MD, MPH; ID/HIV MD; UCSF (tweets own); No conflicts; Wrote book on COVID & pandemic playbook pub. Mayo Clinic Press called Endemic: A Post-Pandemic Playbook
A pandemic playbook-Lancet Infectious Diseases. "Gandhi underscores importance of compassion and empathy in public health responses, using the stigma & discrimination faced by those w/ HIV to advocate for more compassionate approach..flexibility crucial"
Does anyone besides me feel that the messaging over the last month in the US has basically served to terrify the vaccinated and make unvaccinated eligible adults doubt the effectiveness of the vaccines?
Okay, took me a long time to make this table (icons and everything) so please appreciate column 6. What protects from severe disease? T-cells! See this lovely article:
If virus totally toothless, defanged (Twilight references), vaccinated safe.
Child mask mandates for COVID-19: a systematic review -"current body of scientific data does not support masking children for protection against COVID". Hope MDs and public health officials will always be willing to change minds with evidence & data
7 reasons why think immunity to COVID from vaccination or infection will be long-lived (and why I continue to marvel that CEOs of companies who stand to make profit from boosters get to message that boosters needed; instead, please donate vax to India).
1. Memory B cells:
My concern about the almost-complete lockdown order in 5 counties in Bay Area is that it is similar to March, but we have learned so much about the virus since March! In March, a complete lockdown was indicated because we didn’t know if the virus was spread from surfaces;
Pfizer CEO said boosters may be needed. Unlikely
1) T cell immunity from vax (and Abs) work against variants; 2) T cells last long time- 34 y & counting after measles vax; 3) 1st SARS recovered have T cells 17 yr later; 4) Covid Vax generate memory B cells (lymph node biopsy)
0 hospitalizations for COVID-19 at my hospital (SF General) today after being 1-2 there for weeks. Cases 18 in city of 896K with lots of testing; test positivity rate 0.3%. 76% 1st vaccination rate; middle/high schoolers on Zoom & SF masking.
What's risk of getting COVID outside? VERY LOW. Previous meta-analysis showed outside transmission 20x less likely; this study shows just 1/1000 cases (0.1%) traced to outdoor transmission. States (CA, low cases) could peel off outside mask mandates now
SOCIAL ISOLATION LINKED TO POOR HEALTH OUTCOMES, CDC: Recent report found social isolation associated with about a 50% increased risk of dementia, a 29% increased risk of heart disease and a 32% increased risk of stroke; ways to address for our health
The risk of children under 18 developing serious illness or dying from Covid-19 is very slim, said researchers, who found a death rate of 0.005% in England—lower than initially thought via
@WSJ
CDC keeping track of breakthrough infections in U.S., rate remains astoundingly low. Out of 87 million fully vax, only 5079 symptomatic breakthroughs (0.005%) & only 0.0003% hospitalizations related to COVID-19 & only 0.00009% deaths related to COVID
I am so sorry; this virus & some messaging has invoked so much fear. Someone emailed me today with a lot of fear that news stories on variants means vaccines won't get us back to normal life. They will, I promise. Human contact, normal interactions, all of this will happen again.
CELLULAR IMMUNITY and IMMUNE MEMORY: Would like to explain this bit more (simply I hope) with some key recent papers although there are so many. First of all, remember we have B cells & T cells to protect us. B cells produce antibodies & T cells attack specific parts of pathogen
Wanted to drill down a bit more about the importance of the T-cell response to SARS-CoV-2 to give you more reassurance of enduring protection from vaccines (even against variants). Technical article here but CD4/CD8 cells have role in both acute infection
Now that science has defanged the virus with vaccines & therapeutics (and Omicron added so much more immunity), this is what UK public health officials say - return to normal, protect vulnerable; UK lifted mask mandate for all, including schools, yesterday
REINSTATED: City of Chicago Employees Fired For Refusing COVID Vaccine Must Be Reinstated, Judge YES: Vaccines no longer prevent transmission, infection confers immunity, high degree of population immunity now (should also stop vax US entry requirement)
Article where I try to explain the immune system and immune response to COVID-19 vaccination as simply as I can with a past look at other infectious diseases pandemics and how only immunity can get us through
Today, I withdraw my support on Gov Newsom's vax mandates for kids; Bay Area counties said will release mask mandates for adults 8 weeks after 5-11 vax but CADPH/CDC says not for kids; AGAIN IN CA, KIDS MORE RESTRICTED THAN ADULTS (bars>>>schools). NOT RIGHT
@medpagetoday
no, the study was methodologically flawed of which you speak
@medpagetoday
- please please we have to regain trust in public health by not amplifying such studies. we have polio in NY - please understand, this lost of trust is real & our duty to combat
Epidemiological update: Omicron continued reporting from EU CDC equivalent as of 6 December. "All [Omicron] cases for which there is available information on severity were either asymptomatic or mild. No deaths". Immune system more than antibodies
"Roughly two-thirds of patients who have tested positive at hospitals run by the L.A. County Department of Health Services were admitted for something other than the coronavirus, according to Health Services Director Dr. C. Ghaly". Similar to SA paper tweeted yesterday (63%)
Third lab now to show omicron less pathogenic (see earlier threads for other studies), likely explaining findings around world (with increased immunity)
BREAKING🎄 The 6th preprint from G2P-Japan -
#Omicron
is less infectious and pathogenic than
#Delta
and even an early pandemic SARS-CoV-2 in infected hamster model. 1/5
Israel & UK children back in school (actually no masking, distancing because that is what rapid vax gets you) and today, CA indicated there is no guarantee we will be back in fall & there will be mitigation/pandemic measures. Something unscientific here.
