Dr Ellie Murray, ScD
@EpiEllie
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Epidemiology asst professor @BUSPH |social media ed @amjepi | cohost @casualinfer podcast | Causal inference & public health #epitwitterđ¨đŚ insta/đ§ľ:laughing.e
She, her, Dr
Joined June 2013
Everyone keeps talking about covid becoming endemic, but as I listen to the conversation, itâs becoming more & more clear to me that very few of you know what âendemicâ means. So hereâs a thread on how pandemics end.
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I love twitter bc where else can I, an person with two graduate degrees from Harvard in both infectious disease epidemiology and biostatistics, be assured I am wrong about infectious disease epi and statistics by a software engineer who has âread multiple FDA package insertsâ.
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I did a couple raw milk posts this week, and a frequent comment was: âif babies can drink raw milk, why canât adults?â. It shouldnât need to be said but:. Human mothers are NOT cows. Human milk is NOT the same as cow milk. NEVER give a human baby ârawâ cow milk.
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My dentistâs first question to me, knowing Iâm an epidemiologist, was âwhen will this all be overâ. Was super unsatisfying for us both for me to have to answer, âwhenever we want, if the government would just take concerted & decisive actionâ.
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People love to claim to we canât change peopleâs behavior. But did you know the idea of âdesignated driversâ is only normal in America thanks to the work of a group of Harvard scholars?. Hereâs 5 reasons they succeeded.
Responsible designated driver ensuring a safe journey home
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COVID fatigue is a real & weâre all exhausted, but I suspect a lot is actually *decision* fatigue. The absence of clear rules, information, and guidance means having to think through our every action to decide what feels safest. Good leadership would give us all a break.
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Mask wearing is literally the same type of thing as refrigerators, sunscreen, bug spray, spaying your pets, cancer screening, seatbelts. NONE of those things work perfectly all the time. But ALL of them help reduce harms some of the time. Harm reduction is the goal.
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The idea that âeveryone has already gotten COVID at least onceâ is just the latest attempt to make you forget about the risks it poses and go back keeping the economy afloat. Sure, some infections are asymptomatic, but that doesnât mean everyone who hasnt been sick was infected.
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We are dealing with a massive public health crisis on a scale none of us has ever lived through before, and yet many senior public health folks are shushing junior folks who speak out & warning us to think of our careers. But what is my career for, if not to speak up now?.
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If you *are* at a Super Bowl party right now, please donât forget to quarantine for the next 11-14 days. You might have decided the risk to yourself is worth it, but everyone else you would normally interact with didnât get that choice.
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Remember when the CDC said âeveryoneâs gonna eat raw cookie dough anyway, so weâve decided to tell them itâs actually fine & safeâ?. Oh, wait, no. They did such an effective campaign against it that companies like Pillsbury realized there was a market to sell safe-to-eat dough.
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sorry if thatâs elitist, but I worked really really really hard to know more about this stuff than the average person, so đ¤ˇđźââď¸.
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If you have to clarify âno, no, my plan isnât eugenics, I just think we should infect everyone because only the weak will dieâ, I hate to break it to you but your plan actually is eugenics. And I am not here for it.
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Here is the real secret: because our leaders chose not to shut down the economy to stop omicron, omicron has shut the economy down for us. And this way is much much worse.
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Vaccines work. Vaccine denial kills. Itâs that simple.
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âFunnyâ story: when doctors learned washing their hands reduced infections, they actually *did* give up washing their hands after the guy figured it out left. And then more people died. And even today, hospitals spend BIG money reminding & convincing doctors to wash their hands.
@BurnabyNOW_News When doctors learned washing their hands reduced infections, they didn't stop washing their hands when all infections cleared up. Why is masking not still mandatory at hospitals? Why are we taking a step backwards?.
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I am so tired of people who know nothing about infectious disease spouting âeveryone will get covidâ nonsense. COVID is not inevitable. Societyâs choices control how much illness & death & hospitalization & disruption & grief & loss we suffer. Be empowered. Demand better.
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THINK LIKE AN EPIDEMIOLOGIST: why are COVID deaths *still* not going up 3 weeks after case counts started increasing? There are many possible explanations, but one I havenât seen mentioned is the impact of widespread testing on *early detection*. A #tweetorial on LEAD TIME BIAS.
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Having read multiple software installation guides does not make me think I know more about software engineering than a software engineer. But maybe Iâve been selling myself short all these years!.
