As individuals toggle between optimism and impending doom, the two factors that determine how you see the world are your vaccination status and where you live, said UCSF chair of the department of medicine Dr. Bob Wachter. To help evaluate the risks of certain actions, Wachter brought on three Grand Rounds regulars to discuss regional covid-19 updates and to answer questions about what they’re comfortable doing now that they’re vaccinated.
Regional Updates
UCSF professor of medicine Dr. George Rutherford began his presentation with an update on the “quite telling” international situation. Countries like the United Kingdom and the United States that have done “fabulous jobs getting people vaccinated” have demonstrated “massive” drop-offs in transmission, whereas countries such as France, Canada and Brazil — all struggling with vaccinations — have “not been able to move the dial,” Rutherford said. One anomaly is Chile, which has done “very well” in vaccinating people, but has not been able to drive down its rate yet, though he is unsure why.
In the United States, there have been close to 31 million cases, with a seven-day average of 65,556 new cases per day. Deaths continue to decline, though yesterday there were 2,564 reported deaths. “All eyes are on the upper Midwest” as the large outbreak in Michigan continues, Rutherford said. The outbreak is driven largely by the B.1.1.7 (UK) variant, and appears to have been spurred by youth athletic events. Rutherford said it may be related to the outbreak in Ontario, despite borders being officially closed. Meanwhile, the outbreak on the Eastern seaboard is “starting to turn the corner.”
California is “faring much better,” with a one percent positivity test rate, a basic reproductive number (R number) of 0.8 and hospitalizations continuing to fall. ICU capacity statewide is at 31 percent, and the remaining counties with increasing cases “are all very small,” Rutherford said. The government announced that it is moving away from the tier system on June 15, when many Covid-19 restrictions are to be removed if two criteria are met: equitable vaccine accessibility for those 16 and older, and a consistently low burden of disease.
However, this does not mean covid has gone away, Rutherford said; there are about 5,000 new infections a day in California.
Cases in the Bay Area are mostly steady, with low case counts in all counties except for Solano and Napa. San Francisco is close to meeting all criteria for the yellow tier, which it must continue to do for three weeks to receive yellow designation.
Over 20 million vaccines have been administered in California, and the seven-day average is 324,689 doses per day. Some 34 percent of Californians are fully vaccinated and, in San Francisco, 45.6 percent of people have received at least one dose, though Rutherford said this number is lower because not everyone vaccinated in San Francisco lives there.
Florida, “home of the famous spring break,” has the highest number of B.1.1.7 cases, and is trailed by Michigan, Minnesota, Colorado, and California. Rutherford believes that the B.1.1.7 variant hasn’t driven the epidemic curve in California because other variants, like B.1.427 and B.1.429 (the “West Coast” variants), are here.
Though this trend may not hold up over time, the “good news” is that a New England Journal article indicates that these variants are neutralized by the Novavax and Moderna vaccines, Rutherford said.
Asked about the “biological and probably political bet” to reopen on June 15, Rutherford told Wachter that “biologically, it’s not a bad bet.” Yet he still noted uncertainty around the B.1.1.7 variant in Southern California and youth sports.
He believes we are “on the way” to herd immunity statewide on June 15. After listing what could derail these efforts (unknown vaccine side effects, vaccination levels slowing, widespread transmission of more variants, or diversion of the vaccine to other states), Rutherford said, “I just don’t see it happening.”
“Is it safe to … ?”
Next, Wachter brought on UCSF medicine professors Dr. Monica Gandhi and Dr. Peter Chin-Hong to answer a series of questions about the safety of certain actions once vaccinated.
Wachter started off by asking if Rutherford’s outlook was “appropriately sunny?”
“I love warm weather,” Chin-Hong said, “but the question is really, ‘What’s in the future?’” He is worried about the waning of natural immunity in fall or winter, and young adults who may not get vaccinated in time. However, he is “basking in the sun” right now.
Gandhi, on the other hand, seemed completely unfazed by fear, calling herself “literally giddy” about vaccine effectiveness in real-world settings and praising it so much that Wachter said, “Talk me down, Monica.”
“There is nothing in my mind why there would be a surge in the fall or the winter” when the vaccines are being distributed, she said.
Gandhi cited a CDC study of vaccine effectiveness in healthcare workers across the United States released on March 29. The study found that, out of 1,000 people who were vaccinated, only one person later became infected with Covid-19, and out of 1,000 people who were unvaccinated, only 161 became infected. Chin-Hong pushed back, suggesting that healthcare workers may take other precautions more seriously. In response, Gandhi cited a Pfizer study of 40,000 individuals across the globe, which found that the vaccine was 100 percent effective in stopping severe illness and death.
The vaccines, she said, “are even better in the real world than they were in the clinical trials, and that’s saying something.”
Gandhi and Chin-Hong are both comfortable eating at indoor restaurants, going to the gym, getting haircuts, and traveling on airplanes now that they’re vaccinated. Chin-Hong was cautious about events with bigger crowds, such as music festivals, especially because there is still a small chance of acquiring covid once vaccinated. Both agreed that it is important to continue masking in public, though for Gandhi this was less out of caution and more out of politeness for social norms, as not everyone has gotten the chance to be vaccinated yet.
The pair explained two important factors in risk assessment: vaccination status and the amount of virus circulating in one’s community. For example, flying domestically in California is more advisable than flying to Michigan.
For those who are unvaccinated, such as children, Chin-Hong said that alternatives to travel should be taken if possible, but he believes that it is warranted in some situations, such as for family reasons.
Gandhi said that unvaccinated people can go to gyms and outdoor restaurants safely, but advised against indoor dining. Chin-Hong cautioned unvaccinated individuals against taking risks such as not wearing one’s mask in a gym, especially considering variants.
“I’m worried about both the biology and the sort of feeling that ‘I’m invincible, because everyone else feels like they are,’” he said.
The two shared similar beliefs about vaccine passports, saying that it is unfair to require immunity passports before everyone has had an equal opportunity to be vaccinated, but that they will likely become a reality eventually.
“The writing’s on the wall. Whether or not we like it or not, it’s happening,” Chin-Hong said, noting that it is already required on airplanes and in some places in Los Angeles and New York. He said that alternatives, such as requiring testing before entering public spaces, may be more ethical.
See our previous Grand Rounds coverage here.
“requiring testing before entering public spaces may be more ethical” should read “ethically problematic,” although any mandatory need to show test results at all (other than to enter a country, perhaps) is morally questionable.