A Tweet Thread by Bob Wachter @Bob_WachterChair, UCSF Dept of Medicine. Career: What happens when a poli sci major becomes an academic physician. Author: “The Digital Doctor”. Hubby/Dad/Golfer.San Franciscomedicine.ucsf.edu

Covid (@UCSF) Chronicles, Day 495 When I began my tweets 494d ago, it was before we had reliable local, US, or world data. So I focused on data from @UCSFHospitals. Today, we’re awash in data, yet I find my hospital’s data still provides a unique lens into our situation.

So today, a few data points from @UCSF, with my interpretation. They reinforce the case that the combo of Delta & relaxed behavior is leading to a powerful & worrisome upsurge that requires a change in approach. I knew things were bad, but it’s even worse than I thought. What’s particularly noteworthy about @UCSF experience is that it’s in a city w/ the nation’s highest vax rate. And cases are rising fast in our employees, of whom 93% are vaxxed. (Special thanks to Ralph Gonzales, Bob Kosnik & @saramurrayMD for some of the data.)

Here goes:Let’s start w/ context: in SF, 69% of all people (76% >age 12) are fully vaccinated. (Vs CA, 52% of population; U.S. 50%.) So the surge in SF is especially sobering, since it indicates that we’ll need an immunity rate far higher than 70-75% to achieve “local” herd immunity. Let’s look at hospitalizations. On June 1, we had one Covid patient in our ~700-bed @UCSFHospitals (we never quite got to zero); none were in the ICU. Today we have 28 hospitalized pts @UCSFHospitals: 15 on the floor & 13 in the ICU (7 on vents). A staggering increase.

I don’t have the vaccinated/unvaxxed breakdown for today’s census, but it’s been running >90% unvaxxed in recent wks. When we do see vaccinated patients in the hospital, many are immunocompromised (a group in which vaccine’s effect is attenuated – we need a new approach). My interpretation: even in a city with very high vaccination levels, serious cases have skyrocketed, mostly in unvaccinated people. Now think about what will happen in a region in which 60-70% of the population is unvaccinated, not SF’s 25-30%. Really scary stuff.

In April, I wrote @washingtonpost that “this is the most dangerous moment to be unvaccinated.” https://washingtonpost.com/opinions/2021/04/19/this-is-most-dangerous-moment-be-unvaccinated/…. I was wrong – now is even MORE dangerous since Delta has taken over, caution’s been thrown to the wind, and there’s far more virus around.

How much virus is around? Since early in the pandemic, I’ve used a piece of data available @UCSF to estimate the chances that a person who feels well in SF is carrying the virus. It’s our “asymptomatic test positivity rate” and it comes from the fact that we test all our hospitalized & ED patients who have no Covid symptoms, as well as people undergoing surgeries or procedures like cardiac caths. That fraction was as low as about 0.1% in early June – which was pretty reassuring – it meant that the chances that person near you in a SF store had asymptomatic Covid was ~1-in-1000. Today, it’s 2.14%! So now that asymptomatic person has a ~1-in-50 chance of being positive. (And this % may be an underestimate since our pts are older than avg, a group with a higher vax rate).My interpretation: the risk of getting Covid is related to your vax status, whether you’re taking steps to lower risk (masking, etc), & whether you’re exposed to the virus. Even in highly vaccinated SF, the odds of being exposed have gone up ~ 20-fold since June 1.

The point’s been made that, if everybody’s vaccinated, all infections will be in vaccinated people (even if vax efficacy stays high). Among @UCSF students/employees, we’re not at 100% but we’re close: 32,550 of our 35,018 people (93%) are vaccinated. (Mandate starts 9/1.)Given this vax rate, it shouldn’t surprise that 83% (77/93) of our July cases are in vaccinated folks. This DOESN’T mean vax isn’t working – calculated efficacy from these data is 82%. We’d expect 422 cases in our vaccinated population, not 77, if the vaccine didn’t work.

At least @UCSF, we see no evidence that efficacy is waning: no case uptick in those vaxxed in Dec-Jan vs. more recently. And the vaccines are still >90% effective in preventing severe illness: only 1 these 77 breakthrough infections required a (brief) hospitalization. Taken together, it’s clear that – even in highly vaccinated SF; it’s also a city in which people remained pretty careful despite relaxed rules – we’re experiencing a unmistakable surge. The vaccines work great, but, as we now appreciate, they don’t prevent all infections.

Even w/ surge, we’re not overwhelmed @UCSF, thanks to vaccines. Scary to consider regions where vulnerable % is much higher. I’m glad the U.S. is finally seeing an uptick in vaccination, but it won’t help for a month (since vax efficacy of dose 1 against Delta is so low).

As @DrLeanaWen convincingly argued @washingtonpost, it’s time to add back restrictions, esp. indoor masking. https://washingtonpost.com/opinions/2021/07/20/pandemic-has-changed-course-again-biden-administration-urgently-needs-do-same/… As for me, it’s back to double-masks indoors & N95s on planes. And sadly, that’s it for indoor dining for a while. None of this pleases me.

.Along with renewed restrictions, it’s clear that gentle persuasion did not achieve the vax rate we need to defeat Covid. Yes, the politics are hard, but dying is worse, as is re-tanking the economy. It’s time for vaccine mandates – nothing else gets us where we need to go.

