- Good afternoon. Welcome back to Medical Grand Rounds. I'm Bob Wachter, Chair of the Department
of Medicine at UCSF. This is a kickoff to
our new academic year. And so we will be back here
with Grand Rounds weekly for the next nine months or so. I hope you will turn this
into your weekly habit. We are based on the
experience we had with COVID over the past year, where it's sort of upping our game and got some fantastic
sessions planned for you. Some of them will be COVID, some of them will not be, but the other really
interesting issues in healthcare that I think you'll wanna learn about and hear about from our speakers, just a little bit of an advanced. Notice today will be a COVID session. We'll do another one on October 14th with our friend Ashish Jha. He and I will chat for an hour. So put that on your
calendar for October 14th. Next week, we'll do one of our clinical
problem solving exercises, where we present an unknown to Rabih Geha. One of our super clinician educators. The week after that on September 23rd, we will do a session on the controversy over the new Alzheimer's
drug with Rita Redberg, talking about some of the policy and FDA approval issues and Gil Rabinovici from
neurology talking about some of the clinical aspects and the clinical data on that drug. The week after on September 30th, we'll have Eddie Chang, the Chair of the
Department of Neurosurgery. Talk about his remarkable research on the really essence of speech and how the human brain
comes up with speech and what he and his group have done, which is develop a speech neuroprosthesis for people that are unable to speak. And obviously, it's gotten
worldwide attention. So a lot of really interesting
cool stuff coming up, but let's focus on today. I'm not gonna spend any time going through why we're talking about COVID still, when we signed off in May, we were hoping that maybe we
would be over the worst of it and maybe a ripple of
COVID here and there. But clearly that has not
been how the summer has gone. So it felt like it was
time to bring together three of our favorite
speakers to update us on where things are with COVID. I can be brief with their bios 'cause we've met them before. First will be George Rutherford, who will give us a short talk
on the state of the pandemic in this fourth surge. George is a Professor in Epi and Biostat and serves as Medical Director of our Prevention and Public Health Group and has been our go-to person for all things COVID epidemiology for the last year and a half. We'll also have Peter Chin-Hong. Peter is Professor of Medicine in our Division of Infectious
Diseases at UCSF Health. He's also Associate Dean
for Regional Campuses at the UCSF School of Medicine and has been a go-to
person for us on clinical and other aspects of the pandemic as he has been for the media. As has our third speaker, Monica Gandhi, who is Professor of Medicine, Associate Division Chief
of the Division of HIV, Infectious Disease and
Global Medicine based in San Francisco General. She also directs UCSF Gladstone
Center for Aids Research and is the Medical
Director of the HIV Clinic. So these are three absolute
world-class experts, no surprise that they have
been essential communicators about the pandemic, both locally and to the media, nationally and internationally. And so we're thrilled to have them here to educate us about what's going on. And the what's going on part, we will try to cover as much
as we can in the next hour. Everything from the current wave to the schools, to masking, to Delta, to Mu, to boosters. So I'll talk fast, they'll talk fast. If you have questions, please type them in the Q&A, we'll get to as many of yours as we can. And if you're interested
closed captioning is available at the bottom of the screen. So with that, I will turn it
over to George Rutherford. - Thanks, Bob. Okay. So I had hoped that when
we had broken in May, that we'd be looking pretty good now. It's sort of good, but not great. And we need to be, this is going to continue to be a problem. We have had a fourth surge since May in the United States and in California. As you'll recall back
here in April and May, there was a surge in the Upper Midwest that probably really
represented a fourth surge. Although it may have been the tail of this sort of big winter surge. We did not see the same
thing in California, but they have done the
less have had a surge through July and August. United States right now, sorry, is running at more
than 140,000 cases a day with more than 1,500 cases a day. California is a little bit
more than 10,000 cases a day, and has clearly turned down. The US has seemingly turned down, although there's this kind of really jagged sawtooth pattern to cases, and it's a little unsure
whether we can say this is a true turndown or not. The cautionary tale here
is from the United Kingdom, where they had a very
similar pattern with a surge, a dropdown across the summer, a later summer surge, a decline, which like we're seeing now, but then it went right back up again. And I just want to be say, you know, we need to be careful that
this doesn't happen here. In the UK, 65% of the entire
population is fully vaccinated, whereas in the US right now this morning, 53% of the entire population
is totally vaccinated. So we are at risk for this happening, and it's going to take
some concerted effort to keep it from not happening. Where are case going on now in the US? Well, they're going all through the south, the Southeast up in near
