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Since we're on the topic, shouldn't this (hospital admissions) be the almost singular criterion to influence public policy / restrictive measures? The line I'v

Since we're on the topic, shouldn't this (hospital admissions) be the almost singular criterion to influence public policy / restrictive measures? The line I've heard repeatedly is we're waiting for "total" herd immunity, as in ensuring almost all of a population is potentially protected from the virus. Frequently quoting fall / end of 2021, potentially into 2022. Shouldn't the only benchmark be those with medium-to-high risk of hospitalization? (Determination of risk however you'd like to do it.) Put another way, you wouldn't shut the world down if a bunch of people got sick for a few days. You may, and indeed we have, shut it down if a large part of the population were at risk of hospitalization or death. In many developed countries, that population is looking at full inoculation (for those who want it) sometime this spring. Should that not be the "end" of it?

vmchale 6y ago
> hospital admissions) be the almost singular criterion to influence public policy / restrictive measures? From a control theory perspective, it's one of the worst measures because it's delayed. Much more efficient to measure cases - then you don't need restricted social life as long.
- inglor_cz 6y ago
  In the wild phase of the pandemic, yes. But once enough people are vaccinated, the pattern may change. For example, you may still catch quite a lot of cases through PCR testing which is very sensitive, but the share of asymptomatic cases will be much higher and the share of people who are going to suffer a severe case much smaller. The entire societal signature of the disease will change depending on vaccination levels and maybe even particular vaccines used.
- teawrecks 6y ago
  The point isn't that we use hospital admissions as a metric to infer cases or some other metric, it IS the metric that matters. The problem over the last year wasn't that there exists a person who is at risk, it's that there didn't exist any healthcare system capacity to treat them. From very early on in the pandemic, it seemed to me like our goal for optimal balance between caution/risk was to try and maintain the highest level of hospital occupancy that is sustainable. If every single person quarantines perfectly, then our hospitals are empty, but so is every business. If no one quarantines, our businesses are full, but so are hospitals and everyone's viral load; i.e. maximum mortality. With the vaccines now available, it seems like our goal should still be be to maintain the highest level of sustainable medical system occupancy.
  - _coveredInBees 6y ago
    Call me a renegade, but I think the only goal should be to minimize the total number of deaths from Covid. Trying to maximize sustainable medical system occupancy is almost certainly not aligned with the former goal.
    - arrosenberg 6y ago
      No perfect solutions there. If there was perfect quarantine, we would still lose additional lives from suicide, domestic violence, etc. from the increased stress. There is definitely a balance to be struck, and making sure we have capacity to treat all of the sick seems to be as good as any.
      - _coveredInBees 6y ago
        Yeah, making sure we have capacity to treat anyone sick is certainly one of the highest priorities (and the reason there was such a scramble trying to contain the virus from wreaking havoc if we went past that). And I get that there are other "costs" to the virus and lockdown and a holistic, balanced view is useful. Heck, I have two young children who have been remote schooling for almost a year now while both parents work full-time. I just object with the parent's following statement: > With the vaccines now available, it seems like our goal should still be be to maintain the highest level of sustainable medical system occupancy. If we are still trying to maintain the highest level of sustainable medical system occupancy while the percentage of population that has been vaccinated is slowly increasing, it would actually mean we are doing a horrible job in trying to limit preventable deaths when a fully vaccinated populace + herd immunity is not too far away. Maybe when a much larger percentage of the population is vaccinated, the spread and rate of deaths will be low enough that this may change, but we are still nowhere near that stage.
- standardUser 6y ago
  It's an important metric because earlier indicators aren't as useful. The rate of new cases is tricky because we don't really care if someone gets COVID-19 anymore than we care if they get the common cold, assuming they have only mild symptoms and fully recover. Hospitalizations are the first unambiguous metric we have to know there is a serious problem that may require a dramatic response.
  - ceejayoz 6y ago
    > It's an important metric because earlier indicators aren't as useful. Sure they are. They're less precise, but they're more useful, because they're more likely to let you combat the spike before it gets out of control. It's like a smoke alarm. Maybe it's going off because it's over-sensitive and someone just took a shower... but it's a better early warning system than waiting for active flames to appear.
    - standardUser 6y ago
      I agree, but once vaccinations are widespread and we are confident that severe illness will be very rare, it would be hard to take drastic measures based only on the rate of new cases. There could be a huge surge of cases but we would expect a low hospitalization rate, so we would likely want to wait.
      - ceejayoz 6y ago
        Once vaccinations are widespread, yes. Until then, getting out in front of a spike remains necessary.
        km3r 6y ago
        Immunity through vaccination + natural immunity is getting closer to 'widespread' now (in the US). We are likely near 30%, and of that 30%, a growing proportion is the most vulnerable sections of the population. A spike in cases now would be increasing less connected to a future rise in hospitalizations. I think its fair to say, that if we do not see a spike within the next 3-4 weeks, we are in the clear for future spikes. By April 1st, we should be nearing 40%, with the difference primarily being now vaccinated old and immune compromised people.
deleted 6y ago
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hristov 6y ago
The problem with that sort of thinking is if you let the virus circulate and multiply you are risking mutations that are resistant to the vaccines. There already are two mutations that are already somewhat resistant to the vaccines according to initial anecdotal evidence. But practically speaking most nations are taking this approach and have been reducing social distancing measures when hospitalization rates go down. (Often with negative results.)
dragontamer 6y ago
> Since we're on the topic, shouldn't this (hospital admissions) be the almost singular criterion to influence public policy / restrictive measures? Given the high correlation between COVID# cases (or %Positive) and hospitalizations, why not just use COVID# and "gain" 2 weeks of information? Hospitalizations are weeks delayed from COVID# or %Positive spikes. Its a slow moving disease: taking 5 to 14 days before people feel sick, and then a week or two AFTER that before people decide to go to the hospital. As such, if you see a spike of hospitalization, you're already 3-weeks late to the results (ie: hospital spikes are associated with infections that occurred 3+ weeks ago). In contrast, watching COVID# or %Positive numbers gets you much closer to the ~5-14 day period where symptoms appear (and thanks to contact tracing, some people may test themselves before symptoms arrive: gaining a few precious days in the information war). Hospitalizations and Deaths are strongly correlated (with a few weeks delay). So you're effectively gaining a week-or-two worth of information. Its better to be only 1-2 weeks behind (watching COVID#), rather than being 3-4 weeks behind (watching Hospitalization#).
