Almost two years after the first session of UCSF’s Covid Grand Rounds, “we’ve clearly entered a new stage,” said Dr. Bob Wachter, chair of UCSF’s department of medicine. But even as case and hospitalization rates are plummeting, individuals face the difficult task of navigating the murky line between safe and not safe.
“We’ve come to appreciate that there’s no real, bright line between safe and not safe,” Wachter explained. To help, he had three experts on hand to discuss mandates, vaccines among children, and other long-term questions as Covid-19 becomes endemic.
‘Are we going back to normal too soon?’
Dr. Peter Chin-Hong, professor of medicine at UCSF Health, described “this weird mix of anxiety and also, you know, feeling fed up and ready to move on” — a feeling he said was mirrored by polls of the general public. He cited a Kaiser Family Foundation poll, in which 61 percent of respondents said they are worried about spreading covid to immunocompromised individuals, but 63 percent of the same respondents also reported that local businesses will suffer if mandates are not lifted, and 64 percent said mandates are harming adolescents’ mental health.
Asked if the end of mandates in states like California are justified by the state of the pandemic, or if they are largely driven by people wanting to move on, Chin-Hong said both theories are likely correct.
Dr. Monica Gandhi, associate chief of Zuckerberg San Francisco General’s Division of HIV, Infectious Diseases, and Global Medicine, said she wants to reframe the question ‘are we going back to normal too soon?’ into a discussion focused on the many tools we have to fight covid, namely vaccines and therapeutics.
Gandhi, who helped advise the White House on its latest proposal for fighting covid long-term, highlighted several key focuses of the plan: vaccination, including figuring out who needs boosters and “vaccinating the world;” test-to-treat that includes developing systems to test and heal those who are unvaccinated or who don’t respond well to vaccines; business and recovery; and wastewater tracking to detect covid levels in the population over time.
Chin-Hong said that he “loved” the emphasis on test-and-treat. However, he expressed concerns about the cost of $30 billion, saying “it was not chump change,” and some think the country will need $100 billion to transition to an endemic phase.
Funding preventative measures in the United States has never been easy. Or, as Chin-Hong put it, “Prevention is never sexy.”
The experts said education is needed for the covid drugs out there.
Paxlovid, an oral antiviral pill that helps treat covid, is a case in point. “There is enough of it for the people who know about it, but there are vast swaths of people and clinicians who don’t really know how to access it,” he said. He called for an “information blitz” to educate people about the drug, especially because the United States government requested one billion additional doses from the manufacturer.
Regarding the potential use of future mandates, Gandhi said she is a firm believer in vaccine mandates, but said that if mask mandates are to continue, they should require certain types of masks that are proven to be effective, such as N95s.
“It really matters what mask you wear,” she said. “There is no doubt … that we have been asking children in schools essentially to cover their faces with the wrong mask for two years.” Gandhi said the best way to reduce severe disease is to get vaccinated (as opposed to masking), and that some studies showed “mask mandates didn’t really change anything,” because people wear different kinds of masks or because masks are worn improperly.
If community transmission is low and her work drops its mask mandate, Gandhi said she will not wear a mask indoors, citing a need for more immune diversity through exposure to different pathogens.
Chin-Hong had a different take, noting that he will wear his mask if it’s crowded indoors (though he will dine indoors), and that he’s “getting plenty of exposure to help my microbiome in other parts.” No mandate doesn’t have to mean no masks, he said, but he agrees that vaccination is the most important measure.
Interpreting vaccine data
For the second half of Grand Rounds, Wachter brought on Dr. Yvonne Maldonado, chief of the Division of Infectious Diseases in the department of Pediatrics at Stanford University. Maldonado “emerged as a national and world leader in understanding the role of vaccines,” Wachter said.
A lot of discussion around vaccines today is about risk perception and “how we interpret the same data and decide to make our decisions based on our own understanding of risk,” Maldonado said.
As a pediatrician, Maldonado homed in on the relationship between children, covid and vaccines during her presentation. Though she has noticed an “underlying narrative that children don’t get infected and they don’t get sick,” Maldonado brought figures that show otherwise. In one week in January, over one million children were reported infected. Children have represented 20 to 25 percent of covid cases over time, and 58 percent of children have been infected with covid, she said.
Maldonado said while as many as 95 percent of people over the age of 65 have been vaccinated, only 57 percent of children aged 12 to 17 can say the same, in addition to a meager 25 percent of children aged five to 11. Though it can’t be proven, it appears that the younger you are, the more likely it is that you have had the virus.
Maldonado attributed this disparity to the problem of risk perception, noting that some people may have been scared off by reports of myocarditis (inflammation of the heart muscle) in some vaccine recipients, while others may have felt that vaccination was less necessary given that hospitalization numbers among children seem to be lower.
Maldonado said that the risk of myocarditis following vaccination is higher in adolescent males than females, but the risk of myocarditis is “quite low,” and especially in relation to the number of hospitalizations and intensive care unit admissions prevention by mRNA vaccines.
She also presented on a study of more than 3,000 children ages 5 to 11 who were given the Pfizer vaccine. The study found the vaccine had an efficacy rate of 91 percent in this age group; however, two doses of Pfzier vaccine in children under five did not have the same levels of success. Instead researchers are moving forward with a three dose vaccine study that Maldonado said should be finished by the end of March. Moderna is also conducting trials with smaller doses of its vaccine for young children.
Discussing data focused on vaccination in adults, Maldonado noted that “unvaccinated people are still at so much higher risk of primary infection or reinfection, so we really need to take a look carefully at how data are curated and what the top line messages are because we can get lost in the weeds.” One study found that immunity from infection waned after one year, but that immunity remained higher than 90 percent if individuals got an mRNA dose after infection.
Regarding second booster shots, she said that there isn’t much data on their efficacy yet, but that early data from Israel indicates they “may not be effective within a short window after the third dose.”
See our previous Grand Rounds coverage here.