This week we set records for the largest number of new daily cases, and next week we'll cross more than 100,000 new daily cases detected. Given our current nationwide test capacity, there are probably 5-10 times as many cases per day as we're catching. The federal government and many state governments have decided that stopping covid is no longer something they care to solve. We are still several months away from the first round of a deployed vaccine, so prepare for one of the darkest winters of our lifetimes.

In Idaho, the lieutenant governor appeared in a video that claims the pandemic "may or may not be occurring." In Utah this week, they said they expect to start to ration care in the new two weeks.

In the last few months, we've seen a lower fatality rate partially due to a few factors. We have discovered some therapeutics and learned better how to treat Covid. Still, a huge factor has been that we've had excess hospital capacity. In NY, in March / April, many of those who were dying did so merely because there wasn't the ability to treat them in any way.

Rationed care, triage care, whatever you want to call it, the rules are simple. You are out of capacity, and you pick the patient who is most likely to survive and let the other die. What's worse, if you have the misfortune of getting sick with something not Covid related in these areas, your odds of dying are significantly increased.

Europe is also entering a new wave of infections. London, France, and Germany have announced one-month lockdowns to get their epidemics back under control. Notably, there isn't even a discussion of implementing prevention measures in many states with the US's worst outbreaks.

There is another way. It's practically a pasttime to lament poor governance in California. Still, the response here to Covid has been the best of class. Our Governor, Mayors, and health experts have worked hand in hand to keep us safe.

Over the last six months, California has built out the infrastructure we need to test, trace, and isolate cases. This past week the Governor did a ribbon-cutting for a new facility that will double (!) the state 48-hour test capacity from 150,000 to 300,000 tests. That means we can test nearly 1% of the entire state every day, incredible work.

Beyond that, UC Berkeley announced that it's expanding the pilot to test wastewater in the Bay Area, now covering 2 million people. Wastewater testing has been showing to be one of the few leading indicators of infection spikes. Although I wish we would have had it sooner, it will allow us to continue the reopening dance and slow down when things start to spike.

It's not just the testing; it's using it to reopen smartly. The four-color system is simple but allows us to dance the Hammer and Dance essay from early in the pandemic. Just this week, SF announced a pause on reopening due to a slight increase in the case count, a measured, responsible decision by the city.

The vaccines continue their march towards certification. Moderna and Pfizer, our two leaders, both continue to signal they expect to go for a EUA in mid to late November.

AstraZeneca says phase II showed it to be effective in the elderly and fewer side effects [reactogenicity] than in younger ones. This is good news as the elderly will be an early priority. They also announced they have a capacity of 1.5 billion doses in 2021.

Vaccines often need to be specially crafted for children due to the differences in their immune systems. This week J&J joined Pfizer by saying they will begin testing in teens [12-18]. The more of the population we can inoculate, the faster we can get to herd immunity.

As vaccines get closer to EUA's, the next item to watch is distribution prep. It will come as no surprise that the states taking Covid most seriously are also the ones that are starting to get ready for approval. This matters because it's likely that many places won't have done the prework needed and, as a result, won't get much allocation because it will be wasted. California released a detailed report of their prioritization, and detailed work is ongoing on the cold chain.

In therapeutics, data from both Lilly and Regeneron showed their monoclonal antibodies not to be as effective as hoped, especially in extremely sick patients. Obviously, this is disappointing, but this is why we do trials; there are others in testing.

This week several reports suggest that children, especially teens, are as susceptible to illness and spread as adults. It seems like previously, the small amount of testing done made it appear they were immune.

This week, a European detailed test and trace analysis showed a significant spread event on a plane. The flight was only at 17% occupancy, and still, over 13 people from it tested positive. The various subgroups came from different countries, but it's unknown if they got it at the gate, on the ground, or in the air.

On Tuesday, we will have an election, and it will probably be chaotic. I'll be heading off-grid for a few days. My logic is that I can't influence it, and watching it will be stressful. I understand not everyone has that option, but I would encourage you to do your best to limit your viewing, binge a movie, or catch up on a show.

Either way, it'll be a hard few weeks. Take care out there.