Category: Medicine

The Invisible Graveyard is Invisible No More

We called it the invisible graveyard, the place they buried people killed by FDA delay. Back then only a few of us–mostly libertarians long practiced in seeing the invisible hand–could see the invisible graveyard. Normal people looked at us oddly and quickly ran away when we frantically pointed to the dead. “There! there! Can’t you see the bodies?” Now, however, the veil has been lifted and even normal people see.

Here is Ezra Klein writing in the NYTimes:

The problem here is the Food and Drug Administration. They have been disastrously slow in approving these tests and have held them to a standard more appropriate to doctor’s offices than home testing. “The F.D.A. needs to catch up to the science,” Mina said, frustration evident in his voice. “They are inadvertently killing people by not following the science.” On my podcast, I asked Vivek Murthy, President Biden’s nominee for surgeon general, whether the F.D.A. had been too cautious. “I do think we’ve been too conservative,” he told me. Murthy went on to argue that there’s a difference between the diagnostic testing doctors do and the surveillance testing the public could do and that the F.D.A. had failed to appreciate the difference. Speeding the F.D.A. on this issue will be an early, and crucial, test for the Biden administration. In this case, Democrats need to deregulate.

Even back in December when I was tweeting from the rooftops things like:

Your daily reminder that 14,696 people have died from COVID in the United States since Pfizer applied for an EUA from the FDA.

people argued that I was exaggerating the simple math of FDA delay. Today, however, the reality of deadly delay is almost conventional wisdom. Here’s Klein again:

The new strains spread quickly. The speed of our countermeasures will decide our fate. What feel like reasonable delays in our normal experience of time — a few weeks here for Congress to debate a bill, a few weeks there for the F.D.A. to hold meetings — could lead to the kind of explosive infections that overwhelm our hospitals and fill our morgues.

Vaccine politics in Europe and America

The contentiousness is much worse in Europe, where zero- and negative-sum thinking is the order of the day.  That is the theme of my latest Bloomberg column, here is one bit:

In most of Europe, it’s hard to see much good news. It’s one thing not to have a vaccine. It’s far worse to turn on television or go on the internet and see people in other countries being vaccinated as their pandemics recede. Most of Europe will not be making significant vaccination progress until April, and even then shortages may remain.

At stake is the very legitimacy of the EU. Most of the vaccination contracts were handled at the EU level, although Germany sidestepped the agreed-upon procedures and cut some deals. If the EU fails at the most significant crisis in a generation, it may not maintain much legitimacy.

And:

When people judge how painful an experience was, they often place a high value on first and last impressions. The last impressions of the U.S. and U.K. will be pretty positive. Most of the U.S. pandemic will be over by July, even under a subpar vaccination schedule. And it may turn out that mRNA vaccines are more protective against the new strains of Covid than any alternatives….

Many European countries may end up with fewer deaths per capita than the U.S. But at the end of the pandemic many Europeans may feel like their leaders failed them, that they suffered lockdowns for many months but received little in return. Right now vaccine politics is all about momentum, and so far only a few countries have it.

Here is a related piece by Bruno M.  And a good piece (slow to start) on what went wrong in the EU.

To Every One Who Has, More Will Be Given

From an email to Fairfax County teachers:

Due to a decrease in vaccine allocation, we are temporarily reducing appointment availability over the coming weeks. Vaccine supply is fluid across the country, and we are matching currently scheduled appointments to anticipated inventory.

We are pleased to share that more than 22,000 Fairfax County Public Schools teachers and employees have already been able to schedule their first shot.  At this time we are honoring those who have current appointments. Should our vaccine supply not be sufficiently replenished, we will suspend initial appointments (first doses) for eligible individuals in 1b and prioritize those who require their second vaccine dose in the weeks to come.

It’s really quite stunning when you think about it.

Hat tip: Max.

The culture that is Japan

A contentious requirement for Japan-specific trials has delayed the rollout of Covid-19 vaccines in Asia’s largest advanced economy and threatened the Tokyo Olympics.

Small clinical trials that demonstrate the vaccines generate a similar level of antibodies when used in Japan are the main outstanding condition for approval of the jabs from BioNTech/Pfizer and several other companies.

Japan’s demand for proof that safety and efficacy do not differ in the country means that it will not start vaccinations until the end of February — three months after the earliest rollouts and fewer than five months before the delayed Tokyo Olympics are due to start.

Here is the full FT article.  Via the Approve AstraZeneca wisdom that is Garett Jones.