- scrollaway 6y ago
  > Given the high correlation between COVID# cases (or %Positive) and hospitalizations, why not just use COVID# and "gain" 2 weeks of information? As we vaccinate the people at the highest risk of hospitalization, the correlation will change: Numbers may stay very similar, but hospitalizations should go way down.
  - dragontamer 6y ago
    > As we vaccinate the people at the highest risk of hospitalization, the correlation will change: Numbers may stay very similar, but hospitalizations should go way down. Then we'll know in 2 weeks to change the policy and account for it. Note that vaccinations will *also* cause the %positive and case# to decline. USA is approaching 15% vaccinated at over 95% efficacy means that you'll have 15% fewer cases (as well as 15% fewer hospitalizations later on). I'm not convinced that cases will become desynchronized with hospitalizations: my expectation is that vaccination will cause a decline in both case# and hospitalization#, roughly in proportion. But if case# and hospitalization# become less correlated, then it won't take long (~2 weeks to see the first effects, maybe 4-weeks to be sure of the effects) to see such a split in the time-delayed correlation. ------- EDIT: Why the downvotes? Today, there's a new study being pre-pub'd that shows that Pfizer's mRNA vaccine is ~90% effective at stopping the spread of the virus (https://thehill.com/policy/healthcare/539783-pfizer-vaccine-stops-covid-19-spread-israeli-study https://thehill.com/policy/healthcare/539783-pfizer-vaccine-...). When you have a vaccine that's both 90% effective at stopping the spread and 95% effective at stopping hospitalizations, then the spread and hospitalization numbers will both go down severely (that is: #cases and #hospitalizations reported both go down). This assumption that #cases and #hospitalizations will become "desynchronized" isn't necessarily written in stone. Its possible both numbers drop down dramatically in the coming weeks as vaccines are distributed... indeed, its highly likely IMO.
bluGill 6y ago
Nobody has figured out what "long covid" is, or how long it lasts. The anecdotes I've heard about the effects to the relatively young mean I'd just assume not open up.
- deleted 6y ago
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maxerickson 6y ago
It's preferable to have very low infection numbers, to reduce the likelihood of mutations taking hold. Doesn't mean you go on forever waiting for 0 infections, you just wait a bit longer than the minimum number of vaccinations to go back to activities with highest risks of transmission.
- garmaine 6y ago
  With both travel restrictions and lockdown, It takes about 6 weeks to get to (effectively) zero new cases. Not forever.
  - jgalt212 6y ago
    Yes, but you're still stuck with a population who remains very susceptible to the diseases. Lockdowns, as I'm sure Australia will discover, are not a complete solution to the problem.
    - siquick 6y ago
      We're pretty happy here in Australia with how few of our friends and family have been affected by COVID. Life is practically back to normal and has been this way in Sydney for a while. Vaccination roll-out started this week. You'd be hard pushed to find a single person who would trade our state's response with pretty much any other countries response.
      - jgalt212 6y ago
        I'd rather be lucky than good. -- Lefty Gomez
  - rhino369 6y ago
    That depends on how many cases you started with and how low you can get the transmission rate. No way could the EU or USA get to zero in 6 weeks. It took Victoria Australia about 6 weeks to get from 500 cases to 20. America and Europe have a 100X more than 500 cases. And the longer you need to lockdown, the less restrictive the lockdowns can be.
garmaine 6y ago
> Since we're on the topic, shouldn't this (hospital admissions) be the almost singular criterion to influence public policy / restrictive measures? No. This is the "flatten the curve" logic which was a horrible misjudgment. Having the disease in circulation in the community is not only doing tremendous damage to many, many people (even if the hospitals aren't full), but is also allowing the virus to mutate and potentially escape immunity protections or become more deadly. If you re-open as soon as the hospitals start to free up again, you just start moving the pendulum back in the direction of crisis. Countries like Australia and New Zealand have shown that if you keep up lockdown measures for just a month or two after the hospitals free up (AND if you institute and keep real travel quarantine restrictions), you can get the virus to effectively ZERO community spread and keep it there. We can achieve this, and we ought to be aiming for it.
- scrollaway 6y ago
  > Countries like Australia and New Zealand have shown that if you keep up lockdown measures for just a month or two after the hospitals free up (AND if you institute and keep real travel quarantine restrictions), you can get the virus to effectively ZERO community spread and keep it there. It's too late for that anywhere that isn't super remote like AU/NZ. Even South Korea and Japan, isolated as they are and with very strict measures, controls on lockdown, and a population that strictly follows them, cannot get / is not getting to zero community spread: It's doing regular, short, strict lockdowns instead. This is the model that the west should adopt but instead a lot of countries are faffing around. Belgium has been in a five-months-long semi-lockdown that is leaving everyone severely depressed, is hugely damaging to the economy, and has plateau'd the spread to very non-zero numbers so the disease is still very much present. Worst of both worlds.
  - garmaine 6y ago
    Japan does NOT have strict lockdowns in place. I know, I work for a Japanese company. Heck they've been giving out travel vouchers for free travel around the country. Not a model for pandemic response at all. Australia is hardly isolated. Tons of flights in and out every day, and a vital part of the world economy. Really, any country can be "isolated" if they just close the borders to non-quarantined (REAL quarantine) travel, which is much more important than lockdowns.
wpietri 6y ago
I take it you haven't been following what's going on with "Long Covid". But even among people who aren't hospitalized, there's lasting harm: https://www.medpagetoday.com/infectiousdisease/covid19/91270 https://www.medpagetoday.com/infectiousdisease/covid19/91270 I know somebody who's had this. Despite never being hospitalized, after getting sick they had to take a long medical leave from work in hopes of getting their strength back. That's worlds away from "sick for a few days".
- metalliqaz 6y ago
  I have been "fatigued" for 3+ years due to having children. Life goes on.
  - ben_ 6y ago
    Don't be so crass, people are suffering because of this that didn't chose to
    - colecut 6y ago
      That is a not insignificant percentage of parents
  - psnatch 6y ago
    Amusing - me too. Obviously you raise the false equivalency, though.
  - Broken_Hippo 6y ago
    "fatigued" from not getting enough sleep or being physically active is not the same thing as folks get from diseases. When you are fatigued from children, you can sleep and take care of it. It is solvable. It isn't like that with disease. The worse I've had is the complete inability to stand long enough to make a simple dinner, for example, and this was after napping and sitting most of the day. I'm lucky: Mine passed. Some people live with this day after day after day, and this is more similar to what folks with disease-related fatigue.
- 6y ago
rhino369 6y ago
