I know I have a mixed twitter following which earns me ire, but the reason I was so impressed by the @CDCgov guidance on schools last Friday and the follow-up @CAPublicHealth statement was how in-person learning with mitigation was stressed so much because so important for kids
@CAPublicHealth opted for universal masking in schools in order to forgo distancing so that children could get back to school. I saw @sfchronicle editorial board saying this am that they did an "about face" on this but they did not, actually. @CAPublicHealth (@TAragonMD)
said they would clarify their messaging so doesn't fall on districts to interpret and enforce, which they will. With delta, mitigation indicated at first, they chose masks will clarify for districts a likely metric-based approach of when mitigations ease
nytimes.com/2021/06/08/opi…
In terms of cases, there are 2 things to do right now which is to 1) either not test asymptomatic after vax (CDC rec) or please consider CT value so you decide whether that is a "vaccine success" - dead or low virus in nose as you kill it; 2) please follow hospitalizations as
cases become uncoupled (not entirely delinked; we aren't there yet; but becoming so) from severe disease in countries with high vax rates. Cases do not lead to hospital capacity strain like before vax. 5 patients in our hospital in SF with COVID, all unvax'd. Must encourage vax
Having "off ramps" for mitigation measures provides security for 1) those who want their children back in normal school; 2) parents nervous to return children to school with media coverage of delta. Compromise? Metric-based approaches to peel off mitigations in our @NYT piece
Please remember everyone's individual risk tolerance different; most important thing I believe the @CDCgov and CADPH agree on is in-person learning for school so masks will aid that & then off ramps for mitigation by metrics will help those who are frustrated. Kids need kids

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More from @MonicaGandhi9

16 Jul
The Reassuring Data on the Delta Variant. By I and @LeslieBienen and @citizen_oregon . There are 3 things concerning about a variant - transmissibility, whether increased virulence & whether evades vaccines. Virus likely more "fit" which we explain
wsj.com/articles/delta…
but to public, the delta will become the dominant variant if more fit. So, 2nd question is whether the delta is more virulent. Luckily, there is CDC publicly-available data one can download & look at this. 1st step is to show hospitalizations not increasing in kids with delta Image
Then one wants to look at regions with prominent delta prevalence in the US and ask whether "hospitalizations per case" is increasing to see if more virulent. Luckily, not the case as shown by the chart in the paper - actually hospitalizations per case less with more delta Image
Read 7 tweets
15 Jul
I know many would like to put back masks for the vaccinated; every county's jurisdiction. But I encourage you to try to understand why @CDCgov released masks for vax'd which was around effectiveness of vaccines (even with delta)/reduced transmission after
washingtonpost.com/outlook/2021/0…
I know vax'd talk to each other; unvax'd talk to each other and we are not conversing but their reasoning was helping unvax'd become convinced to vaccinate. This seems even more important to me today - to use science to convince those still on the fence to please get the vaccine Image
After CDC said masks not needed for vax'd in May, uptick in vax. So, masking after vax should done based on your personal risk tolerance/immunocompromise/elderly, but consider psychology of messaging in this delicate period
cnn.com/2021/05/27/hea…
Read 4 tweets
15 Jul
Nice explanation of why symptoms define real vax "breakthrough" @KatherineJWu: "Bungling messaging around shots’ astounding success has made it hard to convey the truly minimal risk that the vaccinated face & the enormous gamble taken by those" not vax'd
theatlantic.com/science/archiv…
Good to check in with CDC breakthrough data in light of delta to see if same; hasn't budged:
Of >157 million people fully vax'd,
0.002% hospitalized with COVID-19
0.0004% deaths from COVID-19 (4 in 1 million)
cdc.gov/vaccines/covid…
This Israeli study gives risk factors for a severe breakthrough infection among vaccinated- small number (152) because vax so effective but high rate of immunocompromise or severe other medical conditions. Good demographic for 3rd dose
jpost.com/health-science…
Read 4 tweets
14 Jul
You know what just hit me when I read about 100% of the patients in LA County public system in hospital with COVID being unvax'd or see this in SF much smaller numbers (unvax'd in hospital) or see data from around country that 99% of those in hospital are unvax'd?
The vaccines are extraordinarily effective (even against the delta variant) since the PHE England data said Pfizer 96% preventative against hospitalizations. And it reminds me of this yellow line from the clinical trials that show such high protection against hospitalization
Efficacy is the term for outcomes in clinical trial; effectiveness is what you see in "real life". And effectiveness mirroring efficacy (even with delta variant) is unusual for a drug or vax. CDC publicly-available data doesn't show increase in hospitalizations in kids
Read 4 tweets
13 Jul
Thread on MOLNUPIRAVIR. First, what is this medication? First we should remember, there is not a highly effective outpatient oral treatment for COVID yet. There are tantalizing glimpses into other meds but they are still in clinical trials. So, let's explore this one.
Molnupiravir was not developed for SARS-CoV-2- originally thought of as a broad-spectrum antiviral because it is a "nucleoside analogs". We use those a lot in HIV but they basically inhibit the virus from replicating because this compound interrupts the process of copying
Remdesivir is a nucleoside analog that we use for inpatient treatment because it is intravenous. But what if there was an outpatient oral treatment that you could give to someone like Tamiflu (or in the case of HIV treaters, we give this type of med in combo with others)
Read 16 tweets
13 Jul
Yes, well, we call "dead virus in the nose" as you know, fellow ID MD, "colonization" instead of infection. How do we know that immunity from vax (or natural infection) limits viral load replication in the nose? Have large 5 studies showing low viral load after vax with exposure
What immune response gets into the nose? Well, we know the COVID vaccines produce IgA (the "mucosal" or nose immunoglobulin) from multiple studies & IgG from the vaccines very happily get into the nose too- see this paper that shows high IgG, nasal cavity
pubmed.ncbi.nlm.nih.gov/23882268/
And of course even our trusty T cells will fight virus in the nose if you are exposed to the virus or vaccine, limiting viral replication (and limiting the utility of a test of an asymptomatic person after vax unless you measure viral load on PCR machine)
pubmed.ncbi.nlm.nih.gov/9490657/
Read 4 tweets

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