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Iâm so tired of talking about the pandemic and having to say the same things over and over. The pandemic isnât finished and if we donât commit to helping those countries or regions where surges are happening, it wonât be finished for a long time to come.
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Every time I tweet about this I get people in mentions saying âbut we donât take precautions for the flu!â. Those people are 100% WRONG!. Thousands of people work daily to monitor, prepare for, & respond to fluctuations in flu number and in the flu virus itself! Itâs a HUGE task!.
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Mammograms, pap smears, colonoscopies, prostate exams & PSA tests, prenatal care & ultrasounds, well-baby visits, STD screening, cholesterol & blood pressure tests, newborn genetic tests, oral cancer checks at the dentist, that thing where the eye doctor âdilatesâ your pupilsâŚ.
"Think about it. Before COVID, did anyone go out and seek testing to determine if they were sick?" @GovRonDeSantis today
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We need more of thisđđźđđź. If weâre going to expect people to manage their own risk, then we should also create spaces or times where the risk levels are varied.
This Sun, Dec 4, we'll be offering our monthly mask-required hours from 11â1. These hours are offered to better accommodate immunocompromised individuals & those who prefer to visit when everyone is masked. If that's you, we hope you'll stop by! .
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THINK LIKE AN EPIDEMIOLOGIST: . The CDCâs recent announcement that the Delta variant has an average reproductive number of 6-9 has a lot of people concerned & many are asking me about whether this means we need COVID boosters. Letâs talk through the math of how we might decide!
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THINK LIKE AN EPIDEMIOLOGIST: what the heck is going on with respiratory viruses right now and is it because of covid, because of our attempts to stop covid, or something else?. Itâs so much more complicated than some catchy buzzword youâve seen. Letâs dig in deep together!.
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Our @NEJM study showed school mask mandates *reduce* COVID illness & absences. Others disagreed. But we take scientific critique seriously. So we checked everything suggested to us. And now weâve published an updated Appendix with the details. Our results hold: Mandates work.
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I saw someone say that much of what we see as scary about polio is actually âlong polioâ & tbh thatâs pretty true. I think the âlongâ framing makes it clear long COVID isnât unprecedented & that we need to face up to it. What other long infectious diseases are there? . A list*.
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oh nos! my subtweet has a typo! i guess i have to throw out my degrees now! itâs all over for me!!.
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Whatever people think of masks for covid, the evidence is super duper clear that when we all wore masks there was no flu. Epidemics dont have to ârun their courseââwe can cut this flu season short anytime we want with masking, hand-washing, and flu vaccines.
The U.S. is officially in a flu epidemic, federal health officials say. Theyâre preparing to deploy troops and ventilators if necessary
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It was never really âlockdownâ vs âno lockdownâ. Instead, the choice is:. Option 1: unfunded lockdown of ambiguous length lifted as soon as politically feasible with no long term plan. Option2: funded lockdown with strong support systems & clear targets for phased re-opening.
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So hereâs the kicker: âendemicâ doesnât mean ânever think about covid againâ. Itâs exactly the opposite!. Endemic means someone is ALWAYS thinking about covid. Endemic means public health is always monitoring disease & always intervening when cases cross the âacceptableâ level.
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The biggest problem with people who are âjust asking questionsâ is, IMO, the fact that they are never âlistening to the answersâ.
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Really wish the CDC would just step up to the plate and say: âfrom now until Feb, or until trajectory of covid deaths is declining, masks are mandatory on transit & in all public + government spaces, and we strongly recommend state & local health departments take the same actionâ.
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If you were waiting until new surge started before wearing masks or pushing for mask wearing in your community, the wait is over. Every indicator says now is for sure the time.
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Everytime someone says âbut 99% of people who get covid donât dieâ I really wonder what their lives are like. Would you get on an airplane that advertised â99% of passengers survive the flight!â? . Would you eat at a restaurant where â99% of customers dont die from our food!â?.
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If youâd never heard of epidemiology before #COVID19, itâs probably because many epidemiologists spend all their time controlling outbreaks so that they never become news. Donât try to reinvent the wheel. Donât assume no one knows what to do. Listen to the experts.
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âIs covid back?â is such a ridiculous framing. It never went away, and we have seen an increase at exactly this time of year for the past 3 years. Might as well say:. âIs school back? Despite a quiet summer, classrooms across the country are increasingly full of childrenâ.
