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Monica Gandhi MD, MPH Profile picture
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5 Nov, 10 tweets, 4 min read
TWILIGHT ZONE: I call it the twilight zone that highly vaccinated states in the US are the most likely to be following CDC guidance to both 1) test if COVID exposed; 2) have mask mandates in response to red/orange zones which are only red/orange because of #1 (artifactual)
Problem with the "twilight zone" is that the CDC put us here on July 30 when they revised their masking guidelines to forget about vaccination status in a region & go back to former definition of community spread, which as explained, does not make sense in places of high vax
I had student with me in clinic today from UC school & at 100% vax rate, students all masking, temperature screening, testing like in 2020 but they are ...100% vaccinated so 2020 not 2021 style. CDC problem here: didn't say "unmask when 80% vax" just mask
cdc.gov/mmwr/volumes/7…
So, we went from trying to motivate vax to literally de-motivating vax by this CDC document since highly vax'd places will continue to mask (they follow CDC) & many states in US ignored this, unwittingly setting up natural experiments in US (& vax >>masks)
theatlantic.com/ideas/archive/…
Now, all scrambling to figure out off-ramps where we literally de-motivated vax in US by this artifactual definition of community spread (doesn't work in context of vax by CDC own testing guidelines) - restrictions bizarrely now only in highly vax'd places
theatlantic.com/health/archive…
Now everyone trying to come up with their way to get around the twilight zone created by the CDC where "spread" no longer reflects community spread, rates always going to appear higher in highly vax'd regions that test. 1 thought here: vax replace masks
washingtonpost.com/opinions/2021/…
And that would be fine but not everyone is going to vaccinate and vaccines do reduce transmission so maybe come up with another metric like Massachusetts did & say no masks when 80% vaccinated? Everyone scrambling for something different. @NYT article on
off-ramps for masking interviewed 11 different people who said 11 different things so this is not a matter of "science" but matter of values- just pick something and sticking with it. I said unmask adults/children 8 weeks after 5-11 vax available.
nytimes.com/2021/10/29/opi…
But what I am seeing in this country (and in a city SF that was very restricted in a restricted state) is that the paradox of red states back to normal, blue states; Biden (press secretary) acting like 2020 (no vax) and not 2021 (have vax) not motivating vaccine uptake
We know from field of HIV that it was MOTIVATING to HIV treatment (pills hard at first) and then PrEP to say "life returns to normal". Irony of CDC guidance now is that it de-motivates vaccine uptake. Vaccines safest way to endemicity & normalcy;

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More from @MonicaGandhi9

Monica Gandhi MD, MPH Profile picture
6 Nov
ORAL ANTIVIRALS (e.g. molnupiravir and now "Paxlovid"): Why is everyone so excited about designated antivirals that target enzymes involved in the viral lifecycle of SARS-CoV-2? Because they will directly treat COVID & hopefully prevent severe disease
smithsonianmag.com/science-nature…
So, what is the lifecycle of the virus & where do these antivirals work? Good article on lifecycle, showing various steps how SARS-CoV-2 enters the cell & replicates. There is a polymerase called the viral RNA-dependent RNA polymerase and a viral protease
nature.com/articles/s4157…
Molnupiravir is a nucleoside analog that we have discussed before but it essentially is incorporated into the growing RNA strand of a new virus by the RNA-dependent RNA polymerase which messes up the RNA & can't continue to make new virus
Read 10 tweets
Monica Gandhi MD, MPH Profile picture
5 Nov
Totally agree @DrLeanaWen, we somehow muddled the messaging to say masks more effective than vaccines instead of vice versa and didn't motivate vaccination uptake starting from July. We can reverse this now.
I see many people discussing that "messaging" doesn't matter- all misinformation. I don't agree. We learned from all things infectious diseases that messaging does matter- if you tell someone vaccines don't reduce transmission & they have to mask forever after, not good message
If you tell a parent that "hey get your child the vaccine to protect others but their lives will always be restricted & they will mask in schools", not a good way to win over parents
Read 4 tweets
Monica Gandhi MD, MPH Profile picture
2 Nov
Entire Bay Area is back in CDC's orange and red tiers for COVID spread - right, but this is because a highly vaccinated place will always be at risk of being in these "tiers" due to the outdated definition of the CDC's metrics of community spread.
sfchronicle.com/health/article…
To put it most simply, he current CDC guidance states that masks should be used in areas of high to substantial transmission (based on test positivity and cases/100,000 rates) but those metrics only made sense when mass asymptomatic testing was occurring prior to vaccination.
After vaccination, per the CDC guidance, only those with exposures or symptoms should test so tests are likely to reveal positive cases, which is not a good measure of community transmission or spread (but just means the people who should test are testing). Marin mask mandate
Read 6 tweets
Monica Gandhi MD, MPH Profile picture
2 Nov
Wow, a powerful visual of how kids lost more school in the US than another wealthy nation. We here in blue CA were 50 out of 50 in the country in opening schools so we have a lot to make up now, including instituting test-to-stay:
washingtonpost.com/outlook/2021/1…
A difficult slide from the CDC ACIP meeting today for 5-11 suicides as many -including @LeslieBienen and @JeanneNoble18 - were trying to get statistics on self-harm among children during CDC-supported US school closures. We wrote this piece about it. wsj.com/articles/the-p…
2020 statistics still pending to see if higher (was higher in CA if you read WSJ piece above). In Bay Area/ CA, most health officers have said adult masking ends 8 weeks after availability of 5-11 vax. Not contingent on children getting it, just available. To restore kid's lives
Read 4 tweets
Monica Gandhi MD, MPH Profile picture
2 Nov
Yes, America has lost the plot. "On the ground, the U.S. is now running an uncontrolled experiment with every strategy all at once. COVID-19 policies differ wildly by state, county, university, workplace, and school district."
"Due to polarization.have also settled into the most illogical pattern possible: least vaccinated communities have some of the laxest restrictions, while highly vaccinated communities (most protected) tend to have some of the most aggressive measures aimed at driving down cases."
But I am seeing education/schools as a lightning rod issue for American parents and so perhaps the plot of the twilight zone occurring in highly vaccinated and protected communities will clarify around this
Read 5 tweets
Monica Gandhi MD, MPH Profile picture
1 Nov
Some parents need more time; that time will be given. As Peter Marks from FDA says- he has a whole army of FDA experts evaluating safety before full approval. 10 microgram dose seems very safe; I will be vaccinating my 11 year old - 2 doses 8 weeks apart
nytimes.com/2021/10/30/hea…
Biden could only mandate vax once FDA approved (Pfizer >16, Aug 23); kid mandates can't come until full approval (12-15 still under EUA since May 10) for parents to watch safety & mask rules. I encourage kid vax now, mandates only legal with FDA approval
missionlocal.org/2021/10/area-d…
Remember, authors don't write headlines. This is why I am getting my child vaccinated and why I think is a good idea. This does NOT mean it will be mandated until FDA approves and that many parents need/want more time, which is justifiable.
sfchronicle.com/opinion/openfo…
Read 5 tweets

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