Dr. Monica Gandhi
Christopher Michel / Courtesy UCSF
January 9, 2022 8:27 PM EST

This was the week that the virus was really everywhere, with a spike in cases that is mind-boggling. Uncertain about how long this latest wave might really last, and what will come beyond that, we reached out to Dr. Monica Gandhi, an infectious-disease physician and professor of medicine at the University of California, San Francisco.

Dr. Gandhi is notable for her relative optimism that we’re moving beyond the pandemic phase of Covid, to where its impact—and the precautions we need to take in workplaces and in public—becomes more similar to a regular seasonal flu. (Dr. Anthony Fauci, among others, is less ready to predict a “new normal.”)

In our conversation on Friday, Dr. Gandhi shared her conviction that organizations will likely be able to safely bring the bulk of their staff back into the workplace by mid-February, and that masking and testing of people without symptoms would soon be unnecessary for healthy, vaccinated individuals.

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Here are excerpts from our conversation, edited for space and clarity:

 

What do you think is the most likely scenario for the spread of the virus over the next 10 weeks?

The Omicron variant is really transmissible, and also comes down fast. If we can extrapolate from South Africa—where it was first reported—and the United Kingdom, it will come down fast, but it will peak with an incredible number of cases. The estimates are that it will peak in mid-January, which is in just a week, and then come down more quickly. By the beginning of February, we should be back to a stage of low cases.

What will it also do? It’s going to leave a lot of immunity around because many people with the Omicron variant are symptomatic breakthroughs. They’ve been vaccinated and boosted, but they’re still getting mild symptoms. There was a study that showed that you get very broadly neutralizing antibody activity against the other variants and a strengthening of what’s called your t-cell response. As a result, it’s going to leave immunity, even for those of us who are vaccinated, and certainly leave immunity in those who are unvaccinated. Because it’s so transmissible, it’s building this immunity wall. We’re hoping that by the time we get to the beginning of February, we’re going to be stable for a while. It doesn’t mean the virus will go away, but it will be stability.

 

That stability will allow us to return to what sort of activity? Broader workplace return? No masking in public places? People back inside at restaurants?

If you think about what’s going on with the virus right now, we have to compare it to other respiratory pathogens because these are the pathogens that we’ve lived with for a while. Influenza is a respiratory pathogen that typically lands 50 people out of 100,000 in the hospital, every winter. At this point, with the Covid pandemic, we are getting about 3.9 people out of 100,000 in the hospital with Covid, if you’re vaccinated, according to the CDC data. If you’re unvaccinated, it’s 63.9 people out of 100,000. Unfortunately, with a 62% vaccination rate, we have not managed to get our hospitalizations down like other countries because some people have not taken the vaccine. If you’re vaccinated and boosted, your possibility of getting very sick from this virus is extremely low.

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When I think of the workplace, the immunocompromised and elderly with multiple medical conditions are the people who, when they go back, need to be protected more because they’re more at risk for severe breakthroughs. They’re the ones who need to be wearing masks if they feel comfortable doing so.

Ventilation is a huge aspect of our new life because ventilation is not only good for this virus, but it’s good for other respiratory pathogens and it’s good for the environment. Regular, filtered ventilation in a workplace is something incredibly worth investing in. In terms of wearing masks every day, that isn’t actually sustainable and it inhibits communication. If you’re fully vaccinated in a workplace, nor is it necessary, because we’re living with risks that are lower than the risks that we used to live with, which allows normality.

There was a paper Thursday, in JAMA, that appealed to the Biden administration to understand that we can’t eliminate the virus. We can’t achieve what’s called ‘Covid zero.’ It’s not because people didn’t try. It’s because it’s the nature of the virus: There are animal reservoirs, it’s very transmissible, we don’t have sterilizing immunity from the vaccines, it looks like a lot of other viruses, and it has a long infectious period. What we can do is prevent what we were so scared about with Covid, which is hospitalizations and deaths in those who are vaccinated. For those who are unvaccinated and have declined persistently to be vaccinated, we have antivirals. They are oral. They are easy. They need to be ramped up. It’s called Paxlovid, and it’s a way to treat it.

