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# epidemiology

Wellness

## The reassuring math explaining COVID hospitalization percentages for vaccinated people

As if dealing with an ever-changing understanding of the novel coronavirus over the past year and a half hasn't been enough, we've also had to try to understand the math behind the data analysis, which for some of us (hi, English major here) is a nightmare.

It's vitally important that we understand these numbers, though, because misinformation peddlers are using them to push misconceptions about vaccines. And even though the math isn't actually that complicated, those of us who aren't particularly mathematically inclined may read headlines like "50% of COVID patients in XX hospital are fully vaccinated" and find ourselves alarmed. Wasn't the vaccine supposed to prevent hospitalizations? If half of the people in the hospital are vaccinated, doesn't that mean the vaccine makes no difference?

Well, no. That's not at all what it means, and here's why. It's all about the denominators.

On a super basic level: 2 = 2, but 2 out of 20 is not the same as 2 out of 80. If 4 people are hospitalized, 2 vaccinated and 2 not vaccinated, in an area with an 80% vaccination rate, it's not a meaningful measurement to say that half of the hospitalizations are in vaccinated people. Your chances of hospitalization with the vaccination are significantly lower because of the denominator.

Biostatistician Lucy D'Agostino McGowan simplified why the percent vaccinated in hospitalizations numbers aren't as scary as they sound with some helpful visuals in a Twitter thread.

The director of the Maine CDC, Nirav D. Shah, gave an even more thorough explanation for those who actually want to wade a little deeper into the statistical waters.

He wrote:

"It's important to consider the full picture when interpreting data on things like the % of people fully vaccinated who are hospitalized with #COVID19, or the fact that 74% of the cases in the P-town outbreak were fully vaccinated.

I have seen folks express concern upon learning, for example, that 45% of people hospitalized w/COVID19 are vaccinated.

"But I thought the vaccine keeps you out of the hospital? Is this evidence that vaccines aren't working?" No, it is not. I'll walk through why here.

First, some basic assumptions. There are two Worlds, each with 1M people. And we'll consider the same infectious disease affecting each World, with the parameters below.

There is also a vaccine, with the effectiveness parameters noted below. These could all be changed.In World 1, 50% of the population has been vaccinated against the disease. Out of the 1M people, there are 30,000 infections and 2525 hospitalizations.

Among vaccinated folks, 25 end up in the hospital. The other 2500 hospitalized are UNvaccinated.World 2 is different: 90% of the population is vaccinated.

Here, there are only 14,000 cases. And only 545 people are hospitalized in total.

BUT, 45 of the hospitalized are vaccinated! Compare that with only 25 vaccinated folks in the hospital in World 1.What is going on?

How could it be that, in a World with 90% of the population vaccinated, 20 *more* vaccinated people are hospitalized with the disease (45 vs. 25?)? Is the vaccine not working in World 2?

It's important to compare World 1 and World 2 side by side.

First, note that the case rate in World 2 (90% vaccinated) is far lower than in World 1 (50%). The vaccine is working.

Second, the hospitalization RATE is also far lower in World 2: 545/million vs. 2525/mil.But because there are simply more vaccinated people in World 2, something that affects them at the same rate as others (hospitalization) will generate more cases, numerically.

Indeed, the % of all hospitalized who are fully vaccinated is HIGHER in World 2 than in World 1.In World 2 (90%), 8.25% of all those in the hospital are vaccinated. But in World 1 (50%), it's only 1%!

This is NOT evidence that the vaccines are ineffective. It is a function of the fact that there are simply more vaccinated folks in World 2 relative to unvaccinated.

The question to ask yourself is this: which world would you rather be in?

For that, you would look to the hospitalization rate: 545 vs. 2525/million. World 2, with its higher vaccination rate, is preferable, given that it experiences 1980 fewer hospitalizations. In World 1, fewer people are vaccinated, so their rate of hospitalization is just lower.

Where else does this (common) phenomenon occur?

For a stark example, consider this: what % of skydiving accidents occur in people who were wearing a parachute? Probably 100%.

Are parachutes not effective? They are. But the baseline rate of parachute wearing among those who sky dive is 100%.

Another example: what percentage of fatal car accidents occur in people who were wearing a seat belt? It's about 52%.

Does that mean the effectiveness of seat belts is a coin flip? No, the baseline rate matters. Seat belt usage is around 85%. As with so many things, where you end up depends on the baseline rate of where you started.

Lots of vaccinated folks are being hospitalized with COVID because there are a growing number of vaccinated folks. But the RATE of total hospitalizations is going down. That's good. Similarly, in P-town, 74% (346) of the cases were among vaccinated folks.