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You might have noticed something important here, and itâs something I think MANY of the people shrugging off covid becoming endemic get wrong:. âEndemicâ does NOT mean âharmlessâ.
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1. HARM REDUCTION approach. The Harvard Designated Driver Campaign is a great example of harm reduction. The idea of designated driver is about how to help keep people safer, when they go out drinking. Not how to stop them from going drinking.
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A school board official on the radio jut said âwe surveyed teachers and, after counting ânon responsesâ as votes for âin personâ, about 50% of teachers want to teach in person this fallâ. đ¤Śđźââď¸đ¤Śđźââď¸YOU CANNOT IMPUTE THE ANSWER YOU PREFER WHEN YOUR DATA ARE MISSINGđđđ.
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Always enjoy the first lecture in my Outbreak Response course where I walk students through how the CDC handbook *says* that outbreaks should be handled, while they look increasingly confused because the CDC hasnât been doing anything of the sort.
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The government is predicting 100 million COVID cases this winter. Weâve seen ~1% fatality rates from past waves. if that holds, then weâll see a million *extra* deaths this winter. But itâs fine because they are planning to⌠<checks notes> drop covid funding from this bill?.
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3. POSITIVE framing. People donât like downers, so messages like âDonât drink and driveâ can be harder to sell. But, âThe Designated Driver is the Life of the Partyâ is much more positive.
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Because pandemics donât end by a disease just fading away, & pandemics donât end with everyone able to completely forget about the disease. Pandemics end when we decide how much death and disease weâre satisfied with. I dont know about you, but for meâthisđđźis too much death.
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If everyone you know is suddenly getting âfood poisoningâ, just FYI that it is probably not actually food poisoning but is instead norovirus. Norovirus (sometimes called âstomach fluâ but not actually flu) is seasonal, and right now in the US it is norovirus season.
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Of course this doesnt mean COVID could be over tomorrow, but if we take coordinated, decisive, and evidence-based action NOW, we could think about making Thanksgiving or Christmas plans. If we dont, then this is what our life looks like for the foreseeable future.
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PUBLIC HEALTH MINUTE:. Honey is sweet and sticky and wonderful and everyone loves it, and babies are sweet and sticky and wonderful and everyone loves them. But you should NEVER ever give honey to babies. Why? . The short answer is: botulism. The longer answer: a đ§ľ.
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Tularemia is a Category A pathogen, meaning its severity and transmissibilityâand the fact that itâs relatively easy to get from wild rabbitsâmake it potentially modifiable into a bioweapon. Please donât ever give a wild rabbit CPR.
Two nights ago I gave a wild baby rabbit CPR w breaths after I took it from my Petey (cat). Today, Iâm being admitted to the hospital with signs of âbunny feverâ (Tularemia). Iâm on 8L oxygen, a cocktail of very expensive antibiotics, anti-diuretics. Need light & love, please!.
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Itâs august, & iâm more afraid of whats going to happen over the coming months than at anytime since i saw the first covid report on dec 31. in feb, i thought the failure to act was slowness. in april, i thought it was incompetence. i dont know how to process that it was malice.
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The thing about calling for forgiveness for things said when âwe were all in the dark about covidâ is that *we* werenât in the darkâyes there were obvi things to be learned about a new virus, but the basic principles of virology, epidemiology, public health, etc cast some light.
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2. CLEAR & SIMPLE message. If you want people to internalize a message, youâve gotta make it simple. The idea of âone person doesnât drink and then they drive everyone homeâ could have been complicated to justify. But âdesignated driverâ isnâtâthe name says it all!.
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So, yes, our only viable choice left is covid becoming endemic. It didnât have to be this way, but our leaders MADE a choice. And now they need to make another choice: They need to choose an âacceptableâ level of COVID death & disease.
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âEmployees can get back to work if they are infectious but not sick enough to be bedriddenâ is the new âjust train kids to hide under their desks when someone is shooting their classmatesâ. Neither solves the problem. Both make things worse.
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Earlier this week someone confidently told me that COVID, because it is caused by a virus, is not an infectious disease. And then looked really really skeptical when I replied that viruses are, in fact, infectious.
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5. SHOW-DONT-TELL strategy. The biggest successes of the designated driver campaign likely didnât happen because of the posters in high-schools. Instead, success came from the Harvard teamâs work to get the message incorporated into TV and movies. This helped normalize it.
