29 July 2020

Pondering the reopening of schools - updated*


Addendum:
This perceptive and incisive comment from a reader who responded to another reader's comment that the CDC recommends reopening schools -
"the CDC recommends re-opening schools" 
The link you provide actually doesn't say so. It explains why schools are good for kids, but nobody is disputing that. 
It also says: 
The best available evidence from countries that have opened schools indicates that COVID-19 poses low risks to school-aged children, at least in areas with low community transmission, and suggests that children are unlikely to be major drivers of the spread of the virus. 
Where the key phrase is: in areas with low community transmission, which is a condition met in few communities in the US at the moment. the document fails to point this out. 
And it concludes with the obvious statement: Reopening schools creates opportunity to invest in the education which is also a statement nobody argues about. 
In conclusion, the document discussed the absolutely uncontroversial point that reopening schools is good for kids. It shuffles the necessary condition for reopening school safely to a subordinate phrase, and glosses over the fact that few communities in the US meet that condition. 
It's a document carefully written to appear to be saying the opposite of what it actually says.
And I will add I that I am so disappointed - and embarrassed - that the CDC, which I used to have great respect for during my years in academia, has now been reduced to a political tool by the Trump administration, releasing statements to support the GOP position of aggressively reopening the economy and the schools.

The CDC document linked above is truly deceptive.  And dangerous, because it is being quoted widely. 

27 comments:

  1. I mean, the CDC recommends re-opening schools:

    https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/reopening-schools.html

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    1. They also asserted that "If you are NOT sick: You do not need to wear a facemask unless you are caring for someone who is sick (and they are not able to wear a facemask). Facemasks may be in short supply and they should be saved for caregivers." The seem to have changed their tune on that one.

      https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html

      Delete
    2. My understanding is the CDC made the no mask recommendation based on sars-1, which is not very contagious if you were not symptomatic. That virus lives more deep in the lungs where you would not spread it much unless you are coughing. This sars (covid-19) likes it up in the nasal cavity which makes it more likely to spread with just breathing. So the made the wrong call.

      My understanding as to why they said kids should go back to school is the prez ordered them to say that.

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    3. Which recommendation? The guidelines that the president* says were "too tough" or the ones they release after pressure from the White House? Because those are very different.

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    4. the CDC recommends re-opening schools

      The link you provide actually doesn't say so. It explains why schools are good for kids, but nobody is disputing that.

      It also says:
      The best available evidence from countries that have opened schools indicates that COVID-19 poses low risks to school-aged children, at least in areas with low community transmission, and suggests that children are unlikely to be major drivers of the spread of the virus.

      Where the key phrase is: in areas with low community transmission, which is a condition met in few communities in the US at the moment. the document fails to point this out.

      And it concludes with the obvious statement: Reopening schools creates opportunity to invest in the education which is also a statement nobody argues about.

      In conclusion, the document discussed the absolutely uncontroversial point that reopening schools is good for kids. It shuffles the necessary condition for reopening school safely to a subordinate phrase, and glosses over the fact that few communities in the US meet that condition.

      It's a document carefully written to appear to be saying the opposite of what it actually says.

      Delete
    5. Exactly. Well said, Nepkarel.

      In fact I'm going to transfer your comment to the body of the post so more readers will see it.

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    6. I'm disappointed in this willful misreading of a clearly sourced and, as you yourself say, factually correct article, and of this sudden distrust of the CDC based not on facts, but on personal bias against their conclusions. The title is "The Importance of Re-opening America's Schools this Fall." There is an action, a timeline for the action to be taken, and a description of it's weight to society, all in one sentence. What follows it a concise, well-argued discussion of the impacts of keeping schools closed, and the benefits of re-opening, as well as a recommendation that schools re-open with measures to protect teachers from COVID.

      It's not "saying the opposite of what it actually says." Its meaning is plain, and it's substance is valid.

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    7. It's not "saying the opposite of what it actually says."

      No, it doesn't and I refer to the OP as proof.

      Its meaning is plain, and it's substance is valid.

      Its meaning is indeed plain. Plain of the nature 'The Sun rides in the East and the Moon shines at night'. But it does not say what many claim is says. It is deviously written to suggest something it does not say.

      The statements
      1: Schools are good for kids &
      2: Schools can re-open safely as a pandemic rages through the community
      are not one and the same.

      The document purposely conflates the two issues. It is written to give POTUS and SecEd a document they can point to as backup for their reckless position that schools can re-open safely.

      Delete
  2. So what is the CDC wrong about?

