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‘How Do You Decide When to Open the World Back Up?’ ‘How Do You Decide When to Open the World Back Up?’
(about 13 hours later)
Good morning.Good morning.
(Here’s the sign-up, if you don’t already get California Today delivered to your inbox.)(Here’s the sign-up, if you don’t already get California Today delivered to your inbox.)
Believe it or not, it’s April.Believe it or not, it’s April.
In California, we’ve been staying home for weeks now, and although experts have said — cautiously — that distancing efforts appear to be making a difference, measuring that progress is complex.In California, we’ve been staying home for weeks now, and although experts have said — cautiously — that distancing efforts appear to be making a difference, measuring that progress is complex.
Each day, state, local and federal officials and agencies unleash floods of new data that seem to clarify some parts of the picture while complicating others.Each day, state, local and federal officials and agencies unleash floods of new data that seem to clarify some parts of the picture while complicating others.
Dr. Bob Wachter, a professor and chair of the University of California, San Francisco’s department of medicine, has been posting updates on Twitter explaining what he’s seeing day by day.Dr. Bob Wachter, a professor and chair of the University of California, San Francisco’s department of medicine, has been posting updates on Twitter explaining what he’s seeing day by day.
On Tuesday, as public health officials in the Bay Area expanded shelter-in-place orders, I asked him to take a step back and help demystify some of the bigger trends for us.On Tuesday, as public health officials in the Bay Area expanded shelter-in-place orders, I asked him to take a step back and help demystify some of the bigger trends for us.
Here’s our conversation, lightly edited and condensed:Here’s our conversation, lightly edited and condensed:
How are you doing? Things must be hectic.How are you doing? Things must be hectic.
I’m mostly working out of my house. It’s got a kind of odd “Wizard of Oz” feel — trying to understand what’s going on and making a whole bunch of decisions.I’m mostly working out of my house. It’s got a kind of odd “Wizard of Oz” feel — trying to understand what’s going on and making a whole bunch of decisions.
And we have this layer of having prepared for the apocalypse, but we haven’t seen it here, which we’re of course grateful for.And we have this layer of having prepared for the apocalypse, but we haven’t seen it here, which we’re of course grateful for.
You’ve mentioned that may be a signal that the early orders to stay home in California are helping keep hospitals from being hit as hard here. Meanwhile, testing is less available. So are confirmed case numbers still useful?You’ve mentioned that may be a signal that the early orders to stay home in California are helping keep hospitals from being hit as hard here. Meanwhile, testing is less available. So are confirmed case numbers still useful?
Yes, they are useful, but you have to adjust them for two factors.Yes, they are useful, but you have to adjust them for two factors.
One is the prevalence of testing in a community. But even though there’s more testing, the increase in New York compared to California is so many orders of magnitude higher that it doesn’t account for the difference.One is the prevalence of testing in a community. But even though there’s more testing, the increase in New York compared to California is so many orders of magnitude higher that it doesn’t account for the difference.
The second is overall population.The second is overall population.
If you adjust for those things, what I’m looking at is the overall increase — particularly the day-over-day increase.If you adjust for those things, what I’m looking at is the overall increase — particularly the day-over-day increase.
The number of new cases diagnosed today in San Francisco is about two-thirds of what it was four or five days ago, which means the slope of the increase is lower than it was, which, to me, is reasonably good evidence of some flattening of the curve.The number of new cases diagnosed today in San Francisco is about two-thirds of what it was four or five days ago, which means the slope of the increase is lower than it was, which, to me, is reasonably good evidence of some flattening of the curve.
If this thing was expanding in the way epidemics do when they’re not being mitigated or addressed, the growth is exponential.If this thing was expanding in the way epidemics do when they’re not being mitigated or addressed, the growth is exponential.
What about hospitalizations? What are you looking at there?What about hospitalizations? What are you looking at there?
My hospital made that number public early on and I think that was an incredibly smart decision, because data are better than what replaces data, which is rumors and speculation.My hospital made that number public early on and I think that was an incredibly smart decision, because data are better than what replaces data, which is rumors and speculation.
I don’t pay that much attention to the number of patients under investigation — people who come in with Covid-19 symptoms. Most will turn out not to have Covid-19. A lot who come in will have pneumonia. On average, one out of 20 will be positive.I don’t pay that much attention to the number of patients under investigation — people who come in with Covid-19 symptoms. Most will turn out not to have Covid-19. A lot who come in will have pneumonia. On average, one out of 20 will be positive.
