CDC Publishes Data Prompting the Mask Guideline change

Today the CDC posted the data supporting the change in the mask guidelines for the fully vaccinated. It’s in the July 30, 2021 Morbidity and Mortality Weekly Report (MMWR) describing the outbreak of several hundred new cases of the Delta variant COVID-19 infection in Barnstable County, Massachusetts following July 4th events. Those who were fully vaccinated shed virus as much as the unvaccinated.

Organizers of the Iowa State Fair and those planning to attend, take note.

Brown CM, Vostok J, Johnson H, et al. Outbreak of SARS-CoV-2 Infections, Including COVID-19 Vaccine Breakthrough Infections, Associated with Large Public Gatherings — Barnstable County, Massachusetts, July 2021. MMWR Morb Mortal Wkly Rep. ePub: 30 July 2021. DOI: icon.

What the Heck is a Shewhart Chart?

This is just a post from a retired psychiatrist who barely passed the statistics course in medical school, so take it with a big grain of salt. I found an article written by Rocco J. Perla about something called Shewhart control charts to monitor the course of pandemic fluctuations. I noticed it because of what Perla commented on, which is the tendency of the press to make sensational headlines about every squeak in the turning wheel of COVID-19, including CDC making changes in masking guidelines leading to congressmen calling for investigations of the CDC for making the changes. It makes it look as though we don’t know what we’re doing.

I don’t know if Shewhart charts can help us make better decisions about what to advise us to do at the community level to help monitor and predict outbreaks. But it looks like we need to try something better soon. Because I can’t stand the pop-up ads at the U.S. News & World Report web site and limitations on how many articles I can view for free where I first saw Perla’s story, I looked up his original article published in the Int J Qual Health Care.

This led to my discovering the web site ISQua (International Society for Quality in Health Care). There I found a Shewchart for my state of Iowa, which shows what happened here this month. I don’t know if the Iowa Department of Public Health (IDPH) is already using it and I’m not qualified to tell them what to do. By the way, I think that mindset of “Don’t tell me what to do” crankiness might be an epiphenomenon of the COVID-19 pandemic. Nobody wants to be told to wear masks or to get a vaccine. It just leads to a pandemic of backlashes. I don’t know if Rocco is right about the Shewhart chart method not being in use by public health officials. But I want to go on record as not telling anybody what to do.

The Shewhart charts look labor intensive and maybe that’s why some public health departments don’t use them. They’re understaffed and overworked. Iowa has been scaling back the collection and reporting of COVID-19 data, partly because things appeared to be so rosy early in July. I’m not so sure how rosy they’ll be after the Iowa State Fair in August, which is expected to draw about a million visitors.

But I’m not telling anyone not to go to the state fair and I’m not telling anyone to wear a mask and I’m not telling anyone to get vaccinated. I’m not even telling anyone to pay any attention to Perla’s article on the Shewhart chart. I am telling you that I’m too old and cranky to be getting backlashes about any of this business.

Have fun at the fair.

Perla RJ, Provost SM, Parry GJ, Little K, Provost LP. Understanding variation in reported covid-19 deaths with a novel Shewhart chart application. Int J Qual Health Care. 2021;33(1): mzaa069. doi:10.1093/intqhc/mzaa069

Inkelas M, Blair C, Furukawa D, Manuel VG, Malenfant JH, Martin E, et al. (2021) Using control charts to understand community variation in COVID-19. PLoS ONE 16(4): e0248500.

Listening to the CDC

Like everyone else, I groaned aloud about the revised CDC mask guidelines yesterday. I still trust the CDC guidance, and I’m sure many might disagree with me. I think some headlines overstate the CDC mask change. I don’t believe it’s a “reversal” per se. I think it’s common sense to wear a mask if you’re inside somewhere with a lot of people whose vaccination status you know nothing about.

I think it’s worthwhile to actually read the CDC web site’s mask guidance in the section entitled “When You’ve Been Fully Vaccinated.” What it says is:

“To maximize protection from the Delta variant and prevent possibly spreading it to others, wear a mask indoor in public if you are in an area of substantial transmission.”

It’s a good idea to check your geographical area (COVID-19 Integrated County View) to see what the transmission situation is. It’s moderate where we live in Iowa. That’s enough for me to go back to wearing a mask in tight quarters with people I don’t know.

