State by State
Nearly all states in the country have entered a phased reopening this week. While most that are reopening are continuing to show a downward trend in the number of cases, there are several, however, that have shown small to moderate increases in case numbers that will bear watching. These states include:
- South Carolina
Four states have never shown a distinct downward trend but are moving with reopening anyway. These states include:
- North Carolina
Eight states have gone to a regionalized reopening process with decisions made at a local level. Three of these still show increasing statewide trends although there are localized significant decreases that are allowing those regions to begin the reopening process. These three states are:
Four of the states that are proceeding with very limited reopening are nonetheless showing a downward trend. The states include:
- New York
The last regionalized opening state is Washington which is flat on its current trend. Only one state remains in the stay-at-home phase and this is New Jersey. New Jersey does, however, show a steady downward trend in cases.
Most countries peaked between the end of March and the second week in April. Almost all have seen a continued steady downtrend in cases. Sweden, the one country that never did a nationwide lockdown, remained flat on its number of cases throughout the last 2 months. There have been some recent unusual upticks in case counts in Sweden, but not yet enough to call a trend.
Most countries are generally doing well and are past peak infections. The notable exception is India which is still on a significant upward trend and is not showing any signs of peaking yet.
Middle Eastern countries
Most countries are either just past their peak or in a flat period where it is too close to call a definitive direction.
A common question over the past few weeks is the status of vaccine development. In the news, you commonly hear discussions of various phases and different types of vaccines.
Here is a quick review of the typical course of vaccine development. Before any testing is done there is preclinical work. The candidate vaccines are developed in labs, then followed by initial testing in animal models. Next are the clinical trials with three phases of testing:
Conducted on tens of patients and is designed to identify the appropriate dosage. Historically about 63% of vaccines move from phase 1 to phase 2.
Safety trials in larger groups, typically 100s of patients. Phase 2 is designed to identify any immediate safety issues and to confirm that the dose selected consistently produces an effective immune response. Historically about 33% of vaccines moved from phase 2 to phase 3.
Large placebo-controlled studies. These are studies that are done with tens of thousands of patients. Typically, about 75% of vaccines that make it to phase 3 move on to approval.
However, this process often takes 5 – 7 years. For COVID—19, the process is being compressed into less than a year. Some reports say there are greater than 100 vaccines in development worldwide. Many of these are using standard development approaches that have been used for years.
Out of all the vaccines under development, only two are in or near phase 2, so far. These are a messenger RNA vaccine being developed by Moderna in the US, and an adenovirus vaccine from a team led by the University of Oxford in England. In addition to these two vaccines, there are four other vaccines just reaching early clinical trials. These include vaccines from Johnson & Johnson, Sanofi in partnership with GlaxoSmithKline, and vaccines from two smaller companies Novovacs and Inovia.
No one expects all of these vaccines will come through the testing process successfully, but the development and distribution system will be ready for the first that does. With this unprecedented effort, most authorities do believe that we may have a vaccine ready for Emergency Use Authorization in the latter part of this year. On that timeline, we would have significant quantities of vaccine available in the last quarter of this year and into the first quarter of next year.
There is no guarantee, but officials such as Dr. Anthony Fauci from the US National Institutes of Health believe this is possible.
Recently, a member of the US Food and Drug Administration vaccine advisory committee was publicly interviewed by the Journal of the American Medical Association. He noted that while this effort, on this timeline, is unprecedented in the history of the world. It is also true that never in the history of the world have so many companies, governments, bright scientists, and money been brought together in developing a vaccine.
One last but important note on vaccines:
As we hear data on vaccines, it is important to remember that a vaccine does not have to be 100% successful to make a huge impact. In some years, the annual flu vaccine has effectiveness rates near 50%. Even then, however, that kind of rate, in conjunction with existing immunity from people who have been infected in the past, is enough to keep any outbreak under control.
Many sources treat a second wave of COVID-19 in the fall as inevitable. While it is near-inevitable that we will have COVID-19 with us through this year, a second wave is not inevitable. The major case for a second wave is based on multiple models that predict this, but we know that many, were inaccurate in their initial projections. Many of the models are based on the assumption that populations around the world will not sustain the social distancing requirements and restrictions that have been put in place. Along with a predicted lack of a vaccine or drug therapy that can significantly modify the pandemic before the end of the year. Additionally, there are numerous historical examples, most notably the pandemic of 1918 that followed a pattern of a spring wave followed by an even worse fall wave.
Fortunately, there are good arguments against the second wave.
- No one proposes removing all social distancing measures. Experience is showing that as the most restrictive measures are removed, people are still practicing fair individual social distancing, including wearing of masks. Additionally, the key characteristics of this virus are inherently different than previous viruses. While the way this virus spreads is like other respiratory viruses, there are significant differences, including the importance of the role of super spreaders. Knowledge of the super-spreader role can help us all to reduce their incidence and impact, primarily through avoiding large indoor gatherings in tight locations.
- Another factor arguing against a second wave is that workplaces and schools are taking a major role in monitoring and protecting against outbreaks. This is very different than the experience in previous epidemics. Several other more technical issues mitigate against a second wave.
The bottom line is that there is still much we do not know about COVID-19. The important message is that you should not assume there will be a second wave. However, it is important to maintain vigilance and continue to take reasonable social distancing actions as we proceed to reopen and put people back to work.
Hydroxychloroquine was, early on, touted as a potential game-changer in combating this virus. While several large studies have demonstrated that hydroxychloroquine is not effective when given late in the course of the disease. There was one well-done study released this week, which demonstrated that the early use of hydroxychloroquine alone was not associated with significant improvement. But it also showed that hydroxychloroquine was not associated with any adverse outcomes. At this point, all we can say is that more research is required, especially as to the role of hydroxychloroquine and zinc in combination.