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The Birx Plan for Early Vaccination of the Nursing Homes

In Covid in the nursing homes: the US experience, Markus Bjoerkheim and I show that the Great Barrington “focused protection” plan was unlikely to have worked. I covered this last week. But there was one strategy which could have saved tens of thousands of lives–early vaccination. If the vaccine trials had been completed just 5 weeks earlier, for example, we could have saved 14 thousand lives in the nursing homes alone. But put aside the possibility of completing the trials earlier. There was another realistic possibility under our noses. We had could have offered nursing home residents the vaccine on a compassionate use basis, i.e. even before all the clinical trials were completed. An early vaccination option was neither unprecedented nor a question of 20-20 hindsight, early vaccination was discussed at the time:

Deborah Birx, the coordinator of the White House Coronavirus Task Force, forcefully advocated that nursing home residents should be given the option of being vaccinated earlier under a compassionate use authorization (Borrell, 2022). Many other treatments, such as convalescent plasma, were authorized under compassionate use procedures and there was more than enough vaccine available to vaccinate all nursing home residents. As a first approximation we find the Birx plan would have prevented in the order of 200,000 nursing home cases and 40,000 nursing home deaths. To put that in perspective, it amounts to reducing overall nursing home Covid deaths by over 26 per cent (using all CMS reported resident nursing home deaths as of 5 December 2021, and estimates of underreported deaths from Shen et al. (2021)).

The lesson is not primarily about the past. It’s about the central importance of vaccines in any plan to protect the vulnerable and about how we should be bolder and braver the next time.

Addendum: See also Tyler’s tremendous post (further below) on focused protection.

Immigrants keep us out of nursing homes

We examine whether immigration causally affects the likelihood that the U.S.-born elderly live in institutional settings. Using a shift-share instrument to identify exogenous variation in immigration, we find that a 10 percentage point increase in the less-educated foreign-born labor force share in a local area reduces institutionalization among the elderly by 1.5 and 3.8 percentage points for those aged 65+ and 80+, a 26-29 percent effect relative to the mean. The estimates imply that a typical U.S-born individual over age 65 in the year 2000 was 0.5 percentage points (10 percent) less likely to be living in an institution than would have been the case if immigration had remained at 1980 levels. We show that immigration affects the availability and cost of home services, including those provided by home health aides, gardeners and housekeepers, and other less-educated workers, reducing the cost of aging in the community.

Here is more from Kristin F. Butcher, Kelsey Moran, and Tara Watson.

Nursing homes across nations

This is all from Michael A. Alcorn, from my email, no further indentation offered:

“Just to keep hammering on this nursing home point… I saw your Tweet about Eastern vs. Western Europe and decided to explore the nursing home angle there too. The WHO has data on the number of nursing and elderly home beds for different countries here. Unfortunately, the data only goes up to 2013-ish for many countries, but it’s suggestive nonetheless.

Italy and France were clearly trending up seven years ago in its number of beds… would be interesting to see if Italy had a similar jump to Spain at some point. The number of beds gives us a proxy for the number of people who are highly vulnerable to COVID-19. Obviously, these countries have different total populations, but I don’t think that should matter too much because I suspect nursing homes tend to be highly concentrated within countries (e.g., how many of France’s nursing homes are in the Paris metro?). Based on what I’ve read about nursing home staff often being low paid and so perhaps coming to work when sick and working at multiple facilities, I suspect nursing home density is nonlinearly related to the number of COVID-19 deaths in a country (especially when you account for some of the truly horrifying government decisions regarding nursing homes).

Here are those Nordic countries everyone likes to compare:

You can get exact numbers on the website, but Sweden had twice as many nursing home beds as Finland and three times as many as Norway. The ship might have sailed on what we can do to protect these vulnerable populations, but I would love to see a Fast Grant go towards investigating the COVID-19/nursing home tragedy.”

Claims about nursing homes

From Neil Emery:

 Nursing homes are chronically understaffed in times of economic prosperity. But, when the job market tightens, a one percent increase in unemployment sees full time employment in nursing facilities rise three times as fast. After a recession, when the economy picks back up and jobs become available again, low skilled workers abandon nursing homes jobs’ low pay and even fewer accolades for better prospects. The shift of workers in and out of nursing jobs drives the swings in the national death rate and underscores the importance of these under-appreciated jobs.

A look at the relationship between economic downturns and health outcomes in the United States reveals a complex picture: harm from lost insurance and increased anxiety but better care for the elderly. These two trends coexist because, while harm concentrates in working age people, retirees reap the majority of the benefit.

