Welcome to an expedited episode of The Podcast by KevinMD. Monica Gandhi is an infectious disease physician and co-author of the New York Times opinion article, “Why Hospitalizations Are Now a Better Indicator of Covid’s Impact.”
Kevin Pho, MD: Hi, and welcome to the show where we share the stories of the many who intersect with our health care system, but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today in the show we have Monica Gandhi. She is an infectious disease physician and the director of the Center for AIDS Research at a university of California, San Francisco. And she’s a co-author of the New York Times opinion piece, “Why Hospitalizations Are Now a Better Indicator of COVID’s Impact.” Monica, welcome to the show.
Monica Gandhi, MD: Thank you so much.
Kevin Pho, MD: Now for those who didn’t get a chance to read your New York Times opinion piece, can you just summarize some of the key points?
Monica Gandhi, MD: Yes. So essentially, it was entitled, “Why Hospitalizations Are Now a Better Indicator of COVID’s Impact,” but what it was talking about is that the beginning of the pandemic, almost two years ago now, we tracked cases very closely. And the reason we did that, is that hospitalizations essentially followed a parallel sort of curve as cases. Certainly not everyone who was a case of COVID got hospitalized. It was more in vulnerable patients, older people, but it meant that as our cases went up, we could see hospitalizations across the country go up, and then the vaccines happened.
Now we’re at the one-year anniversary, actually, it’s sort of fascinating. It was December 11, 2020, was the first EUA issued by the FDA for the Pfizer vaccine, so this was published on the one-year anniversary of that. And with vaccinations, we’ve seen that cases go up, but at least in highly vaccinated regions, hospitalizations do not follow suit.
And in fact, the Delta variant really showed us this very clearly, that around the country, low-vaccinated regions cases and hospitalizations went up in the same way, high vaccinated regions like San Francisco Bay Area, cases went up but hospitalizations stayed low. And that decoupling of hospitalizations from cases is because the vaccines really prevent severe disease, which is what we’re all sworn to protect.
And so the final bit of the article is to say, let’s track hospitalizations for our metrics of how we impose or take up and take down restrictions like masking. So for example, in Marin County, the health officer said, okay, I’m going to release indoor masking. And he did it a month ago. Omicron came, cases have gone up, but the hospitalizations are staying very low. There are five hospitalizations in the entire county. So he said, I’m not going to put back masks because I’m going on hospitalizations. And San Francisco, right, five miles south have said, well, we’re keeping on indoor masking. So that’s kind of all over the place in terms of our recommendations.
And then finally, the reason that we wrote this is the impact on children and their restrictions is quite high in the United States, especially with school closures, and a case in a child does not actually mean the same thing as a case in an unvaccinated older person. So it will also allow us to put our focus back on where the vulnerabilities lie with getting COVID severe disease after vaccination.
Kevin Pho, MD: You wrote in a piece that America is in the slow process of accepting that COVID-19 will become endemic. What does it mean for COVID to become endemic?
Monica Gandhi, MD: Well, what it means to me is that this is a highly transmissible respiratory virus. With each variant, we get more transmissibility, it seems, and it’s really impossible to eliminate or eradicate a virus like that. It isn’t, actually, for lack of trying, to be fair, Australia, New Zealand tried elimination strategies, but it really is impossible. It just goes everywhere and it spreads very readily. And so that’s what endemicity means that we live with a number of respiratory viruses, influenza, parainfluenza, RSV, multiple respiratory viruses that tend to get worse in the winter because we’re around each other more in the winter, tend to get better in warmer climates. And we live with them, but what we have to do with COVID is defang it, take away its ability to cause severe disease, because that’s why we shut down all of society.
And the vaccinations have really done that to a large degree. And for those who are unvaccinated, and choose that status, we have treatments, oral treatments coming. And then finally, we have to get more global vaccine equity to prevent this everywhere. But it means living with it, and endemicity means it simply doesn’t have the properties to eradicate. It has an animal reservoir. It looks like a bunch of other different respiratory ailments. It has a long infectious period, all three of those characteristics make it unlike smallpox, which was the only infection we could eradicate.
