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Monica Gandhi MD, MPH Profile picture
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24 Oct, 9 tweets, 3 min read
CONTROL: I have always loved @Bob_Wachter's multidimensional chess analogy and was a privilege to speak in his 300 attendees in-person conference last week as COVID approaches control here
I think " state of control for communicable diseases (when disease is brought to low circulating levels and impact) takes constant vigilance; vigilance is in vaccinating those who are still without immunity (e.g. children) and using treatment for those who decline vaccination.”
Impending state of control in the US is not just from vaccinations but from a highly transmissible variant causing natural infection; vaccine so much safer and was easier conduit in many other countries. Control manageable place; doesn't cause public fear
washingtonpost.com/outlook/2021/0…
Child 5-11 vaccine here by November 2 week and here is what this highly promising outpatient antiviral treatment (molnupiravir) does
Natural immunity powerful: still recommend 1 dose after natural 2 reasons: 1) hybrid immunity stronger & places with high rates of natural immunity plus vax doing best; 2) T cells mature, go to respiratory tract with 1 dose after infection (2 not needed)
elifesciences.org/articles/72619
And this not only describes hybrid immunity but I will have for you by Tuesday (student helping) all the seroprevalence studies I can find with vax rate to show that places with high natural + high vax seem to be have best control
Here is something simple but a comparison between California (38% seroprevalence before vaccine) and Israel (3.8% seroprevalence before vaccine or bit more) and how they did with vax roll-out
twitter.com/i/web/status/1…
Finally, combatting misinformation important but I think there are two mistaken messages put out recently by administration that we can correct to give more confidence in the vaccines. Thanks
Cases (which, with highly transmissible delta variant and a very sensitive test- can be false positives, dead virus in nose, or low virus because you are fighting it with immunity in your nose) do NOT mean vaccines aren't working for intended purpose

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More from @MonicaGandhi9

Monica Gandhi MD, MPH Profile picture
19 Oct
Why I think PRIMARY SERIES OF COVID VACCINES SHOULD NOW BE SPACED OUT >6 WEEKS: We now have 3 lines of research that we should extend the duration between 2-shot COVID vax series: 1) immunologic; 2) effectiveness; 3) safety. Vaccinology principles here
academic.oup.com/cid/advance-ar…
Immunologic research here- Extending duration between doses 6-14 weeks compared to 3-4 weeks with Pfizer vaccine both increased neutralizing antibodies AND production of T cells (CD4 expressing IL-2)
cell.com/cell/fulltext/…
Data from Canada over the past week shows us that extending the duration from 3 to 7-8 weeks for the Pfizer vaccine increased vaccine effectiveness from hospitalization 82% to 92% (and increased protected against any infection from 47% to over 90%)
cbc.ca/news/canada/mo…
Read 5 tweets
Monica Gandhi MD, MPH Profile picture
16 Oct
HYBRID IMMUNITY: Amazing article that explains "hybrid immunity" (infection then vaccination) and why it essentially provides superhuman protection (no one is advocating for natural infection but it happened; vaccination then exposure will likely do same)
nature.com/articles/d4158…
Article explains it is all about developing those memory B cells which explode with antibodies (they are the recipe) if see virus again (aided by T cells). 2 other important lines:
1) Extending the interval between vaccine doses could also mimic aspects of hybrid immunity
2) Places with high rates of natural immunity & therefore hybrid immunity (as vaccination is on top of natural immunity) have lowest rate of transmission. Makes sense as some of those "superhuman" antibodies are IgA & IgG in nose - note CA vs Israel
twitter.com/i/web/status/1…
Read 6 tweets
Monica Gandhi MD, MPH Profile picture
16 Oct
RED vs BLUE STATES in US: When @DLeonhardt wrote this important article about the vaccine divide in red vs blue states, I think something got missed, which is the part that blue states had more cases than red prior to the vaccine (& yes, blue states mask)
nytimes.com/2021/09/27/bri…
As an ID doctor who thinks about #harmreduction and the differences between poor/rich in the bluest city in the bluest state in the country, I see this as related to over-restrictions that didn't make sense like closing outdoors, didn't protect working class, favored wealthy
California was 50 out of 50 in opening schools in US & San Francisco (of all the Bay Area counties) kept public schools closed the longest (but private schools open here so wealthy allowed schooling). Think will be important to acknowledge in our after-conversations of COVID
Read 6 tweets
Monica Gandhi MD, MPH Profile picture
15 Oct
BOOSTER confusion: My thoughts
Immunocompromised: Get 3rd shot
>65 & got Pfizer 3 weeks apart: Recommend booster
>65 & got Moderna: Can decide with your MD, holding up well!
J&J: Get 2nd shot (J&J or mRNA) >=2 months after 1st
(All others- ask MD, evaluate risk & decide)
This is why if you got your Pfizer 2nd shot at a longer interval (7-8 weeks or more), the data from Canada shows you are better protected (and also a basic principle of vaccinology)
Essentially, extending interval between Pfizer from 3-4 to 6-14 weeks increased both antibodies & - most importantly for durable immunity - CD4 cells (T cells). Basis for my recommendation above (probably why Israel, using Pfizer 3 weeks, boosted)
cell.com/cell/fulltext/…
Read 4 tweets
Monica Gandhi MD, MPH Profile picture
13 Oct
HETEROLOGOUS VACCINATION (means one dose of one type of vaccine & 2nd dose of another type of vaccine): Paper came out today (mix & match) that finally looked at J&J + mRNA vaccine together; 1st let me tell you about studies in past which examined this with AztraZeneca + mRNA
Study from the UK (Com-CoV) looked at an adenovirus DNA vaccine (examples are AztreZeneca (AZ) J&J, Sputnik V - in this case it was AZ) and the mRNA vaccine (only two examples are Moderna + Pfizer, in this case studied Pfizer) 28, 84 days (4,7 wks) apart
papers.ssrn.com/sol3/papers.cf…
Did combination in the 4 ways (Pfizer/Pfizer, AZ/AZ, AZ/Pfizer, Pfizer/AZ) and found that the best combination in terms of both neutralizing antibody titers AND T cells was AZ then Pfizer (so adenovirus/DNA then mRNA). 2nd study from Spain, summary here
nature.com/articles/d4158…
Read 8 tweets
Monica Gandhi MD, MPH Profile picture
10 Oct
"Dr. Gottlieb sees Covid’s ‘pandemic phase’ ending when antiviral pills, kids' vaccines available": wanted to explain from infectious diseases principles what @ScottGottliebMD means by this which makes sense to me
cnb.cx/3DjvoR0
There was a time between alpha and delta when there was talk of herd immunity - where the vaccinated or immune would protect the non-immune. But delta is so transmissible, that it changed the equation & the dialogue
washingtonpost.com/outlook/2021/0…
Now "control" and "endemicity" being discussed (as in article I wrote for @washingtonpost above) where control is a place where the virus is brought down to low circulating levels but outbreaks still seen among unvaccinated & ongoing vaccination of susceptible (kids) needed
Read 14 tweets

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