🦠 COVID-19 | "The worst is yet to come"

📊 Daily Data Brief: July 11, 2020, 01:12 GMT (❗️July 08, 2020, 12:16 GMT)

Cumulative case: 12,616,579 (+635,213cumulative cases 

Active cases:  4,727,180 (+219,017) (this is the number of currently infected patients)

Total Deaths:   562,039  (+14,714)

Serious/Critical Cases: 58,896 (+658)

Recovered:  7,327,360 (+401,482)

Source: Worldometers

1) Seven-day rolling average of new deaths(ECDC data)

Showing a chart from the FT today highlighting the worrying situation in Brazil, Mexico, India and Russia and Iran (NEW❗️). Also the FT comparative charts now allow up to 6 countries.

2) Rt estimate per State (US)  (NEW❗️changed to RT.live which offers better visualisation of States above whose Rt>1)

3) Rt estimate per Country

Texas Governor Gregg Abbot said on June 25:

“We can protect Texans’ lives.”

He followed this prophecy on July 10 as Texas was at the epicentre of an epidemic surge:

“The worst is yet to come”

As Nicholas A Christakis (Yale Professor) noted in a thread New York City Mayor Bill de Blasio had professed the same about New Yorkers on March 5 and March 22.

As one says: ‘Plus ça change…”

This is also what today’s article of the day is about. The inability of leaders to learn from other leaders who have faced SARS-CoV-2 earlier. And the big question is whether countries which are just emerging from their first containment learn from others who are now facing a second surge, such as Melbourne, Israel and now Hong Kong (thread of the day). Unfortunately it does not appear so.

For example why would UK Chancellor Sunak give dine-out vouchers when the World Health Organisation was about to change its recommendation about airborne transmission of the virus:

A big focus is on school reopening in the US and there is a whole section on it today with one report and two articles. This topic is also covered in the video of the day by Scott Gottlieb and the podcast of the day by Bob Wachter.

A dedicated section on the state of the US epidemic starting with the latest data, but also looking at the growing testing bottleneck and racial inequities.

Finally a rich section with a review on our state of knowledge on COVID-19 and one on T-cell-based immunity. Another research letter looking at long term side effects of hospitalised patients (image of the day). A report detailing current monoclonal antibody production capacity and a policy recommendation to add ahead of trial results.

The pandemic is accelerating, a second wave is forming in a number of places, and as Texas Governor and New York city mayor have said previously: “The worst is yet to come”

🇺🇸 Article of the day: David Wallace Wells writes “America Is Refusing to Learn How to Fight the Coronavirus” for the New York Magazine. (Link)

Wallace Wells starts by narrating the state of the pandemic in the US, with the reliving in a number of South Western states of the situation in New York earlier in the pandemic: rising cases and hospitalisations numbers, depletion of ICU availability and now also rising death numbers.

He next echoes the Corona Daily June 28 editionLearning nothing, politicising everything”, noting that the same way New York had been unable to learn from Lombardy, the South Western states now at the core of the US surge have been unable or unwilling to learn from New York.

Why? Wallace Wells lays responsibly at Trump and the Republican party in no uncertain terms and adds:

“the pandemic has highlighted about this country — its racial inequitiesits yawning class dividesits toxic partisanshipits hobbled state capacity — it is maddeningly ineducable.”

What is to come according to Wallace Wells:

“In America, it has meant failing once in the spring and now again in the summer, with the prospects increasingly grim for a robust response in the fall, when the pandemic will likely intensify, thanks to the moderate effect of seasonality on coronavirus transmission”

Wallace Wells is no kinder to other Western nations, which according to him showed ‘cultural arrogance’ towards Asia before at least (and unlike the US), changing course and then succeeding (for now) in curbing their SARS-CoV-2 spread (except for Sweden’s cautionary tale).