Yes, absolutely that should be the "end" of it. Especially since we are already giving the vaccine to front line works who aren't old or in danger. Anyone who wants to hole up until they get the vaccine should be able to. But I'll take the low risk.
- pipeoperator 6y ago
  Everyone can empathise with wanting life to get back to normal. However the problem with folk wanting to take the individual risk is that the “low” percentage of people needing medical help can still overburden health care systems. This potentially means that people with other illness / disease can’t / don’t see a doctor in time, and others in a society take the brunt. Yes, let’s open up; but let’s not throw caution to the wind either.
  - leesalminen 6y ago
    > can still overburden health care systems But they haven’t. The prevailing opinion I’m seeing on HN recently is that the US didn’t do a “real” lockdown which is why there are still so many cases. They opine that Americans largely didn’t “comply” with the government orders rendering any potential positive effects from lockdowns moot. If you take that at face value, then shouldn’t we have had an overwhelmed medical system by now? The Denver convention center was turned into a makeshift hospital for almost a year. They never had a single patient. My relatives lost their low-paying jobs and are still jobless today. Remember the military hospital ships that were sent to NY and LA? They never saw a single COVID patient? At this point I just don’t see any evidence that our healthcare system overwhelmed in any meaningful way. It’s FUD. Don’t try and post an article about how some random ICU was at 80% capacity. ICUs are designed to be near operating capacity because it’s a waste of resources to over supply.
    - dragonwriter 6y ago
      > If you take that at face value, then shouldn’t we have had an overwhelmed medical system by now? We did, in many cases, had overwhelmed medical systems at the local peaks, which were not nationally synchronized. > Remember the military hospital ships that were sent to NY and LA? They never saw a single COVID patient? You mean the ones that the military explicitly restricted to not taking COVID patients? Yeah, I remember that. Funny how they never saw any COVID patients.
dev1n 6y ago
No. People (extraordinarily healthy people) are suffering pulmonary embolisms (and thus hospitalized) weeks after they have been cleared from the virus. There is a very, very, very long tail to this disease outside of the initial 2 - 4 weeks of being sick.
- aantix 6y ago
  >People (extraordinarily healthy people) are suffering pulmonary embolism What are the numbers?
  - rcpt 6y ago
    I've posted elsewhere but Here: https://www.medrxiv.org/content/10.1101/2021.01.16.21249950v1 https://www.medrxiv.org/content/10.1101/2021.01.16.21249950v...
    - aantix 6y ago
      Where in that study does it show the the numbers for the pre-COVID healthy cohort?
      - rcpt 6y ago
        I believe what you're asking about is covered in table 1 and figure 2. They're reporting hazard ratios after propensity score matching with people who had the flu during the same time period.
  - dev1n 6y ago
    Do you only care about people if an event is statistically significant?
    - vorpalhex 6y ago
      For public health choices? Yes! 1 in a million events should not be optimized for.
rcpt 6y ago
As long as one believes that chronic covid does not exist or alter one's life expectancy and the comfort of the elderly is our top priority then yes. Once the olds are safe the virus shall run wild through the young.
umvi 6y ago
> You may, and indeed we have, shut it down if a large part of the population were at risk of hospitalization or death I wouldn't really call 1% of the population "a large part" of it. It's just, our healthcare capacity relative to the size of the overall population is miniscule. So even a disease that threatens .1% of the population with death and 1% with hospitalization is enough to overwhelm the healthcare system. And apparently policy makers aren't willing to let people die due to overwhelmed hospitals - they would rather shut down the entire economy than let that happen. History will tell if that was the right decision. Almost nobody notices or remembers blips of abnormally high "excess deaths" for a particular year, but everyone notices and remembers economic depressions that last a decade.
- orra 6y ago
  > So even a disease that threatens .1% of the population with death The IFR for COVID is likely ten times that, at least in societies with decent numbers of older people. > Almost nobody notices or remembers blips of abnormally high "excess deaths" for a particular year This isn't a bad flu season in a 5 year cycle. The excess deaths caused by COVID last year are not just 'abnormally high'. They're more like once in a lifetime abnormally high.
  - umvi 6y ago
    > The IFR for COVID is likely ten times that, at least in societies with decent numbers of older people. Right I purposely picked a disease less deadly than covid that could still overwhelm the healthcare system > This isn't a bad flu season in a 5 year cycle. The excess deaths caused by COVID last year are not just 'abnormally high'. They're more like once in a lifetime abnormally high. Right, and I still maintain that those excess deaths will be largely forgotten within the next few years or so by the majority of the populace. 500k excess deaths in 2020 followed by several years with fewer than normal deaths (since an abnormal amount of old people that otherwise would have died weren't around to die). Great Depression 2.0 on the other hand is something that wouldn't be forgotten for a lifetime for the people that live through it.
    - 6y ago
ravenstine 6y ago
Should we have an "end"? To play devil's advocate, clearly the world can handle a certain amount of locking-down, the social distancing, the mask wearing, etc., so it seems it is better if we just accept these restrictions indefinitely because we can save more people. Maybe we're fine not having mass gatherings, not eating indoors, and not leaving the house without a mask if it means saving the vulnerable. After all, it could be that COVID stays in the body like herpes and creates a different set of problems years later. Until we know for sure, the safest course of action for the public is for them to remain quarantined. After all, how bad is your life, really? If your life is tolerable, that means the restrictions are tolerable as well. EDIT: It's like nobody knows what playing "devil's advocate" means anymore. I think it's valid to ask that, if all the measures we are taking are objectively good, whether we should take them from now on.
- AndrewBissell 6y ago
  Have you actually looked into the numbers regarding what lockdowns have done to mental health, not to mention the economic impacts which are going to feed back into people's well being in all sorts of ways? Just because your subjective experience of being a shut-in for nearly a year has been a tolerable one does not mean that has been the case for large numbers of people. I want my kids to go to a harvest festival again with a live band and tons of people like the one they did in fall 2019. No, this is not something worth giving up simply to preserve a few years of life for some nonzero number of society's most vulnerable and aged. And no, I'm not any more willing to wait five years to see whether there's some lurking complications from the disease, any more than people have been willing to do that with the vaccines which are being distributed.
- ghaff 6y ago
  The vast majority of people are not fine with any of those things for an extended period. In fact, in the US, once late spring/summer roll around people are going to be out and about.
  - ravenstine 6y ago
    Really? That's what people said back when it was proposed that we shut everything down for a few weeks to "flatten the curve". Now look how long we've gone. I'd say Americans have very well tolerated this new way of life and could do so in perpetuity. I wouldn't count the protests and riots last summer since they were politically motivated.