to the Lower Midwest, but also in the Intermountain West with states like Wyoming
and Utah, Nevada, Idaho, and then even the sort of Northern and Eastern tiers of California being quite heavily affected, and this is per a hundred thousand. Cases in Florida are starting
to come down somewhat at which is most welcome, but it's, you know, with the hurricane that's gone through and flooding and all those problems, it's unclear how that's going to affect the Gulf Coast. One thing that's come out is that this surge is affected children. These are data that
just came out from CDC, and they're showing a
surge in 0 to 17 year olds out here in August. But if you look by State and if you divide the
States into quartile, the quarter of the States with the lowest vaccination average, vaccination coverage have the highest risk for ED visits, sorry, this is for emergency department visits. I realized this is Medicine Grand Rounds, everybody thinks it's something else. For emergency department visits with a 3.3 times higher odds and 3.7 times higher admissions in the States with the
lowest levels of vaccination. California, by the way, is up in this highest tier. Here in California, as I said, this is a disease of the, kind of the northern and eastern more tier with a big surges in Del Norte, in Siskiyou Tehama, Colusa, Sutter and Yuba and even down here in Kings County, but there's a lot in Shasta, and some of these other big thing. The big population center
in this part of the world is here in Redding. In the Bay Area, we're doing quite well. Although Contra Costa and Solano
are lagging behind somewhat particularly Solano County, and in Southern California, Ventura, Los Angeles,
Orange are doing well on a per capita basis. Overall, the R sub e for California, the effective reproductive
number is less than one. We have a test positivity
rate of about 4.5%, which is coming down. And we've had a flattening
out of hospitalizations with only a 3% change
over the last 14 days. In the Bay Area, only two counties have, you know, it's just a jumping around, Alameda has declining case rates as do Marin and Napa, San Francisco itself has had 70 more cases over the last week, but everybody's doing pretty well. All this our sub es except for a couple like in Solano are below, are at or near or below one. The percentage of tests that are positive again with the exception of
Solano are all under four. And you can see how this tracks with the percentage of the population that has had a first dose of a vaccine. So you're in Marin where it's highest. This is where the one of the lowest for the percentage of positive. Okay? In California, we've administered 46.6
million doses of vaccine. We're flattening out here at around 75 to 80,000 doses a day. 65.8% of Californians have
received one dose or more, and 57.4% have been fully vaccinated, which is by the way less
than in the United Kingdom. In San Francisco, 79.5 have had one dose or more, and 73.3% of every, this is of everybody, including children are fully vaccinated. And here you can see the
data for the greater, this is for California, and the highest eight counties are all Bay Area counties, and then you get to Imperial in San Diego. So that's all. I think that's good news. We're pushing although it's not kind of surging back up
quite likely to hope. The vaccinations are indeed climbing. The problem we're facing is Delta. The Delta variant, and the Delta variant is big trouble. It's become essentially the
only variant circulating in the United States, and over here in region nine, which includes California, as well as Arizona, Hawaii, Nevada, and the Pacific territories. It's 99.5% of all the isolates
that have been sequenced. So we've entered a phase where Delta is completely overwhelmed everything else, and it's not budging. So kind of what's going on just to summarize what's
going on in the US. There's the rise of the much more transmissible Delta variant. Now it's almost a 100%
of isolates in the US. We have a problem with
failure to vaccinate, which is far more important
than vaccine failure. We have a continued mixing
of unvaccinated people with result in transmission. I saw that the Sturgis Harley-Davidson
Annual Motorcycle Rally happened last month in South Dakota. So that's probably not a good thing. We have had less than full of adherence to non-pharmaceutical interventions. We've had a failure to develop immunity and some immunocompromised individuals. And this has led to a recommendation for an additional dose
in the primary series of the mRNA vaccines. There are some mixed evidence of declining vaccine effectiveness, has been temporarily associated with the rise of the Delta virus. It's unclear whether that's waning, first of all, whether
it's anything at all, whether it's waning immunity or whether they're escape mutations. And this has led to the whole discussion and a breakthrough infections, which are still uncommon, but it's a prompting, likely to prompt action
at the federal level. This is a study that was
just published last week in the New England
Journal from UC San Diego, looking at vaccine effectiveness by month among healthcare workers. These are mRNA vaccines. So 94%, 96%, 96%, 94%, and then 66% in July. There's similar data
from a number of places that have similar levels of
declining vaccine effectiveness. However, we're still
seeing most of the cases in people who are unvaccinated and most of the hospitalizations and people who are unvaccinated. This takes us up to almost the end of July from Los Angeles County. The dashed line are people