Looking ahead, it is also starting to dawn on the public that the vaccine will not be a panacea or at least not a quick one:

“while early returns from vaccine studies have been promising, vaccines currently in development promise considerably less than hopeful Americans might think: protection more like the annual flu vaccine, which shields only about 40 percent of the population, rather than an iconic silver-bullet vaccine like the one for measles, mumps, and rubella, which protects 97 percent.”

Like the Gottlieb interview below, the article does not project the optimism that America had accustomed the rest of world of and that it now so badly needs as this pandemic ravages lives and economies globally. American citizens, commentators and experts often appear at a loss, despite promising scientific and therapeutic advances. America is wounded by this pandemic, and the world has yet to fill the leadership vacuum it creates.

Whilst some might rejoice in the failing of a country which they had perceived as arrogant as it continued to push what others had dubbed ‘late stage capitalism’ with its afferent inequities, they have yet to come up with a viable alternative and a better future.

Whilst there is an opportunity for ‘vital action’ as historian Ada Palmer highlighted in her uplifting article in the last edition of the Corona Daily, the emergence of a “post-pandemic Renaissance” remains hard to notice for now.

China was hoping to export its model, while others were hoping to a permanent return to their cherished (but failed) centralised welfare state. One appears still-born particularly following the crackdown on Hong Kong, while the rebirth of the other is more likely to be temporary in nature.

A more promising one is around sustainability, and moving away from a society which creates wants through micro-targeting (Bernays 2.0) rather than caters for needs. It is hard to know whether the current weight of COVID-19 is enough to catalyse the emergence of this more sustainable society, or whether only a further worsening of the pandemic will drive the ‘vital action’ needed to make it a sustained reality.

🛑 Image of day: “87.4% of hospitalised patients has at least one symptom 60 days after being infected”, Tara Smith (Professor infectious disease epidemiology at Kent State) reporting on a paperPersistent Symptoms in Patients After Acute COVID-19” in JAMA.

🇺🇸 Video of the day: A big focus on school reopening and update on the US situation with former Food and Drug Administration commissioner, Scott Gottlieb.

He highlights the dichotomy of strategies between US states given the lack of a coordinated national strategy. North Eastern states privileged a suppression approach in line with Asian and Western Europe, while other states in the South West appear to allow viral spread like the ‘Swedish model’. The latter state are now looking at re-opening schools late-August with large daily infection numbers. Worrisome. (Link)

🇭🇰 Thread of the day: “Second wave starts in Hong Kong” by Ben Cowling (Public Health professor, University of Hong Kong) (Twitter thread).

One of the poster child of initial success in dealing with COVID-19 is now faltering.

More worrying is the concurrent emergence of multiple clusters, and the decision to close schools (will the same happen in the South West of the US in the fall):

Still uncertain how this ‘second wave’ started but Cowling points to case importation and advocates imposing tighter testing and quarantine of people arriving in Hong Kong.

US update:

📈 “US daily report by the COVID Tracking Project”. (Twitter thread).

Excellent daily thread on the US situation: new record number of tests (823k) and of daily cases (67k). As expected death counts are now increasing both nationally and in the hardest hit states:

Also of note is that Florida has finally reported its COVID-19 hospitalisation number for the first time adding 7,000 and bringing the nationwide tally to 51k a number not seen since the first week of May at the height of the New York first case surge.

🧪 Phil Galewitz writes “As COVID Testing Soars, Wait Times For Results Jump To A Week — Or More” for Kaiser Health News. The value of testing is highly dependent on how fast the patient can get its results back to inform him early of the need to isolate. Galewitz tells the story of a University of Arizona student who decided to get tested and self-isolate after attending a Black Lives Matter rally. 22 days later and he still has not received the result.

As the virus accelerates its spread, it stresses the testing capacity, lengthens the results response time and weakens the effectiveness of the test-trace-isolate capacity. It makes the recourse to a lockdown more likely, unless citizens strictly, widely and immediately comply with the 3 Ws: wear masks, watch their distance and continue to wash their hands. (Link)

❗️ “Growing COVID-19 Hotspots in the U.S. South and West will Likely Widen Disparities for People of Color” in Kaiser Health News.

