Coronavirus in one state (149)

I enlisted the assistance of attorney Theresa Bevilacqua to recommit the Minnesota Department of Health to good faith compliance with the terms of the settlement agreement resolving my lawsuit against Commissioner Jan Malcolm and press flack Michael Schommer. MDH counsel stated that they want to make my arrangement with them work as intended. Previous deficiencies will be cured in due course, in part by my reformulation of a poorly phrased question and in part by their search of the data at their disposal. After Theresa’a conversation with him yesterday, I received the department’s answers to questions I submitted on January 4 and a promised cure of previous deficiencies. Here are my questions of January 4 with the MDH answers received early yesterday evening:

1. Question: A Power Line reader writes with a question based on these facts: “My 91-year-old father is a resident in an assisted living facility in [a Twin Cities suburb]. The facility has been on lockdown for the past 10-plus weeks. I have not seen Dad since mid-October. Dad and everyone else – residents and staff alike – have been tested for Covid-19 every week since on or about Dec 1, 2020. Staff was undergoing weekly testing for at least a month before that. On December 28 Dad received his first dose of one of the vaccines. On December 29 he tested positive. Talk about cruel timing. Dad remains asymptomatic for now, but his age and his underlying medical conditions put him at very high risk. Dad has seldom left his room in the past two years. He was into social distancing before it was cool. Anyone from the facility/staff who visits him — to deliver meals or medications — wears full PPE including a mask and face shield. The ineffectiveness of masks seems obvious to me… If the virus can spread to a self-isolated person in a facility where PPE compliance is 100 percent (or you are terminated) then it will spread where and when it wishes. MDH’s own statistics about infection rates and community spread in such licensed facilities appear to support my conclusion.” Our reader has requested that we ask you how this can possibly happen if masks are effective. Please respond.

Answer: The specific question(s) posed by this inquiry seem to be: With all of the precautions supposedly taken in LTC facilities – full PPE, face masks, etc. how is it possible that a LTCF resident could become infected with COVID-19? Doesn’t this demonstrate that PPE and face masks are ineffective and that the virus will simply “do what it wants”?

This question speaks to the very contagious nature of the virus. Just as other members of the community are susceptible to high rates of transmission, so are our health care workers. We know that not all individuals with COVID-19 show signs of illness. For this reason, health care workers must wear all recommended PPE and should participate in routine occupational COVID-19 testing. Despite these measures, we know that infectious health care workers can sometimes spread the virus that causes COVID-19 to coworkers and to residents. PPE has an important role in source control (preventing infectious droplets from entering the air and onto surfaces), but the level of source control provided is not well-studied. We know that PPE is protective, but it cannot be said that PPE provides 100% effective source control in every circumstance. Even when an infectious health care worker is in full PPE there is still some potential that a person in close prolonged contact could be exposed. For this reason, great care is taken to identify residents cared for by an infectious health care worker – so that if someone develops illness, they can be monitored and care for appropriately. Whenever possible, potentially infectious health care workers should be quarantining and avoiding direct patient contact.

It should be noted that, generally speaking, PPE is meant to protect the person wearing PPE from infection, but as noted above also serves to protect residents under some circumstances. Masks largely prevent the wearer from infecting others, but have been shown to provide some protection to the wearer as well. A long-term care setting, where the population is extremely vulnerable and patients and workers are in confined, enclosed spaces, cannot be used to draw conclusions about the effectiveness of masks. The scientific literature strongly supports the use of masks to reduce transmission of the virus by the general public.

UPDATE: I received this addendum from MDH to the answer above after posting this morning:

We’d like to provide some additional context and information regarding your first item of concern:

Preventing the spread of COVID-19 requires a multi-pronged approach, several components need to be in place, it’s not just the mask. All must work together to achieve the greatest effectiveness. Long-term care facilities should have systems in place to identify ill staff and residents (e.g. monitoring temperatures & signs and symptoms) as well as frequent testing. Early identification allows the facility to isolate the resident and to have ill staff refrain from reporting to work. The facility should also ensure both staff and residents are performing frequent hand hygiene. Contaminated hands is one of the ways infection can spread. Frequent cleaning and disinfection of environmental surfaces as well as equipment between resident uses (e.g. a thermometer that goes room to room) are important. MDH resources do recommend that residents wear a cloth mask within 6 feet of others, including health care workers. Any gap in infection prevention and control can contribute to the spread and all interventions need to occur consistently. There are other factors in play but these are some of the common areas we stress. Again, this is why this anecdote stemming from a long-term care facility is not a good gauge of mask or PPE effectiveness.

As noted, there are a number of articles in the scientific literature on the effectiveness of masks. Here is one good one in particular – it discusses percentages of mask effectiveness.

END OF UPDATE.

2. Question: A long-time friend writes with these observations about the restrictions on gym use: “The new order requires that participants be 12 feet apart while exercising (regardless of the type of exercise, like yoga versus cardio). What was wrong with 6 feet? The facility can have no more than 100 people in it, regardless of its size. Huh? Masks must be worn at all times. I would like to know whether the person who came up with that has ever tried to complete a cardio step class with a mask on. Classes cannot have more than 10 (including the instructor), again, regardless of the size of the room. So you could hold a ‘gentle yoga’ class on the basketball court, but only 10 people could participate. Consumption of food or beverage is not permitted in the class. Apparently, you can drink water, but since that is a beverage, presumably you would have to slip outside that classroom for a quick gulp. One of my instructors collapsed a couple weeks ago for lack of hydration. I need a jug of Gatorade to make it through cardio step. Most people do. I wonder if they know they are flouting the Governor’s order. Why the restrictions are tightening as the case count is plummeting is a mystery, particularly at our Y, which, to my knowledge, has had no infections. The rules also betray their author’s complete lack of familiarity with what actually goes on in a class.” Would you please comment on these observations?