who are unvaccinated. These are infection rates, and the dark blue line is the people who were fully vaccinated. And it's actually 4.9 times higher in numbers of cases among the unvaccinated and hospitalizations are 29.4 times higher among the unvaccinated. And these are hard data from Los Angeles. I think it's probably consistent
with what we're seeing. So the US is considering recommending a third dose of mRNA vaccines. There are two issues. One is non-response amongst solid organ transplant recipients and other immunosuppressed patients. And the second is this
issue of waning immunity. Again, we'll add some
discussion about that. There is a recommendation
for an additional dose after the primary series
for transplant recipients and immunosuppressed patients immediately. And then there's this
discussion about a third dose for everyone else, six to eight months after the second dose, after their second dose
beginning on September 20th. This would recapitulate the rollout from last winter with
long-term care residents and healthcare workers
being vaccinated first than adults over 70, 75,
and over in a frontline. The central workers next, then adults 65 and over, all essential workers, and some of those younger people with high risk medical conditions. Right now there's an opened up, there's an active discussion
of whether this should just be for people who receive
the Pfizer vaccine only, and there's some interesting
reasons for that. And meanwhile, for those
of you who got J&J vaccine, we're awaiting the results of a one versus two dose
trial that they did. At least at San Francisco
General, SFDPH has gone ahead and offered mRNA vaccines to people who had a single dose of J&J vaccine. This is something that's
evolving as we're talking. And it'll finally, where does this put us? This as the Institute for
Health Metrics and Evaluation at the University of Washington. There are most likely scenario, which is the middle one, which has 57% of
Americans fully vaccinated by December 31st, and that mask use is roughly
comparable over time. It has this, you know, still
not coming all the way down. And these are case counts of, you know, tens of thousands per day. The worst case scenario, this is where everybody
stops wearing masks, and the best case scenario is when we can keep masks on people. So we'll have to see how this plays out. This does not include in the models, it doesn't include
issues of schools per se, which are a bit of a wild card as to how they'll play out. What I'm happy to say is
that at least in my dealings with a handful of school districts, including large school districts, there is very little
in school transmission. Almost all the kids who've
been found to be infected have been infected
either in their families or in the community and not in the schools per se. There are a handful that are, but it's only a handful. So I'll stop there, and happy to hop back on. - Great. When you stay, stay back on George, and let's bring on Peter and Monica. And let me start with you just to clarify, it's first a terrific and sets us up beautifully for a whole lot of
questions that will come. Why does surges come down? You know, you hear talk that you've sort of reached
a level of immunity, but like really? And then you hear talk, it's just a fear of God, but like, why did that start on that day? And then why did the UK go back up? So do you have any good
explanation for why it seems like these
last two to three months and they always come down. - The New York Times had a
really interesting article that said that all these Delta surges are on two months timeframes. They go up, they go down, they go up, they go down, and there was some postulation
that it might be biological. I doubt that. I think that this is really, I mean, there's gonna be
some biology to it obviously, but I think it's also behavioral, people wearing masks, maintaining socially distancing, but more importantly, getting vaccinated and using this as a
spur to get vaccinated. So it is what it is. And I think we could go on, and Delta's so transmissible that I think you could easily, without any kind of, it did no abatement at all, they basically find almost
everybody who was unvaccinated and give them Delta virus. So I think the fact that it's coming down, this speaks our efforts to control it. - Great. All right. Let's turn to-
- Please don't quickly. - Oh go ahead, Monica.
- I could just say- - Yeah, please.
- When I think abut that, because I think it's really interesting to see the cases coming down and like you just showed in
California and San Francisco, that the cases came down in Missouri first and that's actually where they rose first. They banned a mask mandate. There was no capacity limits. And there wasn't actually
a lot of behavior change and their vaccines didn't go up that much as we would've liked, they did go up some. There is of course, a role of people getting infected, natural immunity bringing cases down. India had 4% vaccination
rate in early March when the Delta variant rose, and George, I wish it was vaccination, but unfortunately, we just didn't have the
vaccine supply there to provide everyone with vaccines. There was behavior change, but it's 1.37 billion people. A lot of people are in close proximity. And of course, it is a lot of some of it in lower vaccination rates regions of the surges coming down as natural and need to be.