choward 6y ago
I agree completely. The only reason they used for shutting everything down at first was so hospitals don't get overrun. That's clearly not happening right now in most places. Also, it's not uncommon for the flu to cause hospitals to exceed capacity and we don't shut down for that.
- Solvitieg 6y ago
  This is what I found bizarre about NZ's approach. Their goals was 0 _cases_ in the entire country. It's a great accomplishment but perhaps unnecessary.
  - laurencerowe 6y ago
    The big advantage of getting to zero is that after the initial severe lockdown life gets mostly back to normal.
    - ghaff 6y ago
      Almost zero. And normal only in the sense that many people don't care that much if very few people are allowed to enter the country.
    - choward 6y ago
      Not really. They still have outbreaks and do lockdowns. I wouldn't call that "mostly back to normal". https://apnews.com/article/new-zealand-coronavirus-pandemic-auckland-70a1da6f3471990b915552f81929c90b https://apnews.com/article/new-zealand-coronavirus-pandemic-...
      - tialaramex 6y ago
        That's true. They do have outbreaks, about half a dozen people this time, perhaps related to a job at a laundry working with quarantine facilities. For several days Auckland residents couldn't go to the pub. Normally of course they can go to the pub. Or a night club. Or a packed stadium to watch sports. But it's true that for several days last week in Auckland they weren't allowed to do that. And the same back in... September maybe? And according to you that isn't "mostly back to normal" so we can assume you believe it isn't "mostly back to normal" anywhere and never will be. That's just not a very useful benchmark.
smileysteve 6y ago
> The line I've heard repeatedly is we're waiting for "total" herd immunity It depends which line you are considering; if wearing masks yes. If "reopening and returning to normal" that remark is most resembles a hyperbole. In the United States, on April 16th 2020, the Coronavirus task force outlined a 3 phase plan dependent on 3 criteria based on 2 week averages 1) Hospital Vacancy, 2) New cases decreasing (from where they were), and 3) Percent positive testing rate under 10% (that suggests that the tests numbers are close to accurate and not in community spread)(5% is the standard that Europe uses as a liberal goal, 2.5% is the recommended) For an answer on those 3 in the US (today) 1) Hospitals are just now where they were on April 16 2) New cases is about 3x where they were April 16 3) We've been under 10% since 1/21 (now at a 7 day average of 5%) So the goal posts haven't gotten harder. They did get easier; restaurants shouldn't have been open for socially distanced dining based on the plan until 1/21.
didibus 6y ago
I don't know about all states as they have different rules, but in Washington they track: 1. Trend in 14-day rate of new COVID-19 cases per 100,000 population, shown as Trend in case rate; 2. Trend in 14-day rate of new COVID-19 hospital admissions per 100,000 population, shown as Trend in hospital admission rate; 3. Average 7-day percent occupancy of ICU staffed beds, shown as Percent ICU occupancy; 4. 7-day percent positive of COVID-19 tests, shown as Percent positivity. And there are phased reopening plans, where restrictions are slowly lifted based on different tresholds for the above. So if the above 4 metrics meet some treshold we might go into phase 2 where now indoor dining at half capacity is permitted for example. If the numbers than stay under the treshold and eventually keep going down, we'd go to phase 3, etc. If the numbers get worse after moving to phase 2 we'd go back to phase 1 with more restrictions. Seems pretty reasonable to me. They're always kind of revising the tresholds to some extent as well, so it's not set in stone. But it makes sense for me to take a staged approach to reopening and just make sure we're truly over Covid before going all back to normal (so it doesn't come back).
qndreoi 6y ago
In US State Ohio recently, the benchmark for restrictions was changed to the number of people hospitalized for COVID in the state. When it fell below a threshold, bars and restaurants were allowed to stay open later.
NovaJehovah 6y ago
It's generally a political challenge for a free society to get the power and the megaphones back from the people they were given to during a crisis. After an acute terrorism threat ends, it's hard to get power back from the military and the police. In this case, it will be hard to take back power and the narrative from the public health establishment. While they perform a crucial role in our society, they will tend to value safety over freedom and quality of life to an extent that would be crippling if we let them continue to set the agenda after the acute phase of the crisis has passed.
- dragonwriter 6y ago
  > In this case, it will be hard to take back power and the narrative from the public health establishment. Sitting in California where county sheriffs basically comprehensively vetoed the public health establishment throughout the crisis, I don't see that likely to be a real problem.
  - NovaJehovah 6y ago
    That didn't stop thousands of businesses from being closed. But regardless, the narrative is just as important. After some threshold of vaccine distribution, people need to be convinced that it's ok to return to normal life, and that they don't need to cower in fear in their homes or wear masks for years and years just because we haven't completely eliminated covid. There's a cost to all of this.
    - dragonwriter 6y ago
      > After some threshold of vaccine distribution, people need to be convinced that it's ok to return to normal life, and that they don't need to cower in fear in their homes or wear masks for years and years. No one has suggested people should cower in fear, and people seem pretty happy going about without masks, or with masks worn in an openly defiant manner (under the chin, off of one ear, etc.) in public places with prominent mask mandate signage today, so, again, I don't think the issue you are alluding to is even remotely serious. As a society, whatever the formal provisions of law say, we haven't given public health authorities the power in practice that you argue we will have problems with when we need to take it away.
dustinmoris 6y ago
> Should that not be the "end" of it? Yes 100%. As soon as the "vulnerable" have received their vaccine we should remove all restrictions even if the vaccine doesn't 100% prevent the "old fat cigarette smoking weak people" from dying from this cough virus because after the vaccination there is nothing more we can do. Vaccines are the single most effective way to prevent disease after clean water. It is the cherry on top of a cake in terms of what humans can achieve medically. A vaccine is literally the dream to achieve for any illness which could affect us. As a result, as soon as we have deployed our best and most effective weapon against this virus we must open up again. If the vaccine doesn't prevent fat people from dying then nothing will and we just have to accept that fat people will die due to their own wrong doings. After all that's how the world is designed to work.
_ph_ 6y ago
So far there was a tight coupling between the number of positive tested people and the hospitalisation count. It was important to base politics on the positive test results because they are several weeks "ahead" of the hospitalisation trend. It would have been foolish to not use those weeks for necessary actions. Now, with the vacinations, things change a bit. As soon we can show a significant reduction in hospitalisation, of course this needs to taken into respect. But with the vacinations, I would also expect the infection count to drop, as there are good indications that the vacinations reduce the infection count to drop.

