Farzad Mostashari
@Farzad_MD
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Founder, Aledade/ Former National Coordinator for Health IT/ NYC Health Dept/ CDC EIS Officer
Washington, DC
Joined April 2011
1/ Would you want your employees, your customers, your partners, and government regulators to hear what you tell investors?. It's not done! Different audiences will understand and react to the same thing very differently. I'm going to take that risk today, show you my deck 😱🙏
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1/ All masks are not the same, and it's hard to tell which ones work better, but this article provides some insights. First, "paper" surgical masks are really very very good.
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1/ After 2 years of working hard to avoid getting-- and spreading-- COVID, the pandemic finally caught up with my family. I thought I would share some of the things I learned along the way.
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1/ I'm very worried that we don't have a clear strategy for #COVID19 response. We need to clearly define when the public health goal is containment-trying to keep the virus from circulating- and when the goal shifts to mitigation-working to reduce the peak impact of the outbreak.
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22/ It's nuts how misunderstood this is, even by medical professionals and institutions who should know better. PCR tests will stay positive long after you are no longer infectious. THAT'S NOT TRUE FOR RAPID ANTIGEN TESTS. If you're antigen positive, assume you're infectious.
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Yikes- . Coughing COVID+ passenger. no mask. 10 hr flight. 92% attack rate among passengers seated w/in 6 feet.
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10/ Maybe a good use of executive authority/ DPA would be to ship a few boxes of good surgical masks to every household in America. Would cost one thousandth of what's being debated on economic stimulus. (when what we need to reboot the economy is control of the outbreak).
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7/ But the bottom line here is that almost all of these masks cut down droplet spread by 80% or more. That is huge. Simple version: If we all wore effective masks and wore them well, then the reproductive number could fall from 2.5 to less than 1.0, and outbreak would extinguish.
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3/ My elderly parents have been essentially home-bound for the past 2 years, with very limited number of contacts. We still don't know exactly how my dad got it. 🤷♀️. But I am so grateful that we delayed his infection until he had a chance to get vaccinated and boosted 🙏.
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24/ We are all fine, thanks to vaccines (and my ability to work the system to get my parents therapeutics right away). But it shouldn't be this hard. Renal tests before Paxlovid is a problem. Inability to reach PCPs urgently is terrible,.Leaving isolation without - Ag is nuts.
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6/ Trying to do containment when there is exponential community spread is like focusing on putting out sparks when the house is on fire. when that happens, we need to switch strategies to mitigation- taking protective measures to slow spread & reduce peak impact on healthcare
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New York City Emergency Room visits continued the downward trajectory through the weekend!. I'm hoping we see a blunting of the hospitalization rate soon. We may have turned the corner on infections, though ICU admissions and deaths will not peak for 1-2 weeks.
22/ MARCH 30 update:. Syndromic surveillance for ED and ILI visits have continued downward trend. It is a big relief to see something actually going down, not just flattening the curve. Data is though Saturday 3/28, shows actually lower volume than Sat 3/21 for ILI.
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18/ *Leaving Isolation. The CDC advice to leave isolation after 5 days without requiring negative rapid antigen test is . unsupported by the science IMO. My dad was still antigen+ (infectious) until Day 8. Should he have returned home to sleep next to my 83yo mom on Day 5?. No
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9/ Here's the hack- schedule a virtual urgent care visit. it's faster than getting a message to the PCP who knows him best. The urgent care nurse ran through checklist, and quickly agreed he qualified. One problem- they want a recent (last 6 mos) renal function test for dosing.
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1/ We are all seeing the massive wave of Omicron sweep through our communities. Severity will make the difference between a bad winter and a horrific one. We keep saying "hospitalizations are still low, but it's early". When is it time? . In NYC, it should be showing now.
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@MollyJongFast I called her office late one night in 1995 in New Haven to leave a message about something (Bosnian?). me (surprised to get a human): I'd like to leave a message for Rep DeLauro. @rosadelauro: Call me Rosa. and she stayed on the phone with me until I was done stammering.
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20/ I was still antigen positive on day 5. I was still antigen + on Day 10, so I drove home 10 hours instead of flying on commercial (OK per CDC). I isolated & masked & ventilated around my household members until I turned negative. on Day 15!. Thankful I didn't give it to them
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9/ I can't tell you how many people have asked me if they should travel to certain cities- we are left to our own devices to figure out where there is sustained community transmission. I can find no official webpage that updates this key status for the US. @CDCgov must do better.
