Thread by @ASlavitt

COVID Update April 25: The calls started early today. People wanted to talk to me about the science & the trap of vaccine-savior thinking. I listened & answered questions & took notes. We also discussed distribution/equity issues if there is a vaccine.

Shortly. 1/

QUIZ WHILE I COMPOSE:

Which country does the most tests for every confirmed case? How many times more tests/case higher than the US?

Extra credit: chloroquine & hydrochloroquine average < 1000 rxs/day. How many Rxs the day after Trump mentioned in presser?

The @chicagotribune wrote this very nice article.

Read it if you want but notice the headline— “this will be over.” But today got me thinking “what if it’s not?” 3/

chicagotribune.com/coronavirus/ct…

“What do we do if no vaccine rescues us” was the conversation I found myself having with some epidemiologists, scientists, doctors & engineers.

It felt too early in the morning for that conversation. I hadn’t walked Brodie. These people were too calm about it. 4/

I couldn’t tell if they were calm because they’d been thinking about this forever & I hadn’t, because they were trained analytical types, fatalists, were a little sociopathic, or because they felt it was actually quite solvable. 5/

This was the same crew, most of whom were famous in their areas, that would say jarring things from time to time— about not being able to get back to normal for a long time, about viruses being able to wipe us out. But I learned & tester so much of what I would hear with them.6/

If you read my tweets or hear my podcast, you know I’m not a scientist. So I asked a lot of questions. 7/

I heard about antibody dependent enhancement— how antibodies don’t equal immunity. And antibodies could often make things worse in the wrong amount. 8/

I heard about d-dimers, protease inhibitors, steroids, whether this is a cardiac, a pulmonary, or an immunological disease. About how it is causing strokes and clots in young healthy people.

I was hearing about how patients were exhibiting things never seen before.8/

At no point did I hear that scientists couldn’t beat this thing. And even if they couldn’t, there were strategies that worked. Even the most pessimistic mind seemed to believe that.

10 yrs out we will look back & know what worked. But for now there are scenarios. 9/

So one type of scenario is the development of a safe & effective vaccine sometime in 2021.

There are a lot of moving pieces to create a vaccine. And make sure it’s safe. And produce enough. And distribute it. 10/

There are promising trials— too numerous to mention. Following those closely will be lots of ups & downs. Things that seem promising early often fade. Things don’t work on everyone. 11/

And it’s possible that a vaccine will be safe, but only partly effective or offer a partial inoculation. If that’s the case it may be used health care & nursing home workers & high risk people. 12/

I will finish in a little bit.

Sorry, better if I explain later the distraction. I should answer the quiz before I get to the next scenario.

Vietnam. They do 706 cases for every positive one. The US is at 5.6. 126x.

Extra credit— 31,000 14/

The second scenario we spent a lot of time on today is the COVID-19 as a chronic disease without a reliable vaccine.

While initially jarring to contemplate, there is good evidence & history that this would be a manageable nor a crippling situation. 15/

Today the conditions brought on by severe COVID-19 are scary & mysterious. It attacks the lungs & travels to other organ systems. We’re still learning about it. But with the help of supercomputers & data, we will learn fast. 16/

We’re not sure which therapies work in later stages (we know which don’t). But we have good anecdotal evidence that they work to reduce the viral load & lethality of given early. 17/

We are quickly learning what is causing our immune systems to react. There’s evidence that it’s the level of d-dimer in the body. In fact it may not be the severity of the strain but the peculiarities of our own immune systems which could determine the severity of the virus. 18/

So while antibodies may be the most effective treatment, it may in fact be things which prohibit the virus from replicating in our body that’s the key if we can do it early. Biologics, protease inhibitors, or even steroids could be effective. 19/

Today— in the middle of the emergency with no visibility or testing— it’s easy to forget what would happen if we could instantly determine who had SARS-CoV-2 & could treat people early. 20/

Yes, in that situation the virus would still spread fast. But effective treatments would shorten the illness period & the lethality— possibly even reduce the shedding period. In this world, people would still die from this virus, but much less frequently. 21/

That’s not a silver bullet situation. But its a manageable one. In fact scenarios 1 and 2 are both possible in tandem. A partially effective virus, early testing & effective therapies. 22/

As Bill Joy, the brilliant thinker & engineer reminded me, great medicines have saved lives, but it’s the simpler things like clean water that have saved the most lives. 23/

If there is a silver bullet, it may not be a vaccine or therapy that outsmarts the virus. There’s a third scenario where the virus is destroyed completely by something far simpler— a reusable, cleanable highly functional & nearly free mask. 24/

Viruses can’t survive with nowhere to go. Cutting the virus off at the pass may be simplest done by never letting the droplets get into the air. 25/

The more some think about the third scenario, the more the first 2 become less scary & less important. 26/

We have learned the daunting power of exponential math when it comes to infection rate or R0. At an R0 of 2.3, 1 person spreads COVID-19 to an average of 4100 people in 10 generations. At 1.3, it’s only 14. At 3.3 it’s 153,000 people.

But what if you reverse that. 27/

If high quality masks were ubiquitous & 1000 people have COVID-19 & the R is .9, after 10 cycles, it reduces itself to 350. But at .8, it’s only 107. At .3, after only 6 cycles, the virus is virtually stopped. 28/

The math is just an illustration. But it’s been effective in Hong Kong. And with the shortage of N-95s and the homemade mask fad, that doesn’t seem in our possibility set right now. But it is. It is if we can make enough & distribute to everyone. 29/

In this scenario, lots of things, compliance, culture change, fit, ubiquity, fashion, ease of use, breatheability, & equitable distribution are all factors. 30/

Even if you don’t welcome the idea of wearing a mask for a period of time (and I would argue why not?), the larger point is we are not powerless in the face of this virus. We have science, ingenuity & collective action. 31/

Social distancing works but it’s a temporary answer. Lack of testing will haunt us but will be solved. Ventilators & hospitals will be prepared over time. We will see patterns on how to treat or vaccinate or both. 32/

In the meantime, there are ways to beat the virus & return to versions of a normal life. Masks hold the promise of protection at a minimum & eradication at best. 33/

Just as there is a lot about the virus we don’t understand, there’s a lot about how it spreads we don’t understand.

Even if r = 2 or 3 or 4 or 5, averages lie. In city x, it can be higher than city y. Persons a, b, and c can have an r of 0 & person d an r of 40. 34/

It can peter out and come back. It can weaken over time. If this weren’t happening to us, but to insects under a microscope over time, we would make lots of dispassionate observations. That’s what these people I was talking to are good at— dispassionate analysis.35/

I know this has been long. And been interrupted. And I hope I explained my notes at least somewhat clearly. Uncertainty doesn’t feel great. But it is where we are. All disrupted. But there are many paths out. /end