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Bob Wachter+ Your Authors @Bob_Wachter Chair, UCSF Dept of Medicine. Career: What happens when a poli sci major becomes an academic physician. Latest book: The Digital Doctor: Hope, Hype & Harm... Jul. 10, 2020 5 min read + Your Authors

1/ Covid (@UCSF) Chronicles, Day 114

Medical Grand Rounds returns today: @YouTube here  We cover the state of the pandemic, opening the schools, and the San Quentin prison outbreak. My summary below, after a brief update on our local situation.

2/ Local update: not great. @UCSFHospitals, up to 25 patients, 10 vented. (Some were transferred from Imperial County & San Quentin.) Our highest # s since mid-April. Test positivity rate quite concerning: up 3x (for both symptomatic & asymptomatic pts) over past few weeks.

3/ In San Francisco, cases have stabilized a bit, averaging 43/day (Fig on L). SF hospitalizations up to 76 (Fig R), highest since early May. As with patients @UCSF, some are transfers from other counties, but most are from SF.

4/ On to George Rutherford presentation on the surges in CA and rest of country. @ 5:40: yesterday In U.S. there were 59,000 cases, highest ever. Now up to 3M cases in U.S., 132,000 deaths. These are staggering numbers.

5/ @ 7:15, George on CA surge, more in south than north. Still no spike in deaths, but we are seeing more deaths in AZ, TX, FL, so CA likely to see increase soon (Fig on L). Drivers of CA surge on R. (Note that Imperial County has had 500 pts moved to outside ICUs, incl. @UCSF.)

6/ @ 14:25, as prelude to Opening Schools presentation, George reviews epi evidence. Still seems like younger kids don’t get sick often, nor transmit disease much. Study in Iceland found 0/848 positive specimens in children under 10. However, 10-19 y.o.’s match adult prevalence.

7/ @ 19:55, in non-U.S. outbreaks, having child be the index case is very unusual, especially w/ young kids. Main concern is Multi-system Inflammatory Syndrome, subject of recent @NEJM publication: . Still rare but increasing incidence, so it's a concern.

8/ Next segment: Should and can we open the schools? Starting @ 31:30, Naomi Bardach and Liz Rogers, pediatricians @UCSF, discuss. While opening up is not without risks, it’s become clearer that risks of keeping schools closed are actually quite high, below.

9/ @ 41:20: Bardach notes main risk factors for kids are when community prevalence of Covid high. That said, at least for kids in K-6, “If communities do need to go back…to shelter-in-place, schools may be able to provide some in-person education w/ proper precautions/testing.”

10/ @ 43:50: High schools are likely different than elementary schools. Big outbreaks (including in Israel) are mostly seen with older kids. Still “benefits to reopening with safety protocols in place likely substantially outweigh the risks to teachers, children and communities.”

11/ @ 45:40, How do we open schools? (Fig, most important items in bold). “We know we can’t stop Covid but we can mitigate the risk of getting it.” If schools are making resource choices, cleaning and disinfecting likely lower yield than other activities listed on slide.

12/ @ 53:20: I ask Rogers (top R) how to counsel family w/ middle-schooler w/ parent with cancer. “It’s 1 thing to advise schools/district; it’s a different question how to guide a family to make decisions.” Some families may come in and out of school – based on individual risk.

13/ @ 54:30: I ask George about pooled testing. He makes point that you lose a little sensitivity. “I’m kind of a fan of it… but telling parents and school boards that we’re going to have a lower standard of detection just so we can do more tests is probably not going to fly.”

14/ @ 57:00: I ask how practical masking/distancing are. George says it’s going to be very hard to make it work for ages 2-6. At age 7, probably workable. Naomi: most worried about adult-to-adult transmission (ie teachers), not so worried re: little kids. Older kids: more risk.

15/ Turning to the massive outbreak at San Quentin prison, with Brie Williams @briewsf & David Sears. Begins @ 1:03:00: Figure on L shows poor, crowded living conditions at a SoCal prison. Quote on R from a prison guard.

16/ @ 1:02:50: Brie, director of @AmendatUCSF, which focuses on improving care/culture in correctional facilities, discusses report that she, Sears, & colleagues wrote on SQ. Note Covid rate in other CA facilities (CDCR), & rate in San Quentin: 428 cases/1000 people, remarkable.

17/ @ 1:03:30: Brie describes genesis of San Quentin disaster: began when 120 prisoners were moved by bus from Chino prison in SoCal (which had an outbreak) to San Quentin. (Sadly ironic, of course.) 14 tested positive for Covid-19 on arrival, and spread like wildfire.

18/ @ 1:04:30: 6/13 memo by Brie, David & @UCBerkeleySPH group ( ). “If you’ve been to Alcatraz, you’ve been to San Quentin,” she says, citing aging facility, poor ventilation, & crowding. Other problems: limited testing, and staff moving from unit to unit.

19/ @ 1:06:10: several recommendations in 6/23 memo. Key one was “decarceration.” (Brie prefers term: “Public-health focused depopulation”.) I asked her about this @ 1:17:45. “With incredibly overcrowded, unsanitary, & poorly ventilated institutions, we’ll have more spread….”

20/ She notes many prisoners are near end of terms & have low rates of recitivism. She believes risk of staying in prison outweighs benefit to them & society. “Covid has made us rethink the public health ramifications of this type of warehousing & overcrowding in our prisons.”

21/ @ 1:07:20: Now a staggering outbreak, ~1500 cases (Fig); test positivity rate up to ~75%, nearly unheard of. ~60 SQ patients currently hospitalized across Northern CA, including several @UCSF. Now ~200 infections among prison staff (up from 43 on 6/22). 7 prisoners have died.

22/ @ 1:09:25: A powerful quote by physician at San Quentin below. “They cleaned (their cells) like they had a chance. They never did….it’s not their fault.” @AmendatUCSF has put together advice for hospitals caring for prisoners w/ Covid: 

23/ @ 1:12:00: Some progress at San Quentin, shown below. CA Dept. of Corrections now doing statewide outbreak planning. >30 @UCSF clinicians/staff have already volunteered to help out at SQ.

24/ @ 1:21:10: David Sears, @UCSF ID doc and medical director for @AmendatUCSF, discusses what went wrong. “[The transfer from Chino] was definitely a medical error." The people who were transferred had tested negative, but the tests were done three weeks earlier.

25/ Hope you can watch, again here: 
Both schools and prisons illustrate how Covid has put all of our institutions to the test, & how we need thoughtful, evidence-based approaches to tough problems.

Back tomorrow to review some of the news of the week.

You can follow @Bob_Wachter.


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