Dr. Tom Frieden Blog: Covid Epidemiology

A weekly summary of the latest developments.

January 11: 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. Dr. Craig Spencer provides a vivid portrayal of these challenges here.

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.

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

December 21, 2020

Covid Epi Weekly: First Sighting of Vaccine-Induced Immunity

Imagine you’ve been on a dangerous sea voyage. One of 200 people over the age of 65 have perished as have many others. Safe land is sighted in the distance. Everyone on board must do everything possible to reduce deaths until safe harbor is reached.

At this stage of the pandemic, we’re facing a tale of two realities. On one hand, the U.S. is experiencing the worst spread of Covid since pandemic started. Cases, hospitalizations, and deaths continue to set records. At the same time, the rollout of highly effective, safe vaccines has given us the most hope we’ve had for a beginning of the end.

First, let’s discuss the latest epidemiology. It’s great that CDC and HHS have FINALLY been allowed to release some of the information they have. This information belongs to the public, not to anyone in Washington. It’s 10 months late, but the headline says it all.

Unfortunately, what the data shows is NOT great. Every U.S. region and most counties for which there are data are at the highest level in terms of case incidence — more than 200 cases per 100,000 a week. That’s about six times the rate at which we figured contact tracing would be hard or impossible.

Counties across the US are sustained hotspots, meaning there is a high case burden and a risk of overwhelming health care systems. Here’s the point: the longer you delay closures, the longer you have to keep things shut, the higher the risk of overwhelmed ICUs, and the more people die.

Hospital beds are being filled by Covid patients. There were 156,000 admissions in the past week and there are more than 113,000 people currently hospitalized. Cases are still increasing, and a further increase in hospitalizations will follow. Note the increase after Thanksgiving in most regions.

This post-Thanksgiving bump is evident in cases and test positivity. With December holidays coming, it’s best to celebrate at home. When people travel, the virus travels. When people share air, the virus spreads. Not every state had a bump — protection protocols save lives.

Now that this CDC and HHS information is finally public, it’s clear what’s happening. There are very high rates in most of the country, but much of the country has seen decreases over the past week, particularly the Upper Midwest. The Thanksgiving surge is ebbing, just in time for the next holiday surge. Tennessee has become a new hottest spot: deeply red, deeply concerning.

It’s worth focusing on the graphic below, which gives a sense of both test positivity and trend. States all over the map are … all over the map. Some states are high and increasing, some are high and decreasing, some are staying high, and some are staying low. Hawaii, Vermont, and Maine are the Covid-safest places in the United States to be today.

Farewell and thanks to Covid Exit Strategy, which provided excellent data and visualizations of the state of the pandemic in the US. Welcome Covid Act Now, which will be taking its place. However, if CDC and HHS continue to improve their data sharing, these sites — and this weekly thread! — will become unnecessary. (I’d like that a lot!) Communication, based on facts, is an essential weapon to fight the pandemic.

Now for the view of the safe harbor — vaccine-induced immunity. It’s coming, but there will be barriers: production, distribution, adverse events, uptake, and more. It won’t be fast or easy, but it will happen. Two authorized vaccines are good, four authorized vaccines will be better. More are coming next year.

Production is a big unknown. Johnson & Johnson is the only company that has extensive vaccine production experience of the first four companies likely to have a vaccine. We can expect adverse events -- some related to vaccines, some not. Complete transparency and immediate communication are both essential.

There’s not enough vaccine now, so we MUST do better protecting the most vulnerable. There have been horrific outbreaks and deaths in nursing homes, the grim harvest of misguided advice to let infections spread among young people. Monoclonal antibody treatment must be scaled up fast. It’s simply inexcusable that this isn’t happening.

It’s misguided to debate whether the elderly or essential workers should get vaccinated first. Essential workers who are more likely to be infected and die (for example, a bus driver with diabetes) should also be at the front of the line. But an 85-year-old is at massively higher risk than a 65-year-old. Granularity can help de-conflict. ACIP guidelines released over the weekend are sensible and thoughtful; key will be fair and effective allocation. The beginnings of would could be one encouraging example from Tennessee.

Outbreaks and deaths among incarcerated people continue. Sensible decarceration is a public health and ethical imperative. A prison sentence shouldn’t be a death sentence.