I was dismayed to read an opinion piece entitled “Stop listening to the CDC,” in which the author said that “the vaccinated are not responsible for the unvaccinated, and vice versa.”

That made me remember my former pastor, Reverend Glen Bandel, who is now in his 90s. When my mother was very sick, he spent a long night sitting up with her. My brother and I were too little to manage the crisis by ourselves. She was unable to keep any food or fluid down and he made many trips from her room to the bathroom, to empty her bucket of vomit in the toilet. You could have made a case for hospitalizing her, but we somehow got by without it.

If we all believed that we are not responsible for each other, we would have been extinct long ago, let alone getting through this pandemic in the last 18 months. Not all of us who got the COVID-19 vaccine did it just for ourselves. I think a great many also did it for those they loved and for whom they felt responsible. This is called altruism and I think humans are still capable of it, despite what you read in the news.

Update on Advisory Committee On Immunization Practices Meeting July 22, 2021

Presentation slides for the ACIP meeting today are available here. Updates to clinical communication indicate that, while patients with a history of Guillain-Barre Syndrome (GBS) are eligible for any of the authorized vaccines, they should discuss with their clinical teams the availability of mRNA vaccines given the association of GBS with the J&J vaccine.

For the summary of the issues regarding giving booster vaccine doses to immunocompromised patients, see data from slide 15 onwards.

Vaccines and Shirt Pocket Flap Puckers

This morning I put on my shirt and noticed the pocket flap puckers for the umpteenth time. I also got a reminder about how difficult it is to keep fingernail clippings from zinging all over the bathroom. I did a quick web search and saw that both problems are perennial with no great solutions. There’s an eerie resemblance to the COVID-19 vaccine hesitancy challenges.

One author says the shirt pocket flap pucker problem (say that three times quickly right now!) is caused by shirt manufacturers who fail to hem correctly and by shirt wearers who fail to properly launder them. Various solutions to the nail clipping problem involves innovative modifications to clipper design and other ingenious suggestions you can try yourself, including clipping with your digits inside a sandwich bag to catch the flying parings.

In other words, there are system changes and user changes, which seems to apply to the vaccines as well. For example, there are some researchers investigating the use of intranasal immunization. This has a few advantages, including maybe helping those who are afraid of needles, which is a population probably bigger than we think.

There are systems advantages as well as challenges to the intranasal route. It capitalizes on the IgA immunity cells in the nasal mucosa, which could help prevent travel of the virus to the lungs. The University of Iowa Hospitals & Clinics research team has found that this works in mice. On the other hand, other researchers are abandoning the approach because they haven’t had success in early human trials. And the vaccine injections are highly effective by comparison. Side effects of the intranasal might include more than just wanting to make you sneeze. Although you could cover your nose with a sandwich bag or maybe pinch your nostrils shut with a pair of nail clippers (but what to do with the nostril parings?). Some raise concerns about how close you get to the brain. There was a reported case of Bell’s Palsy after an intranasal influenza vaccination in 2002. Incidentally, the likelihood of getting Bell’s Palsy after the COVID-19 jab is less than getting it from the virus infection itself (MedPage Today report June 2021).

Congress could pass laws preventing shirt manufacturers from making them with pocket flaps in the first place. After all, what pickpocket would be bold enough to try to pick your shirt pocket, assuming you buttoned it? Or the President could write an executive order mandating the owners of shirts with pocket flaps launder them properly, or at least iron them. There could be a door-to-door campaign to distribute innovative nail clippers, or offer free pedicure and manicure services (only after full licensing, of course).

Well, anytime you need my innovative suggestions you can always choose to opt out.

Advisory Committee On Immunization Practices Meeting July 22, 2021

The Advisory Committee on Immunization Practices (ACIP) will meet with the CDC July 22, 2021 to discuss COVID-19 vaccine boosters for immunocompromised individuals and the association of the J&J vaccine with Guillain-Barre Syndrome. See the draft agenda here.

New FDA Warning Regarding association of Guillain-Barre Syndrome with J&J Covid-19 Vaccine

On July 13, 2021, the FDA issued a revision to the J&J COVID-19 vaccine fact sheets regarding the increased risk of Guillain-Barre Syndrome (GBS) with the vaccine. According to the announcement, the benefits still outweigh the risks for getting the vaccine and so far no causal association has been found. GBS is rare and has been associated with other vaccines, including the flu vaccine. GBS has not been associated with the mRNA vaccines, so far.