This is sobering: UCSF Benioff Children’s Hospital has seen a 66 percent increase in the number of suicidal children in the emergency room and a 75 percent increase in youth who required hospitalization for mental health services.
Reinfection so rare: Rate of re-infection (with symptomatic disease; you wouldn't even know if asymptomatic if no test) after COVID-19 vax? Super rare. 102 breakthroughs among >1 million people vaccinated in WA so 0.001% (0.00001); only 1/10 of those sick
MASK STUDY, SPAIN: "Face mask mandates in schools not associated with lower SARS-CoV-2 incidence or transmission, suggesting this intervention not effective. Instead, age-dependency was most important factor" on transmission risk in school. CDC data on age-stratification below.
Very happy to share this preprint!!!
@copedicat
@BIOCOMSC1
Unravelling the Role of the Mandatory Use of Face Covering Masks for the Control of SARS-CoV-2 in Schools: A Quasi-Experimental Study Nested in a Population-Based Cohort in Catalonia (Spain)
@SSRN
outside, is not data-driven. Decisions that are non-data driven, despite the public knowing so much more about the virus as well, will erode trust in public health officials and foster noncompliance with such orders. This can drive people indoors who used to gather outdoors
SCHOOLS: "Dr. Carlos del Rio, interim dean at Emory, said public health experts didn’t foresee the effect of learning loss/isolationism on students. That impact could be the most long-lasting, UCSF professor Dr. Mark Smith said...We made a mistake with schools,” del Rio said. “I…
“We test anybody who’s admitted to the hospital .. to see whether or not they have Covid, and we’re definitely seeing an increase in cases. However, we’re really not seeing an increase in children who are hospitalized for Covid”
via
@nbcnews
Here is a good example of what we mean by severe disease "uncoupling" from cases in the setting of vaccination. UK data below. Cases rose, but severe disease did not. Not completely delinked, but almost.
Please allow me to go back to this question of "do vaccines prevent transmission?". What do vaccines do? Stimulate antibody (from B cells) and T cell responses (not often measured) and then a "boost" of 2nd dose helps stronger memory B/T cell to form.
HI
@sdbaral
, as you know, I have tried to be civil on twitter & have never sworn (I am from Utah), but I am sorry - you are so right. This is completely awful and so wrong for any geopolitical relations. Please lift this travel ban now.
Why am I talking about end to masks and distancing (some others are not?). Because it is job of a good ID doctor worth their salt to talk about ending mitigation when no longer needed. In HIV, we say End the HIV Epidemic, Getting to Zero, for motivation. Mass vax will end masks
"Omicron could be the first step for the virus to adapt to be more benign" (cold like symptoms). With 1.7 million cases in UK, hospitalizations, deaths, severe cases remain low
"Significant weight gain occurred during the COVID-19
pandemic among youths in large health system in S. CA, especially among the youngest children. These findings, if generalizable to the US suggest an increase in pediatric obesity due to the pandemic."
@ZDoggMD
@TikTokSupport
The level of censorship and lack of tolerance for nuanced scientific discourse during this pandemic has been really disturbing.