We’ve made some progress on global vaccine access -- potentially 2 billion doses will be made available to countries through COVAX. More doses, more money, and more support for vaccination programs are all needed. Ironically, many countries last on line for the vaccine have vaccination systems that are best able to deliver it.

It’s literally now or never to fix public health at local, city, state, national, global levels. If this isn’t a teachable moment, there will never be one. Vaccination may end this pandemic, but not the risk of pandemics. Money, technical capacity, and operational capacity are all needed.

We must work together to make 2021 the year the world got serious about preventing pandemics.

So we come to the end of my last weekly analysis of this awful year. We’re in this world together. Those who die diminish us all. Those who build community strengthen us all. Seasons and years pass.

What could possibly be more important than preventing disability and death?

“As are generations of leaves, so are those of humanity.

The wind scatters leaves on the ground, but the trees burgeon

With leaves again when the spring season returns.

So one generation of people will rise while another dies.”

Homer, The Iliad

December 14, 2020

Covid Epi Weekly: First Sighting of Vaccine-Induced Immunity

Imagine you’ve been on a dangerous sea voyage. One of 200 people over the age of 65 have perished as have many others. Safe land is sighted in the distance. Everyone on board must do everything possible to reduce deaths until safe harbor is reached.

At this stage of the pandemic, we’re facing a tale of two realities. On one hand, the U.S. is experiencing the worst spread of Covid since pandemic started. Cases, hospitalizations, and deaths continue to set records. At the same time, the rollout of highly effective, safe vaccines has given us the most hope we’ve had for a beginning of the end.

First, let’s discuss the latest epidemiology. It’s great that CDC and HHS have FINALLY been allowed to release some of the information they have. This information belongs to the public, not to anyone in Washington. It’s 10 months late, but the headline says it all.

Unfortunately, what the data shows isn’t great. Every US region and most counties for which there are data are at the highest level in terms of case incidence — more than 200 cases per 100,000 a week. That’s about six times the rate at which we figured contact tracing would be hard or impossible.

Counties across the US are sustained hotspots, meaning there is a high case burden and a risk of overwhelming health care systems. Here’s the point: the longer you delay closures, the longer you have to keep things shut, the higher the risk of overwhelmed ICUs, and the more people die.

Hospital beds are being filled by Covid patients. There were 156,000 admissions in the past week and there are more than 113,000 people currently hospitalized. Cases are still increasing, and a further increase in hospitalizations will follow. Note the increase after Thanksgiving in most regions.

This post-Thanksgiving bump is evident in cases and test positivity. With December holidays coming, it’s best to celebrate at home. When people travel, the virus travels. When people share air, the virus spreads. Not every state had a bump — protection protocols save lives.

Now that this CDC and HHS information is finally public, it’s clear what’s happening. There are very high rates in most of the country, but much of the country has seen decreases over the past week, particularly the Upper Midwest. The Thanksgiving surge is ebbing, just in time for the next holiday surge. Tennessee has become a new hottest spot: deeply red, deeply concerning.

It’s worth focusing on the graphic below, which gives a sense of both test positivity and trend. States all over the map are … all over the map. Some states are high and increasing, some are high and decreasing, some are staying high, and some are staying low. Hawaii, Vermont, and Maine are the Covid-safest places in the United States to be today.

Farewell and thanks to Covid Exit Strategy, which provided excellent data and visualizations of the state of the pandemic in the US. Welcome Covid Act Now, which will be taking its place. However, if CDC and HHS continue to improve their data sharing, these sites — and this weekly thread! — will become unnecessary. (I’d like that a lot!) Communication, based on facts, is an essential weapon to fight the pandemic.

Now for the view of the safe harbor — vaccine-induced immunity. It’s coming, but there will be barriers: production, distribution, adverse events, uptake, and more. It won’t be fast or easy, but it will happen. Two authorized vaccines are good, four authorized vaccines will be better. More are coming next year.

Production is a big unknown. Johnson & Johnson is the only company that has extensive vaccine production experience of the first four companies likely to have a vaccine. We can expect adverse events -- some related to vaccines, some not. Complete transparency and immediate communication are both essential.

There’s not enough vaccine now, so we MUST do better protecting the most vulnerable. There have been horrific outbreaks and deaths in nursing homes, the grim harvest of misguided advice to let infections spread among young people. Monoclonal antibody treatment must be scaled up fast. It’s simply inexcusable that this isn’t happening.