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8/ *Therapeutics.I am SO GLAD for science, and that we delayed his infection until Paxlovid was widely available. Pharmacies all had it in stock. But getting a prescription from his academic medical center PCP quickly was beyond my abilities. Portal messages, answering system 👿.
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2/ *Infection*.Our behavior didn't change, but the virus did. As @ScottGottliebMD has noted- it sure seems like the most recent BA2 surge is increasingly hitting the remaining uninfected, who've been limiting social interactions, social distancing, masking.
1/ Omicron is ripping through America right now, to an extent we won't fully realize until later. At this point, I think most people can hope to delay infection, but not to avoid it. I don't think herd immunity is a realistic goal anymore. Here's what I think it means for us.
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4/ Here's the nub of my worry. We are treating the outbreak in the US as if we are in containment mode- case identification, contact tracing, quarantine and active monitoring of exposed individuals. But I fear that in many locales there is already sustained community spread.
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17/ My mom's response to the mAb was impressively fast. I went from pretty worried about her clinically to completely at ease within 24 hours. I think they are massively underused right now. If you have an elderly/ at risk loved one with COVID infection, I'd try to get it.
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5/ New cases are being identified every day that do not have a travel history or connection to a known case.*and we know that these are just the tip of the iceberg* because of the delays in testing. That means that in the next two weeks the number of diagnosed cases will explode.
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10/ Most alarming, I don't see any public-facing transparency on whether #COVID19 has resulted in noticeable increases in people going to the emergency room, or being hospitalized. And here's the thing-we invested hundreds of millions of dollars to develop exactly this capability.
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8/ And continuing to pursue a failed containment strategy can also delay making the hard decisions involved in mitigation. Closing schools.Cancelling events. Telling people to stay home. I see no guidance as to which localities are at this stage, and what they should do.
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7/ Exhausting our public health workforce with contact tracing, asymptomatic testing and active monitoring when the cat is out of the bag is not just wasteful, it actively undermines our ability to mount an effective response to an outbreak that is just beginning to explode.
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26/ I forgot to add- *Side Effects. Monoclonal had zero side effects. Paxlovid has very unpleasant bitter/metallic taste and stomach cramps/ diarrhea. (be careful of elderly people risk of falls if rushing to bathroom while weakened, consider walker use).
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1/ #EpiTwitter tweetstorm coming. Warning: strong opinions. The analysis is naive and the findings are ridiculous; the fact that it was published is a sign that when medical journal editors hear "deep learning AI" their brains stop working.
Predicting skin #cancers with deep learning #AI using electronic medical records importance of medications; non-melanoma AUC 0.89 @JAMADerm
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21/ It's impressive when you see a really strong positive antigen test. The Test stripe turns positive almost instantly as the fluid hits it. You can see here (on Day 12) how positive the test is within seconds-so quickly that the fluid hasn't even had a chance to hit the Control
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24/ China's unprecedented success in containment has led us down the wrong path. We can't do what they did. Not just in terms of open society, but in sheer resources. In Wuhan >1,800 TEAMS of epidemiologists, min 5 people/team, were tracing tens thousands of contacts a day.
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5/ I was basically fine after day 2. (53 yo). My dad (86 yo) didn't need to be hospitalized but he got pretty sick for a while. Without good care at home, and certainly without the vaccine and booster and therapeutics (more on this) I could easily have imagined a bad outcome.
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2/ The disposable surgical masks (nonwoven, 3-layer) may seem flimsy, but they are engineered to do this job, and they are available now at around 50c each. If you want to be extra safe, add a face shield. That's what doctors do when they aren't dealing w a high risk covid case.
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4/ *Symptoms*.We had what you would expect- initial chills, bodyaches, then runny nose. My dad had a cough very early, I had it later, but quite persistent (I still have it 3 weeks later). A symptom I didn't expect was wheezing. I didn't measure peak flows but would have been bad.
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16/ so. I called the MA Dept Public Health at the minute they opened on 8 am Monday morning, and got a reservation for a Monoclonal Ab infusion that day at 2 pm. Not charge. They can help with wheelchairs/ transportation. But you have to know how to work the system
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11/ On this, I am an expert. After 9/11, I was part of a group of what would now be called Data Scientists who pioneered "syndromic surveillance"- monitoring things like emergency department registration data for real-time public health surveillance.
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6/ *Diagnosis*.PCR is more sensitive early on in the course- but delays in reporting make it useless compared to rapid antigen. I got a pharmacy drive-thru PCR test (by @verilylifesci), but it took 3 days for the results to come back positive . Rapid antigen test + next day.