vmchale 6y ago

> hospital admissions) be the almost singular criterion to influence public policy / restrictive measures? From a control theory perspective, it's one of the worst measures because it's delayed. Much more efficient to measure cases - then you don't need restricted social life as long.

inglor_cz 6y ago
In the wild phase of the pandemic, yes. But once enough people are vaccinated, the pattern may change. For example, you may still catch quite a lot of cases through PCR testing which is very sensitive, but the share of asymptomatic cases will be much higher and the share of people who are going to suffer a severe case much smaller. The entire societal signature of the disease will change depending on vaccination levels and maybe even particular vaccines used.
teawrecks 6y ago
The point isn't that we use hospital admissions as a metric to infer cases or some other metric, it IS the metric that matters. The problem over the last year wasn't that there exists a person who is at risk, it's that there didn't exist any healthcare system capacity to treat them. From very early on in the pandemic, it seemed to me like our goal for optimal balance between caution/risk was to try and maintain the highest level of hospital occupancy that is sustainable. If every single person quarantines perfectly, then our hospitals are empty, but so is every business. If no one quarantines, our businesses are full, but so are hospitals and everyone's viral load; i.e. maximum mortality. With the vaccines now available, it seems like our goal should still be be to maintain the highest level of sustainable medical system occupancy.
- _coveredInBees 6y ago
  Call me a renegade, but I think the only goal should be to minimize the total number of deaths from Covid. Trying to maximize sustainable medical system occupancy is almost certainly not aligned with the former goal.
  - arrosenberg 6y ago
    No perfect solutions there. If there was perfect quarantine, we would still lose additional lives from suicide, domestic violence, etc. from the increased stress. There is definitely a balance to be struck, and making sure we have capacity to treat all of the sick seems to be as good as any.
    - _coveredInBees 6y ago
      Yeah, making sure we have capacity to treat anyone sick is certainly one of the highest priorities (and the reason there was such a scramble trying to contain the virus from wreaking havoc if we went past that). And I get that there are other "costs" to the virus and lockdown and a holistic, balanced view is useful. Heck, I have two young children who have been remote schooling for almost a year now while both parents work full-time. I just object with the parent's following statement: > With the vaccines now available, it seems like our goal should still be be to maintain the highest level of sustainable medical system occupancy. If we are still trying to maintain the highest level of sustainable medical system occupancy while the percentage of population that has been vaccinated is slowly increasing, it would actually mean we are doing a horrible job in trying to limit preventable deaths when a fully vaccinated populace + herd immunity is not too far away. Maybe when a much larger percentage of the population is vaccinated, the spread and rate of deaths will be low enough that this may change, but we are still nowhere near that stage.
standardUser 6y ago
It's an important metric because earlier indicators aren't as useful. The rate of new cases is tricky because we don't really care if someone gets COVID-19 anymore than we care if they get the common cold, assuming they have only mild symptoms and fully recover. Hospitalizations are the first unambiguous metric we have to know there is a serious problem that may require a dramatic response.
- ceejayoz 6y ago
  > It's an important metric because earlier indicators aren't as useful. Sure they are. They're less precise, but they're more useful, because they're more likely to let you combat the spike before it gets out of control. It's like a smoke alarm. Maybe it's going off because it's over-sensitive and someone just took a shower... but it's a better early warning system than waiting for active flames to appear.
  - standardUser 6y ago
    I agree, but once vaccinations are widespread and we are confident that severe illness will be very rare, it would be hard to take drastic measures based only on the rate of new cases. There could be a huge surge of cases but we would expect a low hospitalization rate, so we would likely want to wait.
    - ceejayoz 6y ago
      Once vaccinations are widespread, yes. Until then, getting out in front of a spike remains necessary.
      - km3r 6y ago
        Immunity through vaccination + natural immunity is getting closer to 'widespread' now (in the US). We are likely near 30%, and of that 30%, a growing proportion is the most vulnerable sections of the population. A spike in cases now would be increasing less connected to a future rise in hospitalizations. I think its fair to say, that if we do not see a spike within the next 3-4 weeks, we are in the clear for future spikes. By April 1st, we should be nearing 40%, with the difference primarily being now vaccinated old and immune compromised people.

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hristov 6y ago

The problem with that sort of thinking is if you let the virus circulate and multiply you are risking mutations that are resistant to the vaccines. There already are two mutations that are already somewhat resistant to the vaccines according to initial anecdotal evidence. But practically speaking most nations are taking this approach and have been reducing social distancing measures when hospitalization rates go down. (Often with negative results.)

dragontamer 6y ago

> Since we're on the topic, shouldn't this (hospital admissions) be the almost singular criterion to influence public policy / restrictive measures? Given the high correlation between COVID# cases (or %Positive) and hospitalizations, why not just use COVID# and "gain" 2 weeks of information? Hospitalizations are weeks delayed from COVID# or %Positive spikes. Its a slow moving disease: taking 5 to 14 days before people feel sick, and then a week or two AFTER that before people decide to go to the hospital. As such, if you see a spike of hospitalization, you're already 3-weeks late to the results (ie: hospital spikes are associated with infections that occurred 3+ weeks ago). In contrast, watching COVID# or %Positive numbers gets you much closer to the ~5-14 day period where symptoms appear (and thanks to contact tracing, some people may test themselves before symptoms arrive: gaining a few precious days in the information war). Hospitalizations and Deaths are strongly correlated (with a few weeks delay). So you're effectively gaining a week-or-two worth of information. Its better to be only 1-2 weeks behind (watching COVID#), rather than being 3-4 weeks behind (watching Hospitalization#).

