Thread by @Bob_Wachter

1/ Covid (@UCSF) Chronicles, Day 94

Today, weekly round-up, w/ focus on new surge states & implications of steroid trial.

First, @UCSFHospitals: way down, 7 pts, 2 on vents (Fig on L). SF also rock-stable: 33 hosp. pts, 8 ICUs. Case trendline (Fig R) low & declining. All good.

2/ A few weeks ago, I worried that Covid had become old news – that we were growing inured despite 700-1000 deaths per day in U.S. With the Floyd murder, racial justice rightly became above-the-fold news. But Covid remains an ongoing tragic story. It's crucial to focus on both.

3/ Are we in the “second wave”? No. Overall trend line shows we’re still squarely in first wave: no fall in cases – in fact mild upswing in U.S. (Fig L) Closer look (on R) reveals we’re in a new phase of Wave 1: steep drops in Northeast, & new surges in previously-spared states.

4/ The Northeast (especially NY) story is worth celebrating – without forgetting the tragedies of March-May. Falling case #'s translate to many lives saved. How did they begin to defeat Covid? a) Strong messaging/policies (Cuomo etc); b) citizens sheltering, distancing, masking…

5/ Also: fewer at-risk people, as many either died (1 in 380 New Yorkers) or had Covid and are probably immune (1 in 5). There is also a political dimension (of course): early surge states are largely left-leaning; probably less likely to reject govt/policy advice & regulations.

6/ And it’s pretty hard to label Covid “a hoax” or “like the flu” when you hear constant wail of ambulances or see refrigerated morgues outside hospitals.

For spared regions, Covid remained a bit theoretical, especially when seen through through a red lens of partisanship.

7/ NY has cooled so much that @nygovcuomo is quitting his daily briefings; masterpieces of leadership-under-crisis. This @JohnCassidy piece @NewYorker bit.ly/3dhgk9a highlights the surges in TX, AZ & FL, partly due to irresponsible public messaging on masks (below).

8/ The current toxic Venn diagram of Covid-Meets-Political-Partisanship is shown in the mind-blowing graphic below, which illustrates that the vast majority of the early cases were in states/counties that voted for Hillary. Today, the surges are nearly all in Trump country.

9/ Today, we know a lot about the virus, including how it spreads and how to prevent it. So today's risks – for individuals & regions – are mostly about behavior, particularly masking/distancing. And the surges are predictably occurring in places with the most at-risk behavior.

10/ Apotheosis of irresponsibility is Trump rally in Oklahoma, a surging state (below). It’ll all be there: crowds, no masks, shouting. Trump is forcing attendees to pledge not to sue. Perhaps their aging parents & the MDs/RNs in nearby hospitals should be asked to weigh in too.

11/ Bottom line: cases should be falling, even w/ opening up. But look at U.S. vs EU stats. Americans are dying unnecessarily. Moreover, the economy will get hit again as we’re forced into regional lockdowns (either by law or by people w/ common sense). It’s shameful & maddening.

12/ A friend recently said, “The virus is a great teacher.” Yes, but not really. Fire is a great teacher – touch it & it hurts like hell. For SARS Co-V2, a person or state can act badly & do fine–for a while, confirming a belief that precautions are for wimps. Until it’s too late

13/ As case rates rise, we’re not seeing corresponding rise in deaths (Fig). Several possible reasons: a) might be too early: deaths often lag 2-3 weeks behind cases; b) w/ more testing, milder cases diagnosed w/ better prognosis than when we only tested pts w/ severe symptoms…

14/ ...c) In hard-hit regions, some at-risk people already infected/died; d) early mortality rates came from overwhelmed places (Wuhan, Italy, NYC). Hospitals w/ capacity may do better (good reason to avoid overwhelming the system); e) We’re getting better at treating Covid…

15/ On last point, some of the improvements came before we had proven drug treatments (namely remdesivir & dexamethasone). For example, using prone positioning and diagnosing/treating blood clots has undoubtedly helped. But these therapies (remdes/dex) are likely playing a role.

16/ (For more on dexameth trial, see tweets 4-15 in yesterday’s thread; summary of @SDoernberg's review of Recovery trial & implications bit.ly/2YSmgAj. You may ask how steroids could have played a role when trial just came out. A) Many docs were using steroids already.)

17/ But the mortality improvements are significant. Some early studies from China cited 80-90% mortality in patients intubated for Covid – so high that there were tentative discussions about whether pts should be automatic DNRs, given such a low benefit and high infectious risk.

18/ Studies in Italy and U.S. showed better odds, with mortality rates for intubated patients mostly ~50%. My totally back-of-the-envelope estimates: not being overwhelmed lowers mortality to 40%. Smarter care (proning, anticoagulants when needed) might get you to ~30-35%...

19/ If remdesivir cuts mortality by 10-20% and steroids by 30%, perhaps combination will cut it by 35-40% (all educated guesses based on studies). Perhaps that’ll lower mortality for Covid patients needing intubation/vent to ~20%. Still scary, but much better than 3 months ago.

20/ And, unlike in the movies, people don’t wake up after getting off a vent and go out for a beer. As we find effective treatments to prevent vent or shorten course, not only will lives be saved, but can expect fewer pts w/ post-ICU PTSD, cognitive problems, bad lungs, and more.

21/ Switching gears, last wk I railed against the airlines for not enforcing masking bit.ly/2BknMTM. This week, they changed course – & @AmericanAir threw a jerk off a flight for refusing to wear mask bit.ly/3dcGVUU. Good – this makes me far more likely to fly

22/ In fact, one of my Covid metrics comes from the “would I fly” question. Below: my prior calculation; assumed inconsistent masking and was based on older mortality rates, which I translated into a ~1% chance of dying if I got Covid. Risk of death from one flight: 1 in 75,000.

23/ If everybody masked for most of flight, transmission would fall by ~2/3rds (source: bit.ly/3fLlj4r). Below are my new estimated odds. Now, my chances of catching the virus go down by 2/3rds (1 in 2250 rather than 1 in 750); chance of dying now 1 in 225,000. Better.

24/ If, on top of masks, my chances of dying from a case of Covid fall by ~50% (via steroids, remdesivir, other stuff), w/ case-fatality rate 0.5% rather than 1%, now I’ve gotten down to a pretty low risk: 1 in 450,000 chance of dying from catching Covid in flight. Now, I’ll fly.

25/ Sadly, I didn’t know much about Juneteenth until this year, signaling my own need to be better. I was moved by this 1965 speech by James Baldwin bit.ly/3eiSgnO

Back Thursday for Grand Rounds: my interview with John Barry, author of The Great Influenza. Stay safe.