There was also the infamous flip-flop on school reopening when the American Academy of Pediatrics (AAP) announced their strong support for reopening, only to reverse their position within a span of two weeks. All it took was Trump’s vocal push to reopen schools for the AAP and the teachers’ unions to circle the wagons and issue a joint statement that said “substantial new investments” would be required in order to reopen “safely” and that we should “listen to educators and administrators” about how to reopen schools.

School reopening instantly became a political lightning rod, with many experts driven more by ideology and groupthink than by what was best for children. The public health and medical experts failed us, and so did the media. Government messaging and news articles focused on the fears of school reopening, warning that children could get very sick or spread Covid to teachers and vulnerable relatives. Many of these articles included unsupported claims and inaccurate or misleading statistics, but they were very effective at scaring parents, teachers, and school and government officials. It took a long time for the truth to get through to a lot of people about how badly they were misled about our Covid response, especially regarding schools.

Over the past five years, I’ve repeatedly corrected the CDC, other government institutions, journalists, and Twitter doctors about their claims. I’ve sent many emails to academics, news editors, and government agencies to clarify data and ask for corrections. Unfortunately, people and organizations often stand by their incorrect statements, and when they do issue a correction, it’s typically seen by only a limited number of people. That’s a big part of what this Substack has been for — breaking down and sharing the truth about misleading studies, news articles, and government data.

But I have hope that the American public is becoming more aware of the realities of our flawed Covid response and the institutions that contributed to it. Books like In Covid's Wake: How Our Politics Failed Us by Frances E. Lee and Stephen Macedo and An Abundance of Caution: American Schools, the Virus, and a Story of Bad Decisions by David Zweig document some of the ways we were failed by scientists, politicians, and the media. Both books have received fairly widespread media coverage, and many people are now in agreement that much of our Covid response was heavy-handed and illogical. Our Covid mitigations did little to “slow the spread,” while causing significant harm to our children, the economy, and society as a whole.

Over the past five years, I’ve had the pleasure of meeting several of the people I’ve connected with on Twitter. I hosted a couple of gatherings with Matt Shapiro of for local Atlanta Georgia friends. And some of us met Dr. Vinay Prasad (recently tapped to lead the FDA’s CBER) when he came to Atlanta for a discussion with Carlos del Rio in 2024. Then last month, I had the pleasure of meeting many of my “Team Reality” Twitter friends at a party in Washington, D.C. to celebrate Dr. Jay Bhattacharya’s confirmation as NIH Director. Two weeks later, I enjoyed meeting several more people at David Zweig’s book launch event in New York City.

Meeting so many of my Covid heroes and Twitter friends was such a fun way to cap off five years of analyzing data and tweeting and writing about Covid from my home in Atlanta. After years of sharing studies and news articles, comparing notes, and answering questions on data and policy, it was nice to meet so many of these virtual friends in person, at a time when our ideas are finally seen as less “fringe” than they once were. In many ways, the five-year anniversary of Covid has felt like a turning point in the Covid discourse, where it’s now acceptable for mainstream people to acknowledge at least some of the excesses of our Covid response.

I received David’s book shortly before heading to New York City and started reading it on the plane. I plan to do a full review of it once I’m done, but so far, it feels like the exact book I would have written about Covid. I first came across David after reading his May 2020 article, The Case for Reopening Schools. I eventually got in touch with him, and we communicated many times in the years following, and it’s clear we are very much of the same mind about Covid.

One of the very first things I learned about Covid was that it had a strong age gradient, with school-age children at the lowest risk. As a mother, that was what mattered most to me, and I was thrilled. I never imagined I’d spend years arguing about that good news with people who were determined to keep parents afraid. I am so thankful we have his book to document what happened, and I hope people learn from the many ways things went wrong.

Public health, journalists, and the “expert class” in general lost a ton of credibility over the way they handled Covid. A lot of people who trusted these institutions in the past have been sorely disappointed. I spent the past five years begging the CDC and others in public health to do a better job of honestly and accurately communicating with the public. I’d love to see that actually happen.

Note: I paused subscription charges on this Substack about a year ago, and I am keeping them paused indefinitely, as I’m writing a lot less frequently than I used to. If anything changes, I will contact subscribers before resuming charges. If you aren’t already a subscriber, but want to be notified of any of my future pieces, I encourage you to subscribe for free.

I have taken a long break from publishing any new articles, and paid subscriptions are still paused indefinitely, but I wanted to send out the following article in honor of Dr. Jay Bhattacharya, as a show of support for his nomination as NIH Director.

With Dr. Jay Bhattacharya in DC today for his confirmation hearing, you’ve probably heard a lot about the Great Barrington Declaration again. You’ve probably heard how the previous NIH Director, Francis Collins, called Dr. Jay a “fringe epidemiologist” and insisted we needed a “quick and devastating published take down” of the GBD. What you may not realize is how many people were saying things very similar to the Great Barrington Declaration in early 2020. Many of the principles behind the GBD were commonly-held beliefs in epidemiology and public health, and often found in basic pandemic plans until Covid hit. Phrases like “herd immunity” and “focused protection” and “shielding the vulnerable” from GBD authors were lambasted as irresponsible and impractical, but in reality, they are not that different from what many experts were saying early-on.

Of course, many of these experts later changed their tune, and I’m sure they justify their about-face for one reason or another, but it’s hard to argue that Dr. Jay’s ideas were “fringe” or completely unorthodox. The truth is, they echoed what many people said in early 2020 before panic took over. That’s when so many of the “experts” seemingly chose to ignore basic public health principles of balancing risks and benefits of interventions and maintaining a functioning society, and instead adopted a wildly different approach to Covid.

As Collins later acknowledged, the public health establishment in the government had a monomaniacal focus on stopping Covid, without giving any consideration at all to whether the response “totally disrupts people's lives, ruins the economy,” and harms children by keeping kids out of school for extended periods. He claimed this is the “public health mindset” — but it’s not supposed to be! Public health training is supposed to be all about balancing benefits and harms; but considering most public health experts either abandoned or forgot that during Covid, I have to wonder if maybe that's no longer a fundamental aspect of the current field of public health industry.

Below are some highlights of experts who sounded very reasonable about Covid early on about how we should respond:

Michael Osterholm

Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota (and later a member of the Biden transition team’s COVID-19 Advisory Board), wrote an op-ed in the Wall Street Journal in March 2020, titled “Facing Covid-19 Reality: A National Lockdown Is No Cure.” It was hard to even choose quotes to highlight from this article, because the whole thing reads like the Great Barrington Declaration, with discussion of minimizing harms to the economy and society, carefully considering second-order effects of things like business and school closures, emphasizing the impact of herd immunity, and protecting the elderly and at-risk while the young and healthy keep society running. (Osterholm was also vocal about cloth masks being oversold as a way to stop the pandemic.)

“Covid-19 will go away eventually in one of two ways. Either we will develop a vaccine to prevent it, or the virus will burn itself out as the spread of infection comes to confer a form of herd immunity on the population.”

“Hong Kong closed schools; Singapore did not, and there was hardly any difference in the rate of transmission. The second-order effect of shutting schools is that hardest hit will be those least able to afford to miss work to care for homebound children.”

“Consider the effect of shutting down…. The likely result would be not just a depression but a complete economic breakdown…. We can’t have everyone stay home and still produce and distribute the basics needed to sustain life and fight the disease.”

Jeremy Faust

Jeremy Faust, an ER doctor at Brigham and Women’s Hospital who teaches at Harvard Medical School, wrote this reassuring article about Covid for Slate in March 2020, encouraging protection of those at high-risk instead of “worrying about preventing systemic spread among healthy people”. Sound familiar?

“This all suggests that COVID-19 is a relatively benign disease for most young people, and a potentially devastating one for the old and chronically ill, albeit not nearly as risky as reported. Given the low mortality rate among younger patients with coronavirus … we need to divert our focus away from worrying about preventing systemic spread among healthy people—which is likely either inevitable, or out of our control—and commit most if not all of our resources toward protecting those truly at risk of developing critical illness and even death: everyone over 70, and people who are already at higher risk from this kind of virus.”

(Of course, he later became a Covid alarmist. Somewhat ironically, He wrote an op-ed in The New York Times with Rochelle Walensky in December 2020, titled, “People Thought Covid-19 Was Relatively Harmless for Younger Adults. They Were Wrong,” in which they blamed all excess mortality in young people on undiagnosed Covid, incorrectly dismissing other causes of death, like overdoses. Just two months later, in February 2021, he released a new paper, acknowledging that drug overdoses, murders, and motor vehicle accidents, all increased sharply in summer 2020, contributing significantly to excess mortality among young people in 2020.)

Anthony Fauci

Anthony Fauci (NIAID), Clifford Lane (NIAID), and Robert Redfield (CDC), published an editorial in Feb. 2020 in The New England Journal of Medicine about Covid, in which they also predicted the fatality rate would be less than originally reported, and suggested that the US may need to move to mitigation efforts such as voluntary isolation of sick people (in contrast to required quarantine of healthy individuals, which became a key part of the US response):

“If one assumes that the number of asymptomatic or minimally symptomatic cases is several times as high as the number of reported cases, the case fatality rate may be considerably less than 1%. This suggests that the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%) or a pandemic influenza (similar to those in 1957 and 1968)…”

Marc Lipsitch

In February and March of 2020, Harvard epidemiology professor Marc Lipsitch was interviewed by reporters for The Atlantic and CBS News. He predicted that the majority of people would ultimately become infected with Covid and that it would not be able to be contained, noting that the risk was concentrated in the elderly, and that many would have mild disease. Like the NEJM article, he also recommended the age-old advice of staying home when sick, and suggested voluntary limitations on public gatherings were likely.

In February 2020, he told The Atlantic’s James Hamblin, “I think the likely outcome is that it will ultimately not be containable,” and that “it’s likely that many will have mild disease, or may be asymptomatic….”

In March 2020, he spoke to CBS News about the inevitability of widespread disease and death, focused in the elderly:

“If it really does spread as widely as that projection says, and that's what I think is likely to happen, then there are gonna be millions of people dying. And I don't think there's any way to get around that…. So the susceptibility to symptomatic infection seems to go up strictly with age, and especially up at the very oldest ages. Among those who are symptomatic, the risk of dying goes up further. So it really is concentrated in those older age groups, the high risk…. I think it is now almost inevitable that this will transmit in a global fashion and take a big toll on essentially the entire globe. I just don't see any way around that….”

Henderson, Inglesby, and Nuzzo

For more reading on this topic, I suggest reading the 2006 paper by famed epidemiologist D.A. Henderson, “Disease Mitigation Measures in the Control of Pandemic Influenza,” which concluded with this “overriding principle”:

Unfortunately, D.A. Henderson, who is credited with the worldwide eradication of smallpox, died in 2016. But two of his co-authors on that paper, Tom Inglesby and Jennifer Nuzzo, were quoted early on expressing some of the same views discussed in the paper. Tom Inglesby wrote a long Twitter thread in early February 2020 that included these key points:

Jennifer Nuzzo told New Scientist in February 2020 that she was concerned about the harms of stringent interventions in China and discussed how she thought the US should be preparing for Covid.

“…Nuzzo thinks it is already too late to stop the virus going pandemic, and that China’s drastic measures to contain it will cause a lot of harm. ‘I’m really worried about the potential disruption that their measures will cause,’ she says. Nuzzo thinks efforts should focus on preparing communities to cope with the virus rather than trying to halt its spread.”

She was also an early outspoken critic of both travel bans/quarantines and school closures. In a February op-ed for The Washington Post about travel bans, she wrote:

“If leaders use their influence in support of evidence-based measures, rather than ones that risk increasing the social and economic tolls of the epidemic, it will be helpful to the coronavirus response.”

In March 2020, she wrote an op-ed in The New York Times, arguing against school closures:

“Though there may be an inclination to present school closings as a well-established tool to protect public health, their full impact is simply unknown. Downplaying the disruption these measures may cause or overstating their benefits can erode public confidence in government at a time when it is needed the most.”

In closing, imagine what our Covid response would have been like if those in charge had retained some of these critical principles of epidemiology and public health beyond March 2020. While experts may take issue with some individual elements of The Great Barrington Declaration, I saw it as an attempted return to sanity, and an opening to discuss the harms of our approach. Unfortunately, there was coordinated effort to discredit the ideas in it, and the people behind it. Five years later, I wonder if we have learned anything from the massive global panic that accompanied Covid. I hope Dr. Bhattacharya is given the opportunity to take the reins at NIH, and see if we can move towards a more evidence-based approach to US public health.

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What’s all the talk about clades?

The monkeypox virus (MPVX), which causes the disease now known as mpox, has been endemic to central and western Africa for decades. Two versions, or clades, of the virus have been spreading in Africa for many years: clade 1, previously known as the Congo Basin clade, and clade 2, previously known as the West Africa clade1. Of these endemic clades, clade 1 has historically been more severe than clade 2.2

In 2022, a variant of clade 2 known as clade 2b (IIb) began spreading globally, primarily through sexual contact among gay and bisexual men (also referred to as MSM, “men who have sex with men”). That outbreak spread quickly, then peaked and numbers have been low since, due to some combination immunity from infection and vaccination, as well as awareness and behavior changes. Clade 2b also had a lower fatality rate globally than previously seen with clade 2a in Africa.

The current 2024 outbreak is being driven by clade 1 — both the endemic 1a variety, as well as a new variant known as clade 1b.

Clade 1b (Ib) was discovered in Africa in late 2023 and began spreading quickly in the eastern portion of the Democratic Republic of Congo (DRC) and neighboring countries, primarily through sexual contact — but not only among men. This version has also been affecting women, with spread seen among sex workers.3 It’s still early to know much with certainty about this newest strain, but reports that clade 1b is the “deadliest yet” are unfounded.

An early outbreak of 1b in the South Kivu region of DRC had a CFR (case fatality rate) of 0.6% among ~3000 cases.4 Clade 1b has also spread among children and young people in the country of Burundi, which borders South Kivu, but no fatalities have been reported yet from the outbreak in Burundi.5

According to the European CDC, “preliminary data show that infections by clade Ib virus concern mostly the adult population, whereas infections by clade Ia concern mostly children.”6

While the outbreak in Africa involves both clade 1a and 1b, the WHO seems to be more concerned about clade 1b spreading to other countries. I suspect this because sexual networks are larger and more geographically diverse, giving more opportunity for spread outside of Africa than clade 1a, which spreads more from infected animals and within families.

More Details about Transmission & Severity

More information about the four varieties of mpox are detailed below. The two that are driving the current outbreak are clade 1a and 1b. However, clade 2 is still circulating in endemic parts of Africa, and clade 2b is still being found in countries all over the world — but in much smaller numbers than during the 2022 outbreak. When you hear about a suspected case of mpox in the news, it’s important to wait and find out what clade it is. We shouldn’t be surprised to see sporadic reports of clade 2b, particularly among MSM.

As of August 25, 2024, we only have two confirmed reports of clade 1 outside of Africa (both clade 1b) — in Sweden and in Thailand. Both cases were in travelers who recently came from affected areas in Africa. Other news reports about suspected cases turned out to be clade 2b or not mpox at all.

In countries in Africa where mpox is endemic, it has been known to spread through a variety of methods, both from animals and infected people to their close contacts7:

• Close physical contact: The virus spreads via skin-to-skin contact with sores, through saliva and other bodily fluids, during sex or other intimate interactions, and from pregnant mothers to their unborn babies.

  • NOTE: Some sources list “talking or breathing close” as potential avenues for transmission, but it is thought that cases of true respiratory spread are rare. The CDC specifies prolonged close contact for these avenues, which would likely also include some aspect of touch or droplet spread.

• Surfaces/objects: Shared items such as bedding, clothes, dishes, etc. may spread the disease if contaminated by an infected person.

• Infected animals: In areas of Central and Western Africa, small wild animals carry the MPVX virus, and it can spread through close contact with these animals or their bodily fluids or feces, or by hunting and eating these animals.

• During pregnancy: An infected mother may pass the virus on to her unborn baby.

While it is still early, and testing and case reporting in African countries is imprecise, it appears that the new clade 1b may have lower severity than the endemic clade 1a, just like clade 2b had lower severity than the endemic clade 2a. Many reports have claimed that this new variant is known to be the most deadly, but they seem to be conflating the new clade 1b with the endemic clade 1a.

Why did the WHO declare an emergency over mpox?

The World Health Organization (WHO) recently declared a Public Health Emergency of International Concern (PHEIC) to alert countries around the world about the increased spread in Africa. They were concerned about the new 1b clade spreading via sexual networks outside of Africa, much like clade 2b did in 2022. They also wanted to draw international resources (public health response teams, funding, and vaccines) to Africa to help curtail the spread there. DRC has been in political turmoil, and needs assistance in responding to the outbreak.

What about children? Should we worry about schools?

Endemic versions of mpox have often caused outbreaks among families and children — this is not new. The clade 2b outbreak in 2022 did not affect many children, but fears about spread in schools and colleges were not uncommon on social media and even in mainstream media based on claims by some medical and public health in the US. We’re already seeing a lot of fear mongering about this new variant affecting more children. While children have made up the majority of cases and deaths during the current outbreak in Africa, the majority of this is believed to be spread of the endemic clade 1a that has historically affected children and families — not the new clade 1b.

