Thread by @Bob_Wachter

1/ Covid (@UCSF) Chronicles, Day 184

Can't think of a bigger or more charged issue than vaccines. For today’s @UCSF grand rounds, it was great to have 3 world-class speakers: @PeterHotez of @bcmhouston, Jaime Sepulveda, & @ProfHeidiLarson @LSHTM. Here: tinyurl.com/y69j3m94

2/ Quick review of @UCSFHospitals, 20 pts, 5 on vents – both lowest since June (Fig on L). San Francisco: 53 cases/day, also lowest since June. 91 deaths, w/ only one death in Sept. Case positivity rate 2.15%. 62 pts in SF hospitals (Fig R). Overall, we continue to do quite well.

3/ On to this week’s grand rounds. @ 6:15, @PeterHotez began by illustrating the value of vaccines; tens of thousands of lives have been saved between 2000 and 2017 by vaccinating children (Figure).

4/ @ 8:00, & more at 29:00 Unfortunately, we’re seeing unraveling of some of the gains, due to political instability, wars, deforestation, and, particularly anti-science attitudes. These trends began before Covid-19, but may be accelerating in the face of the pandemic (Figure).

5/ @ 11:15, “chilling example” of lists of deaths in Houston on 9/11/20 (Figure). Note predominance of Latinos, blacks. In his many TV appearances, Peter says he's "taken a more political tone… and it’s deliberate” because these disparities, he believes, are being ignored.

6/ @13:10, Hotez says “making a Covid-19 vaccine is not as hard as you think. It’s an old-school problem in virology; you need to induce a strong immune response against the spike protein of the virus.” This slide (from Fauci), shows various vaccine candidates and approaches.

7/ @ 14:52: Major U.S. effort is Operation Warp Speed, focused on pharma companies (@bcmhouston is working on its own vaccine, outside OWS). Speed is not so much to rush clinical trials, but to gear up manufacturing and distribution to save time once we find a good, safe vaccine.

8/ @ 16:10. Peter’s analysis of advantages/disadvantages of Operation Warp Speed. “I’m an enthusiastic champion.” But concerns: no real communication strategy (leaving it to pharma companies, and so far "their messaging has been awful”) & America's “go it alone” strategy.

9/ @ 18:00, Hotez emphasizes importance of “vaccine diplomacy” – he notes that cross-national cooperation was central to the development of both the polio and smallpox vaccines. But today, we’re starting to see “vaccinationalism,” which is very concerning.

10/ @ 25:00, Hotez discusses his concerns about the anti-vaccine movement. He notes that it’s taking on a “far right twist that worries me,” with a strong presence in Austin, TX. He has an autistic daughter and has written about the lack of association between vaccines & autism.

11/ @ 30:00: Hotez is confident that “there will be multiple vaccines” that prove to be safe & effective. But he notes that @US_FDA process is slow and not set up to expedite approval. He worries about Trump, but “I don’t see a path for a vaccine approval before the election.”

12/ Next, Jaime Sepulveda, head @IGHSatUCSF, reviewed process of global vaccine allocation. @ 40:00, he sees 4 obstacles to global vaccine distribution (Fig on L). While vaccine nationalism is not unprecedented, “racist attitudes” from White House make it worse (Fig R).

13/ @ 50:00, @ProfHeidiLarson describes thinking re: vaccine confidence/hesitancy. At first, she thought severity of Covid would lead to less anti-vaccine sentiment. Instead, “it’s gone to the other extreme” w/ anti-vaxxers syncing up w/ other libertarian/nationalist movements.

14/ On other hand, @ 51:30, as per her recent @TheLancet paper tinyurl.com/y6ow7vmel, there’s some good news: a “slight increase” (mostly in EU countries) in confidence in vaccines, particularly in “importance” and “effectiveness,” less in safety.

15/ @ 53:30: “If there's been a silver lining of all the dissent & antagonism… it’s been a wakeup call to the vaccine & immunization community.” As vaccines picked up steam in past few decades, “we kind of dropped the ball” as we added vaccines. “Covid is a huge opportunity.”

16/ @ 56:15: Larson: “We don’t have as much of a misinformation problem as we have a relationship problem. Misinformation is a symptom, not the cause. How governments respond to Covid will either support or undermine Covid vaccine uptake.” Building trust is key.

17/ @ 58:00: Heidi's recent study: 41% “strongly agree” they’d take vaccine. “Not as bad as the headlines.” And, “it’s not unreasonable for (people) to have a certain amount of uncertainty,” until trials are reported. “We need to have empathy; say, ‘we understand your concerns.’”

18/ @ 1:00:00: I asked Heidi why there's more skepticism re: vaccines than other Rx’s. A): Taken by everybody, made by pharma, often required by govt…“None of these things...make it warm & fuzzy.” Plus our successes mean that people don’t see consequences of NOT having vaccines.

19/ @ 1:04:00: I asked Heidi who are the best vaccine "influencers." Sure, it may be celebrities or sports figures or scientists. But often best are neighbors, clergy – trusted people in their own communities. Thus our current lack of day-to-day interactions creates new problem.

20/ @ 1:09:30, I asked @PeterHotez re: @US_FDA & the vaccine. “This isn’t the first time that the White House has tried to get into the business of one of the agencies.” Peter is “reasonably confident that regulatory systems & scientific community will be able to hold the line.”

21/ @ 1:16:00 – It's a huge problem that U.S. has “withdrawn from WHO,” with vacuum being filled by Russia and China. Sepulveda: “U.S. is losing a very important leadership role, and that will come at the cost of geopolitics.” Hotez: “It almost has a cold war feel to it.”

22/ @ 1:18:00: One year from now, Hotez predicts “we'll have vaccines, people will feel better about traveling on airplanes” but… depending on the coverage levels, we "will still need extensive public health control measures, and American people are not being prepared for that.”

23/ That’s it, a truly fascinating session. Hope you find time to watch it, again here: tinyurl.com/y69j3m94. Perhaps no issue in my lifetime that has combined science, policy, politics, history, economics, psychology, diplomacy, and more… with the stakes truly astronomical.

24/ Quick preview of next Thursday’s grand rounds: we’ll focus on SF’s Covid experience, best of any major U.S. city. Speakers: SF mayor @LondonBreed, @SF_DPH leaders Grant Colfax & Tomas Aragon, @UCSF’s George Rutherford, Diane Havlir, and Paul Volberding. Till then, stay safe.