But there, what percentage of folks were vaccinated vs. unvaccinated? If the baseline rate of vaccinated was sky high, then this finding is entirely predictable. This is a common theme in epidemiology and statistics. Once you know to look for it, it jumps out all over the place. But without the context around background rates, denominators, etc., it's easy to scare yourself and make incorrect decisions.

Another example: imagine World 3, also with 1M people. 999,999 are vaccinated.

Two cases of COVID occur. One in the unvaccinated person. The other in a vaccinated person.

So 50% of new COVID cases are in the vaccinated. Really? Yes, but deceiving. Denominators matter."

Denominators matter. Even those of us who aren't mathematicians or statisticians can understand that, but we do need media reports to be clear about it; otherwise, we end up with people believing that the vaccines don't do much.

We also need to remember that data is always being gathered and that our understanding of this virus, the vaccines, and how best to balance safety measures and other needs will continue to evolve. The constant shifts are hard, but such is the nature of a novel viral pandemic, and it looks like we're still going to be in it for a while.

Wellness

## A Starbucks barista's reaction to a customer's anti-mask, anti-BLM rant was perfection

Eight months into the pandemic, you'd think people would have the basics figured out. Sure, there was some confusion in the beginning as to whether or not masks were going to help, but that was months ago (which might as well be years in pandemic time). Plenty of studies have shown that face masks are an effective way to limit the spread of the virus and public health officials say universal masking is one of the keys to being able to safely resume some normal activities.

Normal activities include things like getting a coffee at Starbucks, but a viral video of a barista's encounter with an anti-masker shows why the U.S. will likely be living in the worst of both worlds—massive spread and economic woe—for the foreseeable future.

Alex Beckom works at a Starbucks in Santee, California and shared a video taken after a woman pulled down her "Trump 2020" mask to ask the 19-year-old barista a question, pulled it back up when the barista asked her to, then pulled it down again.

All Beckom did was inform the woman that she needed to keep her mask on, and the scene turned into the woman throwing a fit. She claimed that she didn't have to listen to the barista because "this is America." She said the virus (or the pandemic, or the mask order—it's not clear) is "a hoax." And she berated Black Lives Matter, which had nothing whatsoever to do with the exchange, other than Beckom existing in front of her in her Black skin.

Beckom remained completely professional and friendly throughout the bizarre interchange, even after the woman accused her of discriminating against her for being a Trump supporter, and even after the woman said "F*ck Black Lives Matter," and then yelled the same thing again as she left the store.

"If she thinks she's being discriminated against, that's on her," Beckom told 10 News, San Diego's ABC affiliate. "I never brought up anything about her politics ... I wasn't even angry. I was just like, 'Why is this happening?'"

Beckom had every right to ask the woman to keep her mask on, both due to company policy and the state of California mandate. And no one would blame Beckom if she'd had a more emotional or forceful response considering this woman's rude and inappropriate behavior, but the contrast of her calm reaction beautifully highlighted how off-the-rails the woman's own response was.

The video has had more than 4 million views since Beckom shared it on Sunday, and people have praised the dignity and grace with which the barista handled the situation.

"I think it's important to show this type of behavior shouldn't be normalized and shouldn't be acceptable ..." Beckom told 10 News. "As this behavior continues, the cycle continues, and we need to get this cycle to stop."

Indeed, we do need to get this cycle to stop. People like this woman are partially why the U.S. is in the dismal state that we're in with the coronavirus pandemic. Calling it a hoax, refusing to keep her mask on, berating a lovely young woman who is just doing her job—these kinds of videos are so old, but so indicative of where we are.

But Beckom's response is also an indicator that there is hope to be had in all of this madness. To have such presence of mind and maturity at 19 years old is impressive, and the more we see people doing the right thing, the better. Beckom represents the millions of Americans who work with the public and have to put up with people's nonsense. It's heartening to see someone so young handling it so well.

Keep up the great work, Alex. (And hey Starbucks, maybe give that woman a raise. In the meantime, here's a GoFundMe if you want to give her a tip for her excellent customer service.)

Wellness

## The CDC says 6% of COVID deaths are only from COVID. Doctors explain what that really means.

As seemingly happens every week during the pandemic, misinformation has been floating around about some statistics the CDC shared on its website. This time, it stems from a now-removed tweet that President Trump retweeted from a QAnon follower (yup), which claims that the CDC "quietly" added some data to their website to clarify that only 6% of COVID-19 deaths were a result of COVID alone, whereas 94% of them included other "serious illnesses" as causes of death.