The Burundi outbreak of clade 1b has impacted children, but there have been no fatalities reported. Typically, children have had the highest fatality rates of the endemic strains of mpox, but we do not yet have data about infection or fatality rates for the new clade 1b among children. At this point, there is no reason to fear school closures or spread of mpox in schools outside of Africa.

Why would spread in Africa be different than the US?

To understand the increased risk of spread among children and families in central Africa compared to the risk in the US, you must recognize how different the situation is in Africa. Children in central Africa are often malnourished and sick with other diseases, making them more vulnerable. In addition, their sanitation systems and hygiene practices are not like in the US, and many families live in overcrowded housing and shelters, and they share beds and other personal items. Conflict/war in DRC has also contributed to deteriorating conditions in the area.

In addition, the education and healthcare systems in central Africa are vastly different than the US, so they may not have appropriate information about how to prevent the spread of mpox, and their hospitals are not as equipped to isolate and treat those infected. In addition, many children and young people are exposed to mpox when hunting, skinning, or cooking wild animals in central Africa that carry the disease. These factors all lead to vastly more opportunities for mpox to spread among children and families in central Africa than in the West.

What should we do?

For now, helping to slow the outbreak in Africa will help protect other countries around the world. Some countries are donating vaccines, some are sending teams or other resources to help educate and train people on the ground in Africa. It’s also important to increase awareness about transmission and symptoms to those traveling to or from Africa, and respond quickly if cases are imported or found to be spreading in other countries outside the affected region. Other than that, the risk in the US and other Western nations remains low at this time.

In the US, the CDC is continuing to recommend mpox vaccination for gay/bisexual men at risk of contracting the disease. Some countries, like Sweden, are also beginning to vaccinate aid workers and healthcare workers who will be working in locations with active outbreaks.

One final thought…

There has been a great deal of fear mongering since the WHO announced the PHEIC along the lines of “mpox is back, it’s more deadly than ever, and this time it’s coming for your kids!”

This is irresponsible and inaccurate messaging. Many people have blamed public health for these exaggerations, assuming it’s propaganda from the WHO. After Covid, I absolutely understand this tendency to blame public health for exaggerating the risk. However, in the case of mpox, I have actually found official messaging from health agencies to be more factual and reassuring, while the media has been talking to “experts” who are getting the data wrong and exaggerating the risk to countries outside of Africa from the current outbreak. Please be sure you’re getting your information from reliable sources.

References:

There were many different arguments made in favor of school reopening — schools are important to children, families, and society at large for many reasons. We knew that children were being harmed by long-term school closures, that kids were among the least at risk from Covid, and that schools could reopen safely without driving spread in the community. As a vocal school reopening advocate myself, I could write a whole article on this, but it hardly seems necessary now that most experts readily acknowledge that long-term school closures were a failed policy that should never be repeated.

But debate over his tweets about school reopening led Dr. Adams to make a fairly outrageous claim about children and Long Covid that I think needs to be addressed, given his position as former Surgeon General, and the complete lack of evidence supporting his assertion. He claimed that most US pediatricians “are increasingly concerned about the long-term neuro cognitive impacts of repeated Covid infections.” And he bullied and maligned doctors who dared disagree with him, much like he bullied me in the past when I debunked a pre-print and CDC presentation that falsely claimed that Covid was a top five cause of death for children.

He also made the strawman argument that the UK doctors who pushed back on his claims were saying that Long Covid isn’t an issue “AT ALL.” (As usual with Covid discourse, nuance is completely dead.)

I want to be clear — those disputing Dr. Adams’ claim are not saying that children are never affected by post-Covid health issues. They are just suggesting that those issues are not substantially different than post-viral issues from flu or RSV or other illnesses.

One of the claims Dr. Adams keeps repeating is that most Long Covid results from mild infections. This is true, but only because the vast majority of Covid infections are mild, so even a small percentage of those cases adds up. It is well-established that severity of acute infection is a strong risk factor for post-Covid conditions, and it is also well-known that Covid infections are typically more mild in children.

Evaluating the Evidence

In an attempt to back up his claims, Dr. Adams shared several links to articles and studies about Long Covid and kids. I have gone through his articles and studies one-by-one to show that they do not, in fact, support his assertion that Long Covid in kids is a growing concern among US pediatricians.

“Millions of US Children Experience Range of Long COVID Effects”
(JAMA Medical News in Brief, February 2024)

I do not have full access to this full article because it’s behind a paywall, but it appears to be just a JAMA news summary of a narrative review that was published in Pediatrics, the journal of the American Academy of Pediatrics (AAP). Another AAP paper about quality evidence states that narrative reviews are different from systematic reviews and can be “susceptible to selection bias through omission of key studies or bias from emphasis of results produced by flawed methods.” The AAP narrative review on Long Covid includes the following claim:

“Given that ∼20% of COVID cases in the United States are in children, and that current pediatric postacute sequelae of SARS CoV-2 (PASC) prevalence estimates are 10% to 20%, PASC is estimated to affect up to 5.8 million children, representing a significant community impact.”

This is a very questionable estimate based on a weak understanding of the data, which I have tweeted about before. It was also criticized by biologist David Wessner in Forbes, who noted, “it’s unclear how the authors determined that 10-20% of children with Covid-19 will develop long Covid.” He also noted that Dr. Suchitra Rao and some of the other authors of the current Pediatrics review previously published a study in JAMA that concluded, “PASC in children appears to be uncommon.” (PASC, post-acute sequelae of SARS-CoV-2, is another name for Long Covid.)

In addition, Dr. Melissa Stockwell, one of the lead authors on the narrative review was interviewed for The Sick Times, in which she stated that part of the reason for the paper was that “pediatricians just don’t know about this [Long Covid in kids].” That seems to be evidence that most US pediatricians are not, in fact, concerned about post-Covid impact in kids, directly contradicting Dr. Adams’ claim.

Battling long COVID: Pediatricians talk strategies, prevention measures for children with lingering symptoms
(AAP News, April 2023)

This is a news article featuring a Long Covid advocate, Dr. Amy Edwards, who founded and is now the Director of the Pediatric COVID Recovery Clinic at UH Rainbow Babies & Children’s Hospital. Of course doctors who run Long Covid clinics see a lot of Long Covid patients, but that doesn’t tell us much. The theme of this article, and much of Dr. Edward’s advocacy, is about increasing awareness that children can get Long Covid. This is not disputed by those who disagreed with Dr. Adams, and again, the need for an awareness campaign seems to be evidence that most pediatricians are not especially concerned about post-Covid impact in kids.

Long-COVID in children and adolescents: a systematic review and meta-analyses
(Scientific Reports, June 2022)

Dr. Adams claimed this systematic review was published in Nature (a prestigious journal), but it was actually published in Scientific Reports, an open-access journal launched by Nature.

This paper is from Dr. Sandra Lopez-Leon, another Long Covid researcher. I previously critiqued a flawed systematic review she did on Long Covid in adults that estimated an unrealistic Long Covid prevalence of 80%, so I approached her systematic review on pediatric Long Covid with similar level of skepticism.

This review and meta-analysis of Long Covid in kids found a prevalence of 25.24% in children, but it is skewed by a few anomalous studies that were included in the analysis that showed very high prevalence:

• Stephenson found 66% prevalence of symptoms in UK children after 3 months in the Covid-19 group, but also found 53% of the control group had symptoms at three months. The Lancet also published a detailed response to this paper that points out some additional issues with these findings.

• Roge found 70% Long Covid prevalence in Latvia (inexplicably listed as 64% in the systematic review), but it was performed at a hospital with a pediatric Long Covid clinic. Study participants applied for “an in-depth evaluation and long-term medical surveillance after SARS-CoV-2 infection” or were referred to the hospital’s services by doctors. This greatly skews the study cohort toward children who were experiencing Long Covid symptoms.

• Asadi-Pooya found 45% prevalence of Long Covid, among a small cohort of children hospitalized for Covid in Iran in 2020. 31% of those who reported Long Covid were admitted to the ICU during their hospital stay.

• Fink found 43% prevalence of Long Covid among a small cohort in Brazil, but 83% had a pre-existing immunosuppressive condition, and 38% were hospitalized during the acute phase of Covid.

These four studies clearly skewed the prevalence higher, and there were several additional studies in the analysis that only included hospitalized patients. Confounders and biases like these make any prevalence estimates from this data worthless.

Not 'little adults': Experts say long COVID undercounted, misdiagnosed in kids
(CIDRAP, October 2023)

This is an article in CIDRAP, a publication that has repeatedly posted misleading and inaccurate claims about Covid, particularly about Long Covid and about children. This article is based not on a specific study, but on the overall topic of kids and Covid, based on interviews with three Long Covid activists — two researchers, David Putrino and Ziyad Al-Aly, plus Hannah Davis, the cofounder of the Long Covid advocacy group Patient-Led Research Collaborative. This is clearly an advocacy piece, not an unbiased assessment that represents the majority opinion on Long Covid in children.

Putrino is a Long Covid researcher and activist, who is well known for making outrageous and unsupported Long Covid claims. During his recent appearance on NewsNation with Chris Cuomo, he claimed without evidence that “there is no such thing as a mild SARS-CoV-2 infection. There is no such thing as a SARS-CoV-2 infection that does not have prolonged consequences.” Al-Aly is another high-profile Long Covid researcher and outspoken activist, who has spent the last four years publishing Long Covid studies based on electronic health records from the Veterans Affairs system. EHR data is prone to coding issues, plus this is a cohort of mostly older men, so the findings cannot be generalized to the wider US population, much less the pediatric population. Both of these researchers are incentivized to exaggerate Long Covid prevalence in order to advocate for more grant money for Long Covid research — because that’s what funds their work.

The reality of pediatric long COVID
(APA Monitor on Psychology, April 2023)

Finally, this article in the magazine of the American Psychological Association (APA) is an overview of pediatric Long Covid that examines how psychologists can help treat it and calls for more research. It doesn’t include any evidence of widespread concern among pediatricians over cognitive impacts. The article, written by a freelance journalist, says the following about Long Covid prevalence:

“Even calculating the prevalence of the syndrome in children has been a challenge. Early estimates ranged from 4% to 66% of those infected with the virus, but recent calculations fall closer to 10% (Zimmermann, P., et al., The Pediatric Infectious Disease Journal, Vol. 40, No. 12, 2021; Radtke, T., et al., JAMA, Vol. 326, No. 9, 2021).”

It is unclear where this article’s 10% estimate comes from. The 4-66% range mentioned comes from the Zimmermann paper that is cited, which noted major limitations in the underlying Long Covid studies, including poor case definitions, lack of control groups to distinguish symptoms caused by infection versus those causes by other aspects of the pandemic, and selection bias due to low response rate.

“In summary, the evidence for long COVID in children and adolescents is limited, and all studies to date have substantial limitations or do not show a difference between children who had been infected by SARS-CoV-2 and those who were not. The absence of a control group in the majority of studies makes it difficult to separate symptoms attributable to long COVID from pandemic-associated symptoms.” (Zimmermann et al., 2021)

The Radtke study that she cited reported very low prevalence of Long Covid in children, with 4% of seropositive children versus 2% of seronegative children reporting 1 or more symptoms that lasted longer than 12 weeks. So it is not clear how the author concluded that recent data was coalescing around a 10% prevalence of pediatric Long Covid.

Final Thoughts…

Dr. Jerome Adams, an anesthesiologist and the former US Surgeon General, would like to believe that he speaks for most US pediatricians, but in reality, he is listening to the most extreme Long Covid advocates and assuming that is a baseline for most American doctors. The studies and articles he linked are evidence that pediatric Long Covid exists and is important to study, but do not support his assertion that the cognitive impacts of repeat infections are a growing concern among the majority of US pediatricians.

Dr. Adams took any opposition as Long Covid denialism instead of carefully listening to what pediatric specialists from the UK and US were telling him. He seemed to assume the worst about anyone who disagrees, arguing that they were dismissive, uninformed, disrespectful, and uninterested in scientific discussion. However, I’d suggest that’s a description of his own tweets on this topic over the past several days. He even accused Dr. Mark Lindsay, a pediatric cardiologist at Massachusetts General, of having Long Covid cognitive impairment — simply for stating the obvious truth that most US pediatricians are not concerned about neuro cognitive issues stemming from repeat Covid-19 infections in children.

I would urge Dr. Adams to do some introspection on his beliefs about pediatric Long Covid, as well as his behavior with other doctors and scientists. He points the finger at others, but doesn’t seem to recognize his own recent behavior on Twitter was of a doctor engaging respectfully and learning from others with differing viewpoints and pediatric expertise. He jumped right to attacks instead of scientific discourse. Hopefully he will take the time to read this article and consider that his perspective on Long Covid and kids might be skewed by a few vocal activists, and is not representative of the concerns of most doctors. Everyone who disagrees with him should not be treated like a brain-damaged science denier.

I’ve been very busy lately with my actual job and some other things, so I haven’t been writing much lately. I paused paid subscriptions for the summer to try and get caught up. I’m not taking the summer off - I plan to start writing again even while payments are paused. Hopefully you’ll be hearing more from me soon! Today seemed like a good day to start…

I woke up to this outrageous claim from CIDRAP in my Twitter feed:

This is not the first time that I’ve written about CIDRAP amplifying misleading claims from a Covid study to amp up fears about Covid and kids. They also misreported a study about Long Covid, claiming that 84% of Covid survivors had Long Covid symptoms 2 years later. Like that ridiculous Long Covid claim, the claim from their current tweet and article on Covid risks among kids just doesn’t pass a basic sanity check. Michael Mina did some basic math to show how absurd this claim is:

Unfortunately, the reporters at CIDRAP (along with many other Covid journalists and even some scientists) seem to lack the common sense to do these kinds of sanity checks on the data — because this keeps happening.

A Meta-Analysis of “Risk Factors for Pediatric Critical COVID-19”

The study, “Risk Factors for Pediatric Critical COVID-19: A Systematic Review and Meta-Analysis” is primarily about which comorbidities are risk factors for severe Covid — it’s focused on severe cases and kids with comorbidities. However, the study does include the 4% claim cited by CIDRAP. I can’t access the full text of the published paper from the Journal of the Pediatric Infectious Diseases Society, but the study’s abstract does state: “In previously healthy children, the absolute risk of critical disease from COVID-19 was 4% (95% CI, 1%-10%).” I wanted more details of the underlying data, so I found the pre-print of the study, and the following section of the Results is where this 4% statistic comes from:

This small section is the only mention of outcomes in children without comorbidities, and it doesn’t include nearly enough caveats about the underlying data. It is a poor conclusion to draw and shouldn’t have been included in the abstract at all in my opinion. The abstract even says that “the absolute risk for critical COVID-19 in children and adolescents without underlying health conditions is relatively low,” which doesn’t seem consistent with a 4% “absolute risk of critical disease” from their results. In reality, the absolute risk among previously healthy children is at least an order of magnitude lower than that.

Underlying Study Data

It should be obvious to the casual observer that the 4% was calculated from a population that doesn’t represent typical healthy children. So I looked up each of the 6 studies included in this subset of studies from the meta-analysis. Of the 6 studies that looked at medical complexity, 4 were among hospitalized children (3 of the 4 in Brazil)1, one was among 12-17-year-olds with symptomatic Covid recorded in medical records2, and one was a large study of children with documented Covid in Mexico3.

Also, all of the studies were from early in the pandemic (2020 and part of 2021), so they were primarily first infections, they were primarily pre-vaccine, and all were pre-Omicron. So they don’t tell us much about the current situation, even among children who may be hospitalized with Covid in 2024.

The large study in Mexico included over 130,000 children and found 0.3% of children with documented Covid infections and no comorbidities died between March 2020 and mid-June 2021. And that is still biased to more severe cases, because many asymptomatic and mild infections aren’t documented in medical records. Despite the overwhelming findings from this large study of children from the broader community (not just hospitalized children), the study authors calculated an absolute risk from a small subset of children from these 6 studies (less than 16,000 patients). They don’t provide any further details the subset that they used for their calculations, but clearly the studies of hospitalized children and symptomatic teens skewed the results significantly.

Denominators Matter

There’s been much discussion about the importance of denominators throughout the pandemic, but scientists, journalists, and others keep making the same mistakes. When we use percentages to talk about Covid outcomes or other things, we’re talking about a fraction of the population. But it’s super important to understand WHICH population we’re talking about. Outcomes among hospitalized patients, or among the elderly, differ greatly from outcomes in the general population.

Just like the percentage of adults who ride mountain bikes is much higher among attendees at a mountain biking race than among all adults, the percentage of children with critical Covid is obviously much higher among children who are hospitalized for Covid than among all children. We see this same error with Long Covid studies, where the findings are percentages among patients at a Long Covid clinic, or among patients who already have Long Covid, but are often reported as if they are percentages among a representative sample of the population.

The Sad State of Covid Science and Journalism

The authors of this study were irresponsible to include the claim that “the absolute risk of critical disease from COVID-19 was 4%” among healthy children without comorbidities, without explaining that their data was heavily biased toward patients already hospitalized with COVID. Without that caveat, the 4% claim is a gross misrepresentation of the underlying data. And this study isn’t from some obscure scientist at a no-name institution — the senior author, Dr. Carlos Oliveira, is an Assistant Professor of Pediatrics, Biostatistics, and Biomedical Informatics & Data Science at Yale! Surely he knows that 4% of American children didn’t have severe Covid outcomes. Why include that misleading statistic in the paper?!?