scrollaway 6y ago
> Given the high correlation between COVID# cases (or %Positive) and hospitalizations, why not just use COVID# and "gain" 2 weeks of information? As we vaccinate the people at the highest risk of hospitalization, the correlation will change: Numbers may stay very similar, but hospitalizations should go way down.
- dragontamer 6y ago
  > As we vaccinate the people at the highest risk of hospitalization, the correlation will change: Numbers may stay very similar, but hospitalizations should go way down. Then we'll know in 2 weeks to change the policy and account for it. Note that vaccinations will *also* cause the %positive and case# to decline. USA is approaching 15% vaccinated at over 95% efficacy means that you'll have 15% fewer cases (as well as 15% fewer hospitalizations later on). I'm not convinced that cases will become desynchronized with hospitalizations: my expectation is that vaccination will cause a decline in both case# and hospitalization#, roughly in proportion. But if case# and hospitalization# become less correlated, then it won't take long (~2 weeks to see the first effects, maybe 4-weeks to be sure of the effects) to see such a split in the time-delayed correlation. ------- EDIT: Why the downvotes? Today, there's a new study being pre-pub'd that shows that Pfizer's mRNA vaccine is ~90% effective at stopping the spread of the virus (https://thehill.com/policy/healthcare/539783-pfizer-vaccine-stops-covid-19-spread-israeli-study https://thehill.com/policy/healthcare/539783-pfizer-vaccine-...). When you have a vaccine that's both 90% effective at stopping the spread and 95% effective at stopping hospitalizations, then the spread and hospitalization numbers will both go down severely (that is: #cases and #hospitalizations reported both go down). This assumption that #cases and #hospitalizations will become "desynchronized" isn't necessarily written in stone. Its possible both numbers drop down dramatically in the coming weeks as vaccines are distributed... indeed, its highly likely IMO.

bluGill 6y ago

Nobody has figured out what "long covid" is, or how long it lasts. The anecdotes I've heard about the effects to the relatively young mean I'd just assume not open up.

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maxerickson 6y ago

It's preferable to have very low infection numbers, to reduce the likelihood of mutations taking hold. Doesn't mean you go on forever waiting for 0 infections, you just wait a bit longer than the minimum number of vaccinations to go back to activities with highest risks of transmission.

garmaine 6y ago
With both travel restrictions and lockdown, It takes about 6 weeks to get to (effectively) zero new cases. Not forever.
- jgalt212 6y ago
  Yes, but you're still stuck with a population who remains very susceptible to the diseases. Lockdowns, as I'm sure Australia will discover, are not a complete solution to the problem.
  - siquick 6y ago
    We're pretty happy here in Australia with how few of our friends and family have been affected by COVID. Life is practically back to normal and has been this way in Sydney for a while. Vaccination roll-out started this week. You'd be hard pushed to find a single person who would trade our state's response with pretty much any other countries response.
    - jgalt212 6y ago
      I'd rather be lucky than good. -- Lefty Gomez
- rhino369 6y ago
  That depends on how many cases you started with and how low you can get the transmission rate. No way could the EU or USA get to zero in 6 weeks. It took Victoria Australia about 6 weeks to get from 500 cases to 20. America and Europe have a 100X more than 500 cases. And the longer you need to lockdown, the less restrictive the lockdowns can be.

garmaine 6y ago

> Since we're on the topic, shouldn't this (hospital admissions) be the almost singular criterion to influence public policy / restrictive measures? No. This is the "flatten the curve" logic which was a horrible misjudgment. Having the disease in circulation in the community is not only doing tremendous damage to many, many people (even if the hospitals aren't full), but is also allowing the virus to mutate and potentially escape immunity protections or become more deadly. If you re-open as soon as the hospitals start to free up again, you just start moving the pendulum back in the direction of crisis. Countries like Australia and New Zealand have shown that if you keep up lockdown measures for just a month or two after the hospitals free up (AND if you institute and keep real travel quarantine restrictions), you can get the virus to effectively ZERO community spread and keep it there. We can achieve this, and we ought to be aiming for it.

scrollaway 6y ago
> Countries like Australia and New Zealand have shown that if you keep up lockdown measures for just a month or two after the hospitals free up (AND if you institute and keep real travel quarantine restrictions), you can get the virus to effectively ZERO community spread and keep it there. It's too late for that anywhere that isn't super remote like AU/NZ. Even South Korea and Japan, isolated as they are and with very strict measures, controls on lockdown, and a population that strictly follows them, cannot get / is not getting to zero community spread: It's doing regular, short, strict lockdowns instead. This is the model that the west should adopt but instead a lot of countries are faffing around. Belgium has been in a five-months-long semi-lockdown that is leaving everyone severely depressed, is hugely damaging to the economy, and has plateau'd the spread to very non-zero numbers so the disease is still very much present. Worst of both worlds.
- garmaine 6y ago
  Japan does NOT have strict lockdowns in place. I know, I work for a Japanese company. Heck they've been giving out travel vouchers for free travel around the country. Not a model for pandemic response at all. Australia is hardly isolated. Tons of flights in and out every day, and a vital part of the world economy. Really, any country can be "isolated" if they just close the borders to non-quarantined (REAL quarantine) travel, which is much more important than lockdowns.

wpietri 6y ago

I take it you haven't been following what's going on with "Long Covid". But even among people who aren't hospitalized, there's lasting harm: https://www.medpagetoday.com/infectiousdisease/covid19/91270 https://www.medpagetoday.com/infectiousdisease/covid19/91270 I know somebody who's had this. Despite never being hospitalized, after getting sick they had to take a long medical leave from work in hopes of getting their strength back. That's worlds away from "sick for a few days".

metalliqaz 6y ago
I have been "fatigued" for 3+ years due to having children. Life goes on.
- ben_ 6y ago
  Don't be so crass, people are suffering because of this that didn't chose to
  - colecut 6y ago
    That is a not insignificant percentage of parents
- psnatch 6y ago
  Amusing - me too. Obviously you raise the false equivalency, though.
- Broken_Hippo 6y ago
  "fatigued" from not getting enough sleep or being physically active is not the same thing as folks get from diseases. When you are fatigued from children, you can sleep and take care of it. It is solvable. It isn't like that with disease. The worse I've had is the complete inability to stand long enough to make a simple dinner, for example, and this was after napping and sitting most of the day. I'm lucky: Mine passed. Some people live with this day after day after day, and this is more similar to what folks with disease-related fatigue.
6y ago

rhino369 6y ago

Yes, absolutely that should be the "end" of it. Especially since we are already giving the vaccine to front line works who aren't old or in danger. Anyone who wants to hole up until they get the vaccine should be able to. But I'll take the low risk.

