1/ Covid (@UCSF) Chronicles, Day 252
Lots going on – I’ll try to go a bit beyond the headlines. Let’s start with a brief Public Service Announcement, then the Covid situation in SF, vaccine distribution, a little on schools, and then a crazy case of pharmaceutical serendipity.
Lots going on – I’ll try to go a bit beyond the headlines. Let’s start with a brief Public Service Announcement, then the Covid situation in SF, vaccine distribution, a little on schools, and then a crazy case of pharmaceutical serendipity.
2/ Short PSA: your plans for T-giving are set. My recommendation: add 10% more caution than you were planning. Open the windows, keep a fan going, sit 7 feet apart, not 6. Something. It might make a difference. And then enjoy, without guilt.
3/ On to SF. While we’re definitely “surging” here, we began at such a low baseline that our numbers are still fairly benign. It doesn’t mean they’ll stay that way, particularly if Thanksgiving brings people and virus closer together. And it definitely could do that (see #2).
4/ @UCSFHospitals, 13 pts, 3 on vents. Our hospital # ‘s have bounced around, but there’s not a big upwards trend (Fig L) – at least not yet. Test positivity rate is up to 5.4% in pts w/ symptoms; 0.8% in those w/o (Fig R) – 2.5% overall. These too are up, but not remarkably so. 
5/ SF cases averaging 110/d, pretty steep bump (Fig L). But deaths flat @ 158, amazingly low. Test positivity 2.2% in SF, up from low of 0.8% but still pretty good, & not increasing much. Hospital pts in SF: 55 (Fig R), enough to cause anxiety, but not close to stressing system.
6/ Of course, Midwest situation is dire. In earlier surges, we worried about bed/vent/PPE capacity; this time it’s the people, with ~1000 clinical staff sidelined by Covid at both Mayo & Cleveland Clinics tinyurl.com/y2vopj8b. And the widespread nature of this surge means…
7/ … that relief can’t come from elsewhere. For example, @UCSF sent MDs & RNs to NYC and Navajo Nation in April. But we simply can’t risk it this time, when we could be slammed ourselves in 1-2 weeks. This is playing out everywhere, and removing some of the system’s resiliency.
8/ That’s the bad news. Now the good: we have at least 3 highly effective vaccines! Now the distribution challenge begins. Some of it is Logistics 101: trains, planes, boats, trucks, freezers, databases, etc. But the really hard stuff will be closer to the ground: who goes first?
9/ As I guessed, the fear that folks might not take vaccine is receding w/ efficacy/safety news, along w/ seeing that @US_FDA stared down Trump & re-earned trust. New poll: ~70% would take vaccine if endorsed by health officials (read: Fauci), up from 50% tinyurl.com/y5okjqdd
10/ So big test will be meeting demand. In addition to funding the vaccine science & studies (except @Pfizer, which self-funded), Op Warp Speed also funded massive production – even before we knew they’d work! The minute FDA says yes, 6M doses will go out tinyurl.com/y6rk99op
11/ @CDCgov is finalizing recs re: who goes first; then each state will be free to tweak. Likely docs/nurses first, then “essential workers” (definition TBD, but, given key role of schools, I hope teachers are included tinyurl.com/yxbbudad) & older patients in long-term care.
12/ Then: everyone >65, and those with co-morbidities. That’s about half the U.S. How about avg risk people? Probably May-July.
Here’s a great WashPo explainer on vaccines: tinyurl.com/yy2rnonk. Plus highly recommend my interview of @DrPaulOffit: tinyurl.com/y24l8sl4
Here’s a great WashPo explainer on vaccines: tinyurl.com/yy2rnonk. Plus highly recommend my interview of @DrPaulOffit: tinyurl.com/y24l8sl4
13/ Teachers are key, since decisions about schools remain so fraught and crucial. Terrific "The Daily" @nytimes today on NYC’s decision to shut the schools down because the city hit a 3% test positivity rate, an arbitrary (and awfully low) threshold tinyurl.com/y4b6ohga .…
14/ … particularly since experience to date shows that schools, especially elementary, can be opened safely in places that have low-moderate spread. Plus we’re becoming more & more aware of many costs (to both kids & parents) of keeping schools shuttered tinyurl.com/y3r3hkzw
15/ Whatever the rules, in about 3 weeks we’re going to have real vaccine doses & real people who want their shots. @UCSF (which will get an early Pfizer shipment), we’re already fielding expected calls – from alumni, friends of the institution, patients (both sick & well), etc.
16/ A good problem to have (last month, we didn’t know if vaccines would work at all), but there'll be tough decisions. I’m hoping CDC/state guidelines are fairly prescriptive – too much local control will open door to abuse & cronyism. We need folks to be able to trust process.
17/ @US_FDA also blessed 2nd monoclonal Ab: Trump’s Regeneron cocktail. No evidence that monoclonals cut mortality, but they do seem to prevent ER visits & hospitalizations tinyurl.com/yy4re523 It’s a decent bet that more research will show fewer deaths; just not yet proven.
18/ Combination of all this – multiple vaccines (which cut total # of Covid cases, as well as severe ones) ready for use; strong demand for vaccines; monoclonal antibodies on top of other meds (mostly steroids) & treatments that lower mortality in pts who still get Covid – ...
19/ … makes me more & more optimistic that we’ll make a big dent in Covid by spring. And it’s not crazy to have hope that we’ll achieve herd immunity by summer – which will require that 65-70% of the population is protected, via vaccine or prior infection tinyurl.com/yyar7deg
20/ While Prez-elect Biden hasn’t made his health personnel picks yet (other than Covid Task Force: superb), his economic & foreign policy choices give every indication that we’re returning to a world in which competence, experience, and evidence rule the day. God, it feels good.
21/ And, even before January 20, we’re getting the sense that @CDCgov tinyurl.com/y6apke6n and @US_FDA tinyurl.com/y4kwwpad are snapping back from their Trump-induced coma to their usual status as world-class, relatively apolitical organizations. Not a moment too soon.
22/ The @AstraZeneca vaccine results are fascinating – it’s not clear why the Half-Dose-First, Full-Dose-Second regimen worked best (its efficacy was similar to the Pfizer/Moderna 90%; vs. two full doses, which were about 70% effective). The most stunning thing about it is…
23/ …that the decision to give some subjects a half-dose was, it seems, an honest-to-goodness mistake – one that might have gone undetected if people running the trial hadn’t noticed that some recipients of Dose 1 were having surprisingly few side effects tinyurl.com/y2nqyzzw
24/ Not the first time that a twist in a drug trial led to a Eureka! moment. Below is from my book on medical errors, “Internal Bleeding”. It describes 2 wild stories of pharmaceutical serendipity. Not life-saving, exactly, but, as Larry David would say, pretty... pretty good.
25/ That's it. Have a joyful (and safe) Thanksgiving. You deserve it.
And remember, if it's Thanksgiving, then it must be nearly 2021.
And remember, if it's Thanksgiving, then it must be nearly 2021.
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