that they did not have a delta wave at all. They were powerless against Omicron.

Look at South Korea now with their cases and Omicron. Yes there cases per capital are lower than other places, but that spike is heading in one direction right now. Up up up. Their mask and policies are not working. And news stories say they’re about to enter into all sorts of other severe lockdowns. So yes locking people in their houses or apartments was probably an effective measure, masks… I’m not seeing it.

https://ourworldindata.org/explorers/coronavirus-data-explorer?zoomToSelection=true&time=2020-03-01..latest&facet=none&pickerSort=desc&pickerMetric=total_cases&hideControls=true&Metric=Confirmed+cases&Interval=7-day+rolling+average&Relative+to+Population=false&Color+by+test+positivity=false&country=~KOR

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Feb 5, 2022·edited Feb 5, 2022Author

My argument is not that masks will stop Omicron but that they probably reduce the spread and protect people on an individual level. They were more effective in the past, I agree that in the big picture they probably aren't worth it given higher transmissibility and lax enforcement which is why I personally don't like general purpose mask mandates. I'd be fine with mandates for a high-risk place like a nursing home.

I was alluding to border controls when I talked about Covid Zero and travel restrictions and my argument there is that border controls were effective pre-variants, but the issue is enforcement — Australia deported Djokovic because he wasn't vaccinated but no blue state governors really blocked people from entering their states during the beginning of the pandemic.

Sorry to hear you got Omicron, get well soon!

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Just saw this. I am just worry about justifications for selective mask mandates because that’s not how they tend to happen. Instead we end up with 100% mask mandates, that are always a lot slower to be taken away then to be put up. Also, I don’t think requiring masks at nursing homes really counts as a mask mandate. Masks are required in ICUs, and I don’t consider that a mandate. I have no problem with wearing masks in doctors offices for the rest of my life. But wearing masks on planes forever when you fly 100 days a year sort of sucks.

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Let me just update this to say that I just tested positive for Omicron this morning here in Mexico. They have 100% masking requirements. In fact we have to wear KN 95s at the job site, even if we were walking in a parking lot with no one beside us.

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I’m not worried. I’m vaccinated and boosted.

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Vaccines are great, aren't they?

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What is the situation for traveling back to the US after testing positive? I'm traveling abroad in a couple of weeks, and the only risk I've worried about is testing positive and being quarantined, I have no idea where, at what cost and for how long, before returning to the US.

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7-days quarantine for my work. But all the US requires is a negative test. Depending on the country determines whether they “force” a quarantine. But if so had a negative test tomorrow, nothing stopping me from flying.

As far as cost, it’s all on my work. So I don’t care. They arrange food. Medicine. Etc.

Best thing is I earn 8-hours overtime on Saturday and Sunday. And I get a 30% bonus for all my quarantine time M-F.

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I think you said you're in Mexico. What does 'quarantine' actually mean? Are you restricted to your hotel room with only room service, or can you go outdoors for a walk? I realize other countries may differ in what 'quarantine' means.

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My nephew and his wife got Omicron while visiting Italy in January and their departure was delayed by 2 weeks. They got Covid but after the first 5 days of not feeling well, they quickly recovered however their testing kept coming up positive. They picked up home tests at the drugstore every day because if they did an official test the Italian government could hold them up to 21 days. As it was, it cost over $2500 for their overstay and Delta was not terrifically helpful. They told them an American Dr. had to officially give them clearance home (they live in FL and the only PCP was his wife's and she refused to do it--told her to find an Italian Dr. to assess). They ultimately went through some WebMD appointment to finally get clearance to come back to the states. I felt so badly but I didn't know of any MD that did not know them who would clear them. I suggested they contact the US consulate.

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My booster calculation came from the fact that I travel internationally. My priority is reducing the odds of adding up critically ill in a foreign Latin American country.

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My intuition suggests that masks CAN work against Omicron… but you have to be near-religious about it. As in, wear a KN95 in a semi-crowded movie theater for the movie’s entire run time, but don’t pretend you can eat a whole meal indoors and only use your mask to go to the bathroom.

All of which is to say: getting vaccinated and boosted saves all of this needless hoop-jumping.

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"Work" and "not work" isn't the right framing.

If you inhale exactly one covid particle (of whatever flavor), your body is probably going to kill it off before you experience symptoms or would test positive to even very sensitive tests. If you inhale one billion, or whatever, you are far more likely to get sick. And it stands to reason (I am a fluid dynamicist and I feel comfortable saying this) that masks will reduce the number of viral particles you inhale in a given setting.

Is a potentially minor payoff worth the minor cost, especially when there is no endpoint? That is the question we should be asking (FWIW, my answer is "absolutely not").

