For the second straight day, a bright light shines through the gloom of
a darkening COVID outlook this fall. Yesterday the good news was that
fears of schools becoming mass incubators of coronavirus appear to be overblown. Positivity rates across a sample of tens of thousands of
students and staff in NYC are minuscule. Maybe we can have safe in-
class instruction this fall.
Today’s news is even better. As cases explode in Europe and climb
towards a new peak in the U.S., a tantalizing mystery has emerged: Why
aren’t we seeing the same crushing death tolls in hot spots that we saw
in the spring? Deaths *are* rising in Europe from their summer lows
(upwards of 150 daily on bad days in the UK and France recently) but
they’re nowhere near the gory levels of April even though both
countries are setting records in the number of daily cases. The trends
in cases and deaths here in the U.S. also diverged awhile ago:
The pessimistic theory of why deaths in western countries haven’t
approached their spring peaks is that the number of infections during
the spring was much, much greater than the meager testing available at
the time was able to detect. Deaths still track cases under this
theory; the spring death toll was a simple function of there having
been a gigantic “hidden” epidemic at the time.
The more optimistic theory is that science has simply caught up to some
degree. People who would have died if they were infected in March are
surviving now because doctors have gotten better, and better equipped,
to treat the disease. According to NPR, two new studies suggest that
the optimistic theory is correct. COVID has become less lethal.
[One] study, which was of a single health system, finds that
mortality has dropped among hospitalized patients by nearly
18 points since the pandemic began. Patients in the study had
a 25.6% chance of dying at the start of the pandemic; they
now have a 7.6% chance…
So have death rates dropped because of improvements in
treatments? Or is it because of the change in who’s getting
sick? To find out, Horwitz and her colleagues looked at over
5,000 hospitalizations in the NYU Langone Health system
between March and August. They adjusted for factors including
age and other diseases, like diabetes, to rule out the
possibility that the numbers had dropped only because younger,
healthier people were getting diagnosed. They found that death
rates dropped for all groups, even older patients by 18
percentage points on average…
“I would classify this as a silver lining to what has been
quite a hard time for many people,” says Bilal Mateen, a data
science fellow at the Alan Turing Institute in the U.K. He
has conducted his own research of 21,000 hospitalized cases
in England, which also found a similarly sharp drop in the
death rate. The work, which will soon appear in the journal
Critical Care Medicine and was released earlier in preprint,
shows an unadjusted drop in death rates among hospitalized
patients of around 20 percentage points since the worst days
of the pandemic.
Mateen says drops are clear across ages, underlying conditions
and racial groups.
There’s no silver-bullet explanation for the decline, researchers
suspect. Partly it’s a matter of doctors getting better at anticipating dangerous complications, like blood clots. Partly it’s a matter of
younger, hardier people composing a larger percentage of patients.
Partly it’s a function of mask-wearing, one researcher speculated,
believing that masks might filter out some particles before they’re
inhaled, leading to smaller viral loads and less severe cases. Doctors
did stress, though, that even a 7.6 percent chance of death is
unusually high for a disease, and certainly higher than the flu. The
fact that so many COVID survivors suffer complications afterward,
sometimes long-term, also distinguishes it from more familiar
respiratory diseases. Coronavirus may be less likely to kill you now
but it’s still capable of making life miserable for weeks or months.
“But what about antibody treatments?” you say. Regeneron’s treatment
saved Trump, didn’t it? Well … maybe not. The data from two new
randomized clinical trials, one from Italy and other from France, found
no major benefit from the antibody treatment tocilizumab. And even if Regeneron’s and Eli Lilly’s treatments do help, they’ll be in short
supply initially and pose logistical difficulties. The drugs are
administered intravenously, so you’d need to get to a clinic or ER to
be treated. And because state agencies that are consumed with other
COVID business are being tasked to coordinate distribution, it’s an
open question as to how efficient the dispersal will be.
Just like it’s also an open question whether Regeneron’s drug did
anything for the president. He keeps talking about how great he felt
after getting it but that could easily be explained by the
dexamethasone he was getting, not the antibody drug. Steroids (in)
famously can induce feelings of strength and even invincibility.
While we’re busy tempering expectations about the efficacy of antibody
drugs, we should probably take a moment for a reality check on the
vaccine too. Lord knows it’ll help reduce infections, but the dream
scenario where we all get the shot, whip off our masks, and have a big
indoor kegger where we’re all breathing in each other’s faces probably
If most of the infections are in the placebo group—say 26 out
of 32—that would suggest the vaccine is at least 76 percent
effective. That’d be pretty good. But scientists have cautioned
that a COVID-19 vaccine might be less effective than we’d
like, based on how vaccines against respiratory viruses tend
to work. The FDA has set a bar of at least 50 percent efficacy
for a COVID-19 vaccine. It’ll take longer and more cases for
trials to reach a conclusion if vaccine efficacy is on the
lower side. So if the first interim results are a little
disappointing, that “doesn’t mean this is a failed vaccine,”
Lowe says. “We’re just going to keep on rolling.” We’ll have
a better idea of efficacy once we’ve seen how the vaccine
performs in more people.
Conversely, it shouldn’t come as a shock if some of these
vaccine candidates do turn out to be ineffective. The
development process from Phase 1 to 2 to 3 has gone very
smoothly so far. But, in general, more than 90 percent of
drugs and treatments fail, and close to 50 percent of them
fail in Phase 3. Lowe says he expects COVID-19 vaccine
candidates to do much better because scientists are building
on research into MERS and SARS, two related coronaviruses.
I haven’t yet digested the possibility that masks could become a
regular part of American life for the next several years or longer,
especially in winter, because the vaccine just isn’t effective enough
to put COVID down for the count. *Maybe* the combination of the
vaccine, masks, and improved treatments will get us to the point
relatively quickly where the disease isn’t much worse than the flu even
if you do get it, but we may be playing the waiting game for awhile.
Which wouldn’t be an entirely bad thing: Even if only, say, a third of Americans made a point of wearing masks semi-regularly in winter, that
would break many chains of transmission both for coronavirus and for
lesser respiratory diseases like influenza. We might see an abiding
perennial drop in flu hospitalizations.
Here’s Scott Gottlieb warning that we may be only a week or so behind
Europe in experiencing rampant community spread here in the U.S.
Europe’s present was our near-future back in the spring; Gottlieb’s
speculating that that will be true in the fall as well, especially with
case counts in the U.S. already climbing. If you’re thinking that’s not
a big deal given the lower mortality rates now, note this bit from the
NPR piece: “Mateen says that his data strongly suggest that keeping
hospitals below their maximum capacity also helps to increase survival
rates. When cases surge and hospitals fill up, ‘staff are stretched,
mistakes are made, it’s no one’s fault — it’s that the system isn’t
built to operate near 100%,’ he says.” The more infected people there
are, the more hospital beds will be occupied, and thus the more
preventable deaths are likely to result.
“We can’t let our guard down right now,” @ScottGottliebMD
says as coronavirus cases rise and the holidays approach.
“These are going to be some tough months ahead of us.”
— The News with Shepard Smith (@thenewsoncnbc) October 19, 2020
Every American should want President Trump and his administration to
handle the coronavirus epidemic effectively and successfully. Those who
seem eager to see the president fail and to call every administration
misstep a fiasco risk letting their partisanship blind them to the
demands not only of civic responsibility but of basic decency.