Our Virginia regulatory state is failing us

As of tomorrow, hospitals in Virginia will no longer be able to administer COVID-19 vaccines. Thousands of elderly people are having their vaccine appointments canceled. From now on, all COVID-19 vaccines will go to the local health departments and none directly to hospitals.

Virginia Hospital Center had been running clinics all day every day to give people the vaccine. Appointments there for all 1st dose vaccines have been canceled because the hospital will no longer be able to get the vaccines.

Northam’s health department has also forbidden people from crossing county lines to get the vaccine. If the county next to you has an abundance of the vaccine, you can’t get it. Only residents of that county may get their vaccine.

These new rules will result in many people either having their vaccination appointment canceled or delayed for months. Currently, 7.5 million people in Virginia, Maryland, and DC qualify to get the vaccine, if only they had access to it. The new rules limit the options citizens have for getting the shot. Everyone MUST go through their local health department to be vaccinated. That means in a county such as Loudoun, with a population of over 420,000, and two health department locations to receive the vaccine, will continue to inoculate 400 to 900 people a day. There are no other options. The Loudoun health department has said they are trying to open a third location for vaccinations (possibly at Dulles Town Center) but that could take months. If Loudoun continues at its current pace it will take well over a year for the local health department to inoculate all those who want vaccines. If Loudoun hospitals were allowed to open clinics for vaccines, many more people could be inoculated every day but the Northam administration will not permit it.

Here is the link, via Hans.  In general, Virginia is a fairly well-run state, but as of late it has not been cracking the top 40 for vaccine distribution.

The canine culture that is Miami

The Miami Heat are bringing back some fans, with help from some dogs.

The Heat will use coronavirus-sniffing dogs at AmericanAirlines Arena to screen fans who want to attend their games. They’ve been working on the plan for months, and the highly trained dogs have been in place for some games this season in which the team has allowed a handful of guests — mostly friends and family of players and staff.

Starting this week, a limited number of ticket holders will be in the seats as well, provided they get past the dogs first.

“If you think about it, detection dogs are not new,” said Matthew Jafarian, the Heat’s executive vice president for business strategy. “You’ve seen them in airports, they’ve been used in mission-critical situations by the police and the military. We’ve used them at the arena for years to detect explosives.”

Here is the full story, the first game under this regime is Thursday.

It is a marathon, not a sprint

For all of its achievements, we still do not know if New Zealand will have ended up doing a good job against Covid-19:

New Zealand’s “go hard, go early” strategy to combat Covid-19 attracted global praise and eliminated local transmission of the virus. But the country’s slow rollout of vaccines is putting people at unnecessary risk and threatens to delay its economic recovery, critics warned.

Wellington plans to start vaccinating frontline workers in April and the general public from July under a cautious strategy that avoids the emergency authorisation of vaccines pursued by crisis-stricken nations such as the US and UK.

And note this:

There are at least 19 cases of the coronavirus variants first identified in the UK or South Africa in managed quarantine facilities in New Zealand for overseas arrivals, according to government data.

And this:

Mr Hipkins said there was “absolutely no complacency” in the government’s response.

Here is the full FT story.

That was then, this is now, now it’s now again

To see how much the sanitary and medical revolutions have changed the risks of global interaction, examine what kills Americans abroad these days: cardiovascular events including heart attacks account for 49 percent of all deaths, injuries for a further 25 percent, and infectious diseases other than pneumonia for just 1 percent…even travel to pathogen-rich environments has become far, far safer than it used to be: a study of 185 deaths of US Peace Corps volunteers,  placed in some of the world’s least healthy countries, found that unintentional injuries and suicides were far more deadly than infection, accounting for more than 80 percent of deaths between them.

That is from Charles Kenny’s new and excellent The Plague Cycle: The Unending War Between Humanity and Infectious Disease, which was started well before Covid.

We Will Get to Herd Immunity in 2021…One Way or Another

By July it will all be over. The only question is how many people have to die between now and then?

Youyang Gu, whose projections have been among the most accurate, projects that the United States will have reached herd immunity by July, with about half of the immunity coming from vaccinations and half from infections. Long before we reach herd immunity, however, the infection and death rates will fall. Gu is projecting that by March infections will be half what they are now and by May about one-tenth the current rate. The drop will catch people by surprise just like the increase. We are not good at exponentials. The economy will boom in Q2 as infections decline.

If that sounds good bear in mind that 400,000 people are dead already and the CDC expects another 100,000 dead by February. We have a very limited window in the United States to make a big push on vaccines and we are failing. We are failing phenomenally badly.