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Not to mention, you'd have to keep wearing masks until covid goes away (in other words the rest of your life), and at best all you're doing is decreasing the frequency of your exposure, not eliminating it.

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founding

I think decreasing frequency of exposure during the highest waves seems like a worthwhile goal. It still gets the majority of the reduction in harm that someone might be aiming for with total elimination of risk (even though it's not total) and *also* gets the majority of the mask-free activity that someone might be aiming for with completely ignoring covid (even though it's also not total on that).

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Yeah you make good points about that.

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Well since I just tested positive for Omicron this morning here in Mexico where 100% mask is required. In fact the job site that I’m working on requires KN 95s 100% of the time. Even if you were walking in the middle of a parking lot with no one around you had better be wearing your mask. I’ve been eating in my hotel room, not even going out in the evenings.

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If masks were 100% effective we wouldn't need vaccines. Anecdotal evidence doesn't say much about our situation. If they were 99% effective some people would still get sick.

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deletedFeb 5, 2022·edited Feb 5, 2022
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At the beginning of the pandemic.

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Feb 5, 2022·edited Feb 5, 2022Liked by Milan Singh

Found another study about case incidence.

"As of January 8, 2022, age-adjusted 14-day cumulative incidence and hospitalization rates remained highest among unvaccinated persons (6,743.5 and 187.8 per 100,000, respectively), and lowest among fully vaccinated persons with a booster (1,889.0 and 8.2, respectively) and fully vaccinated persons without a booster (3,355.5 and 35.4, respectively)."

So there remains an effect on infection rates.

https://www.cdc.gov/mmwr/volumes/71/wr/mm7105e1.htm#T1_down

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What about ventillation? Seems like an oversight to leave that out. No good evidence on this? I feel like this could be a good one politically for an exit strategy from all the masking debates since it requires nothing other than money and no behavior change.

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Yeah I wasn't able to find any good research on ventilation measures like opening windows. What I found on HEPA filters is that they can catch Covid particles and according to one study they did reduce the number of particles in the air in hospitals, but it's not clear if the filter will catch the particles before you inhale them. We had to cut that part out for length.

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Understandable. It would be very hard to generate really ironclad data (i.e. clinical trial type data) about ventillation/filtration in terms of reducing transmission, but I think the plausibility for ventillation/air-filtration is very strong given that: 1) superspreading is only possible via long-range aerosol transmission (and indeed it js commonly accepted that unmasked outdoor interactions are generally safe) 2) air-filtration has been demonstrated to reduce virus in air, as you mention (e.g. https://pubmed.ncbi.nlm.nih.gov/34718446/ ). Those two facts taken together along with the zero risk of air-filtration, and other well-established benefits of breathing clean-air would seem to more than justify broader adoption of air-filtration as a mitigation measure.

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founding

I would think the evidence regarding ventilation would be better than the evidence regarding masking, but masking probably has more studies because it was such a political flashpoint.

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Feb 5, 2022·edited Feb 5, 2022

The other aspect is the divide between the medical-science and physical-science research worlds on ventilation: all the ventilation studies apparently get published in engineering journals, so doctors and public health folks don't see them on Medline --- and they discount anything that relies on prior knowledge of physical laws, rather than doing an RCT. At least, that's what the COVID-is-airborne aerosol folks seem to have concluded.

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founding

I think the medical world is just so used to biological systems being complex that they don't trust *any* rational theory, and *only* count purely empirical studies. At least, that's my read of the "evidence-based medicine" movement.

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Yeah, and they're not totally wrong on that since there's a long history of extrapolation in biological systems leading to very badly wrong results. But I worry that it's hedgehogism when being foxy is maybe more useful here.

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"Covid-19 primarily spreads through aerosol droplets and the further away one gets from the source of the aerosols, the lower the concentration of viral particles.

...And it so happens that respiratory aerosol droplets don’t spread beyond six feet, hence the “stay six feet apart” guideline."

As I understand it, this is just plain wrong, at least based on what Zeynep Tufekci has been wring about aerosol transmission for almost 2 years.

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Yes, Milan seems to have missed the aerosol literature and managed to mangle the (distinction between (supposed) ballistic droplets and aerosols. :(

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The presentation of the vaccines' efficacy against infection in this piece is horribly misleading.

The outdated 90% plus efficacy against infection figure is highlighted in both text and in charts while the more relevant, and much lower efficacy against infection for Omicron is not presented as a similar percentage figure. As I understand it, vaccine efficacy against Omicron is roughtly 70% at best and degrades to somewhere near 30-40% after just a couple months after a booster. Those lower percentages should have been cited in the article.

