1/ Covid (@UCSF) Chronicles, Day 244

One of the features of this stage of Covid is that we’re seeing more areas in which two or more complex issues influence one another. Today, I’ll cover a few of the most interesting ones – issues for which Venn diagram thinking is useful.
2/ The big one, of course, is the explosion of cases and hospitalizations around the U.S. – coming alongside a flood of positive news regarding vaccines. It feels like we're watching a Covid split-screen; on one screen a horror film, on the other a feel-good rom-com.
3/ Now that we’re looking at a pandemic that may be all-but-gone by fall (and an economy that may spring back), the case for fast, vigorous action to flatten the curve is even stronger. Obviously, the politics are hard (see: Michigan), but the right calls seem easier to identify.
4/ Let’s turn to the vaccine news, which just gets better each day. tinyurl.com/y4xoebr8 Just in the past 2 weeks we’ve learned that two vaccine candidates – @pfizer & @moderna_tx – are 95% effective in preventing Covid cases, across different age & risk groups. Breathtaking.
5/ There’s still more to learn, but we now know that these vaccines work in preventing both mild & severe cases, & that they're safe, other than 1-2 days of unpleasant side effects. And there’s new evidence that indicates that immunity may last for years. tinyurl.com/y5t9fsao
6/ At 95% efficacy, I’m far more confident that we’ll hit the mark (~70% of people taking the vaccine) to achieve herd immunity – and do it humanely, with vaccines… in contrast to the Scott Atlas way, a culling-the-herd horror that would cost hundreds of thousands of lives.
7/ Another interesting Venn diagram is between monoclonal antibodies & vaccines. In the swirl of vaccine news, not much notice was paid to FDA's approval (via EUA) of Lilly’s monoclonal Ab. tinyurl.com/y3f6oqth Approval is also expected for Regeneron’s (& Trump's) Ab cocktail.
8/ Monoclonals are tough both to manufacture (Lilly/Regeneron are ramping up) and to give tinyurl.com/yyqo4s6v Pts will need to be dx'ed fast, set up to get an IV infusion, & given the Abs (takes 1hr, then 1hr hour of monitoring), all within a day or so. Logistically, tricky.
9/ I can’t see patients getting their antibodies in a busy ER; few will want more contagious Covid patients than necessary. True, big hospitals have infusion centers, but they’re filled with immunocompromised cancer pts, or pts with other diseases taking immunosuppressive drugs.
10/ So, to make this work hospitals will likely need new monoclonal infusion centers. It's doable (we’ve done it @ucsfhospitals), but it’s complex & costly. I won’t be surprised if some hospitals see the vaccine news as a reason not to do what it takes to stand up such a center.
11/ But won’t it take 6-8 months for vaccines to be broadly available? Yes, but those who should get monoclonals (elderly pts & those w/ major co-morbidities) will also be first up for vaccines, most likely before March. This will narrow the window for monoclonal use even more.
12/ (By the way, we’ll cover both vaccines and monoclonals at @UCSF Dept. of Medicine grand rounds tomorrow, live @ noon Pacific for UCSF-ers, posted ~7pm @YouTube. Speakers: @DrPaulOffit of @Penn on vaccines, @annieluet of UCSF on monoclonals & other therapeutics.)
13/ Another Venn diagram: the Covid surge & the flu. I’ve never been too worried about this nexus, since the same precautions that prevent Covid (masks, handwashing, distancing) also prevent flu. And, while flu vaccine isn’t anywhere near 95% effective, it does work fairly well…
14/ …and the Covid scare has increased the flu vaccination rate. In fact, we’re seeing pretty low rates of flu so far tinyurl.com/yayzl8ve We’re not out of the woods, but I’m fairly confident we can take Flu/Covid Twin Pandemic scenario off our overflowing 2020 bingo cards.
15/ Speaking of flu, “Covid is like the flu” is a lie that has cost too many lives. But MAKING Covid like the flu may be what it takes to return to normal. As I’ve said before, we don’t wear masks, close schools, etc during flu season, though flu leads to ~40K deaths/year in U.S.
16/ In other words, we “tolerate” those flu deaths & live “normally” despite them. The good news, then, is that we don’t have to eradicate Covid to get to normal. Rather, we need to sustainably cut the case rate via a vaccine, & cut the mortality rate in those who do get Covid...
17/ …to a point that Covid is, in fact, like flu in terms of overall risk.(To be clear: it’s not that way today, or ever in 2020.) Again, w/ 95% effective vaccine, & therapeutics that have halved Covid's death rate, it’s reasonable to expect a “like-the-flu” state by fall 2021.
18/ More news overshadowed by vaccines: this wk FDA approved 1st home Covid test tinyurl.com/y4eet4tq Unlike monoclonals, these tests will have lots of runway, since testing will remain central to our strategy until we hit vaccine-induced herd immunity, hopefully by mid-2021.
19/ We may be entering a world of immunity passports, where you need to demonstrate that you’ve either been vaccinated or that you're currently virus-free to gain entry into indoor spaces, including schools, businesses, or entertainment venues. So testing will remain important…
20/ …especially rapid tests that quickly tell if you’re contagious – tests @michaelmina_lab has been advocating for mths tinyurl.com/ybtulu96 Now that we have such tests, rolling them out will be key part of a national strategy to safely open things up once this surge abates.
21/ “National strategy” brings us, inevitably, to Trump. Science has done its thing: producing tests, therapeutics, & now vaccines in record time. With all this good news, how could we screw things up? Because now the hard, thankless work begins – developing and executing a plan.
22/ The Trump team’s track record here is miserable, as it has been on All-Things-Covid, with the notable exception of Operation Warp Speed. Think about prior efforts to distribute tests, PPE, remdesivir, ventilators – plans that either didn’t exist or were managed incompetently.
23/ The Trump team needs to share its plans (if there are any) for the distribution of tests & vaccines, and to work with the incoming Biden administration to make the handoffs seamless. Getting this right will prevent millions of Covid cases & hundreds of thousands of deaths.
24/ And the successful execution of a vaccine distribution plan will be the one Trump Covid legacy of which he can be proud.

