Dr Ellie Murray, ScD
@EpiEllie
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Epidemiology asst professor @BUSPH |social media ed @amjepi | cohost @casualinfer podcast | Causal inference & public health #epitwitter 🇨🇦 insta/🧵:laughing.e
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Joined June 2013
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Everyone keeps talking about covid becoming endemic, but as I listen to the conversation, it’s becoming more & more clear to me that very few of you know what “endemic” means.
So here’s a thread on how pandemics end.
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My dentist’s first question to me, knowing I’m an epidemiologist, was “when will this all be over”. Was super unsatisfying for us both for me to have to answer, “whenever we want, if the government would just take concerted & decisive action”
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People love to claim to we can’t change people’s behavior.
But did you know the idea of “designated drivers” is only normal in America thanks to the work of a group of Harvard scholars?
Here’s 5 reasons they succeeded.
Responsible designated driver ensuring a safe journey home
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COVID fatigue is a real & we’re all exhausted, but I suspect a lot is actually *decision* fatigue.
The absence of clear rules, information, and guidance means having to think through our every action to decide what feels safest. Good leadership would give us all a break.
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Mask wearing is literally the same type of thing as refrigerators, sunscreen, bug spray, spaying your pets, cancer screening, seatbelts.
NONE of those things work perfectly all the time. But ALL of them help reduce harms some of the time.
Harm reduction is the goal.
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The idea that “everyone has already gotten COVID at least once” is just the latest attempt to make you forget about the risks it poses and go back keeping the economy afloat.
Sure, some infections are asymptomatic, but that doesn’t mean everyone who hasnt been sick was infected.
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We are dealing with a massive public health crisis on a scale none of us has ever lived through before, and yet many senior public health folks are shushing junior folks who speak out & warning us to think of our careers.
But what is my career for, if not to speak up now?
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If you *are* at a Super Bowl party right now, please don’t forget to quarantine for the next 11-14 days.
You might have decided the risk to yourself is worth it, but everyone else you would normally interact with didn’t get that choice.
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Remember when the CDC said “everyone’s gonna eat raw cookie dough anyway, so we’ve decided to tell them it’s actually fine & safe”?
Oh, wait, no.
They did such an effective campaign against it that companies like Pillsbury realized there was a market to sell safe-to-eat dough.
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If you have to clarify “no, no, my plan isn’t eugenics, I just think we should infect everyone because only the weak will die”, I hate to break it to you but your plan actually is eugenics.
And I am not here for it.
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Here is the real secret: because our leaders chose not to shut down the economy to stop omicron, omicron has shut the economy down for us.
And this way is much much worse.
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“Funny” story: when doctors learned washing their hands reduced infections, they actually *did* give up washing their hands after the guy figured it out left. And then more people died.
And even today, hospitals spend BIG money reminding & convincing doctors to wash their hands.
@BurnabyNOW_News
When doctors learned washing their hands reduced infections, they didn't stop washing their hands when all infections cleared up. Why is masking not still mandatory at hospitals? Why are we taking a step backwards?
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I am so tired of people who know nothing about infectious disease spouting “everyone will get covid” nonsense.
COVID is not inevitable.
Society’s choices control how much illness & death & hospitalization & disruption & grief & loss we suffer.
Be empowered. Demand better.
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THINK LIKE AN EPIDEMIOLOGIST: why are COVID deaths *still* not going up 3 weeks after case counts started increasing? There are many possible explanations, but one I haven’t seen mentioned is the impact of widespread testing on *early detection*.
A
#tweetorial
on LEAD TIME BIAS.
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I’m so tired of talking about the pandemic and having to say the same things over and over.
The pandemic isn’t finished and if we don’t commit to helping those countries or regions where surges are happening, it won’t be finished for a long time to come.
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Mammograms, pap smears, colonoscopies, prostate exams & PSA tests, prenatal care & ultrasounds, well-baby visits, STD screening, cholesterol & blood pressure tests, newborn genetic tests, oral cancer checks at the dentist, that thing where the eye doctor “dilates” your pupils…
"Think about it. Before COVID, did anyone go out and seek testing to determine if they were sick?"
@GovRonDeSantis
today
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Every time I tweet about this I get people in mentions saying “but we don’t take precautions for the flu!”
Those people are 100% WRONG!
Thousands of people work daily to monitor, prepare for, & respond to fluctuations in flu number and in the flu virus itself! It’s a HUGE task!
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We need more of this👇🏼👇🏼.