I also think the writers at CIDRAP needs to do a better job of understanding and vetting the studies they report on to make sure their reporting is accurate. They are a trusted voice for many people, and their studies often get amplified by the Zero Covid crowd on Twitter. It is profoundly unhelpful to continue scaring people with these misleading and unrealistic statistics. Journalists need to understand the harm they cause by publishing these irresponsible claims.

By the way… I’m already seeing this same error with H5N1 (bird flu) in the media as well, and will probably write more on that later. Many news reports refer to a 50% “fatality rate”, but that’s only among known cases that were previously documented. Among the 3 cases identified so far in the US (one in 2022 and two this year), none have died. The two known cases this year have only experienced eye infections.
UPDATE: The moment I published this, I saw that another case of H5N1 has been identified in the US. That patient did have respiratory symptoms but is recovering. (5/30/24)

Last week, Dr. Katelyn Jetelina, aka “Your Local Epidemiologist”, published an article we co-wrote about our conversation on the loss of trust in public health. We got a big response, and I wanted to take some time to address some of the feedback we received, both positive and negative. Katelyn had the same idea, and though we wrote our responses independently, we identified many of the same themes in the feedback. My response is below, and you can read Katelyn’s response here.

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A lot of the feedback was positive, with comments like this:

Wonderful! We need more respectful dialogue between people who disagree.

Absolutely, and that’s why I reached out to Katelyn in the first place. I also reached out to others throughout the pandemic, in hopes of engaging in some healthy dialogue about Covid and our response because I wanted to actually make an impact. With tensions high during the pandemic, many people weren’t willing to listen to any dissenting voices, but I’m hopeful that we’re at a place now where there’s a little more willingness now to look back at the past four years and discuss what happened.

On the other hand, there was also some of this…

Kelley is a minimizer, how dare you platform her! / Katelyn is bad, don’t trust her!

Honestly, I was nervous we’d see a lot more of this from both sides, but it wasn’t as bad as I anticipated, which was a relief. There’s a tendency to unfairly malign people who weren’t on your “side” during Covid. I admit, I got pretty frustrated with people at times, but I tried to focus my criticisms at ideas, not people, to keep it productive. And I was always honest about the data. Reasonable people can disagree on the interpretation of the data, or the value judgments people make based on it, but I think honesty about what we know and don’t know is critical.

When I posted our article on Twitter, I saw a lot of comments along these lines:

I still don’t trust public health. Where’s the accountability and apologies?

I get this. I really do. I started tweeting in May 2020 about school reopening, and the New York Times finally published an article this week acknowledging much of what many of us have been saying for years. And some people are still pushing back and defending school closures!

This conversation with Katelyn wasn’t meant to suggest that we’ve mended all the fences and public trust has been restored. But I think an important first step is to open up the dialogue and help the public health community understand that people who fought against things like school closures, mask mandates, and vaccine mandates, include thoughtful, data-driven people. We aren’t evil people who don’t care about the health of children and grandmas — we just think many aspects of health and well-being other than avoiding Covid weren’t given enough weight in the pandemic response.

To truly regain our trust, public health needs to acknowledge things they got wrong, admit areas where there is uncertainty, and rely more on data-driven risk/benefit analysis in future recommendations.

Meanwhile, Katelyn’s Substack comments included the flip side of those complaints:

I don’t trust public health because they gave up fighting Covid.

To these folks, I’m not sure what to say, other than I am sorry that public health spent the past four years terrifying you about a virus that was never going to be stopped and that we are all going to get at some point, likely many times throughout our lives. Anthony LaMesa refers to the US approach in many respects as “Zero Covid-lite” — public health gave false promises of containment or near eradication that were overly optimistic and that ignored the enormous societal costs it would take to try and achieve.

I think many people in public health are now in the precarious position of trying to carefully back down from some of their earlier rhetoric without losing credibility among those who they spent years stirring up into a panic. The CDC has faced harsh criticism by the Covid cautious for some of their updated guidance, when in reality, the CDC is 1-2 years behind many other countries at acknowledging the reality of Covid as an endemic respiratory virus.

Another comment I saw a lot in Katelyn’s Substack comments…

The problem is that everything was politicized!

This is a common complaint among those on the left, who want to blame Trump and his influence on the CDC for every bad thing that happened in the pandemic. Honestly, I don’t think it would have made much difference who was president. No country had a magical solution that saved people from Covid. Any country that people pointed to as a success at some point — from the Czech Republic to New Zealand to China all had a huge wave of Covid later on. The level of restrictions required to control Covid while waiting for vaccines was massive, and frankly, not compatible with American values and freedoms.

And things were certainly politicized in the other direction as well. The Biden campaign pushed hard on the message that schools weren’t safe, and that they couldn’t be reopened without a huge infusion of government money (much of which wasn’t ever used to help reopen schools). And once Biden took office, his administration did everything they could in an effort to prove that “they took Covid seriously,” but there’s no solid data that their approach was any more effective.

One of the major issues we saw was that the science itself was often politicized — many studies were published that seemed to push a predetermined narrative rather than test a hypothesis and then come to an objective conclusion. I’ve spent a lot of time on Twitter and my Substack exposing flaws in some of these studies, and the state of “the science” has been frustrating to say the least.

Even if the science were politically neutral, it’s still up to politicians to make decisions for the country/state/locality about how to respond, given what the data shows. There’s more to navigating through a pandemic than just “following the science” as the following study, by famed epidemiologist D. A. Henderson and colleagues, so aptly described in this “overriding principle” below:

Finally, a few comments were more specific, and I want to touch on those as well. The one thing I wrote about that several people reacted strongly to is this:

Kelley didn’t know people who were hospitalized or died?!?

To be clear, I wasn’t denying that people were hospitalized or died from Covid, but I was trying to relay to Katelyn and others that much of the public health messaging didn’t come across as believable to people who didn’t know a lot of older or other high-risk people. Senior citizens and people living in NYC in Spring 2020 certainly had different experiences, but the messaging could have been better if it acknowledged that the risks were not being experienced evenly across all communities. It seemed like public health was committed to pushing a message that Covid was as big of a threat to a family with young kids as it was to an elderly cancer patient.

And some specific items I left out that people mentioned in my Twitter replies…

Other public health actions that caused people to lose trust:

• Sudden embrace of lockdowns in March 2020 based on data from China

• Efforts to cover up the origin of SARS-CoV-2

• Promotion of ineffective cloth masks based on weak studies when it was obvious that they weren’t effective in the real-world

• Acceptance of the George Floyd protests while other in-person gatherings were restricted

• Denial of post-infection protection, aka “natural immunity”

• Refusal to seriously acknowledge (or compensate people for) adverse events from vaccines

• College vaccine mandates (mandating vaccination among young people at low risk of disease but in the highest risk group for vaccine myocarditis)

• Vaccine mandates to get a green card for legal immigration into the US (while others coming into this country are not required to get Covid vaccines)

Long Road Ahead

It will take time to get us out of the mess we’re in now. I plan to keep reaching out and trying to bridge the gap between people who held dissenting views throughout the pandemic. We’ve all been through a difficult time, and it’s clear that there are a lot of raw emotions on both sides still, but I think earnestly listening to each other is an important step in rebuilding trust. I recommend keeping an open mind and trying to give others the benefit of the doubt as we navigate a way forward — you might find that you agree on more than you realize.

With the recent discovery that the CDC drafted — but never sent — a Health Alert in May 2021 about myocarditis after mRNA vaccination, I put together this timeline about vaccine myocarditis news and updates from government officials. I include a combination of documents from CDC and FDA, as well as what was covered in the mainstream media.

I think this timeline shows a pattern in which CDC & FDA failed to adequately investigate and inform the public about the risks of myocarditis early in the vaccine rollout. However, there was public acknowledgement by the CDC, as early as May 20, 2021, about a potential pattern of myocarditis after the 2nd dose of mRNA vaccines, particularly in young men.

On June 1, 2021, the CDC confirmed that they had identified a higher than expected signal of myocarditis for young men after mRNA vaccination, but that they still recommended Covid vaccination for everyone in this age group. Despite a lot more analysis and discussion of myocarditis after that, and a changing landscape with widespread natural immunity, the CDC & FDA position has changed very little since that time.

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February - March 2021

As Zachary Stieber and Lia Onely reported last fall in The Epoch Times, we now know that Israel first warned the CDC about a potential myocarditis signal in 16-30 year-old recipients as early as February 28, 2021, and that US government officials completed an internal review was completed by March 9, 2021. However, it took nearly two more months before there were any public reports in the US about the potential for myocarditis after Covid vaccination.

NOTE: Zachary Stieber has done more to investigate and report on the government’s knowledge of myocarditis from Covid vaccines than anyone I know. He maintains an excellent and extremely thorough timeline of his findings here.

April 2021

April 25, 2021: Israel’s Health Ministry announced they were investigating a link between myocarditis and the Pfizer Covid-19 vaccine, particularly in young men.

April 26, 2021: Military.com reported that the Department of Defense is tracking cases of myocarditis after Covid vaccination among troops.

April 27, 2021: Walensky said that she was in touch with the US DoD about the cases found in the military, she claimed that the CDC had not seen a signal for vaccine myocarditis. “We have not seen a signal and we've actually looked intentionally for the signal in the over 200 million doses we've given.”

May 2021

May 11, 2021: Matt Oster, a pediatric cardiologist and a member of the CDC COVID-19 Vaccine Task Force, emailed the CDC to share increasing concerns regarding vaccine myocarditis, stating: “I'm starting to get more and more concerned about myocarditis in adolescents and young adults following COVID-19 vaccination.”

Dr. Oster added in a follow-up email on May 12, 2021: “I keep hearing about more and more cases, and the story is almost always the same: <30 (usually teen), usually male but not always, onset typically 2-4 days after 2nd dose, high troponins, admitted but usually with quick resolution of symptoms/troponin/echo findings…”

May 12, 2021: ACIP recommended Covid-19 vaccines to children ages 12-15, following FDA authorization (EUA) on May 10, 2021. CDC Director signed off on the ACIP recommendation.

May 20, 2021: A statement from the May 17 VaST Work Group meeting was posted on the CDC website: “VaST concluded that there are relatively few reports of myocarditis to date.” The statement claimed — illogically — that while the reports typically occurred within 4 days after dose 2 of mRNA vaccines, they did not differ from expected baseline rates. The fact that they more often occurred within 4 days after dose 2 of mRNA vaccines would seem to indicate that was not part of the expected baseline of myocarditis. This announcement led to a story in the New York Times.

May 20, 2021: Oregon Health Authority issued an email alert to doctors about vaccine myocarditis. (Emails obtained by Zachary Stieber of Epoch Times show that the CDC alerted state vaccine safety liaisons about reports of myocarditis/pericarditis on May 19th.)

May 21, 2021: Email sent from Dr. Demetre Daskalakis to others at CDC, regarding the draft of a HAN (Health Alert Network) advisory on vaccine myocarditis. The email specifically mentioned calls with Oregon and California. This HAN advisory was never sent.

NOTE: We do not have a copy of the draft HAN at this time, but based on other CDC emails and documents from around this period, I suspect that the alert would have stated that cases of myocarditis and pericarditis have been reported shortly after vaccination with Covid mRNA vaccines, but that a link had not been confirmed. It would have likely also provided information about potential symptoms and diagnostic tests to perform, and encouraged doctors to be on alert for this condition and report cases to VAERS promptly, while reiterating the CDC recommendation for Covid-19 vaccination for ages 12 and older.

HAN advisories are frequently covered by the US media, so it is possible that the decision not to release a HAN was due to the CDC opting to notify medical professionals about the concerns via methods that would be less likely to trigger widespread reporting by the US media.

May 21, 2021: The same day as the draft HAN was being discussed, the Seattle / King County Public Health issued their own Health Advisory about vaccine myocarditis. A portion of the advisory is shown below. A later portion of the advisory states, “At this time it is not clear if there is a causal association with vaccination.” The advisory also referenced the statement from the VaST meeting on May 17.

May 27-28, 2021: CDC published public guidance about vaccine myocarditis and clinical considerations on their website, acknowledging that increased cases of myocarditis and pericarditis have been reported in the US after mRNA vaccination, but that “CDC continues to recommend COVID-19 vaccination for everyone 12 years of age and older….” These pages did NOT indicate that the rates after vaccination were outside expected rates or that any causal link had been established.

June 2021

June 1, 2021: A statement from the May 24 VaST Work Group meeting was posted on the CDC website finally acknowledging a potential safety signal: “there was a higher number of observed than expected myocarditis/pericarditis cases in 16–24-year-olds.”

June 1, 2021: An official report by the Israeli Ministry of Health determined that rates of vaccine myocarditis among young men, ages 16 to 24 were between one in 3,000-6,000, as reported in Science and New York Magazine.

June 3, 2021: The first children aged 12-15 to be vaccinated with the Pfizer vaccine became eligible to receive their second doses of the vaccine (3 weeks after first shots began).

June 10, 2021: FDA VRBPAC meeting discussed vaccine myocarditis as part of a larger vaccine safety presentation. This was covered briefly in the New York Times.

June 23, 2021: CDC’s ACIP meeting discussed vaccine myocarditis at length, including a VaST assessment, and a benefit-risk discussion. The VaST presentation acknowledged that there was a likely association of myocarditis with mRNA vaccination. However, the benefit-risk analysis concluded that the benefits of vaccination outweigh the risks. The ACIP did recommend that the FDA place a warning about myocarditis on the EUA fact sheets for Covid vaccinations. The ACIP myocarditis discussion was covered by CNBC and The New York Times.

June 23, 2021: Immediately following the ACIP meeting, a joint statement was released by HHS, CDC, AAP, and others in support of the CDC’s decisions on vaccination and myocarditis. For those paying attention, it was very clear that the outcome of this meeting was pre-determined.

June 25, 2021: The FDA released updated EUA fact sheets for both the Pfizer and Moderna vaccines that warned about myocarditis, but did not include any details about the groups at higher risk. CNN had a brief story on the updated fact sheets, but the myocarditis concerns still did not receive much media attention. Below is a screenshot from the Moderna fact sheet. (The Pfizer fact sheet used the same language, except with Pfizer-BioNTech in place of Moderna.)

June 29, 2021: MedPage Today published an op-ed by Dr. Vinay Prasad and others, including analysis done by mathematician Wes Pegden, critiquing the benefit-risk numbers presented by the CDC at the recent ACIP meeting.

July 6, 2021: MMWR released with findings from June 23 ACIP discussion of vaccine myocarditis risks.

NOTE: The summer of 2021 was a pivotal time for the rollout of Covid vaccines in young people. Many colleges and universities began mandating Covid vaccination for students, even though college-aged men were in the group most at risk for vaccine myocarditis, and second doses were being rolled out to those in the 12-15 age range. Despite recognition of the link between the vaccine and myocarditis, the official position was that vaccination was less of a risk than Covid.

July 16, 2021: WIRED Magazine published an article by David Zweig, “The CDC Owes Parents Better Messaging on the Vaccine for Kids,” detailing much of the controversy behind the CDC’s nuance-free messaging on Covid vaccination for young people:

Fall 2021 & Later…

October 6-7, 2021: Scandinavian countries made headlines for limiting Moderna vaccines for young men. This news received some coverage in the US, including stories by Reuters, AP, and Wall Street Journal. The CDC never officially acknowledged that myocarditis rates were often found to be higher after Moderna vaccines, as compared to Pfizer vaccines. (The higher rate with Moderna was brought up as a question as early as the June 23 ACIP meeting, but the response was that the numbers were too small to draw a conclusion at that time.)

November 19, 2021: When the FDA granted EUA authorization for boosters for ages 18+, they released updated fact sheets for both the Pfizer and Moderna vaccines with revised warnings about myocarditis, adding that it was more common in males under the age of 40. Below is a screenshot from the Moderna fact sheet. (The Pfizer fact sheet used the same language, except with Pfizer-BioNTech in place of Moderna.)

February 22, 2022: In an update to the Clinical Considerations for Use of Covid-19 Vaccines, CDC finally suggested an 8-week interval between mRNA doses may lower the risk of myocarditis after the second dose. This is nearly a year after some experts started calling for extending second doses to reduce myocarditis risks.

It also included a section about myocarditis under “Patient Counseling,” explicitly stating that patients — “especially males ages 12-29” — should be made aware of the risk of myocarditis and/or pericarditis, and about the need for medical attention if symptoms develop shortly after vaccination.

April 1, 2022: The CDC released a controversial MMWR analysis of cardiac complications after Covid versus vaccination, claiming that in teen boys and young men, cardiac complications from Covid were higher than after mRNA vaccination. This analysis was based on electronic health records, so it only included Covid cases that were severe enough to seek medical attention, skewing the myocarditis after Covid rates higher. NBC News reported on this, explicitly stating that it “may be reassuring to those reluctant to get their teenage boys vaccinated.”

Timing Unknown: At some point in 2022 or 2023, vaccine fact sheets added additional information about specific age groups most affected by vaccine myocarditis.

• Moderna: males 18 through 24 years of age

• Pfizer: males 12 through 17 years of age

I haven’t been able to determine when these age ranges became part of the official communications about the vaccines. As far as I can tell, the 18-24 age group first appears on the Moderna website in a January 31, 2022 press release, and the 12-17 age group first appears on the Pfizer website in an July 8, 2022 press release. However, I could not confirm these age groups were consistently listed in vaccine fact sheets until the release of the 2023/2024 version of the vaccines (based on the XBB variant) in September 2023. It is difficult to locate all the old vaccine fact sheets, so I’m not certain when this language was consistently included, but here is a Pfizer EUA Fact Sheet from December 2022 listing the age range.