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    1. I read the CDC document and browsed their COVID-19 database. There's nothing they are "wrong" about regarding the children and the importance of school to their mental and physical health. And the risk to children is quite low. We all know the plague rats survived the Black Death quite well.

      What's missing (AFAIK) is data about the transmission of coronavirus to teachers and to parents/grandparents, which I think was the principal concern in the tweet embedded above.

      Personally, I would not want to be teaching in an indoor classroom with 20-30 tweens, of whom maybe a third are carrying the virus. And then having more classes through the day. Every day.

      Delete
  3. Sadly, the CDC can no longer be relied upon for credible information. Trump has subverted and perverted it to his own purposes. Some "CDC" messages are not even produced by the CDC anymore but are instead the product of White House staffers with no expertise in the field.

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  4. Anyone who has ever worked in a classroom/education setting (as I have) is well aware that school classrooms are essentially plague pits under normal circumstances. Children bring every germ they come into contact with into the classroom, and since children are not known for outstanding personal hygiene habits, these germs tend to spread quickly and vigorously. And when the germ du jour is a pandemic-level plague? Well... forcing schools to open is the stupidest possible decision that anyone could make. You don't need million-dollar health studies to tell you that. All you need is common sense. Which, sadly, is not common at all.

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  5. I am a Speech Pathologist in a Special Ed preschool and my fear for fall is valid. I hate that we are losing valuable time (because teletherapy is not the same thing as in person therapy) but it's not worth my life.

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  6. I am a mother trying to figure out what to do this fall for my first grader. I have seen no good/clear guidance that helps me understand the risks and benefits, everything is tainted with political double speak, everyone is scared. No one seems to care about the teachers. (I care! I am faced with the decision to quit my job of 12 years, that I love, to support online classes because I see no other way). Something no one is talking about, but which keeps me up at night, is not that my son gets sick, but that he has to live with the knowledge that he gave coronavirus to someone else and killed them... like one of his parents. It seems so cruel. When did America become so cruel?

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  7. "The new statement came from a working group convened by officials at the Department of Health and Human Services after Mr. Trump made his critical comments. A federal official familiar with the group said it included minimal representation from the C.D.C., which had already written most of the other material released on Thursday.

    The official, who spoke on the condition of anonymity, said the Substance Abuse and Mental Health Services Administration, an agency within the Health and Human Services Department, took the lead in writing the statement, which focuses heavily on the positive impacts on children’s mental health from going to school.

    Experts on the subject at the C.D.C. were cut off from direct communication with the working group after their input on the statement was interpreted as being too cautious, the official said. Instead, the group communicated directly with the office of Dr. Robert R. Redfield, the C.D.C. director, which did seek input from experts at the agency. But the C.D.C. was by no means in charge, the official said...

    Anita Cicero, deputy director of the Johns Hopkins Center for Health Security, described the C.D.C.’s new statement as a “sales job.”

    --https://www.nytimes.com/2020/07/24/health/cdc-schools-coronavirus.html

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  8. And from the Washington Post:
    On Thursday, Trump said schools may need to delay reopening in places that are “current hot spots,” and on Friday, Redfield echoed the thought. “In areas where there are hot spots, remote and distance learning may need to be adopted for some amount of time,” Redfield told reporters on a call to discuss the new guidelines.

    Redfield was then asked for a definition of “hot spots.” He said it would include places where more than 5 percent of coronavirus tests come back positive. Looking county by county, he said “the majority of the nation” is not a hot spot.

    Yet by his definition, large sections of the country are in fact hot spots.

    Johns Hopkins University shows that over the past week, 33 states and Puerto Rico have “positivity rates” above 5 percent. In 12 states, the rate was more than 10 percent.

    On Thursday, Trump said schools may need to delay reopening in places that are “current hot spots,” and on Friday, Redfield echoed the thought. “In areas where there are hot spots, remote and distance learning may need to be adopted for some amount of time,” Redfield told reporters on a call to discuss the new guidelines.

    Redfield was then asked for a definition of “hot spots.” He said it would include places where more than 5 percent of coronavirus tests come back positive. Looking county by county, he said “the majority of the nation” is not a hot spot.

    Yet by his definition, large sections of the country are in fact hot spots.

    Johns Hopkins University shows that over the past week, 33 states and Puerto Rico have “positivity rates” above 5 percent. In 12 states, the rate was more than 10 percent.

    In Florida, only two counties have positive rates below 5 percent — Alachua County and Bay County, which together hold about 2 percent of Florida’s population.