pipeoperator 6y ago
Everyone can empathise with wanting life to get back to normal. However the problem with folk wanting to take the individual risk is that the “low” percentage of people needing medical help can still overburden health care systems. This potentially means that people with other illness / disease can’t / don’t see a doctor in time, and others in a society take the brunt. Yes, let’s open up; but let’s not throw caution to the wind either.
- leesalminen 6y ago
  > can still overburden health care systems But they haven’t. The prevailing opinion I’m seeing on HN recently is that the US didn’t do a “real” lockdown which is why there are still so many cases. They opine that Americans largely didn’t “comply” with the government orders rendering any potential positive effects from lockdowns moot. If you take that at face value, then shouldn’t we have had an overwhelmed medical system by now? The Denver convention center was turned into a makeshift hospital for almost a year. They never had a single patient. My relatives lost their low-paying jobs and are still jobless today. Remember the military hospital ships that were sent to NY and LA? They never saw a single COVID patient? At this point I just don’t see any evidence that our healthcare system overwhelmed in any meaningful way. It’s FUD. Don’t try and post an article about how some random ICU was at 80% capacity. ICUs are designed to be near operating capacity because it’s a waste of resources to over supply.
  - dragonwriter 6y ago
    > If you take that at face value, then shouldn’t we have had an overwhelmed medical system by now? We did, in many cases, had overwhelmed medical systems at the local peaks, which were not nationally synchronized. > Remember the military hospital ships that were sent to NY and LA? They never saw a single COVID patient? You mean the ones that the military explicitly restricted to not taking COVID patients? Yeah, I remember that. Funny how they never saw any COVID patients.

dev1n 6y ago

No. People (extraordinarily healthy people) are suffering pulmonary embolisms (and thus hospitalized) weeks after they have been cleared from the virus. There is a very, very, very long tail to this disease outside of the initial 2 - 4 weeks of being sick.

aantix 6y ago
>People (extraordinarily healthy people) are suffering pulmonary embolism What are the numbers?
- rcpt 6y ago
  I've posted elsewhere but Here: https://www.medrxiv.org/content/10.1101/2021.01.16.21249950v1 https://www.medrxiv.org/content/10.1101/2021.01.16.21249950v...
  - aantix 6y ago
    Where in that study does it show the the numbers for the pre-COVID healthy cohort?
    - rcpt 6y ago
      I believe what you're asking about is covered in table 1 and figure 2. They're reporting hazard ratios after propensity score matching with people who had the flu during the same time period.
- dev1n 6y ago
  Do you only care about people if an event is statistically significant?
  - vorpalhex 6y ago
    For public health choices? Yes! 1 in a million events should not be optimized for.

rcpt 6y ago

As long as one believes that chronic covid does not exist or alter one's life expectancy and the comfort of the elderly is our top priority then yes. Once the olds are safe the virus shall run wild through the young.

umvi 6y ago

> You may, and indeed we have, shut it down if a large part of the population were at risk of hospitalization or death I wouldn't really call 1% of the population "a large part" of it. It's just, our healthcare capacity relative to the size of the overall population is miniscule. So even a disease that threatens .1% of the population with death and 1% with hospitalization is enough to overwhelm the healthcare system. And apparently policy makers aren't willing to let people die due to overwhelmed hospitals - they would rather shut down the entire economy than let that happen. History will tell if that was the right decision. Almost nobody notices or remembers blips of abnormally high "excess deaths" for a particular year, but everyone notices and remembers economic depressions that last a decade.

orra 6y ago
> So even a disease that threatens .1% of the population with death The IFR for COVID is likely ten times that, at least in societies with decent numbers of older people. > Almost nobody notices or remembers blips of abnormally high "excess deaths" for a particular year This isn't a bad flu season in a 5 year cycle. The excess deaths caused by COVID last year are not just 'abnormally high'. They're more like once in a lifetime abnormally high.
- umvi 6y ago
  > The IFR for COVID is likely ten times that, at least in societies with decent numbers of older people. Right I purposely picked a disease less deadly than covid that could still overwhelm the healthcare system > This isn't a bad flu season in a 5 year cycle. The excess deaths caused by COVID last year are not just 'abnormally high'. They're more like once in a lifetime abnormally high. Right, and I still maintain that those excess deaths will be largely forgotten within the next few years or so by the majority of the populace. 500k excess deaths in 2020 followed by several years with fewer than normal deaths (since an abnormal amount of old people that otherwise would have died weren't around to die). Great Depression 2.0 on the other hand is something that wouldn't be forgotten for a lifetime for the people that live through it.
  - 6y ago

ravenstine 6y ago

Should we have an "end"? To play devil's advocate, clearly the world can handle a certain amount of locking-down, the social distancing, the mask wearing, etc., so it seems it is better if we just accept these restrictions indefinitely because we can save more people. Maybe we're fine not having mass gatherings, not eating indoors, and not leaving the house without a mask if it means saving the vulnerable. After all, it could be that COVID stays in the body like herpes and creates a different set of problems years later. Until we know for sure, the safest course of action for the public is for them to remain quarantined. After all, how bad is your life, really? If your life is tolerable, that means the restrictions are tolerable as well. EDIT: It's like nobody knows what playing "devil's advocate" means anymore. I think it's valid to ask that, if all the measures we are taking are objectively good, whether we should take them from now on.

AndrewBissell 6y ago
Have you actually looked into the numbers regarding what lockdowns have done to mental health, not to mention the economic impacts which are going to feed back into people's well being in all sorts of ways? Just because your subjective experience of being a shut-in for nearly a year has been a tolerable one does not mean that has been the case for large numbers of people. I want my kids to go to a harvest festival again with a live band and tons of people like the one they did in fall 2019. No, this is not something worth giving up simply to preserve a few years of life for some nonzero number of society's most vulnerable and aged. And no, I'm not any more willing to wait five years to see whether there's some lurking complications from the disease, any more than people have been willing to do that with the vaccines which are being distributed.
ghaff 6y ago
The vast majority of people are not fine with any of those things for an extended period. In fact, in the US, once late spring/summer roll around people are going to be out and about.
- ravenstine 6y ago
  Really? That's what people said back when it was proposed that we shut everything down for a few weeks to "flatten the curve". Now look how long we've gone. I'd say Americans have very well tolerated this new way of life and could do so in perpetuity. I wouldn't count the protests and riots last summer since they were politically motivated.

choward 6y ago

I agree completely. The only reason they used for shutting everything down at first was so hospitals don't get overrun. That's clearly not happening right now in most places. Also, it's not uncommon for the flu to cause hospitals to exceed capacity and we don't shut down for that.

