I believe this is one of the most important articles written this entire pandemic

It hits on a topic that is central to our failed pandemic response

Public Health is not just a lot of Medicine stacked up.

Medicine can even be anti-public health

1/ nytimes.com/2022/01/14/opi…
A very simple example is isolation.

A doctor would NEVER prescribe isolation for a patient for their medical purposes.

We know however that isolation is needed for public health during a respiratory virus pandemic.

2/
But isolation is one of a few areas where we put public health policy in place - often w less than exacting data - because it was obvious that it’s important.

For the most part we think of pandemic response as physicians - this is simply wrong. As detailed in the article

3/
Bc this will come off the wrong way to MANY physicians - I am NOT saying doctors are not contributing to public health daily

I am saying that prioritizing a medical lens over a public health/engineering lens in policy/regulation pushes in the wrong directions for a pandemic

4/
Doctors in their individual capacity are doing exactly the right thing in this pandemic.

But our public health Policies to curb a global pandemic cannot rely on how doctors think at the bedside and the risk tolerances that physicians have. It’s different in public policy

5/
One way to think about it is airport security.

A TSA agent is there to ensure that every bag getting through is getting the best treatment possible to make sure it doesn’t have explosives.

But we do NOT ask TSA agents to engineer the overall airport security system.

6/
We know that those are very different skill sets and the metrics and tolerances in different vantage points are entirely different.

For example, part of travel security doesn’t even occur in the airport at all. It is at a much higher level than the conveyor belt.

7/
I failed to tag the author of the article in the first tweet - @aaronecarroll

8/

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More from @michaelmina_lab

Jan 17,
I'm #COVID19 Positive.
Was bound to happen at some point
I feel terrible today: Fever, aches, chills (Immune mediated symptoms). Cough (maybe immune, maybe virus)

So, here we go.
I'll update this thread daily. See photo for rapid test results + infection/test result description Multiple tests from Left to...
I am exceedingly frustrated that b/c my wife & I didn't get dose 2 until 8/21 - we cannot get boosted yet

We have a 3 month old, Lila, who'd benefit greatly during Omicron by high antibodies in breast milk. But w/out my wife being boosted, Lila won't get much protection.

2/
At 0-12 hours into symptoms:
No rapid Ag or rapid molecular tests were positive

At 24 hours into symptoms: All nasal tests were bright positive
Throat swab test was fully Negative

Symptoms start earlier for many ppl now (see this thread for why ()

3/
Read 5 tweets
Jan 17,
After ~2 yrs of uphill battle to get CDC to recognize rapid Ag tests are sensitive enough to answer the question “Am I Infectious?”…

It is astounding that CDC is now pretending rapid Ag tests are too sensitive to answer this question - bc they wont support a test-to-exit policy
It feels like a serious twilight zone whiplash to hear Rochelle, Fauci, and a small cadre of physicians who want to support them saying “we don’t know if rapid antigen tests correlate w culturable/infectious virus”

Yes - we do know this. We’ve known it for over a year!
CDC telling America masks didn’t work, just because we didn’t have enough, didn’t exactly go over well and was one of the most destructive decisions in the pandemic.

It’s unclear to me why they feel that repeating that same mistake today w rapid tests makes sense.
Read 5 tweets
Jan 16,
Why does public health have very different metrics than medicine?

Ex:

If freq rapid tests gets 100 infected ppl to spread to 90 new ppl, this is a PH victory -> exponential decay cases

However, in medical thinking, if 10 ppl infect 9 new ppl, it would be a medical failure!

1/
In the ex above I plot what an R of 1.3 vs. an R of 0.9 would look like

Of course with Omicron, R is not 1.3 but more like 6+
So getting below 1 with rapid testing would require massive effort

But dropping Re from 6 to 2 would be a major PH benefit.
2/
Nevertheless, the point here is not to focus on the specific R value but to understand that the tolerances goals of public health are massively different sometimes than medicine

What might be a failure in medicine can be a major success in public health. And vice versa!

3/
Read 4 tweets
Jan 16,
#RapidTest Strategy

In light of WH/@POTUS massive distribution of #rapidtests ideally to all

Imagine if

a) Add extra swabs so 2-3 ppl pool specimens

b) All Americans simultaneously test 4x in a single week

We could see massive crashes in cases & more effective future efforts
@POTUS How would this work - if most american's detected that they are infected - across the whole of the US - in a single week AND acted to isolate appropriately, we could massively temporarily reduce the effective R of the virus and bring cases tumbling down.

2/
@POTUS Although it would last for as long as the testing is going, it could help get things a better under control and provide a better footing for ourselves in the weeks after.

3/
Read 7 tweets
Jan 12,
On early exit from isolation at day 5

** There is likely NO single identifiable group of ppl who pose a greater risk of spreading virus than those leaving isolation at 5 days w/out a Neg test

Rate of being infectious at d5 may be >40%

*Test-to-Exit*

It’s smart Public Health
To be clear - this is five days from symptom onset when MANY ppl are arriving back to work infectious!

Reluctance to incorporate a negative test into the return protocol is mind boggling.
The test should be a rapid Ag test because OCR stays positive far too long after someone is no longer infectious. A rapid Antigen test turns negative when infectiousness stops.
Read 6 tweets
Jan 10,
@phil_luttazi The global exit strategy from this pandemic is/always has been the building up of immunity

This virus will never disappear and herd immunity to eliminate is not a thing for a virus like this

So we are stuck with effectively one option (with multiple paths to get there)

1/
@phil_luttazi We must build up a sufficiently robust and diverse immune response so that the importance that this virus has in our lives falls lower and lower.

As adults we are on the same steep learning curve that babies are on in early life. But doing this as adults is risky business

2/
@phil_luttazi However, we have no choice. The virus is with us and just like the other viruses we contend with as babies, it’s not going away.

So it would be foolish to assume that vaccination is our only approach to building immunity when we have a virus that will cycle for our lifetimes

3/
Read 14 tweets

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