Issue 36: Vertigo
11.21.20 | The good news about the future of the pandemic is better than we could have hoped; the bad news about this winter is worse than we could have feared
Hello,
It’s a strange time in the country as we head into Thanksgiving. Last month I wrote that the coming weeks would have a “strange dissonance to them” as the near-term conditions of the pandemic worsened and the long-term outlook brightened on the release of vaccine trial reports.
Well, the expected good news is far better than we could have hoped, and the anticipated bad news is far worse than we feared. This week’s newsletter will cover both sets, starting with the good news about vaccines: what the recent clinical trial reports mean and when we can expect to see the vaccines administered.
/ Highly effective vaccines are coming
This week Pfizer submitted paperwork to the FDA for an emergency use authorization on its Covid vaccine, after data from the Phase 3 clinical trial showed the vaccine had a 95 percent effectiveness rate. It’s astonishing news for a couple of reasons: vaccines are coming somewhat earlier than first expected (not even a full year has passed since the virus was discovered and its genome sequenced), and these vaccines are, according to reports, far more effective than expected (the Moderna vaccine likewise is reportedly 95 percent effective, and the company will apply for its EUA shortly).
It’s worth putting the effectiveness figures in perspective by comparing them with the flu shot. In a given year, flu vaccines have about a 40 percent effectiveness rate, depending on the dominant strains circulating and the individual characteristics (age etc) of the person receiving the shot. If you’ve ever complained that you got your flu shot and picked up the flu anyway, well, that’s to be expected given the relatively low effectiveness of the vaccines.
Still, if enough people get vaccinated even this low rate of protection puts a significant damper on spread of the virus each year. But in the U.S. flu vaccination rates are also low (about 63 percent last season), so each year we get a new wave of influenza, causing tens of millions of infections, hundreds of thousands of hospitalizations, and tens of thousands of deaths (see the estimates for last season here).
As work on the Covid vaccines got underway, the hope was that they would be at least a little more effective than the flu vaccines, in the 50 to 60 percent range. At that level of protection, mass vaccination would have curbed the pandemic but only combined with masks, social distancing, the whole suite of other interventions we’re used to by now.
The Covid vaccines developed by Pfizer and Moderna, on the other hand, hit 95 percent effectiveness in their Phase 3 trials, which is on par with the measles vaccine — measles, which nearly every child in America used to contract until we functionally eliminated the virus the U.S. in the year 2000 through vaccination.
So it’s just extremely good news, with the caveat that neither Pfizer nor Moderna have released the full data from their trials, and we’re essentially taking their word on it for now. Furthermore it’s unclear whether or not the vaccines prevent infection altogether or still allow people to catch the virus and spread it to others. All we know is that, of the more than 43,000 volunteers enrolled in the Pfizer Phase 3 trial, 170 of them caught symptomatic Covid infections, and 162 of them were in the control group — they’d received a placebo rather than the actual vaccine — and that of the 10 severe Covid cases among trial participants nine of them were in the placebo group.
All that said, odds are that you’re going to be able to get vaccinated against Covid by the middle of this coming summer, and live a “normal” winter in 2021. Your devoted staff at The CovOdyssey cannot tell you what a relief it is to finally be able to type that, after 37 weeks of putting out this newsletter. Really, the end is in sight.
What’s going to happen next is that on December 10 the FDA will convene a panel of outside experts to analyze the trial data, and a few weeks later will decide whether or not to grant the EUA. Meanwhile Pfizer is already manufacturing millions of doses of its vaccine to be ready to be administered the moment the authorization comes. That could mean that frontline health workers and first responders and some high risk groups could receive their shots by the end of December or early January.
/ Next month will be extremely grim
The bad news is that the weeks between now and the end of December are likely to be the darkest of the pandemic, unless conditions deteriorate even further in the new year. Friday saw a staggering 198,537 new cases reported, with a record-breaking 82,178 hospitalizations. There’s no indication that the growth curve is leveling off. Indeed, a report from the White House Coronavirus Task Force this week described a state of “aggressive, unrelenting, expanding broad community spread across the country, reaching most counties, without evidence of improvement but rather, further deterioration,” and that “current mitigation efforts are inadequate and must be increased to flatten the curve to sustain the health system for both Covid and non-Covid emergencies.”
It’s unclear where the peak might sit. We will almost certainly cross the 200,000 cases a day threshold in the coming week at the same time that millions of Americans get together for Thanksgiving. Those holiday get-togethers will likely accelerate the spread of the virus. It’s why the CDC has recommended people don’t travel for the holiday and don’t hold in-person gatherings with multiple households.
Having everyone tested right before the holiday isn’t a fool-proof method of keeping your gathering safe — the test might produce a false negative, or you might be carrying the virus below the detection threshold at the time of the test, only to become contagious in time for the holiday (this Wired piece has a nice run-down). Social distancing at an indoor gathering isn’t all that safe either, given that people can’t eat with masks on and the virus travels through aerosols. There’s so much virus circulating in communities across the country now — so many chances for at least one person at a gathering to have picked up an infection in time to spread it — that safety precautions that might have been enough to skate by in the summer won’t be enough now (it’s not a bad time to look back at the ‘swiss cheese’ model of virus defense).