I get it that the vaccines do a great job protecting against hospitalization and death and it's fine to highlight that or even lead with that. But if you're going to highlight efficacy against infection, do it honestly and reliably.

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"https://coronavirus.health.ny.gov/covid-19-breakthrough-data"

Then what do you make of these fantastic case reductions in the fully vaccinated from New York state?

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Not very much. It's just raw data with lots of confounds. It needs to be interpreted by people who know what they're doing to make it meaningful.

If you're interested, Eric Topal recently did a good rundown of the latest research on VE against Omicron:

https://erictopol.substack.com/p/where-do-we-stand-with-omicron

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What really bothers me about some of the NPIs is that there’s no clear roadmap for return to normal. Take Washington DC, which for months has had one of the strictest mask mandates in the country. It made at least some sense to keep it through the holidays, and consequently through the Omicron spike. But with cases falling precipitously, there doesn’t seem to be a lot of clear communication about why it’s going all the way to the end of February. Especially since we just implemented a super-based vaccine mandate for dining!

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Feb 5, 2022·edited Feb 5, 2022

To some extent this is on the CDC. I live in Los Angeles. There is no way LA will adopt masking policies less strict than the CDC. If they aren’t followed by somewhere like LA (literally run by a former Dem cabinet secretary) they are pointless.

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But also it's extremely not on the CDC. The CDC issues advice--if you do X, we think the science predicts Y. The CDC does not make policy and should not make policy. When policymakers take CDC advice and treat it as policy, they are doing a bad, lazy job, and they should be replaced.

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I think the dynamic of local governments being afraid to be less strict than the CDC is pretty real. And at some level, I think that that's not a bad lazy job, it's a qualification issue. The parents who are on the town school committee didn't run because of their desire to use their epidemiological expertise to design the school's COVID response.

I certainly understand why at the local level they don't feel qualified to second guess the CDC, even if the CDC is being clearly overly cautious from a cost-benefit standpoint.

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Really? I am a healthcare worker and most of us working in hospitals feel that the CDC is not over-cautious. We think they are prone to political influence-- particularly by economic pressures... or shall I say that there is corporate/economic sector pressures that appear to swing the sails on CDC recommendations for healthcare and other workers who have Covid or have been exposed to Covid..

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I don't think the CDC has been doing a good job of saying "if you do X, we think the science predicts Y". They've been talking very much in absolutes, with no conditionals. They say "it is safe to go to indoor spaces without a mask in these counties, not in those counties" and "these groups need vaccines and these groups don't need vaccines", without any guidelines as to what they mean by "safe" or "need".

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I think the CDC has done a shitpile job and should be gutted reputationally as a rapid-response public health organization.

I have no reason to doubt their remit as a public health research organization, but that's a very different question. I don't know why we thought it was a good idea to combine those two taskings.

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I really want Matt Yglesias to tell us something about what he hopes is the best case for the CDC/FDA-type bodies going forward. I've been hearing a little bit of rumbling about a 9/11-commission style body, and I would love it if they recommended some big overhaul of these bodies. I hope.

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Yup. They've been unwilling throughout all of this to tie the mandate to any kind of external metric.

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I’d like to see more in here about which groups are at high risk and why. Over 55 for sure but also which comorbidities increase risk the most? Immunocompromised, too. Many times the discussion about NPIs and vaccines turns to protecting these populations.

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Medical data is rarely that precise because data on diagnosis and comorbidities is extremely messy. There have been studies done though and they always find the same usual, and unsurprising things - diabetes, obesity, COPD, kidney disease. Anything associated with death from cardiovascular or pulmonary sources is a covid risk, and all those types of deaths have been elevated since the pandemic started.

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People with organ transplants, certain genetic diseases like SCID, or who had a blood cancer that was treated by the elimination of all B cells are at the highest risk of all the immunocompromised. People with those conditions are just about the only vaccinated people ending up in ICUs. If we had more of those monoclonal antibodies, it would be a very good idea to give them to people in this group prophylactically. There are also some medications that are taken for autoimmune diseases that can make you higher risk, but still not as high risk as someone with an organ transplant.

It's sometimes hard to unravel the risk from individual comorbidities because people tend to have more than one: diabetes is the most common cause of kidney disease and the most common type of diabetes is Type II which is much more common in people with diabetes.

Interestingly, it's not clear if asthma is a risk factor for severe Covid. It may be because asthma is caused by an immune response that's evolved to protect against worm infections (seriously) and so if you suppress that type of immune response it doesn't have much effect on your immune response to a virus. And seasonal allergies may actually reduce the risk.

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