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Mike Hoerger, PhD MSCR MBA Profile picture
@michael_hoerger
Nov 15, 2022 • 8 tweets • 3 min read • Read on X
I've yet to see a well-designed study showing that #COVID #RapidTests are no longer efficacious.

This one is no exception. Why?
5 reasons.

clinicalmicrobiologyandinfection.com/article/S1198-… Image
1. They compare same-day PCR against self-administered/interpreted rapid tests.

For most ppl, that's not reality. It's RAT today or PCR result in 1-3 days (or do both).

A fairer comparison would be a RAT today versus a PCR yesterday (since you'd have to wait for results).
2. They excluded 13% of the sample who were "confirmatory testers" (weird term) -- basically, people who had just tested RAT+ and were coming in for a PCR.

Basically, they excluded the people for whom the test easily worked. Drug trialists pull this stuff all the time.
3. The study excluded ppl with symptoms. Some people use RATs before socializing to reduce risk (hopefully with other Swiss Cheese slices). BUT many use RATs when symptomatic. I don't think the study fairly represents how RATs are being used. Image
4. As RATs became more common, many novices started using them without following instructions well. It would have been helpful if the researchers also administered and interpreted a RAT. I suspect the diminished utility is more "user error" than a property of the test. Fixable.
5. RATs detect most closely the infectious window. A PCR will flip positive a litter earlier & stay positive longer. If a goal is to prevent forward transmission, rather than merely diagnosis, then studies like this are not testing hypotheses with real-world significance.

Mina: Image
Overall, I see RATs as an important piece of mitigation. Even in this anti-RAT study, positive & negative predictive values were 85%-98% across tests (Table S2).

That's about as efficacious an N95 among a novice wearer. All of our shields have holes, so we combine them. Image
RAT efficacy estimates are much higher than many "too good to be true" interventions you see pushed heavily: SSRIs, enovid, nasal sprays. 🤣🤣🤣

The evidence that those protect against COVID is so poor as to harm by distraction. Go buy some bittrex.

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More from @michael_hoerger

Mike Hoerger, PhD MSCR MBA Profile picture
Oct 22
PMC COVID-19 Forecasting Model, Oct 21, 2024
🧵1 of 4

Every indication is that the 10th U.S. Covid wave is on the way. Within 2 weeks, expect transmission to be meaningfully higher.

Current estimates from PMC:
🔹1 in 115 actively infectious
🔹Higher transmission than during 43% of the pandemic
🔹Nearly 3 million weekly infections

These estimates are high in the absolute sense, but low relative to the recent summer wave and likely winter surge.

The CDC data show transmission increasing in the Northeast, and a slowing of the decline in transmission elsewhere. Biobot data also show flattening transmission. The raw CDC and Biobot wastewater data are delayed >1 week. Walgreens shows positive cases, testing, and positivity ratios flattening and is delayed only 1 day.

For those unfamiliar with the model, find full weekly reports for the past 14+ months at pmc19.com/data

The models combine data from IHME, Biobot, and CDC to use wastewater to estimate case levels (r = .93 to .96) and forecast levels the next month based on typical (median) levels for that date and recent patterns of changes in transmission the past 4 weeks.

Our work has been cited in top scientific journals and media outlets, which are fully sourced in a detailed technical appendix at pmc19.com/data/PMC_COVID…

Examples include JAMA Onc, JAMA-NO, BMC Public Health, Time, People, TODAY, the Washington Post, the Institute for New Economic Thinking, Salon, Forbes, the New Republic, Fox, CBS, and NBC. See pgs 10-11 at the above link.GRAPH Shows forecasted entry into a 10th Covid wave. TABLES Current Levels for Oct 21, 2024 % of the Population Infectious 0.9% (1 in 115) New Daily Infections 414,000 New Weekly Infections 2,898,000 Resulting Weekly Long COVID Cases 145,000 to 580,000 Monthly Forecast Average % of the Population Infectious 1.3% (1 in 76) Average New Daily Infections 627,600 New Infections During the Next Month 18,828,000 Resulting Monthly Long COVID Cases 941,000 to 3,766,000 Running Totals Infections Nationwide in 2024 225,097,000 Average Number of Infections Per Person All-Time, U.S. 3.46 How Does ...
PMC COVID-19 Forecasting Model, Oct 21, 2024
🧵2 of 4

These graphs show the forecast for changes in transmission over the next month.