Since this is largest study of re-infection (albeit with the 3 week Pfizer vax which probably has lowest antibodies) and shows that natural immunity confers strong protection from re-infection (& 1 dose helps), US at this point needs to consider immunity rather than vax passports
MASK MANDATES: Good summary
@LizHighleyman
/
@Slate
Cochrane review. Bottom line: Maybe work at individual level, doesn't meet level of evidence at population level (need more studies) to mandate even in healthcare: "maybe let people decide for themselves"
Provincetown outbreak: analysis by retired MD who was there. Misinterpretation by CDC/press "increases fear in vax'd, when fear is unfounded. And sends message to unvax'd that the vaccines aren’t working". Viral load in vax'd not same as infectivity
As summarized yesterday, Omicron 80% less likely to cause hospitalizations for COVID-19. Problem with a highly transmissible variant if you swab everyone's noses in hospital (which we do) is need to distinguish between being there WITH vs FOR COVID
APOLOGY & PRIVILEGE: As I get closer to date of downgrading twitter, I want to apologize to my fellow MDs for anything I said on here that was too fast, not backed up by data, or plain wrong. And I want to say what a privilege it has been to learn from everyone here! Thank you!
PANDEMIC BABIES: "uptick in developmental delays and challenging behaviors in children belonging to the “COVID generation.” Born during or shortly before the pandemic, many of these children are talking, walking and interacting later and less frequently"
"CDC cited a study from New York state that showed the mRNA vaccines’ efficacy against any infection had declined to 79.8%. But that same study showed protection against serious illness was still above 90%. For many experts, it was evidence not of a problem, but of a success"
The mixed blessing of the 95% VE: When Pfizer & Moderna reported late last year that their Covid vaccines were highly effective, our expectations for these vaccines soared. It's time for us to get more realistic about what the vaccines can do.
Updated CDC 4/24/21: Out of 87 million fully vax only 5079 symptomatic breakthroughs (0.005%); only 0.0003% hospitalizations and 0.00009% deaths related to COVID| Great article
@DrLeanaWen
: The covid-19 vaccines are an extraordinary success story.
Yes thanks; good UK data; similar data from Denmark today 1st 785 Omicron cases: 76% were fully vaccinated, 7.1% boosted, 4.3% prior infection. Severity much lower than what was seen with delta: 1.2% of cases were hospitalized; 0.3% ICU; no deaths
"Still early, but so far only 65 Omicron hospitalizations in the UK. Symptoms in vaccinated are mild (runny nose, headache, fatigue, sore throat) and shortly lived. Matching symptoms to South Africa"
Dr. John Campbell
@MonicaGandhi9
@thehowie
#Omicron
ENDEMIC: Received copy today with dedication to late husband; Book is on exactly what you would expect:
*
#harmreduction
in pandemic responses (e.g. school closures, closing other med care, not allowing visitors in hospital)
*Power of
#biomedical
-advances to get back to normal
Inaccurate; not ok for doctors to not treat the unvaccinated; MDs taught to treat patients with compassion, provide best care possible (if you see the Atlantic article I wrote on antivirals, unvax'd is one of the biggest reasons to get Paxlovid out now)
BREAKING NEWS ON DELTA VARIANT (except not really, preprint was posted PHE on June 14): Vaccine effectiveness against hospitalization with delta was similar to that seen with alpha - 94% after 1st dose, 96% after 2nd dose Pfizer. 71% after 1st dose with AZ; 92% after 2 doses
If I could message, I would start with history of infectious diseases, how the immune system works, how the vaccines are working well if you understand the immune system, and how (like Europe) we can get back to normal life with vax
San Francisco just extended stay-at-home orders indefinitely which is not indicated by CA state parameters or current rates of hospitalizations/ICU capacity so I hope New Year will bring SFDPH and Mayor to start considering the loss of jobs, impact on poor, overdose deaths, etc.