The tweet used this statistic to make it seem that COVID had really only killed around 9,000 people. That's not at all what it means.

First of all here's what the CDC website actually states: "For 6% of the deaths, COVID-19 was the only cause mentioned. For deaths with conditions or causes in addition to COVID-19, on average, there were 2.6 additional conditions or causes per death."

Many experts have weighed in on the confusion to set the record straight.

Dr. Zubin Damania is a hospitalist (a dedicated in-patient physician who works exclusively in a hospital) who also has his own show where he discusses all things medical. One of his hallmarks is trying to separate politics from medical fact, which theoretically should make him a refreshing source no matter where you land on the political spectrum.

He explains in a video how death certificates are filled out and why "additional conditions or causes" doesn't in any way negate a death from COVID-19. Basically, this data doesn't tell us anything we didn't already know, but the political spin to make it sound like this information is some kind of bombshell is simply not sound science.

As Dr. Damania points out, you can make all the arguments against lockdowns or express your opinion that the economic sacrifices don't outweigh the cost in lives or whatever without misrepresenting the science and the facts.

That CDC 6% COVID Death Rate, Explainedwww.youtube.com

If you prefer to read a news article about why the 6% statistic doesn't mean what some people are saying it means, here's a thorough article that explains the whole thing.

If you prefer the brevity of a TikTok, here you go:

@dr.noc BEWARE the armchair epidemiologists and their misguided theories. ##covid19 ##science ##coronavirus ##medicine ##nursing ##outrage
♬ original sound - dr.noc

Here's a Facebook post from an epidemiologist:

And how about a Twitter thread from an oncologist and editor of a cancer journal, who surely knows a thing or two about death statistics? He summed it up perhaps more succinctly than anyone.

"600,000 die of cancer each year. 95% likely have comorbidities. Doesn't mean cancer was not the cause of their death."

Bottom line, COVID-19 has killed more than 180,000 Americans. Just like with every other death from disease, other comorbidities are listed on death certificates. You can look at the WHO instructions for how to list causes of death with COVID-19 here. (Scroll down to page 3 to see a death certificate filled out correctly, in which COVID-19 led to acute respiratory distress and pneumonia, and how all three are listed.) Nothing about these stats is new or shocking information.

Popular

## 'We can virtually eliminate the virus any time we decide to.' Andy Slavitt explains how

True
Firefox

The U.S. is an outlier among developed nations in our handling of the coronavirus pandemic. While other countries have gone through rough outbreaks, none have the sustained growth in cases that the U.S. is seeing. Rather than try to control the outbreak so we can somewhat resume normal life, Americans seem to have decided to continue with normal life during a pandemic that's already killed close to 150,000 Americans and given at least a million more long-term health problems. From conspiracy theories to partisan bickering to "the gov't can't tell me what to do" individualism, the U.S. is a hot mess on the pandemic front, and the coronavirus is thriving off of our disunity.

But it doesn't have to be this way. Other countries have proven that it is possible to get a hold of this thing and keep it from running rampant. As former Acting Administrator of the Centers for Medicare and Medicaid Services and Senior Adviser to the Bipartisan Policy Center Andy Slavitt explains, we could nip the pandemic in the bud in a matter of weeks if we can just agree to do it.

"COVID Update July 26: We can virtually eliminate the virus any time we decide to. We can be back to a reasonably normal existence: schools, travel, job growth, safer nursing homes & other settings. And we could do it in a matter of weeks. If we want to."

He pointed out that New Zealand managed to completely eliminate the virus with its decisive, unified approach. And for those who would say that's easier to do on an island, he also pointed to Germany, which had an outbreak for a bit, but got it under control.

He also pointed to Italy, France, and Spain, who had it bad around the same time we did, but managed to get their outbreaks under control, as most developed nations—and even many less developed nations—have.

"But don't tell me the U.S. can't take action if we want to," he wrote. "And we can't face the families of 150,000 people who didn't have to die & tell them this had to happen. And I think it's why our national political leaders won't go near these families & the grieving process."

Then he offered the good news: "We are always 4-6 weeks from being able to do what countries around the world have done."

But we have to go all in, or as he says, "throw the kitchen sink at COVID-19 in the U.S." None of this half-ass shut down, let people do whatever they feel like business. Slavitt defines the kitchen sink as:

1. Start with universal mask wearing. We didn't do this in Mar-April and let's chalk it up to faulty instructions. But we know better now.