The number of confirmed cases we have at any given time has gone up slightly from between eight and 10 last week, to now 13 to 15. But if we’re seeing 14 confirmed cases and a comparable hospital in New York has 150 to 200 cases, there’s something going on.The number of confirmed cases we have at any given time has gone up slightly from between eight and 10 last week, to now 13 to 15. But if we’re seeing 14 confirmed cases and a comparable hospital in New York has 150 to 200 cases, there’s something going on.
A number that has shifted for us in the last several days is that about a week ago, if there were 10 Covid-19 patients at U.C.S.F., eight might have been on the main floor of the hospital while two were in intensive care. That ratio has flipped. Today, we have 14 total and nine in the I.C.U.A number that has shifted for us in the last several days is that about a week ago, if there were 10 Covid-19 patients at U.C.S.F., eight might have been on the main floor of the hospital while two were in intensive care. That ratio has flipped. Today, we have 14 total and nine in the I.C.U.
I suspect that has a couple of factors associated with that. Once people are sick enough to be on a mechanical ventilator, many will die. Those who live will spend several weeks on a ventilator. Floor patients can come in and leave more quickly.I suspect that has a couple of factors associated with that. Once people are sick enough to be on a mechanical ventilator, many will die. Those who live will spend several weeks on a ventilator. Floor patients can come in and leave more quickly.
The second factor is that these patients can get very sick very quickly, so if your I.C.U. is packed, your threshold for sending someone there is very high, and we’re not getting crushed in the same way.The second factor is that these patients can get very sick very quickly, so if your I.C.U. is packed, your threshold for sending someone there is very high, and we’re not getting crushed in the same way.
Today, for example, of our nine people in the I.C.U. five are intubated and on mechanical ventilation and four are not, so our I.C.U. number might not be totally comparable with a hospital experiencing a surge — they’d still be watching those patients on the floor.Today, for example, of our nine people in the I.C.U. five are intubated and on mechanical ventilation and four are not, so our I.C.U. number might not be totally comparable with a hospital experiencing a surge — they’d still be watching those patients on the floor.
Can you talk to me about how you’re looking at hospital capacity in relation to cases? The state is scrambling to add and staff up a lot of hospital space, but what are you keeping an eye on to try to gauge if it will be enough?Can you talk to me about how you’re looking at hospital capacity in relation to cases? The state is scrambling to add and staff up a lot of hospital space, but what are you keeping an eye on to try to gauge if it will be enough?
It’s complicated and it’s fluid.It’s complicated and it’s fluid.
A hospital like ours, a month ago, was packed every day. In the main adult hospital we have about 550 beds and if you asked, we would’ve said we have zero capacity for new patients.A hospital like ours, a month ago, was packed every day. In the main adult hospital we have about 550 beds and if you asked, we would’ve said we have zero capacity for new patients.
But once it became clear that the coronavirus could come to the U.S. and be pretty dire, we dialed down using all the levers we had. That meant the cancellation of any surgery that wasn’t an absolute emergency.But once it became clear that the coronavirus could come to the U.S. and be pretty dire, we dialed down using all the levers we had. That meant the cancellation of any surgery that wasn’t an absolute emergency.
The model I’ve been looking at is the University of Washington’s and it looks like California is on track to do OK.The model I’ve been looking at is the University of Washington’s and it looks like California is on track to do OK.
What about testing? That’s been a concern. Is there a number of tests being administered per day that would be adequate?What about testing? That’s been a concern. Is there a number of tests being administered per day that would be adequate?
Updated June 16, 2020Updated June 16, 2020
The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.
The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.
So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.
Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.
The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.
Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission.Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission.
States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.
Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.
If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)
Taking one’s temperature to look for signs of fever is not as easy as it sounds, as “normal” temperature numbers can vary, but generally, keep an eye out for a temperature of 100.5 degrees Fahrenheit or higher. If you don’t have a thermometer (they can be pricey these days), there are other ways to figure out if you have a fever, or are at risk of Covid-19 complications.Taking one’s temperature to look for signs of fever is not as easy as it sounds, as “normal” temperature numbers can vary, but generally, keep an eye out for a temperature of 100.5 degrees Fahrenheit or higher. If you don’t have a thermometer (they can be pricey these days), there are other ways to figure out if you have a fever, or are at risk of Covid-19 complications.
