1/ Covid (@UCSF) Chronicles, Day 211

Now 7 months into the U.S. pandemic and 3 weeks from the election, everybody is exhausted and overwhelmed. Everyone's new question seems to be, “are you optimistic or pessimistic?” The question is simple; the answer, of course, is complex.
2/ Today, I’ll start with the view from San Francisco – consumed by The Trump Show, it’s been a while since I presented our local data. I’ll then describe the scary surges elsewhere and add my take on the optimist/pessimist question.
3/ First, @UCSFHospitals, we have only 10 Covid patients in hospital & just 2 on vents, both lowest since May (Figure). Test positivity rate @UCSF is ~4% in patients w/ symptoms, 0.5% in asymptomatic pts. In Aug, these # 's were 10% / 1.5%, so a vast improvement in every metric.
4/ In SF, no hints of a surge. 26 new cases/day, one-fifth of our July peak (Fig on L). Test positivity: super-low, 0.8%; now below even NYC’s very low %. 29 hospitalized pts in all of SF (Fig R). 123 deaths since March – none in past 10 days. More of SF open, incl. playgrounds.
5/ CA is also doing well tinyurl.com/y44dy9re.

Sadly, though, much of the U.S. isn’t. We're up to 216K total deaths, with ~800 new deaths and ~55,000 cases each day. As @nytimes map below shows, major surge mostly in the upper-Midwest; Wisconsin is getting hammered.
6/ San Francisco continues to demonstrate what might have been. If the rest of the U.S. matched SF’s per capita death rate tinyurl.com/y6yry4gh, 170,000 dead Americans would be alive today. It's not rocket science: just strong leadership and people wearing masks & distancing.
7/ But too many parts of country lacked leadership, or people chose not to (or, rarely, couldn't) follow the recs, or both. The cost is a new surge that may outstrip the earlier ones. This @voxdotcom explainer breaks down why’s & wheres of the fall surge tinyurl.com/y4eptjfu
8/ With <3 weeks to the election, it’s impossible to sidestep the political context; it’s completely intertwined w/ the Covid response. This astounding #dataviz shows how recent surges are mostly in red states, vs. the early surges, which were in blue ones tinyurl.com/y4t94tch
9/ Re: Trump’s own Covid case, he’s now over his period of being infectious & seems to have done well clinically. But his take-aways – not that bad, miracle cure, sickness=weakness – are all wrong. Red meat to his fans, but bad medicine…and, per @538politics , bad politics too.
10/ The White House seems to have given up on fighting Covid with a national strategy, settling instead on a herd immunity scheme (ie, let people get infected) that is uniformly rejected by credible experts and would lead to >100,000 unnecessary deaths tinyurl.com/y2djcpyx
11/ So, am I optimistic or pessimistic? Both, & each day’s news brings new grist for the mill.

My take – short-term: pessimism; long-term: optimism – is similar to Donald McNeil’s @nytimes – whose Jan/Feb pessimism proved prescient, but who now sees hope tinyurl.com/y3l2kk8u
12/ Will the U.S. develop a sound strategy? Utterly dependent on outcome of election. If Biden wins, expect push for mask requirement, and coherent roll-out of tests, treatments & vaccines. Biden’s advisors are experts & he’ll listen to them. w/ Biden's odds ~6:1, I’m optimistic.
13/ On monoclonals: they will probably represent an advance, though not a “miracle cure.” Yesterday, Lilly (@LillyPad) put its monoclonal trial on hold to investigate possible side effect; not clear what this means tinyurl.com/y3jej386
14/ Even if monoclonals ultimately prove safe & reasonably effective, I’m worried about their practicality. @Regeneron “hopes” to produce 250,000 doses/month, which – w/ 60K cases/day in U.S. – would meet a fraction of demand. And, since vast majority of Covid patients do fine…
15/ …and a single treatment with antibodies will cost several thousand $ s (not “free,” per Trump), it’s not clear who will get treated. Maybe people with very high virus levels (though not definitively linked to worse outcomes), maybe those at highest risk? Lots of uncertainty.
16/ In any case, monoclonals don’t seem like a game-changer to me. In the absence of a vaccine (or even if we have a partially effective one), we'll need safe & less expensive drugs (hopefully oral) for newly infected people to prevent spread to others & clinical deterioration…
17/ … just like we have for HIV. (There’s still no HIV vaccine, after 40 years, but few deaths thanks to effective oral meds.) Our current Covid meds have probably cut the death rate by 30-40%. Maybe we’ll do a bit better than that with new meds, but I’m not super-optimistic.
18/ On the other hand, the prevailing wisdom that vaccines look very promising seems right to me – with all signals (at least until yesterday) pointing to a high level of effectiveness and reasonable safety. But nothing's simple: now two of the leading vaccine candidates…
19/ … (@JNJNews & @AstraZeneca) have paused their studies to investigate safety concerns tinyurl.com/y4eyvggm Might be nothing (and it’s prudent for the companies to be cautious), but it could be something. Even so, I'd bet on several vaccines crossing the FDA bar by January.
20/ Re: surveys showing that 50% of Americans might not take an approved vaccine tinyurl.com/y4e3eocy, here I’m optimistic, particularly if Biden wins & @US_FDA snaps back to its normal science-based self. Enough people have been touched by Covid…
21/ …that analogies to other vaccines – which prevent diseases that many folks have never seen – are limited. Once Fauci and other health leaders get their shots, so, I believe, will vast majority of other people. If a non-politicized FDA approves one, I'll be on line for mine.
22/ How long will immunity last? Still a great unknown. The credible reports of reinfection tinyurl.com/y53ykzfa are so rare that they’re the exception that proves the rule – it seems super-likely that immunity will last for at least a year, for the vast majority of people.
23/ So, am I optimistic or pessimistic? It's hard to be anything but pessimistic for the next 3-6 months: there’ll be more cases, more deaths (and not just in U.S.; Europe now seeing massive surge tinyurl.com/y5c6mznz).

