This week's update is a real mixed bag. Digging into the infection spread this week, it's hard to be anything but depressed, knowing what's to come.  The good news this week is that the march towards a vaccine continues to make progress.

It appears we are in the middle of the upswing of a massive third wave. What's worse is that this is right before Halloween, the election, Thanksgiving, Christmas, and New Years. This wave will only be amplified by the holidays; as one commentator put it, "the next 12 weeks will likely be the worst we've seen."

The upper midwest and parts of the south see fully out of control epidemics. This isn't just more testing; hospitalizations are starting to rise dramatically across the board; some are beginning to hit capacity.

Governor Abbott of Texas has asked the military for the use of the Fort Bliss military hospital. Why? Because El Paso's outbreak is causing the local hospitals to hit capacity. Despite this, Abbott declines to take any real action to combat the epidemic. He's not willing to reimplement the restrictions he put in place this summer.

Mark Meadows, the White House Chief of Staff, said on TV this morning, "We're not going to control the pandemic…". This is just false! We can control the pandemic! California and other countries show we can do orders of magnitude better than we are as a country.  Outside of the genocides, there's never been a preventable mass causality event like we see today in the US. At this point, we could easily see another 100,000 deaths in the next quarter.

The people who die of Covid in the next 100 days are like soldiers who die in a battle after a cease-fire has been signed. Pointless, preventable deaths.

Israel also had a second wave and quickly implemented a second lockdown. It showed to be even more effective than the first, and they are already starting to reopen. California spent the last few months building out a best of class test and trace capability to continue to allow us to manage the spread. Boston implemented a septic tracking system that gives them an early warning for when cases begin to spike. The Trump administration could have coordinated all of this at a national level but chose not to.

Yes, lethality is down due to a better understand and a handful of widely available front-line therapeutics, but that won't save people whose' hospital systems have hit capacity.

We continue to find extreme long term effects from those that are infected but don't die. In some people having Covid can trigger type I diabetes. That's even before we've seen any actual long term effects. In other viral diseases, they can cause complications years, even decades later. 7-10 years after measles, you can get SSPE, which is fatal. Post-polio syndrome can occur 30+ years after having the disease.

What gives me hope this week is that science continues to come in with better understanding and progress.The great news this week is that both the AstraZeneca and Johnson and Johnson vaccine trials restarted. Both had an adverse event and paused, but it was determined neither had to do with the vaccine after further investigation. J&J continues to be the best long term option, in my opinion, because it's a single shot and doesn't require deep freezing.

The two leading contenders for the first EUA continue to be Moderna and Pfizer. Both expect to reach the data required in the next four weeks. Also, both require some pretty tricky logistics to deploy.

The FDA has released a plan for who will get vaccinated in what phase. The first wave, called 1a, will be first responders, ~5% of the population. For these 15-20 million people, the logistics of the first two vaccines shouldn't pose a problem. They are a group that will be compliant and can make an effort needed. This should buy time for the easier to distribute ones to get approved.

Besides the one-shot J&J vaccine, another one I'm excited about is called Novavax is in Phase III and doesn't require freezing. Novavax requires two doses and, if approved, will have enough data in January to apply for a EUA.

As we get closer to the EUA the unified approach to good science among the pharma companies will likely start to break down. Once the first one is approved, that company has very different motivations than the ones to come. There will also be discussions about later vaccines that could be more effective than the first few, but how the FDA handles the EUA will affect that.

Obviously, this is very complicated, and I'm going to dig into the nuance of it in the next few weeks. Overall I'm taking solace that it looks like we will have multiple vaccines approved before February 1st. It reminds me of the Manhattan Project, where they pursued two designs, hoping one would work when in the end, both did.

For every additional vaccine that gets approved, it will unlock tens of millions of more doses in the coming months, which means we can get to herd immunity that much faster.

This week there was also a report released that suggests that having the flu and Covid at the same time makes Covid more lethal. Go get your flu shot! Not just this year but every year!

Prepare yourself for the next few weeks. Case counts will likely rise, along with hospitalizations and deaths. It is preventable, but it seems many states are not choosing that path. Sometime in the next few weeks, we'll likely get the first authorized vaccine, which will signal that we've begun the end game. Once we have a vaccine, there will still be immense work to do to roll it out, but the logistics are known.

Take care out there.