Thread by @Bob_Wachter

Covid (@UCSF) Chronicles, Day 230

1/ @NateSilver538 & team @538politics tell us that Biden has a 90% chance of winning. If he does, many things will change, but when it comes to the unmitigated disaster that is the scourge of Covid , it’s important to avoid magical thinking.

2/ A Biden administration won’t be able to turn this thing around on a dime. So today, after an overview of the state of the pandemic (SF and then the broader nation), I’ll give you my take on how a Biden administration may approach Covid in its initial days.

3/ Let’s start with the view from SF. Given porous borders, with the rest of the U.S. surging it would be shocking to see no uptick in our numbers. So my real question is not whether we’re seeing a few more cases – we are. It’s whether the uptick is manageable, or out of control.

4/ Against that test, we continue to do well. @UCSFHospitals we have 14 patients, 3 on vents (Fig L). That’s up a bit from last mth, but plateaued in recent days. Test positivity rate remains v. low: 2.4% overall; 1.85% in pts w/ Covid symptoms, 0.23% in asymptomatic pts (Fig R).

5/ I usually focus on asymptomatic % to estimate the chance that someone near me in a store has Covid. But the symptomatic % is also useful. It means that, in SF, 98% of folks w/ symptoms that could be Covid (e.g. fever, cough) actually don’t have it. (They’re all sure they do.)

6/ SF also continues to do well, despite mild upticks. Avg 41 cases/d, up from low of 27 (Fig on L). Hospitalized pts: 36, up from low of 21 but plateaued in past wk (Fig R). Test + rate still low: 1.08%, up from 0.8%. All told, a bit worse than early Oct, but still pretty mild.

7/ By way of contrast, compare SF’s test positivity rate (1.08%) with these eye-popping rates from other U.S. states:

SD 50%; WY 43%; IA 36%; ID & KS 34%; AL 19%, UT 17%; MN 16%; WI & PA 14%; ND & MO 13%; AZ 12%; TX & KY 11%; AR, TN, NE, NV, MN all 10%.

(h/t @BeckersHR)

8/ CA's rate is 3%. Like SF, CA is seeing uptick in cases, but it’s also mild. Figure shows CA & the other states that surged in the summer (AZ, TX, FL), compared w/ Wisc. One gets the sense that prior surges are protective – likely a combo of people w/ antibodies & fear of God.

9/ So, while the narrative is that this is the first surge hitting everywhere, we see big variations by region. Fig L shows Midwest vs other regions. Similar story in EU, where entire continent is surging, but there’s still variation by nation (France/Italy are the worst; Fig R).

10/ Fauci said yest, we “could not possibly be positioned more poorly” heading into winter tinyurl.com/y4ldztxj The fact that we started surge @ 40K cases/d is part of the problem. And fact that there’s no longer even a pretense of fed. leadership makes things that much worse.

11/ So, what happens if Biden wins? The biggest change: a new tone, one marked by empathy and a deference to science. You can also count on Biden naming a world-class Covid transition team – a prelude to the kind of leaders we can anticipate for @HHSGov, @US_FDA & @CDCgov.

12/ What will Biden do in attacking Covid? Much of it depends on the state of the pandemic when he takes office. The spring and summer surges each lasted about 2 months; if that's true this time, it should be winding down by late Jan. Unfortunately, this surge may be different…

13/ … in that it is so broad in scope, and includes many regions that remain reluctant to enact aggressive preventive measures. It also comes nearly a year into the pandemic, when people are understandably exhausted and frustrated, which may make it difficult for them…

14/ … to embrace the kinds of changes needed to tamp down the spread of the virus.

So I see two possible scenarios. First, if the U.S. is still surging as we approach the inauguration, I wouldn’t be surprised to see a national quasi-lockdown, w/ new guidelines issued by CDC…

15/ … encouraging (?requiring?) regions with big surges (hi test positivity, cases, hospitalizations) to re-boot – in essence, bringing down the Hammer again before re-attempting the Dance. A version of this is now being deployed in France, UK, & Germany tinyurl.com/yxuk7lvr

16/ Of course, Biden’s team will be reluctant to do this, but it may be the bitter medicine we need. Also expect a new testing strategy – a major nat'l effort to make more tests (esp. faster ones) available, accompanied by a nat'l testing/contact tracing plan that's been absent.

17/ A new lockdown would be a forerunner of a well thought-out plan to open back up. Will it work? Expect major conflict w/ states-rights folks, plenty of lawsuits – & general obstruction from the right. But it may be our only hope if the pandemic continues to be out of control.

18/ The second scenario is less dire: the surge is improved in January, in which case we'll see less of a lockdown. Instead, we’ll see a greater emphasis on sustainability thru 2021: the focus being on preventing yet another surge – masking, etc., plus the nat'l testing strategy.

19/ Either way, also expect a national mask etc. campaign, using celebs, sports stars & other influencers. Hope will be that – now that every region has lived through a brutal surge & w/ Trump gone – even our hyper-partisan nation might unify around a commonsense approach.

20/ As I’ve said before, I don’t find much to argue about regarding Trump's approach to the development of vaccines and therapeutics. I expect this to remain mostly unchanged; key difference will be to insulate and support the FDA’s approval process so that we don’t end up with…

21/ … a repeat of the hydroxychroloquine and convalescent plasma fiascos that so damaged trust in the FDA tinyurl.com/yxw4hdew. Rebuilding that trust in advance of a vaccine may well be the most important Covid-related work for the new administration and its leaders.

22/ While I'm hopeful, we should be realistic. Even w/ strong leadership, the pandemic will be with us at least till summer. Even then, we may not be able to resume our former “normal” lives. But Covid has been an eye-opener in so many ways, & one hopes that some things will be…

23/ … better than “normal” – a redoubled commitment to equity, an energized public health system, a newly discovered reverence for science and truth, and a set of reasonable guardrails that will prevent the abuses of power and incompetence that have stained the past four years.

24/ In the early days of Trump, we learned we'd be confronted w/ “alternative facts.” And (hopefully) the last days of Trump have seen chants of “Fire Fauci.” These mantras have bookended 4 years in which an utter lack of compassion, disdain for science, lying, gaslighting...

25/ … and corruption have contributed to the unnecessary deaths of hundreds of thousands of Americans. We can only hope that tomorrow will be the dawn of a new era, that we honor those who lost their lives unnecessarily, and that we, at the very least, learn from our mistakes.