Covid Epi Weekly: Humanity vs the Virus – the Virus is Winning

We’re facing a perfect storm: Uncontrolled spread in most of the US, slow vaccine rollout, and worrisome mutations that increase transmissibility and could undermine diagnostic testing, antibody treatment, and vaccine efficacy. 

A misleading narrative suggests that uncontrolled spread of Covid shows that public health measures don’t work. The plain truth is that most places didn’t stick with the program long enough to get cases to a manageable level, and now masking and distancing aren’t being done reliably.

So yes, if you don’t use masks correctly and consistently, they don’t work. And vaccines don't work if people don’t take them. Fortunately, in terms of tracking where the virus and our response are, CDC data is getting ever more available and useful and the Covid Tracking Project remains invaluable.

Uncontrolled spread

The US is seeing record high cases, hospitalizations, and deaths – with continued increases. There’s a one- to two-week lag between cases and hospitalizations, as well as between hospitalizations and deaths. Expect continued increases in deaths in the days and weeks ahead. Scaling up antibody treatment might help, but, like vaccines, rollout has been botched. One bright spot is that there are an increasing number of effective treatments for Covid, including monoclonal antibodies early in the course of illness, and steroids such as dexamethasone late in the course of illness.

How stressed are hospitals? A new tool using HHS data shows the percentage of beds with Covid patients, which is a more reliable indicator than the percentage of ICU beds filled, since ICU beds can be added more easily than hospital beds (by converting surgical recovery suites, anesthesia rooms, etc). Anything over 15-20% of all beds filled with Covid patients is bad – and that’s the situation now in much of the U.S.

But the limitation of beds isn’t the most dangerous, the limitation of staff is. Health care workers are exhausted and at risk. Relief is months away, and no reinforcements are likely to arrive from other parts of the country. That’s why it’s so important that vaccines get rolled out to health care workers quickly, and antibody treatments used to prevent hospitalizations in patients at risk for serious illness.

Why do some parts of the country have much more Covid than others? Rates of hospitalization range four to ten-fold among states. Fundamentally, there are four factors:

1. Opening too soon, leading to rapid resurgence
2. Failure to distance and mask
3. Failure to find and stop outbreaks
4. Superspreading events (bad luck).

In most places, public health measures didn’t fail – they weren’t applied. To a striking degree, this breaks down along partisan lines. 

Look at Staten Island. The northern part, which is poorer and more Black and Latinx, has worse health outcomes and shorter life expectancy. But southern Staten Island, which is richer, whiter, and regularly votes Republican, has higher rates of Covid, including higher test positivity (~15% vs. ~10%).

We see similar differences, generally, between southern and northern California and the US South and North.

Humans take vacations but the virus doesn’t. Data scientist Youyang Gu shows in this thread that we’re nowhere near herd immunity.

As famed molecular biologist Josh Lederberg used to say, microbes outnumber us: it’s our brains against their numbers. Places like Vermont and Oregon are doing much better than others.

A reporter asked me the other day why California is doing as badly as Texas despite having more restrictions. That’s a faulty premise. If Texas had California’s death rate, 8,120 dead Texans would be alive today. And many places in California haven’t masked or distanced. There’s been a societal failure to implement public health measures.

Nationally, PCR test positivity rates are increasing steadily in 12-17 year olds and in 5-11 year olds, and are these groups have the highest test positivity of any age groups. Although imperfect, positivity rates are important to track – and this is not a good trend. Kids are seeding the virus throughout communities and the country.

Slow vaccine rollout

A second concerning trend is the delayed and uneven rollout of vaccines. Some of the challenges are understandable – the vaccines are new and difficult to store. Other challenges stem from incompetence. For example, the federal government has failed to support state and local microplans. Even for a competent government this would have been hard, and….

If vaccination is run like a grocery delivery rather than a comprehensive campaign, it won’t succeed.

Grocery delivery: temperature, restocking cadence. 

Vaccination program: community engagement, microplanning, two-way communication, identification of trusted messengers and messaging in every community.

These are important but not well known documents about vaccination. Good CDC guidance, buried.

