Speed was the theme of this week’s UCSF Grand Rounds: the speed of peer-reviewed publication, the speed of new drug approval, the speed of vaccine development.
One of the most central issues in this global pandemic is the balance between speed and safety, said Dr. Bob Wachter, chair of the Department of Medicine at UCSF.
“It’s logical and actually even essential to move faster. But just like driving above the speed limit, you may get to your destination faster, but you also increase the risks of an accident. And what we are seeing is a relaxing of the speed limits along with research and COVID,” Wachter said.
Before diving into a panel discussion on the need for speed versus the need for certainty, the now-familiar face of Dr. George Rutherford, UCSF professor of epidemiology and biostatistics, gave viewers an update on coronavirus cases and deaths around the nation. With the U.S. approaching 2 million cases and over 110,000 deaths, Rutherford described a “kind of semi-declining, plateauing … epidemic curve” nationally.
Rutherford described how both in California and the Bay Area, the death rates are lower than one would expect based on population percentages. “I think that’s a testament to not only medical care, but our ability to keep pressures off the ICU,” he said.
Examining trends statewide, Rutherford also noted that protests in the wake of the killing of George Floyd appear not to have resulted in a spike of cases. He pointed to declining rates of COVID-19 in Minnesota and Washington D.C., where protests began about two weeks ago, saying that if there was going to be a spike, the increase would come seven days after protests.
Asymptomatic versus pre-symptomatic transmission
Then Rutherford began the discussion into scientific studies, this time to correct what the World Health Organization called a “misunderstanding” regarding its assertion Monday that asymptomatic transmission was rare.
“We know that people are infectious for a couple of days before they develop symptoms,” said Rutherford, explaining the confusion between those who haven’t presented symptoms yet (pre-symptomatic) and those who don’t present symptoms at all when infected (asymptomatic).
“This [infecting others before showing symptoms] is not a rare phenomenon,” he said, clarifying that, “you can think of people with symptoms as being more infectious because they cough and sneeze.” Masks are meant to cut down transmission from those who are not presenting symptoms. “The conclusions here,” Rutherford said, referencing several studies, “are asymptomatic and pre-symptomatic infections are very real and they’re very common. And the solution is to wear your mask.”
The speed of sharing
The WHO isn’t the only source of authority that has made mistakes when sharing information with the public about COVID-19.
Several of the panelists described the stress that has come with the need-for-speed approach of peer-reviewed journals that attempt to publish important coronavirus research as more and more unreviewed pre-print research is shared via Twitter and traditional media outlets.
“Just about every COVID submission comes with the request to have it reviewed yesterday and published last week,” said Dr. Rita Redberg, cardiologist and editor of JAMA Internal Medicine, a journal of the American Medical Association. “We’re of course still trying to maintain our mission, but it is hard to ignore the pressure that everyone feels to get important things out there to help people.”
Redberg described an oversaturated situation in which journals are receiving three times the amount of submissions with fewer staff and the need for faster turnaround time in the peer-review process.
Striking the balance between speed and urgency has been a difficult one, and it has not come without mistakes. The Guardian reported June 4 that The Lancet, one of the oldest and most well-known peer-reviewed medical journals, retracted a study regarding the harmful effects of hydroxychloroquine for COVID-19 treatment after inconsistencies were found in the data. Several hydroxychloroquine studies, halted immediately after the paper was published, have since restarted.
Dr. Vinay Prasad, associate professor of medicine at UCSF and author of Ending Medical Reversal and Malignant: How Bad Policy and Bad Evidence Harm People with Cancer, also raised criticisms of several pre-print studies (which haven’t undergone peer review) that provided misleading information about the coronavirus. He discussed one study from researchers at Stanford that was picked apart on Twitter after it projected that the fatality rate for COVID-19 was much lower (between .12 and .20 in the US), making it similar to the flu.
Prasad said he found some of the criticism fair, but also believes that part of the reason the study was so heavily scrutinized online was because the authors had previously questioned the importance of shelter-in-place. Some conservative commentators and media figures began to discuss the study, politicizing the study — something that is not unfamiliar in the midst of COVID-19.
Politics and the need for science-based decisionmaking
Rutherford shot down claims that the virus was getting weaker, and also expressed concern for proposed political conventions and rallies.
“The virus doesn’t watch TV, it doesn’t watch FOX, it doesn’t watch CNN. You know, it doesn’t read the paper, it doesn’t listen to what everybody is doing . . . It has one purpose in life, and that’s to reproduce in you,” he said, emphasizing the last word. “And I think the more you wrap your head around that, the safer we’ll all be.”
“It will go to political conventions,” said Rutherford.
One more issue that Wachter feared could get political is the fast-tracked approval and use of a coronavirus vaccine without conclusive evidence — a likely possibility, said Dr. Rob Califf, director of Medical Strategy and Policy at Google and former Commissioner of the US Food & Drug Administration.
Wachter noted that “Sometime in the next four to six months, the FDA is going to be presented with data on vaccines.” He asked Califf his thoughts on the possibility that the FDC Commissioner could have a large say in the decision to green light a vaccine.
“If it’s a clear cut decision one way or another based on science, there should be no place for politics and the commissioner should protect the scientific decision,” Califf said. “But if it’s in the gray zone and someone has to make a decision and it’s not a purely scientific decision, I don’t see a way around it [having the commissioner make a decision]. And, you know, I think in that case, the commissioner really, I think will have a vital role to play.”
None of the other panelists relished the idea of making such a decision when the time comes. Luckily for them, they won’t have to.
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I have a great deal of respect for UCSF and for George Rutherford, who has a job of spokesperson deserving of understanding, and pity. Yet, in town halls, and grand rounds, he has on occasion made some comments which seem to come out of the blue. For example, saying that the solution to pre-symptomatc and asymptomatic transmission is to wear masks, which once again undermines the need for physical distancing, testing, tracing and quarantine. I understand he has great faith in face coverings, but he should provide some backup for such comments, as almost everyone, pro and anti maskers, agree that face coverings (not N95 respirators or surgical masks) in community settings are meant to supplement, not supplant physical distancing. And today he says any increase in cases coming from last week’s protests would have come seven days afterwards. Where does 7 come from? People who have been in contact with a positively tested person (symptomatic or otherwise) are advised by the CDC, WHO and most everyone other than the Trump campaign, to self-quarantine for 14 days. Is there something about the protests being outside that cuts the time in half? Were they all wearing N95 respirators? Is there “new science” which supports 7 days as opposed to 14? Note: I was at the Mission rally in DP nine days ago wearing a bandana — I hope he’s right.
@mark Rabine You are putting words in George Rutherford’s mouth. You need to reread what was printed. He said nothing about quarantine. “…if there was going to be a spike, the increase would come seven days after protests.”
Symptoms start to show at about the 7 day mark in some people