This was the week that the virus was really everywhere, with a spike in cases that is mind-boggling. Uncertain about how long this latest wave might really last, and what will come beyond that, we reached out to Dr. Monica Gandhi, an infectious-disease physician and professor of medicine at the University of California, San Francisco.
Dr. Gandhi is notable for her relative optimism that we’re moving beyond the pandemic phase of Covid, to where its impact—and the precautions we need to take in workplaces and in public—becomes more similar to a regular seasonal flu. (Dr. Anthony Fauci, among others, is less ready to predict a “new normal.”)
In our conversation on Friday, Dr. Gandhi shared her conviction that organizations will likely be able to safely bring the bulk of their staff back into the workplace by mid-February, and that masking and testing of people without symptoms would soon be unnecessary for healthy, vaccinated individuals.
Here is a transcript of our conversation, edited for clarity:
What do you think is the most likely scenario for the spread of the virus over the next 10 weeks?
The Omicron variant is really transmissible and also comes down fast. If we can extrapolate from South Africa—where it was first reported—and the United Kingdom, it will come down fast, but it will peak with an incredible number of cases. The estimates are that it will peak in mid-January, which is in just a week, and then come down more quickly. By the beginning of February, we should be back to a stage of low cases. What will it also do? It's going to leave a lot of immunity around because many people with the Omicron variant are symptomatic breakthroughs. They've been vaccinated and boosted, but they're still getting mild symptoms. There was a study that showed that you get very broadly neutralizing antibody activity against the other variants and a strengthening of what's called your t-cell response. As a result, it's going to leave immunity, even for those of us who are vaccinated, and certainly leave immunity in those who are unvaccinated. Because it's so transmissible, it's building this immunity wall. We're hoping that by the time we get to the beginning of February, we're going to be stable for a while. It doesn't mean the virus will go away, but it will be stability.
So that stability will allow us to return to what sort of activity? Broader workplace return, no masking in public places, people back inside at restaurants?
If you think about what's going on with the virus right now, we have to compare it to other respiratory pathogens because these are the pathogens that we've lived with for a while. Influenza is a respiratory pathogen that typically lands 50 people out of 100,000 in the hospital, every winter. At this point, with the Covid pandemic, we are getting about 3.9 people out of 100,000 in the hospital with Covid, if you're vaccinated, according to the CDC data. If you're unvaccinated, it's 63.9 people out of 100,000. Unfortunately, with a 62% vaccination rate, we have not managed to get our hospitalizations down like other countries because some people have not taken the vaccine. If you're vaccinated and boosted, your possibility of getting very sick from this virus is extremely low.
There was a large CDC analysis of a million people, and the only people who are having vaccinated breakthroughs are a very specific group—they're immunocompromised and elderly with multiple medical conditions. When I think of the workplace, those are the people who, when they go back, need to be protected more because they're more at risk for severe breakthroughs. They're the ones who need to be wearing masks if they feel comfortable doing so. Ventilation is a huge aspect of our new life because ventilation is not only good for this virus, but it's good for other respiratory pathogens and it's good for the environment. Regular, filtered ventilation in a workplace is something incredibly worth investing in. In terms of wearing masks every day, that isn't actually sustainable and it inhibits communication. If you're fully vaccinated in a workplace, nor is it necessary. Because we're living with risks that are lower than the risks that we used to live with, which allows normality. This is the conclusion people are coming to.
There was a paper yesterday, in JAMA, that appealed to the Biden administration to understand that we can't eliminate the virus. We can't achieve what's called Covid zero. It's not because people didn't try. It's because it's the nature of the virus: There are animal reservoirs, it's very transmissible, we don't have sterilizing immunity from the vaccines, it looks like a lot of other viruses, and it has a long infectious period. What we can do is prevent what we were so scared about with Covid, which is hospitalizations and deaths in those who are vaccinated. For those who are unvaccinated and have declined persistently to be vaccinated, we have antivirals. They are oral. They are easy. They need to be ramped up. It's called Paxlovid, and it's a way to treat it. Then, we have to go back to living the way that we used to with the threat of other respiratory pathogens always above us, but knowing that we have so many tools to fight it. I think this will be the last wave for a while. We could get another variant in the future, but this variant causes a lot of immunity that protects you from other variants.
That's a pretty optimistic statement that this could be the last wave for a while. I think a lot of people would be happy to hear your view on that....
Yes, it's called getting to the endemic stage. If you get a lot of immunity into the population, you get to what's called endemic. But it's hard won.
From what you're saying, is it fair to conclude that by the middle of February organizations should have confidence that they could safely bring the bulk of their staff back into the workplace?