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If you are angry that 20 months into this pandemic we still need to wear masks, good! Iâm angry too! . We could be happily going about our lives if the response had been better. But Iâm wearing my mask now because I donât want to STILL be in a pandemic in ANOTHER 20 months.
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Sure, maybe the flu doesnt impact *your* life, except some years you get a flu shot, or maybe you have once or twice really actually gotten the flu & not just a bad cold you *called* the flu. (Pro-tip: if you dont feel like youâve been hit by a train, itâs probably not the flu).
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Whether a disease is endemic, epidemic, eliminated, or eradicated does NOT tell us how serious it is, and does NOT tell us how many people get sick or die. We have to CHOOSE that number.
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But that is because PUBLIC HEALTH KNOWS WHAT ITâS DOING!!!. There are clearly defined âacceptableâ levels for different strains of the flu, and we spend so so much time & energy & money working to keep the flu below those levels. So that YOU donât get sick.
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School districts that refuse to provide alternative or remote schooling options in a pandemic but then send truancy notes to parents who keep their kids home because of the pandemic really need to think hard about whoâs interests they are serving.
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Pandemics always end, even if we do nothing. Thatâs the nature of infectious diseases. Success is ending a pandemic early, decisively, and with less death or suffering. Failure is ending a pandemic gradually, sporadically, and with the potential for new variants to cause surges.
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âthe pandemic is overâ.
Life expectancy in the U.S. has fallen to the lowest levels seen in 26 years, new federal data shows.
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This is your irregular reminder that if youâre interested in reading a scientific paper but canât access it online, send an email to the author & they will be more than happy to send you a free copy of the pdf.
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Lately, all my covid convos are one of these 3:. Leaders: thereâs no point in precautions b/c everyone is done with covid. Media: people are done with covid, no point in publishing anything else. âGeneral publicâ: covid is over right? All the media & leaders tell me so.
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Contrarians love to ask: âBut what did people do before [insert public health measure]??â. And the answer is always just: âThey died, or they buried everyone they loved.â
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4. OTHER-FOCUSED framing. Public health is about communities, and thatâs extra clear in public health messaging campaigns. Other-focused framing centers the people who are the reason your actions matterâlike your friends, who you, as the designated driver, help get home safely.
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This time last year, if youâd asked me about basic income, I would have called it a beautiful fantasy. Now, after 12 months of an uncontrolled pandemic, my opinion is radically altered: basic income is an absolute and irreplaceable necessity for a civilized society.
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When the machine learning algorithm looks super complex & scary but itâs really just logistic regression.
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Looking forward to the discourse about how lazy everyone is and how itâs hurting the economy during the coming winter surge
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Shut down non-essential indoors activities again & halt interstate travel until all the following are in place: . Produce ludicrous amounts of N95 face masks & testing supplies. So much contact tracing. Safe quarantine & isolation sites. House the homeless. .
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What should we be doing? I have lots of ideas but youâre not going to like them. They all boil down to coordinating federally & collective action. Youâre going to say Iâm a socialist. I probably am. Iâm Canadian. Ready?.
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Also, human babies CAN get sick from human milk but itâs also their best food sourceâeven though it is sometimes not an option for all babies or parents. So, letâs talk about how human babies can get sick from human milk.
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Realistically, despite New Zealandâs valiant efforts, we are not going to do that. We donât have the political or social will to eliminate or eradicate covid. But that means we HAVE TO continue to CONTROL covid! . Thatâs the only other option. THAT is what endemic means!
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Another problem with the âletâs just let everyone get COVID & not care if the most vulnerable people dieâ idea (aside from it being ghoulish) is that COVID itself appears to cause a range of long-term conditions creating more vulnerable people at risk of dying in the next wave.
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Free rapid tests & face masks, delivered weekly to every household in America by the USPS, how about?.
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Now we get to Option 1 (continually occurring disease). This is easier short-term but itâs the hardest *long-term*. Itâs also super vague: it could mean anything from hundreds or thousands per day to one or two per year. The other name for this is, you guessed it, âendemicâ.
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If a disease is really bad, âacceptableâ is very lowâpotentially even indistinguishable from elimination. The plague (yes that one!) is kinda common among rodents in parts of the US, but if even ONE person shows up to a doctor with symptoms, public health jumps into action!
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900,000 COVID deaths. It is not going away. The end of the omicron wave is not the end of covid. Itâs a breathing space to plan for the next wave. And the one after that. And all the ones after that.