The first graph shows year-over-year transmission. The 2nd focuses on the most recent year. Within a month, expect to see 0.7 to 1.0 million daily infections, if the assumptions of the model hold.

If lucky, we could get a slightly longer "lull" than what the model shows. The model likely underestimates the true value for the recent summer peak because many children were infected while going back to school, in fact, the highest peak at that time period all-time. Wastewater underestimates child infections ("contributions" correlate highly with body weight, so it takes four ill 50 lb kids to show up as one ill 200 lb adult). In underestimating the peak, transmission also fell more rapidly than anticipated post-peak. To the extent we underestimated the magnitude of the peak, there may be fewer than anticipated infections the next two weeks and a longer lull.

If you look at the first graph, however, you will see a clear patterns of escalating transmission in November, so it's more a matter of how quickly the situation will worsen than whether it will worsen.

During this relative "lull," it's an excellent time to stock up on high-quality masks, get vaccinated, upgrade the quality and quantity of air cleaners, re-stock on rapid tests, and encourage others to do the same.Two graphs, described in Tweet.
PMC COVID-19 Forecasting Model, Oct 21, 2024
🧵3 of 4

Regional differences suggest that the NE may already be rebounding in transmission. Transmission declines are slowing elsewhere.

We compare the PMC map in standard red against the CDC map using the same data in cool blue.Estimated Percentage Actively Infectious* National 0.9% (1 in 115) Northeast 1.0% (1 in 101) Midwest 0.9% (1 in 114) South 0.8% (1 in 130) West 0.9% (1 in 106)
Read 4 tweets
Mike Hoerger, PhD MSCR MBA Profile picture
Oct 7
PMC COVID-19 Forecasting Model, Oct 7, 2024
🧵 1/4

540,000 daily infections during the "lull" between the 9th & 10th U.S. Covid waves.

🔹1.1% (1 in 88) actively infectious
🔹19 million anticipated infections the next month
🔹Higher transmission than half the pandemicGraph: 10 waves of the pandemic Tables/stats: Current Levels for Oct 7, 2024 % of the Population Infectious 1.1% (1 in 88) New Daily Infections 541,000 New Weekly Infections 3,787,000 Resulting Weekly Long COVID Cases 189,000 to 757,000 Monthly Forecast Average % of the Population Infectious 1.3% (1 in 74) Average New Daily Infections 643,433 New Infections During the Next Month 19,303,000 Resulting Monthly Long COVID Cases 965,000 to 3,861,000 Running Totals Infections Nationwide in 2024 220,311,000 Average Number of Infections Per Person All-Time, U.S. 3.44 How Does Risk Increase wi...
PMC COVID-19 Forecasting Model, Oct 7, 2024
🧵 2/4

Year-over-year, we have seen the steepest drop in transmission all-time on the back end of a summer/fall wave.

Similar transmission the next month, a very high lull. Expect transmission to accelerate in mid-Nov.Two graphs Year-over-year transmission. A very high late-summer wave, the highest all-time during Aug/Sep, followed by the steepest decline on the back of a summer wave, all-time. Forecast. Note similar transmission over the next month, 40-60% of the summer wave's peak. Expect transmission to pick up considerably in mid-Nov in anticipation of a winter surge peaking around New Year's Eve
PMC COVID-19 Forecasting Model, Oct 7, 2024
🧵 3/4

Relative to the Northeast, transmission is 2x higher in the Midwest/South & 2.5x higher in the West region.