1. Checklist on HCW vaccine confidence and comms
2. Vaccine program action items for jurisdictions
3. HCW administration skills checklist 

We also put together materials on how to plan for and communicate about Covid vaccination.

Here’s some plain talk on vaccines. They’re stunningly effective and, so far, reassuringly safe. The CDC shared some data behind the allergic reactions to Pfizer vaccine: there were 11 cases per million, 70%+ among people with a history of anaphylaxis or allergy. Among people without such a history, the rate is about 1/500,000 

Operation Warp Speed must stop hoarding vaccines!!! There’s no need to hold back half of the doses. Get them out fast. Although it’s possible manufacturers will miss their production targets, that’s a lesser risk than not flooding the zone ASAP with vaccines. (This is a different issue than the single dose issue in England, about which, more later.)

We should move to Phase 1C1 immediately (like, today) – vaccines should be made available to all 65+, all health workers, all nursing home residents and staff, and frontline essential workers. NEJM published some good information on how to promote vaccination. Bottom line: focus on making it convenient and on communicating with the movable middle.

Hint: the same folks who aren’t likely to wear masks are also not likely to get vaccines. We need to segment the market and target messages to different groups. The focus should be on getting back to normal, protecting jobs, and protecting our families. Demonstrate that despite a rocky start we’re making real progress.

There are still lots of unknowns regarding the AstraZeneca/Oxford vaccine. It may be less likely to give “sterilizing immunity.” Studies are urgently needed on the prime/boost approach to see if higher protective efficacy is confirmed. It’s reassuring that the data indicates fewer serious infections and no serious adverse events.

But...if it turns out that we have vaccines that are 70% effective (e.g., AstraZeneca, unless the prime/boost data is confirmed) vs. 90%+ effective, it’s going to raise terrible questions. Scientific knowledge should be in the public domain. It's a moral imperative to make the best vaccines for the most people.

New strains

Now, if uncontrolled spread and slow vaccine rollout didn’t alarm you, let’s talk about new strains of the virus. At first I thought maybe the UK was blaming mutations for sloppy public health work – but no. The strain really is more transmissible. It’s not inevitable that it will spread in the US, but it’s likely.

I've never seen an epidemic curve like this one. If the variant becomes common in the US, it will be close to the worst-case scenario, with a baseline of full hospitals. (Not worst case: case fatality rate is about 1/200, worst case could be 1/10 or even higher.) The strain has the potential to create a perfect storm, especially with political turmoil and a leadership vacuum.

What’s happening in Ireland is deeply concerning. In just a few weeks, the new strain has gone from making up less than 1 in 10 new cases, to nearly 1 in 4 new cases. We could use more data to understand this better, and the relaxation of indoor restrictions undoubtedly helped, but the trend is ominous. 

Let’s be clear: new strains will continue to emerge, as they do with most viruses. B.1.1.7 is more transmissible, so it will cause more infections, hospitalizations, and deaths. Strains may emerge that make testing less accurate, treatment less helpful, or vaccines less effective. B.1.1.7 is a shot across the bow. Covid will be with us for years.

So far, we’ve failed at controlling Covid in the US. Now if a more infectious strain takes hold, we’ll have to do so much better. We’ll have to curb avoidable indoor exposures. Maybe, wear better masks. Although we should definitely not change the vaccine dose schedule now, if we get to a UK-like situation, it has to be considered.

We have another nine days of absent leadership and active undermining of lifesaving public health measures. These days are so very dangerous, for so many reasons, including the potential for exponential growth of the B.1.1.7 strain.

Many years ago, Senator Moynihan said, "Everyone is entitled to their own opinion, but not their own facts." That should not be too much to ask. We need to get back to that perspective, urgently, to protect ourselves and our families.

This long article on the impact of Covid on young Black men is a must-read. As I think about 2020, I mourn the 400K+ deaths in the US (that’s the accurate number considering excess mortality), many of which were preventable. But I will also never forget – and do not want to forget – the horrific, lynching-like killing of George Floyd.

“Concern for man and his fate must always form the chief interest of all technical endeavors. Never forget this in the midst of your diagrams and equations.”

– Albert Einstein