The FDA also added additional myocarditis symptoms that may be seen in children to some vaccine fact sheets. I believe, but am not certain, that these additional symptoms were only listed beginning with the release of the 2023/2024 version of the vaccines (based on the XBB variant) in September 2023:

Related Articles:

After two weeks of publishing erroneous hospital data for Hawaii County that led to a CDC Covid level of High, triggering required masking inside federal buildings on the Big Island, the CDC has now corrected the data, and the island’s Covid level is back to Low.

Will CDC ever realize that their error checking algorithms are inadequate?

Hawaii Volcanoes NP Requires Indoor Masking and Cancels Indoor Programming

On Friday, November 17, CDC’s weekly Covid levels were published, and Hawaii County, which is the island of Hawaii (aka “The Big Island”), went from Low hospitalization to High hospitalization. As a result, on Monday, Nov. 20, Hawaii Volcanoes National Park Service announced on Twitter that indoor programs would be canceled and masking would be required indoors. The indoor mask requirement is due to a Biden Executive Order (EO 13991) issued Jan. 20, 2021, which requires masks on federal property when CDC hospital admission levels are high in a county. (It’s unclear why the national park also canceled indoor programming due to the hospital level change.)

The only problem? The data was highly suspicious. Based on a quick review of available data from a variety of sources, I felt confident at the time saying there was a “high likelihood” that the data was wrong. The CDC web site showed 75 new admissions from the most recent week, and a 733% increase in hospitalizations over the prior week, meaning the prior week had 9 new admissions. That kind of jump from 9 to 75 is extremely unlikely, and hospitalization data from the the State of Hawaii Covid dashboard showed a much lower rate of new admissions with a 7-day average of 7/day for the entire state of Hawaii (and Hawaii County has only 15% of the state’s population).

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The Next Week…

A week later, on November 27, the CDC’s weekly Covid level update still had the island at High. The CDC web site said there were 42 new admissions from the most recent week, and a 600% increase in hospitalizations over the prior week. That would mean the prior week had only 6 new admissions (versus the 75 that was reported at the time). This suggested that the prior week’s data had been corrected and revised down from 75 to 6. Unfortunately, the CDC failed to consider that the 42 for the latest week was also incorrect. And again, the State of Hawaii Covid dashboard showed a much lower rate of new admissions. So, despite obvious data errors, the mask mandate continued at Hawaii Volcanoes State Park.

When I tweeted about this error for the second week in a row, Phil Kerpen (@kerpen) accessed the CDC’s facility level dataset to find where the error was coming from. It turns out, Ka’u Hospital incorrectly reported 69 new admissions for the week of Nov. 5, and 40 new admissions for the week of Nov. 12. The data file confirmed my suspicions that the earlier week had been corrected to remove the 69 erroneous admissions, but the latest week was not corrected.

Prior to these weeks, Ka’u Hospital had never reported more than 3 admissions in a single week, and the hospital only has around 20 beds! Proper data analysis and error checking should have been able to identify these obvious issues. A Twitter user called the hospital and informed the person in charge of this data collection of the situation so that it could be corrected. If not, who knows how long the CDC would have let this go on.

The footnotes on the page state that they review the data for errors and remove outliers, but clearly they are not doing a good enough job of this if a 20 bed hospital that has never reported more than 3 Covid admissions suddenly spikes to 69 admissions. If that’s not an outlier, what is?

“While CDC reviews these data for errors and corrects those found, some reporting errors might still exist within the data. To minimize errors and inconsistencies in data reported, CDC removes outliers before calculating the metrics. CDC and partners work with reporters to correct these errors and update the data in subsequent weeks.”

CDC Level Finally Corrected

On Friday, Dec. 1, the CDC’s weekly Covid level update finally has the island back at Low, with only 4 new hospital admissions for the entire week. This is shown as a 100% increase, meaning the previous week was revised down from 42 to 2 new weekly admissions on the island.

For two weeks, CDC published erroneous data that mandated indoor masking at a national park, and for some reason, caused indoor programming to be canceled. Now that the Covid level is back to Low, the mask mandate should be automatically lifted as of today (Monday, Dec. 4). Will indoor programming resume? Or was there something else behind that decision, and they just blamed it on the hospitalization level? So far, they have not posted an update to their Facebook or Twitter accounts.

For the past two weeks while they were in the High level, public health officials in Hawaii surely knew there was no concerning increase in hospitalizations. In fact, now that the data has been corrected, we can see that hospital admissions are falling in the state.

Final Thoughts…

The CDC has shown time and time again they are completely unaccountable for their bad data. I emailed them twice about this issue (once each week that it was wrong), and I got no response at all — not even an acknowledgement that they received my message. In the past, I’ve usually gotten replies — at least auto-replies acknowledging receipt.

The Biden Executive Order requiring masks on federal property according to CDC recommendations should end. But also, if the CDC is going to publish hospital admission levels like this, they simply must improve their error handling, as well as be responsive when issues are identified by outsiders.

This is the second of my Thanksgiving week articles with good news about decreasing Covid mortality in the US: Covid is no longer the third or fourth leading cause of death in the US.
Happy Thanksgiving, everyone!

In May 2023, the CDC published an MMWR announcing that Covid-19 had dropped from the 3rd to the 4th leading cause of death in the US overall. I had predicted it would be the 4th leading cause for 2022 on Feb. 10, nearly three months before the CDC’s report was released:

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In May, in response to the CDC’s report, I wrote a short thread on Twitter about the 2022 data and a look ahead for 2023. I’ve shared the thread many times when people try to claim that Covid is still the 4th leading cause of death in the US, and I thought now would be a good time to expand it into a more thorough Substack article. In the thread, I explained that the 2022 ranking was heavily skewed by high Covid deaths reported during the initial Omicron wave in January and February 2022.

By the time the CDC published their MMWR about the 2022 ranking of leading causes of death, it was clear that Covid had already fallen further down the rankings as a leading cause of death on a rolling 12-month basis in 2023. I don’t typically like making predictions, but in May 2023, I felt confident tweeting, “Covid is on pace to be near the bottom of the top 10 leading causes for 2023.” Based on the latest data, it appears I was right on target.

Below is a table showing the top 10 leading causes of death for rolling 12-month periods by the ending month shown. (I included rankings once per quarter since it doesn’t change frequently.) Covid dropped from 4th to 8th by March 2023, and it has stayed at 8th through the 12-month period ending September 2023.

Note that all of the numbers and rankings shown are based on Covid being listed as the underlying cause of death from the death certificate. That is what the CDC’s leading causes of death ranking uses.

Looking Ahead

Will Covid remain the 8th leading cause of death in the US for all of 2023? It’s hard to say. That will be determined based on how US deaths from October - December 2023 compare to October - December 2022. If Covid deaths in Q4 2023 are less than in Q4 2022 as expected, Covid could definitely drop further down in the ranking. The graph below shows how the rolling 12-month total of Covid deaths has declined during 2023, so that Covid-19 is now very close to kidney disease (currently 9th), and approaching liver disease (currently 10th). Suicides and flu/pneumonia are in 11th and 12th place in the rankings for now (suicide data is only displayed through April because the CDC has a 6-month lag in reporting external causes of death).

Revisiting “Expert” Predictions

In September 2022, NBC News ran a story that claimed Covid would be a leading cause of death in the US “indefinitely.” The article estimated that “the U.S. could expect 113,000 to 188,000 deaths a year from Covid, putting it on par with Alzheimer’s, chronic lower respiratory diseases and stroke,” and later added that “experts said Covid is likely to remain among the U.S.'s 10 leading causes of death for the foreseeable future.” For some reason, this headline began to recirculate among the ZeroCovid community on Twitter last week.

For 2022, Covid did rank as the 4th leading cause of death in the US, with around 186,500 deaths. However, deaths are on track to be less than one-third of that this year. If current trends continue, Covid could easily drop out of the top 10 in 2024, if not sooner.

To be fair, the article also included the caveat that “some experts are hopeful that Covid could drop in the U.S. cause-of-death rankings over time.” Of course that was buried half way down the text, and it certainly wasn’t reflected in their click-bait headline….

While the analysis in this article is all based on provisional mortality data from CDC WONDER, we are far enough through the year that the ranking and trends are fairly well established. The unknown is just how the final quarter of 2023 will go, but we’re over half way through November and hospitalizations with Covid are lower than this time last year, which seems promising. I’ll revisit this mortality data again in February 2024 when we have provisional data through the end of 2023.

Also see my earlier article from this week on pediatric Covid mortality:

For the week of Thanksgiving, I thought I would share some updates with good news about decreasing Covid mortality in the US. This article provides an update on the oft-cited claim that Covid is the 8th leading cause of death and the leading infectious disease killer in kids.

I have been tracking pediatric Covid mortality in the US since early on, and I have responded to many claims about kids and Covid in that time. But no paper has garnered more attention on this topic than a paper by academics from University of Oxford and Imperial College that claimed Covid was a leading cause of death in children and young people in the US. The article below about the study has been shared widely on social media by Peter Hotez, Lisa Iannattone, and others.

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An early pre-print of the paper that incorrectly claimed Covid was a top 5 cause of death in all pediatric age groups was originally cited by the CDC in ACIP and FDA VRBPAC meetings to approve pediatric vaccines. I promptly debunked those claims, and the paper was re-written as a result of my criticism. I also responded to the published version of the paper in January 2023, which was based on Covid deaths during August 2021 - July 2022. Now that we have data from the following 12-month period, I thought it was time to re-run the numbers.

NOTE: While I have issues with the use of the 0-19 age group, which the study authors refer to as “children and young people” in their paper, instead of the more traditional pediatric age grouping of 0-17, I re-analyzed the data for the same 0-19 age group used in the study for consistency.

Overall Leading Causes of Death

The study authors ranked Covid deaths for ages 0-19 years from August 2021 - July 2022 against 2019 leading cause of death totals to show that Covid was the 8th leading cause of death among this age group. Below, I graphed rolling 12-month Covid death totals for ages 0-19 using the latest data from CDC WONDER. The time period used in the study appears in the graph below by the ending month (July 2022). This was the peak 12-month death total for this age group as you can see in the graph.

The rolling 12-month death total fell sharply after July 2022, as the deaths from the Delta wave in Aug/Sept 2021 were no longer included in the 12-month total. The 12-month total fell sharply again in January 2023, as the Omicron peak in January 2022 was no longer in the 12-month total. As long as deaths remain lower than the same month in the prior year, the 12-month rolling totals will continue to decline.

I also included reference lines of the 7th-10th leading causes of death from 2019, so that you can see how the Covid ranking rose and fell compared to 2019 deaths:

• From September 2021 - December 2022, Covid ranked 8th compared to 2019.

• From January - May 2023, Covid ranked 9th compared to 2019.

• In June 2023, Covid ranked 10th compared to 2019.

• From July 2023 on, Covid is no longer a top 10 cause of death when ranked alongside 2019 leading causes.

Beginning with the same August 2022 - July 2023 time period, Covid is also no longer a top 10 cause of death in ages 0-19 compared to other deaths from that time period (instead of comparing to 2019 data). Here’s where Covid ranks among some of the other causes of death from August 2022 - July 2023:

7. Heart Disease (788)

8. Flu & Pneumonia (546)

9. Sepsis (315)

10. Stroke (273)

11. Covid-19 (261)

Covid accounted for only 0.6% of deaths in ages 0-19 during the August 2022 - July 2023 time period, compared to 1.9% of deaths during the peak period used in the study.

Leading Infectious Causes of Death

The paper also found that Covid was ranked “first in deaths caused by infectious and respiratory diseases” for children and young people during the peak time period used in the study.

This is also no longer the case for the period August 2022 - July 2023 (one year after the time period used in the paper). During this 12-month period, Covid-19 was listed as the underlying cause of 261 deaths (crude rate 0.3 per 100,000), which would rank 6th in the table below from the paper, behind “influenza and pneumonia”, “other and unspecified infectious and parasitic diseases and their sequelae”, “other diseases of the respiratory system”, “pneumonia,” and “septicemia” (sepsis).

Leading Causes of Death by Age Subgroups

Finally, I thought it was worth noting that death by age within children and young people have shifted significantly from the study period (August 2021 - July 2022) to the same period a year later. Deaths fell in every age subgroup, but they have fallen more sharply in those ages 5 and older. In the study period, deaths were highest in the 15-19 age group and lowest in the 5-9 age group. A year later, deaths were lowest in the 10-14 age group and highest in the <1 year age group.

Final Thoughts…

One of my issues with the published paper was that must have known that they were using the absolute peak time period for Covid deaths in this age group, by including both the Delta and initial Omicron waves. Almost half of the deaths in the 12-month period used in the paper occurred in just three unusual months — August ’21, September ’21, and January ’22. But their conclusions were written as if it were the “new normal” that Covid would deaths would remain at that level without interventions.

What the data shows instead is that deaths dropped sharply after the initial Omicron wave peaked in January 2022. When the paper came out in January 2023, the 12-month total of Covid deaths for ages 0-19 was already half of what it was during the period used in the paper, with Aug./Sept. 2022 deaths just a third of the Delta wave in Aug./Sept. 2021. We later saw that deaths for ages 0-19 in January 2023 were a fifth of January 2022. Yet even now, in November 2023, people are still citing this outdated and misleading paper as if nothing has changed. It’s time to put these claims to rest — Covid is no longer a top 10 leading cause of death or the leading infectious cause of death in children and young people (age 0-19) in the US.

Also see my follow-up article from this week on overall Covid mortality in the US:

I’ve been working on a few in-depth articles that I’m excited about, but in the meantime, here are some thoughts on the recent NYT article you may have seen about an increase in cognitive issues reported by younger Americans.

A recent article in The New York Times warns that disability rates are rising in young people and tries to make the case for Long Covid as the driver of this trend. The article was shared by all the usual suspects on Twitter, including Eric Feigl-Ding, Eric Topol, and Lisa Iannattone. Zeynep wrote a long thread on the data, in which she insists that she can’t see “another plausible explanation” and that Long Covid is “the best fit.” But does the data really hold up?

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The NYT analysis is based on statistics from a monthly survey done by the US Census Bureau and US Bureau of Labor Statistics called the Current Population Survey (CPS). It’s not a Long Covid survey, but beginning in 2008, the survey has asked these six “disability questions,” and the article focused on the responses to the bolded question, which has increased more than the others in recent years:

• Are you deaf, or do you have serious difficulty hearing?

• Are you blind, or do you have serious difficulty seeing, even when wearing glasses?

• Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

• Do you have serious difficulty walking or climbing stairs?

• Do you have difficulty dressing or bathing?

• Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?

The article is based on graphing the percent of affirmative responses to the cognitive disability question over time, compared to some of the other disability questions and split out by age (18-44 versus 45-64), as shown in the above graph. The analysis basically consists of looking at this graph and noticing that there was a sharp increase in people ages 18-44 answering “yes” to this question since the start of the pandemic:

“Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?”

It’s important to keep in mind that while the chart looks very dramatic, the y-axis only goes to 4%. We’re talking about an increase of less than 1% of the population. While that small percentage is still a large number of Americans, two studies cited in this NYT article estimate Long Covid cognitive issues occur in 20-30% of those infected. Most people have had Covid at this point, and it’s clear we’re not seeing anywhere remotely close to 20-30% of people reporting serious cognitive issues. Even if the increase in Yes responses to this disability question was entirely due to Long Covid, the prevalence is significantly less than most Long Covid advocates claim.

Long Covid

The article claims Long Covid is a major cause behind this increase, providing the following evidence to support this assertion:

• Richard Dietz, an economist at the Federal Reserve Bank of New York, analyzed this data a year ago and attributed the increase primarily to Long Covid. Note that he suffers from a condition similar to Long Covid, known as ME/CFS (Myalgic Encephalomyelitis/Chronic Fatigue Syndrome), so he may be particularly sympathetic to and biased toward Long Covid as the mechanism.

• Dr. Ziyad Al-Aly confirmed that “cognitive impairment is a ‘hallmark of long Covid’.” Dr. Al-Aly is an epidemiologist known for a series of Long Covid studies based on electronic health records (EHR) from the Veterans Administration. The studies have been highly criticized by many respected doctors, researchers, and other analysts due to issues with the dataset (VA patients skew to older men and EHR data is messy) as well as other problems with his methodology and interpretation of the data.

• Two systematic reviews cited in the article place estimates of cognitive impairment after Covid infections at 20% and 30%. Both of those papers include many weak and biased studies with issues such as: very small sample size, older and/or hospitalized patients, patients referred to Long Covid clinics, subjective cognitive complaints, lack of controls, etc. These estimates simply can’t considered an accurate estimate of prevalence of Long Covid cognitive issues in the population at large.

• Some research indicates that biological changes from the virus could affect cognition, such as through brain inflammation or reduced serotonin levels.

• Anecdotes about two young people (age 30 and 31) who suffered from Long Covid are included in the article — one has primarily cognitive issues, and the other has more significant issues and is essentially bedridden.

Mental Health

The article does admit that there is another possibility behind the increase in cognitive issues in young people.

