Governor Newsom relaxed California’s requirements for accelerated reopening. The new criteria focus less on how many deaths a county or municipality have and more on the number of cases. The new criteria will allow for up to 25 cases per 100,000 members of the population and no more than an 8% positive test rate. This was a major sticking point for larger counties as the previous criteria required a county have no deaths before they could reopen. It’s estimated that 53 out of 58 counties could be eligible to accelerate their reopening under these new requirements.
Drug maker Moderna announced yesterday that its COVID-19 vaccine passed an important test. This early phase included 8 people and results have demonstrated that the vaccine was safe for them and that it produced a strong anti-COVID-19 antibody response. The company then studied those antibodies in the lab and found that they had a neutralizing effect on SARS-CoV-2 in vitro (scientific term for in a testtube). This is a standard approach and generally bodes well for an antibody’s ability to neutralize the virus in vivo (scientific term for in a living organism). Moderna’s approach to vaccines is different. Traditionally a vaccine contains inactivated virus or virus proteins which when injected into the body fool the immune system into thinking a real virus is present. The body then starts making antibodies to the harmless version of the virus. Once antibodies are present, they can mount an effective immune response when exposed to the real thing. Moderna instead uses something called an RNA vaccine. Instead of injecting virus bits or inactivated virus, they inject actual mRNA (genetic material) which codes for specific proteins on or in the virus itself (e.g. spike protein important for viral entry into a human cell). If Moderna had injected DNA into the the body there might be a risk of that DNA disrupting the body’s normal genetic code, but mRNA doesn’t incorporate into our genes, it only gets read to make protein. Once the vaccine mRNA is in the body actually starts creating the protein from the pathogen and expressing it on cell surfaces which is then recognized by memory cells allowing an immune response to a virus that the body has never actually seen. When a real virus invades, the body is ready for it and attacks it before it can do real damage. This type of vaccine has some advantages over traditional vaccines. They can be produced more quickly and more cheaply, they are less dangerous for patients since there’s no virus being used for the immune response and they can be scaled up quickly for mass vaccinations during a pandemic. Moderna plans to move on to their next phase of testing which will be an expansion to around 600 patients. Very good news indeed, but remember it’s still a long way to knowing for sure that this vaccine works and is safe.
More and more data is showing that we could very effectively control the virus if we quarantined our mouth and nose more effectively. If 80% of the population was fully compliant with wearing masks whenever in public, the data shows we could stop the spread of this virus. This, of course, could have major implications for reopening our society and getting businesses back up and running. For an excellent dive into the importance of masks take a look at this must-read.
Governor Newsom announced the start of Phase II of California’s COVID-19 response today by allowing limited pick-up service openings for businesses like book stores, sporting goods stores, and florists as early as this coming Friday. This is a measured loosening of restrictions to be sure as there’s no real congregating allowed and this is probably the most that could safely be undertaken at this point. We have not met several of the criteria outlined by infectious disease experts for safe relaxation of stay-at-home orders. In particular, while testing is increasing, we are not at the level where comprehensive evaluation of any symptomatic person can be achieved with results on the same day or within hours. Additionally, it’s not clear that daily new cases are declining let alone for 14 days straight, another of the primary relaxation criteria. Given this, it’s a bit of a risk to begin loosening of restrictions at this point but I’m guessing he hopes allowing these relatively safe activities will help put an end to the incredibly risky behavior of protesters around the state in recent days. Some experts like Dr. Robert Kim-Farley from UCLA are predicting that Phase III which will include the opening of higher risk businesses like movie theaters and gyms might occur sometime in the late summer, possibly August or September. Timelines like this are notoriously difficult to predict however, since they sometimes depend on non-medical decision making by political leaders. I wouldn’t be shocked to see that timeline bumped up somewhat.
It seems pretty clear now that the United States’ COVID-19 disease course is not following a Gaussian curve with an equal slope on the way up to and down from the peak. Instead the disease is declining at a much slower rate than when it ramped up to the peak. This slow tapering recovery will unfortunately lead to significantly more cases and deaths from the initial disease surge than predicted by models that assume a Gaussian distribution as there will ultimately be more area under the curve.