I just realized that maybe re-infection even with mild symptomatic breakthroughs more common in Israel/US than UK/Canada because former opted for 3 weeks between vax doses instead of 12 & then 8 weeks in UK/Canada (longer duration increases antibodies)
These days in U.S., asked what end of epidemic would look like & I wanted to explain why COVID - once controlled- will be more like measles (where public doesn't think about every day) than influenza (where public does think about in winter). COVID has highly effective vaccine
Why should we not worry about VARIANTS "escaping" immunity from vaccines or natural infection; why are we not likely to need vaccine BOOSTERS? Remember immunity is both antibody and cell-mediated (CD4 and CD8 cells). Long-term immunity mediated by memory B & T cells (both get
DELTA variant. To discuss this, let's actually start with discussing the spike protein of the virus. Remember, the spike protein of the virus is how the virus binds to our host cell. The spike protein is the protein that is encoded by the mRNA & adenovirus-DNA vaccines (J&J)
Think 3 biggest mistakes of US response to COVID was 1) closing schools for so long in many places, disrupting after; 2) not allowing family to see their loved ones in hospital; 3) (important for next pandemic) - not providing other medical care
Omicron spike in San Francisco is confirming data from South Africa: high case numbers but little to no change in hospitalizations. There's no rationale left for continuing to organize our lives around this virus.
MGH study: "The societal and lifestyle disruptions caused by the pandemic may have triggered inflammation in the brain that can affect mental health, according to the study. The impacts manifest as symptoms including fatigue, brain fog and mental distress"
Someone asked me yesterday why schools aren't mainly open in San Francisco (despite 30 cases in city of 896K yesterday (& they test), <10 hospitalizations) or California (hundreds of thousand of tests done, 1400 cases in state of 40 million, lowest case rate in nation).
Well, outside is really safe and you don't want people to hold their breath for too long for pictures so maybe just trust our high immunity in the state of CA like Denmark, UK, France, Finland trusting theirs.
Tuberculosis deaths rise for the first time in more than a decade due to the COVID-19 pandemic- we have seen this with malaria and destabilization of HIV outcomes too
Please consider signing our petition to get excess doses of excess mRNA vaccine (after ensuring enough for US) to India from the US given the public health emergency unfolding in India right now; vaccination rate in India must quickly increase
I know that 8% missing their 2nd shot seems like a lot but 92% coming for 2nd shot in the greatest mass vaccination campaign in history seems like an incredible success to me
Updated CDC breakthrough data:
Out of 154 million fully vaccinated individuals in US:
3187 COVID-19 hospitalizations (0.002% breakthroughs)
656 COVID-19 deaths (0.0004% or 4 in a million)
Omicron COVID variant was in Europe before South African detected & flagged for world. Agree with AztraZeneca -no evidence vax doesn't protect from severe disease with variants (AZ less profit oriented); 2) S. Africa scientists that they felt 'punished'
TOOLS TO KEEP COVID ENDEMIC NOW HERE: Long thread to explain that we now have all the tools necessary in the US to keep COVID in the endemic & out of the emergency phase. At this point in the pandemic (May '22), world & US seeing its lowest number of COVID deaths since March 2020
Good to see that 22 peer reviewed studies find temperature screens for COVID-19 not useful as we can hopefully turn our attention to other strategies (vax being most important) G
"California schools: Get Covid shots or go back to distance learning "- I don't agree, CA. Yesterday showed us how angry parents were at Democrats endorsing school closures; don't go back to virtual. Please don't restrict kids (less at risk) than adults
Therefore, to institute the same measures as in March, including shutting down of playgrounds (despite lack of evidence on surface transmission), outdoor dining (where there has been no data to show that this is unsafe), and prohibiting members of different households to gather
OMICRON: Hospitalizations from Omicron compared to previous waves, large study, S. Africa:
-63% of patients hospitalized had incidental COVID (in nose, not there for COVID)
-Of those with COVID, 45% needed oxygen compared to 99.5% previous waves
Not only am I not convinced we have the science yet to recommend booster shoots for everyone but I am very worried about
#globalvaxequity
and how the Biden Administration could donate some of our >>300 million doses to help vaccinate teh world
New roadmap for pandemic, 2022. Written with
@JeanneNoble18
(ER MD); Discusses no more school closures; who needs masks and which ones but no more blanket mask mandates; booster nuance with young men/previously infected; rational testing;
#globalvaxequity
"Respirators/ other high-quality masks are highly effective at protecting their wearers, regardless of what people around them are doing ('my mask protects you and your mask protects me’ is obsolete). Allows for masks optional for students & staff
I am so sorry about this long-lasting pandemic & the curveballs of a virus as immunity rises; may we all have a better 2022 from an author of a book about a plague. See you then & please please
#globalvaccineequity
CALIFORNIA SCHOOL CLOSURES (CA was 50 out of 50 states in re-opening) - 'Students harmed by remote learning inequities can take California to trial, judge rules"
via
@sfchronicle
Important study showing how rare reinfection and COVID severe disease is after recovered COVID. This analysis excluded those who got vaccines. Adds to our growing list
No time in history do we have this extraordinary detection of asymptomatic infection since latter can transmit to others. So, please be assured that YOU ARE SAFE after vaccine from what matters - disease and spreading. Two vaccinated people can be as close as 2 spoons in drawer!