“Long Covid is probably not the only factor driving the increase in disability, experts say.”

Looking at the graph, you can see that cognitive issues had already been increasing for young people prior to 2020. Experts have pointed to rising ADHD and autism diagnoses as a reason that young people may be more aware of and willing to report cognitive issues. It’s also become more socially acceptable to embrace mental health diagnoses in recent years.

Additionally, in response to Covid, the whole of society was changed in many significant ways that adversely affected people’s mental health. Depression is known to cause issues with attention, memory, and decision making. Anxiety can interfere with the ability to concentrate and can also cause insomnia, which further contributes to brain fog. And chronic stress can impair memory and concentration directly, as well as lead to other mental health issues. Many of these issues were disproportionately seen in younger adults.

The article includes Dr. Margaret Sibley, a professor of psychiatry, acknowledged that pandemic stress may have worsened ADHD and other mental health issues. In addition, ADHD consultations and medicines also became easier to access via online virtual services during the pandemic, and advertising for ADHD treatment increased, which may have led to an increase in reports of people with difficulties concentrating.

Other Possible Factors

The following factors were not mentioned in the article, but I think are also important considerations with regard to changes we’ve seen over the past few years.

• Drugs and alcohol: The pandemic led to an increase in drug and alcohol use, which contributes to cognitive issues like trouble with memory and concentration. In addition, programs like AA often shifted to virtual and many people could not get the support needed to deal with their substance abuse.

• Virtual school and work: The sudden switch for much of the population to remote work and school may have contributed to focus and attentiveness issues, as well as fatigue and stress. Not everyone is well-suited to interacting online for much of the day. The Atlantic examined Zoom fatigue in 2022.

• Smartphones and social media: An increasing reliance on smartphones and use of social media apps like TikTok built around short-form videos have exacerbated attention issues in many young people. A Wall Street Journal article, TikTok Brain Explained: Why Some Kids Seem Hooked on Social Video Feeds, has been written about this phenomenon.

• Social isolation and loneliness: The pandemic disrupted many people’s social interactions and led to intentional and unintentional isolation in many cases. There is a complex relationship between isolation, loneliness, depression, and cognitive decline that can’t be ignored when thinking about cognitive issues during the pandemic.

• Grief: Many people lost loved ones during the Covid pandemic, whether due to Covid or some other cause, and it’s well-known that grief can cause a type of brain fog, with impairments to memory and concentration.

• Diet and exercise: Many people developed poor dietary habits to deal with pandemic stressors and abandoned healthy habits like regular exercise that may have also contributed to worsening cognitive performance.

• Long Covid nocebo effect: The power of suggestion is often overlooked, but there is a sort of negative placebo effect called the nocebo effect that’s a known phenomenon in medicine. Often, the term is used to describe people who report side effects from placebo pills, but a similar phenomenon may be occurring with Long Covid. After hearing about the horrors of Long Covid from public health and in the media, some people may have started to actually perceive those symptoms in themselves after a Covid infection (or even a presumed infection).

It’s likely that a combination of many factors has contributed to the increasing numbers of Americans reporting serious issues with memory, concentration, and decision making. Some of the increase may be the result of true post-viral / auto-immune cognitive impairment. Depression, anxiety, and stress almost certainly play a role as well, along with some of the other possible factors I listed above. I think it’s naïve to assume Long Covid is the lone cause or even major cause of this trend, considering all of the other changes that have occurred in the past four years that have affected people.

Most complex societal problems have multiple causes — I actually found it very odd that Zeynep insisted there would be just one single cause behind the increase. Our society and the way we interact with the world is complex, and slamming on the brakes on society has led to some dramatic results in many aspects of our lives. I think it’s clear that a virus is not the only thing that has caused cognitive issues for Americans over the past four years.

I originally wrote a Twitter thread about this last night, but I expanded it into a Substack article that’s got a little more detail (and is a little less ragey). I was pretty floored when I found out about their plans yesterday, and vented my frustration quickly on Twitter, and now have had a chance to fully organize my thoughts as a warning about what’s coming.

Yesterday, Alexander Tin of CBS News shared a Twitter thread with some notes from a CDC respiratory virus season briefing. His thread was both shocking and depressing. It’s clear that the CDC has learned nothing and is determined to double-down on their bad decisions throughout the pandemic instead of actually trying to rebuild trust in their failed institution.

As part of the briefing, the CDC shared some of their messaging plans for fall/winter virus season. If that sounds more like a PR pitch than a science briefing to you, there’s a reason for that… I’ve even written about it before:

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Simplified Messaging

It seems they’ve been doing some marketing/PR research, focus groups probably, about how to get more people vaccinated. They decided to forgo sharing accurate information, and instead rely on overly simple, ease-to-understand messages. CDC Director Mandy Cohen said, “Too often, we are sacrificing understanding for precision.” Honestly, this is just a slap in the face for many Americans who have already been treated to overly simplified, nuance-free messaging from the CDC throughout the pandemic.

Just a few examples of the CDC’s past oversimplifications:

• CDC recommended masks for 2-year-olds and up, because they wanted to mask literally everyone, but knew it would be a suffocation risk for those under 2. They couldn’t conceive of any reason why young children may not be good candidates for masking.

• CDC frequently ignores the massive age-gradient in Covid severity and gives broad recommendations that don’t acknowledge young healthy people are at low risk from severe disease.

• Former CDC Director Walensky made repeated false claims unsupported by the evidence that the vaccines stopped transmission.

• CDC continues to downplay concerns of vaccine myocarditis in young men and insists that vaccines and boosters are worth it across all age groups.

We don’t need more understandable messaging. We need more accurate information. We need a serious, data-driven science organization that can be trusted by Americans and those abroad. Instead, people look to CDC guidance with horror because they seem to dumb down everything to the point that they aren’t getting the facts right.

“Protect Grandma”

Their creative team even shared some of their new social media campaign that “leverages emotional ties to loved ones as the key motivator.” Somehow they think that this will “counterbalance...concerns around fear mongering.” I honestly don’t understand this at all. It sounds more like they realize their attempts to convince most Americans they are at high risk aren’t working, so they’re shifting back to their earlier messaging that kept schools closed — “Young people may not be at risk, but you’ve got to sacrifice to protect Grandma.”

But it’s 2023, and even many older people aren’t at high risk anymore. (More on that in another article I’m working on.) In my experience, grandparents aren’t asking everyone around them to do anything special to keep them “safe.” Older people are able to get boosted if they want, and can make their own decisions about their health. Most older people I know are just happy to live life. They’re going to stores and restaurants and church and other events, and not concerned about the vaccination status of people around them, they don’t expect anyone to test before visiting, and they don’t want to see family all masked up around them. Most people are back to normal. But the CDC can’t stand that apparently.

“Stop the Spread”

Most of America has accepted that Covid is here to stay, and that we’re not still trying to “flatten the curve” or “stop the spread” beyond doing reasonable things that we’ve always done to avoid sharing illnesses, like washing hands, coughing into our elbows, and staying home when we’re really sick.

But the preview that the CDC shared of their upcoming social media campaign is focused on this “stop the spread” propaganda that tells people to literally “DO EVERYTHING” to keep well, and lists vaccines, testing, air quality improvements, and masks. In 2023. Why are we still doing this kind of nonsense? Most countries abandoned widespread testing long ago, but the US is determined to keep a bunch of foreign test makers in business for some reason.

Masks (Ugh!)

The US is also in the minority of countries still talking about masks at this point. When asked about when the CDC considers masking important, Nirav Shah suggested that masking after you’ve been exposed to someone who has Covid “is a great way” to avoid exposing someone else. C’mon — nobody is doing this. It’s just completely out of touch with the situation in 2023. People are being exposed to Covid on a regular basis, without knowing when or where or by whom.

Masking after the few times you’ve been around someone who bothers to test and notify you that you were exposed is just silliness at this point. There’s no evidence this would make any difference. But some schools and employers mandate this lunacy, because the CDC recommends it and convinced them it was important. This is especially frustrating given the incredibly weak data we have on mask effectiveness — despite the mask propaganda that CDC has published in MMWR.

Isolation is Here to Stay

Lastly, in case you thought that the CDC might come to grips with the fact that their isolation guidance is completely out of step with many other countries and even the state of Oregon... I regret to inform you that the CDC has no intention of updating isolation guidance.

I wrote the article below earlier this year about the need to revise isolation guidance, but any changes may have to be done at the state level (as they did in Oregon), because the CDC seems completely unwilling to adjust isolation recommendations in the face of widespread population immunity.

Moving On

Overall, it feels like instead of shifting into a new mode for 2023 and beyond where Covid doesn’t control our lives, the CDC is determined to just make “winter virus season” an even bigger deal. Their marketing communication efforts are going to push hard across the board on vaccines and other NPIs for Covid, flu, and even RSV. (Note that the RSV vaccine isn’t even available for all age groups and their official vaccine guidance is much more measured). This has confirmed that contrary to what the ZeroCovid activists would have you believe, the CDC has no intention of moving on from their new found position of power regarding respiratory viruses. This means people will need to push harder with state and local governments, businesses, and schools to encourage them to start ignoring CDC recommendations, instead of treating it like some sort of divine guidance from public health gods.

My apologies for my Substack being a bit quiet lately. I had some personal matters that I’ve been dealing with over the past couple of months, but I have lots of good stuff on the horizon. I’m currently working on an investigation about the US government’s continued investment in rapid Covid testing that should be out soon!

On Friday, September 22, CNN ran a surprising piece about rising Covid hospitalizations, particularly concerning children. I shouldn’t have been that surprised, considering the hype around the current Covid “surge” has been ridiculous. It’s much less significant than our last two waves, but I feel like those didn’t seem to cause nearly as much hand-wringing. The CNN article was based in part on recent report from the American Academy of Pediatrics (AAP) — COVID-19 hospital admissions among children rising again. This panic over pediatric hospitalizations was especially frustrating because several reliable indicators (test positivity, wastewater data, and percent of ER visits) were already showing that we were at or past the peak for this wave.

Pediatric ER Visits Declining

My focus has primarily been children, so one of the key indicators I’ve been watching is the percentage of pediatric ER visits with Covid. This metric has been declining for weeks. (It’s not data lag, as this is a surveillance system based on “electronic diagnostic codes transmitted automatically in near real-time.”) ER visits are typically a leading indicator and hospital admissions follow shortly after.

For those who are surprised to see the 0-1 age group so much higher than other age groups, it’s important to note that babies and toddlers are more affected by any respiratory illness due in part to their smaller airways and lower levels of immunity. There is also a lower threshold for visiting the ER or being hospitalized with a baby or young toddler (parents and doctors are more willing to wait and see with older children, who are less vulnerable and can communicate better). For context, last winter, ER visits for influenza and RSV were higher for children under 2 than they were for Covid.

Timing of Prior Summer Waves

Comparing the current wave to prior years would also suggest that we are past the peak this year, with numbers heading down into fall. (And yes, they’ll most likely go up again in the winter with a January peak.)

The CDC publishes a graph of hospital admissions with Covid that you can filter by age. Based on that graph for ages 0-17 (pediatrics), the peak in 2021 was Sept. 4 (at 0.47/100K) and the peak in 2022 was July 31 (at 0.46/100K), with a second slightly lower peak on Aug. 27 (at 0.44/100K). Based on this graph, the 2023 pediatric hospital admissions peak looks like it will be the same time frame (late Aug. - early Sept.) at ~0.2/100K — less than half of the last two summer waves. So why the panic over the current wave? (Note that this is the latest data as of 9/25, which now shows the decline, but the data from 9/18 reflected a plateau beginning late August, inconsistent with CNN’s claim that pediatric hospitalizations “are rising fast.”)

“From Covid” or “With Covid”?

Of course I couldn’t write about Covid hospital admissions without addressing this topic. Incidental hospital admissions have always been an issue, because the data collected by HHS/CDC is hospital admissions with a positive Covid test — without accounting for why the patient was being hospitalized. Some people have tried to downplay this weakness with the data from the beginning, despite significant evidence that this was a big contributor to the numbers. Now some people, including Dr. Jerome Adams, are falsely claiming that the distinction doesn’t exist at all anymore and that hospitals are no longer testing asymptomatic people.

The truth is, we don’t have good data now to know how many hospitals are still testing asymptomatic people before surgery or upon admission. It’s certainly plausible that there are fewer incidental admissions now, but we know some people are still being admitted with incidental Covid diagnoses, so it’s not accurate to say the problem has gone away entirely. Data from Massachusetts shows that a majority of current Covid hospitalizations aren’t getting treated with dexamethasone for Covid breathing issues, but that’s just from one state and is almost all adults. Unfortunately, we just don’t know the extent of this issue in the national pediatric hospital admissions data at this point.

Hospitalizations in Children <5

One of the issues that the AAP focused on was that children under 5 were affected more seriously. This is primarily due to hospitalizations in infants, as I mentioned earlier when showing the ER visit data.

This data from the COVID-NET hospital surveillance network confirms that the rate of hospitalization is highest for infants under 6 months old, and then it drops significantly. I used cumulative rates in this graph so you can see the dramatic difference between each of the under 5 age groups as well as the 5-11 and 12-17 age groups over the 2022-23 season.

The AAP stated that “While children ages 0-4 are one-quarter of the overall U.S. child population, they comprise roughly half of recent COVID-19 hospital admissions.” This is presented as if it is a new concerning trend, but it has been true since June 2022. The 5-11 age group has always had the lowest hospitalization rates, and now that teens have widespread immunity, the 0-4 age group makes up a disproportionate amount of pediatric hospitalizations.

Using the same hospital dataset the AAP is using, the latest data for ages 0-4 shows that it reached a plateau on August 28 when viewed as a rolling 7-day average. AAP’s report uses weekly totals each Saturday, which showed a small increase for the weeks ending Sept. 2 and Sept. 9, and then drops in the latest file for the week ending Sept. 16 (not available at the time of their report).

The AAP managed to time their report right at the peak of weekly totals just before a significant — 18% — drop for hospital admissions in children ages 0-4 for the week ending Sept. 16.

Data Error for Teen Hospitalizations

What stood out to me in the AAP report was the sharp spike in hospital admissions of children ages 12-17 shown in their (blurry) graph. You can also see that spike in the 12-17 line in the graph from my website above. That huge jump in teen hospitalizations seemed unnatural, and I found it strange that the AAP didn’t mention it in their report. I guess they either knew it was faulty data and didn’t want to draw attention to it, or they believed the data, but it didn’t fit with the messaging they had planned.

I wanted to find the cause of this data artifact, so I looked at the source file from healthdata.gov and found some unusual data from Texas for this age group. Specifically daily hospital admissions for ages 12-17 in Texas went from single digits to over 30 overnight. These numbers would have been at or near record highs for daily teen hospital admits in Texas, which is entirely implausible, especially out of the blue — it’s clearly a data entry error. (I documented several similar errors with this dataset in this preprint.) From the latest data file, we can see that the typo persisted for 5 days before being fixed going forward. Unfortunately, the prior erroneous data was not corrected, so it’s impossible to know the correct values, but this faulty data appears to have inflated the cited number of total pediatric hospital admissions for the week ending Sept. 9 by ~120, or 10%.

Why the fear-mongering now?

The point of news stories about pediatric hospital admissions “rising fast” or being “very concerning” is to scare parents into action. In the past, reports like this were attempts to close schools or mask students. Now the push is to vaccinate young children in the US. The quote in the AAP report from the AAP President makes it clear that making the case for vaccinating young kids is the primary goal of this report. The AAP probably knew they only had a week after the latest Covid vaccines came out to publish a report of pediatric hospital increases, and they jumped on it.

“This increase in hospitalizations, especially for the youngest children, is very concerning,” said AAP President Sandy L. Chung, M.D., FAAP. “We know this is the age group with the lowest vaccination rates. Right now, we have updated COVID vaccines that can help children's immune systems learn to detect and resist the virus, including the strain that is circulating now. The virus is still here, and I'd urge parents to talk with their pediatricians about how they can protect their family.”

It’s hard to trust these “experts” when the US recommendations when these reports and media panic seem timed perfectly to push the narrative they want.

Will the AAP release another report soon to show that pediatric hospitalizations are declining? If so, would CNN cover it? Would it get shared by the same people on social media?

Just before I took my Twitter break, I debunked a viral graph that incorrectly showed pediatric Covid hospitalizations in the NYC metro area were skyrocketing. For that, I was maligned as a Covid minimizer and even a child murderer by the CovidZero crowd. I’ve gotten used to such vile attacks from that side.

Then yesterday, my first day back posting on Twitter, a friend directed me to a tweet linking to an article in DailyMail that claimed that less than 2% of Covid deaths in recent weeks had Covid listed as the underlying cause. The article was a gross misunderstanding of the CDC graph referenced. The footnotes of the CDC graph make it clear that the percentage shown is the percentage deaths attributed to Covid out of “the number of deaths from all causes” (emphasis mine). When I pointed this error out, I was accused by those on the right of trying to prolong the Covid fear, for being a pharma shill, for virtue signaling….

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Data illiteracy and tribal allegiance are major problems in Covid discourse. While I often call out the CDC, the mainstream media, and various scientists and others for exaggerating Covid risks, I also don’t hesitate to point out when demonstrably false information is spread that goes the other way. I’m on the side of truth and accuracy. It does not help people arguing for real investigation into our Covid data and our Covid response to promote completely bogus stories like this latest one.