Kevin Pho, MD: Now learning to live with the virus long-term, you write, it’s going to require changes in both mindset and policy. Now, what are some examples of some of these changes that you’re talking about?
Monica Gandhi, MD: Well, you know, we have been living on tenterhooks for the last two years. A lot of nervousness if there’s a new variant, or cases are going up in a region. And by that fear, I think we have really made it difficult for people to make sort of wise risk calculus decisions. Like if they want to be together, even if they’re fully vaccinated, there’s still a lot of fear. And that came about with the Omicron variant.
I think that the other second thing is when you look at the risks and benefits of any intervention that you’re imposing on society for public health problems. So we basically close schools in this country, more than U.K. and Europe, at least in the blue states. And that was an intervention that was imposed because we thought that there was a benefit to slow community transmission.
It didn’t end up benefiting community transmission in any study. Schools being open, especially with mitigation procedures, were not dangerous in terms of community spread, but beyond that, it led to collateral damage. And what’s the collateral damage, mental illness increasing in children, eating disorders, learning loss for many. And that becomes a collateral damage aspect of the pandemic.
And so this two years in, now we have to say, if we learn to live with. The virus, what we do as a public health field is we do everything we can to prevent disease. That is so important. Prevent people from getting sick. We have a bunch of unvaccinated people that we still need to focus on in this country who are very susceptible to severe COVID, disabled people, not working people who are on disability. People also, who are retirees, who are not part of a vaccine mandate. Many, many, 10 to 20 million in that category alone, let alone those who’ve declined.
And so it’s really focusing on disease, now. We’ll still track cases, but this is actually what we do with influenza all the time. We track cases in health departments, but the public doesn’t know about the cases. The public knows about hospitalizations. And health departments are tracking cases to figure out, oh, wait, we now need a booster shot. We now need to get serious, there are cases that are going up here. We need to do some more things, but it doesn’t become the public’s responsibility to look at cases.
Kevin Pho, MD: Now you mentioned Singapore, which is beginning to track hospitalizations over case counts. Can you talk more about that?
Monica Gandhi, MD: So Singapore is a very highly vaccinated country. I believe it’s 87% vaccinated. And because the virus is so transmissible, even despite quite a bit of other public health measures, masking, and capacity limits, and everything else, they saw that with Delta, their cases were still going up. They were mild or asymptomatic, just detected on surveillance screening. And they made a decision that their hospitalizations were staying low, and that what the public would know about then, and what they would report to the public, is hospitalizations.
And now the public no longer has the case counts every day, even though health departments do. And the public’s watching hospitalizations and they’re feeling, oh, okay, I’m seeing our highly vaccinated region have this low amount of hospitalizations, that makes me feel safer going into the winter and being around each other. And then the case counts are being tracked carefully by health departments. And they made this decision, I think, about a month ago. And they were very emblematic in a way with what happened with Delta because kind of like the Bay Area, they had a lot of cases, but they were so highly vaccinated, they didn’t see an impact in hospitals.
Kevin Pho, MD: Now, one of the things that you imply was perhaps regional criteria for restrictions based on that region’s vaccination rates, because as you know, the vaccination rates in our country, they vary wildly. So in your ideal situation, or your ideal world, how exactly would you report this?
Monica Gandhi, MD: You know, that’s a great question. We didn’t put that in the piece, and I’ve been thinking about that a lot. It does seem that 80% vaccination rate among those eligible, and in most countries, it’s 12 and up, really has kept severe disease low in the Delta surge. And even 75%, there was a B-cell immunologist at the University of Rochester that actually tracked this for us, but it seemed like 75% to 80% was the kind of ideal vaccination rate. If you couple that with also hospitalizations rates being low, so say a vaccination rate of 75, 80% and a hospitalization rate of five to 10, over a hundred thousand. That’s at least the two criteria that Marin county is using for their mask mandates in their restrictions. So they’re almost approaching 90% vaccination, but they have about one over a hundred thousand people in the hospital. So putting those two together, if you want to come up with a vaccination rate and a hospitalization rate, I do 75 to 80% for vax, and hospitalization five to 10, over a hundred thousand in the hospital.