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19/ I still feel bad that I wasn't even more careful to leave a longer buffer. My mom tested positive a week after my dad came home when he turned antigen negative. We can't be sure where she got it from, but it sure seems likely that it was residual shedding from my dad.
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12/ Treatment option #2- Monoclonal Antibodies. My mom got COVID next. My goal was to get her monoclonals quickly- . "Bebtelovimab should be used as the monoclonal antibody of choice in regions where BA.2 is the dominant subvariant if preferred therapies are not feasible".
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17/ If we are already seeing a detectable increase in symptomatic ER visits due to COVID19, at this stage of the outbreak, should we expect 20x that burden of illness in 4 weeks if doubling time is 6 days?.We need to be working URGENTLY on expanding/protecting healthcare capacity.
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13/ Once again, even though there isn't *that much* supply, there's no shortage! . Why?. You have to know how to navigate the system to get it. Again, forget about calling your PCP office to arrange for it, even if they are within one of the blessed academic institutions
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7/ I was trying to get confirmatory PCR test for my dad, but only same-day service was a for-profiteering place that charged $250. I actually ended up buying a @CueHealth 15 minute home PCR machine ($70 a cartridge)- which is an amazing device, but ended up not mattering
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10/ I ended up convincing them that his most recent test (9 mons ago) already showed moderate renal impairment, so let's just go with the renal dosing already, and get the pills started today. The instructions are a bit hard to follow- so they put a sticker on the blister pack
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22/ Then switch to containment. Let everyone know when you make the switch and why. Stop routine testing in mild/asymptomatic.Stop contact tracing.Cancel mass gatherings. we urgently need to find out if children are infectious, not just infected, and whether school closures work.
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14/ The concept of "urgent primary care" is a non-starter in normie medicine, it seems. The patient portal forces you to choose "non-urgent medical question". the call line takes a message, but tells you it could take 24-48 hrs to get a response. "Go to the Emergency Room" sucks.
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We are about to build a #covid19 patient risk score by using risk coefficients for severe illness/ death from published studies. We plan to use this to prioritize patients in primary care for outreach and extra support. If anyone has already built this, can you please share?.
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11/ make sure you take it correctly!. You have to "take one of each color" pill, but the color on the back can confuse things- . I heard of one person whose family gave them 2 ritonavir tabs in the morning, and 2 nirmatrevlir tabs at night . That . won't work.
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3/ an interesting finding: valved N95 masks were significantly worse than fitted, nonvalved n95 masks for preventing the spread of droplets. Makes sense- valve lets out breath. These may be better at protecting the wearer, but not as good as surgical masks for preventing spread.
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28/ *note/context. They love their PCP, who is smart, hard working, and cares a lot for them. It's just that her organization has made a conscious decision to make it hard for patients to reach her and communicate with her directly. It's more "efficient" fee-for-service that way.
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27/ *Costs. My parents have Medicare and supplemental insurance, and we could certainly afford tests or treatments, but very grateful that the medications and antibody infusion are free- paid for by the government to remove financial barriers. They got 8 free rapid antigen tests.
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23/ Here is wrong advice from @KPMemberService . I generally think Kaiser-Permanente has excellent evidence-based, data-driven care (which is why I'm a member). But I've been frankly disappointed with their COVID response in proactive vaccine distribution, therapeutics, or this👇
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15/ This is what the ILI data in NYC looks like now. It looks like there is a clear signal now of increasing influenza-like illness (cough and fever) in NYC. I don't know if this is "worried well" or a resurgence of flu, or what the age distribution is, but those are answerable
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1/ Omicron is ripping through America right now, to an extent we won't fully realize until later. At this point, I think most people can hope to delay infection, but not to avoid it. I don't think herd immunity is a realistic goal anymore. Here's what I think it means for us.
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15/ NB- I'm CEO of @AledadeACO and our 1,000+ independent primary care practices coach their patients "Call us 1st!" - it's easy to see how that would translate into 14% fewer ED visits, 15% lower hospitalizations, and a lot less suffering. But that's not most of the world.
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1/ This is what has been worrying epidemiologists about #COVID19- if asymptomatic/pre-symptomatic individuals are driving the outbreak, then coming out of lockdown will be exceedingly difficult. here's what it might take.
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1/ This thread will be alarming, I'm sorry. The American Academy of Family Practice CEO is crying out about the financial crisis threatening frontline primary care practices, but no one seems to be listening. I'll give you some news from those frontlines (and ask for your help).