Solvitieg 6y ago
This is what I found bizarre about NZ's approach. Their goals was 0 _cases_ in the entire country. It's a great accomplishment but perhaps unnecessary.
- laurencerowe 6y ago
  The big advantage of getting to zero is that after the initial severe lockdown life gets mostly back to normal.
  - ghaff 6y ago
    Almost zero. And normal only in the sense that many people don't care that much if very few people are allowed to enter the country.
  - choward 6y ago
    Not really. They still have outbreaks and do lockdowns. I wouldn't call that "mostly back to normal". https://apnews.com/article/new-zealand-coronavirus-pandemic-auckland-70a1da6f3471990b915552f81929c90b https://apnews.com/article/new-zealand-coronavirus-pandemic-...
    - tialaramex 6y ago
      That's true. They do have outbreaks, about half a dozen people this time, perhaps related to a job at a laundry working with quarantine facilities. For several days Auckland residents couldn't go to the pub. Normally of course they can go to the pub. Or a night club. Or a packed stadium to watch sports. But it's true that for several days last week in Auckland they weren't allowed to do that. And the same back in... September maybe? And according to you that isn't "mostly back to normal" so we can assume you believe it isn't "mostly back to normal" anywhere and never will be. That's just not a very useful benchmark.

smileysteve 6y ago

> The line I've heard repeatedly is we're waiting for "total" herd immunity It depends which line you are considering; if wearing masks yes. If "reopening and returning to normal" that remark is most resembles a hyperbole. In the United States, on April 16th 2020, the Coronavirus task force outlined a 3 phase plan dependent on 3 criteria based on 2 week averages 1) Hospital Vacancy, 2) New cases decreasing (from where they were), and 3) Percent positive testing rate under 10% (that suggests that the tests numbers are close to accurate and not in community spread)(5% is the standard that Europe uses as a liberal goal, 2.5% is the recommended) For an answer on those 3 in the US (today) 1) Hospitals are just now where they were on April 16 2) New cases is about 3x where they were April 16 3) We've been under 10% since 1/21 (now at a 7 day average of 5%) So the goal posts haven't gotten harder. They did get easier; restaurants shouldn't have been open for socially distanced dining based on the plan until 1/21.

didibus 6y ago

I don't know about all states as they have different rules, but in Washington they track: 1. Trend in 14-day rate of new COVID-19 cases per 100,000 population, shown as Trend in case rate; 2. Trend in 14-day rate of new COVID-19 hospital admissions per 100,000 population, shown as Trend in hospital admission rate; 3. Average 7-day percent occupancy of ICU staffed beds, shown as Percent ICU occupancy; 4. 7-day percent positive of COVID-19 tests, shown as Percent positivity. And there are phased reopening plans, where restrictions are slowly lifted based on different tresholds for the above. So if the above 4 metrics meet some treshold we might go into phase 2 where now indoor dining at half capacity is permitted for example. If the numbers than stay under the treshold and eventually keep going down, we'd go to phase 3, etc. If the numbers get worse after moving to phase 2 we'd go back to phase 1 with more restrictions. Seems pretty reasonable to me. They're always kind of revising the tresholds to some extent as well, so it's not set in stone. But it makes sense for me to take a staged approach to reopening and just make sure we're truly over Covid before going all back to normal (so it doesn't come back).

qndreoi 6y ago

In US State Ohio recently, the benchmark for restrictions was changed to the number of people hospitalized for COVID in the state. When it fell below a threshold, bars and restaurants were allowed to stay open later.

NovaJehovah 6y ago

It's generally a political challenge for a free society to get the power and the megaphones back from the people they were given to during a crisis. After an acute terrorism threat ends, it's hard to get power back from the military and the police. In this case, it will be hard to take back power and the narrative from the public health establishment. While they perform a crucial role in our society, they will tend to value safety over freedom and quality of life to an extent that would be crippling if we let them continue to set the agenda after the acute phase of the crisis has passed.

dragonwriter 6y ago
> In this case, it will be hard to take back power and the narrative from the public health establishment. Sitting in California where county sheriffs basically comprehensively vetoed the public health establishment throughout the crisis, I don't see that likely to be a real problem.
- NovaJehovah 6y ago
  That didn't stop thousands of businesses from being closed. But regardless, the narrative is just as important. After some threshold of vaccine distribution, people need to be convinced that it's ok to return to normal life, and that they don't need to cower in fear in their homes or wear masks for years and years just because we haven't completely eliminated covid. There's a cost to all of this.
  - dragonwriter 6y ago
    > After some threshold of vaccine distribution, people need to be convinced that it's ok to return to normal life, and that they don't need to cower in fear in their homes or wear masks for years and years. No one has suggested people should cower in fear, and people seem pretty happy going about without masks, or with masks worn in an openly defiant manner (under the chin, off of one ear, etc.) in public places with prominent mask mandate signage today, so, again, I don't think the issue you are alluding to is even remotely serious. As a society, whatever the formal provisions of law say, we haven't given public health authorities the power in practice that you argue we will have problems with when we need to take it away.

dustinmoris 6y ago

> Should that not be the "end" of it? Yes 100%. As soon as the "vulnerable" have received their vaccine we should remove all restrictions even if the vaccine doesn't 100% prevent the "old fat cigarette smoking weak people" from dying from this cough virus because after the vaccination there is nothing more we can do. Vaccines are the single most effective way to prevent disease after clean water. It is the cherry on top of a cake in terms of what humans can achieve medically. A vaccine is literally the dream to achieve for any illness which could affect us. As a result, as soon as we have deployed our best and most effective weapon against this virus we must open up again. If the vaccine doesn't prevent fat people from dying then nothing will and we just have to accept that fat people will die due to their own wrong doings. After all that's how the world is designed to work.

_ph_ 6y ago

So far there was a tight coupling between the number of positive tested people and the hospitalisation count. It was important to base politics on the positive test results because they are several weeks "ahead" of the hospitalisation trend. It would have been foolish to not use those weeks for necessary actions. Now, with the vacinations, things change a bit. As soon we can show a significant reduction in hospitalisation, of course this needs to taken into respect. But with the vacinations, I would also expect the infection count to drop, as there are good indications that the vacinations reduce the infection count to drop.