Unfortunately, if past is predictor, we should have low expectations for the next 63 days, hoping only that the darkness will lift on January 20th. /end

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More from @Bob_Wachter

20 Nov
1/ Covid (@UCSF) Chronicles, Day 247

Fabulous @UCSF Covid Grand Rounds today: @DrPaulOffit @Penn on vaccines, @annieluet on treatments: tinyurl.com/y6swyu9e

I’ll start with a few SF & national updates, then summarize a few key points, mostly focused on the vaccine segment.
2/ Local update: interesting disconnect between cases vs. hospitalizations/deaths here in SF & @UCSFHospitals. While cases up in SF, @UCSF, we’re still pretty stable (Fig L): 15 pts, only 1 on vent. Test + rate mildly up: 4.85% in pts w/ symptoms; 0.78% in those without (Fig R). ImageImage
3/ SF cases are still spiking, though maybe (wishful thinking?) a tiny plateau (Fig L), now 95/day. Hospitalizations pretty stable @ 41, 2x of two wks ago but not skyrocketing (Fig R). Deaths stable: 156 since start of Covid. Test positivity 1.97%: also up but still fairly good. ImageImage
Read 25 tweets
13 Nov
1/ Covid (@UCSF) Chronicles, Day 237

California hit its millionth case today. A milestone like that might seem an odd occasion to highlight the state as a national model for its Covid response. But I will.

Here's @nytimes piece marking millionth case tinyurl.com/y4e4zxnp
2/ I’m quoted in Times piece: “We’re so huge that this number can make it seem like we’re doing badly – & we are beginning to surge like the rest of the country – but in point of fact we are doing comparatively well.”

That, & what the U.S. can learn from CA, is today's topic.
3/ While CA’s numbers are going in the wrong direction, when compared to the Midwest we’re doing OK – at least not so badly that we can’t turn this thing around. The figure shows CA's per capita case rate, plotted against several Midwestern states.
Read 24 tweets
9 Nov
Covid (@UCSF) Chronicles, Day 237

Didn't plan to tweet today, but can’t resist a few quick takes on @pfizer vaccine news tinyurl.com/yygwoxwf

90% efficacy is far better than even most optimistic projections. An election analogy: these are CA results, rather than PA. (1/16)
The 90% is for preventing symptomatic disease (ie, fever, cough). But we don’t know yet how well this vaccine prevents severe symptoms that lead to hospitalizations, ICU admissions, & death. That’ll be key. It seems likely it will, but that still needs to be demonstrated. (2/16)
Now that the efficacy data are out, the next big question is safety. The need to wait two months to observe at least half the volunteers is the reason the vaccine won’t be ready to be considered by @US_FDA for an Emergency Use Authorization (EUA) until later this month. (3/16)
Read 16 tweets
9 Nov
Covid (@UCSF) Chronicles, Day 236

1/ I don’t know any scientists or clinicians who aren’t thrilled about Biden’s victory tinyurl.com/y43cwpln The only way to defeat Covid is by being frank about the challenges while following the science & evidence. Biden will do all of that.
2/ Biden is set to introduce his Covid team tomorrow, led by Obama's surgeon general @vivek_murthy, & @DavidAKesslerMD, former FDA head (& ex-@UCSF dean) tinyurl.com/y2rwyaks I know both well & am confident that they’ll be excellent leaders. (Role of M. Nunez-Smith still TBD.)
3/ Biden’s decision to announce this task force as his first major act as Prez-elect is important & strategic. He knows that if he doesn’t get the pandemic under control there’s little else he will achieve as #46.

And, it goes without saying that the administration’s success…
Read 25 tweets
6 Nov
Covid (@UCSF) Chronicles, Day 233

1/ Today was an amazing @UCSF Dept. of Medicine grand rounds. We discussed the election and its impact on Covid & healthcare with an all-star crew: @KBibbinsDomingo, @ASlavitt, and @ZekeEmanuel. The 1 hour video is here:
2/ I’d normally tweet a long summary of the chat, but I’ll be honest: between obsessively watching cable (how does @JohnKingCNN stay awake?) & refreshing this addictive swing-state calculator (tinyurl.com/y5e3lecj try it!), I don’t have the energy. So just a few take-aways.
3/ I hope you’ll find the time to watch the far-ranging discussion. We covered how a President Biden (now a near-certainty, as both PA and GA are poised to flip) will and should handle the transition and the early days of his presidency, both in terms of healthcare and Covid.
Read 14 tweets
3 Nov
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.
Read 25 tweets

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