This same financial situation is threatening thousands of family physician offices as well - the frontlines are crumbling and they need money for supplies and operations.
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We have been super careful for the past few weeks, hoping to see family over Thanksgiving. Those plans are cancelled. There's light at the end of the tunnel. Vaccine distribution can start soon. We can wait. Here's to being together in 2021.
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2/ Let me first voice my tremendous respect for the public health experts at the @CDCgov & state/local governments. I'm proud to have worked as a CDC Epidemic Intelligence Service Officer, and I never had smarter, harder working colleagues than during my 12 yrs at @nycHealthy.
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In case you've been wondering, yes, mRNA vaccines are going to be a big deal for more than just COVID.
Today, we shared positive pre-clinical data demonstrating our ability to combine 6 mRNAs against 3 different respiratory viruses in 1 vaccine: COVID-19 booster + Flu booster + RSV booster. #mRNA
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23/ needless to say, all the positive steps that people are taking on changing our habits are good at every stage and may be bringing down the reproductive rate. not shaking hands.washing hands, using hand sanitizer.practicing not touching your face (good luck).working from home.
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19/ And if a healthcare worker is "exposed" (because they weren't wearing an N95 mask they probably don't need) to a patient who later tests positive for coronavirus, should they then be taken out of circulation, quarantined for 14 days?. What does that do to healthcare capacity?.
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1/ I've been feeling more and more disengaged from COVID work, disillusioned with the growing realization that all the smart research and policy doesn't make a damn bit of difference. Not for the 1st time, I've seen that what I thought was an information problem is something else.
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4/ Cotton is hit or miss. More layers generally better. Different materials in different layers (cotton/polypro blend) seems to be better. What's pretty important is how well it fits, and whether there are big gaps.
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25/ Special thanks to all my friends and experts who helped guide me and comfort us during this time, but especially @bijans and @FranklinHuang.
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12/ We established data feeds to all sorts of ongoing data, adapted statistical methods, developed standards, and privacy frameworks, and put these types of surveillance programs into practice across the country. I was in one of the leading centers, NYC.
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21/ we need a strategy. like this:. 1) Severe Acute Respiratory Illness (SARI) surveillance, Active case finding, contact tracing, quarantine. UNTIL we have evidence of sustained community transmission (multiple community-acquired cases, validated non-flu ED ILI signal). THEN.
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20/ And you know what doesn't help? . Pushing testing of asymptomatic contacts or mild cases (no-copay, "if you want a test you can get it") after you already have widespread community transmission. That further exposes other patients and healthcare workers, and saps resources.
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16/ And the only reason I'm using NYC as an example here is that we made the decision to make this data publicly available on the web. I don't know if federal authorities are tightly monitoring fever/cough ER visit trends across the country and investigating if #COVID19 I hope so.
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13/ When I joined feds @ONC_HealthIT to roll out EHRs, we included sending data to public health, including syndromic surveillance, as elements of "meaningful use" for hospitals.Over 70% of hospitals in the US are sending realtime data to public health now.
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18/ . and you know what doesn't help? .An "abundance of caution" in CDC guidance to impose airborne precautions/N95 masks (as for TB) vs droplet precautions (as in flu) . we don't have enough N95 masks.
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That feeling when a tech journalist explains your business better than you can, and you're the founder. @fmanjoo.
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6/ fleece is terrible! . The authors speculate that fleece may actually chop up large particles into smaller ones instead of blocking, which is exactly what you don't want!
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9/ But more experienced medical manufacturers will often have data on performance viz "ASTM" standards. F2299 (particulate filtering) is probably most relevant, but if the box has any info on ASTM testing, I think you're good.
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1/ The rate of Omicron infections in NYC is unprecedented. I'd estimate 100,000 infections occurred . yesterday. Maybe 300,000 over the past 10 days. 1% hospitalization rate would mean 3,000 admits to come over the next few days. I hope it's much less than that (86 so far).
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"There's no systematic plan for when a city should close schools, when they should tell businesses that they have to telework, when they should close movie theaters, cancel large gatherings. We. should have recommendations to cities and support from the federal government".
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Gabby Thomas Makes History As the Fastest Harvard-Educated Epidemiologist in the World. 🤣.
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We’ve known how to fight the coronavirus since March. We just have to do it. - me in the @washingtonpost
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1/ Is there is any evidence that stay-home orders put into place in the past week or two have had a measurable impact on slowing the outbreak?. Where would we see it first? (We need better eyes!). We *may* have some early signals in public data that infections in NYC slowed 🙏
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3/ Let me next acknowledge that it has been over 10 years since I was involved in an epidemiological/outbreak investigation or surveillance . What I'm going to describe is informed by my past experience and conversations w experts, but I am not an expert in #COVID19.