If we’re going to expect people to manage their own risk, then we should also create spaces or times where the risk levels are varied.
This Sun, Dec 4, we'll be offering our monthly mask-required hours from 11–1. These hours are offered to better accommodate immunocompromised individuals & those who prefer to visit when everyone is masked. If that's you, we hope you'll stop by!
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THINK LIKE AN EPIDEMIOLOGIST:
The CDC’s recent announcement that the Delta variant has an average reproductive number of 6-9 has a lot of people concerned & many are asking me about whether this means we need COVID boosters.
Let’s talk through the math of how we might decide!
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THINK LIKE AN EPIDEMIOLOGIST: what the heck is going on with respiratory viruses right now and is it because of covid, because of our attempts to stop covid, or something else?
It’s so much more complicated than some catchy buzzword you’ve seen. Let’s dig in deep together!
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Our
@NEJM
study showed school mask mandates *reduce* COVID illness & absences.
Others disagreed. But we take scientific critique seriously. So we checked everything suggested to us. And now we’ve published an updated Appendix with the details.
Our results hold: Mandates work.
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I saw someone say that much of what we see as scary about polio is actually “long polio” & tbh that’s pretty true.
I think the “long” framing makes it clear long COVID isn’t unprecedented & that we need to face up to it.
What other long infectious diseases are there?
A list*
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Whatever people think of masks for covid, the evidence is super duper clear that when we all wore masks there was no flu.
Epidemics dont have to “run their course”—we can cut this flu season short anytime we want with masking, hand-washing, and flu vaccines.
The U.S. is officially in a flu epidemic, federal health officials say. They’re preparing to deploy troops and ventilators if necessary
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It was never really “lockdown” vs “no lockdown”. Instead, the choice is:
Option 1: unfunded lockdown of ambiguous length lifted as soon as politically feasible with no long term plan.
Option2: funded lockdown with strong support systems & clear targets for phased re-opening.
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The biggest problem with people who are “just asking questions” is, IMO, the fact that they are never “listening to the answers”
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So here’s the kicker: “endemic” doesn’t mean “never think about covid again”. It’s exactly the opposite!
Endemic means someone is ALWAYS thinking about covid.
Endemic means public health is always monitoring disease & always intervening when cases cross the “acceptable” level.
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Really wish the CDC would just step up to the plate and say: “from now until Feb, or until trajectory of covid deaths is declining, masks are mandatory on transit & in all public + government spaces, and we strongly recommend state & local health departments take the same action”
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If you were waiting until new surge started before wearing masks or pushing for mask wearing in your community, the wait is over. Every indicator says now is for sure the time.
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Everytime someone says “but 99% of people who get covid don’t die” I really wonder what their lives are like.
Would you get on an airplane that advertised “99% of passengers survive the flight!”?
Would you eat at a restaurant where “99% of customers dont die from our food!”?
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“Is covid back?” is such a ridiculous framing.
It never went away, and we have seen an increase at exactly this time of year for the past 3 years.
Might as well say:
“Is school back? Despite a quiet summer, classrooms across the country are increasingly full of children”
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If you’d never heard of epidemiology before
#COVID19
, it’s probably because many epidemiologists spend all their time controlling outbreaks so that they never become news.
Don’t try to reinvent the wheel. Don’t assume no one knows what to do. Listen to the experts.
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You might have noticed something important here, and it’s something I think MANY of the people shrugging off covid becoming endemic get wrong:
“Endemic” does NOT mean “harmless”.
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1. HARM REDUCTION approach
The Harvard Designated Driver Campaign is a great example of harm reduction.
The idea of designated driver is about how to help keep people safer, when they go out drinking. Not how to stop them from going drinking.
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A school board official on the radio jut said “we surveyed teachers and, after counting ‘non responses’ as votes for ‘in person’, about 50% of teachers want to teach in person this fall”.
🤦🏼♀️🤦🏼♀️YOU CANNOT IMPUTE THE ANSWER YOU PREFER WHEN YOUR DATA ARE MISSING🔊🔊🔊
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Always enjoy the first lecture in my Outbreak Response course where I walk students through how the CDC handbook *says* that outbreaks should be handled, while they look increasingly confused because the CDC hasn’t been doing anything of the sort.
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The government is predicting 100 million COVID cases this winter.
We’ve seen ~1% fatality rates from past waves. if that holds, then we’ll see a million *extra* deaths this winter.
But it’s fine because they are planning to… <checks notes> drop covid funding from this bill?