To understand how bad we are failing compare with flu vaccinations. Every year the US gives out about 150 million flu vaccinations within the space of about 3 months or 1.6 million shots a day. Thus, we vaccinate for flu at more than twice the speed we are vaccinating for COVID! Yes, COVID vaccination has its own difficulties but this is an emergency with tens of thousands of lives at stake.

I would love it if we mobilized serious resources and vaccinated at Israel’s rate–30% of the population in a month. But if we simply vaccinated for COVID at the same rate as we do for flu we would save thousands of lives and hundreds of billions of dollars in GDP. The comparison with flu vaccinations also reminds us that we don’t necessarily need the National Guard or mass clinics in stadiums. Use the HMOs and the pharmacies!

And let’s make it easier for the pharmacies. It’s beyond ridiculous that we are allowing counties to set their own guidelines for who should be vaccinated first. We need one, or at most 50, set of guidelines and lets not worry so much at people jumping the queue. (The ones jumping the queue are probably the ones who want to get back to the bars and social life the most so vaccinating them first has some side benefits.)

Of course, the faster we vaccinate the more vaccine quantities will become the binding constraint which is why we also need to approve more vaccines, move to First Doses First (delay second doses like the British), and use Moderna half-doses. Fire on all cylinders!

Time is of the essence.

Hat tip: Kevin Bryan and Witold Wiecek.

Protection against dengue?

The dengue virus uses a particular protein, called Non-Structural Protein 1 (NS1), to latch onto the protective cells around organs. It weakens the protective barrier, allowing the virus to infect the cell, and may cause the rupture of blood vessels. The research team’s antibody, called 2B7, physically blocks the NS1 protein, preventing it from attaching itself to cells and slowing the virus’s spread. Moreover, because it attacks the protein directly and not the virus particle itself, 2B7 is effective against all four dengue virus strains.

That is cited by the excellent Jodi Ettenberg, from new January 2021 research.  If I  hear more I will let you know.

Praise the British

Britain has fully vaccinated more people against #COVID19 than every other nation on earth combined.

Link and picture here.  That is as of January 13, at least.  You may recall my previous and much-attacked July Bloomberg column suggesting that along a number of dimensions the UK pandemic response actually was quite good.

Addendum: Numerical correction from Alex on America, though you still can praise the British.

California Covid-19 Vaccine Availability

The State of California has approved giving the COVID-19 vaccine to people age 65 and older. We are calling hospitals and pharmacies daily to check which are currently administering vaccines. We called more than 100 on Thursday, January 14th, and aim to call several hundred on Friday, January 15th. Our goal is getting shots in arms as quickly as possible for you or your loved ones.

We intend to call all the vaccination sites in California. If you have a missing location to report, or think we have incorrect contact information, please let us know.

We’ve also compiled county policies on vaccination here.

Here is the link, there should be more projects like this one — think matching models!

The Magical Extra Doses and Supply Chain Optimization

1-ml syringe design yields 2 micro literes and standard syringe and needle hub yield 84 micro liters on average.
Image from Wikipedia, Low dead space syringe.

As pharmacists began vaccinations using the Pfizer vaccine some of them discovered that it was possible to extract a 6th or even 7th dose from a standard 5-dose vial. Where were the extra doses coming from? The fortuitous discovery was not due to over-filling. The vials contained just 5 doses when using standard syringes. But some of the vaccine distribution sites had access to low dead-volume syringes, syringes that leave less vaccine trapped between the plunger and needle — the “dead volume” — after a shot is given. Thus, less vaccine was wasted in the syringe and more available for putting into arms using the low dead-volume syringes.

This is quite remarkable. Increasing vaccine supply by 20% by building more factories could cost billions. We should do that, it would be worth it. But in this case, we managed to increase supply by at least 20% use a relatively inexpensive redesign of the syringe. What this indicates is the importance of thinking along the entire supply chain for opportunities for optimization.

The catch? Not all syringes provided by Operation Warp Speed and Pfizer are low dead-volume syringes so not every vaccine distribution site is getting the extra doses. We do need to invest more in the syringe supply chain.

Fact of the day, get to those rooftops!

Pepvar’s first goal should be supporting the production of enough doses to vaccinate the entire world within a year. It is estimated that building such capacity for an mRNA vaccine like Moderna’s would cost less than $4 billion — that’s significantly less than the U.S. government already spends each day on Covid-19 relief — with the cost about $2 per dose. Of course, making the vaccines is just the first step: Pepvar must

People, even if that estimate is off by a factor of ten or more…etc.  Here is the NYT link, bJames KrellensteinPeter Staley and .