Michael Osterholm, a foremost expert on viruses and pandemics who many people saw for the first time on Joe Rogan’s podcast is the Director of the Center for Infectious Disease Research and Policy (CIDRAP). Last week his group at CIDRAP released a report that describes three possible pandemic wave scenarios based on lessons learned from previous pandemics. The first scenario sees one to two years of recurring peaks and valleys similar to what we’ve just experienced requiring periodic reinstitution of mitigation measures like we’re currently living under. For obvious reasons, this scenario could have dramatic economic repercussions. The second scenario mimics the 1918 influenza pandemic which saw an initial peak in the spring and a massive, much more devastating peak in the fall after relaxation of social distancing measures during the summer. This second peak would almost certainly overwhelm our healthcare system and lead to very large numbers of deaths but would not be followed by significant peaks after the fall peak as the virus would have burned through most of the population. The third scenario describes a slow burn after the current, initial surge. In this scenario there are no peaks and valleys, just a constant relatively stable number of ongoing cases and deaths. This scenario would not require large-scale mitigation measures after the initial peak. While this pattern has not been seen with previous influenza pandemics it could occur with a novel coronavirus such as SARS-CoV-2/COVID-19. Whatever scenario plays out, the CIDRAP group advises that Americans should get used to the idea of significant COVID-19 activity for the next 18-24 months. As the pandemic starts to fade away, it’s likely that SARS-CoV-2 will continue to cause less and less severe illness over the next decade eventually settling in as a non-life threatening upper respiratory infection much like it’s other cold-causing coronavirus cousins.
A brief look this morning at some data where I live. Here are some of the data for Riverside County since April 15
Daily New Cases
Daily New Deaths
So looking at a population like Riverside County can be challenging compared to larger centers around the country. There will inevitably be variations in the graphs because of a relatively smaller population and regional reporting characteristics.
What you probably can see is that there appears to be an overall decline in Daily New Cases in Riverside over the last several weeks. Most days in the last week are running under 100 new cases. It’s a general trend and there’s a lot of noise here so it’s difficult to draw any solid conclusions. One thing to note is the odd reporting on April 20. That day there were problems with the State’s data entry tool, CalREDIE. The 22nd made up for that when the system was working better but it’s probably more accurate to average those two days to something more like 122 and 123.
Similarly there appear to be changes in Daily New Deaths, the difference being an increase more recently. Again, all the caveats about sample size and variation are applicable here so we probably need to watch the data a bit longer to know for sure that the trends are true. But an increasing Daily New Death rate with a decreasing Daily New Case rate does tell us something. It’s possible that we’re at or maybe a bit past our peak for this wave of the infection in Riverside County. Typically, the deaths start to go up after peak which makes sense. If you have an increased number of people going into the hospital over a few days, they don’t generally die right away but within a week or two those that are most severe will die–hence, tragically deaths go up even though cases are going down. Further data over the next several weeks will likely tell us one way or the other. I’ll post updates in future days but keep an eye on those numbers. The easiest way to do that I’ve found is STAT’s COVID-19 tracker. You can view down to county level on this tool to monitor Daily New Cases and Daily New Deaths.
One other bit of news for Riverside before I go is that our doubling time has increased to 13 days! That starts to bring us in line with the State which is good news! I remember when we were doubling every 4.6 days and we (public health) longed for a doubling time in the double digits. Seems like a lifetime ago, I think it was a month.
For some time I’ve been considering leaving Facebook. While there are many positive aspects of the social media giant, there are some things about it that I find hard to stomach. It’s a great place to share photos of family and pets and jiu jitsu, but it’s a terrible place for conversations. The world is polarized and so is Facebook, actually, the world may be polarized because of Facebook. I love to talk science though. Writing about COVID-19, while not a cheery subject, has helped me process some of the feelings I have about living through it, especially as a public health physician, worried father and husband. I just want to do it more on my terms. No yelling, no anti-science comments, just people who want to understand what on earth is happening right now with the best tool the human race has ever devised for understanding our world. So welcome to my new home!