    In Arizona, only Greenlee County, the least populated jurisdiction in the state with 9,483 people, has a positivity rate at 5 percent. Florida and Arizona have overall positivity rates well above 10 percent.

    Nationally, the positivity rate is 10 percent, the CDC says...

    Given this variation, opening schools should be a local call, Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, said in a Post online broadcast.

    “It depends on where you are,” he said. “We live in a very large country that is geographically and demographically diverse and certainly different in the extent to which there is covid virus activity.”

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  9. It's like dealing with evil fey. *Technically* there is no lie. But it's written to ironic effect. I have to do numerous double takes, partake in very careful analysis, and re-read and double check. And I'm a way over educated word nerd with a science background.

    It is deliberately misleading, with potentially fatal consequences.

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  10. You know what they call students whose parents must send them to school? Orphans

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  11. What does "low risk" mean? Does that mean low risk of DYING? Or does that mean low-risk of getting the virus? If the former, great...but if they DO catch it, then they can spread it to someone who isn't low-risk of dying.

    In a nearby county (Suwannee County in Florida), the school has given three options: virtual school, traditional school, or hybrid school (once-a-week meeting with someone who may not be in-field). BUT HERE'S THE KICKER: They have clearly stated that they will NOT require face masks or washing hands, etc.

    WHY, for heaven's sake? As best I can figure it, it has to do with the political forces in the school board. There are perhaps a large number of people in this rural county that are against face masks. I get that. But the school is one place where we demand that our children be kept safe.

    My child goes there due to the poor education in our own county. We have elected for hybrid.

    I cannot understand what a school board would act like CHILDREN should not be told to adopt certain safety precautions. What next--refusing to tell them they have to do their work or stop talking when the teacher is teaching?

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  12. With respect Minnesotastan, it has become such that, paradoxically, the truth is that you almost can't tell what the truth is any longer!

    We have heard that hydroxychloroquine does not work. Then we hear that it DOES work if it is given early on. Just this week, an article in Newsweek, by a Yale professor of epidemiology, stated that according to his study of other studies, it does indeed help those at high risk, etc.

    This matter has been so deeply politicized, you can't tell if their saying things just to help Trump...or just to hurt Trump.

    Consider the claim that it does not work. Does that mean it has NO BENEFIT AT ALL to a patient...or just in patients that are nearly gone, etc.? It's about like a survey--the wording matters.

    You don't have to be a fan of Trump to accept that maybe this drug does have some role to play. I like Fauci, but I noticed something very bothersome the other day...

    In his appearance before Congress, he did everything he could to NOT say that the protesters were spreading COVID-19. Why not? Why not just come out and say that ANY group of people--INCLUDING PROTESTERS--is at danger of spreading the virus? He did say something about groups, but why was he so reluctant to say anything expressly about the most noted crowds that are gathering today? It makes me think there is a political angle on even his otherwise good judgment.

    Further, just because there has not yet been some full, double-blind study on hydroxychloroquine, doesn't mean it doesn't work. In an emergency, you work with what works; you don't wait until you have all the studies in--which is what some of the naysayers seem to want to do.

    At some point, someone found out that flour worked on smothering out a kitchen fire. I wonder how they did that? I doubt it has been fully tested in double-blind studies, but as I said, when you have an emergency, and if I'm the patient, I don't care if you say, "Hey, let's see if cheddar cheese works."

    If anyone died because someone refused to use hydroxychloroquine due it not having been fully and scientifically proven to be effective, that's a shame. If there is even anecdotal evidence for something, and nothing else is working, GIVE IT A TRY.

    Of course, if it works only in the early stages, why wait until the late stages?

    Again, all said with respect. This is NOT in support of Trump. But I do like that he gets that if there is some evidence that it helps, at least try it.

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    1. For those interested, this is the link to Dr. Risch's opinion piece in Newsweek:
      https://www.newsweek.com/key-defeating-covid-19-already-exists-we-need-start-using-it-opinion-1519535

      Aaron, I have not read Dr. Risch's original publication in the American Journal of Epidemiology (a well-respected journal), but I did find this commment about it:

      "Risch points readers to his review -- he is the only author -- published in late May in the American Journal of Epidemiology that cites five studies in support of HCQ, particularly when used early in the course of COVID-19.

      None are randomized controlled trials. One is the heavily publicized and now discredited French study by Didier Raoult, MD, and colleagues in March that sparked initial hopes for HCQ. Two have no corresponding data or publications.

      Risch asserts his own re-analysis of the French study suggests a stronger benefit for HCQ plus azithromycin when started earlier in the illness compared with standard of care. But researchers have called the original data involving only 42 patients "uninterpretable."

