1/ Covid (@UCSF) Chronicles, Day 171
Ending 2 weeks off in (totally) smoke-free & (relatively) Covid-free New Hampshire. As I resurface, I’m reminded of the scene in Hamilton in which Jefferson, after 5 yrs in Paris, asks “What’d I miss?” tinyurl.com/y5a87hna Answer: plenty.
Ending 2 weeks off in (totally) smoke-free & (relatively) Covid-free New Hampshire. As I resurface, I’m reminded of the scene in Hamilton in which Jefferson, after 5 yrs in Paris, asks “What’d I miss?” tinyurl.com/y5a87hna Answer: plenty.
2/ I’ll start with an update on local numbers, then segue to the most meaningful events and trends since mid-August. I’ll focus on 3 biggies: the phase of the pandemic, testing, & vaccines. Of course, in today's world, you can’t talk about any of it without talking politics too.
3/ Beginning with @UCSF and SF: things are looking pretty good. @UCSFHospitals, 28 cases, 6 on vents (Fig L). While not matching our lows of May/June, big improvement from last mth. Case positivity rate also down by ~50% (Fig R): 5.65% in pts w/ symptoms; 0.65% in asymptomatic. 
4/ San Francisco numbers are also good. Case positivity rate 2.5%, down from July peak of ~4% (Fig L). 73 cases/d (Fig R); 61 hospitalized pts, both down by ~50%. SF still has best # 's of all U.S. big cities in dance portion of “the Hammer & the Dance.” tinyurl.com/yx27etx9
5/ All of the states that surged in early summer (Fig on L: cases/capita in CA/AZ/FL/GA/TX; on R, weekly deaths/capita) are falling from their June/July highs. Based on the improvements in CA, @GavinNewsom announced a new, more cautious, re-opening plan tinyurl.com/yxbsbt7q
6/ Switching to the big themes in the U.S: we've seen 5 phases of Covid so far, as shown below: 1) the calm of February; 2) the March/April surge in the Northeast; 3) the May lull; 4) the June-July surges, which takes us up to today's new plateau....
7/ The problem is that we’ve become desensitized – while the falling case & death rates are good news, today’s cases and death plateaus are awful, with far higher numbers than those in May-June. Shown below, Spring/Fall case (Fig on L) & death rates (Fig on R).
8/ So, we’re going into our next (anticipated) spike in far worse shape than in May. Two weeks ago tinyurl.com/y4jb2tql, I predicted the Midwest would be the next hot zone, based on table below. That prediction seems to be coming true.
9/ The growing surge in the Midwest is illustrated by this figure, showing that cases have tripled since June (as usual, hospitalizations are lagging but inevitable)…
10/ Perhaps more vividly, this figure, built from rt.live, shows that all but one Midwest state have a transmission rate >1.0, which predicts growing case load. Of note, Ohio (the 1 exception at 0.99) has had conspicuously good Covid leadership by @GovMikeDeWine.
11/ Unfortunately, few other Midwest governors seem to have learned the lessons from the prior surges in NY, CA, & the Southern states. If they had, they'd be vigorously promoting masking and starting to close things down now, rather than waiting until their states get hammered.
12/ It’s worth noting that many of the presidential election swing states align with those that seem poised to be pummeled by Covid in October. This might make Trump’s Change-the-Subject-In-The-Swing-States strategy a bit more challenging to pull off. We’ll see…
13/ The second rapidly evolving area is testing. I won’t cover it in depth; instead, I recommend you read @Atul_Gawande’s great piece in this week’s @NewYorker tinyurl.com/yxezaqhr. We'd have widely available, cheap, fast tests by now if the feds had acted early and well…
14/ … And a robust testing system would have given us a decent chance of successfully opening (and keeping open) schools and many businesses. Instead, we have, as Gawande says, a system “as messed up as a pile of coat hangers.” (Read: dumpster fire.)
15/ Third area w/ lots of developments is vaccines – with two competing areas of rapid change. The first is the science, where most of the news is good and the pace of progress is truly breathtaking.
The second, alas, is the politics, which threatens to muck the whole thing up.
The second, alas, is the politics, which threatens to muck the whole thing up.
16/ On the science, we continue to hit all the benchmarks: with more evidence of real immunity after infection, including a new @NEJM study from Iceland tinyurl.com/y6dej6rr showing high rates of antibodies (including in older patients) that persist for at least 4 months.
17/ We now have 1 well documented case of reinfection tinyurl.com/y4vpqsl9 – the rarity makes this more reassuring than concerning. And we’ve seen several studies showing strong immune responses (antibody and T cells) from vaccines, with tolerable side effects. All good news.
18/ Interestingly, until now, vaccines have been the one area in which the federal response has been on target: funding to de-risk drug development; placing bets on most-likely-to-succeed vaccines; anticipatory investments in manufacturing & distribution. Little to criticize.
19/ But, given the Administration’s record on Covid, counting on continued strong performance on vaccines without getting tangled in the politics was too much to hope for. With Trump down in the polls, mucking with the FDA approval process was just too hard to resist.
21/ The problem is that an approval based on inadequate data will lead to a massive lack of confidence in Covid vaccines. We may face the twin problems of low uptake of good vaccines and an inability to complete the rigorous studies to prove that the vaccines work.
22. While much of the discussion has focused on proof of efficacy, I’m equally worried about safety. If the vaccine is approved prematurely, we might miss a very bad side effect, as we did with the 1976 Swine Flu vaccine/Guillain-Barre fiasco tinyurl.com/udyd79l.
23/ Also, if trials are weak you can bet that some people will call every new case of stroke, cancer, ALS, etc. a vaccine side effect. Since even rare diseases happen often enough (below) for vaccine recipients to (coincidentally) get them, it'll be a field day for anti-vaxxers.
24/ All in all, it’s going to be a hold-onto-your-hat couple of months. If the pandemic weren’t enough, the overlay of the protests and racial justice issues and the economy and the presidential election make the whole thing mind-blowingly complex... and, yes, fascinating.
25/ We’ll restart Grand Rounds next Thursday (George Rutherford & Monica Gandhi on epi trends & changing case-fatality rates). The following Thursday (Sept 17): @PeterHotez and @ProfHeidiLarson on vaccines. As always, I’ll tweet & post them on YouTube.
Till then, stay safe.
Till then, stay safe.