These articles were spread all over Twitter yesterday by journalists, politicians, and many others. But the articles and tweets got the data completely wrong. The CDC data simply does not show what the articles claim. The data in the CDC graph was completely misunderstood. This is partly the fault of the CDC, who has proven over and over again that they are not skilled at communicating data to the masses. But it’s also the fault of reporters and others who don’t take the time to ensure they understand the data that they are reporting. The footer on that page clearly states: “The percentage of all reported deaths that are attributed as COVID-19 is calculated as the number of COVID-19 deaths divided by the number of deaths from all causes x 100.” It’s not the percentage of Covid deaths, but the percentage of ALL deaths.

CDC also provides data to calculate the percentage of “Covid-associated” deaths each week that have Covid listed as the underlying cause of death, and the numbers are much higher than 2%. Prior to March 2022, that percentage was 90%, and from March 2022 on, that percentage is 66%. The CDC issued a report about this in November 2022 (very similar to a Twitter thread I did on the same topic in September 2022). The numbers from March 2022 and later haven’t fluctuated much, and are still at 66%, just as they were a year ago. From this CDC data set, I graphed the percentage of Covid deaths where Covid is listed as the underlying cause below, so you can see this trend.

I also used the same CDC data source to recreate the graph shown on the CDC dashboard that is referenced in the DailyMail and NY Post articles. This shows the percentage of ALL deaths that “involve” Covid-19. Note: Deaths “involving Covid-19”, also known as “Covid-associated deaths” are deaths where Covid is listed as an underlying cause or a contributing factor on the death certificate.

This doesn’t mean that the CDC data is perfectly accurate. It’s quite possible that the CDC data overstates how many deaths are caused by Covid-19, either as an underlying or a contributing cause. I happen to agree with that. But it’s still entirely false to claim that the CDC is reporting less than 2% of Covid deaths are actually caused by Covid. Next time you see an extreme claim like that, especially if it happens to fit your biases, it’s best to do a sanity check before amplifying it.

I hope this puts this issue to rest. I have contacted the authors of the DailyMail article and the NY Post articles, as well as the DailyMail corrections department and the NY Post online editor. Hopefully these articles will be retracted or significantly rewritten soon.

UPDATE: DailyMail contacted me and has updated their article to reflect the accurate data. New York Post has also updated their article (though it’s still not quite right, and they did not add a correction notice or update the content in the video included with the story).

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“We’re heading into another surge!”

These warnings are often accompanied by graphs showing only the most recent few months, but looking at the past year or two gives a better perspective about the size of this so-called “surge.” Yes, there’s a small summer wave underway. There’s been one every summer, particularly in the Southern US. Most waves increase for about 6-8 weeks before peaking, and this one started in June, so there’s a good chance we are nearing or at the peak.

Regionally, the Southern US is already showing signs of peaking according to wastewater data from biobot.io, and SARS-CoV-2 test positivity data from BioFire appears to be cresting nationally as well.

“Over two thousand children have died from Covid!”

This is simply false. The claim is based on numbers from the CDC’s flawed Data Tracker Demographics page. The official CDC mortality data currently shows 1,673 children aged 0-17 who died with Covid listed anywhere on their death certificate (from CDC NCHS) , and 1,124 with Covid where Covid is listed as the underlying cause (from CDC WONDER). I broke these numbers out by year, so that you can see that deaths have dropped significantly in 2023 (beginning in March 2022, but the effects of the Omicron wave in Jan/Feb 2022 skews the 2022 annual numbers).

I’ve written about the flawed data tracker before, and David Zweig wrote an excellent piece about it more recently. It continues to be a problem because it’s used by journalists and other Covid maximizers to scare parents.

And even these lower official numbers from the CDC are still likely inflated due to how much we test for Covid, the generous way CDC has chosen to code Covid deaths, the FEMA payouts for Covid funerals, etc.

“Covid is a leading cause of death in children!”

This claim is all about semantics. Covid is in the top 10 leading causes of death for children, but this ranking is very misleading. For 2022, the top 5 causes of death for ages 0-17, according to the ranking used in CDC WONDER are:

1. Certain conditions originating in the perinatal period (P00-P96): 10,150

2. Accidents (unintentional injuries) (V01-X59,Y85-Y86): 6,243

3. Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99): 4,967

4. Assault (homicide) (*U01-*U02,X85-Y09,Y87.1): 2,361

5. Intentional self-harm (suicide) (*U03,X60-X84,Y87.0): 1,585

Covid comes in ranked at number 8 in 2022, with 468 deaths (about 1% of deaths overall in ages 0-17). And almost 40% of those deaths were from the first Omicron wave in Jan/Feb 2022 — subsequent waves have been significantly smaller.

“Covid is the top infectious cause of death in children!”

This is from a paper that looked at Covid deaths from August 2021-July 2022, capturing the worst two waves for children and young people (Delta and Omicron). The authors compared Covid deaths during that time with the CDC’s rankable causes of death from infectious or respiratory diseases from 2019. Based on that, Covid is ranked first. But (a) we test for Covid much, much more than we tested for other diseases in 2019, and (b) this is a selection of the worst period for Covid deaths in young people.

In the one year period after the initial Omicron wave, Covid is no longer ranked as the leading cause of death from infectious/respiratory disease in young people. Using the same age group (0-19) and methodology used in the paper, Covid from March 2022-February 2023 would be ranked 4th, with 368 deaths.

“MIS-C is a serious threat to children!”

Anyone bringing up MIS-C as a serious threat in 2023 is just being dishonest. With every wave, the risk of MIS-C has been reduced, and since the initial Omicron wave, MIS-C has all but disappeared in the US and elsewhere in the world, where it’s often referred to as PIMS-TS (see data from the UK and Germany).

“Kids also get Long Covid!”

A systematic analysis of studies on Long Covid in children was recently published by AAP, and a CIDRAP article highlighted one of the findings to claim that 1 in 6 children experience Long Covid. However, the 1 in 6 claim from this study is very misleading and suffers from many of the same issues as other dubious Long Covid studies. The paper is based on a very skewed subgroup of children who were mostly hospitalized during initial infection. Also, most of the studies included were from the first year of the pandemic, before the Omicron variant and widespread population immunity.

Better studies looking at the incidence Long Covid in children in the wider population have found rates closer to 1% having any symptoms that last weeks or months after the initial infection. See these pediatric Long Covid studies from Sweden, Denmark, Switzerland, and the UK.

“Covid causes diabetes in kids!”

This claim is based on a flawed and highly-criticized CDC MMWR that uses electronic health records to determine that children were more likely to be newly diagnosed with diabetes in the months after infection. But it doesn’t even differentiate between type 1 and type 2 diabetes. Type 2 diabetes is associated with obesity, which is also a strong risk factor for severe Covid, so this data likely includes obese children who had undiagnosed type 2 diabetes prior to getting sick with Covid. There are also several other issues with the study as discussed in this brief Substack by Dr. Vinay Prasad. Additionally, a recent paper showed that “despite the plausibility of a biologic connection, systematic testing…did not show that Covid-19 precipitated type 1 diabetes.”

“Children should wear a mask to avoid Covid!”

It’s hard to believe anyone is still calling for masks in 2023, much less children. Here are some reasons why children should not be masking in school.

• There’s a reason most people don’t wear masks anymore. Wearing a mask is hot, it’s uncomfortable, it makes verbal communication harder, it interferes with emotional expression and mental health…

• In younger grades and foreign language classes, it’s important for teachers and students to see each other’s mouths move so that they can properly learn the phonetic sounds.

• Cloth and surgical masks have not been shown to be effective, and high-quality respirators are not designed or tested to fit children. There are no N-95s certified for children.

• Children don’t wear masks snugly and securely throughout the day, and masks must be taken off at school to eat, drink, nap, etc., further reducing any potential minimal benefit.

Closing Thoughts…

Almost all children already have natural immunity to Covid at this point. According to CDC seroprevalence data, as of December 2022, 92% of children had immunity from infection, and 96% of children had immunity from either infection or vaccination. And more children have gained natural immunity since then. There are few children left who don’t have some exposure to Covid already, which further reduces their already extremely low risk of severe outcomes.

Almost the only people being hospitalized with Covid at this point are those 70 and older, as shown in the graph below, and they often present with a variety of pre-existing ailments. Since Omicron, Covid pneumonia, along with MIS-C is all but gone, and even hospitalized cases are much different than they were early in the pandemic.

Schools were closed in a panic in 2020, because decision-makers erroneously feared that Covid would make children very sick or that schools would cause significant spread in the community. Those assumptions proved incorrect. Many schools made the mistake of remaining closed for much of the 2020-2021 school year, and then operating with excessive mitigations the following year. Most schools were finally back to normal for the 2022-2023 school year, with no significant Covid illness. Anyone now seeking to interfere with a fifth(!) year of school for children needs to deal with their own anxieties, and let children and schools operate as normal without trying to scare parents, teachers, and administrators with their unfounded fears.

“Alarming Impact of Long Covid”

The study analyzed data from 1,802 patients, and these are some of the key rates of symptoms being reported from the study in the news:

• 85% reported decreased quality of life

• 51% had cognitive impairment

• 45% had altered lung function

• 83% had abnormal CT chest scans

• 12% had elevated heart rate on rhythm monitoring

At first glance, that sounds bad, but let’s look a little closer… This study was done based on data from the Northwestern Medicine Comprehensive COVID Center, a multidisciplinary Long Covid specialty center. These are not a random selection of typical Long Covid patients, but patients who sought treatment for Long Covid from a specialized center, so they are more likely to have complex or severe Long Covid symptoms. Furthermore, the center began in the neurology department at Northwestern and may have attracted more patients with neurological issues.

On top of that, the percentages above are not out of all 1,802 patients seen by the center. They are out of the subset of patients who received testing for each particular issue. It’s more informative when you see the raw numbers for each of those percentages below, as stated in the paper’s results section:

• 742/878 (85%) reported decreased quality of life

• 284/553 (51%) had cognitive impairment

• 195/434 (44.9%) had alteration of lung function

• 249/299 (83.3%) had abnormal CT chest scans

• 14/116 (12.1%) had elevated heart rate on rhythm monitoring

The FOX32 article at least says that the percentages are “among those tested” (though doesn’t quantify that), but other articles leave that caveat out, making them not just misleading, but factually incorrect. The news articles seem to be the result of a recent press release put out by Northwestern Medicine about the study and their Comprehensive COVID-19 Center.

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Analysis of Selected Findings

Abnormal CT Chest Scans

The most troubling percentage from that list — 83% with abnormal CT chest scans — makes more sense when you break down who was tested. Less than a third of the patients in the study visited the pulmonology clinic, and only 299 (16.6%) patients were given chest CTs based on their symptoms. Of those patients, 83% (249/299) had abnormal findings on their CT scans. Among those patients, there were notable differences between hospitalized and non-hospitalized patients. The data in Table 3 shows that 93% (138/149) of hospitalized patients and 74% (111/150) of non-hospitalized patients had abnormal findings. When you look at the total subgroup of non-hospitalized patients in the study, only 7.6% (111/1452) of non-hospitalized patients at this Long Covid specialty center had abnormal chest CTs.

And to make matters worse… I’m not certain that the 111 number is even correct, based on more detailed data in Table 3 showing data on the specific abnormal findings. If you add up the positive findings for non-hospitalized patients in the table (the numerators inside the red box), there are only 90 instances of abnormal CT findings, which would indicate there were no more than 90 non-hospitalized patients with abnormal findings. It seems like either the number of people listed with “none of the above” CT findings or the denominators shown are too low. Either error would reduce the percentage of non-hospitalized patients with abnormal CT findings.

Reduced Quality of Life

I also found a potential error with the reported 85% of those who reported lower quality of life via “questionnaires for self-perceived quality of life in domains of cognitive function…, fatigue, sleep disturbance, anxiety, and depression”. The data in Table 2 shows that number to be 742/916 (81%), but the results section says 742/878 (85%). The number 878 doesn’t show up anywhere else in the paper.

Regardless of whether the number is 81% or 85%, it’s not surprising that most people who met the following criteria for an appointment with the neurology clinic reported quality of life issues:

“Clinical criteria for appointment to the neurology clinic included individuals with confirmed diagnosis of SARS-CoV-2 infection or carrying a diagnosis of COVID-19 presenting with brain fog, cognitive problems, confusion, headache, decreased sense of smell and taste, weakness, numbness, muscle pain and loss of consciousness. People with no diagnosis of COVID-19 but worried they have been exposed to SARS-CoV-2 or having neurologic symptoms listed above were evaluated as well.”

Elevated Heart Rate

Despite a lot of talk about cardiovascular issues among Long Covid patients, that is the specialty that had the least number of clinic appointments in the study, and the area that had the lowest rates of identified issues. The finding they noted in their results was that 12.1% had an elevated heart rate (average ≥90 bpm) — of the 116 patients who underwent rhythm monitoring, which is a relatively common test for anyone experiencing heart rhythm issues. (I’ve used a rhythm monitor myself twice prior to Covid.)

Among the 116 rhythm monitors performed, only “2 (1.7%) showed clinically significant ventricular arrhythmias” and only one identified “new atrial fibrillation.” Somehow that reassuring information didn’t make it into the summaries of the study. Weird, huh?

Incidence of Long Covid

Although this Northwestern study wasn’t about the incidence rate of Long Covid, the paper did make two separate and very different claims about Long Covid incidence:

• “Long COVID affects 10%-30%², ⁵¹, ⁵² of SARS-CoV-2-infected individuals, depending on variant and severity of acute illness.”

• “The incidence of long COVID remains uncertain, with estimates ranging from 30% to 50% among COVID-19 survivors.^10”

The study authors couldn’t decide whether to claim Long Covid affects 10-30% or 30-50% of people who have Covid-19?

I couldn’t find any obvious estimates of Long Covid incidence in the cited papers corresponding to the numbers used in the recent study, and two of the four cited papers (2, 51) were of hospitalized patients from Wuhan in early 2020, so they are of limited usefulness in determining Long Covid prevalence.

In addition to the above incidence rates, the Northwestern study cited a GAO report that estimated “up to 23 million Americans suffered from long COVID.” The GAO report says: “Studies in the U.S. estimate that 10 to 30 percent of COVID-19 survivors develop long COVID. If so, 7.7 million to 23 million people in the U.S. may have developed long COVID as of February 2022.” However, there are no citations for the 10-30% number in that report.

The Northwestern study also cites a July 2022 letter from the American Academy of Neurology, which claims that Long Covid is “the third leading neurologic disorder in the US.” That claim was made based on an estimate that 30% of Covid survivors have Long Covid, and the letter has multiple references to both the GAO report and to the same Dr. Igor Koralnik who is a co-author of the Northwestern Long Covid study.

As you can see, many of these claims about Long Covid prevalence are of dubious accuracy and circular in nature. The widely-shared FOX32 Chicago article about the Northwestern study repeats the claim “Long Covid occurs in about a third of Covid survivors and is now the third leading neurologic disorder in the United States,” as if these were facts instead of a highly variable estimate, along with a hypothetical ranking based on that estimate.

Let’s Get Real

Recent serological data from the CDC estimates that 77.5% of Americans have had Covid. Long Covid estimates of ~30% would suggest that around 1 in every 4 Americans has either had or currently has Long Covid! Everyone should be able to acknowledge that’s simply not based in reality; however, these estimates continue to be repeated in academic papers and in the media. Some people seem to believe that a large portion of Americans are walking around suffering from post-Covid sequelae, often with debilitating neurological and pulmonary symptoms.

Most Long Covid studies are terribly flawed, and the reporting on them in the media and the discourse about them on social media makes the situation even worse. This study proves to be no exception. Unfortunately, these misleading studies serve to feed many people’s anxieties about Covid, worsening their mental and physical health. We need more responsible science and journalism on the topic of Long Covid, not more alarmism and hype.

Many people were glad to see Dr. del Rio admit that school closures were a mistake, but stunned by the idea that the harms weren’t predicted by public health experts. Personally, I was a bit skeptical of this claim.

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I have interacted with Dr. del Rio many times on Twitter during the pandemic, partly because he is local to me here in Atlanta, and he works at my alma mater, Emory University. While we don’t always see eye to eye, something didn’t seem right about these comments he supposedly made. So I tracked down the video of the actual UCSF Grand Rounds that this article was written based on, in which Bob Wachter spoke with Carlos del Rio, Katelyn Jetelina, and Mark D. Smith.

What I found was that the article was a very rough approximation of what the participants said. Even the statements in the article that are in quotation marks are NOT direct quotes from the video. It is simply poor journalism, unfortunately, which led to this viral tweet. Nobody in the video ever said that public health didn’t know school closures would be harmful.

What Was Actually Said…

In the video, Bob Wachter asked the three participants about school closures:

“…if we did get it wrong, was it because we overestimated the risk, or we underestimated the downsides of keeping kids out of school, like, what the educational attainment downsides were, what the mental health downsides were, what the downsides for parents were, all those sort of things? Sort of which part of it did we get wrong, if we got any of it wrong?”

None of the participants replied that we underestimated or didn’t foresee the harms to students of school closures. The responses from epidemiologist Katelyn Jetelina and Mark Smith, a medical doctor, both stated unequivocally that experts believed Covid would be more dangerous for children than it turned out to be. Dr. del Rio said he agreed with Dr. Jetelina, and added that public health forgot how important schools are to parents and the economy.