It’s misguided to debate whether the elderly or essential workers should get vaccinated first. Essential workers who are more likely to be infected and die (for example, a bus driver with diabetes) should also be at the front of the line. But an 85-year-old is at massively higher risk than a 65-year-old. Granularity can help de-conflict. ACIP guidelines released over the weekend are sensible and thoughtful; key will be fair and effective allocation. The beginnings of would could be one encouraging example from Tennessee.

Outbreaks and deaths among incarcerated people continue. Sensible decarceration is a public health and ethical imperative. A prison sentence shouldn’t be a death sentence.

We’ve made some progress on global vaccine access -- potentially 2 billion doses will be made available to countries through COVAX. More doses, more money, and more support for vaccination programs are all needed. Ironically, many countries last on line for the vaccine have vaccination systems that are best able to deliver it.

It’s literally now or never to fix public health at local, city, state, national, global levels. If this isn’t a teachable moment, there will never be one. Vaccination may end this pandemic, but not the risk of pandemics. Money, technical capacity, and operational capacity are all needed.

We must work together to make 2021 the year the world got serious about preventing pandemics.

So we come to the end of my last weekly analysis of this awful year. We’re in this world together. Those who die diminish us all. Those who build community strengthen us all. Seasons and years pass.

What could possibly be more important than preventing disability and death?

“As are generations of leaves, so are those of humanity.

The wind scatters leaves on the ground, but the trees burgeon

With leaves again when the spring season returns.

So one generation of people will rise while another dies.”

Homer, The Iliad

With the first doses delivered this morning, the first step on the road to immunity through vaccination has been taken. At the same time, we’ve seen a deeply discouraging lack of action to stop the pandemic. The coming weeks will be devastating, but I fear that numbness to suffering is spreading as rapidly as the virus.

First the good news. The FDA has provided good transparency about vaccines and the data is about as good as could be. The vaccines are highly effective, including for older people (though few frail elderly were included in the studies), and against severe infection. We haven’t seen any serious adverse events, but we need to track for this when millions are vaccinate

The road ahead for vaccination will be bumpy. Production, supply, distribution, uptake, and possible adverse events—all present potentially huge challenges. New vaccines from other companies will likely be approved in the New Year. The vaccination campaign will be an enormous challenge, but if the communication is done well, it can succeed.

Unfortunately, we’re not there yet. It will be months before most people can get vaccinated. We must double down on protection protocols. The post-Thanksgiving surge is driving rates up, and December holidays could bring new horrors at the start of 2021. I fear we are numbing to the numbers.

Cases continue to increase, hospitalizations are at highest rate ever, and deaths are continuing to hit new highs. It’s horrifying to see a 13% test positivity rate nationally, with 40 states reporting positivity rates greater than 8%. Although cases in the Midwest are coming down, they’re still very high, and cases are increasing almost everywhere else.

It gets worse. Covid has exposed horrific disparities. In Rhode Island, more than 1 in 8 Hispanic/Latinx people has tested positive, which is nearly 4x the rate among white people (1 in 31). In the Dakotas, 1 in 8 Black people has tested positive. In South Dakota, 1 in 7 Native Americans has tested positive.

Global disparities will worsen in 2021. Countries in Africa have fragile health systems that can be quickly overwhelmed by Covid. As vaccination rolls out in richer countries in 2021, will healthy people in the US get vaccinated before health care workers and nursing home residents in Africa? That would be indefensible. There are just a few million health care workers in Africa. They should be at the front of the global line — there’s already a terrible shortage of health care workers on the continent.

As 2020 draws to a close, the next few months will determine our future. These are some of my takeaways from a year of horrors:

  • We must remember that public health is fundamental to society

  • Science is as vulnerable to politics as humans are to viruses

  • We will look back and ask why we didn’t do more.

  • We can control our health, but only if we work together. (Look at the enormous difference cooperation makes — see the two graphs below.)

We just released materials to promote safer holiday celebrations. By being careful now, we’ll have more to celebrate and less to regret in the new year. Being in a bubble or pod is an important concept, but each bubble is only as strong as its weakest part.

As German Chancellor Angela Merkel said, patience, discipline, and solidarity are key. These three characteristics are essential for a successful response. We are inextricably connected. Empathy gives us the sense of others’ suffering, joys, and losses.

“The death of human empathy is one of the earliest and most telling signs of a culture about to fall into barbarism.” — Hannah Arendt

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