UCSF Grand Rounds moderator and Department of Medicine chair Bob Wachter summed up the biggest challenges regarding the ongoing Covid-19 pandemic in the introduction of Grand Rounds by paraphrasing Charles Dickens.
“This continues to be the worst of times, but the promise of the best of times is tantalizingly close,” Wachter said. “We are probably a week or two away from having two remarkably effective vaccines available for use, and yet 2,800 Americans died of Covid-19 yesterday, nearly two a minute.”
With the U. S. coronavirus death toll now equivalent to Orlando’s population — almost 275,000 — Wachter took up two important questions: the “brutally difficult” decisions about reopening or shutting down schools, and how vaccines will be distributed when they become available.
But first, UCSF professor and Epidemiology and Biostatistics Dr. George Rutherford updated viewers with the latest information on how we’re doing at the local and national level. The short answer is: not well.
“The cases in the United States are far, far, far from out of the blue,” Rutherford said, noting that we are “deeply into the third phase.” And that phase is a wave of infections.
Though there appears to be a dip in recent days on the graph, Rutherford said that this could be a result of people not yet getting tested after the long weekend following Thanksgiving. Cases, it’s clear, “continue to rise explosively across the country.” More than 100,000 people were hospitalized for Covid-19 across the country on Wednesday, with a four to seven-day moving average of 94,000 people hospitalized per day. That, Rutherford noted, was almost twice as high as the first and second waves.
In California, there are almost 1.3 million cases, 100,000 of which were diagnosed in the last seven days, and a 7.3 percent positivity rate, but the real source of anxiety is diminishing intensive care unit capacity. Rutherford said the government was “pushing alarm bells” on Monday as only 1,810 ICU available beds remained in the state, with projections that hospitals statewide will be over ICU capacity by Dec. 24.
As a result of these predictions, Governor Gavin Newsom announced several new restrictions today, including a three-week shelter-in-place for regions where the ICU availability is at 15 percent or less. Currently, one region is “on the precipice” of this shutdown, according to Erica Pan, state health officer and deputy director of the Department of Public Health’s Center for Infectious Disease. One exception to the shutdown is schools. Pan said the state government is “doing everything it can to keep schools open in California,” noting little evidence of transmission in schools, though there is still concern that schools may choose to shut their doors on their own.
Most of the Bay Area’s public schools remain online, but many private schools have been open for more than a month.
What should schools be doing?
Brown University Professor of Economics Emily Oster’s short answer was: open kindergarten through fifth grade for in-person learning five days a week, with masks, and let parents decide if they want their children to attend.
Oster, whom Wachter called “one of the leading experts of the country on these issues,” came to her conclusion while working on the ongoing COVID-19 School Response Dashboard, a project that tracks and publicly shares data on coronavirus cases in elementary, middle and high schools.
The project examines schools across the country on a voluntary basis, tracking how many children are at each school, mitigation strategies that are being taken to prevent the spread of covid, and how many covid cases there are every two weeks.
In the most recent biweekly wave, from early to mid-November, the daily student case rate per 100,000 students was 18, or around 1.5 students in a school with a student population of 1,000. Staff had a daily case rate of 34 per 100,000 in the same period.
There are around 3.1 million enrolled students being recorded in the project, with 1.5 million of them attending in-person school. The 3.1 million represent about 5.5 percent of the country’s total K-12 school population.
The project has three goals: to create a generalizable review of risk, to see how school rates of covid compare with community rates, and to understand how mitigation efforts impact covid rates in schools for creating plans to reopen. If schools are contributing to the spread of covid, the case rate in schools would likely be higher than the community rate. If schools are not a site of spread, Oster said, the case rate in schools should be similar to the community case rate. Currently, the community case rate associated with the schools being monitored is 29 per 100,000.
Data from New York, where all schools are required to share their information, indicates that staff and high school student rates of covid line up with community rates, while elementary and middle school rates are “significantly lower.” Oster attributes these lower rates to strong evidence that younger children are less prone to infection.
Comprehensive data from Texas, however, indicated that school staff are at a higher risk than the community.
Other schools that had a higher risk than their communities were, predictably, schools that did not mandate student mask use. Interestingly, case rates drop among students as the density of students attending in-person school rises, something Oster believes needs to be further examined.
In response to Oster’s presentation, Rutherford noted the “gathering consensus that teachers represent essential workers” and may be considered in tier 1B for vaccination.
How is California preparing for vaccine rollout?
Pan began her presentation by noting that “we’ve done an amazing job in California, but we could not escape our borders.” However, she noted that the vaccine is “the light at the end of our tunnel.”
Working within a background environment of vaccine hesitancy and the politicization of health measures, Pan said the state’s priorities are the vaccine’s efficacy and safety. California has developed a Scientific Review Workgroup with Nevada, Oregon and Washington that will meet within 24 hours of the Food and Drug Administration’s approval of any vaccine. However, Dr. Paul Offit, a University of Pennsylvania pediatrician who specializes in vaccine development, advised in Grand Rounds on Nov. 19 that states should not form their own advisory committees, noting that splintering is “too chaotic,” and that the FDA and CDC should be trusted.
previous grand rounds coverage
There is also a Community Vaccine Advisory Committee with individuals such as teachers, nurses, and members of communities of color to provide advice to the state and create trust.
Additionally, the state is working on a Prioritization Framework Allocation Plan to consider federal guidelines around vaccine distribution, especially those for phase 1A (healthcare workers and those in long-term residential facilities) and phase 1B (other essential workers).
“Our three key values are safety, equity, and transparency, and we are trying to make sure we incorporate those into everything we do,” Pan said. She believes the communications campaign is one of the biggest challenges.
California has been selected to engage in microplanning with the Centers for Disease Control and Prevention and the Department of Defense for vaccine distribution. The state is expecting to receive 300,000 doses of the vaccine from the federal government, though Pan noted that these numbers sometimes change. Luckily, the state has extensive experience in mass vaccination for H1N1 in 2009, Hepatitis A outbreaks in the housing-insecure population, and the annual flu vaccine.
Pan said that, every year, tens of millions of routine vaccines are given in California, 90 percent of which take place in clinical settings. While the government helps with the allocation of vaccines, shipment of vaccines is handled directly by the distributors.
She explained that the distribution will be a trickle, as allocation of 300,000 doses in a state with over two million healthcare workers and a population of 40 million will require “tough decisions” from local health departments and healthcare systems.
Initially, 300,000 people will receive their first dose of the vaccine, and two to three weeks later those same individuals will receive their second. The federal government will continue to send doses in the weeks following. As time goes on, access will expand to essential workers and other members of the population. Overall, Pan expects California will receive about one million doses by the end of the year.
Desi Kotis, UCSF’s chief pharmacy executive, expects UCSF will receive the vaccine in the next few weeks; it’s been pre-approved for the Pfizer vaccine and is anticipating the Moderna vaccine. The Pfizer vaccine is going to the FDA for Emergency Use Authorization approval on Dec. 10, followed by Moderna on Dec. 17. UCSF has been collaborating closely with the city’s and state’s public health departments.
The Pfizer vaccine is “very precarious to store and distribute,” Kotis said, but UCSF currently has storage for “way over a half a million doses” in its San Francisco facilities alone.