We’re a long way from an effective treatment for COVID-19. That means going to see a Warriors game is unlikely to happen in the next year and, when the city begins to reopen, it will happen on a rolling basis. New outbreaks will be controlled by ramped-up testing and contact tracing, including ample testing in neighborhoods like the Mission District that have populations disproportionately affected by COVID-19.
These were among the myriad of topics that a group of UCSF doctors and specialists discussed during Thursday’s 90-minute grand rounds — an ongoing event for its medical staff that has increasingly become popular viewing for civilians. We offer our summary, but you too can tune in on Thursdays at noon or watch it later on YouTube.
In a manner that is both cordial and straightforward, Dr. Bob Wachter, chair of the Department of Medicine at UCSF, introduced, questioned and moderated the UCSF team. He began with a surprise video visit from Dr. Tomás Díaz, one of the 20 UCSF doctors and medical staff who volunteered to assist in New York, where more than 30,000 residents have been hospitalized and 7,563 have died.
Diaz described a scene at Weill Cornell Hospital in Manhattan with some 200 patients on ventilators. To put that in contrast, Wachter said, UCSF has four patients on ventilators and ZSFG has 10 or 11. “The idea of a couple of 100 is remarkable,” Wachter said, referring to the demands on a hospital’s staff.
Overview: CA is doing well, and what reopening might look like
Dr. George Rutherford, a professor of epidemiology and biostatistics, opened grand rounds with an overview of the pandemic starting with the world map — showing the virus largely sparing Africa and much of South America — and zeroing in on the U.S. map where he described the three weeks in March as “a huge, colossal disaster.”
California, however, benefited from swift action and political leadership, he said.
“You can see how relatively flat our curves are looking,” he said, adding that for San Francisco, Sunday may have represented “the apex” of acute and ICU bed use, with 92 patients total.
He pointed out the anomalies in the data: At least 42 percent of San Francisco’s cases are in patients 40 years or younger, and Latinx residents are disproportionately represented among diagnosed cases, representing 24 percent of the cases, compared to 16 percent of the city’s population.
Rutherford stressed the importance of the Department of Public Health’s and UCSF’s stepped-up contact tracing project to find and isolate COVID-19 positive residents – a project that will become key in preventing new outbreaks once the city re-opens.
“The next phase sounds more complicated,” Wachter interjected asking Rutherford if he saw the parsing of businesses and segments of the population that got to be first to resume work.
“If it was my decision, I would be parsing,” said Rutherford. “The last thing we need is a big outbreak with lots of mortality.” He envisioned opening gradually, perhaps in the first quarter with manufacturing and construction, followed by retail, entertainment and finally those who have been able to telecommute easily.
“I fully expect everyone to wear masks,” in the reopening, he said.
Pro sports? “I just can’t see it … certainly not with spectators.”
Later in the lecture, Rutherford said that schools might be on staggered schedules and restaurants may have fewer chairs. How you reopen can be done in many different ways, he said. Italy re-opened by professions. In terms of retail, book and stationery stores went first in Italy. A mark, he said, of “a literate country.”
Dr. Kirsten Bibbins-Domingo, a professor of epidemiology and biostatistics at UCSF, showed slides clearly indicating a higher prevalence of outbreaks in minority populations across the country. “In New York, you see the fatality rates with Latinx and African Americans at twice the rates” of their representation in the population, she said.
In San Francisco, the Latinx population represents 24 percent of the cases and only 16 percent of the population. She said the figures represent pre-existing disparities, but with more data they may also find such factors as a lack of effective messaging and test availability.
“We are seeing a huge outbreak in the Latinx population,” she said. “Those individuals are not technically homeless, but living in crowded housing, and the same dynamic is at play.” They are working every day as front-line workers and then returning to crowded housing situations and that means they are “more vulnerable to bad outcomes.”
A solution, she said, would be to do much more testing. The Mission Neighborhood Health Center recently opened a testing center for patients with symptoms. Doing more proactive, aggressive testing, Bibbins-Domingo said, could help prevent the spread of COVID-19.
“I think we have always known that homeless shelters were going to be a tinderbox,” said Dr. Margot Kushel, a professor of medicine. She supported the strategy to get people into hotels as fast as possible and prioritizing the most vulnerable. At the end of the session, calling herself “a glass-half-full kind of person,” she saw hope.
“If we can move thousands of people indoors at a time when the government is under financial constraints, then we can certainly do this in better times,” she said. She saw some excitement at the state level about making some of these transitions permanent and perhaps acquiring properties with new federal funds.
Remedies and a Vaccine
Dr. Annie Luetkemeyer, a professor of medicine at UCSF and the principal investigator in the clinical trial of remdesivir, an antiviral medication developed by Gilead Sciences, walked us through some possible remedies being tested, including plasma from residents who have survived the virus, remdesivir and hydroxychloroquine and chloroquine, Donald Trump’s favorites.
Her summation: After limited testing “we have no idea if” hydroxychloroquine and chloroquine work, and there are indicators of downsides, especially in heart patients. “Because we can give it, doesn’t mean that we have to give it,” she said, recommending an honest conversation with the patient before deciding to use it.
Remdesivir is still in trials, and can only be administered intravenously and only for compassionate use. It may be worth trying, she said, but they do not yet know if it works. Convalescent plasma, which is in trials, “doesn’t appear to be hurting people. We need more information,” Luetkemeyer said.