Then, we have to go back to living the way that we used to with the threat of other respiratory pathogens always above us, but knowing that we have so many tools to fight it. I think this will be the last wave for a while. We could get another variant in the future, but this variant causes a lot of immunity that protects you from other variants.

 

That’s a pretty optimistic statement that this could be the last wave for a while. I think a lot of people would be happy to hear your view on that….

Yes, it’s called getting to the endemic stage. If you get a lot of immunity into the population, you get to what’s called endemic. But it’s hard won.

 

From what you’re saying, is it fair to conclude that by the middle of February organizations should have confidence that they could safely bring the bulk of their staff back into the workplace?

Yes, I think that’s a fair conclusion. Omicron certainly extended that timeline from what we thought would be January. Mid-February is a really fair conclusion.

And we need to protect our vulnerable. So who are the vulnerable? They’re people who have immunocompromising medications or older people with multiple medical conditions. In the workplace, I would provide additional protection for them. They’re the ones who are closest to the ventilation, for example, or they are the ones who—if they’re comfortable doing so—are wearing masks. This is a respiratory pathogen that, just like every winter with other respiratory pathogens, people who are immunocompromised are more susceptible to.

 

What is your advice for what activities people should or should not engage in over the next two weeks?

Anyone who is vulnerable should not be engaging in activities. My father is 87, and he’s immunocompromised at the moment because he’s getting therapy. We don’t let him do anything. But if you’re vaccinated, boosted, and immunocompetent, then at some point we’re going to have to just live. People are seeing each other and going inside and eating, which was the point of vaccination and boosting. And yes, there are more mild infections that are happening with Omicron, but you also want to be realistic two years into the pandemic. Closing schools and businesses when we have the vaccines is understandable, as we have to get through this wave. But at some point you have to make a decision to live with the risks of a respiratory pathogen as a society with vaccines and go back to normal life.

So what would I do over the next two weeks? I don’t let my father do anything. I’m more immunocompetent, so yes, I go to work. I go inside to the office. I have been to restaurants. I’m a fully vaccinated boosted person.

 

Among the approaches that workplaces and schools have adopted is widespread testing. Do you think that testing of people who don’t have symptoms should be a priority?

When we decide that Covid is the same risk of other respiratory pathogens—which is actually much lower risk for those who are vaccinated—then we will go to a system in which we only test people who are ill and don’t test people who are asymptomatic. That will be the difference in going to an influenza surveillance modality, from pandemic to endemic, as opposed to staying in pandemic mode. I wrote a New York Times piece about this called ‘Why Hospitalizations Are Now a Better Indicator of Covid’s Impact,’ and I would encourage people to read that to explain why we’ll go away from asymptomatic testing at that point.

 

To be clear, your argument is that we are now at the endemic stage and so we should be making the transition?

Omicron will take us into the endemic stage because of the wall of immunity that will be built, so we’ll be there in a couple of months.

 

What should employers do about the many people who choose to be unvaccinated and probably are not going to change their minds about that?

I wrote a piece on my support of vaccine mandates three or four months ago, and I was a big proponent of vaccine passports and vaccine mandates. However, I have now seen that, like you just said, there are some people who will not change their minds. That’s the mass misinformation that has been allowed to disseminate in the news. At a certain point, we have to realize that we have ways to protect the unvaccinated.

What changed since I wrote the vaccine mandate article was the advent of oral antivirals. Molnupiravir is one, which is okay, but Paxlovid is much, much better. It prevents hospitalization and death among people who are unvaccinated and at risk for severe disease by 89%.

That is actually the same rate as a vaccine. At a certain point, there has to be an understanding that we have ways to both protect the unvaccinated and compassionately treat them. If we cannot, through vaccine mandates, change this—and with the Supreme Court hearing the case on vaccine mandates today, I don’t know what will happen—then I do believe that we have to consider the availability of antivirals and allow society to move forward.

Read a full transcript of our conversation, including additional discussion of what schools and parents should be doing, and how to explain ongoing disagreement in the medical community about the outlook for Omicron.

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