And even if Biden wins he won’t start until Jan 2021.
24/ Moreover, I don’t see a game-changing med soon. Even if vaccines work, distribution will be mid-2021.

But I'm long-term optimistic. By this time next year, it seems very likely we’ll be in a much better place with Covid (largely via a vaccine), and probably w/ the economy.
25/ Still, we’ll need a collective reckoning re: the failures of 2020. There will be other threats – infectious & not – that challenge our political system & social fabric. If we don’t learn from our mistakes w/ Covid, it’s hard to be optimistic about threats beyond the horizon.

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More from @Bob_Wachter

10 Oct
Just watched the @TuckerCarlson segment with Trump interview by @DrMarcSiegel. Takeaway: Trump looks good, his voice is strong, no visible shortness of breath, he's finishing sentences without stopping for air. Mental status and judgment seem unchanged from his usual. (1/9)
Siegel actually did a decent interview – asking questions testing recall, along with others that got at judgment and insight (latter included asking about lessons learned from this experience). I'm not a Trump fan but it's hard to make 25th Amendment case from what we saw. (2/9)
And, while Trump is still not completely out of the woods – there's still a small (<5%) chance of a significant setback – with a patient this stable 8 days into the illness, his most likely course is a relatively uneventful recovery. (3/9)
Read 9 tweets
9 Oct
1/ Covid (@UCSF) Chronicles, Day 205

It’s hard to believe that we first learned of Trump’s Covid diagnosis exactly one week ago tinyurl.com/yxq2vbv3. Here are a bunch of hot takes on today’s issues, which continue to move at hyper-speed.
2/ On Trump’s clinical status. Yesterday, his doc reported that Trump's vital signs were stable, including normal oxygen saturation w/o supplemental O2. Today’s videos show no obvious shortness of breath (he completes sentences without stopping for air): tinyurl.com/y3p9l8lh
3) Based on his @FoxBusiness phone-in today tinyurl.com/y5h5brpe, his mental status & judgment seem to be at his baseline (that's the standard we use). Whatever you think about Trump's mind, there’s no new evidence of lack of capacity to do his job based on Covid or meds.
Read 25 tweets
4 Oct
Impressions of today's Walter Reed presser:

a) Conley's mea culpa: “I was trying to reflect the upbeat attitude of the team. Didn’t want to give any information that would steer the course of his illness.” Trump's fingerprints.

But even so, today was only slightly better. (1/8)
b/ Biggest news is that T had 2 episodes of hypoxia (down to 93-94% O2 saturation), & Conley evaded whether sat was ever <90. "Never in low 80s" is all he offered.

c/ Re: Chest CT: "There were some expected findings but nothing of concern." What the hell does that mean?...(2/8)
...To be clear, the "expected findings" on a chest CT is NORMAL. If it was normal, he should say that. Anything else should have been described.

(The only semi-benign interpretation would be if the prez has a known chronic finding – like a benign nodule – that was seen)...(3/8)
Read 8 tweets
3 Oct
I’ve not yet seen report on whether Trump has received dexamethasone (steroids); we know he already got remdesivir (antiviral) & “cocktail” of monoclonal antibodies.

But steroids, the only drugs proven to lower Covid mortality, raise a complex set of issues. An explainer. 1/9
The key is the dynamics of the immune system in Covid: early on, damage is being done by the virus itself, so rapid treatment w/ an antiviral & other efforts to bolster the immune response make perfect sense (although “making sense” & “proven to work” are 2 different things). 2/9
But steroids act differently – they suppress the immune system. Why could that work? Because later in Covid, some of the harm is by damage caused by our own immune systems going haywire – attacking our bodies in a frenzied effort to kill the intruder tinyurl.com/yyra4qnd 3/9
Read 10 tweets
3 Oct
1/ Covid (@UCSF) Chronicles, Day 199

OK, now this is now officially mind-blowing. Of course, today’s thread will be all about the President’s illness, what might come next, and what it means.
2/ Once Hope Hicks tested positive, the thinking was that she might have given it to Trump on flights Tues (to OH for debate) or Wed (rally in MN) tinyurl.com/y4e5sgmf But that theory was kiboshed yesterday: the >3 day incubation period meant the exposure was likely earlier.
3/ The perfect timing would have been last weekend. Perhaps a big event where people were mask-less, not distanced, with backslaps and hugging.

Like the Saturday nomination ceremony at the White House for #AmyConeyBarrett.
Read 25 tweets
29 Sep
1/ Covid (@UCSF) Chronicles, Day 195

As a politics junkie, I spend much of each day refreshing the election projections @538politics (tinyurl.com/y4vqs85a; it currently has Biden at a 78% chance of victory).
2/ While @NateSilver538’s model has many variables, I’m guessing it’s missing one of the most important: Covid status in swing states. That’s today’s topic.

I’ll focus on the 8 states that 538 deems the most likely to be tipping points: PA, FL, WI, MI, AZ, NC, OH, and NV.
3/ My thesis: in a close race, whether Covid is front of mind may determine whether persuadable voters base their votes on Trump’s handling of Covid, or on other things.

The fact that the US is likely now starting its 3rd surge (whether in your state or not) should be enough…
Read 25 tweets

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