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3. POSITIVE framing
People don’t like downers, so messages like “Don’t drink and drive” can be harder to sell.
But, “The Designated Driver is the Life of the Party” is much more positive.
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If everyone you know is suddenly getting “food poisoning”, just FYI that it is probably not actually food poisoning but is instead norovirus.
Norovirus (sometimes called “stomach flu” but not actually flu) is seasonal, and right now in the US it is norovirus season.
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Because pandemics don’t end by a disease just fading away, & pandemics don’t end with everyone able to completely forget about the disease.
Pandemics end when we decide how much death and disease we’re satisfied with.
I dont know about you, but for me—this👇🏼is too much death.
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Of course this doesnt mean COVID could be over tomorrow, but if we take coordinated, decisive, and evidence-based action NOW, we could think about making Thanksgiving or Christmas plans. If we dont, then this is what our life looks like for the foreseeable future.
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Tularemia is a Category A pathogen, meaning its severity and transmissibility—and the fact that it’s relatively easy to get from wild rabbits—make it potentially modifiable into a bioweapon.
Please don’t ever give a wild rabbit CPR.
Two nights ago I gave a wild baby rabbit CPR w breaths after I took it from my Petey (cat). Today, I’m being admitted to the hospital with signs of “bunny fever” (Tularemia). I’m on 8L oxygen, a cocktail of very expensive antibiotics, anti-diuretics. Need light & love, please!
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It’s august, & i’m more afraid of whats going to happen over the coming months than at anytime since i saw the first covid report on dec 31.
in feb, i thought the failure to act was slowness. in april, i thought it was incompetence. i dont know how to process that it was malice.
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The thing about calling for forgiveness for things said when “we were all in the dark about covid” is that *we* weren’t in the dark—yes there were obvi things to be learned about a new virus, but the basic principles of virology, epidemiology, public health, etc cast some light.
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PUBLIC HEALTH MINUTE:
Honey is sweet and sticky and wonderful and everyone loves it, and babies are sweet and sticky and wonderful and everyone loves them.
But you should NEVER ever give honey to babies.
Why?
The short answer is: botulism.
The longer answer: a 🧵
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2. CLEAR & SIMPLE message
If you want people to internalize a message, you’ve gotta make it simple.
The idea of “one person doesn’t drink and then they drive everyone home” could have been complicated to justify.
But “designated driver” isn’t—the name says it all!
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“Employees can get back to work if they are infectious but not sick enough to be bedridden” is the new “just train kids to hide under their desks when someone is shooting their classmates”.
Neither solves the problem. Both make things worse.
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Earlier this week someone confidently told me that COVID, because it is caused by a virus, is not an infectious disease.
And then looked really really skeptical when I replied that viruses are, in fact, infectious.
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5. SHOW-DONT-TELL strategy
The biggest successes of the designated driver campaign likely didn’t happen because of the posters in high-schools.
Instead, success came from the Harvard team’s work to get the message incorporated into TV and movies. This helped normalize it.
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If you are angry that 20 months into this pandemic we still need to wear masks, good! I’m angry too!
We could be happily going about our lives if the response had been better.
But I’m wearing my mask now because I don’t want to STILL be in a pandemic in ANOTHER 20 months.
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So, yes, our only viable choice left is covid becoming endemic. It didn’t have to be this way, but our leaders MADE a choice.
And now they need to make another choice: They need to choose an “acceptable” level of COVID death & disease.
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Sure, maybe the flu doesnt impact *your* life, except some years you get a flu shot, or maybe you have once or twice really actually gotten the flu & not just a bad cold you *called* the flu.
(Pro-tip: if you dont feel like you’ve been hit by a train, it’s probably not the flu).
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Whether a disease is endemic, epidemic, eliminated, or eradicated does NOT tell us how serious it is, and does NOT tell us how many people get sick or die.
We have to CHOOSE that number.
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School districts that refuse to provide alternative or remote schooling options in a pandemic but then send truancy notes to parents who keep their kids home because of the pandemic really need to think hard about who’s interests they are serving.
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But that is because PUBLIC HEALTH KNOWS WHAT IT’S DOING!!!
There are clearly defined “acceptable” levels for different strains of the flu, and we spend so so much time & energy & money working to keep the flu below those levels. So that YOU don’t get sick.
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“the pandemic is over”
Life expectancy in the U.S. has fallen to the lowest levels seen in 26 years, new federal data shows.