- Yeah. - So just maybe complete
the dots there though in terms of Missouri. So if you say, I mean, people didn't get vaccinated that fast and they didn't get here.
- And they didn't wear mask. - And they didn't wear a
mask. So when it comes down, what is your hypothesis
about what's going on? - That essentially, there are people who get sick from it and go into the hospital, but there are other people
who have mild disease and get immune. And essentially, it does take some time. It takes two months. This happened in India as well, but immunity will bring
down that pandemic. We all want it to be through vaccination. - The natural effect in immunity, you think is some-
- Yeah. - Sort of level of natural immunity through natural infection. And that-
- Correct. - Yeah. I agree with Monica too. That natural immunity
has been underestimated. Maybe it's not as sexy, or it's kind of taboo to talk about it, but I'm particularly
struck by the contrast between Michigan and Florida, for example, very similar demographics. But if you remember in Michigan, before the Delta surge, they had that whole huge winter Alpha-
- Alpha surge. - Surge with indoor sports. And then now people are
like scratching their heads. You know, why is Michigan doing
so well, generally speaking, compared to very similar
vaccination rate of Florida? So that speaks to that as well. - Yeah. Yeah. Let me ask
one of the three of you is getting a lot of emails, that's pinging. So if you can turn that off, that would be great. Let me start to ask Peter and Monica, if you're anything like me, probably George too, you're getting a ton of calls
from friends and family. Some that you've forgotten about, and they have a question for you. Like, what do I do this happened? So what is the most common
question that you're getting from the people that you
haven't heard from in 20 years? And how do you answer it? Peter, do you have one? - Yeah. I mean, the most common
question is for me is, should I travel? And I think that's, you know, people are itching to travel. They've been vaccinated. We thought the world would be open and we'd all go forth and count. Specifically, a lot of people
recently with Mu in Columbia, they had booked tickets to go to Columbia and they are saying, "Should I cancel that trip to Cartagena?" And so I've been getting a
lot of questions around that. - And what do you tell? - I tell them, you know,
take your precautions. The level of disease in
Columbia is not terrible, and just because it has Mu
there doesn't mean that, you know, if you're
going to a seaside city, you take your precautions, use your disease mitigation strategies. I wouldn't necessarily cancel that trip, but again, this comes to
like one of the points you're going to bring up, which is how do you
live with the pandemic? How do you, you know, manage disease rather than
live under infection, fear? - I get the real answer to that question. - What are you talking about
the flight, by the way, are you convinced the flights are okay? - I think the flights are okay with multiple exchanges for hour, but what I'm worried about
is the routes to the flight, the gate area, the concessions, the food court, the transport from the
airport to the hotel. That's much more, you know, if people really wanna be
risk averse in flights, sit by the window, tilt on the vent, keep your mask on for most of the time, go to the bathroom before the flight and after the flight, but minimize going to the,
you know, the corridor and keep your head in one direction. (laughs) - Keep your head in one direction. Okay, George, you was going to say? - I'm gonna say the real
answer to your question is never turned down the
opportunity to go to Cartagena. - Yeah.
(laughs) - Fabulous place.
(laughs) - You know, one thing I would say about travel that is being asked to me too. You're absolutely right. Like totally agree with both of you, that air exchange is
excellent on that plane. And I actually just, because I have an
unvaccinated younger child, I always put the vent on. So that just brings in more, even though we're kind of cold, and then I'll be a little
more maskey on the plane. When you travel on multiple
international airlines, you actually need KN95. So, you know, I think
it's important to remember that not all masks are equal, KN95s are good masks, double masks are good masks. So are like a two piece of cloth and a filter paper inside. So if he's unvaccinated, my younger child, and I'm gonna be maskey with him. - So I hadn't heard
the term maskey before. So let's get into maskiness, while we're there, I mean, this is gonna go everywhere. I need to peel back and
talk about Mu at some point. All right. So you're being maskey. So tell me what being, you were taking a flight to New York couple of months ago-
- Right. - When the case comes
were a little bit lighter, you're taking it today, and your maskier today. So exactly, what does that
mean in terms of what mask and in terms of your behavior, as it relates to the
peanuts and the drink? (laughs) - So, yeah, a couple of
months ago, things were good. Things were so good
between Alpha and Delta. I'm so sorry the Delta happened. And by the way, it happened because we don't have
global vaccine equity, which we can talk about later. And so what happened is
during Delta flights. I actually-
- When you say Delta flights, are we talking about the airline or? - No, no, sorry- - I knew you were
talking about Delta plus. - We need to be very clear here. - Like economy plus.