I do not know if these claims are true, but see the post for a discussion of the evidence.

Nursing home networks and Covid-19

We construct network measures of nursing home connectedness and estimate that nursing homes have, on average, connections with 15 other facilities. Controlling for demographic and other factors, a home’s staff-network connections and its centrality within the greater network strongly predict COVID-19 cases. Traditional federal regulatory metrics of nursing home quality are unimportant in predicting outbreaks, consistent with recent research. Results suggest that eliminating staff linkages between nursing homes could reduce COVID-19 infections in nursing homes by 44 percent.

That is from a new NBER working paper by M. Keith Chen, Judith A. Chevalier, and Elisa F. Long, and I am going to nominate this as one of the very best and most important papers of the year.

Nursing home estimates of the day

“Health inspectors cited roughly 75% of nursing homes nationwide for failing to have or follow a plan to prevent the spread of infectious diseases in the past four years, between 2016 and January 2020”

“A report released by academics at the London School of Economics (LSE) on April 15 said between 42 percent and 57 percent of deaths from the coronavirus in Italy, Spain, France, Ireland and Belgium have been linked to care homes for the elderly.”

From the (since updated) report: “In the remaining 5 countries for which we have official data (Belgium, Canada, France, Ireland and Norway), and where the number of total deaths ranges from 136 to 17,167, the % of COVID-related deaths in care homes ranges from 49% to 64%).”

“Residents of long-term care facilities account for half of the total deaths in Massachusetts”

Those are all from an email from Michael A. Alcorn.

The Big Fail

The Big Fail, Joe Nocera and Bethany McLean’s new book about the pandemic, is an angry book. Rightly so. It decries the way the bien pensant, the self-righteously conventional, were able to sideline, suppress and belittle other voices as unscientific, fraudulent purveyors of misinformation. The Big Fail gives the other voices their hearing— Martin Kulldorff, Sunetra Gupta, Jay Bhattacharya and Emily Oster are recast not as villains but as heroes; as is Ron DeSantis who is given credit for bucking the conventional during the pandemic (Nocera and McLean wonder what happened to the data-driven DeSantis, as do I.)

Amazingly, even as highly-qualified epidemiologists and economists were labelled “anti-science” for not following the party line, the biggest policy of them all, lockdowns, had little to no scientific backing:

…[lockdowns] became the default strategy for most of the rest of the world. Even though they had never been used before to fight a pandemic, even though their effectiveness had never been studied, and even though they were criticized as authoritarian overreach—despite all that, the entire world, with a few notable exceptions, was soon locking down its citizens with varying degrees of severity.

In the United States, lockdowns became equated with “following the science.” It was anything but. Yes, there were computer models suggesting lockdowns would be effective, but there were never any actual scientific studies supporting the strategy. It was a giant experiment, one that would bring devastating social and economic consequences.

The narrative lined up “scientific experts” against “deniers, fauxers, and herders” with the scientific experts united on the pro-lockdown side (the following has no indent but draws from an earlier post). But let’s consider. In Europe one country above all others followed the “ideal” of an expert-led pandemic response. A country where the public health authority was free from interference from politicians. A country where the public had tremendous trust in the state. A country where the public were committed to collective solidarity and public welfare. That country, of course, was Sweden. Yet in Sweden the highly regarded Public Health Agency, led by state epidemiologist Anders Tegnell, an expert in infectious diseases, opposed lockdowns, travel restrictions, and the general use of masks.

It’s important to understand that Tegnell wasn’t an outsider marching to his own drummer, anti-lockdown was probably the dominant expert opinion prior to COVID. In a 2006 review of pandemic policy, for example, four highly-regarded experts argued:

It is difficult to identify circumstances in the past half-century when large-scale quarantine has been effectively used in the control of any disease. The negative consequences of large-scale quarantine are so extreme (forced confinement of sick people with the well; complete restriction of movement of large populations; difficulty in getting critical supplies, medicines, and food to people inside the quarantine zone) that this mitigation measure should be eliminated from serious consideration.

Travel restrictions, such as closing airports and screening travelers at borders, have historically been ineffective.

….a policy calling for communitywide cancellation of public events seems inadvisable.

The authors included Thomas V. Inglesby, the Director of the Johns Hopkins Center for Health Security, one of the most highly respected centers for infectious diseases in the world, and D.A. Henderson, the legendary epidemiologist widely credited with eliminating smallpox from the planet.

Nocera and McLean also remind us of the insanity of the mask debate, especially in the later years of the pandemic.

But by the spring of 2022, the CDC had dropped its mask recommendations–except, incredibly, for children five and under, who again, were the least likely to be infected.