These virulence studies showing Omicron may be more mild not only due to increased immunity in population but something to do with its viral pathogenesis are fascinating
2. Omicron Spike protein induces relatively poor cell-cell fusion compared to WT and Delta. We expressed spike in cells stably expressing split GFP, so that Green signal could be measured over time upon cell-cell fusion and syncitia formation. The difference is significant.
And one more thing but after the phrase "we are going to lockdown", the next clause should be "and this is how we will support workers/businesses". At federal, state, city level.
Very hopeful if true. I was researching all the theories about how influenza 1918 ended (lower virulence vs higher immunity) and will post tomorrow. In 2021 we can do virulence experiments too
1 of 6:
#Omicron
- Is this the end of the pandemic?
No restrictions will be needed to protect hospitals in any way in any country.
Gauteng, South Africa has peaked with case levels similar to Delta, but with deaths expected to be 25 times lower.
Mask mandates (hope CDC will say tomorrow):
1) No outdoor masking (unless in rallies, packed stadiums until Ro<1 in your region)
2) Indoor masking mandates end when all >16 has opportunity to get 2nd dose (can recommend masks, people can choose, but can't mandate)
ASYMPTOMATIC SPREAD OF COVID: Systematic review shows most spread (>80%) actually when patient is symptomatic, putting it on par with other respiratory pathogens like flu (flu more contagious with symptoms)
MASKING CHILDREN: Masks seemed like good idea at beginning of pandemic of new pathogen; but we have to admit (to regain trust in public health) that the best quality data does not show mask mandates effective (of course anyone can wear fit/filtered mask)
Wanted to explain concept of CONTROL vs ELIMINATION (& eradication) with an infectious diseases, why getting immunity up in a population can get us to control, & why living with a controlled infectious diseases is very manageable (and no longer problem of the public just ID MDs)
I genuinely with all my heart apologize for anyone who continues to try to scare you about variants; we have been through so much already. This is not like coming down from another surge; this time we have the increasing protection from vaccines as cases/hospitalizations drop
@eickelhoft
Everything rests here on fundamental understanding of immunology
#covid19
*Main arm of immune system that fights viruses T-cells
*T-cell responses to vaccines unfazed by variants.
*T-cells turn variant-disease into mild
*Variants will not deter progress
I am very excited to get off twitter in a few months once this is over as such a politicized pandemic. I have been grateful to all of you, however, for teaching me so much about different viewpoints & how to be nuanced in a pandemic
@VPrasadMDMPH
, I am beginning to realize how much wrong we did in this pandemic & I don't know what to do but keep on writing immunology after immunology thread to try to convince people that vax + natural immunity means we are ok now
Nate is 100% right.
Denying a vaccinated! 15 year old this opportunity to socialize after a year of isolation and existential suffering reflects a misunderstanding of risk and benefit that has been promoted on this website and in the media
I'm sorry for both child & parents
NU VARIANT (B.1.1.529) in South Africa & why unlikely to evade vaccine-induced immunity. So, what is this variant? Number 1, we don't know yet if it is more transmissible. Still being studied & described. 59 cases uploaded to database
Good thing that antibodies are just the tip of the iceberg when it comes to immunity and protection from an infection. Years of immunology research have shown us this so let's not use the words "waning immunity" but "waning antibodies" (normal, not a glitch; you have B/T cells)
Not good news. We knew the burst of antibodies after a booster would be temporary, but hoped the longer spacing between doses might lead to more sustained immunity. Still, memory B-cells & T-cells should protect against severe illness.
Good. We need this kind of breakdown everywhere with such a transmissible variant that can be in the nose and universal screening of all admitted patients for Covid in hospitals
Across the Jackson Health System hospitals, we currently have 327 patients who have tested positive for COVID-19.
Of those, 187 patients – or 57 percent – are admitted to the hospital primarily for non-COVID reasons.
I predict as cases fall with vaccination in each state/city, public health officials will look at data and remove masks mandates in the outdoors first (unless in crowded places). Given the low risk of transmission outside, makes a lot of sense: