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Monica Gandhi MD, MPH Profile picture
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14 Jun, 9 tweets, 4 min read
Wonderful paper by @ID_ethics. The reason ID people keep on turning to past pandemics is that we have used a lot of models in the current pandemic that don't end up being accurate. No time in history do we test this much or sequence asymptomatic infections in nose.
"While some degree of epistemic humility .prudent, apparent bias in favour of modelling techniques over analyses of historical data should be discarded.". those who only look at vax% when discussing delta variant, discuss natural immunity/testing after vax
Some thought leaders in US tweeting have interactions with companies making vax. Instead, we want to look deeply and cleanly at data- all the immunological research being done on natural immunity and vaccine immunity. % vax of a community is not only form of immunity.
And although I would have loved us to have NO natural infection from new virus but all vaccine-induced immunity, we didn't have vax out of gate. So, when you say "this community will have high rates of transmission when opening", consider natural + vaccine immunity in predictions
Increasing data on risk of re-infection after natural infection or vaccines; we will know over time on durability but both produce memory B and T cells; I would get 1 dose after infection but will go over Abs and T cells with delta variant on Tuesday. Thx
Moreover, Manaus study showing 76% seropositivity led to confusion since P.1 outbreaks after. Please remember this study done in BLOOD DONORS who came in to check if Ab positive or to give convalescent plasma- skewed towards those with previous infection
thelancet.com/journals/lance…
Just like in India in urban slums with 60% seropositivity, this does not represent seroprevalence/previous infection in the general population. Studies now show us that T cell immunity in previously infected still work against variants (here with P.1.)
biorxiv.org/content/10.110…
With delta variant, you want antibodies high so get BOTH doses while still circulating & closer together than 12 weeks but doesn't mean T cell immunity will be evaded from the vaccine (or natural infection) which protects against severe disease
So, just like in UK, we do a lot of testing of asymptomatic individuals after vax (more so in CA actually), which is not indicated. So, we have to ensure hospitalizations/deaths not increasing with variants as our metric as cases & severe disease decouple

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More from @MonicaGandhi9

Monica Gandhi MD, MPH Profile picture
16 Jun
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) Image
The vaccine gives you genetic material that enables YOU to make that spike protein and then you raise an immune response against it (of course natural infection makes you raise an immune response against virus). Genetic material goes away & you have immune response. J&J just one
step "upstream" from mRNA vaccines so gives you DNA which you MAKE into mRNA and then you make spike protein. mRNA vax allows you to make protein directly. Not that different though J&J vax takes longer to give full immunity (phase II trial, up to 60 days)
nejm.org/doi/full/10.10…
Read 15 tweets
Monica Gandhi MD, MPH Profile picture
14 Jun
Another paper describing durable immunity to natural infection. "Immunological memory ..distinct aspect of immune system...where B & T cells specific for a virus maintained in state of dormancy.. poised to spring into action if they encounter virus again"
nature.com/articles/d4158…
The reason I think this is so important is that it 1) gives credence to those who are questioning why WHO discusses natural immunity but we aren't; 2) saves vaccines for non-immune with global distribution for now; 3) allows sense of normalcy without fear
washingtonpost.com/outlook/2021/0…
And simple primer on immune system here as well although Nature paper very well written and explains the long-term nature of immunity to natural infection extremely elegantly.
leaps.org/booster-shot/
Read 4 tweets
Monica Gandhi MD, MPH Profile picture
14 Jun
NOVAVAX trial from this morning: First want to remind you that we have 9 vaccine candidates out there, 6 of which involve the spike protein in some way (Novavax actually gives the spike protein + an adjuvant) and 3 of which are whole inactivated virions. Table below
Here is our clinical trial data for the 6 spike protein vaccines (will summarize Novavax in moment as the phase 3 trial called PREVENT-19 came out today) and the next tweet shows the phase 3 data for the 3 whole inactivated vaccines (Covaxin, Sinopharm, Sinovac)
And here is phase 3 clinical trial data for the 3 whole inactivated vaccines. Okay, then, going back to Novavax, it is the spike protein put together with an effective adjuvant and we had a phase 2b study in S. Africa & UK study before, but PREVENT-19 was largest, results 6/14
Read 7 tweets
Monica Gandhi MD, MPH Profile picture
11 Jun
I am interested in increasing trust in public health. 4 things we can address now to increase that trust:
1) Natural immunity: Real, don't know duration of immunity from either route; 1 dose only? Acknowledge natural immunity, our knowledge limits
2) Vax in kids: Acknowledge that adult vax massively reducing community transmission in US, kids less at risk of getting sick. Acknowledge risks vs benefits of vax in kids under study. 1 dose, lower dose to reduce risk of myocarditis? If low rates, can kids have normal life?
3) PCR test: Acknowledge limits of PCR especially after vax. PCR picks up "dead virus" or low virus in nose because very sensitive (can tell if must cycle the machine a lot; CT >30 is low viral load). Don't isolate someone with high CT (use Ag; no asymptomatic testing after vax)
Read 11 tweets
Monica Gandhi MD, MPH Profile picture
10 Jun
My last school opening article (a plea, really). Returning to school buildings full time next year will improve the mental health of young people, write @MonicaGandhi9 and @JeanneNoble18 wsj.com/articles/the-p… via @WSJOpinion
-CDC said last week adolescent hospitalizations due to COVID were on the rise, media picked up the message Not true: child cases and hospitalizations down 84% and 69% since Jan
-CDC failed to highlight that 20% of hospitalizations in their study Jan-March 2021 were psychiatric
-Mental health (MH) effects hard to study since healthcare utilization down & MH services for children already has gap
-Only way is to look at ED visits & suicides. Data from Children's Hospital Oakland: 66% increase in 10-17 screening yes for active or recent suicidal ideation
Read 7 tweets
Monica Gandhi MD, MPH Profile picture
8 Jun
Thanks to @NYT for publishing this guest essay by @TracyBethHoeg, @DrDanielJohnson (Pediatric ID) by me saying we must fully reopen schools this fall and here's how. Main points: 1) Full in-person learning need not be tied to child vaccination status
nytimes.com/2021/06/08/opi…
given falling cases & hospitalizations in children with adult vax (61% & 40%, respectively in just last 6 weeks; 80% since January)
2) Hand-washing great for rotavirus, noravirus, rhinovirus; excessive hand sanitation, cleaning not needed for COVID;
3) No plexiglass barriers
4) No mass asymptomatic testing unless community transmission high (won't be anywhere by September - 200/100K)
5) Test symptomatic individuals
6) Don't close class for a child testing positive; unvaccinated teachers follow CDC I&Q protocols
Read 8 tweets

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