2. Keep the bars & restaurants & churches & transit closed. All hot spots.

3. Prohibit interstate travel.

4. Prohibit travel into the country (no one will let us into their country so that shouldn't be hard).

5. Have hotels set up to allow people with symptoms to isolate from their families at no cost.

6. Instead of 50% lockdown (which is what we did in March in April), let's say it's a 90% lockdown.

Naturally, that would mean things would be tight and tough for a few weeks. We'd need the government to help bridge the financial gap. But we could do it.

As Slavitt pointed out, "Our grandparents who lived through a decade long depression, a 6 year world war, or whatever hardship they faced in their country would tell us we would make it."

Slavitt explained how we could even form "friend & family bubbles" like the NBA has successfully done.

At first, cases and deaths would continue to rise and people would continue to die, because there's always a lag.

And because of that, the "COVID truthers would have a field day, tweeting every day the same routine" about how the lockdown wasn't working and the government is fascist and the numbers are skewed. "But if someone took Trump's phone, it would help," he added.

Then, after a few weeks, the R value—the rate at which the infection reproduces—of the virus would drop drastically. "If you have 60,000 cases in your community, in 50 days, it would drop to 58. 6000 becomes 6. 600 becomes 1."

This is the exponential math that is a hallmark of epidemiology. The idea isn't to get to zero, but to get cases down low enough to be able to implement the testing, contact tracing, and isolating that keeps spread low even during a reopening—but which can only be done when numbers are low enough. The U.S. in general has not had numbers low enough to do that since the beginning of the pandemic because we were too slow and too all over the place to take the necessary steps toward that goal.

With fewer cases, we wouldn't need to do as much testing, which would allow our testing capacity to build to a level where we could actually test everyone we need to.

We could also catch up on PPE production, and keep the mental health crises that go along with an uncontrolled pandemic limited to a couple of months instead of the ongoing nightmare we're in right now.

As Larry Brilliant, the epidemiologist who helped find the cure for smallpox, points out, we are smarter than this virus. "If it was just our science and the goodwill of American people, absent bad governance, we would have defeated it already. I don't mean we would have eradicated it, but we would have been much further along into kicking it into the dustbin of history."

Slavitt pointed out that even in countries that are now seeing an uptick in cases after having gotten numbers very low, the recent daily peaks are in the hundreds, not the tens of thousands that we're seeing in the U.S.

Think about what that would mean for us. For our medical workers. For the scientists trying to get a vaccine safely on the market. We've already started to get used to social distancing norms during the pandemic, but if we could get the virus under control, those measures would be a lot more effective.

Yes, it would mean 6 to 8 weeks of disruption. But in the big scheme of things, that's not that long. And we're already suffering through months of disruption anyway because we took a haphazard, disunified approach, which is harming us economically, emotionally, and epidemiologically.

And since we don't know yet if a vaccine will be the be all end all for this pandemic, we have to figure out how to manage without one for now.

Of course, as Slavitt points out, "The major objection to all this? People who think this infringes on their 'rights.'"

But we all give up some "rights" simply by living in a civilized society. There are rule and laws we all have to follow. We can't just do whatever we want—not when what we want to do puts others in harm's way. And during a pandemic, public health measures are designed to protect people, in the same way that food handling regulations and road safety laws do.

What about herd immunity? We don't know enough about how immunity with this virus works yet. Also, any attempt at reaching herd immunity means a mass number of casualties—not only hundreds of thousands of deaths, but millions upon millions of chronically ill people. Not ideal, especially when we actually can get this thing under control with a serious short-term strategy.

We all saw the Florida and Texas and Arizona outbreaks coming as governors tossed aside public health advice and citizens flaunted their "freedom" to gather in crowds, not wear a mask, and not do what needed to be done.

The thing is, it will all have to be done anyway, eventually. "We will do this. Theres is no other way," Slavitt wrote. "The question is when. The question is who will convince us. The question is the leadership it takes."

Really, it boils down to what it has always boiled down to—listening to the majority of epidemiologists who have prepared their whole careers for this moment and taking decisive, unified action that lines up with the science. The more we keep pretending that the virus isn't real, or isn't that bad, or is some kind of hoax or conspiracy that the entire world is somehow in on, the longer we're going to suffer.

Let's hit the reset button here—shut down for 6 weeks, pay everyone to stay home, and get our numbers down to a manageable level so we can keep them there. Let's be proactive instead of reactive. Let's stop being the world's poster child for what not to do in a pandemic. We may not be able to lead the world in a crisis at this point, but we could at least attempt not to embarrass ourselves any further.