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Mike Hoerger, PhD MSCR MBA Profile picture
@michael_hoerger
Aug 1 • 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
Jul 25
PMC COVID-19 Forecast, Jul 25, 2024 (U.S.)

The U.S. is hovering around 900,000 daily infections.

Nearly 2% of the U.S. population is actively infectious with COVID. Ultimately, such infections are expected to result in >40,000 new daily #LongCovid cases.

#YallMasking?
1/CURRENT ESTIMATES FOR July 26, 2024 Wastewater Levels (copies/mL) 634 New Daily Cases 922,000 % of Population Infectious 1.93% (1 in 52 people) New Daily Long COVID Cases 4-WEEK FORECAST FOR August 23, 2024 Wastewater Levels (copies/mL) 668 (5% higher) New Daily Cases 934,000 % of Population Infectious 1.95% (1 in 51 people) New Daily Long COVID Cases 47,000 to 187,000
In the rising 9th U.S. Covid wave, we have higher transmission than 69% of the pandemic, lower than during 31% of the pandemic.

In a deck of cards, imagine the J, Q, K, & Ace as days with higher transmission, all other cards the days with lower transmission.
2/ There is more COVID-19 transmission today than during 69% of the pandemic. CURRENT ESTIMATES FOR July 26, 2024 Wastewater Levels (copies/mL) 634 New Daily Cases 922,000 % of Population Infectious 1.93% (1 in 52 people) New Daily Long COVID Cases 46,000 to 184,000 WEEKLY ESTIMATES FOR July 26, 2024 New Weekly Cases 6,500,000 New Weekly Long COVID Cases 323,000 to 1,291,000 2024 CUMULATIVE ESTIMATES AS OF July 26, 2024 Total 2024 Cases To Date 149,473,220 Total 2024 Long COVID Cases To Date 7,474,000 to 29,895,000
How many people will you interact with this week? Here are the chances at least one of those people is infectious with Covid.

20 people? --> 1 in 3 chance
100-300 on an airplane? --> 85-99% chance

Wear a well-fitting high-quality mask (respirator) to avoid breathing virus.
3/ How Does Risk Increase with More Social Contacts? Number of People | Chances Anyone is Infectious 1 1.9% 2 3.8% 3 5.7% 4 7.5% 5 9.3% 6 11.0% 7 12.7% 8 14.4% 9 16.1% 10 17.7% 15 25.3% 20 32.3% 25 38.6% 30 44.3% 35 49.4% 40 54.1% 50 62.2% 75 76.8% 100 85.7% 150 94.6% 200 98.0% 300 99.7% 400 >99.9% 500 >99.9%
Read 4 tweets
Mike Hoerger, PhD MSCR MBA Profile picture
Jul 20
Long COVID Risk Tables

You probably saw this week's NEJM article on #LongCOVID. We did a special section on it in this week's PMC COVID-19 Forecasting Report (pgs 6-8).


THREAD of tables. 🧵🔢

1/
Details:
Our model continues to provide estimates of Long COVID cases that will ultimately result from each day’s infections.

We provide a credible interval that 5-20% of infections will result in Long COVID.

This week, Al-Aly and colleagues reported in the New England Journal that in the more recent era of the pandemic, vaccinated individuals have a 3.5% chance of developing Long COVID from a particular infection.

They focused on medically documented new serious health conditions. We continue to view 5% as a useful lower bound for two reasons.

Long COVID chances were higher in unvaccinated individuals in their study, and there were no analyses based on time since last vaccination.

With many Americans still unvaccinated and many not vaccinated in the past year, the true estimate for a 2024 infection could well surpass 5% for a medically documented new serious health condition.

Moreover, Long COVID is a heterogeneous condition, and many cases are likely not medically documented, especially at the less debilitating end of the spectrum.

The following tables show the risk of ever developing Long COVID from an infection assuming 3.5%, 5.0%, and 20.0% rates.

These statistics document the seriousness of Long COVID with Americans getting infected nearly once a year (average of 12.5 months by our estimates).

However, it is also important to know that some effects are enduring, and others more likely to improve, so many with Long COVID will improve.

Many will also have repeated bouts of Long COVID, likely with different phenotypes.pmc19.com/data/
If you assume 3.5% of people get Long COVID per infection, the risk grows sizably with reinfections, which are happening nearly once per year. Avg of 9 infections/American the next decade.

In the previous Tweet, we note how 3.5% is an obvious underestimate.

2/ What are the chances of developing new Long COVID? Number of Infections | Chances of Long Covid 1 3.5% 2 6.9% 3 10.1% 4 13.3% 5 16.3% 6 19.2% 7 22.1% 8 24.8% 9 27.4% 10 30.0% 15 41.4% 20 51.0% 25 59.0% 30 65.7% 35 71.3% 40 76.0% 50 83.2% 75 93.1% 100 97.2% 150 99.5% 200 >99.9% 300 >99.9% 400 >99.9% 500 >99.9%
Based on that 3.5% estimate, a more realistic low-ball estimate of serious long COVID is 5-7%, given that not all serious new health conditions are documented in medical records & rates are higher among those unvaxxed or not recently vaxxed.

