Thread by @Bob_Wachter

1/ Covid (@UCSF) Chronicles, Day 122

@UCSFHospitals: 29 pts, 8 vented (Fig L). Sadly, 1 more death, so 2 in last 3d (after none for ~1 mth). Test positivity stable at 2.1%; asymptomatic rate ticked up to 1.1% (highest I can recall); rate among pts w/ symptoms down to 5.65% (R).

2/ In SF, slow uptick in cases, now 80/d, up from ~30 in June. Even w/ bump, SF remains low in per capita cases & deaths (Fig). Note that Miami now tops NYC in cases per 100K, & PHX, LA, ATL, HOU are closing in. Deaths are still way behind NYC, but starting to rise, as predicted.

3/ As for surging states, CA has plateaued a bit, AZ is down but still huge #. Relentless surges in TX & FL. And GA has earned its place on this graph by virtue of both its surge & the fact that Governor Kemp has decided to double down on boneheadedness tinyurl.com/yb68nlfs

4/ While CA's surge isn't the worst of them, we're still seeing shortages – of MDs (military medics called in to staff 8 hospitals tinyurl.com/y3knjpwm) and testing – CA is now reserving tests for patients with symptoms & for high-risk patients/settings tinyurl.com/yysg8kcr

5/ Moving beyond the numbers, I had a similar take as @ASlavitt’s yesterday tinyurl.com/y6j3pmod – that we’re moving toward a new stage in the science & politics of Covid. March/April were about panic, lockdown, an apocalyptic NYC, & the “public health vs. the economy” debate.

6/ May-July has been about consequences of opening up: new surges, mask partisanship, attempts by the administration to seize the narrative through misdirection and obfuscation. Plus a new appreciation for Covid disparities, in the context of the George Floyd murder & protests.

7/ And now we’re heading into August, and so attention has turned to schools. To me, schools present some of the most brutally difficult choices, given the reasonably strong evidence that kids (particularly young ones) rarely get sick and don’t transmit virus too often...

8/ …and growing evidence of harm from kids staying home, for all parties. This might cause one to support opening. And yet it’s crystal clear that you can’t open the schools in a region that is surging – which just adds to the importance of getting the outbreaks under control.

9/ Despite the challenge of the schools, I'll bet that the issue that will dominate the fall will be the science & politics of vaccines. Why? Because reality is setting in: until we have a safe & effective vaccine, we’re stuck in our current hellscape – maybe for several years.

10/ News on the vaccine science front is promising: many different candidates are being developed, scores of companies from many countries are in the game, and early trials have hit their marks, with development of neutralizing antibodies and no real show-stopping side effects.

11/ In addition, monkey studies are particularly impressive, with evidence in rhesus macaques that a vaccine (made in China) prevented infection, even when big slugs of SARS-CoV-2 were blown into the monkeys' lungs tinyurl.com/y9yqjdoy

12/ The @UniofOxford-@AstraZeneca vaccine seems to have the lead, as described in this fawning piece @BW tinyurl.com/ybfskrml. There are also reports that the Oxford vaccine is stimulating both antibodies & T-cells, which is what we really want to see tinyurl.com/ycxexe44

13/ This week, we also saw more results from the lead U.S. player @moderna_tx (confirming prior press release) showing development of antibodies in all 45 subjects and no serious reactions tinyurl.com/y7l3bv8v Results again sent Moderna’s stock skywards tinyurl.com/yytagm3v

14/ Not only is the science going well, but this seems to be one area in which the administration hasn’t screwed up, at least not yet. While there has been concern about how the feds chose which companies to bet on and a troubling lack of transparency tinyurl.com/yaqluvhp…

15/ …there’s widespread support for the size of the investment – and particularly the government's decision to provide advance support for manufacturing & distribution, so a vaccine is ready to ship and inject soon after it’s been proven safe & effective tinyurl.com/y5lxccs2

16/ Now that Covid has shown that it'll surge when areas open or get complacent, an effective vaccine is really our only way out of this mess. (Super-effective meds would work too, but that seems even harder.) And we’ve also seen how surges kill the economy, schools…everything.

17/ It would be nice if I just stopped here, after compiling the good news. News that might mean a relatively seamless march back to normalcy, maybe by early 2021.

But, as with everything in this damn pandemic, it’s likely to be far more complicated, on any number of fronts…

18/ First, the science is not straightforward; there are many speed-bumps ahead. Here’s @Merck CEO Ken Frazier cautioning against vaccine hype tinyurl.com/y9lj8nlb, and virologist @WmHaseltine w/ his pessimistic take on reaching the vaccine finish line tinyurl.com/y9vzppyj

19/ Second, while I’m thrilled we’re making this investment in manufacturing & distribution, this country failed to build an effective manufacturing & distribution system for PPE or viral testing. So some skepticism here is warranted, at least under the current administration.

20/ Third, it seems Russian hackers are trying to steal the vaccine formula tinyurl.com/y7tq8vcv And, while we’re thinking about cybersecurity, given the centrality of a vaccine to the world’s clinical & economic health, it seems prudent to think about physical security too…

21/ And, even if we get to an effective vaccine, we’re still going to have to deal with brutally difficult prioritization decisions: who gets the vaccine first tinyurl.com/y9zmspz8 (likely healthcare workers & people at highest Covid risk)? And then how …

22/ … to manage the cross-national issues (will Americans be given access to a Chinese vaccine, and vice versa?) tinyurl.com/y5te9ew9 And, perhaps trickiest of all, how to deal with millions of Americans who simply refuse to be vaccinated tinyurl.com/y77qefrx.

23/ Now I’m getting bummed out, so I’ll tick off but won’t dwell on other challenges: getting clinical trials done quickly & well, whether vaccine challenge trials are ethical, who will pay the costs of a Covid vaccine, & whether the @US_FDA approval process will be politicized –

24/ particularly if the results of clinical trials are not a slam dunk (ie, the vaccine is only partly effective). I discussed this fascinating topic with former FDA commish @califf001 in @UCSF Grand Rounds last month, @ 1:07:30 on video tinyurl.com/y5s6v6jh.

25/ After these bummer threads, let's end on brighter note. I just stumbled onto this vid of a worldwide performance of La Bamba. It seems like a Covid thing but its actually from 2014. Enjoy tinyurl.com/y5sxabwq

Back Thurs for Grand Rounds, sooner if there's news. Stay safe