The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.
If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.
If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.
The way I think about it is this: There are two reasons one tests. One is for your own clinical needs, meaning people are coming to your emergency room, calling into clinics, who might have symptoms or health care workers who might have symptoms. Now we’re even beginning to test asymptomatic patients who are going into transplant surgery or others.The way I think about it is this: There are two reasons one tests. One is for your own clinical needs, meaning people are coming to your emergency room, calling into clinics, who might have symptoms or health care workers who might have symptoms. Now we’re even beginning to test asymptomatic patients who are going into transplant surgery or others.
We’re now able to do 300 to 400 tests a day, and that’s enough to meet those clinical needs.We’re now able to do 300 to 400 tests a day, and that’s enough to meet those clinical needs.
That’s entirely separate from testing for epidemiological or surveillance purposes. As everybody’s curves start getting better, how do you decide when to open the world back up? You really need to know the prevalence of illness in the community.That’s entirely separate from testing for epidemiological or surveillance purposes. As everybody’s curves start getting better, how do you decide when to open the world back up? You really need to know the prevalence of illness in the community.
If someone has mild symptoms, there’s nothing we would do about it. There’s no treatment — we’d just tell them to go home. That’s the right call clinically, but from an epidemiological stance we need to know where there are still embers active in the community.If someone has mild symptoms, there’s nothing we would do about it. There’s no treatment — we’d just tell them to go home. That’s the right call clinically, but from an epidemiological stance we need to know where there are still embers active in the community.
It really does influence our overall infection-control strategy.It really does influence our overall infection-control strategy.
Let’s talk about the latter, epidemiological testing. I know there’s no magic number, but is there any level of testing that might make it safe to start thinking about lifting some restrictions?Let’s talk about the latter, epidemiological testing. I know there’s no magic number, but is there any level of testing that might make it safe to start thinking about lifting some restrictions?
There’s a report led by Dr. Scott Gottlieb from the American Enterprise Institute that says we need a national capacity to do 750,000 tests a week. I don’t know what that would translate to in the Bay Area.There’s a report led by Dr. Scott Gottlieb from the American Enterprise Institute that says we need a national capacity to do 750,000 tests a week. I don’t know what that would translate to in the Bay Area.
Everything we do here is a risk-benefit equation — of keeping everybody inside and shutting down the economy, and loosening restrictions.Everything we do here is a risk-benefit equation — of keeping everybody inside and shutting down the economy, and loosening restrictions.
It’s not a problem we’re confronting now. But sometime in May, that will probably be the dominant issue.It’s not a problem we’re confronting now. But sometime in May, that will probably be the dominant issue.
Ironically, in places where the virus is surging, it gets terrible abruptly and then it gets better quickly. In places where you’re flattening the curve, it may take longer until you’re down pretty low.Ironically, in places where the virus is surging, it gets terrible abruptly and then it gets better quickly. In places where you’re flattening the curve, it may take longer until you’re down pretty low.
[Read the latest updates on the pandemic from around the world here.][Read the latest updates on the pandemic from around the world here.]
California Today goes live at 6:30 a.m. Pacific time weekdays. Tell us what you want to see: CAtoday@nytimes.com. Were you forwarded this email? Sign up for California Today here and read every edition online here.California Today goes live at 6:30 a.m. Pacific time weekdays. Tell us what you want to see: CAtoday@nytimes.com. Were you forwarded this email? Sign up for California Today here and read every edition online here.
Jill Cowan grew up in Orange County, graduated from U.C. Berkeley and has reported all over the state, including the Bay Area, Bakersfield and Los Angeles — but she always wants to see more. Follow along here or on Twitter, @jillcowan.Jill Cowan grew up in Orange County, graduated from U.C. Berkeley and has reported all over the state, including the Bay Area, Bakersfield and Los Angeles — but she always wants to see more. Follow along here or on Twitter, @jillcowan.
California Today is edited by Julie Bloom, who grew up in Los Angeles and graduated from U.C. Berkeley.California Today is edited by Julie Bloom, who grew up in Los Angeles and graduated from U.C. Berkeley.