Dr. Katelyn Jetelina

Katelyn Jetelina answered first, and described how experts assumed Covid would be “very bad for young kids.” If this is true, it means that instead of “following the science,” experts ignored all the early data from China, Italy, and the Diamond Princess showing the severe age-gradient with Covid-19, and how it was not a significant threat to most children.

She also said that “we thought, and we were wrong, that schools would accelerate transmission in a community.” However, by summer 2020, there was ample data showing this wasn’t true, again showing that U.S. public health did not “follow the science” when it came to kids and Covid. Many countries in Europe successfully reopened schools in Spring 2020, Sweden famously never closed their lower schools, and New York City had child care centers that successfully stayed open during Spring 2020. Despite this wealth of evidence, many U.S. schools remained closed much longer, with public health warnings about concerns of transmission within and from schools.

Earlier in the discussion, Dr. Jetelina mentioned that as an epidemiologist, she was “very uncomfortable” with schools reopening in August/September 2020 in Texas, where she lived at the time, but then she reluctantly admitted that “looking back, I think it was the right call.” She added that she felt like reopening schools was a difficult decision prior to vaccines, asking teachers to go on the front lines. While I understand that sentiment, I would push back on Dr. Jetelina and remind her that we asked many other professions to continue working in person in 2020 to keep society functioning. Why was it difficult to ask teachers to work in-person, but not doctors, law enforcement officers, or workers at Amazon warehouses and local grocery stores?

Dr. Carlos del Rio

Dr. del Rio stated he agreed with Dr. Jetelina. He said we needed to close schools initially “…for a second. But then we kept them closed for way too long.” I am not sure I agree that there was ever a need to close schools, but I understand March 2020 was filled with a lot of difficult decisions. I do think we should have reopened in April, and I wish he would have said that. I’d be curious if he believes that, in hindsight.

In addition, Dr. del Rio spoke about advising both Atlanta Public Schools (APS) and a local private school on reopening. Atlanta Public Schools had a phased re-opening from January 25 through February 16, 2021, with protocols such as test-to-stay (after an exposure) and voluntary surveillance testing through a private company. Fulton County Schools, which surrounds APS, returned to in-person in October 2020, and schools in suburban Cobb and Gwinnett County also re-opened in Fall 2020. Students in neighboring DeKalb County Schools (where Emory University and the CDC are located) didn’t return until March 2021.

Dr. del Rio also added that public health forgot how harmful school closures would be for parents and for the economy, explaining, “you can’t go to work if you — you can’t work at home or work, period — if you have kids around in the house, right?” It was nice to see some recognition that one of the important functions of schools is to keep society functioning, but I do wish he’d recognized that public health also seemingly prioritized avoiding Covid over everything else — the economy, normal social functioning, and the mental health and academic futures of young people.

Dr. Mark Smith

Finally, Dr. Mark Smith said that he doesn’t want to “second guess” some of the difficult decisions officials made about schools, and echoed Jetelina’s comments about severity in children, saying that “there was every reason to believe that this virus would be particularly bad for kids.” Again, this simply isn’t true, and wasn’t true at the time. All the early data showed that children were at the lowest risk of severe disease from SARS-CoV-2 and most of the severe cases were among seniors and the elderly.

Dr. Smith went on to discuss how the experience during Covid was very different for those who were able to work from home, versus those whose livelihoods depended on jobs and businesses that required being in person. This is a key point that I think was underappreciated by public health, the media, and many Americans. He also emphasized the seriousness of the impact of school closures, saying:

“There’s no question that aspects of the economy and people’s personal lives have been devastated. There’s also no question, this may — the decrease in educational attainment that we’re only now beginning to measure — may be the longest COVID of all, if you will. It may be the thing that has the most lasting impact on the life chances and opportunities of that generation of kids that went through that shutdown.”

My Closing Thoughts

None of these people are in positions of authority to set policy on schools in the U.S., which were mostly decided by public health directors, politicians, and school board members. But they are influencers in the area of public health, and they had influence both at the local and national level, along with many other doctors and scientists. It is nice to see them acknowledge some things that we got wrong about kids and Covid; but at the same time, it’s very discouraging to see how they embraced the incorrect theories that kids were at significant risk of severe Covid outcomes and that schools would lead to Covid spread in the community, despite lots of early data showing that neither of those things were true.

We were told public health was following the science, but I think in many cases, they were driven by their own fears. Public health went all in on avoiding Covid harms, to the detriment of everything else, especially when it came to schools. They failed to do a proper risk-benefit analysis of the recommendations they were making. Many people were begging officials to consider some of the second- and third-order effects of school closures, but we were dismissed as Covid deniers, racists, and grandma killers. In reality, we were evaluating evidence on kids and Covid and were concerned about the obvious harms that were occurring as a result of extended school closures in the U.S.

I’ll end by saying that I agree with Dr. del Rio in that I “hope we don’t make this mistake again.” I think the best way to do that is to get more experts to acknowledge that school closures in the U.S. were a complete failure of public health.

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Video & Transcript

28:36 WACHTER: I think even among people who are clear thinking about how bad it was in 2020, there’s a lot of sentiment that we got the schools wrong. And Katelyn, you mentioned, “I wouldn’t take my kids out of preschool” [if cases started increasing again - approx. 23:40]. Maybe Katelyn, to start, do you think we got the schools wrong? What did we learn about the schools?

28:56 JETELINA: So I was in Texas during the pandemic, and as an epidemiologist, and we actually started schools very early. It was like, it was August, September of 2020. At the time, I was very uncomfortable as an epidemiologist, but it was pushed forward. And, you know, looking back, I think it was the right call. I think that we could’ve prepared schools and prepared teachers far better with ventilation, with contact tracing, with resources, that just weren’t utilized in the time of early 2020.

I think the really hard thing that I had in fall of 2020 was that we just didn’t have vaccines yet. It was hard for me to ask teachers to go, you know, even if they’re, you know, over 65, under 65, it was a very random disease before any immunity. And to ask someone to go on the front line, that was a hard decision for me to make before we had any levels of protection for them. And so, I don’t know.

30:15 WACHTER: Yeah. It really is a hard one. I scratch my head about it too. But do you think a lesson, as people talk about the schools, and we quote, “Got the schools wrong.” First of all, it’s an interesting question in general, but second of all, did we, if we did get it wrong, was it because we overestimated the risk, or we underestimated the downsides of keeping kids out of school, like, what the educational attainment downsides were, what the mental health downsides were, what the downsides for parents were, all those sort of things? Sort of which part of it did we get wrong, if we got any of it wrong?

30:47 JETELINA: That’s a really, I think that’s a really good question. The one thing we got wrong was, well, for one, almost every virus is usually very bad for young kids. And this one just wasn’t. It was very weird. And that is abnormal. So I will say that.

The second thing is we thought, and we were wrong, that schools would accelerate transmission in a community, but rather they just reflected the community transmission. They didn’t become these vectors of really high transmission. I was surprised about that.

31:30 WACHTER: Why not? You would think they would’ve been.

JETELINA: I thought they would’ve been too. I think we have a lot to learn about that. And was it because of SARS-CoV-2? Was it because it was just literally everywhere anyways? I’m not sure. I do know, you know, public health people do recognize whole health, the value of mental health, a safety net, meals at schools, and that was very much a part of the conversation in Texas in early 2020 as well. So it was, a lot of people had to make very hard decisions at that time, and I don’t empathize* anyone in that decision making effort. (*I believe she meant envy, not empathize.)

32:17 WACHTER: Carlos, what do you, what did, first, let’s start with did we get the schools wrong? And if so, what would we, what’s that lesson learned?

32:22 DEL RIO: You know, I agree with Katelyn. I think, you know, initially we closed schools. It was a necessary move for a second. But then we kept them closed for way too long. And that has been bad. And in some places kept schools closed forever, right? They basically, I’m hearing now, many school districts having trouble getting students to come back. This has been really bad for our kids, for parents.

And we have to remember that one of the key ways to reactivate the economy was to open schools again. It’s very important for parents. You can’t go to work if you — you can’t work at home or work, period — if you have kids around in the house, right? If you have to be the teacher and the mother, you can’t do work. You know, you can’t be, no matter what happens. So we forgot that.

In schools, I worked with some schools here in Atlanta, one of them a private school, Paideia School, one of them, you know, the Atlanta public schools. And we did a lot of testing, and we kept schools open as much as possible. And yes, we did it before there were vaccines. And once there were vaccines, we prioritized the teachers. And we didn’t see outbreak. We were able to really control transmission, and send people, you know, home when they were infected, and really prevent the school from being a site of infection. And that was very important for mental health of the kids.

So, my message is that one of the things we got wrong is the schools. And we hope we don’t make this mistake again when we have another pandemic.

33:45 WACHTER: Okay, let me turn to Mark as the, I think only MBA in our group here. One other question, I think there’s less certainty when you hear people say it is, we got the balance of the economy and public health wrong. What do you think?

34:05 SMITH: I’m loathe to second guess from the safety of two thousand — the relative safety of 2023 — some of the hard decisions that people had to make, like in schools, in part because, let’s remember that we didn’t — there was every reason to believe that this virus would be particularly bad for kids. There was every reason to believe things that turned out not to be.

So remember, we were wiping down our groceries, and we wouldn’t touch our face because the virus system, I mean, we didn’t know. Having said that, it does strike me that the ferocity with which some people opposed, what seemed to some, reasonable public health restrictions depended in part on whether you made your livelihood, whether you could do your livelihood at home versus wherever else.

So last week, there was a study published about how likely various occupations were to be working from home. And like software engineers were at the top, and butchers were at the bottom.

And so if you had saved all your life to start a restaurant, and you bought furniture and hired staff and opened your doors in March of 2020, and then it all went to hell, I get how your perspective on the shutdown of the economy, and whether or not we, quote, “got the balance right,” would be a little bit different from someone who could set up their Zoom and do what they do as we’re doing this now.

So you’ll remember the early days when it became immediately apparent that certain ethnicities were harder hit, were sicker, were hospitalized more, were dying, and the explanation in lay press was that they had too many preexisting conditions, right? And the problems with that were, first, no one said, “Well, gee, why is it that Black people have more hypertension, diabetes, Latino people?”

But the second thing was it wasn’t entirely true, that the preexisting condition was that you worked in a meat packing plant, or that you drove the bus, or that you had a multi-generational household. And so the impact of the epidemic and the impact of the restrictions that were imposed to try to control the epidemic under very difficult circumstances hit people quite differently, depending on where you are in the economy.

So it’s part of why I’m punting on the question, ’cause I think it depends a little bit on where you were, and people were making hard decisions under conditions of great uncertainty. There’s no question that aspects of the economy and people’s personal lives have been devastated.

There’s also no question, this may — the decrease in educational attainment that we’re only now beginning to measure — may be the longest COVID of all, if you will. It may be the thing that has the most lasting impact on the life chances and opportunities of that generation of kids that went through that shutdown. So that’s the point.

37:06 WACHTER: Yeah.

37:07 DEL RIO: So Bob, I would say though that an important message is I think in public health, we make the mistake of letting the population say, “It’s either public health or the economy. It’s public health versus the economy.” When the reality is we need a strong, a good public health in order for the economy to be successful. A healthy population is important for the economy to be successful. So we needed to really get the message.

And I think in public health, we didn’t get the message right of telling people, “Look, our goal is to get the economy going. This is the public health and this is how public health is doing. We’re not shutting the economy, we’re actually gonna do the adjustments to get the economy right.” And this, again, it was all about not telling people necessarily what not to do, it was telling people how to do things in order to continue working. And there were ways to do that.

And I think we made the mistake of saying no as opposed to saying, “This is what you need to do.” And I go back to my roots in HIV. You know, it’s harm reduction. It’s not about telling people you shouldn’t have sex. It’s about what to tell them to decrease their risk.

Dr. Walid Gellad, Professor of Medicine at University of Pittsburg and Director of the Center for Pharmaceutical Policy and Prescribing, first brought this paper to my attention, and he shared many of the same initial concerns that I did. When I looked into more in depth, I found additional errors with the underlying data that make it even more flawed than either of us originally suspected.

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Combining Risks for Sex and Doses

The first problem with this study is that it does not look at the subgroup that is of specific concern for post-vax myocarditis from the Covid vaccine — young men after dose 2.

The study combines rates for males and females in their comparisons, even though it is well-known that the risk is MUCH higher in young men than in young women. Much like how they combined men and women, the study also combined risks from the first and second dose in their analysis. It’s also well-known that the risk is MUCH higher after the second dose.

The study authors acknowledge both of these uneven risks in their abstract:

“Myopericarditis was more common among males (66.0 [40.5–107.7] cases) than females (10.1 [6.0–17.0] cases) and among those receiving the second dose (60.4 [37.6–96.9] cases) than those receiving the first dose (16.6 [8.7–31.9] cases).”

However, for their analysis where they compare myocarditis after the Covid vaccine to other vaccines and to Covid infection, they use the combined rate of men and women after either dose, instead of looking at the subgroup of dose 2 for males, which is where the bulk of the myocarditis risk lies. This dilutes the risk of vaccine myocarditis substantially.

Drs. Benjamin Knudsen and Vinay Prasad have an excellent paper showing this effect of how vaccine myocarditis rates are diluted when you don’t stratify properly by sex, age, dose, and manufacturer.

This distinction about dose 2 is important, because the US could have opted to recommend only one dose to young men, substantially reducing their risk from vaccine-induced myocarditis from the Covid vaccine, or spaced out the doses more to reduce risk from dose 2, but the FDA and CDC chose not to do this.

Comparing Rates to Smallpox(!) Vaccination

In order to make their case, the authors compared their diluted risk of myocarditis from the Covid vaccine to the risk of myocarditis from the SMALLPOX vaccine. This vaccine is not commonly used and has well-known risks of myocarditis, so it’s a bizarre and unfair comparison. From another study on smallpox vaccine myocarditis, “Although myocarditis has been reported following many different vaccines, the smallpox vaccine has the strongest association.”

Considering that the Covid vaccine is often compared to the influenza vaccine in that it’s for a common respiratory pathogen that shares a similar level of risk to children, that seems like a much more appropriate comparison.

Here’s what the Lancet paper that they cite for the smallpox vaccination rates says:

The incidence of myopericarditis was 132·1 (81·3–214·6) per million doses of smallpox vaccine (p<0·0001 vs COVID-19 vaccines), 1·3 (0·0–884·1) per million doses of influenza vaccine (p=0·43), and 57·0 (1·1–3036·6) per million doses for studies reporting on a variety of vaccines (p=0·58; appendix p 23).

That’s 132.1 per million for the smallpox vaccine and 1.3 per million for the flu vaccine. I think it’s clear why a study that wants to minimize Covid vaccine myocarditis would compare to the smallpox vaccine. For comparison, the new study found, “The pooled incidences of myopericarditis after mRNA COVID-19 vaccination among adolescents aged 12–17 years were 43.5 (95 % CI, 30.8–61.6) cases per million vaccine doses for both BNT162b2 and mRNA-1273 (39 628 242 doses; 14 studies).”

Comparing Rates to Other Vaccinations

The study also compares their diluted rate of myocarditis from the Covid vaccine to “non-COVID-19 vaccinations (56.0 cases per million vaccine doses)” from the Lancet (the confidence interval is not listed in the recent paper, but is 10.7-293.7). However, this rate from the Lancet paper is still skewed heavily toward smallpox vaccination — 6 of the 11 studies are exclusively for smallpox vaccines, plus the Engler study described below, which was primarily of the smallpox vaccine and is an extreme outlier. The 4 non-smallpox vaccine studies (highlighted in the figure below) include the Kuntz study, also described below, in which the Lancet authors erroneously reported the number of myopericarditis cases.

As you can see from the figure above, the Engler study is so far out of line with every other study that it should have raised some red flags. It’s a small study from the military, with mostly young men (higher risk of myocarditis), and most (85%) of the vaccines given in the study were smallpox vaccinations.

Of the non-smallpox studies, the Kuntz study included two live virus vaccines not typically given in the US: the oral polio vaccine (OPV) and the yellow fever vaccine, so it is also not a good comparison to the Covid vaccine. In addition, the authors of the Lancet meta-analysis included all 152 instances of myocarditis or pericarditis from this study that were coded at any time in the medical records (including prior to vaccination). The 152 diagnoses were first narrowed down to 72 (54 pericarditis and 18 myocarditis), and Kuntz paper states that “the remaining 80 potential cases were excluded because they had miscoded or rule-out diagnoses, lacked sufficient information in the medical record to confirm the diagnosis, or were diagnosed prior to 1996” (when the vaccine study period began). The results were further adjudicated and narrowed down to only 1 case of probable pericarditis in the 42 days following vaccination, yet the Lancet authors included all 152 as cases in their meta-analysis.

Comparing Rates to “Covid-19 Infection”

Finally, this paper compares their diluted rate of myocarditis from Covid vaccination to the rate of myocarditis from Covid infection. For this, they use a very flawed MMWR as their source. The MMWR is based on electronic health records (EHR) to determine the rate of myocarditis after Covid infection. However, as you are surely aware, most young people did not go to the doctor or hospital when they got Covid, so their infections would not be recorded in any EHR. The vast majority of children just had a mild infection and recovered at home. Many did not even take a Covid test at all, much less through their healthcare system.