Kevin Pho, MD: So what about natural immunity? I see studies all over a map on this from people who promote boosters, and people who are less enthusiastic about boosters, but from your best interpretation of the data, where do we stand in terms of natural immunity, especially with the Omicron variant.
Monica Gandhi, MD: You know, I’m not sure exactly what happened in this country, but most countries are acknowledging the sort of biologic fact that recovery from infection also confers protection against infection. And we have very good studies now, I think probably the most notable one, I’ll skip the Israeli study because I think there are some interesting differences between Israel and us that they only use Pfizer and whatnot, but I think the best study was the Cleveland Clinic study that looked at healthcare workers over, I think, 50,000 employees in the Cleveland Clinic setting, and looked at those who had recovery infection, vaccinated, and compared those two. And the rate of reinfection was actually lower among those who had recovery from natural infection. Certainly, those who were unvaccinated, or didn’t have infection, were at very high risk of getting infected. So that’s probably the best prospective study. There was a case-control study by the CDC that wasn’t actually very well done just in Kentucky, so that wasn’t methodologically that great.
Monica Gandhi, MD: And then there’s a Lancet ID review that really went over all the studies, immunologic, but also the clinical studies. Really looks like protective immunity is kind of the same essentially from after recovery, versus getting two doses of the vaccine. So it’s something that we have to reckon with in this country.
Switzerland is saying, OK, if you’re naturally infected fine, you can get into your equal passes, if you’ve had vaccination out to 365 days, and then we’ll reevaluate. Germany actually has quite harsh lockdowns on the unvaccinated, but they make exceptions for those who have recovered in terms of going into restaurants, whatnot. And this is actually all over the map in Europe. Almost all countries of acknowledged natural immunity. So I think it has to be acknowledged here because it’s reaching kind of a shriek, you know, of people feeling upset, including infectious disease doctors are like, yeah, I mean, we’d love you to get vaccinated. But let’s admit it, if you’re recovered, there’s a lot of research that shows that you’re protected.
Kevin Pho, MD: Now my Twitter feed, and I’m sure on your Twitter feed, I’m seeing a lot of public health officials saying that fully vaxxed now means three vaccines. What’s your take on that?
Monica Gandhi, MD: You know, I definitely think that I agreed with the FDA and the CDC, ACIP, at the beginning. Over 65, those who are immunocompromised, those who are around immunocompromised or multiple medical conditions, need a booster. And then I really looked at the New England Journal Israeli study, and the most benefit for a booster was after the age of 50.
And the Omicron variant to me doesn’t change that equation, because there’s just a T-cell paper yesterday, actually from NIAID, from the NIH, that shows us that T-cells are just completely unfazed by the Omicron variant. In fact, only one T-cell was perturbed across the entire spike protein. So those 32 mutations across the Omicron variant don’t hurt your protection against severe disease manifested by T-cells. And neutralizing antibody studies are just one part of the tip of the iceberg for immunity, but we have B-cells and T-cells.
So I don’t think we have the data for the entire swath of the population. And certainly not down to 16, 17, which was approved by the CDC director the other day. And the reason I say that is, to be fair, there are some adverse effects of the vaccines of rare clots in Johnson and Johnson and all the adenovirus DNA vectors, rare myocarditis in the mRNA vaccinations. And a young man, 16, fully two-dose vaccinated, we don’t have any data that shows that a third dose is necessary for their protection, or that it’s safe. So I would rather wait for clinical data on the younger who are healthy and immunocompetent, than make that recommendation. I know there have been statements that that’s going to be called fully vaccinated, but we’re kind of an outlier in multiple ways in the US. And that would be quite an outlier from every other country.