…Once again it was Brown University economist Emily Oster who pointed out how foolish this policy was…The headline was blunt: Masking Policy is Incredibly Irrational Right Now. In this article she noted that even as the CDC had dropped its indoor mask requirements for kids six and older, it continued to maintain the policy for younger children. “Some parents of young kids have been driven insane by this policy,” Oster wrote, “I sympathize–because the policy is completely insane…”

As usual, her critics jumped all over her. As usual, she was right.

Naturally, I don’t agree with everything in the Big Fail. Nocera and McLean, for example, are very negative on the role of private equity in hospitals and nursing homes. My view is that any theory of what is wrong with American health care is true because American health care is wrong in every possible way. Still, I don’t see private equity as a driving force. It’s easy to find examples where private equity owned nursing homes performed poorly but so did many other nursing homes. More systematic analyses find that PE owned nursing homes performed about the same, worse or better than other nursing homes. Personally, I’d bet on about the same overall. Covid in the Nursing Homes: The US Experience (open), my paper with Markus Bjoerkheim, shows that what mattered more than anything else was simply community spread (see also this paper for the ways in which I disagreed with the GBD approach). More generally, my paper with Robert Omberg, Is it possible to prepare for a pandemic? (open) finds that nations with universal health care, for example, didn’t have fewer excess deaths.

The bottom line is that vaccines worked and everything else was a sideshow. Had we approved the vaccines even 5 weeks earlier and delivered them to the nursing homes, we could have saved 14,000 lives and had we vaccinated nursing home residents just 10 weeks earlier, before the vaccine was approved, as Deborah Birx had proposed, we might have saved 40,000 lives. Nevertheless, Operation Warp Speed was the shining jewel of the pandemic. The lesson is that we should fund further vaccine R&D, create a library of prototype vaccines against potential pandemic threats, streamline our regulatory systems for rapid response, agree now on protocols for human challenge trials and keep warm rapid development systems so that we can produce vaccines not in 11 months but in 100 days.

The Big Fail does a great service in critiquing those who stifled debate and in demanding a full public accounting of what happened–an accounting that  has yet to take place.

Addendum 1: I have reviewed most of the big books on the pandemic including the National Covid Commission’s Lessons from the COVID WAR, Scott Gottlieb’s Uncontrolled Spread, Michael Lewis’s The Premonition, Andy Slavitt’s Preventable and Abutaleb and Paletta’s Nightmare Scenario.

Addendum 2: I also liked Nocera and McLean’s All the Devils are Here on the financial crisis. Sad to say that the titles could be swapped without loss of validity.

The Great Barrington Plan: Would Focused Protection Have Worked?

A key part of The Great Barrington Declaration was the idea of focused protection, “allow those who are at minimal risk of death to live their lives normally to build up immunity to the virus through natural infection, while better protecting those who are at highest risk.” This was a reasonable idea and consistent with past practices as recommended by epidemiologists. In a new paper, COVID in the Nursing Homes: The US Experience, my co-author Markus Bjoerkheim and I ask whether focused protection could have worked.

Nursing homes were the epicenter of the pandemic. Even though only about 1.3 million people live in nursing homes at a point in time, the death toll in nursing homes accounted for almost 30 per cent of total Covid-19 deaths in the US during 2020. Thus we asked whether focusing protection on the nursing homes was possible. One way of evaluating focused protection is to see whether any type of nursing homes were better than others. In other words, what can we learn from best practices?

The Centers for Medicaire and Medicaid Services (CMS) has a Five-Star Rating system for nursing homes. The rating system is based on comprehensive data from annual health inspections, staff payrolls, and clinical quality measures from quarterly Minimum Data Set assessments. The rating system has been validated against other measures of quality, such as mortality and hospital readmissions. The ratings are pre-pandemic ratings. Thus, the question to ask is whether higher-quality homes had better Covid-19 outcomes? The answer? No.

The following figure shows predicted deaths by 5-star rating. There is no systematic relationship between nursing homes rating and COVID deaths. (In the figure, we control for factors outside of a nursing homes control, such as case prevalence in the local community. But even if you don’t control for other factors there is little to no relationship. See the paper for more.) Case prevalence in the community not nursing home quality determined death rates.

More generally, we do some exploratory data analysis to see whether there were any “islands of protection” in the sea of COVID and the answer is basically no. Some facilities did more rapid tests and that was good but surprisingly (to us) the numbers of rapid tests needed to scale nationally and make a substantial difference in nursing home deaths was far out of sample and below realistic levels.