Thoughts on COVID-19
Nationally there’s a bit of a worrisome trend with our doubling time. A while back, on Facebook, I mentioned the good news that our national doubling time was increasing and that it was increasing by more than a day, every day. That signifies a peak in terms of new daily cases. The daily increase in doubling time was actually increasing along a sloping curve meaning something approximating an accelerating growth curve. That’s not happening anymore. What we see now is more of a plateauing of our doubling time. It’s been stuck increasing at a rate of about 18-20 hours a day for a week or so–every day our doubling time is increasing by the same amount, 18-20 hours. It’s no longer accelerating. There are a couple reasons for why that might be happening. Some are okay, some are not. It’s possible that regional and state differences in the timing and slope of the COVID-19 curves are making it so that later peaking states are rising while earlier peaking states are waning. That could be okay. It just means we’re all marching to the beat of our own drums and eventually we’ll all start a collective increase in our doubling time rate together. It also could mean that people are slipping with their social distancing and stay-at-home compliance. Spread of infection during recent protests along with religious ceremonies for Easter and Passover could be putting the brakes on our ride away from the peak. More time will tell. For all sorts of great information on the national doubling time, visit https://www.danreichart.com/covid19 He runs one of my favorite statistical sites for COVID-19 and most of my US doubling time information posted to Facebook and now here comes from his great work. His approach is to look at each day anew. Here’s where we are today and this is what we’ll look like in the future if our doubling time stays what it is today.
And now some pretty good news. Scientists from the the Jenner Institute at Oxford have been working on a vaccine. What makes this good news is that it’s a vaccine they made some time ago as a possible vaccine for MERS and they’ve already tested it for safety–last year actually. Safety testing can be one of the longest steps in the process of making a good vaccine. You have to watch people for quite a while to make sure they don’t have any lingering adverse effects–sometimes several years. Having something ready to test for efficacy is a big head-start. The vaccine has recently been tested in rhesus macaque monkeys with good results. Six monkeys were given the vaccine and then exposed to a large amount of the virus. All six are still healthy a month out. Testing in monkeys doesn’t guarantee success in humans but the rhesus macaque is just about the closest thing we have to humans. Given that, testing in humans is likely to happen sooner rather than later. If all goes well (that’s a gigantic IF), and the Institute is given emergency approval, they could have several million doses available as early as September. That would be monumental. Please remember there are still massive efficacy hurdles to jump so take a deep breath and in a very unscientific way, maybe cross your fingers.
With this pandemic, the rush to find an effective treatment has been fully understandable. I posted early about the possibility that hydroxychloroquine might be an effective treatment based on some very small, and it turns out pretty flawed, studies. Newer (also small, also not peer reviewed) studies out of Brazil and the VA system in the US indicate that hydroxychloroquine is ineffective in the treatment of COVID-19 and possibly dangerous (the trial in Brazil was stopped when some of the patients in the high-dose arm of the study developed lethal cardiac arrhythmias). The efficacy and safety of hydroxychloroquine to treat COVID-19 should be established in large, controlled studies and it should not be provided as an off-label treatment for the virus in a non-study setting. There, I said it. Good science takes time and patience. But nobody’s listening to me.
Look to hear from California’s Governor Newsom sometime in the next 48 hours regarding details about relaxation of the stay-at-home/social distancing orders. California’s actions have made a difference. As we’ve known for a century at least, social distancing works and it worked here. While the initial orders were emergent and broad-sweeping, look for the relaxation orders to be more surgical and to come with a period of evaluation. We needed quick, blanket action to prevent massive spread of the virus through the entire population of California when it was doubling every two days. With a doubling time of two days, the virus would have hit everyone in America within about 40 days. Now that we’re much more under control we can relax elements of social distancing one at a time with a period of observation to look for spikes. We can then see which of these measures were the most important in preventing spread of this virus. This process will give us valuable data and will help us in the fall when it’s likely the virus will surge again. Our break from the lockdown may not be as soon as we’d hoped though. This past weekend, some Californians jumped the gun and flocked to the beaches in numbers that are simply unwise at this point. This was a mistake and may very well lead to an uptick in the virus within the next two weeks. It’s just simple virology. If that happens we may not get our relaxation phase as soon as we would have, had people maintained social distancing per state and local public health department orders. Here’s hoping we don’t see that or that what we see isn’t enough to derail our break from the lockdown.
CHRIS DAEL 