Bad decade (9 inf's) ahead.

3/ What are the chances of developing new Long COVID? Number of Infections | Chances of Long Covid 1 5.0% 2 9.8% 3 14.3% 4 18.5% 5 22.6% 6 26.5% 7 30.2% 8 33.7% 9 37.0% 10 40.1% 15 53.7% 20 64.2% 25 72.3% 30 78.5% 35 83.4% 40 87.1% 50 92.3% 75 97.9% 100 99.4% 150 >99.9% 200 >99.9% 300 >99.9% 400 >99.9% 500 >99.9%
Read 6 tweets
Mike Hoerger, PhD MSCR MBA Profile picture
Jun 28
PMC COVID-19 Forecast, June 28, 2024 (U.S.)

You've got about 1 good month left for higher risk medical and dental visits.

Expect 500,000 to 600,000 infections/day the next month -- in a summer "lull."

1/CURRENT ESTIMATES FOR June 28, 2024 Wastewater Levels (copies/mL) 367 New Daily Cases 534,000 % of Population Infectious 1.12% (1 in 90 people) New Daily Long COVID Cases 4-WEEK FORECAST FOR July 26, 2024 Wastewater Levels (copies/mL) 415 (13% higher) New Daily Cases 586,000 % of Population Infectious 1.23% (1 in 82 people) New Daily Long COVID Cases 29,000 to 117,000
PMC COVID-19 Forecast, June 28, 2024 (U.S.)

1.1% of the U.S. is actively infectious (1 in 90). We're looking at 3.7 million infections/week and 187,000+ resulting Long COVID cases/week.

That's 129 million infections in 2024 so far.

2/There is more COVID-19 transmission today than during 44% of the pandemic. CURRENT ESTIMATES FOR June 28, 2024 Wastewater Levels (copies/mL) 367 New Daily Cases 534,000 % of Population Infectious 1.12% (1 in 90 people) New Daily Long COVID Cases 27,000 to 107,000 WEEKLY ESTIMATES FOR June 28, 2024 New Weekly Cases 3,700,000 New Weekly Long COVID Cases 187,000 to 748,000 2024 CUMULATIVE ESTIMATES AS OF June 28, 2024 Total 2024 Cases To Date 129,801,250 Total 2024 Long COVID Cases To Date 6,490,000 to 25,960,000 4-WEEK FORECAST FOR July 26, 2024 Wastew...
PMC COVID-19 Forecast, June 28, 2024 (U.S.)

How does transmission compare to late June in past years?

2023: 1.9x higher today
2022: 2.3x higher in 2022 (BA.2 surge) than today
2021: 5.6x higher today
2020: 2.8x higher today

We're in a hot "lull" with #backtoschool soon.

3/Zoomed in version of "whole pandemic" graph from the prior Tweet. The rates show how transmission varies presently versus this time in prior years.
Read 6 tweets
Mike Hoerger, PhD MSCR MBA Profile picture
Apr 29
PMC COVID-19 Forecast, April 29, 2024 (U.S.)

Transmission continues to decline. About 1 in 161 people in the U.S. are infectious, the lowest levels since July 1. Transmission levels are higher than during 27% of the pandemic, but a good time to catch up on delayed care.
1/4 There is more COVID-19 transmission today than during 27.7% of the pandemic. CURRENT ESTIMATES FOR April 29, 2024 Wastewater Levels (copies/mL) 203 New Daily Cases 296,000 % of Population Infectious 0.62% (1 in 161 people) New Daily Long COVID Cases 15,000 to 59,000 WEEKLY ESTIMATES FOR April 29, 2024 New Weekly Cases 2,100,000 New Weekly Long COVID Cases 104,000 to 414,000 2024 CUMULATIVE ESTIMATES AS OF April 29, 2024 Total 2024 Cases To Date 105,544,710 Total 2024 Long COVID Cases To Date 5,277,000 to 21,109,000 4-WEEK FORECAST FOR May 27, 2024 Wa...
I have some concerns about Biobot's real-time data quality at the moment. Their real-time data have over-reported levels the past 8 weeks (11% last week, previously 6%, 10%, 7%, 5%, 9%, 4%, 5%) relative to later corrections. Huge bias!
2/4
Qualitatively, the over-reporting in real-time data lead me to believe there's a 50-50 chance we see a May "wavelet" versus continued decline for a couple months. Some of the county-level Biobot data seem implausible (e.g., levels of "3" in Mason County, WA, but others too).
3/4 Mason County, WA Levels of 3 copies/mL, per Biobot. About 1 in 10,000 actively infectious, if accurate.
Read 4 tweets
Mike Hoerger, PhD MSCR MBA Profile picture
Mar 1
31 Reasons Why the New 1-Day COVID Isolation Policy is Wrong

#1
Experts in modeling and testing know that people are infectious with COVID for an average of 7 days, with substantial variability around that average.