      A second study from Raoult's group published in May involved 973 patients all of whom got HCQ; there was no randomization or control.

      For his third study, Risch links to a two-page Google document by Vladimir Zelenko, MD, a doctor who cares for a large Orthodox Jewish population in Monsey, New York. Zelenko has made headlines for managing to catch the ear of FDA Commissioner Stephen Hahn, MD, to request help with access to HCQ for an outpatient trial.

      Risch cites data from Zelenko on 405 outpatients who were treated with HCQ, azithromycin, and zinc, of whom six were hospitalized and two died. There was no control group, and the Google document doesn't provide more detail on the data.

      The fourth citation is a controlled, but not randomized, study from Brazil with a total of 636 patients; 412 were treated with HCQ and azithromycin, with 224 who declined treatment serving as controls. Fewer of those on the drugs had to be hospitalized, but with no randomization, the treatment's role is uncertain.

      Finally, Risch cites a small ongoing study in a long-term care facility on Long Island in New York that gave HCQ plus doxycycline to about 200 high-risk COVID patients, again with no control group. Only nine died, suggesting a treatment benefit, but Risch gave no source for the data nor other details.

      Risch published a follow-up to that paper -- again in the American Journal of Epidemiology, on July 20, and again as sole author -- that outlined an additional seven studies that he said support HCQ early in disease. None appear to be large randomized controlled trials, though some have comparator groups. Some lack any citation at all. One study is additional data from Zelenko, on another 400 patients, but again unpublished and without full data.

      In the Newsweek editorial and in the later journal submission, both of which were published following three highly publicized randomized trials that reported no benefit from HCQ, Risch did not address or even acknowledge them.

      In a statement posted on Yale's website, Sten Vermund, MD, PhD, dean of the Yale School of Public Health, distanced himself from Risch's papers.

      "My role as Dean is not to suppress the work of the faculty, but rather, to support the academic freedom of our faculty, whether it is in the mainstream of thinking or is contrarian," Vermund wrote.

      "Yale-affiliated physicians used HCQ early in the response to COVID-19, but it is only used rarely at present due to evidence that it is ineffective and potentially risky."

      https://www.medpagetoday.com/infectiousdisease/covid19/87844

      And here is the Yale School of Public Health's response (cited above):
      This was a response published by the Yale School of Public Health:
      https://publichealth.yale.edu/news-article/26290/

      (to be continued)

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    2. (continued)

      Aaron, your questions are valid and well presented. I don't think I can answer them, but I can make a try at addressing them.

      I spent 30 years in academic medicine, both as a clinician (pulmonary/critical care) and as a bench researcher, publishing in peer-reviewed journals and reviewing others work for those journals. It is not at all unusual for medical research to produce opposing conclusions, so it requires intense mental rigor to weigh and compare studies.

      I'm sure you understand that statistical analysis is crucial. Joe flips a coin 100 times, gets 64 heads and claims it is not a fair coin. Mary flips it 100 times and gets 44 tails and claims it favors tails. You understand these two can argue all they want and not reach "truth."

      As you indicate, randomized, controlled, double-blind studies are desirable, but are extremely difficult to do because of all the factors that need to be "controlled" (age, sex, other diseases, ethnicity...).

      The coronavirus pandemic has resulted in many academic journals loosening their standards for publication in order to get information out as quickly and widely as possible, recognizing that many reports are anecdotal and uncontrolled. The NEJM has dropped its paywall to allow access to its coronavirus articles:

      https://www.nejm.org/coronavirus?query=main_nav_lg

      There obviously is bias in many medical reports - from both sides. Some of it not intentional, but arising because of the ethics and standards of the writers and researchers. On both sides of the questions.

      I do not have any doubts about Fauci. He has an unblemished career not only in research medicine, but in government-funded medical institutions. He understands the difference between his role as a researcher and that of a public policy adviser. He has specifically dodged questions about "should the country lock down" responding only with how best to control the virus - you work out the implementation. He wouldn't have replied that the protestors were spreading the virus unless there were DATA showing the protestors were spreading the virus, which AFAIK has not been forthcoming (or perhaps even studied).

      The scientist inside me cannot agree with your sentiment that "if there is anecdotal evidence for something, give it a try." There have been a lot of things that have been tried out on sick and dying patients who have "nothing to lose", but I cannot accept that approach.