As a result, the rate that this paper shows for myocarditis after infection is skewed to only the sickest of young people, which greatly increases the rate of complications like myocarditis. Said another way, the rate of myocarditis in young people after a documented Covid infection at the doctor is MUCH higher than the rate of myocarditis in all young people after a Covid infection.

In addition, since the Covid vaccination doesn’t prevent you from getting Covid, you could get vaccinated and still have risk of myocarditis after Covid.

The CDC loves these studies that over simplify the data to promote vaccination and minimize harms. The CDC admits that content published in MMWR is the “official voice” of CDC and reflect CDC policy.

Conclusion

This latest meta-analysis is yet another paper designed almost exclusively to promote mRNA vaccination by severely minimizing the risk of myocarditis from the Covid vaccine. In addition to combining risks, it compounds factual errors from the Lancet paper that it heavily relies on for comparison data. It’s odd that it was done by researchers in China, where the mRNA Covid vaccines are not widely used.

Of course, it was picked up and spread widely by Celine Gounder, and has been widely retweeted by other Covid vaccine evangelists. These “experts” either didn’t evaluate the study to see if it was sound, or who didn’t care about the quality of the study because it promotes Covid vaccination in young people.

Finally, the paper concludes, “these findings provide an important context for health policy makers and parents with vaccination hesitancy to weight the risks and benefits of mRNA COVID-19 vaccination among adolescents aged 12–17 years.” One has to wonder what the point of promoting Covid vaccination in adolescents is now, considering there is widespread population immunity from prior infection, combined with their already low risk of severe Covid. When studies like this one use misleading data, they are not providing the “important context” on “risks and benefits” as they claim. Instead papers like this just add to suspicions that public health is irreparably compromised.

Correction 6/22/2023: I initially made an error in the section about the comparison to other vaccines. The recent study used a comparison to the “non-Covid vaccination” rate from the Lancet paper (56.0), and noted that they did NOT compare to the “non-smallpox vaccinations” rate from the same paper (57.0) — which I found contained a smallpox study. However, the “non-Covid vaccination” rate from the Lancet paper is primarily made up of studies on the smallpox vaccine, plus the flawed analysis of the Kuntz paper by the Lancet authors, so the comparison is still problematic.

So far the CIDRAP article is the only media coverage of this study, which was published in JAMA Network Open. The CIDRAP author, Mary Van Beusekom, is familiar to me for publishing an article that grossly overstated Long Covid prevalence. That article was featured in one of my previous Substacks and was actually corrected by CIDRAP due to the error I identified. In this case, the summary of the study seems mostly correct in summarizing the study, but it naively accepts the study’s findings without any acknowledgement of the significant limitations, several of which were noted by the study’s authors. In fact, the word limitation is nowhere to be found in the CIDRAP article. Bad science journalism like this gets eaten up by people when the headline supports their priors.

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I honestly didn’t want to spend any time on this ridiculous study, because there are so many issues with the methodology and conclusions, and several are quite obvious to even a casual observer who is willing to think critically. But there’s been so much discussion about it on Twitter over the past two days, I decided to pull together my thoughts into this article. Here are several limitations and considerations that seriously affect the study’s conclusions…

Using Fever as a Proxy for Infection

I’ll start with the most obvious limitation of this study. It uses fever as a proxy for infection. That’s right, participants were never actually tested for Covid-19. Many fevers during the study period were probably due to Covid, but there are still many limitations and issues with inferring index cases from measured fevers. This approach has some significant limitations:

• Some fevers may have been other illnesses. Kids may have infected parents with other things that are being counted as Covid. Young children are more likely to be checked for fever, and have more fevers for various illnesses. This could also explain why children were more often identified as the index case during times when Covid prevalence was low.

• Many infected people do not have fevers. Many people infected with Covid show mild symptoms and may not run a fever. This methodology misses all household transmissions that didn’t result in a documented fever for 2 or more people in the household. Newman Nahas wisely pointed out that this flaw draws conclusions about people infected with Covid based only on data for those who were febrile. This study doesn’t have any data about potential Covid transmission from those without fevers. Perhaps children with fevers are more likely to be an index case than children with Covid who don’t run fevers, either due to their infectivity or family dynamics of caring for a febrile child.

• Not everyone becomes symptomatic on the same timeframe. A parent could have been infected first, but the young child developed a fever first. In this case, the child would be misidentified as the index case. This would also misattribute transmissions from outside the household, where multiple people in the household were exposed together, and a child was simply the first to be identified with a fever.

• Not everyone in the household used the smart thermometer. This misattributed transmissions that began with an adult who didn’t check their temperature. As an example, if Dad works outside the house and brings Covid home from work, but only Mom and kids used the smart thermometer, Dad is missed as the index case. The study notes that in households with multiple people using the thermometer, adult women (57.7%) were much more likely to participate than adult men (37.6%).

Ascertainment Bias & Other Related Issues

This is related to other issues of using fever as a proxy for infection, but I thought it needed a more lengthy discussion. This study was entirely observational, and the number of times people had their temperatures taken varied significantly. A large number of people were only checked for fever a few times, while others had their temperatures checked potentially hundreds of times. Kids are likely to have temperature checks more than parents, particularly when school is in session, and adults are more likely to check their temperature after their kids are known to be sick.

Many parents checked their child’s temperature daily as a requirement for daycare/school attendance. It would be interesting to see how many times people who were considered an index case had their temperature checked versus those who were not considered an index case. This would also impact the timing of when kids were considered the index case. Parents may be more likely to check their children’s temperatures when school is in session, either as a requirement for the school’s daily “health checks”, or because they were simply nervous about their child(ren) getting or spreading Covid at school.

As David Zweig pointed out, Table 1 in the study shows that young children (ages 0-8) “on a per person basis, were tested 67% more often than adults” — a median of 5 vs 3 temperature readings. These numbers seem suspiciously low to me, especially considering there were an average of 12.1 readings per person in households with 2 or more participants (516,159 / 6,227,726). Some people had their temperatures checked a lot more than 12 times. Were these people more likely to be identified as the index case? The study did not provide data on the number of readings for the inferred index cases versus others.

The study mentions bias in checking children’s temperatures more than adults as a potential limitation, but then uses some seemingly misleading data to dismiss this concern, stating: “Perhaps parents are more likely to take their children's temperatures than their own, thus overestimating proportions with a pediatric index case. However, in this study, there were more temperature readings per person for adults than children.” Their own data from Table 1 in households with 2 or more participants seems to contradict this second sentence, so if both are accurate, I must assume the sentence in the limitations section is referring to the study as a whole, which included many households where only one adult used the thermometer. However, that data isn’t relevant to their household transmission results, so I’m not sure how it’s a relevant fact to counter that limitation.

Also, Kinsa sells three types of thermometers - traditional style (for oral, rectal, or underarm use), contactless forehead style, and an in-ear style. The study doesn’t provide any data on if one type of reading had a higher rate of identifying fevers. Rectal temperatures are known to be more accurate, and are typically only used in young children, which could further bias the data toward early identification of fever in the youngest children.

Finally, I’m not familiar with the Kinsa thermometers and smartphone app, but if you have the app, are all temperatures recorded in the app, or only ones where the adult chooses to send the data to the app? If so, this leads to an additional confounder where a mild fever in an adult might be ignored initially and not recorded, but then fevers in children were recorded for tracking purposes.

Additional Issues

There are many other issues with the study that need to be mentioned as well:

• This study conflicts with most of the existing literature on Covid transmission from children and schools, so it should be viewed with significant skepticism, even aside from the obvious issues with the methodology. The only reason it was uncritically embraced and promoted is because it supports a preconceived notion that many people have been pushing throughout the pandemic — that children are disease vectors. The study’s corresponding author brought his own bias into this study, which he gave away when he wrote “Not surprisingly, children are very frequently the index case,” in his tweet about the study. The truth is that prior studies found schools were not a significant driver of transmission, that children were not a major factor in household transmission, and that increased age and weight increase the amount of aerosolized virus.

• This study found that only ~15% of infections were from in-home transmission. This finding also goes against much of the existing literature, which further brings into question the rest of the findings. It seems likely that many cases where adults were the index case were simply missed due to many of the limitations described in this article. And even if it were somehow accurate that most infections come from outside the home, that would significantly reduce the importance of who the index case is within households.

• The study attempts to link the percentage of child index cases to school reopening, but the study doesn’t provide any data on geography, which was a huge factor in both school reopening and the seasonality of Covid spread, further confounding the data analysis. Some states opened schools much earlier than others, and Covid waves were very regional, with summer waves happening more in the Southern US. It would be very interesting to see where these thermometers are being used and how their inferred transmission data varied regionally.

• The paper doesn’t say how people obtained the thermometers, but refers to them as “commercially available.” The CIDRAP article states that the researchers “gave out” almost 850 thousand smart thermometers, but I suspect that’s not correct. As a result, we must consider that the population who would buy and use Kinsa smart thermometers (which range from $30-50 on the Kinsa web site) may not be representative of the US population as a whole. If the households are wealthier and more Covid conscious, the adults may have been more likely to work from home, avoid restaurants and large in-person gatherings, etc. This would skew the source of infections to children who leave the house to attend school for this population, versus lower income households where adults were often considered essential workers and who were exposed to Covid a lot more outside the home.

• The paper spends a lot of attention discussing temporal aspects of the percentage of inferred index cases from children, and then trying to tie this to school reopening and lifting of in-school mitigations, but the fever data is already so problematic based on the limitations already discussed, plus there are many other confounders with viral patterns related to increasing immunity from infection, vaccination, variants, geography, seasonality, etc. to even attempt to prove causality, so this entire aspect of the paper is just absurd.

And lastly… So what?

This last point isn’t so much a limitation of the study, but a statement about the value of the study’s supposed findings. Even if children did contribute to ~70% of household transmissions, what should we do with that data? The study authors claim their data suggests “a substantial role of school attendance in COVID-19 spread.” Are people pushing this study seriously arguing for more restrictions on school children? We know one of the authors argued for pre-emptive school closures in March 2020. Are people sharing this study still in favor of school closures to mitigate Covid spread, even after we have seen the extensive damage done to children’s education and mental health? Do they think parents should isolate sick children at home alone, instead of lovingly care for them, without concern if that means a parent might get an illness from their child? Do they want masks mandated in schools and daycares, ignoring the harms of masking children all day, everyday, while they are trying to learn and socialize?

We have always accepted that sending children to school and sports and other activities is important, and that yes, it might mean they get sick. That’s a trade-off most people accept because education and socialization is vital to our children’s futures.

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It’s now been more than 16 months since the isolation timeframe was shortened, and the public health emergency has ended, but the CDC’s isolation guidance still stands. And as far as I know, there is no indication that the CDC intends to update their current isolation guidance now that the emergency has ended. However, one state did announce this week that they are no longer recommending a five-day isolation period for those infected with Covid-19. Was it Ron DeSantis and Joseph Ladapo in the “Free State of Florida”? Or Georgia, home of the “experiment in human sacrifice”? Maybe another Covid minimizing state like South Dakota, Missouri, Iowa, or Texas?

Shockingly, no — it was Oregon! That’s right, Oregon, a state that enforced many stringent Covid restrictions over the past three years, is the first state I’m aware of that has dropped recommendations to isolate after testing positive for Covid-19. The Oregon Health Authority announced recently that they “believe widespread population immunity…means many COVID-19 infections are now likely asymptomatic or mildly symptomatic, and the five-day isolation period is doing little to reduce transmission.” This makes a lot of sense. Most people stopped testing a long time ago, and with so many mild cases plus three years of built-up immunity, there’s simply no reason to think that isolating the few people who bother testing would have any meaningful impact on the spread of the virus.

Oregon public health officials are now recommending that people “stay home until fever free for 24 hours and symptoms are improving” and “avoid contact with individuals at increased risk for severe disease.”

I am shocked but thrilled that a state like Oregon was bold enough to update their recommendations in this way. The next step is to spread the word and encourage other state public health departments to follow suit, and not wait on the CDC.

While isolation is no longer mandated by law in many (most?) states, Oregon is the only state I’m aware of that is explicitly ending the 5 day isolation period for Covid, opting instead to treat it like any other common respiratory illness. Every state health department website that I checked either followed and/or linked to CDC guidance. (Technically, Oregon Health Authority still hasn’t updated their main website to reflect their new guidance, so maybe there are some other states flying under the radar.) It’s also worth noting that Florida varies slightly from the CDC by not recommending masking for 5 days after 5 days of isolation.

I did find some news articles about the change in Oregon’s recommendations, so it’s gotten some publicity within Oregon at least. But when I searched Google and Twitter for stories of any other states lifting pandemic measures, I couldn’t find anything about other states dropping their isolation guidance. If you know of any other states ending their isolation protocols, please tell me!

In a recent Washington Post op-ed, doctors Shira Doron, Elissa Perkins, and Westyn Branch-Elliman, argued for the CDC to end the Covid isolation protocols and switch to a “stay home when sick” policy, just like Oregon has done. I’m sure they’ll be glad to see Oregon health officials seem to agree with them.

Many other countries and Canadian provinces have ended their Covid isolation guidance already. As with most Covid protocols, the CDC is behind much of the world in this regard. Below is a list of several countries that have updated Covid isolation guidance, along with links and quotes from their official websites:

• Denmark
  “If you test positive for covid-19 and feel ill, you are recommended to stay at home until you feel well again. If you test positive for covid-19 and don’t feel ill there is no need to stay at home. You don’t have to notify your close contacts.”

• Sweden
  “Stay home from work, school, preschool, and other activities if you feel ill and have symptoms that could be due to COVID-19…. Children and adults can go back to work, school, preschool and other activities when they feel well and are in a general good condition.”

• Norway
  “…there are no longer any rules or recommendations to quarantine or isolate. If you feel ill and experience respiratory symptoms, you should stay home until you feel better. You can go about life as normal if you are not experiencing any symptoms.”

• Finland
  “Currently, official quarantine or isolation is only imposed extremely rarely because they no longer effectively prevent the spread of coronavirus infections.

  Coronavirus infections can be prevented by the same means as other respiratory tract infections.”
  “If you experience symptoms of a respiratory tract infection, you can treat them like other sudden respiratory tract infections. It is a good idea to stay at home when you are ill until the symptoms have clearly decreased.”

• Netherlands
  “If you test positive for COVID-19, you no longer have to self-isolate. The guideline for self-testing if you have symptoms has also been discontinued as of 10 March 2023.”
  “The coronavirus SARS-CoV-2 is a constant presence in the Netherlands, but it is less likely to cause serious illness at this point. This is known as the endemic stage. Even in an endemic stage, there are still vulnerable people who have a higher risk of serious illness from an infection involving SARS-CoV-2 or another respiratory virus. For that reason, it is still important to take them into account. Follow these recommendations if you have symptoms.”

• UK
  “Try to stay at home and avoid contact with other people if you or your child have symptoms and either:

  • have a high temperature

  • do not feel well enough to go to work, school, childcare, or do your normal activities

  You can go back to your normal activities when you feel better or do not have a high temperature.”

  “You are no longer required to do a COVID-19 rapid lateral flow test if you have symptoms.”

• France
  “…if you have suggestive symptoms or test positive for COVID-19, you no longer have to self-isolate.” They do have some recommendations to mask, distance, “avoid contact with frail persons,” among other things.

• Czech Republic
  “Isolation due to covid-19 is no longer automatically ordered based on a positive test result.”
  “The general basic recommendations that significantly reduce the risk of further spread of any respiratory disease still remain valid.

  1. If I am sick, I stay at home and try to avoid contact with elderly or immunocompromised people.

  2. I follow respiratory hygiene.

  3. I wash my hands regularly with soap.

  4. I ventilate enough.

  5. I cover my airways when I sneeze or cough.”

Even some countries known for taking very serious measures against Covid have updated their isolation guidance to be more flexible:

• Australia
  “It is no longer a legal requirement for people diagnosed with COVID-19 to isolate.”
  “For the 7 days following your positive test result, you may consider additional precautionary measures to protecting the health of your loved ones, and those most at risk from severe COVID illness in the community.”

• Hong Kong

  “Symptomatic persons should stay at home for rest and avoid going out, while asymptomatic persons can go out on their will or go to work. To protect the young, students who have tested positive should not attend schools until they have tested negative by RATs. Infected persons should wear well-fitting surgical masks, KF94, KN95 masks, or respirators (such as N95 masks) during the first five days after testing positive.”

• Canada left isolation guidance up to the provincial health departments. Most (if not all) provinces dropped mandatory isolation, and recommended isolation guidance varies by province. The Ontario Ministry of Health recommends the following for anyone with symptoms of Covid-19:
  “Stay home and self-isolate until all of the following apply:

  • your symptoms have been improving for at least 24 hours (or 48 hours if you had nausea, vomiting and/or diarrhea)

  • you do not have a fever

  • you have not developed additional symptoms”

What Can Be Done?

Unfortunately, I doubt that the CDC will update their current isolation guidance anytime soon, especially with CDC Director Walensky leaving in a month — so I recommend working at the state level. Contact your local department of health and ask if they will follow Oregon’s lead and update Covid isolation guidance to treat Covid like any other illness. Given Oregon’s history of strict Covid mitigations, it will be hard for anyone to argue that the Oregon Health Authority is being reckless and “not taking the virus seriously.” You can even send them this article to show all the other countries that have already updated their guidance. I will certainly be sending an email along with this article to Georgia DPH and Governor Kemp’s office.