Thread by @Bob_Wachter

1/ Covid (@UCSF) Chronicles, Day 322

Today, an update on local situation. Then my take on a few issues of the day. There’s some great news, some good news, & some bad news (in the form of variants, lurking just over our horizon). I think we can win The Race, but it’ll be close.

2/ Let’s start w/ local situation & then move out – themes are pretty consistent across U.S. @UCSFHospitals, 50 pts in hospital, 13 on vents (Fig L). Test positivity 3.8%; 9.3% in pts w/ symptoms, 2.6% in asymptomatics (Fig R). While hospitalizations & test positive rates are...

3/ … down 30-50% over past 2 wks, I worry that the curves are now a bit plateaued. (After past surges, once cases/test positivity rates started falling they continued to do so.) While I think we'll keep getting better, this bears watching.

4/ SF is also improving. Cases down to 173/d, ~50% drop (Fig L). Hospitalizations 176 (Fig R); maybe also a whiff of a plateau? Test positivity 3.2%, down from 5.4% last month. All pretty good, though not so good that rates couldn’t go back up from unsafe Super Bowl parties.

5/ SF death total up to 324 – double since 12/1, but still easily lowest death rate (37 deaths/100K) of any big U.S. city/county. Selected others:

NYC: 323/100K
Suffolk (BOS): 195
Cook (Chicago): 184
PHL: 184
MIA: 181
Maricopa (PHX): 170
LA: 168
Fulton (ATL): 90
Harris (HOU): 90

6/ CA cases falling fast, led by rapid drop in LA. Deaths haven’t budged. They're a lagging indicator; death rates should begin to fall soon. Falling cases/test+ argues against high prevalence of more virulent strain in CA (whether a homegrown “CA variant” or the “UK variant”).

7/ Nationally, similar story, w/ steep fall in U.S. cases, across all four regions. Note that the situation, though much better, is still not “good” – even today, there are twice as many cases as we had at peak of summer surge, and 4x number of cases as in surge last spring.

8/ As in CA, U.S. deaths have not yet fallen much – averaging ~3,000/day, still a 9/11 worth of deaths each day. Total deaths now 443K, more than entire population of Oakland, CA; we'll soon match the population of Miami, FL. A staggering toll.

9/ Thankfully, vaccination is speeding up. Roll-out was awful: combo of no fed planning/support, holidays, & underestimation of complexity. But now 64% of available doses injected, double 2 weeks ago
tinyurl.com/lxdb99er Increasingly, problem isn't distribution, it's supply.

10/ Defining issue in Covid is now The Race: can we vaccinate enough people quickly to protect population before we’re pounded by variants? (Particularly B117 [UK] variant, with its 50% increase in infectivity, & possible increase in fatality.) Moment of truth will be in March.

11/ Why March? That’s when @CDCgov believes that UK variant could become dominant strain in the U.S. And, understandably, cities/states/individuals are responding to falling case counts by opening up, which will give mutants an opening. tinyurl.com/38dy4q5k

12/ Also in March, we could (emphasize: COULD) be getting to a place in our vaccination program when enough of the population is immune to blunt this potential surge in cases, particularly of the UK variant. And perhaps we’ll also stay ahead of the spread of…

13/ … the other variants, like the South African and Brazil ones, that may compromise the effectiveness of the vaccines. If the stakes were lower, it would be quite dramatic, even fascinating: The Vaccines vs. The Variants!

But the stakes couldn't be higher.

14/ That's why I’ve advocated a super-pragmatic approach to vaccination: age first to get to highest risk populations; not holding back 2nd doses to get as many folks their first doses as fast as possible. Speed is the name of the game; complexity & rigidity slow things down.

15/ Now that distribution is improving, we must accelerate supply. In my interview w/ Julie Gerberding @inthebubblepod, she made a compelling case for why we can’t simply ramp up manufacturing of Moderna & Pfizer vaccines (@ 22:30). It's not just the $ s.
tinyurl.com/3ptfhbgn

16/ New study: people who’ve had Covid may not need a 2nd shot. If true, that’ll free up a lot of doses. But how to operationalize? Test for antibodies in all before vaccine? Or just test people w/ known Covid? Adds complexity, thus tricky. But promising. tinyurl.com/ijbep1x1

17/ Dept of Sweating-the-Little-Stuff: Using low dead-space syringes will get an extra dose out of every Pfizer vial tinyurl.com/q0b50i5m. Putting more Moderna doses in each vial will help too. Both seem trivial but could create millions more doses. tinyurl.com/2nz4dgk9

18/ But the biggie here is the newbies: 3 vaccines w/ new positive clinical trials results: J&J, Novavax & now Russian Sputnik vaccine. While the top line efficacy rates might not be the 95% that we’ve become used to (and spoiled by) from Pfizer/Moderna, they're high enough, &…

19/ … their advantages (particularly for J&J, one dose, no freezers, cheap) are important tinyurl.com/oggwmzvo Even more important: in all of the trials – of 75,000 recipients & 5 vaccines – there has not been a single reported death. Breathtaking.
tinyurl.com/pepk0h08

20/ Other good news: the UK variant appears to be equally susceptible to the vaccine as the old virus. So Job One is to get 1, 2, or all 3 of these additional vaccines approved & distributed ASAP. That’s the best way to markedly increase supply & win The Race.

21/ Need motivation? Here's my interview w/ Patrick Vallance @uksciencechief. At @ 48:35, he describes how the UK discovered new strain. “This area was growing when everywhere else was shrinking…” From a few cases in Dec, it’s now 75% of cases in London.
tinyurl.com/345q89z8

22/ Safety news for Moderna & Pfizer is great – risk of anaphylaxis is minuscule (~1/100,000; no deaths), & no signal of any potential long-term problem. Yes, some people do have a crummy day-after-vaccination, but it almost always resolves in 1-2 days.
tinyurl.com/zyt0asi1

23/ So overall, I'm more hopeful than fretful. With a competent administration, I’m confident that we’ll do all we can to stay ahead of the variants and get people vaccinated quickly enough to bend the curve. After all, we don’t need to get to herd immunity by March (and we…

24/… can't get there that soon). Instead, we need to get to a place where the combination of people with immunity from infection (probably ~100M in U.S. now) plus those at least partly vaccinated (maybe ~50-60M by March) is big enough to blunt the spread of the virus – even w/…

25/ … a nastier strain in the mix. I’m going to bet that, w/ the Biden team's laser-like focus, 1-2 new vaccines adding to supply, and a better oiled & more flexible distribution program, we’ll get there. We just can’t afford to fail.