“Baseball is like church. Many attend few understand.” – Leo Durocher

Last weekend, we watched grandson Auggie play baseball in a tournament at the Twin Creeks Sports Complex in Sunnyvale. He plays on a team – club? – named the FPs, for Future Prospects (which seems to show a sense of ironic humor that I didn’t have at thirteen). Another team was named Cali and, when I asked Auggie where they were from, he answered, “uh, California”. The kids had had four games over two days and were exhausted. They won their first three games and lost their last – which was the only game we saw, but it was great to see Auggie play.

One thing that I was struck by is that baseball played by 13-year olds is much closer to professional baseball than any other sport I can think of. Watch 13-year olds play basketball or football – either kind – and there is a major difference from the pros, but baseball, not so much. That is not to say that baseball is easy, it takes incredible coordination, more so than football and I do not know enough about baseball to catch the nuances but when a kid hits a deep fly ball, it will probably be caught. Early in the game, while Auggie was playing third base, the batter hit a line drive between third and second. Auggie took a big step, caught the ball, and threw the batter out at first. I think I may have been the only one who was impressed.

Next week the team goes to Aspen for another tournament which we will not see (duh!). In the meanwhile, Charlotte spent a week at a surfing camp in southern Mexico. Then, this week, she goes to a Soccer tournament in San Diago.

When I was a teenager, there were no tournaments like this, we had to stay home and entertain ourselves or, in my case, get a summer job after about sixteen. I talk to some people my age and they tend to glorify the entertain yourself aspect and worry, loudly, that kids are losing some sort of ability to self entertain (it goes along with “they use their smartphones too much”). That is not how I remember it. I remember a summer that was pretty boring and definitely could have used some organized sports to spice it up.

Malm observes that, measuring by capacity, 49 percent of the fossil-fuel-burning energy infrastructure now in operation was installed after 2004. Ezra Klein in an opinion piece entitled It Seems Odd That We Would Just Let the World Burn in the New York Times.

We are not in a drought; drought implies, at the very least, that this lack of water is temporary which this isn’t. This is the new normal isn’t really accurate either because this – whatever you want to call it – isn’t stable. It is getting hotter and the climate is changing, almost imperceptibly, every year. The new normal is a moving target. It seems to me that most people, certainly most people in a position to influence policy, are still treating what is happening as an anomaly. This leads us to cheap and temporary solutions – or, often, no solutions because it will get better- rather than long-range solutions that really deal with the problem. And this isn’t just in California, it is the entire West.

Lake Mead is down 140 feet from normal and is only at 35% of full capacity. Last year, the Colorado River basin got about 80% of normal precipitation but only about 30% of normal got to the lake. The rest was lost to parched ground and evaporation due to the increase in heat. For me, the scariest stat I’ve read so far is that the July snowpack in the Sierras is 0% of normal. The population of California is 39.7 million and the land can’t support that. Maybe we will be able to adapt, to change our infrastructure – like building desalination plants and covering reservoirs to start with – in a way that will allow all of us to live here. But so far, nobody seems to be running for office on that.

The Champlain Towers South collapsed a couple of weeks ago and it pushed everything off the front page. To me, that seemed sort of ghoulish and exploitative. Yes, it was a tragedy and I don’t want to downplay the horror of well over a hundred people dying in one awful night, but it was a specific tragedy. It was on the front page every day and presented as a cliff-hanger however we all knew, early on, that the missing people were not really missing, they were under the rubble and most of them, if not every single one of them, were not alive. But as I started to think about it, I’ve come to realize that that the Champlain Towers is an example of how we – we being almost everybody – treat a slow-moving disaster. In a way, Champlain Towers is a scale model of the way we are dealing with the Global Climate Crisis and, I fear, the end result will be similar.

Champlain Towers had been deteriorating for years with cracks in the concrete structure getting bigger allowing water to penetrate, causing flaking concrete and corrosion. It was something that the owners had been arguing about for years. We are all susceptible to wishful thinking and a large enough number of condo owners did not want to acknowledge the problems. They were worried that, if there really was a problem, or. even worse, problems, their property value would go down. They preferred to let sleeping dogs lie, there is no point in looking for problems. Eventually, as things continued to deteriorate, enough recalcitrant owners agreed on getting an inspection and, in October of 2018, the engineers issued a report which detailed numerous structural problems and pointed out that they were getting even worse and were potentially dangerous. On one level, everybody already knew that and the majority of owners who did not to hire a consultant in the first place were now worried about the cost of repairs.

It turned out that the repairs were going to cost a lot of money, something like $175,000 per condo, and nobody has that kind of money kicking around. Additionally, they found some city engineer who said that the building was safe, so starting the repairs dragged on with nothing happening.

Until it did.

Vermont and South Dakota are actually very similar Both have slightly older, white, rural populations Have comparable median incomes Both have Republican governors And these days, they look super similar on infections Here they are over past 2 months

Vermont has vaccinated (1+ shot) nearly 75% of its population SD? 50% Vermont has a high degree of immunity through vaccinations So how does SD have high population immunity? Prior infections Here’s how pandemic has played out in both states

and you can see it in the suffering of the people of the two states Deaths per capita from COVID in VT vs SD Nearly 6 times as many folks in SD died from COVID as VT 40/100K in VT versus 230/100K in South Dakota

So both states have landed at high population immunity Good But SD got there by having close to 50% of folks infected And suffering high death rates during the fall and winter months So yes vaccines or infections work for population immunity One is much better End