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Mike Hoerger, PhD MSCR MBA Profile picture
@michael_hoerger
Aug 1, 2024 • 26 tweets • 7 min read • Read on X
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Slide Deck - Discussion of "Masking Policies at National Cancer Institute–Designated Cancer Centers During Winter 2023 to 2024 COVID-19 Surge"

x.com/i/spaces/1OdKr…
2/ “It takes 15 years to translate beneficial interventions into widespread practice. We need to improve understanding of the airborne transmission of COVID to accelerate that timeline. Patients cannot wait.” -Michael Hoerger, PhD, MSCR, MBA Medical Scientist
3/ “The JAMA-NO Masking Policy Study Defines Universal Masking in Healthcare as a Key Quality Indicator During COVID-19 Waves” -Michael Hoerger, PhD, MSCR, MBA Medical Scientist COVID is extremely dangerous for people with known and unknown medical vulnerabilities Transmission remains ongoing We examined masking policies at the best and best-of-the-best cancer centers during the 2023-24 winter surge Extremely high rates of universal masking policies at the best-of-the-best centers Masking is an indicator of healthcare quality Tips for how to use these findings
4/
Shows the "during COVID" graph from RT. Descriptions say Transmission Persists, Entering a 9th U.S. Wave Americans are getting infected an average of approximately every 12.5 months. This is not a sustainable 10-year plan.
5/
 "Scenario planning: a framework for mitigating uncertainty in implementing strategic behavioral medicine initiatives during the COVID-19 pandemic"

ncbi.nlm.nih.gov/pmc/articles/P…
Figure from our COVID scenario planning paper, originally for a PCORI grant to study the pandemic impact on food service workers. Caption: In 2020, we defined the worst-case pandemic scenario as “stuck in a nightmare” in an eventually funded grant and publication. Society is using denial to pretend we are in a best-case scenario, when we approach the worst-case scenario that would be allowed to persist. This denial creates a dangerous world for people with cancer, other immunocompromising conditions, and anyone avoiding Long COVID.
6/
Cancer is a COVID-19 risk factor. 40% of Americans will get cancer Cancer is a COVID-19 Risk Factor Lower vaccine response, higher infection risk Treatment delays of weeks to months Greater risk of Long COVID, severe outcomes, hospitalization, and death
7/ Map of the U.S. showing NCI-designated cancer center locations
8/ The Masking Policy Study Pandemic Mitigation Collaborative (PMC) forecasting model identified the winter 2023-24 surge as the 2nd largest and predicted the midpoint 7th annual MLK Day Writing Retreat in Health Disparities Reviewed websites/called all National Cancer Institute (NCI) designated cancer centers to identify policies on masking – surprisingly good data quality Examined geography and indicators of quality as policy predictors
9/ study examined census region and quality indicators
10/
 NCI-designated cancer centers comprise approximately 4% of U.S. cancer centers.

At the NCI-designated cancer centers, about 85% of those in the top quintile had universal masking policies in winter 2023-24, as did about 34% of other NCI-designated centers. Figure, summarized in tweet
11/
 42% of NCI-designated cancer centers had universal masking policies during the winter 2023-24 surge, but numbers were significantly higher in the northeast and at centers with higher quality indicators. 58% had any masking policy, 42% had a universal masking policy. Table shows higher proportions in the NE and at centers with higher quality ratings.
12/
 The Midwest and South lagged on masks in healthcare, despite higher overall transmission during the winter 2023-24 surge. CDC graph of regional C19 transmission the past year. Midwest had more transmission (early). South had more transmission (late).
13/
 Apply the "Diffusion of Innovation" framework to organizational changes surrounding airborne illness transmission Bell curve showing the "Diffusion of Innovation" model innovators, early adopters, early majority, late majority, laggards
14/ Healthcare - Recommendations for “Leaders” Lead: Explain policy decision-making processes Improve compliance Transition from “masking” to well-fitting high-quality (N95 or better) masks Follow CDC transmission data, actuarial data, forecasting data to re-evaluate policies during late-summer waves and “lulls” Launch community outreach and engagement programs to get patients and families high-quality well-fitting masks, air purifiers, tests, and information
15/
COVI-CAN
The Covid Defense Kit for patients undergoing cancer treatment and their families.