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Pandemics always end, even if we do nothing. That’s the nature of infectious diseases.
Success is ending a pandemic early, decisively, and with less death or suffering. Failure is ending a pandemic gradually, sporadically, and with the potential for new variants to cause surges.
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This is your irregular reminder that if you’re interested in reading a scientific paper but can’t access it online, send an email to the author & they will be more than happy to send you a free copy of the pdf.
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Lately, all my covid convos are one of these 3:
Leaders: there’s no point in precautions b/c everyone is done with covid.
Media: people are done with covid, no point in publishing anything else.
“General public”: covid is over right? All the media & leaders tell me so.
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4. OTHER-FOCUSED framing
Public health is about communities, and that’s extra clear in public health messaging campaigns.
Other-focused framing centers the people who are the reason your actions matter—like your friends, who you, as the designated driver, help get home safely.
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When the machine learning algorithm looks super complex & scary but it’s really just logistic regression....
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This time last year, if you’d asked me about basic income, I would have called it a beautiful fantasy.
Now, after 12 months of an uncontrolled pandemic, my opinion is radically altered: basic income is an absolute and irreplaceable necessity for a civilized society.
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Looking forward to the discourse about how lazy everyone is and how it’s hurting the economy during the coming winter surge
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Shut down non-essential indoors activities again & halt interstate travel until all the following are in place:
Produce ludicrous amounts of N95 face masks & testing supplies. So much contact tracing. Safe quarantine & isolation sites. House the homeless....
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What should we be doing? I have lots of ideas but you’re not going to like them. They all boil down to coordinating federally & collective action. You’re going to say I’m a socialist. I probably am. I’m Canadian.
Ready?
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Another problem with the “let’s just let everyone get COVID & not care if the most vulnerable people die” idea (aside from it being ghoulish) is that COVID itself appears to cause a range of long-term conditions creating more vulnerable people at risk of dying in the next wave.
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Realistically, despite New Zealand’s valiant efforts, we are not going to do that.
We don’t have the political or social will to eliminate or eradicate covid.
But that means we HAVE TO continue to CONTROL covid!
That’s the only other option. THAT is what endemic means!
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Free rapid tests & face masks, delivered weekly to every household in America by the USPS, how about?
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Now we get to Option 1 (continually occurring disease). This is easier short-term but it’s the hardest *long-term*.
It’s also super vague: it could mean anything from hundreds or thousands per day to one or two per year.
The other name for this is, you guessed it, “endemic”.
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900,000 COVID deaths.
It is not going away. The end of the omicron wave is not the end of covid. It’s a breathing space to plan for the next wave. And the one after that. And all the ones after that.
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I’m not a virologist, so I can’t add any useful information to help you process news of a new covid variant. But as a public health expert, I can remind you (& our leaders) that the chance of new variants are precisely why we need to treat global pandemics like global problems.
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Some of you have never spent any time around a toddler and it shows.
For the rest of you, what’s the most memorable reason you’ve seen a toddler cry over?
Here’s one from me: wanted a “lottle bit” of pasta & absolutely horrified by the choice of a “little bit” or “a lot”
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If a disease is really bad, ‘acceptable’ is very low—potentially even indistinguishable from elimination.
The plague (yes that one!) is kinda common among rodents in parts of the US, but if even ONE person shows up to a doctor with symptoms, public health jumps into action!
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I still dont understand why we dont have workplace COVID safety standards from OSHA for all occupations.
From the number of airline workers who end up off sick every time masks come off, it is super duper clear that there is a problem there……
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One of the most fucked up things about the US is the way they have managed to turn basic principles of public health into conspiracy theories.
This is the truth: If you do not control the spread of an infection, the spread of the infection will control you!
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Federal paid sick leave & paid *quarantine* leave for all employees. Universal basic income for the duration of the pandemic. Universal Medicare eligibility, or similar. Federal eviction freezes. Easy-to-apply-for subsidies for electricity, water, internet, & other utilities....
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REPEAT AFTER ME: public health interventions that reduce infections are worth doing even if they don’t prevent *all* infections. Fewer infections is always better!!!
Flanders, Belgium: 'Children with chickenpox can go to school from now on'.
Reason: pre-symptomatic transmission exists, so symptomatic transmission should be allowed too.
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The thing about in-person conferences is they are often the only time that far-flung academics get to see their friends from before they moved to wherever they had to move for a job. It’s not just about presenting talks or posters. It’s about maintaining our mental health.