Finally, keep in mind that the United States did focused protection. Visits to nursing homes were stopped and residents and staff were tested to a high degree. What the US did was focused protection and lockdowns and masking and we still we had a tremendous death toll in the nursing homes. Focused protection without community controls would have led to more deaths, both in the nursing homes and in the larger community. Whether that would have been a reasonable tradeoff is another question but there is no evidence that we could have lifted community controls and also better protected the nursing homes. Indeed, as I pointed out at the time, lifting community controls would have made it much more difficult to protect the nursing homes.

Those now-automated service sector jobs?

Arshia Khan asked a group of older adults in Minnesota what they would like in a nursing home, and their answer surprised her. They wanted standup comedy, but not just any comedy: They wanted off-color jokes.

Dr. Khan, a professor of computer science at the University of Minnesota Duluth, programs robots to work in nursing homes.

On a March afternoon in her lab, surrounded by a dozen robots of different sizes and designs, Dr. Khan asked one to show off its stuff. The robot, a four-foot-tall white plastic figure named Pepper, with a tablet screen in its chest, blinked its eyes and wiggled its hips.

“So, which one of you requested the dirty jokes?” Pepper asked, in a computer voice.

There followed a risqué joke about the robot’s relationship with its charging plug, and another about an unhappy date with a Tesla (too conceited). After each, the robot giggled. “I went on a date with a Roomba last week,” the robot said, gesticulating with its arms. Pause. “It totally sucked.”

But alas:

Later this year, pending approval from the university’s institutional review board, 16 of Dr. Khan’s robots will go to eight nursing homes around the state — though without the off-color jokes.

Here is the full NYT story, via a loyal MR reader.

Yet another underreported medical scandal — the overmedicated elderly

“Add Dx of schizophrenia for use of Haldol,” read the doctor’s order, using the medical shorthand for “diagnosis.”

But there was no evidence that Mr. Blakeney actually had schizophrenia.

Antipsychotic drugs — which for decades have faced criticism as “chemical straitjackets” — are dangerous for older people with dementia, nearly doubling their chance of death from heart problems, infections, falls and other ailments. But understaffed nursing homes have often used the sedatives so they don’t have to hire more staff to handle residents…

The share of residents with a schizophrenia diagnosis has soared 70 percent since 2012, according to an analysis of Medicare data. That was the year the federal government, concerned with the overuse of antipsychotic drugs, began publicly disclosing such prescriptions by individual nursing homes.

Today, one in nine residents has received a schizophrenia diagnosis. In the general population, the disorder, which has strong genetic roots, afflicts roughly one in 150 people.

Schizophrenia, which often causes delusions, hallucinations and dampened emotions, is almost always diagnosed before the age of 40.

Here is more from the NYT, not unrelated to issues of guardianship of course.  Furthermore, this tale does not exactly fit the usual “not enough medical care for the poor” narratives, and perhaps that is why the issue has not caught on more.  The medical profession even appears to be slightly…suboptimal in its ethical procedures.

For the pointer I thank Michelle Dawson.

British Vaccine Efficiency

The British vaccination plan has been run very well. As this audience knows, the British delayed the second dose in order to get out more first doses quickly. A life-saving move. The British have also been targeting age and riskier workers very well. The excellent Witold Więcek (an Emergent Ventures prize recipient) has done a back of the envelope calculation which indicates how well the British are targeting.

Since the vaccines have been prioritised for the elderly, the infection fatality risk (IFR) for a typical vaccinated patient is higher than the average IFR in the population. However, we have to account for the fact that many of the early doses are given to health care workers and some of the other key workers. By late February 2021, in the UK around 55% of the vaccines went to people over 70 and over 95% of that age group has been vaccinated. In the US, however, while 55% of vaccines went to people over 65, close to 30% went to people younger than 50. We calculated IFR as an approximate weighted mean of age-specific infection mortality risks, using a meta-analysis estimate in Manheim et al., 2021.

Applying this IFR approach to real-world distributions of vaccine distribution, for UK we obtained 4.7% and for the US 3.2%, a remarkable difference. In other words, despite delivering twice the number of doses (and “running out” of highest risk individuals to vaccinate), a single dose of vaccine in the UK was still used 50% more effectively than in the US. (It should be noted, however, that the UK has a slightly older population than the US.)

Given less centralized health information, it’s hard to see how the US could target much better while also maintaining speed which is why, after the first round of vaccinating the nursing homes and the very elderly, I have leaned towards opening up more vaccination sites and prioritizing speed. So read this as a credit to the British rather than a demerit to the US. Other European countries, however, also have more centralized medical systems and yet have been far behind the British. It has struck me during this crisis how little these kind of system-wide policy variable seem to explain in the efficiency of the pandemic response overall.