COVI-CAN U.S. cancer patients and families get 2 air purifiers, 50 high-quality masks, 5 tests, and an educational booklet Picture shows me demonstrating elements of the kit
16/ Healthcare – Rec’s for the Well-Intentioned Need consistency and better evidence synthesis Understand the importance of universal precautions Understand differences in mask quality and fit Follow CDC transmission data, actuarial data, forecasting data Educate patients, staff, and clinicians – cite this article Focus on buy-in, funding, politics, high-ACH individual office spaces for clinicians and staff to demask safely, safer dining options
17/ Healthcare - Rec’s for the Vast Majority Understand COVID and many illnesses are airborne Understand concrete examples: lingering, shared spaces, transmission beyond 6 ft, breathing as an aerosol-generating procedure (AGP) Understand the importance of universal masking, mask quality, mask fit, air cleaning Understand fundamentals: COVID is not “over,” we do not refer to timepoints by perceptions of disease prevalence (during COVID), repeat viral infections are bad, not “like a cold or the flu,” vax and relax is insufficient, long-term effects more important than acute infection, wastewate...
18/
 "Airborne transmission of respiratory viruses"

science.org/doi/10.1126/sc…
title and figures from "Airborne transmission of respiratory viruses"
19/
 "Back to the future: Redefining 'universal precautions' to include masking for all patient encounters" title and table 1 from "Back to the future: Redefining 'universal precautions' to include masking for all patient encounters" Table lists numerous illnesses transmitted by airborne. Article recommends masks. 2nd author is from NIH
20/
"Masks and respirators for prevention of respiratory infections: a state of the science review"
pubmed.ncbi.nlm.nih.gov/38775460/
title and abstract from "Masks and respirators for prevention of respiratory infections: a state of the science review" First, there is strong and consistent evidence for airborne transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and other respiratory pathogens. Second, masks are, if correctly and consistently worn, effective in reducing transmission of respiratory diseases and show a dose-response effect. Third, respirators are significantly more effective than medical or cloth masks. Fourth, mask mandates are, overall, effective in reducing community ...
21/ Scientists - Recommendations Plan the grant application you believe will shift policy Cite this paper – play up the “equipoise” with the curious teaser that the top cancer centers for some mysterious reason mask Cite the CDC data and PMC dashboard for public health significance Use the PMC dashboard to plan studies around high transmission Reach out to Mike for custom specialty statistics for serious grant applications and papers
22/ Patients, Families, & the General Public Cite the paper in handouts you’re already preparing Print and share the article with clinicians, health administrators, patient advocates, politicians, and other decision makers Business cards, t-shirts, hats, bags, stickers, flyers, posters Anonymous mailings Discussions with insurers, employers, unions, and legal teams Focus on the 85% figure Draw regional contrasts where helpful NE = leaders, South/Midwest = struggling, West = complacent
23/ “It takes 15 years to translate beneficial interventions into widespread practice. We need to improve understanding of the airborne transmission of COVID to accelerate that timeline. Patients cannot wait.” -Michael Hoerger, PhD, MSCR, MBA Medical Scientist
24/ Closing announcement: "Sunsetting" v1 of the PMC Dashboard soon
25/ Questions? Post your questions as a comment on this final Tweet. We can focus on recurring themes if helpful.

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More from @michael_hoerger

Mike Hoerger, PhD MSCR MBA Profile picture
Feb 26
1) Mardi Gras 2020 was 5 years ago today. ⚜️

It was before the pandemic declaration, before the federal government recommended masking.