However, the CDC regions mask extreme variation within region. The 7 highest-transmission states are far north.Map: Transmission highest in Washington state, Oregon, Montana, Minnesota, Vermont, New Hampshire, and Maine. Line Graph: Shows the regional statistics summarized in tweet.
Read 4 tweets
Mike Hoerger, PhD MSCR MBA Profile picture
Sep 30
PMC COVID-19 Forecasting Model, Sep 30, 2024
🧵 1/5

COVID transmission remains extremely high, but we're entering a "lull" in the U.S. sooner than anticipated.

Among all summer/fall waves, the 22% 1-week drop in transmission is steepest all-time.

Details:

In Friday's data release, the CDC retroactively corrected the prior week's numbers downward 6% (for Sep 14). This is a big correction, bigger than average, but nothing nefarious. The most recent week's numbers show an additional 1-week decline in transmission of 22% (from Sep 14 to Sep 21) on top of that 6% correction (for Sep 14), so the transmission estimates have fallen quickly.

Looking back, we estimate that the 1-week drop of 22% is the largest decline on the back end of any summer/fall wave in the U.S.

*If* these numbers hold against future retroactive corrections, it means people have about 5 weeks of similar transmission from today through Nov 7.

Why might we have seen a record decline in post-peak transmission?

Several hypotheses:

1) Reporting Error: The 22% decline could be driven in part by errors in real-time reporting. These average is 5%, based on our analyses of Biobot wastewater data. We do not have long-term data on the accuracy of Verily/CDC real-time reports versus retrospectively corrected values. In the updated graphic, we have added 95% confidence intervals for the real-time values based on Biobot data, which show that 95% of real-time errors fall within 8.33%. Note that the dotted lines do not show 95% confidence intervals for the forecast, merely how the best estimates would change if a large error in the real-time reports of +/- 8.33%. It’s possible that next week the data will get corrected upward, and the forecast will more resemble the top dashed line. In the next Tweet, we show the forecast for our old (Biobot-based model); it’s still showing a slower decline, but they update their data about 5 days slower than the CDC, so it is unclear whether it’s a big real-time reporting error at the CDC or just that the CDC is ahead of the game.

2) Unprecedented School Transmission: This is the largest wave during the August back-to-school period. It’s possible transmission disproportionately affected school children and their families, and in being more targeted than typical transmission, the wave went down faster that what is normative thus far in the pandemic.

3) Laissez Faire Public Health: Public health guidance has weakened (e.g., 1-day isolation policy, not strongly pushing additional mitigation), which likely pushed the peak of the 9th wave higher, which could have led to a faster-than-usual resolution. The model accounts for these changing dynamics reasonably well, but with the school issue noted in hypothesis #2, it is possible the weakened public health guidance disproportionately hit a subset of the population, which altered the back side of the wave.

4) Missing Data: There are no widespread state-level instances of missing data, as is often the case. It is possible that specific areas did not report this week, and if there is a bias toward higher transmission in those places, the numbers will get retroactively corrected upward. This is one example of the issues that contribute to #1.

5) Politics: There is no evidence to suggest the CDC is modifying transmission data for political reasons. We put deep trust in the fundamental scientists doing the critical work translating wastewater into meaningful downloadable data. The inferences, agency graphs, and guidance can be influenced by politics, but the data are sound, given the limitations noted under #1.

Overall, if the data hold or anything reasonable within the ballpark, which is likely, this means a more prolonged and slightly lower lull than previously anticipated. Those putting off medical appointments and other risky activities may see this as a slightly broader window (today through Nov 7) to get things done. Note that even under the most optimistic forecasting scenarios, transmission remains very high in absolute terms, even if low in relative terms.Graph #3 from the PMC dashboard. Shows a steep decline in transmission based on the most recent CDC numbers.
PMC COVID-19 Forecasting Model, Sep 30, 2024
🧵 2/5

Note that while the CDC data show an unprecedentedly steep decline, Biobot data suggest more gradual changes, along the lines we have been forecasting the past several weeks.

This graph shows a resurrected version of our discontinued model 1 (Biobot-only) forecast.