"31 Reasons Why the New 1-Day COVID Isolation Policy is Wrong"
#2
People use defense mechanisms to temporarily avoid the death anxiety evoked by thinking of COVID. The too-short 5-day iso was an example of this (see final example).

Such defenses provide temporary relief and are almost always harmful long-term.
#3
Dropping isolation policies to 1 day will predominantly harm people in poor-ventilation environments.

Restaurants have 35-50x less ventilation than the ASHRAE standards, so this will harm the service industry and unsuspecting “brunch class.”
Read 31 tweets
Mike Hoerger, PhD MSCR MBA Profile picture
Feb 29
PMC COVID-19 Forecast, Week of Feb 26, 2024
1 of 5 🧵

Forecast for the next month
Over the next month, we should see transmission fall from 790,000 infections/day toward more like a range of 200,000-450,000 infections per day, depending on better or worse scenarios.

That's "good" news in the relative sense for those putting off medical appointments the past 6 months, though still extremely high transmission in any objective sense.

See the online report for details on the models.

Surge in Context
At this point in the surge, it is clear that the peak transmission day was around December 27 (1.92 million/day), and the midpoint of “surging” infections (>1 million/day) was around January 9.

We are estimated to have had 85 total days with >1 million infections per day (November 28 through February 20) during the surge, though these numbers may still fluctuate with corrections the next few weeks.

The low-point leading into the surge was October 18 at 547,000 infections/day. Infections have been at “wave” levels (>500,000 infections/day or higher) since the onset of the late summer wave surpassed that milestone on July 27. We are estimated to dip below 500,000 infections/day around March 6.

This is very unfortunate timing because the medical facilities that enacted universal masking may end policies on March 1. Many were hoping for a period of lower transmission before such policies ended. As of today, the estimated low point for transmission is March 27 (348,000 infections/day), but the level and date are subject to much uncertainty.CURRENT ESTIMATES FOR February 26, 2024 Wastewater Levels (copies/mL) 546 New Daily Cases 794,000 % of Population Infectious 1.66% (1 in 60 people) New Daily Long COVID Cases 40,000 to 159,000 4-WEEK FORECAST FOR March 25, 2024 Wastewater Levels (copies/mL) 242 (-56% lower) New Daily Cases 353,000 % of Population Infectious 0.74% (1 in 135 people) New Daily Long COVID Cases 18,000 to 71,000
PMC COVID-19 Forecast, Week of Feb 26, 2024
2 of 5 🧵

Current State of the Pandemic
🔹73 million infections in the U.S. in 2024 (so far)
🔹790,000 daily infections
🔹1.66% (1 in 60) actively infectious
🔹40,000+ resulting #LongCOVID cases/day

Deeper Dive
Transmission is finally starting to decline again, and expect major declines the next four week.

U.S. wastewater levels indicate that COVID transmission is higher than during 58.4% of the days of the pandemic (down from 85.9% a week ago). Transmission is lower than 41.6% of the pandemic.

As we noted the past two weeks, we believed the post-peak hill was itself peaking on around February 7th and that last week’s slightly higher values might get retroactively corrected downward. That was, in fact, the case (the peak was the 7th), and transmission has fallen further since.

We are still at very high “wave” levels, but no longer “surging” at over a million infections/day. The big picture remains very bad, but this is good news for people putting off medical appointments for months.There is more COVID-19 transmission today than during 58.4% of the pandemic. CURRENT ESTIMATES FOR February 26, 2024 Wastewater Levels (copies/mL) 546 New Daily Cases 794,000 % of Population Infectious 1.66% (1 in 60 people) New Daily Long COVID Cases 40,000 to 159,000 WEEKLY ESTIMATES FOR February 26, 2024 New Weekly Cases 5,600,000 New Weekly Long COVID Cases 278,000 to 1,112,000 2024 CUMULATIVE ESTIMATES AS OF February 26, 2024 Total 2024 Cases To Date 73,585,610 Total 2024 Long COVID Cases To Date 3,679,000 to 14,717,000
PMC COVID-19 Forecast, Week of Feb 26, 2024
3 of 5 🧵

Risks in Group Settings
Although transmission is falling, it's easy to get distracted by the relative changes and ignore that the absolute risk remains high, especially in large groups with limited or no mitigation.

In a group of 10, there's a 15% at least one person is actively infectious. In a group of 30, it's a 40% chance, and so forth. Almost nobody would take those chances of a serious illness if informed and capable of grappling with the seriousness of that risk without becoming defensive. Unfortunately, a lot of institutions are pushing minimizer narratives if not directly forcing students and workers into more dangerous settings.How Does Risk Increase with More Social Contacts? Number of People | Chances Anyone is Infectious 1 1.7% 2 3.3% 3 4.9% 4 6.5% 5 8.0% 6 9.6% 7 11.1% 8 12.5% 9 14.0% 10 15.4% 15 22.2% 20 28.5% 25 34.2% 30 39.5% 35 44.4% 40 48.8% 50 56.7% 75 71.5% 100 81.3% 150 91.9% 200 96.5% 300 99.3% 400 99.9% 500 >99.9%
Read 5 tweets

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