UCSF Grand Rounds: Vaccines, variants, mandates and preparing for the future

With Covid-19 hospitalizations in San Francisco doubling since last month, UCSF Department of Medicine Chair Dr. Bob Wachter hosted a conversation that included Dr. Ashish Jha, the White House COVID-19 response coordinator, and a panel of UCSF Grand Rounds veterans to discuss the current surge of omicron sub-variants, questions regarding masks and vaccines, and what the future holds for Americans as the pandemic drags on. 

Dealing with the fifth wave

The United States is “clearly in a fifth wave of transmission, which seems to be driven by a couple of omicron sub-variants,” said Dr. George Rutherford, UCSF professor of epidemiology. Though it’s hard to tell how big the current wave is because of at-home testing, “it’s probably on the same order as the Delta wave.” 

Another uncertainty is the clinical implications of the new variants, Rutherford said, though he expects we will see less virulent infections that are more transmissible. 

Dr. Monica Gandhi, associate chief of Zuckerberg San Francisco General Hospital’s Division of HIV, Infectious Diseases, and Global Medicine, agreed that this wave has had less severe disease than earlier waves. She attributed this to the high vaccination rate and a high rate of natural immunity. 

Dr. Peter Chin-Hong, UCSF professor of medicine, encouraged a combination of tools to prevent infections.

“My overall message is: Carry a mask like you carry an umbrella,” he said. “You bring it out when you feel it’s risky: Indoors, crowded, poor ventilation. There’s a lot of virus going around.” He noted that one in 18 people in San Francisco are infected but show no symptoms. Gandhi said that she thinks of masks as an individual benefit as opposed to a tool to decrease transmission at a mass population level. To protect, she said, a mask must be an N95, KN95, FFP2 or KF94..   

Chin-Hong also said that rapid testing before big gatherings and having a plan to obtain Paxlovid, an oral antiviral that fights covid, are key. The proportion of people who are vaccinated (but not boosted) and dying of covid is slowly increasing, he said.  

While there have been some incidences of people having negative rapid tests when they are infected, Rutherford attributes this to user error, noting that “by and large [at-home rapid testing] works.” Chin-Hong also said that some people are symptomatic before their viral load becomes high enough to register on an antigen test. 

A conversation with Jha

Jha came on next to discuss his experiences as the coordinator of the White House’s covid response, a role he took on in April. He described policy-making nowadays as “three-dimensional chess,” because of the number of challenges confronting Congress, including Ukraine, covid, gun violence, monkeypox and inflation.

The fact that the pandemic is no longer the first story every day is good, because people need a break from the mentally-taxing emergency mode of the past two years, but that also makes it harder to convince lawmakers of the urgency in buying therapeutics or vaccines. Lawmakers understand that the pandemic isn’t over, but this doesn’t necessarily translate into getting votes needed to pass certain plans.

In the near term, Jha encouraged all eligible individuals over 50 to get their booster, especially as infections rise this summer in the American South. For the fall and winter, the two issues the country is facing are: What will the dominant variant be, and how good will vaccines be at fighting said variant? There is an increasing sense that our current vaccines “need an update,” he said, though we do not know if new Moderna and Pfizer vaccines being tested will hold up against BA4 and BA5 until data comes out in the coming weeks. 

Beyond this winter and into next year, Jha said he believes we will eventually move beyond a point of needing to get boosted every four to six months for the rest of our lives because viral evolution will slow down — a point later questioned by Rutherford, Wachter and Gandhi. The latter argued that  variants are beginning to arise from animals infected with covid and passed onto humans. 

Jha discussed what he sees as important features in the new vaccines: Blocking transmission and preventing infection, providing a wide range of protection against variants, and providing more durable, long-term antibodies. There are vaccines in various phases of development and clinical testing that attempt to fulfill those requirements, he said. 

“In my mind, the mental model is, if we can get to a point where we have once-a-year vaccines, I sort of feel like we’re done at that point,” he said, though it may take us another year or two to get there. 

As for metrics for currently measuring covid, Jha said he relies on wastewater data, because reported case numbers have dropped by 60 percent due to at-home testing. “There’s really a pretty big disconnect between infections and cases in many places,” he said. 

Regarding mask mandates, Jha said he has felt, for a long time, that decisions on mandates should be made by local leaders. Jha said he’s spoken with some 15 state governors in the last two weeks, and zero have said they are considering re-instituting a mandate. 

“There’s just very little political appetite at the local level by governors to do this,” he said. He also remarked that the Florida federal judge overturning the U.S. Centers for Disease Control and Prevention travel mask mandate was “problematic,” and that having groups other than public agencies pulling down or putting up mandates could have “real, harmful consequences.”  

Jha’s final remarks consisted of the potential benefits and long-term harms from the pandemic. 

“The virus is going to be around,” he said. “It’s still going to be a really complicated virus to manage” because it is not seasonal, like the flu, and is much more contagious. Yet Jha can imagine in a few years that the challenges covid has raised around vaccines and therapeutics will become part of the way we manage respiratory viruses more broadly, a point Gandhi echoed later on.

“It could end up leaving us, I think in many ways, in much better shape against the flu,” Jha said. “It will have large impacts on, I think, antiviral treatments for other diseases. There’s all this scientific knowledge that we have gained that will have large spillovers.”

The same logic applies to long covid, an issue he said that we’ve really got to get our arms around. “There are a small proportion of people who are really affected in very, very substantial ways,” he said, remarking that it’s not 20 percent of people infected with covid, it is likely in the single-digit percentage. Chin-Hong noted that this proportion could represent one to two million people, if 100 million people have been infected with covid thus far. 

However, Jha finished by stating that “there’s a lot of people who are pretty disabled, but it’s also going to teach us a lot about post-viral syndromes more broadly.” 

“I am hoping that we really double down and triple down on both identifying people who are at risk, figuring out treatments, figuring out diagnostics, moving forward on long covid,” he said. 

See our previous Grand Rounds coverage here.