(laughs) - Actually, Delta has better TV. - Flights during the Delta, is that what you're saying? - Well, I think you're frozen.
- Yeah, Monica is frozen. - And Delta is an unfortunate name. It's like having baseball
league pitcher named Walker. - Yeah, it would not be what you wanna your airline right now. All right. Well, we'll get back to
Monica when she reappears. Peter, let me peel back
to you for a second then maybe George as well. Mu. So you mentioned it, what is it? Is it a scariant, or something we really care about and why? - So I think from Mu, first of all, it has a Greek letter. So that already elevates us
above other things like C.1.2, which doesn't even have
a Greek letter yet. It is a variant of interests
as designated by the WHO, not a variant concern yet, higher level. And then the CDC hasn't said
any variant of interests, all considered. All states have reported
it, as far as I know, but much more common and very regional. So like Northern part of South America, mainly Columbia, some Ecuador, you know, maybe a smattering
of other countries, maybe 40, but less than 1% of
cases globally, so far. And if Mu and Delta went in a boxing ring, Delta is gonna win. If I had to be a variant
right now in 2021, I'd want to emphasize transmissibility over vaccine evasion, because so far they've only emphasized, these variants only emphasize one thing, for Gamma and Beta and like Mu, and Lambda too some extent, it's like a little bit
more vaccine invasion. - Yeah.
- But Delta is like, so transmissible that it makes all the other variants cower in fear. - I call it the variant to rule them all. - So that the idea is
you might hear about Mu, and maybe it is a little bit more able to evade immunity than Delta is, but as long as Delta is so much
more transmissible than it, then Delta is gonna win the battle and be the main variant that we see. Is that clear that Mu is
not that transmissible? - No, no, I mean, I think we probably don't
know many things about Mu, and that's being studied, but so far so good. It's not clear if it's
more transmissible yet. Although there are early
reports in Columbia that it's already crossing and going down. So, you know, I'm taking it
with a small grain of salt. - Okay. - The reason I think it's clear, it's not more transmissible
as it never want. Like it's actually been
here since January, and Delta was out a little later, and it hasn't been able to take it over. - You're able to tell, because if it was more transmissible. - It would. - Yeah, because if you
remember with Delta, it's also not only the, you know, the cross sectional snapshot. It's the tempos. If you remember in May Delta was 5% and then the next month, it was 50%. - Right. - So the rate of increase
was breathtaking, which we haven't really
seen with Mu per se. - In India words, we call it a wall. I mean, it went, it wasn't, it was a wall.
- Yeah. - But that's Delta. Mu has been out since January. I don't think it's gonna win. - Okay. George, anything you want to add on Mu? - No, they're absolutely right. I mean, you know, the next letter is nu
in the Greek alphabet. - Nu, all right. I thought that's in the Hebrew alphabet, but we'll get back to Monica. By the way, I just, while you froze, I checked Delta stock went
down about five points. So when you were talking
about a Delta flight, you're talking about the virus, a flight in the era of Delta, is that correct? All right. Now you're on both of them. There we are. Okay. - Monica is ubiquitous. It serves right.
- Incredible everywhere. - She's in more than one square. - She's everywhere.
