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Monica Gandhi MD, MPH Profile picture
Monica Gandhi MD, MPH
@MonicaGandhi9
MD, MPH; ID/HIV MD; UCSF (tweets own); No conflicts; Wrote book on COVID & pandemic playbook pub. Mayo Clinic Press called Endemic: A Post-Pandemic Playbook
46 subscribers
Aug 30, 2023 • 8 tweets • 3 min read
HOW LONG DOES IMMUNITY LAST? To COVID vaccines or infection? We do not really know but there have been some really nice papers lately that give us more information. Please remember immunity divided into antibodies (which can come down & not work as well against variants) IgA is one in the nose & mouth ("mucosa") that is raised by shots (vaccines) to certain extent but rise higher after natural infection; IgG is the one that is "humoral" or in the bloodstream. Many threads on here about cellular-mediated immunity: B & T cells cover all variants
May 3, 2023 • 4 tweets • 2 min read
RSV VACCINE FOR OLDER ADULTS: Respiratory syncytial virus (RSV) respiratory virus (most common after flu pre-COVID). 2 subtypes, A&B (1 dominates/season). Droplet; Recurrent infections. Most severe in neonates & adults >65; FDA approves 1st RSV vax today
msn.com/en-us/news/us/… RSV vaccine 3 trials of new RSV vaccine, all published in the @NEJM recently so just to keep them straight- here is the vaccine which just got approved May 3 by the FDA for older adults. Remember our T/B cells so protection against severe disease higher!
nejm.org/doi/full/10.10…
Mar 21, 2023 • 15 tweets • 6 min read
NASAL VACCINES: To explain nasal vaccines, we have to explain the immune system first.
IgA is an antibody that helps attack the pathogen and exists in mucosal surfaces (like nose/mouth)
IgG is an antibody that is in the bloodstream
bbc.com/news/world-asi… Cellular immunity is fantastic, redundant (so even if one cell line down in immunocompromised, have other), generated by either vaccine or infection; Comprised of
T cells- so in breadth from vax - works even across spike protein with its mutations
Mar 15, 2023 • 4 tweets • 1 min read
PUBLIC HEALTH POLICY: Seem to be at reckoning phase of COVID response- what worked, what didn't. Which interventions will be used in future pandemic responses? Interventions asked of public need good medical evidence for them (e.g. RCTs preferably, systematic reviews) to impose In our field, Cochrane reviews represent best way to sum up the medical evidence to date by performing meta-analyses or systemic reviews of currently-available data; here is Cochrane on masks & other interventions for respiratory viruses including COVID
cochranelibrary.com/cdsr/doi/10.10…
Mar 6, 2023 • 4 tweets • 2 min read
VACCINE DISCRIMINATION: We need to stop vaccine requirements for US entry like almost every other country. Am finishing COVID chapter for our ID "bible" & vaccines prevented transmission early on with alpha, but not enough now with current variants to justify such discrimination Moreover, shame, stigma, blame (remember COVIDiots?), coercion, discrimination not good public health tools. When used for HIV, public health & ID physicians decried them but tactics used a lot in COVID. This book tries to explore & correct that for future
barnesandnoble.com/w/endemic-moni…
Feb 8, 2023 • 4 tweets • 2 min read
FEAR: Some media & public health officials concerned Americans aren't fearful of COVID now. But the vaccines & therapeutics DO WORK. If we can't celebrate biomedical advances & imbibe their effectiveness (we have better tools for COVID than flu), what is point of developing? In HIV medicine, when therapies came out, we didn't say to people- stay fearful; make this the controlling principle of your life. The book #Endemic I wrote (coming out July 11, 2023) hails these biomedical advances & the age we are in to fight pandemics to reassure the world
Jan 30, 2023 • 8 tweets • 4 min read
POPULATION IMMUNITY: Nothing stresses a respiratory pathogen like winter months & this 3rd pandemic winter shows what high population immunity has done to decrease mortality rates from COVID:
ourworldindata.org/covid-deaths Place with the lowest amount of population immunity is China as less natural infection from zero COVID policies and vaccination (and boosting rates in elderly) not as high as desired. World & @WHO very rightly worried about China- need vax & therapeutics
Jan 29, 2023 • 4 tweets • 2 min read
ADOLESENTS: NIH Study (Stanford study, SF). "School shutdowns, severed social channels, and amplified stress at home and in their communities" during COVID amplified anxiety, depression, and brain aging "reflecting more lasting effects of adversity"
nimh.nih.gov/news/research-… Important piece from @NEJM this week on #harmreduction in pandemic management. Do everything in your power to minimize severe disease but stop interventions which cause harm without decreasing pathogen impact; new era in COVID 2023 w/ immunity/vaccines
Jan 23, 2023 • 7 tweets • 4 min read
ONCE YEARLY? Agree with most on here that 1) yearly vaccination needed but for older & more vulnerable (co-morbidities multiple, immunocompromised); 2) May not able to adapt mRNA vax quickly enough
FDA considers major shift in COVID vaccine strategy npr.org/sections/healt… to new subvariants (e.g. our last bivalent is against BA4/BA5 but Omicron up to XBB1.5) & not clearly better due to adaptive power of cellular immunity (see thread on B cells) so any boost probably ok. Latter in line with @WHO endemic plan put out on March 30, 2022
Jan 19, 2023 • 4 tweets • 2 min read
Excess deaths during COVID are very complicated & vary by region & duration/degree of lockdown; this was very true at Ward 86 (our HIV clinic at county hospital); sorry to hear this for the city of San Francisco; very much appreciate hard work of addiction teams at SFGH Good article-excess mortality in COVID likely neglect other med care: "in countries like Belgium/Sweden [highly vax'd], ratio between excess deaths & COVID deaths 1..net change mortality [from] other diseases/injuries during pandemic period minimal" there
thelancet.com/article/S0140-…
Jan 8, 2023 • 4 tweets • 2 min read
Yes immune system works
-Please see cellular immunity pinned tweet; so many papers! Will post more
-This is 7th human coronavirus; we know how coronaviruses work
-Retroviruses (HIV: start RNA & go to DNA) & coronaviruses (RNA virus) different
-Basic principles of immunology hold Below simple tutorial I hope is how cellular immunity & immune memory work- there will always be variants that may evade antibodies but we are lucky immune system more than antibodies! T and B cells too for variants; Media, good science reporting please!
medscape.com/viewarticle/98…
Jan 7, 2023 • 5 tweets • 1 min read
EXTREMES: Alan Watts (“This is it”): “Furthermore, so far from being the smug rationalization of a Mr. Pangloss, the experience has a tendency to arise in situations of total extremity or despair, when the individual finds himself without any alternative but to surrender himself entirely. Something of this kind came to me in a dream when I was about eight years old. I was sick at the time and almost delirious with fever, and in the dream I found myself attached face-downward and spread-eagled to an immense ball of steel which was spinning about the earth
Jan 6, 2023 • 6 tweets • 2 min read
NEW ANTIVIRAL FOR COVID: This one (related to remdesivir so a nucleoside analog- stops viral replication) is being compared to Paxlovid so will first remind you of Paxlovid data (which is a protease inhibitor- also stops viral replication). Both
should work against variants (as will molnupiravir) since they work upstream from production of the virus, variant or not. I have molnupiravir thread elsewhere which I will update since Lancet published PANORAMIC findings on it- this new one called VV116
nejm.org/doi/full/10.10…
Dec 31, 2022 • 4 tweets • 2 min read
EXCESS DEATHS YOUNGER: Seem to be from delayed medical care (even after vaccines; fear-based narrative & closures), not vax. How do we know? Highly vax'd Sweden didn't have excess deaths in young, had COVID mortality until vax. Other med care important too