COVlD spread quickly through New Orleans, leading to one of the highest mortality rates per capita in the U.S.... Timeline showing Mardi Gras 2020 just 4 days before the first known reported death of C19 in the U.S. Note. "Peak" diagnoses refers to the peak of the 1st wave.
2) New Orleans service workers were disproportionately hit by the early pandemic. Many died. Many developed #LongCOVID at the time or have now through repeat infections. Many have switched to other sectors....

3) The sad fact is that many service workers are continuing to get #LongCOVID through repeat infections today because the pandemic is ongoing and many restaurants have high occupant density and horrendous air quality....

Read 4 tweets
Mike Hoerger, PhD MSCR MBA Profile picture
Feb 17
1) PMC COVlD Dashboard, Feb 17, 2025 (U.S.)

🔥1 in 72 actively infectious
🔥Sustained high transmission
🔥30 states in high/very high transmission (CDC)
🔥3x the transmission of Feb 2021
🔥668,000 daily infections
🔥Only 1 in 28 cases reportedGraph shows 10 waves of the pandemic. Tables summarized partially in post. Additionally, transmission is higher than during 59% of the pandemic. How Does Risk Increase with More Social Contacts? Number of People | Chances anyone is infectious 1 1.4% 2 2.8% 3 4.1% 4 5.5% 5 6.8% 6 8.1% 7 9.4% 8 10.6% 9 11.9% 10 13.1% 15 19.0% 20 24.5% 25 29.7% 30 34.4% 35 38.9% 40 43.0% 50 50.5% 75 65.2% 100 75.5% 300 98.5%
2) PMC COVlD Dashboard, Feb 17, 2025 (U.S.)

This is a mid-sized wave, meaning substantial transmission. Notice that transmission remains steady at high rates.

Expect steady or slightly declining transmission, unless the real-time data are retroactively corrected.Two graphs, showing year-over-year transmission and the forecast, summarized in the post.
3) PMC COVlD Dashboard, Feb 17, 2025 (U.S.)

Notice that 30 states remain in high/very high transmission, per CDC categories.

This is the same as last week. Transmission is 3x higher than in Feb 2021, when people were taking more precautions around masking and testing.Transmission heat map and CDC line graph of regional variation in transmission.
Read 5 tweets
Mike Hoerger, PhD MSCR MBA Profile picture
Feb 11
1) A lot of high-risk/aware patients I talk to -- mostly getting cancer treatment -- tend to protect themselves from infection by staying home more.

In the work we do, we help patients to understand that a well-fitting high-quality mask can allow them to attend events safely.
2) These are some tips for finding a well-fitting mask among common options in the U.S. and Canada.

3) Here's a more comprehensive diagram of masks that fit most. Aside from #5, these are widely available.

*#5 (Aegle) was the first N95 widely available during the ongoing pandemic for <$1. Hard to find these days, but I gave some to students.
Read 7 tweets
Mike Hoerger, PhD MSCR MBA Profile picture
Jan 28
1) PMC COVID Dashboard for the Week of Jan 27, 2025 (U.S.)

🔹1 in 108 actively infectious
🔹3.1 million weekly infections
🔹>150,000 weekly resulting Long Covid conditions Current Levels for Jan 27, 2025 % of the Population Infectious 0.9% (1 in 108) New Daily Infections 443,000 New Weekly Infections 3,101,000 Resulting Weekly Long COVID Cases 155,000 to 620,000 Monthly Forecast Average % of the Population Infectious 0.9% (1 in 106) Average New Daily Infections 452,933 New Infections During the Next Month 13,588,000 Resulting Monthly Long COVID Cases 679,000 to 2,718,000 Running Totals Infections Nationwide in 2025 18,779,000 Average Number of Infections Per Person All-Time, U.S. 3.60 There is more COVID-19 transmission today than during 41.9% of the pan...
2) We predicted the wave peak would be 0.8 to 1.3 million across various forecasts. We presently have it at 0.9-1.0 million, though retroactive corrections can change that. The WHN also runs an excellent model, with a peak estimated at 1.3 million.
whn.global/estimation-of-…
3) Approx 1 million daily infections is quite serious. This is a far cry from the various #nothingburger predictions, and the Monday morning quarterbacks who in hindsight minimize U.S. infections, Long Covid, & disability.