Yes, I think that's a fair conclusion. Omicron certainly extended that timeline from what we thought would be January. Mid-February is a really fair conclusion. And we need to protect our vulnerable. So who are vulnerable? It's the populations that I just talked about, the immunocompromised. These are people who are quite severely immunocompromised and actually on medications, so not people with HIV, for example, who are doing fine in terms of getting severe breakthroughs. They're people who have immunocompromising medications or older people with multiple medical conditions. In the workplace, I would provide additional protection for them. They're the ones who are closest to the ventilation, for example, or they are the ones who, if they're comfortable doing so, are wearing masks. This is a respiratory pathogen that, just like every winter with other respiratory pathogens, people who are immunocompromised are more susceptible to.
What is your advice for people in the shorter term amid this current spike, in terms of the activities that they can feel safe about engaging in such as taking public transit, going on an airplane, dining indoors, going to the office, socializing in groups?
The difference between now and last winter is that we have vaccines down to five years of age and boosters for those 12 and older. There was a reason president Biden didn't shut down this country even though we have such high cases. It was because of this decoupling that's occurring between cases and hospitalizations at this phase of the pandemic. Why is this decoupling occurring? Well, it's not just that we have immunity to Covid, but there is real evidence that Omicron is more inherently mild as a variant. The more mild variants—unlike Delta—are the ones that get you closer to living with the virus. With Delta, we had many more hospitalizations with our cases, especially in low vaccination regions, which was very tragic. With Omicron, there have been six laboratory studies—four animal studies, and two with ex vivo lung cells—that show it just can't infect lung cells very well.
That's probably because it has 50 mutations across its entire genome, 32 in the spike protein. It's just a less able virus, which sometimes a lot of mutations can do to a virus. The fact that it can't infect lung cells very well is probably why there are so many more upper respiratory symptoms and why the ICU admissions, despite a huge number of cases, are not going up. Our hospitalizations are going up, but a lot of those hospitalizations are incidental, with Covid in your nose. That's very fair. We do this in a hospital, screen everyone for Covid because we want put them in their own room. 70% of hospitalizations are incidental at this phase of the pandemic, according to data from San Francisco yesterday. In LA county, 66% of admissions were incidental as of two days ago. They just have Covid in the nose. In South Africa, with Omicron, 63% of hospitalizations are incidental. So it's much lower than we thought.
Incidental means that they have it present but they're not extremely sick from Covid?
Yes, so I work in a hospital, and we screen everyone with a nasal swab. If they test positive, we put them in their own room, but they're there for other things 60% of the time.
To go back, what is your advice for what activities people should or should not engage in over the next two weeks?
Anyone who is vulnerable should not be engaging in activities. My father is 87, and he's immunocompromised at the moment because he's getting therapy. We don't let him do anything. But if you're vaccinated, boosted, and immunocompetent, then at some point we're going to have to just live. People are seeing each other and going inside and eating, which was the point of vaccination and boosting. And yes, there are more mild infections that are happening with Omicron, but you also want to be realistic two years into the pandemic. Closing schools and businesses when we have the vaccines is understandable, as we have to get through this wave. But with such a low hospitalization rate, at some point you have to make a decision to live with the risks of a respiratory pathogen as society with vaccines and go back to normal life.
So what would I do over the next two weeks? I don't let my father do anything. I'm more immunocompetent, so yes, I go to work. I go inside to the office. I have been to restaurants. I'm a fully vaccinated boosted person. But I will tell you that it is disturbing to see these case numbers. There's no doubt that they're influencing our mindset. That will change once we decide to only report out hospitalization numbers, which the country is moving towards, according to Dr. Fauci. He said this on January 2nd, and that will be more in line with what we do with influenza pandemic surveillance. We know the cases every winter, and we don't tell the public—not because we are hiding anything, but because health departments track cases, and then the public is only told about hospitalizations. If the cases are alarming, then you're going from endemic to pandemic with influenza. At that point, the public is told about it and asked to maintain restrictions. That's what we're going to be doing with Covid. We'll tell the public about hospitalizations, but the cases won't be reported out every day. That's going to be a big difference when people aren't looking at cases.
There still seems to be some divergence in the medical profession around whether this will continue to build and whether Omicron will generate enough immunity for the situation to normalize on an ongoing basis. Do we know enough to have a high level of confidence in the sort of scenarios that you're talking about?
We've always been surprised by this virus before, and Delta really was a very painful experience, but people are coming to a conclusion that there is something very different about Omicron. It was detected on Thanksgiving day, so we now have six weeks of data that it simply is not causing the severity of disease that any other variant did. What could be happening right now is that clinicians are seeing one thing because they're in the hospital, while epidemiologists are looking at raw hospitalization numbers and not separating out the incidental versus the not incidental. The divergence that you're seeing in the media is people who are clinicians and those who are not clinicians and don't spend every day in the hospital.