I would not be surprised if the CDC data get retroactively corrected upward a little bit (this is common, not nefarious), AND the Biobot data go down a bit faster (they lag the CDC data by about 5 extra days). There is regional variation between the data sets, which means that BOTH models could actually be accurate without corrections.

Nonetheless, anything in the ballpark of these two forecasts suggests a "lull" from about now through Nov 7. It's a very high lull, but people find these dates useful for risk-based planning.Biobot-based model suggests a much more gradual decline, with transmission still bottoming out in early November.
PMC COVID-19 Forecasting Model, Sep 30, 2024
🧵 3/5

The United States is coming down from a 9th Covid wave and will soon transition into a 10th.

We are still #DuringCOVID.

The peak will likely be around New Year's Eve, though some models suggest slightly later.

A 3-month forecast is extremely volatile. I mention it now because people are already making travel plans.

Hospitals should formalize their plans for requiring universal masking if they have not already done so. Many have missed the mark during the ongoing summer/fall wave due to reliance an outdated zeitgeist of "respiratory virus season" that treats cold, flu, and Covid at interchangeably equal. Covid peaks twice annually and is more disabling long-term. Nonetheless, even hospitals relying on outdated models will be more likely to take the forthcoming wave more seriously.

As we have published, universal masking during Covid waves is a key indicator of healthcare quality. Yes, this is true based on 2024 data. Unfortunately, it's mostly only the very best-of-the-best health centers. Consider printing and mailing this article to places where you receive care.
jamanetwork.com/journals/jaman…Graph #1 from the PMC dashboard, shows we are coming down from a 9th wave, with a 10th wave about to start.
Read 5 tweets
Mike Hoerger, PhD MSCR MBA Profile picture
Sep 24
As an expert in psychological assessment who has testified in court on cognitive assessments I've conducted, people should interpret carefully the new eClinicalMedicine paper on Covid-related cognitive changes.

Quick 25-pt thread⚡️
🧵1/25 Main figure from the paper. It has a lot of information but actually communicates very little that is meaningful. They authors suggest changes in general cognitive skills (A) and curiously mix this with figures showing more viral load among people infected with virus (B). The top half of A is virtually uninterpretable. The bottom half is vastly overstated. I think people see the big findings in B and think a lot is going on cognitively, when it's just about virus.
The field of clinical psychology has developed, implemented, and evaluated normed broadband tests of cognition for the past 119 years.

These are highly specialized instruments with carefully selected tests to cover the breadth of key areas of cognition.

2/25
The study did not use one of the well-established, normed, broadband tests of cognition. Instead, it used a novel app-based hodgepodge of tests with little empirical history.

People should be very cautious in interpreting results. There is no vast literature on the tests.
3/25
Read 25 tweets
Mike Hoerger, PhD MSCR MBA Profile picture
Sep 23
PMC COVID-19 Forecasting Model, Sep 23, 2024
🧵 1/8

The U.S. continues to see an estimated 1.1 million daily COVID infections with 2.2% of the population actively infectious as we descend from the peak of a 9th Covid wave.

Transmission will remain very high the rest of 2024.Main PMC figure showing Covid transmission over time. It shows 9 waves. The current wave peaked in August, and we're still seeing >1 million infections/day in the U.S.
PMC COVID-19 Forecasting Model, Sep 23, 2024
🧵 2/8

Looking at the year-over-year graph, note that we're in uncharted territory for this point in the fall. Expect a very high "lull" in early November before the winter surge sets in.

As we have noted previously, our current estimates are likely slight underestimates given elevated school-based transmission and the CDC data standardization process.

Kids: They are smaller, and make smaller "contributions" to wastewater. Basically, it takes more sick kids to produce the average amount of wastewater virus to equate to an average infection (mostly in adults). This issue evens out over time, but it means the model may underestimate during back-to-school periods.

CDC: They describe the details of their process for standardizing data over time. It's very strong, much better than what most localized wastewater orgs or WWS do. It's a bit Dunning-Kruger to question basic wastewater scientists in doing the most fundamental components of their jobs, and the data continue to correlate >.90 with other metrics like Biobot. In comparing with other data, I take their estimates as spot on, but could also see arguments that they may underestimate transmission by 0-5%. It's something we always keep an eye on. Trust, but verify.