Perhaps they have social media revenue COIs. I don't.
Read 9 tweets
Mike Hoerger, PhD MSCR MBA Profile picture
Jan 20
1) PMC COVID-19 Forecast for Jan 20, 2025 (U.S.)

If we are lucky, the 10th wave has peaked, likely in the 0.9-1.1 million daily infections range, barring significant retroactive corrections.

Over the next month, we should still see about 14 million infections, resulting in 700K to 2.8 million new conditions and enduring symptoms under the umbrella of #LongCOVID. This is simply your reminder than transmission remains high on the back on of a wave.

Regarding the peak, there were huge retroactive downward corrections, especially in Oregon. The CDC data originally showed one of the largest waves there all-time, and then corrected it to say a complete lull the whole time. Once the Biobot data get updated, we may see the peak date change by a week, or jump a bit higher than what you see in the main figure.

What you see in the far end of the forecast is unlikely to be a "high lull," but rather an average between a low lull versus a sustained post-peak haunch of lingering transmission. So, keep an eye on the data. If you're putting off a non-urgent medical appointment, we could get into relatively lower transmission in the next 4-8 weeks. What has me concerned is a sneak-peek of @jlerollblues's long-term forecast indicating a clear possibility of an earlier "mid-year" wave than usual, perhaps even in April. We're still getting pretty lucky on the viral evolution front, but the longer that persists, in absent of major policy change, the bigger the wave we could get. It's a very important time to stay tuned.

Caveats: No data from Biobot in weeks (20% model weight). The California wildfires and pending severe storms in the Deep South are wildcards for transmission. School-based transmission could pick up, but to get a higher peak, transmission would need to pick up much faster in the South and West than in the Midwest and North (unlikely).

In the report, I note that PMC will persist even if the CDC drops or scales back their surveillance program. Also, the most two recent "odd" waves have helped clarify how to handle historical data, and a minor update to the model should help with future atypical waves. If time permits, we will fine-tune those changes further, but there are always more battles on the Covid front than we're able to fight. We also provide a link and light commentary on our recent pre-print showing what our current case estimation model for estimating present/prior daily infections has performed well, and why a lot of other models (BNO, JP, CDC) are underestimates.

Info for new readers:

For those unfamiliar with the PMC model, find full weekly reports for the past 1.5 years 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 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, NBC, and CNN. See pgs 11-13 at the above link.

#MaskUp #VaxUp #CleanTheAir #RapidTestCurrent Levels for Jan 20, 2025 % of the Population Infectious 1.1% (1 in 87) New Daily Infections 547,000 New Weekly Infections 3,829,000 Resulting Weekly Long COVID Cases 191,000 to 766,000 Monthly Forecast Average % of the Population Infectious 1.0% (1 in 102) Average New Daily Infections 466,700 New Infections During the Next Month 14,001,000 Resulting Monthly Long COVID Cases 700,000 to 2,800,000 Running Totals Infections Nationwide in 2025 15,281,000 Average Number of Infections Per Person All-Time, U.S. 3.59 How Does Risk Increase with More Social Contacts? Number of People | Ch...
2) Here is the issue of Oregon I noted, with the "disappearing surge" in the CDC data. By that, I don't mean a surge that declined quickly. I mean, the CDC saying there was a huge surge in OR and then saying it was a lull the whole time. Baffling.

3) It's an important time to reflect that we have never had a federal Covid response commensurate with the magnitude of this $14-billion problem in the U.S.

3/11/20-1/19/21 = 290K infections/day (91 million total)

1/20/21-1/19/25 = 759K infections/day (1.1 billion total)

10 waves and >1 billion estimated infections in 5 years.

We have never had a well-conceived multi-layered mitigation strategy, and the strategy we have had has often underachieved due to insufficient operational management.