The problem with rapid testing was always on the demand side

The U.S. government distributed millions of fast-acting tests for diagnosing coronavirus infections at the end of last year to help tamp down outbreaks in nursing homes and prisons and allow schools to reopen.

But some states haven’t used many of the tests, due to logistical hurdles and accuracy concerns, squandering a valuable tool for managing the pandemic. The first batches, shipped to states in September, are approaching their six-month expiration dates.

At least 32 million of the 142 million BinaxNOW rapid Covid-19 tests distributed by the U.S. government to states starting last year weren’t used as of early February, according to a Wall Street Journal review of their inventories…

“The demand has just not been there,” said Myra Kunas, Minnesota’s interim public health lab director.

…the tests are piling up in many states, the Journal found.

Here is more from Brianna Abbott and Sarah Krouse at the WSJ.  You may recall the discussions of demand-side issues from my CWTs with Paul Romer and Glen Weyl.  The envelope theorem remains underrated.

Where We Stand

There is good news and there is bad news.

Let’s start with the good news.The early results from the Pfizer vaccine are very good, 90% efficacy. That will probably fall a bit but it’s very good news not just for the Pfizer vaccine but for most of the vaccines in the pipeline which target the spike protein.

The Pfizer vaccine does require very cold storage which means it won’t work for large parts of the world. A distribution plan is in place for most of the United States and Pfizer already has 50 million doses, which can cover ~25 million people, in storage.

Many thousands of people are dying every week so Pfizer should apply for and the FDA should issue a EUA without further delay.

One issue is, given limited supply, how to distribute the vaccine. I have suggested we randomize distribution across hospitals, police and fire stations, and nursing homes (see also my piece in Bloomberg with Scott Kominers, The Case for a COVID Vaccine Lottery.) A vaccine lottery is fair, it will make distribution easier by limiting the number of vaccination locations and it will in essence create a very large clinical trial. With millions of participants we will be better able to make fine distinctions between the vaccine’s safety and efficacy in different populations and the results will come in quickly. Thus, if we randomize and collect data, limited capacity has a silver lining.

Second issue. Manufacturing capacity. Pfizer will have enough capacity to produce 1.3 billion doses in 2021 which sounds like a lot but it’s a two dose vaccine and there will be losses in distribution so maybe 500 million people vaccinated. We need to vaccinate billions.

The cost to the world economy of COVID is in the trillions so we want to vaccine a lot faster. Faster than private markets are willing to go. There are other vaccines in the pipeline but we still need to ramp up capacity. Increasing capacity is something that Michael Kremer, Susan Athey, myself and others at Accelerating Health Technologies have been working on since the beginning of the crisis. It’s not too late to do more.

Third issue is testing. Trump got it into his head that more tests means more cases when in fact a lot more tests means fewer cases. There is a Laffer curve for testing. Our failure to get ahead of the virus with tests has meant hundreds of thousands of excess deaths. We are still failing this test. Winter is coming. Infections and deaths are both rising.

Biden won’t be president until late January but there are things he can do now. In particular, Congress already allocated $25 billion to testing in April—that was far too little. We spent trillions on relief and comparatively little fighting the virus. But here is the real shocker, most of the $25 billion allocated in April hasn’t been spent. Let me say that again, most of the money allocated for testing in April has not been spent. Biden can signal today that that money and more will be spent. He can also signal, as in fact he has, that he wants rapid antigen tests approved.

Rapid antigen tests are cheap, paper strip tests that can check for infectiousness and are ideal to getting things like the schools running again.

Even if we start vaccinating this year, we won’t vaccinate a majority of the US population until well into 2021. That’s true but what’s underappreciated is that testing, masks, social distancing and vaccines are complementary. The more people are vaccinated, for example, the greater our testing capacity rises relative to the population at risk.

The pandemic is getting worse not better but we did flatten the curve, albeit imperfectly, and now if we can summon the will, we have the tools including rapid antigen tests, vaccines and monoclonal antibodies to really crush the virus.

Wednesday assorted links

1. Russian billionaire wants to buy cancelled Confederate statues.

2. “Nursing homes have new COVID-19 tests that are fast and cheap. So why won’t N.J. allow them to be used?

3. Where are the missing right-wing firms?  And Arnold.

4. The vaccine protocols.

5. The world forager elite.

6. An evidence-based return to work plan.

7. The nasal spray, which will be entering clinical trials.

8. On the Abraham Accords.