      Delete
  13. Dr. Minnesostatan,

    There are things that can think are a sure thing, yet find out it wasn't nearly so effective as we thought. At the same time, for me, it's kind of like someone bleeding out and we, no having a sterile cloth handy, wrap the wound in an old tee-shirt or such.

    If there are things that have been PROVEN effective (via the kind of studies you indicate), then, indeed, let's use them. But in the absence of any such "cure," I would think that most would be willing to try hydro...xxx. After all, if the choice is between dying or trying an unproven drug, I'll take the latter.

    In any case, thank you for your reasoned reply. God bless.

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    1. Aaron, in this comment you are asking about giving hydroxychloroquine to a dying person. But note that your comment above suggests that hydroxychloroquine "does work if it is given early on." I think Risch himself said that using it in advanced cases was too complicated.

      There is an immense difference there, based on the maxim that is as old as medicine itself - "primum non nocere" (first do no harm). The principle harm to a doomed-to-die person is an extension of their suffering, since the hydroxychloroquine suggestion of efficacy might be survival for 50 days on a ventilator rather than 32 days without, before dying. There's no claim that you give it to the end-stage patient who then wakes up, says "get this tube out" and asks for food.

      But Risch wanted it given early. Suppose your wife were to visit with neighbors who then discover that their Covid swab screen done in preparation for colonoscopy turns out to be positive. Now your wife has known exposure but no illness. Give Hydroxychloroquine to prevent illness?? (that's why Trump said he took it). If she takes it and doesn't get ill, did it work?? That's one problem.

      But let's say I prescribe hydroxychloroquine for your exposed-but-healthy wife and two weeks later she develops aplastic anemia with a shutdown of her marrow. Into the hospital for her, strict isolation, maybe steroids, probably she will recover but unnecessary suffering and expense. Yes it was a 1:5000 chance and just bad luck, but it was also a small chance that she would develop illness and even smaller chance she would be hospitalized for that. Plus, now I worry that you're going to sue the shit out of me for causing her aplastic anemia.

      When you (hopefully never) have the option of "dying or trying an unproven drug", remember that the unproven drug is not the cheddar cheese you suggested earlier. The unproven drug may give you persistent nausea and vomiting, or painful bloating with abdominal gas, or mental confusion with hallucinations. Or it may simply prolong your life to endure whatever symptoms you're having with your underlying illness - the expanding metastases in your bone marrow for example. When it comes time to ponder death, talk to Hospice people and look at alternatives to experimental medicine.

      You're welcome to reply, but I'm going to sign off this discussion thread.

      Delete
    2. (I should have put "early on" in my second sentence in quotes or allcaps to clarify the point I was making)

      Delete
    3. One last final comment.

      I understand, Aaron, that you are concerned that there may be bias in the media or in the scientific world AGAINST hydroxychloroquine for political reasons.

      Please consider the alternate (but not mutually exclusive) possibility that there is bias FOR hydroxychloroquine. For financial reasons.

      A worldwide pandemic is music to the ears of pharmaceutical companies (and manufacturers of medical equipment). When a study reports a favorable response to a drug, what a reviewer needs to do is not only look at the data/controls/analysis etc, but also at the source of funding. Reputable journals will require researchers or investigators to disclose at the end of the article their funding. I don't have time to go to the study out of Brazil, for example, and see if it was funded by a pharmaceutical company that manufactures or distributes the drug.

      These financial incentives can be hidden from publications. A drug rep can bring meds for a hundred patients to a doctor, tell him to treat patients, and if the results look good, he and his wife will receive and all-expenses-paid trip to xyz.

      Or, the pharmaceutical company can fund 20 different studies by 20 different groups of doctors, not fiddle with the data or incentivize the doctors - but instead just have the results of the one or two favorable studies published, dismmissing the othes as "inconclusive."

      This has been going on forever. I'm not saying there is any fakery going on re hydroxychloroquine. But there are millions and billions of dollars involved.

      The same considerations will come up when a dozen different vaccines are brought on the market at the end of the year, with varying claims of efficacy. Billions of doses and hundreds of billions of dollars at stake. Immense incentive for deception.

      Delete
  14. the truth is that you almost can't tell what the truth is any longer!

    This is a feature, not a bug from Trump (and Bannon's) point of view. Trump is a master snake oil sales man. You can only sell fraudulent products if people get confused about what to believe. That's why you see so much 'Whataboutism'? It's a distraction technique. And to quite Steve Bannon: "If you cover everything with shit, everything stinks".

    https://www.vox.com/policy-and-politics/2020/1/16/20991816/impeachment-trial-trump-bannon-misinformation

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