This places society at greater systemic risk from repeat-infection Long COVID. The approach is unreasonable to people with primary immunodeficiencies, cancer, organ transplants, kidney disease, type 1 and 2 diabetes, Long COVID, pregnancy, and many other conditions. Upwards of 2 million older adults in the U.S. are in early retirement, with the labor participation rate still well below pre-pandemic levels, and older adults almost wholly accounting for that presently. The children that were pretended to be magically shielded from Covid are not doing well on the cumulative infection front either.

I do not see that changing. I hope the many scientists and public health officials biting their tongues the past 4 years now feel liberated to speak up on Covid. Note that state and regional organizations and individuals were a big reason why transmission was better under control in year 1 of the pandemic.

Note that our statistics are estimated "true" cases based on the PMC model, not reported cases, which are vast undercounts (ascertainment bias). See the first Tweet for info on our model, including our website, which contains hundreds of pages of reports (pmc19.com/data), or read our recent pre-print showing the high accuracy of our case estimation model, to the extent that is ascertainable (researchsquare.com/article/rs-578…). To believe the true infection estimates are lower than these figures, one would have to suspend cognitive reasoning and merely assume transmission happens at vastly lower rates in the U.S. than those documented through the most-rigorous testing-based program in Europe.figure showing the 10 Covid waves (U.S.)
Read 5 tweets
Mike Hoerger, PhD MSCR MBA Profile picture
Jan 6
1) PMC COVID-19 Dashboard, Jan 6, 2025 (U.S.)

📈1 in 49 people actively infectious
🔥Nearly 1 million daily infections
🎲About a 50-50 chance someone has COVID in a large class if typical risk and no testing/isolating
🏥300,000+ new Long Covid conditions per week

The infections are likely minor underestimates. AZ and OR did not report this week. They were surging, so the lack of data brings down the average. As well, the model gives 80% weight to CDC wastewater data and 20% weight to Biobot, but Biobot took the week off, so this is dependent on observed changes in the CDC data.

It would be wise to add multiple imputation into the model to account for all the non-random missingness during surges, but I won't likely get to that anytime soon.

The peak is looking more and more like 1.4 million daily infections, but I wouldn't be surprised if it's earlier than shown and more like 1.3 million, based on the pattern of retroactive data corrections last winter. If the real-time data really stink, it could come in closer to 1.0-1.1 million. To top 1.6 million, we would probably need some serious immune escape that at present I just don't see happening. However, in past winters, transmission was declining nationally in early/mid January, and back-to-school is a wild card.

Info for new readers:

For those unfamiliar with the PMC model, find full weekly reports for the past 1.5 years 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 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, NBC, and CNN. See pgs 11-13 at the above link.

We will have a pre-print out in the next week or so documenting very compelling evidence for the validity of using wastewater to estimate case rates. Forecasting is challenging in the context of the current viral evolution, but the real-time estimates of cases are impressively accurate to the best we can evaluate it.

#MaskUp #VaxUp #CleanTheAir #RapidTestCurrent Levels for Jan 6, 2025 % of the Population Infectious 2.1% (1 in 49) New Daily Infections 980,000 New Weekly Infections 6,860,000 Resulting Weekly Long COVID Cases 343,000 to 1,372,000 Monthly Forecast Average % of the Population Infectious 2.7% (1 in 38) Average New Daily Infections 1,272,833 New Infections During the Next Month 38,185,000 Resulting Monthly Long COVID Cases 1,909,000 to 7,637,000 Running Totals Infections Nationwide in 2025 5,468,000 Average Number of Infections Per Person All-Time, U.S. 3.55 How Does Risk Increase with More Social Contacts? Number of people |...
2) PMC COVID-19 Dashboard, Jan 6, 2025 (U.S.)

We're in the 10th wave of the pandemic (1st graph), and transmission this year has picked up atypically late, while coming on strong (2nd graph).Two graphs, summarized in tweet
3) PMC COVID-19 Dashboard, Jan 6, 2025 (U.S.)

Note that sputtering in the West's rise is likely an aberration, as surging OR and AZ did not provide data this week.

Read 5 tweets

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