Grim Fandango Nostalgia

I’ve been playing an adventure video game called Grim Fandango Remastered, driven by nostalgia. I can remember playing the first part of it 20 years ago when the original Grim Fandango was released for the PC. I just finished the game this afternoon and I couldn’t remember a darn thing about most of it.

Anyway, the main character is a dead guy, Manuel “Manny” Calavera, working as a travel agent at the Department of Death selling tickets to the newly dead who are trying to get to a kind of heaven called the Ninth Underworld. Manny’s job gets pretty complicated when he uncovers a scam involving counterfeit tickets. He loses a client, Mercedes “Meche” Colomar, an unfortunate victim of the scam, and sets off on a long journey through the underworld to right the wrong.

I think I know what happened. The original version didn’t play well on the PC we had back then. I think I just gave up, not so much because of the difficult puzzles, but because of the glitchy gameplay.

But I do remember being fascinated by the art, the music, and the Day of the Dead theme. Most experts say the game really didn’t get much of a remastering job, but I thought it was gorgeous (and so did Sena, who played along with me toward the end).

I like the story and the mystery. You interact with the characters by asking them questions, which are to some extent fed to you in order to help keep you on track. The puzzles are sometimes fiendishly difficult and I couldn’t finish it without peeking at the walkthrough.

The characters tell a story full of heroism and villainy evoking themes of altruism, loyalty, kindness, and courage in the face of avarice and cruelty. And even the good guys have flaws.

I need a good story like that now and then, especially these days.

Just Because it’s Vintage Doesn’t Mean it’s Wreckage

I still have a vintage calculator. It’s a Sharp ELSI MATE EL-505. You can buy one on eBay for $30. I bought this dinosaur back in the early 1980s just before heading to college at Iowa State University. It’s still usable, so just because it is vintage doesn’t mean it is wreckage. The original batteries last for over a decade at least, and probably longer.

My original major was engineering but I quickly changed my mind and eventually ended up in medical school at The University of Iowa. I’ve been retired from being a consultation-liaison psychiatrist now for a year. A couple of days ago, I ran into someone I know from the hospital and she asked me how retirement was going. She was on her way into and I was on my way out of Best Buy (nothing big, just a toner cartridge). I mumbled something quickly about having ups and downs but in general doing OK. The automatic door kept opening and closing. It was distracting so we said quick goodbyes.

We’ve got a couple of computers at home that are probably quickly becoming vintage, especially now that Microsoft is pushing the next iteration of the operating system (OS), Windows 11. The introduction is having a rough start, beginning with the puzzling PC readiness checker. You got a message that your PC would either be good to go with Windows 11—or not. That was pretty much it until the complaints started cropping up, generally starting with “What the heck do you mean it won’t run on my machine; why not?” They finally dropped the PC checker routine.

We’ve been through pretty much every Windows OS since Windows 95. If you’re wondering why go through all that, let me say that I actually started with a Mac at the hospital in my first year on the job at the hospital, on the advice of my mentor and first supervisor on the psychiatry consult service. He had a Mac and liked it a lot. On the other hand, even though I liked it too, it soon became clear that it was often impossible to interface with the PC-based office support staff network. I ended up going with a PC and have been dealing with Windows ever since.

Actually, my very first computer was given to me by an endocrine staff physician who co-attended with me in the medical-psychiatry unit. I didn’t pay a dollar for it and it was obviously vintage, in the negative connotation as I soon discovered after trundling it out to the parking lot in a cart and getting it home. When I pressed the power button—nothing happened. I returned it the very next day. My colleague could not explain it.

I could not get Windows 95 to run basic computer games at first. Even Myst, a simple point and click game that probably nobody remembers, would freeze and lock up the machine. I spent hours on the phone with tech support. You could do that then. It was not fun. Windows 98 was only slightly better. I’m still trying to forget Windows Me (Windows Millennium Edition or Mistake Edition). Windows XP had some longevity and ran OK. Windows Vista was another dud. I can’t remember much about Windows 7. I hated Windows 8 Live Tiles nonsense. We’ve been coping with Windows 10 and the updates to the present day.

Now here comes Windows 11 and seems like the most I can recall from articles about it is that it will have a Mac-like graphic interface. Then why shouldn’t I just go back to the Mac?

In some ways, my vintage calculator has done better over time than Windows. I can even spell “hello” on it.

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