Answer: There seem to be several specific questions posed:

Why was the safe distance changed from 6 feet to 12 feet for gyms?

(It’s actually 9 ft. in the current Executive Order.) Because when breathing heavily, droplets from your mouth may be expelled farther than 6 ft. – much has been written about this in the published literature.

Do we really expect people to wear masks while exercising vigorously?

Yes.

Isn’t it unsafe?

It is not unsafe – studies have shown that it is safe.

If no food or beverages are allowed in gyms, how is one supposed to have water to drink in order to avoid collapsing of dehydration?

The guidance specifically addresses this: “Consumption of food or beverage is not permitted in the class area. Persons may remove their face coverings briefly to consume water, but members of the class must not be engaged in any activities involving physical exercise or exertion while doing so and must ensure they are socially distanced from others.”

If case counts are/were plummeting, why are/were the restrictions necessary?
Case counts dropped BECAUSE of the restrictions.

Are we aware that our “rules” seem impractical to gym users?

We’re aware that wearing masks during strenuous exercise can seem uncomfortable or unnatural at first. It takes a little while to get used to it. That’s why we recommend that coaches and trainers spend time with athletes to help them adjust. Teams and coaches can help each other in this transition. Athletes should continue to be aware of their breathing and exertion, and take breaks when needed, especially if dizzy or light-headed. It is also important that a face covering be changed immediately if it becomes saturated with moisture. As in all circumstances, people who cannot safely wear a mask due to a medical condition, should not wear one.

There are some sports where we do not recommend that players wear masks. This is based on the AAP guidance which does not recommend masks if they could get tangled (gymnastics, cheer, wrestling) or wet (swimming).

Academic Articles:

Epstein, Danny, et al. “Return to training in the COVID‐19 era: The physiological effects of face masks during exercise.” Scandinavian journal of medicine & science in sports 31.1 (2020): 70-75.

Shaw, Keely, et al. “Wearing of Cloth or Disposable Surgical Face Masks has no Effect on Vigorous Exercise Performance in Healthy Individuals.” International Journal of Environmental Research and Public Health 17.21 (2020): 8110.

Allowing COVID to spread is not a practical choice for society, the economy or people’s health.

3. Question: Deaths in long-term care facilities continue to represent approximately 60–70 percent of all deaths attributed to COVID-19. Whatever the precise percentage at present, it continues to represent a substantial share of all deaths attributed to the disease. Would you please provide MDH’s current assessment of the guidance you have provided and the measures you have undertaken to prevent the spread of disease in long-term care facilities?

Answer: The COVID-19 pandemic has challenged every Minnesotan, but the impacts have been particularly painful for residents of long-term care facilities. The disease has sickened and killed thousands, and has made it difficult for friends and family to connect with residents at a time when that support is needed most.

Minnesota facilities received support and guidance long before the first case was reported in the state. Public health officials at all levels recognized the special dangers COVID-19 posed for long-term care residents and took action based on the knowledge and resources available at the time. From March through November, state officials helped more than 3,232 facilities with infection control measures. More than 567 visits (onsite and remote) were made for infection control and technical assistance, and all nursing homes in Minnesota had regulatory onsite visits.

Under Governor Walz’s leadership Minnesota stepped up its work with long-term care facilities in early May by rolling out a five-point, long-term care plan focusing on seniors living in nursing homes and assisted living facilities. The plan – along with countless hours of work by state employees and facility staffers ‑ made long-term care facilities more resilient and it strengthened protections for residents. In September and October, Minnesota saw a dramatic 73 percent increase in COVID-19 cases for the population as a whole and just a 15 percent increase in long-term care cases. This improvement is a key piece of the story of how things have changed since the earliest days of the pandemic.

All that said, the recent steep rise in community spread showed that that the protective floodwall we worked so hard to build around long-term care could not withstand and was overwhelmed by the rising waters of COVID-19 transmission in the community. That is why we continue to ask all Minnesotans to do their part to help reduce the spread of COVID-19 in their communities. The simple actions to stop the virus – masking, keeping socially distant, staying home and getting tested when you are sick or exposed – are just as important as the work of the state or providers to keep long-term care residents safe. Our teams continue to work hard every day to protect long-term care residents, and we thank Minnesotans for doing their part to eradicate this pandemic.

For a counterpoint to the MDH theme of suppression and control that is a motif in the answers above, see Kevin Roche’s brief post “We will all end up in the same place.” Kevin makes the same point in his most recent update on current research:

Congratulations, Minnesota, we have officially passed the 1000 deaths per million people mark, a great way to celebrate the exceptional response we have had to the epidemic, one that our Governor always reminds us has been so much better than our neighbors. Our most analogous neighbor, Wisconsin, is at a mere 885 deaths per million. And we are closing in on the national average, despite having a younger, less densely populated, lower minority percentage state. And one that is oh so healthy and with great health resources. Not to mention that we have the best data in the country, a better mitigation strategy than any of our neighbors and of course, the IB hisself [i.e., the Incompetent Blowhard — Governor Walz] in charge of it all.

The relevant numbers continue to fall as we descend the curve of the most recent surge of the epidemic that began before Thanksgiving. The questions at yesterday’s press briefing focused on the manifestation of the new variant of COVID-19 in five local cases and the progress of the vaccination program so far in Minnesota.

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