(laughs) - Okay. Why am I more maskey? - Yeah, why are you more maskey? And what does that mean, practically? What are you actually doing? - Yes. So I did fly in both times, and everyone was happily flying
with like the less maskey you know, between Alpha and Delta. So why have I, the couple of reasons to be more conscious about the type of mask you wear right now. Number one. Delta, you know, it's very extreme. If you have 60,000 people come
in at once and have a lot, and all the windows closed and have a lot of intimacy and have no masks, and there's mixed vaccination
and unvaccinated people, which was the Provincetown outbreak. You could have a high
breakthrough infection rate, that is as stressful as a
situation on the vaccines that you can get. And no one, no one, there was seven hospitalizations. They all did fine. Luckily no one died. And it really is a stress test
of how well these vaccines are working against severe disease. Now, in normal circumstances where you're just doing what you're doing, and you're not going inside and doing all of that
with mixed vaccinated and unvaccinated, the breakthrough rate is, I mean, I know, you know, we all saw this New York Times article, but it was compiling data from Utah, from Virginia, from Washington State, and the breakthrough rate will always depend on your region. So higher rates of
community transmissional viral breakthroughs, but it's 1 in 5,000 in
high instance regions, somewhere like San Francisco 1 in 10,000, - Per day, per day. - Per day, right, right. And as our cases have gone down, that will go down. And so you have to decide
what your level of comfort is with that risk. I, as a healthcare worker, actually have very
little comfort with risk, because I have to go to work. But if I weren't a healthcare worker, I was very comfortable
with my parents being here with that low risk that they had, they were just here last week. But what we do inside is we do masks that are really been more proven to work. So there was a large cluster
randomized village level controlled trial. The Bangladesh RCT, it was performed in Bangladesh. It was just in pre-print last week. But the reason it was important
is compared cloth masks to surgical masks in a population level. So it's hard to tell, like who knows everyone was wearing it. They tried to increase use, but at least those over 50 were protected from symptomatic infection. But with surgical masks, not cloth masks. So I would use a surgical mask and I actually bought these pink ones 'cause so tired of blue. And then if I really was
in a high stress situation, like inside around a lot
of unvaccinated people, I would actually put two together. I would put this together
with a cloth mask. We had done some research on how that really blocks out virus more, or take a cloth mask and put filter paper inside of it. They're super easy to get on Amazon. And you have two different mechanisms are repelling the virus, electrostatic from the filter type paper, polypropylene material, and then the cloth is a physical blockage. And that's what I do on my
unvaccinated child on planes during Delta. - So just to be clear, cloth close to you, excuse me, surgical on your face, cloth, tight fitting cloth on top of it. - It can be actually either way. And I actually prefer the surgical on top, because then I can reuse it, 'cause I do wear lipstick, and sort of environmental concerns, but it's really the
principles behind two things. Increased fit, so closer to your face. You could also tuck in the surgical mask and increased filtration
by the two layers. - So one of our colleagues has famously been writing
about the concerns about the level of evidence for masking and some concerns about harm
that mask can cause in kids. Can somebody address whether
they have those concerns? Peter, you wanna start and
let me give it to Monica. - I was looking Jorge
being the only person- - Our only pediatrician here. - Just having been on the American Academy of
Pediatrics website this morning to answer this question for BuzzFeed. They say, it's almost no situation. I mean, if you have to be over two. Okay. If you're under two, there's a suffocation risk. Okay, okay, okay. We gave you that one. And certainly, some very
developmentally delayed children may have a similar risks of suffocation, but for speech or language impairment, no evidence for children
with marginal lung function, no evidence. - So they harm you in any material? - Yeah, no, no harm, and not getting this
disease is a huge help. - Yeah. - Just to be fair though,
to those criticisms. 'Cause I really do wanna be fair that a lot of what this is based on is that let's please
remember that the UK, Europe do not mask children under 12 and the WHO do not mask
children under five. So when various practices
occur across world, it is fair to question, do children need it as much as adults, even in the bungled HRCT, it was adults who benefited for symptomatic reduction
in COVID over 50. - So what's your bottom line
on the state of the evidence around kids and masking? So mandatory, this is sort
of goes into the issue of mandatory masking at school. - You know, this is my bottom line on it, is that I think that I want
children back in school. I don't think I've ever
made a secret about that. And because of that, I think it's best to have masks in school. - Yeah. - Because I don't want distancing, which is why the California DPH said, "Everyone masks," when Delta came out, and no distancing because that's the least
effective of our strategies. There are theoretical benefits, of course, like just like, sorry to use the word condom
and the same word as school, but condoms, we've never tested, but we know that condoms,
you know, block transmission. So there's physical science
reasons to believe it. And I just want children
go to back in school. So I think masking right now
is totally, totally valid. I do think that we need metrics to remove mask where mixed society, not everyone loves
their children in masks, and metrics that are based
on how communities are doing is the right thing to do to remove them, not just the metric of
children being vaccinated. And I also believe that we should be fair just like we were just fair about natural immunity, Peter. We should be fair about what
happens in other countries and acknowledge that. - Yeah.