thetimes.co.uk/article/covid-… My advice 2023: 1) work on non-communicable diseases/preventative health to make up lost time; 2) work on HIV, malaria, TB, antimicrobial resistance, vaccine hesitancy in ID; 3) Boost older/vulnerable COVID vax each winter; 4) Global COVID oral therapies
Dec 30, 2022 • 4 tweets • 2 min read
TRAVEL RESTRICTIONS: Agree it's difficult to stop spread of highly transmissible respiratory viruses (which is why China abandoned this strategy although immunity is way to get through pandemic & they need higher rates of vaccination & boosting in elderly), But testing prior to travel from China, from either an epidemiological or human rights perspective, makes little sense when SARS-CoV-2 is already circulating widely (such border controls are akin to confiscating matches after the forest is already ablaze). This paper
pubmed.ncbi.nlm.nih.gov/33581746/
Dec 22, 2022 • 4 tweets • 2 min read
TRANSIENT: Yes, this is why HIV/ID doctors tell residents/fellows not to check CD4 counts in those with HIV during acute illness because can be transiently low but not reflective of actual level of immunity Another important T cell thread in COVID from @BenMazer
Dec 18, 2022 • 12 tweets • 5 min read
1918 INFLUENZA PANDEMIC: Deadliest pandemic in history; 50 million died (lower world population), estimates up to 100 million. Important review here: "looking to past for clues about severity of future pandemic events is key to shaping pandemic responses"
sciencedirect.com/science/articl… Three major waves in the 1918 influenza pandemic over 1918 (fall, winter, spring), second deadlier than first and the third wave was in fits and starts. Nice review here by CDC on the deadliest pandemic in history: cdc.gov/flu/pandemic-r… Image
Dec 8, 2022 • 5 tweets • 2 min read
COVID VACCINES WORK SO WELL, EVEN WITH IMMUNOCOMPROMISED: Base rate fallacy & miscategorization of deaths among those who swab COVID positive in hospital (50% of hospitals still asymptomatic screening) making WaPo, NYT say "pandemic of vaccinated'; untrue
medscape.com/viewarticle/97… Such reporting makes public distrust the vaccines so want to be clean in reporting like UK/Europe. mRNA vaccines work so well among immunocompromised likely because you make such high levels of protein (mRNA is "recipe") that can raise strong immune response; powerful technology
Nov 28, 2022 • 7 tweets • 3 min read
Not seeing much severe COVID anymore in hospital consistent with most ID MD, hospitalist, ICU attendings, chest radiologists in North America; same in UK where flu overtook COVID mortality in spring; we have excellent tools (Paxlovid >65) + high population immunity to COVID Boosters and Paxlovid both are needed for older people (and flu shots for all as rearing up) and accurate data collection to give people in the US confidence in the power of COVID immunity and the vaccines
thehill.com/opinion/health…
Nov 19, 2022 • 4 tweets • 2 min read
T/B cells protect from severe disease but how do we know B cells in memory? Because in the plethora of papers out of COVID, 2 emerge as gems. Below shows SARS-CoV-2 B cells in bone marrow after infection. This shows memory B cells in lymph nodes after vax
nature.com/articles/s4158… Boosters don't raise IgA (mucosal Ab) in nose to prevent every infection (so can't prevent case increases- last year's booster campaign showed us this) but can protect those who need elevated IgG (blood Ab) when confronting virus (such as older people)
thelancet.com/journals/lanin…
Nov 12, 2022 • 5 tweets • 2 min read
NEW SUBVARIANTS & ADAPTIVE IMMUNITY: See consternation on line that new boosters designed for BA4/BA5 + ancestral strain (half-half, bivalent) but that BQ.1 & BQ.1.1. now make up 44% of our subvariants. covid.cdc.gov/covid-data-tra…
Adaptive immunity calms the concern Many on twitter have written about T & B cells, but let's put it simply. T cells form a blanket across the spike protein & still cover all the the variants, subvariants to date, so you are protected by your T cells (prevent severe disease) from BQ1, etc.
sciencedirect.com/science/articl…