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Monica Gandhi MD, MPH Profile picture
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30 Jul, 6 tweets, 3 min read
See a lot of despair this morning after CDC announcement yesterday re: high viral loads with delta so transmission risk from vax'd & agree that this virus gives us so many twists & turns and so disappointing. But wonder if this helps about the mysteries
nytimes.com/2021/07/30/bri…
Or changing one's expectations with delta away from #covidzero but seeing that we have made much progress in our fight against this terrible virus; defanging the virus with the vaccines so that in areas of high vax, hospitalizations & cases more uncoupled
politico.com/news/magazine/…
Please read @ashishkjha analysis of slides which reminds us of high vax effectiveness against disease & please read this- antibodies take bit of time to make from memory B cells but they do kick in, bring down transmission. T cells prevent severe diseases
And remember, hurricanes are awful (like delta) but they can leave faster (as it is in the UK), leaving a lot of immunity in its wake which helps keeps our population bolstered against this virus (since, fundamentally, only immunity stills a pandemic)
And if anyone took away from the CDC slides yesterday that vax'd people are as infectious as non-vax'd, please read this (no journal will accept that message without further scientific query)
Finally, I think the CDC slides were an acknowledgment the war is different since the virus is endemic. This is what delta did more than other strains- made it endemic. But that doesn't mean we can't fight disease, death & don't have those tools now

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More from @MonicaGandhi9

Monica Gandhi MD, MPH Profile picture
29 Jul
Good summary from WaPo on day's issues 1) waiting on CDC data on vax'd and viral load (we will likely need culture for deeper dive); 2) masks @CarlosdelRio7 "putting toothpaste back in tube"; 3) plummeting UK cases: delta-driven natural immunity+ vax
washingtonpost.com/politics/2021/…
In terms of UK cases falling despite easing lockdowns, not surprising. Delta is a hurricane- if finds vaccinated's nose, will boost immune response if asymptomatic; finds unvax'd adults FAST & tragically causes deaths or natural immunity if non-severe
cnbc.com/2021/07/28/uk-…
Of note,- I'm sure CDC has data on viral loads with delta & will tell us. Delta has higher viral load, different beast than alpha. But is a PCR-determined viral load in a vax'd person with immunity (Abs/T cells in nose) as infectious as in unvax'd? Do we need culture to tell??
Read 14 tweets
Monica Gandhi MD, MPH Profile picture
28 Jul
Bit counterintuitive to think that vaccinated people with antibody & T cell islands in their nose to transmit infection at the same rate as those who are unvaccinated. So, would be good to see data & probably need culture data to confirm not dead viral particles from vax success
However, I think it is about inoculum. If you are vax'd & have high rates of community transmission around you, more likely for virus to get in, cause a mild breakthrough as stimulate antibodies (T cells, which fight severe disease already there)
Delta variant has higher viral loads than alpha or ancestral strain so I am sure -with those higher viral loads, vaccinated people can transmit with mild breakthroughs- However, transmitting at equal rates seems counterintuitive.
Read 4 tweets
Monica Gandhi MD, MPH Profile picture
28 Jul
Spoke to @fayeflam at Bloomberg last week of how vaccine memory should be long. There are many papers on this but I wanted to give you the 4 most interesting ones in this thread in my opinion.
podcasts.apple.com/us/podcast/32-…
So, we all love this paper showing the vaccines generate memory B cells (even in the lymph nodes with biopsies) although La Jolla and other places had already shown memory B cell formation in blood in other studies
nature.com/articles/s4158…
So you have memory B cells and see a variant in the future? Even if your antibodies wane (which they will, not a glitch but natural for the immune system), you have the blueprint to make more from memory B & those antibodies will ADAPT to the variant
medrxiv.org/content/10.110…
Read 6 tweets
Monica Gandhi MD, MPH Profile picture
27 Jul
Wanted to explain what @CDCgov did today in terms of masking guidelines & why I think made sense. They did not say everyone mask- they said mask according to community transmission rates + vaccination rate in your community. I, @syramadad @ashishkjha wrote
washingtonpost.com/outlook/2021/0…
this article in Washington Post a long time ago saying look at community transmission rates + vaccination rates as metrics of when to lift restrictions (we used a hospitalization metric of <5/100K because case rates can become uncoupled from hospitalizations at higher vax rates)
So, what did the CDC do today? They released this MMWR article saying just that- decide on masking on vaccination rates + community transmission rates. Why? Because we aren't where we wanted to be with vax rates in US by this time & we have the delta.
cdc.gov/mmwr/volumes/7…
Read 7 tweets
Monica Gandhi MD, MPH Profile picture
26 Jul
In this critical time of delta circulating, we need clean data on 1) what % admitted to hospital are unvaccinated; 2) if vaccinated, is it breakthrough or asymptomatic with universal screening; 3) if vax'd, need CT of PCR test or some way to know viral load
This article explains concept of viral load and how to determine from PCR cycle threshold (if that is the test hospital is using); rapid antigen is another test using lateral flow assay
washingtonpost.com/outlook/2021/0…
If delta higher viral loads explaining transmissibility,
1) Asymptomatic breakthrough, low viral load: You fought the virus, brought it down & vax success, can't spread
2) Symptomatic breakthrough: Need to know if viral load high enough to transmit
3) Severe breakthrough: Boost
Read 4 tweets
Monica Gandhi MD, MPH Profile picture
25 Jul
Reason viral load (VL) becomes so important now is due to delta. So much more transmissible with those studies showing higher VLs. Those vax'd may get some in nose, will strengthen your immune response to fight it off so need to know if VL stays low
washingtonpost.com/outlook/2021/0…
Then for a mild breakthrough infection after vax, is that when an antiviral like molnupiravir comes into play - best to stop viral replication early for mild disease (severe disease mediated by innate immunity which is why we use steroids)
And then severe disease of course prevented by vaccination which everyone very convinced of at this point with what we have seen from delta. So, working on getting vaccination rates up is of utmost importance as outlined well here @apoorva_nyc
nytimes.com/2021/07/25/hea…
Read 5 tweets

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