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It can take years decades to quantify impact of good policy. "food stamp access during childhood is linked to a 5 percentage point reduction in heart disease & 18 percentage point incr in high school completion rates, c/w those who lacked access" @porszag
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29/ *Care @home. 1) managing meds. Including decisions re taking/not taking regular meds (eg drug interaction between Paxlovid & statins). 2) monitoring vitals, symptom trends (like difficulty breathing) to decide if need to go to ER. 3) ensuring food/water intake. 4) falls prev.
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14/ This what it looks like- daily rates of influenza like illness presenting to emergency departments in NYC, as of last week- . reassuringly, you can see the peak of influenza activity rising each year, and subsiding.
2/ Here’s another: nationwide syndromic surveillance. Look what you can get from @nycHealthy *daily* rates of influenza-like illness ER visits through 2 days ago! with age breakdown. This was part of #MU requirements, but no nationwide data integration.
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5/ as shown in the graph to the right, bandanna only cuts down by about half, and stretches out the period of droplet transmission. (You can barely see the other low squiggly lines on the bottom which are better masks)
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8/ there are a fair number of questions about whether "surgical masks" found online are good enough. Don't look for "FDA approved". FDA has issued broad regulatory flexibilities for mask makers unless they claim liquid resistance (which you don't need).
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I support patients rights to get their own health records- electronic, affordable, NOW. #DataIndependenceDay #HIMSS15. RT pls if you agree.
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1/ I was glad to be asked by @ScottGottliebMD & @ASlavitt to sign on to this important bipartisan proposal to Congress. Let me tell you why I liked this proposal, and some of my calculations for why the financial requests and structure proposed are reasonable. (views my own, etc).
BREAKING: This morning @ScottGottliebMD and I and 14 other bipartisan and scientific public health officials sent a proposal to Congress on how to safely move forward.
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Roses are red.Some docs are foreign/.They take care of your mom.So don’t you deport ‘em.#Healthpolicyvalentines.
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This gave me such hope in February, seemed wishful. @ScottGottliebMD was right.
Dr. Scott Gottlieb says Covid-19 vaccine supply could exceed demand as soon as April.
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1/ “I can’t breathe”. George Floyd said that 16 times, as onlookers watched, helpless. For those of us in health care, those words compel action. “I can’t breathe” means that we must act. We have to help . I've been obsessively ruminating on what I would have done if I was there.
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most primary care offices have no access to vaccines for their patients despite the fact that they hold the trusted relationships necessary to vaccinate a hesitant populace. The Biden Administration can change that . via @statnews.
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It's official! @DrMandyCohen to lead the @CDCgov . I've worked with her closely, and I can tell you that she's exceptional at 2 things that will be key to CDC success.1) Executive decision-making, transparency, and trust.2) Connecting public health with health care.🇺🇸💪
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@julianborger I don't really get this. I think the option of creating outdoor dedicated testing centers that can focus on testing is a good idea, can keep healthcare settings more available for people with other complaints and minimize the spread to both other patients and staff.
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Let's start with mandatory federal funding of state/local public health preparedness that is predictable, sustained, and shielded from economic cycles.
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1/ Like many others, I've been frustrated that we haven't seen the data behind the CDC's new recommendations. Parsing exact wording in transcripts is🤦. We're told there will be a release tomorrow but thanks to the @washingtonpost there's an internal CDC document to parse tonight
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25/ grateful to those who have pointed out that other countries have provided exactly this sort of clarity of strategy. Of course with a country as large/heterogenous as US, different locales will step through at own pace, not nationwide. Here's the UK's.
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1/ People are hardwired to get infuriated when they see injustice. But I fear that applying this lens to covid vaccine distribution will lead to more deaths not fewer. Stanford has screwed up, again. Some people who shouldn't have gotten it, did.
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To my knowledge @PeteButtigieg is the first candidate to specifically call out hospital consolidation. He proposes more strict community benefit requirements for "non-profit" hospitals, cutting down out of network billings, and antitrust scrutiny 👍
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Must read . ‘Still waiting for my turn’: Primary care doctors are being left behind in the vaccine rollout. Hospital-centered distribution plans are leaving out a group of docs and nurses at high risk of exposure, and who are key to gaining vaccine trust
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