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Some of you have never spent any time around a toddler and it shows. For the rest of you, whatâs the most memorable reason youâve seen a toddler cry over?. Hereâs one from me: wanted a âlottle bitâ of pasta & absolutely horrified by the choice of a âlittle bitâ or âa lotâ.
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Iâm not a virologist, so I canât add any useful information to help you process news of a new covid variant. But as a public health expert, I can remind you (& our leaders) that the chance of new variants are precisely why we need to treat global pandemics like global problems.
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One of the most fucked up things about the US is the way they have managed to turn basic principles of public health into conspiracy theories. This is the truth: If you do not control the spread of an infection, the spread of the infection will control you!.
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I still dont understand why we dont have workplace COVID safety standards from OSHA for all occupations. From the number of airline workers who end up off sick every time masks come off, it is super duper clear that there is a problem thereâŚâŚ.
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Federal paid sick leave & paid *quarantine* leave for all employees. Universal basic income for the duration of the pandemic. Universal Medicare eligibility, or similar. Federal eviction freezes. Easy-to-apply-for subsidies for electricity, water, internet, & other utilities. .
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When flu cases cross the threshold & the public health lever switches from âmonitor flu activityâ to âtake action YOU donât notice. But not because it isnt happening â because the acceptable level is LOW ENOUGH that those actions happen before it impacts your daily life.
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REPEAT AFTER ME: public health interventions that reduce infections are worth doing even if they donât prevent *all* infections. Fewer infections is always better!!!.
Flanders, Belgium: 'Children with chickenpox can go to school from now on'. Reason: pre-symptomatic transmission exists, so symptomatic transmission should be allowed too.
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The thing about in-person conferences is they are often the only time that far-flung academics get to see their friends from before they moved to wherever they had to move for a job. Itâs not just about presenting talks or posters. Itâs about maintaining our mental health.
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Yes, eradication is HARD but we could still choose to make it our moonshot if we wanted to. It would definitely take time. It would probably take new science, new ideas, & new tools. And it would take both leaders & everyday people actively committing to doing what it takes.
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This coup attempt didnât start today, it started months ago. It wasnât planned in secret, it was planned live on twitter and television by the president himself. âWhen people show you who they are, believe them the first time.â -Maya Angelou.
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So what does this tell us about how pandemics end? . Well, it tells us that we CAN put in the work to really get rid of it once & for all, if we have the will and the strength and the interest and the resources. It probably gets harder & harder the longer we wait, though.
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This morning I had an appointment with a sleep clinic doctor to help me figure out my sleep issues. Folks, I missed my alarm & slept through the appointment. đ¤Śđźââď¸.
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In more technical terms âendemicâ means: âControlled at or below an âacceptableâ levelâ. What level is âacceptableâ differs from place to place, over time & between diseases, and it may not always be explicit, but when a disease is endemic, there is a threshold!
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Me, an epidemiologist: research shows widespread mask use reduces respiratory infections. Them, a rando: OMG WHY DO YOU WANT EVERYONE TO ALWAYS MASK EVERYWHERE FOREVER?!!!!.
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Opponents of universal health care in the US love to point to wait times in Canada and the UK as the reason why universal health care is bad. But I just tried to schedule a screening mammogram for this month & the first available date in Boston is mid-July. Wait times are bad.
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Beware causal inference with machine learning because the answer isnât in the training data, and the algorithm can only learn what it sees. #causalinference #ML #AI .
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I canât get this tweet out of my head. Literally every media outlet is calling them ârestrictionsâ when they should be calling them âprotectionsâ and that choice is absolutely killing people.
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On the other hand, if a disease is not really that bad at all, the acceptable level can be really very high. Up to 80% of US adults are infected by the virus that causes cold sores (aka oral herpes)!. But public health takes *nearly* no action, except to protect infants.
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As more & more places remove mask requirements, Iâm seeing a trend of people being relieved about all the other things this means they can doâlike indoor events, school functions, etc. But we could have done those things with masks. Without masks, they are all less safe.
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This is a BAD article. âRe-entry anxietyâ isnât a problem with *your* mental health, itâs a problem with *the governmentâs* re-opening plans. If there are #COVID19 cases in your area (and there are), itâs totally ok and appropriate not to want to âresume normal lifeâ.
As COVID-19 lockdowns end, people are experiencing "re-entry anxiety" as they resume aspects of normal life. Here's what to do about it
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