People of color have been disproportionately affected by COVID-19, and they are over represented in the South and West of the US where the epidemic is currently raging (see chart below):

As the authors point out:

“Together the findings point to the importance of prioritizing health equity as part of response and relief efforts and directing resources to communities who are at the highest risk and experiencing disproportionate effects.”

School reopening:

School reopening is getting a lot of coverage particularly in the US with a number of reports and articles on this critical issue. The accelerating growth of the pandemic in some US states has made an already complex issue even more challenging. Everybody wants schools to reopen, and the focus is now on how to do it safely. When you see that Hong Kong is closing schools after an outbreak of around 50 cases, and likely case numbers in the US in August, you get a sense of the size of the difficulty at hand.

Tom Frieden (former director of the Center for Disease Control and Prevention) et al. write “These 8 Basic Steps Will Let Us Reopen Schools” in The Atlantic.

Echoing Bob Wachter in the podcast of the day, they firmly believe that the trade-off must be in favour of reopening:

“We need to reopen schools this fall. But we have to do it carefully. If we move too fast, ignore science, or reopen without careful planning, this will backfire. We can reopen if we follow common sense guidelines.

The 8 practical measures to do it safely detailed in the article are:

Shield the most vulnerable

Reduce risk

Keep the virus out

Reduce occupancy, especially indoors

Reduce mixing among students/staff

Wear masks

Implement new health protocols

Prepare for cases

Resolve to Save Lives (the organisation which Frieden leads) has also written a extensive report on school reopening: “Reopening America’s Schools: A Public Health Approach”.

There is finally a great article (“I’m an epidemiologist and a dad. Here’s why I think schools should reopen”) by Benjamin Linas (associate professor of epidemiology at Boston University) in VOX answering 6 questions on the ensuring safety of kids as they go back to school.

Science, therapeutic and immunity:

🦠 Alessandro Sette and Shane Crotty write “Pre-existing immunity to SARS-CoV-2: the knowns and unknowns” in Nature Immunology Review. This is an important short review in an area which received widespread attention (and misinformation) following the release of their Cell paper on T-Cell based immunity:

“In conclusion, it is now established that SARS-CoV-2 pre-existing immune reactivity exists to some degree in the general population. It is hypothesized, but not yet proven, that this might be due to immunity to CCCs [Common Cold Coronaviruses]. This might have implications for COVID-19 disease severity, herd immunity and vaccine development, which still await to be addressed with actual data.”


💊 “COVID-19 Manufacturing for Monoclonal Antibodies” published by Duke Margolis Center for Health Policy. Monoclonal antibodies are a promising therapeutics alongside or ahead of a first vaccine for COVID-19.

The authors look at the current production capacity for biologics (including monoclonal antibodies) and then propose to build advanced manufacturing capacity in parallel to ongoing clinical trials. Their policy recommendation is aligned with the funding of increased production capacity across the different vaccine platforms currently ongoing and funded by Operation Warp Speed.

A great review and hopefully one whose recommendation will be implemented. (Link)

🦠 W. Joost Wiersinga et al. publish “Pathophysiology, Transmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19)” in JAMA. (Link)

“This narrative review discusses what is currently known about the pathophysiology, epidemiology, diagnosis, management, prognosis, and prevention of coronavirus disease 2019 (COVID-19).”

A great review if you want to know what we know so far at a time when science has made rapid progress and whilst a number of unknowns remain for a still relatively new disease.

🎙 Podcast of the day: UCSF weekly Medicine Grand Round (led by Bob Wachter, Chair of Medicine at UCSF) with its accompanying Twitter thread. (1 hr 28 min)

This week covers update on local/state situation, school reopenings, and the San Quentin prison outbreak.