Kevin Pho, MD: So I just want to follow up with that because I have a 16-year-old daughter, and of course, Pfizer just expanded their emergency youth authorization to 16 to 17-year-olds. So are you saying that this is an individual family decision, weighing the lack of data versus the potential side effects? Or is this something that you’re recommending, just waiting a little bit until more data comes out? What are you telling your patients?
Monica Gandhi, MD: I would say absolutely an individual family decision. If I were in your shoes, I would feel more comfortable with a 16-year-old female getting vaccinated, a third dose, than a 16-year-old male. I just advised someone the other day that if they want their 17-year-old to have the third dose who is male, I would do a Johnson and Johnson because of the, again, rare risk factors that seem to be sex-specific with each vaccine. But I think it should be an individual decision until we have the clinical data, and you can make yours, and I’ll make mine for my 13-year-old. For example, if they ever go down to that, I probably, since they’re males, I’m not going to get them the third dose. I’m happy with the second.
Kevin Pho, MD: So getting back to your opinion piece. So what are some of the obstacles preventing us from emphasizing hospitalizations over case counts?
Monica Gandhi, MD: I think there are two, number one, I want to stress that we in no way are not saying follow case counts, very important for health departments to do. It’s actually what influenza surveillance does. We’re doing the opposite that we do with influenza surveillance, and we wanted it to go more like influenza surveillance now that we have vaccines.
But number one, I think one issue is that we don’t always classify hospitalizations accurately, as you well know, because you’re a physician. We swab everyone’s nose who gets admitted to the hospital, in most centers, for COVID for infection control purposes. And they may be there for something else, but they have COVID on their ICD-10 list because it’s in their nose. And then that gets classified as a COVID hospitalization. That’s a misclassification if it was just in their nose and they were there for something else. So we need to be able to know what they were there for, are they asymptomatic with COVID, that’s not a COVID hospitalization.
I think the other barrier, and I think this is something that I’ve gotten a lot of concern about, is let’s think about long COVID. And I think that that’s terribly important, that at least what we’ve seen with long COVID, is that those symptoms are more after severe COVID not after breakthrough infections, mild breakthrough infections after your vaccinated and that the vaccine itself by providing adaptive immunity, minimizes viral spread, and the inflammation associated with long COVID symptoms. So at least I always push people to This Week in Virology, this episode 88, where they really go over, like 2000 ID physicians not seeing long COVID with mild breakthroughs, but I think that’s a concern for people, and that we have to keep on exploring.
Kevin Pho, MD: We’re talking to Monica Gandhi, she’s an infectious disease physician and she co-wrote the New York Times opinion piece, “Why Hospitalizations Are Now a Better Indicator of COVID’s Impact?”
Monica, what are some of your take-home messages that you want to leave with the KevinMD audience?
Monica Gandhi, MD: You know, I want to leave that, though I think it feels really disappointing that we can’t eradicate or eliminate a highly transmissible respiratory virus, we’re very lucky, in a way, that we’re sitting in this position less than two years later to have these highly effective and safe vaccines, oral treatments coming for those who decline vaccination, oral treatments like Paxlovid, and that we know so much more about the virus, not spread like fomites and other things that we should be eliminated in our concerns.
And we know so much more about the virus that we are in a place where health officials and doctors can help us live with it, and also move on in a way from the fear. Even the Omicron variant didn’t get to be elevated luckily to how much fear we had at the beginning, because the vaccines, if you look at the complex immune system, do cover the Omicron variant, and that’s very reassuring. And maybe it’s more mild, maybe that’s because of immunity. We don’t know, but that’s… We’re going to have to track, but we’re in so much better of a place. And that feels like the beginning of a new year, 2022, with lots of tools to combat this. I know it took a long time, but we’re in a better place, and it’s okay to live with an endemic virus if we have these tools.
Kevin Pho, MD: Monica, thank you so much for sharing your time and insight. And thanks again for being on the show.
Monica Gandhi, MD: Thank you so much.
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