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When flu cases cross the threshold & the public health lever switches from “monitor flu activity” to “take action YOU don’t notice.
But not because it isnt happening — because the acceptable level is LOW ENOUGH that those actions happen before it impacts your daily life.
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This coup attempt didn’t start today, it started months ago.
It wasn’t planned in secret, it was planned live on twitter and television by the president himself.
“When people show you who they are, believe them the first time.” -Maya Angelou
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Yes, eradication is HARD but we could still choose to make it our moonshot if we wanted to.
It would definitely take time. It would probably take new science, new ideas, & new tools. And it would take both leaders & everyday people actively committing to doing what it takes.
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This morning I had an appointment with a sleep clinic doctor to help me figure out my sleep issues.
Folks, I missed my alarm & slept through the appointment. 🤦🏼♀️
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Me, an epidemiologist: research shows widespread mask use reduces respiratory infections
Them, a rando: OMG WHY DO YOU WANT EVERYONE TO ALWAYS MASK EVERYWHERE FOREVER?!!!!
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So what does this tell us about how pandemics end?
Well, it tells us that we CAN put in the work to really get rid of it once & for all, if we have the will and the strength and the interest and the resources.
It probably gets harder & harder the longer we wait, though.
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I can’t get this tweet out of my head.
Literally every media outlet is calling them “restrictions” when they should be calling them “protections” and that choice is absolutely killing people.
What a difference it would make if COVID mitigation measures were referred to as “protections” in the media vs. “restrictions”.
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Beware causal inference with machine learning because the answer isn’t in the training data, and the algorithm can only learn what it sees.
#causalinference
#ML
#AI
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In more technical terms “endemic” means: “Controlled at or below an ‘acceptable’ level”
What level is “acceptable” differs from place to place, over time & between diseases, and it may not always be explicit, but when a disease is endemic, there is a threshold!
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As more & more places remove mask requirements, I’m seeing a trend of people being relieved about all the other things this means they can do—like indoor events, school functions, etc.
But we could have done those things with masks. Without masks, they are all less safe.
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This is a BAD article.
“Re-entry anxiety” isn’t a problem with *your* mental health, it’s a problem with *the government’s* re-opening plans.
If there are
#COVID19
cases in your area (and there are), it’s totally ok and appropriate not to want to “resume normal life”.
As COVID-19 lockdowns end, people are experiencing "re-entry anxiety" as they resume aspects of normal life. Here's what to do about it
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On the other hand, if a disease is not really that bad at all, the acceptable level can be really very high.
Up to 80% of US adults are infected by the virus that causes cold sores (aka oral herpes)!
But public health takes *nearly* no action, except to protect infants.
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Roughly 1 in every 2000 people in America has died of COVID, about 1 in 50 people have had a positive COVID test, and even more people may have been infected but never tested.
Those are huge numbers but nowhere near herd immunity threshold estimates, even the really low ones.
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See how his breath blows directly into the other dude’s face? That’s how COVID spreads outdoors.
Masks help, but if they just weren’t sitting shoulder to shoulder they would be much safer even without masks.
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I’m not afraid to admit my GRE quant score was just ok. I’ve always been bad at speed math. But that didn’t stop me from becoming a good epidemiologist, because epi isn’t about doing math as fast as possible. It’s about taking the time to get the best answer to the right question
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Smallpox was around for a very long time before we took action & it took a long time to defeat.
Similarly, polio eradication is long overdue, but we’re still trying and I’m certain we will get there.
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Option 2 (elimination) is still pretty hard, and long-term not everyone can forget about the disease.
For lots of the world, this is measles is — we’ve got great vaccines & most of us don’t need to worry about measles, but public health officials still monitor for it everywhere.
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Who are all these public health people supposedly arguing for no one to go anywhere or do anything ever, that mean we need so many “think” pieces condemning that?
The public health people I know want governments to step up and address this pandemic like a grown-up.
How? A🧵
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Experts, 3 months ago: If you want to have a semi-normal Thanksgiving follow these simple rules.
Public: nah, seems like a hassle?
Experts, now: in person Thanksgiving is probably not a good idea anymore🤷🏼♀️
Public: what?! how could you let it get this bad?!
☝️Scientists and medical experts are not ruining Thanksgiving.
Ignoring us all is what achieved that.
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If you work somewhere like a daycare, or a nursing home, or (like me) a School of Public Health that shares a campus with a hospital, you probably DO sometimes notice.
Because those are places where flu is most problematic & so they are also where we focus our interventions.
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