Coronavirus in one state (143)

Governor Walz convened yet another press briefing yesterday afternoon. I have posted the audio below. I certainly have overdosed on these events, but I have found them useful in tracking the mix of politics and public health issues that has usurped our freedoms since this past March. Through the lens of the briefings and my own ordeal with the Minnesota Department of Health we can also throw the performance of the circle-of-love media into the mix. As the epidemic has waxed and waned, Minnesota officials have inflicted enormous damage on the lives of citizens and the economy of the state.

I know that listening to these briefings is painful. It is costing me brain cells I can’t afford to lose. I can only say I hope that reporting on what these officials have to say about it all serves a worthy purpose.

Speaking of the press, I would like to share with you the questions I have submitted to MDH over the past three weeks pursuant to my settlement agreement with them. Here is the set of three questions I submitted on December 7 to which MDH responded from behind the curtain of anonymity on December 15:

1. Question: You have said that children are responsible for asymptomatic spread to older, more vulnerable adults. Can you tell us in how many cases you have definitively traced a child as the index case for transmission to a teacher or a person under the age of 25 was the index case for transmission to a person aged 65 or over?

Response: The answer to the question is based on observations from around the world published in the medical literature. Multiple published research studies have shown that, in general, young children transmit less efficiently to others and infect fewer contacts than older children and adults. However, children do transmit COVID-19. And children tend more likely to have mild illness or be asymptomatic, so indeed asymptomatic children transmit SARS-CoV-2. Older children, those 13 years of age or older, have been shown to be as efficient transmitters as adults.

We do not have individual data where we link one case transmitting to another person resulting in their infection, whether it’s from an adult to another adult, even a spouse to a spouse, or a child to an adult. We can’t possibly interview every person in depth and make a subjective interpretation as to who infected whom. Of course, in some instances it might be fairly obvious what happened, but our database is not set up to analyze it that way. Such specific information might be written in notes in the text field, but it would be nearly impossible to troll through these 350,000 text fields to provide a number, which would be a gross massive underestimate anyway.

Question 2: You have said that long-term care facility cases are caused by staff bringing COVID-19 into the facility and transmitting it to residents. Can you tell us in how many cases you have definitively traced a staff member as the index case for transmission to a long-term care resident?

Response: The data show LTC outbreaks are not caused by residents returning from a hospital stay, and that staff persons are most often the first case in LTC outbreaks, based on illness onset. As of December 8, what the data do show are that of the 3,322 outbreaks in LTC facilities we have identified since March, 2,445 (73.6%) had their first case (based on illness onset) in a staff member, and that 13 (0.39%) had their first case in a resident that had been discharged from a hospital.

Question 3: In how many of the deaths attributed to COVID-19 is COVID-19 shown on part 1 of the death certificate as an underlying cause and in how many is it shown on part 2 as a contributory cause?

Response: The National Center for Health Statistics (NCHS) assigns the ICD-10 codes and adheres to the WHO Nomenclature Regulations specified in the International Statistical Classification of Diseases and Related Health Problems. NCHS also uses the ICD international rules for selecting the underlying cause of death for primary mortality tabulation in accordance with the international rules. There are several separate set of rules applied when assigning multiple and underlying cause of death (COD) ICD-10 codes. One cannot determine the underlying cause of death just based on the disease condition literals reported on the death records. Therefore, it is important the cause of death be reported in the correct format as the ICD-10 codes strictly depend on how the certifiers report the cause of death.

The figures below indicate the total number of cases with COVID or related terms reported by the certifiers in Part I and/or Part II. There could be cases where these literals are reported in both sections.

Even if COVID-19 is listed as a secondary cause, our experience indicates almost all of the persons listed below would not have died if they were not infected with SARS-CoV-2.

For the case definition that we use for COVID deaths (the CDC/CSTE case definition for deaths), it is not significant if COVID is listed in Part 1 or Part 2.

As of December 7:

• There are 3,408 death records where COVID or related terms (CORONA VIRUS, CORONAVIRUS, SARS) or coded as COVID-19 (U07.1) are reported in Part I.

• There are 463 death records where COVID or related terms (CORONA VIRUS, CORONAVIRUS, SARS) or coded as COVID-19 (U07.1) are reported in Part II.

Kevin Roche comments on the MDH responses to these questions here. Kevin also commented here on Monday’s MDH press briefing that I covered yesterday in part 142. Kevin’s knowledge of the relevant studies proved particularly useful in these comments.

Many obvious questions have gone unasked at these press briefings. I think I have asked a few. As of this morning, I am awaiting answers to these questions submitted on December 15:

1. I asked you two or three weeks ago how you have asked the tribal casinos to conform to the governor’s current shutdown order (E.O. 20-99, effective as of the time of this question) and what the responses were. You told me that the state has no regulatory role with respect to tribal casinos. I know that. But you have presented the governor’s current shutdown order as a matter of life or death sufficient to justify the infliction of great harm on many businesses throughout the state. Some casinos voluntarily complied with the shutdown order this past March. Please explain to me why you haven’t asked the tribal casinos to comply voluntarily with the terms of the current shutdown order.

2. The research shows that the average time between exposure and development of symptoms is a week or less, and that it is extremely rare for symptoms to appear more than ten days after exposure. Shouldn’t the effectiveness of mitigation measures become evident in case counts within a week or so rather than the four weeks you cite?

3. You have been telling us for several months that a new release of Minnesota model 3.0 was imminent. Versions 1.0 and 2.0 appear to have been wildly inaccurate. Why hasn’t model 3.0 been released consistent with your repeated assertions?

I am also awaiting answers to these questions submitted on December 21:

1. (This is for Director Ehresmann): Referring to your recently published CDC analysis of Minnesota cases related to the Sturgis rally (citation here), please provide your estimate, if any, of how many Minnesotans attended the 10-day rally that drew a crowd of some 400,000 this past summer.

2. Please provide the questionnaire or outline used by staff to interview subjects for the purpose of COVID-19 contact tracing.

3. In light of the World Health Organization release last week warning about the use of PCR test results with high cycle numbers (citation here), will you provide information on the cycle numbers associated with the PCR tests used in state labs (assuming you know what cycle numbers are used by various labs across the state as a threshold for positivity — please state if you do not)?

As for yesterday’s extended production with Walz, MDH Commissioner Malcolm — she thanks the press for its “careful coverage” of the issues this year — and Infectious Disease Division Director Ehresmann, the focus was on vaccines and vaccinations. The nauseating palaver rolls on. Although Malcolm hems and haws on the point, Minnesota is on the other side of the current wave of the epidemic that hit the Upper Midwest regardless of the differing approach taken by the authorities in neighboring states including Wisconsin, Iowa, North Dakota, and (ahem!) South Dakota.

At about 39:30 of the audio, FOX 9’s Theo Keith asks Walz why not ease up now on restaurants. Walz and Malcolm both respond in their accustomed fashion. KSTP’s Tom Hauser follows up at about 44:20 with a question noting the uniformity of the wave across the region and asking if Walz is sure his lockdown regime is performing as advertised. Walz answers in classic form: “If my neighbor’s not doing what’s necessary to keep their [sic] house from burning down, I’m not going to follow them just because of that.” As I say above, it rolls on, emphasis on “nauseating.”