Coronavirus in one state (131)

Governor Walz has preempted the regular Department of Health press briefings over the past 10 days. Yesterday’s briefing (audio below) was the first since November 13, covered in part 125 of this series. The catastrophe that has befallen our nursing homes due to the epidemic was addressed only indirectly, in terms of staffing, but the Star Tribune’s Chris Serres and Glenn Howatt cover it in a manner that is entirely missing from the MDH briefings. They write:

The coronavirus is surging back into Minnesota’s senior homes, with facilities running desperately short of the one resource they cannot go without — staff.

Across the state, a second wave of coronavirus cases is raging through nursing homes and assisted-living facilities that escaped the first wave of outbreaks this spring, once again threatening older adults who are most at risk of dying from COVID-19, the respiratory disease caused by the virus.

Nearly 11,000 residents have tested positive for the new coronavirus, with one out of five dying from COVID-19 complications.

This time, the virus is infiltrating many facilities in rural communities where staffing shortages are more severe and residents have fewer options. Facilities in counties such as Aitkin and Mille Lacs that largely avoided the virus during the spring are now reporting explosive new outbreaks.

An alarming 90% of Minnesota’s nursing homes and 58% of the state’s assisted-living facilities have active outbreaks of the virus, according to new data from the Minnesota Department of Health. That includes more than 70 senior care homes that didn’t have any COVID-19 infected residents one month ago….

Serres and Howatt have much, much more in their story. Having raised the issue of nursing home deaths since the beginning of this series, I can only say it is about time. This is an important story.

Following the settlement of my lawsuit with department officials, I emailed the first three questions I am entitled to submit each week that Walz continues to exercise dictatorial powers under his original March emergency order. Yesterday afternoon I received the department’s answers to the first set of questions. Here are the questions and answers:

Question 1: Will you please provide data detailing the co-morbidities present in all MN Covid deaths since April, including counts, by date, of deaths identified as Covid with no other conditions, one other condition (identified), two other conditions (identified), three other conditions (identified), and four or more other conditions?

Answer: MDH has not analyzed the data in this way and is not providing customized analysis of death records for reporters. However, death records are public; if you would like to have the comprehensive death database file to do your own analysis, it can be provided. That is how we have helped other media outlets that have asked for this kind of analysis.

Our definition of deaths, as explained on the Situation Update page, is:

· Total deaths with laboratory testing are deaths due to COVID-19 with:

A positive PCR test (confirmed case) or antigen test (probable case) for SARS-CoV-2 AND COVID-19 is listed on the death certificate

OR

Clinical history/autopsy findings that provide evidence that the death is related to COVID-19 without an alternative cause (i.e. drowning, homicide, trauma, etc.). This is consistent with the CDC definition:

· CDC: NNDSS Surveillance Case Definitions: Coronavirus Disease 2019 (COVID-19)

Other than what’s on the death certificate, we would only know about co-morbidities if the person had been hospitalized prior to death and was part of a subset of hospitalized cases that is part of a special study where we collect such information. Otherwise we don’t collect such information on hospitalized cases, persons who died in long term care facilities, or persons who die elsewhere. We don’t do a search of all their prior medical history. Of course, some persons will have underlying undiagnosed health conditions that go undetected unless an autopsy is performed.

There are multiple articles published in the medical literature describing co-morbidities and risk factors for mortality, so we do not have to replicate such studies.

Question 2: The mask mandate began July 25. You recently said it takes two full incubation periods or about four weeks for a new measure to be fully effective. For the roughly 8 weeks before that date cases averaged 4148 per week. In the weeks since the mask mandate, cases have averaged 8860 per week and are obviously still rising rapidly. What evidence do you have that the mask mandate has made any difference in the number of cases or case growth?

Answer: The short answer to this question is that it is clear from the evidence that not enough Minnesotans have been wearing masks or social distancing. We know this from the outbreaks we’ve investigated, from the complaints we’ve received, as well as from the trend lines you’re seeing. We know that masks are effective at preventing transmission of the SARS CoV 2 virus. There is extensive information on the CDC website on the efficacy of face masks, including multiple references to other published articles on the efficacy of wearing masks. Similarly there is information on the Infectious Diseases Society of America and the World Health Organization websites on the efficacy of masks with many references to articles published in the medical literature. All three public health or medical organizations have had numerous experts carefully review the scientific data and all three strongly advocate the use of face masks to reduce community transmission. Furthermore, CDC last week presented evidence that face mask use also reduces the risk for the wearer. New research articles are published every day, with one as recent as Friday in the CDC MMWR on masks in Kansas. See this story: Mask mandates work to slow spread of coronavirus, Kansas study finds. Also, this CDC scientific brief contains a good summary of community impacts of wearing face masks.

Just a quick note about the data you cite:

According to our data team, the weekly average in the 8 weeks prior to the mask mandate (7/25) was 3,434 cases. Weekly average post mask mandate: 13,451 cases. Our numbers include the last few weeks, when cases skyrocketed. It wasn’t clear what your cut off point was for the latter, but just wanted to be clear on the data. You might want to check your numbers again or clarify your cut-off dates. The data by date is available in a CSV file on the weekly report page, linked at the bottom of the Situation Update page.

Question 3: Since March, MDH has consistently asserted that cases are a leading indicator of hospitalizations and deaths. I believe that the relationship between cases and deaths has varied widely through the year and is now more than 10x wider than it was in June. Given that the relationship between cases and deaths has varied so widely, can you specify the precise nature of the relationship between cases and hospitalizations/deaths?

Answer: Comparisons over time to hospitalizations and death are difficult since many changes in treating patients have occurred. One should not make such comparisons, as the difference in treating patients in June is markedly different than it is now. Physicians have gained knowledge in treating patients and more aggressive early treatment has improved outcomes. Medications such as dexamethasone and remdesivir, and now monoclonal antibody, have either proven to be effective or become available.

But generally speaking, it is still true that when we see increases in cases, we see increases in hospitalizations, followed by increases in deaths.

Over time I trust that the accumulation of questions and answers will deepen our understanding of the thinking behind the government mandates to which we are subject. In this batch I would draw attention to the second question and answer which starkly clarifies the attribution of blame to us for the current surge. We nevertheless have reason to hope that this wave of the epidemic is peaking. Note: On the question of blame and masks, Kevin Roche has asked me to point out that the mask wearing surveys don’t support the department’s statement.

Yesterday’s MDH press briefing was it for the week. It focused on testing with an excursion on the issue of staffing in nursing homes that is covered in the Star Tribune story linked above. The briefing ran 35 minutes or so and department officials took only four or five questions, none of which raised the question whether the department’s “5-point battle plan” to combat the epidemic in nursing homes might need a tweak or two.

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