A Mississippi newspaper this week caught some attention with the headline “After Big Thanksgiving Dinners, Plan Small Christmas Funerals.” That’s a little dramatic. Plenty of Thanksgiving dinners are going to take place this week with no disease transmission at all. Some people who take safety precautions will see family get sick anyway. Some people will be completely reckless and luck out unscathed. And it’s true that the vast majority of people who contract Covid make it through without serious consequences. But that’s cold comfort to the people who end up with long-term disability from the disease, or see a loved one suffer a nasty case of it even if it doesn’t result in hospitalization, or to the people who lose someone close to them to the virus.
It’s important to think about the individual dramas of this pandemic while also keeping an eye on the aggregate patterns. Patterns like the case fatality rate — the number of deaths per diagnosed cases. That figure has remained stubbornly steady since the summer, between 1.5 percent and 1.7 percent. And at the aggregate level, scientist Trevor Bedford discovered, there’s an average 22-day lag between daily case reports and daily deaths.
So for example this past Friday saw 1,947 reported deaths. That’s a pretty startling number, comparable with some of the worst days of the spring peak. It roughly corresponds to the case-load 22 days earlier, October 30, which saw 99,802 new cases reported. The correspondence isn’t perfect, because of noise in the patterns and timing of data reporting and other confounding factors. But it’s close enough to make estimates. If you did this calculation for every 22-day-lagged pairs of case and fatality averages between July and now and plotted it out, which Bedford did, you get this chart, which shows the 7-day average of daily reported deaths as the solid red line and the estimated deaths based on reported new cases 22 days earlier in dashed gray:
What this means is that, assuming the case fatality rate remains steady (around 1.5 percent), then the record-breaking 198,000 cases we reported on Friday could translate to roughly 2,970 deaths 22 days from now, December 12th.
That’s where the peril of this Thanksgiving week starts to come into focus. The growth of newly reported cases isn’t slowing. Thanksgiving gatherings will almost certainly push the curve up even more. 200,000 daily cases seemed unthinkable over the summer. The CDC ensemble model is currently forecasting as many as 328,000 new cases a day by the week ending December 12th.
It’s also worth noting that the CDC model’s estimates have been consistently too low since the end of the summer — it has so systematically under-forecast new cases that its weekly reports carry this warning: “Over the last several weeks, more reported cases than expected have fallen outside of the forecasted prediction intervals. This suggests that current forecast prediction intervals may not reflect the full range of future reported case numbers. Forecasts for new cases should be interpreted accordingly.” In other words that estimate of 328,000 cases a day by December 12 could turn out to be significantly too low.
All kinds of things could change between now and the new year. Forecasting is an imperfect science, and the crude method of estimating daily deaths from new case reports with a 22-day lag could lose its predictive power altogether. Maybe new restrictions on public life will bend the curve down dramatically, as they have recently in Europe. Maybe people will curb their movements independently as more people they know contract the virus. Maybe natural herd immunity will start to slow the spread. But the numbers they stand right now suggest a late-December/early-January that is unrecognizably different from the present moment.
// Quick Link Roundup
Crisis nurses on the toll of the pandemic: Take 10 minutes out to watch this remarkable short documentary spliced together from first-hand video dispatches by nurses who travel the country filling staffing shortages at hospitals.
— “Covid Chasers: The Nurses Fighting Coronavirus From Hot Spot to Hot Spot.” Shalini Ramachandran et al, The Wall Street Journal.Why the pandemic needs to be seen: One reason to watch the above documentary is that mostly this crisis happens behind closed doors. It’s not a hurricane you see coming. Roxanne Khamsi makes the case that if more of us could see what is going on inside hospitals, there would be less complacency around the virus at large.
— “This Pandemic Must Be Seen.” Roxanne Khamsi, Wired.On deciding to risk it: This is a surprisingly moving and deeply insightful short essay on two moments from this week in which media figures—Rachel Maddow and Farhad Manjoo—separately walked through their risk calculations around the pandemic, and how our decisions reflect the way we construct our social universes.
— “The Moral Calculus of COVID-19.” Jason Kottke, kottke.org.The secret of the new vaccines: The Pfizer and Moderna vaccines work differently than the vaccines we’re used to. Traditional vaccinations introduce deactivated pathogens to train our immune systems to recognize and fight them. The leading Covid vaccines train our immune systems by using messenger RNA to make our own cells produce some of the proteins that make up the novel coronavirus, which on their own are harmless to us but which train our immune systems to recognize SARS-CoV-2 and destroy it. It’s a groundbreaking innovation. STAT News has the story of how it came to be.
— “The Story of mRNA: How a once-dismissed idea became a leading technology in the Covid vaccine race.” Damian Garde and Jonathan Saltzman, STAT News and the Boston Globe.Listening to the pandemic: This week I was a guest on historian Scott Knowles’ CovidCalls podcast, talking about the work I’m doing with my colleagues to create an archive of interviews and diary entries from New Yorkers about their experience of the pandemic. We talked about what we’ve been learning from hearing and analyzing people’s stories of the pandemic, the challenges of doing research remotely, and how history will remember this plague year. You can watch it here or listen through the link below.
— “The Covid-19 Oral History, Narrative and Memory Archive.” Scott Knowles, CovidCalls.
That’s it for this week. Here’s wishing you all a happy and safe Thanksgiving, and I’ll see you in the inbox next Saturday.