Transmission is magnitudes higher than much of the public realizes, so we focus on the big-picture view rather than quibbling over such issues that tend to balance out over time.

I hear @jlerollblues is considering weighting a model based on estimates of the proportion of infections in children. That's actually tougher to estimate than it sounds at first glance. You should key an eye on his models too and the work he and others are doing with the WHN.Estimating a "lull" the 1st week of November, but at an alarming 850k daily infections in the U.S.
PMC COVID-19 Forecasting Model, Sep 23, 2024
🧵 3/8

Zooming in from the big picture, here's the past year of the pandemic.

🔹1.1 million daily infections
🔹Bimodal peak (Aug 10 & 24) of 1.3 million daily infections
🔹50-60% of transmission happens on the back end of waves

Continue to educate family, friends, and co-workers. Look at how the wave descends much more gradually than is arose. Many infections to come, and to try to prevent! Also, most people are not monitoring wastewater. They keep track of the cumulative "anecdata" of people they know sick or diagnosed with Covid recently. In their mind, the peak will feel like late October, when the cumulative count has really built up. You may find people more open to listening during the next month.Annual graph. Shows transmission much higher than a year ago at 1.1 million daily infections today, but nowhere near the 1.9 million daily infections of last winter's peak. The wave is descending slower than it rose, which is a reminder than much transmission happens on the back end of waves.
Read 8 tweets
Mike Hoerger, PhD MSCR MBA Profile picture
Sep 10
PMC COVID-19 Forecasting Model, Sept 9, 2024
🧵1/7

Nationally, we appear to have passed the peak of our late-summer wave, and it's not pretty.

At peak:
🔹>1.3 million daily infections
🔹2.8% (1 in 36) actively infectious
🔹Transmission higher than 90.5% of the pandemic

We are showing a peak around Aug 10, but as you look closely at the graph and in later Tweets, you'll see it was bimodal, with near-identical transmission on Aug 10 and Aug 24.

The CDC consistently corrects historical data, so in hindsight, we might expect the official peak date to flip to the 24th, or for the stats on the 10th to jump higher.

We had expected that Friday's data release might show this was the largest summer peak all-time (by the slimmest of margins), but the prior week's data were retroactively corrected downward by about 5%.

This is a common occurrence, which is why it's important to focus on the big-picture forecast (very bad transmission the remainder of 2024) as opposed to minute details.

Let's walk through the details in this Thread....Figure shows the 9 waves of the U.S. COVID-19 pandemic. We are in the 5th-largest wave, and the 2nd largest summer wave. The statistics in the Tweet summarize the peak of the current wave.
PMC COVID-19 Forecasting Model, Sept 9, 2024
🧵2/7

The current year-over-year graph on Covid transmission is troubling. We just had the worst August of Covid transmission in the U.S.

We are likely to have our worst September, worst October, and potentially worst November of transmission.

We expect to bottom out around 850,000 daily infections in early November, before the winter surge picks up.

These new monthly records for Covid transmission are the consequence of #LaissezFairePublicHealth, especially the 1-day isolation policy, but more generally that public health officials are not describing transmission frankly and the need for multi-layered mitigation.Graph of year-over-year transmission. The current surge appears to have peaked, just under the daily peak of the 2022 summer wave, and is setting the stage for four months of monthly records in transmission, based on year-over-year monthly comparisons.
PMC COVID-19 Forecasting Model, Sept 9, 2024
🧵3/7

Zooming in, see the forest for the trees: About 74 days in a row with 1 million daily infections.

The peak date is somewhat arbitrary, and either Aug 10 or 24 may be estimated the peak in hindsight.Graph shows the prior year of transmission and 1-month forecast. Daily infections will remain >1 million for nearly another month, and are projected to reach 74 days in total. Once below 1 million, only expect daily infections to get down to about 850,000/day in early November, then get much worse.
Read 7 tweets

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