When you see this reduced severity of disease, that's what's giving our clinicians optimism. Bob Wachter, my department chair, is always on service over Christmas. He was tweeting out a lot about what the severity of disease is in the city of San Francisco. When you're sitting there, you see how different it is from Delta. I think that's what's giving clinicians a different view than people who aren't in the hospital. Yes, it's bizarrely true that it seems so much less severe, for two reasons. It's also because we have so much more immunity in our population, especially in highly vaccinated places. It's not just whatever it has to do with pathogenesis. We are in December 2021, January 2022. That's so different than March 2021 with the Delta surge in India. Then it came to our country by July, when we had much less immunity. We have much higher immunity now, not just because of vaccination, but unfortunately because of natural immunity through the Delta surge. All of that taken together, this is a very different feel for the pandemic for those who are doctors.
What is your own thinking about how educational institutions, teachers, and parents should be approaching the current situation?
Unfortunately, we've gotten used to closing schools in some areas of the country, so it has happened even in January 2022. In a risk versus benefit analysis in a society, especially two years into a pandemic with highly effective vaccines available down to the age of five, society has to make decisions about what their values are. Other societies that have equally high incomes as ours had made decisions that schools were not to close early on, in the UK and Europe. The US has been more fraught and imposed more restrictions on children, who are the lowest risk group for Covid-19, than any other group. It's been really backwards.
I don't know if we've sorted out why, but I will say that it's now becoming clear the effects of learning loss, depression, anxiety, and not having a normal life has led to two years of difficulty for children. When you think about what I just explained about a workplace setting, I didn't say asymptomatic testing because asymptomatic testing does not have a role in places that are highly vaccinated. It isn't going to be asymptomatic testing in schools. Children are less at risk for severe outcomes. Before, I said that the ones who are wearing masks are those who are at risk for severe breakthroughs. Those aren't children, so I recommend no masking in schools after a couple of months; no asymptomatic screening; and as much as possible, go back to normal school with ventilation, which is a profoundly important and under-discussed aspect of pandemic control.
We should have normal school in a couple of months, and we should realize that we have highly effective vaccines that allow that. If we don't make that transition in our head—that preventing severe disease is the goal, not preventing reinfection—then we will continue to close schools. I hope that we can make that transition in our head away from Covid-zero policies. Again, I would refer people to the JAMA paper of the six Biden task force experts who wrote very passionately to president Biden yesterday saying, we need a new normal and cannot keep on closing schools and closing businesses.
What you're saying suggests that you would be in favor of keeping schools open now, even with asymptomatic cases?
Yes, because we're two years in and we have vaccines. That's why. Teachers are protected.
Among the approaches that workplaces and schools have adopted is widespread testing. You implied that you don't think that asymptomatic testing should be a priority....
When we decide that Covid is the same risk of other respiratory pathogens—which it's actually much lower risk for those who are vaccinated—then we will go to a system in which we only test people who are ill and don't test people who are asymptomatic. That will be the difference in going to an influenza surveillance modality, from pandemic to endemic, as opposed to staying in pandemic mode. I wrote a New York Times piece about this called 'Why Hospitalizations Are Now a Better Indicator of Covid’s Impact,' and I would encourage people to read that to explain why we'll go away from asymptomatic testing at that point.
And, to be clear, your argument is that we are now at the endemic stage and so we should be making the transition?
Omicron will take us into the endemic stage because of the wall of immunity that will be built, so we'll be there in a couple of months.
What should employers do about the many people who choose to be unvaccinated and probably are not going to change their minds about that?
I wrote a piece on my support of vaccine mandates three or four months ago, and I was a big proponent of vaccine passports and vaccine mandates. However, I have now seen that, like you just said, there are some people who will not change their minds. That's the mass misinformation that has been allowed to disseminate in the news. At a certain point, we have to realize that we have ways to protect the unvaccinated. What changed since I wrote the vaccine mandate article was the advent of oral antivirals. Molnupiravir is one, which is okay, but Paxlovid is much, much better. It prevents hospitalization and death among people who are unvaccinated and at risk for severe disease by 89%.
That is actually the same rate as a vaccine. At a certain point, there has to be an understanding that we have ways to both protect the unvaccinated and compassionately treat them. If we cannot, through vaccine mandates, change this—and with the Supreme Court hearing the case on vaccine mandates today, I don't know what will happen—then I do believe that we have to consider the availability of antivirals and allow society to move forward. I'm in a different place than I was four months ago. And I was really with the administration on vaccine mandates.
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