- Not say, "Oh, it doesn't matter that other countries don't mask children. We're the right people. We should acknowledge that variability. - I mean, I think everyone's
talking the same thing, which is-
- Yeah. - There are multiple
strategies to protect kids in school. Now, if the UK is not masking, they're doing other things
much better than we are in lieu of not masking. So they're doing quarantining, contact tracing, a lot of testing in the UK. We can't really have enough tests to deliver that uniformly. So I think when you read the headlines, UK isn't using mask in schools, it's because they using other
disease mitigation strategies. And it's, you know, to me, it's all about Swiss cheese. You don't have that ration, you have choice if you
can distance your desk. That's great. But if you can't do robust testing, contact tracing and quarantining, like the UK does, you know, the mask is
relatively cheap, unexpensive, and kids actually, from
what I understand it, they wear it and they don't complain. - Okay.
- Yeah. - And just to be clear, Monica, when you talked about condoms, you're talking about in HIV and you're talking to not
putting a condom over your face. - No.
(laughs) No, I just really like, that's why I was like
hesitating doing that. I'm sorry. - We're mixing diseases and uses here. - Never had a randomized control trial. - I just wanna be clear. - We've never had RCT of condoms. - I got it.
- Right? Because it's just basic common sense. - George, so Peter mentioned the
idea that other countries are doing more testing.
- Yeah. - Why are we not? You know, I'm hearing
reports out of Austria and Germany that it's, you know, there is absolutely ubiquitous, you know, antigen testing everywhere. You walk into the gym, you walk into the school, you walk in the supermarket, what's gone on here to make that so hard? - Well, I mean, other
countries like Los Angeles test kids every week to go to school, and the UK does this sort
of modified quarantine. They have another word for it, but they basically test kids every day to keep them in school. I think- - If they've been
exposed, just to be clear. - Yeah, if they've been exposed. Yeah, exactly. Sorry, right. Yeah. So I think it's something that we're, you know, that we need to use more up. I got a note today that, so the state just ordered another 7 million doses of, 7 million BinaxNOW kits. So we may have the supplies to do it. I think it's just been underutilized and we need to push on it some more. - And if you were having
a testing strategy for the schools or for your workplace, what would it be? Would it be PCR? Would it be the antigen? Would it be twice a week,
once a week, every day, how would you order it? - Depends on how much
money you have. Right? You know, so if you're in the NBA. - I thought your balancing, you know, nobody has unlimited resources, you're balancing resources with what you think is
good enough efficacy to make a difference. What would it be? - Yeah, I think antigen testing is the way to go, and I'd probably do it two times a week or every three days or
something like that. - Peter, yeah? - I mean, to me, it depends on what else you have going on. So like at Sanford, they are doing, and Jorge knows this, because we talked about this together, but in Sanford, they doing
once weekly testing, I think, but they also have a vaccine mandates. So if you don't have anything else, then you probably have to
do more frequent testing to kind of be more reassured in general. - I'd really like to agree
with how you just said Peter, because I just do wanna point out that San Francisco
Department of Public Health just put out data 33 minutes ago. - Yeah.
- That was breaking news. That show really low rates
of transmission in schools, just like George had said, even as we have started our schools, August 16th was the date of
school opening here in SFUSD. They don't do asymptomatic testing, which is a decision-
- Yeah. that we made because of the, when we get into lower prevalence is that you have a false positive rate. - Yeah.
- What they're doing is that they're doing the quarantine kids, if they've had an exposure. What the private schools
are doing right now is because they have plenty of BinaxNOW, they will call tests to stay, which I think is a
really important strategy that if you've been exposed,
you get antigen testing. So to be able to stay-
- Yeah. - In school, and unfortunately, SFUSD
has not yet done that. And they're keeping kids
out of school for 10 days. What I'm really hoping is that they'll take the 7 million
tests that you just said from the California DPH, and please use test to stay strategies, which are really successful
around the country. Boston's doing it,
trying to do it at least, UK has been doing it. We've had an exposure, so by asymptomatic that
exposure you test to stay. - Yeah. - I'd like to introduce
just one last thing even that whole SF - There's a cluster
randomized trial from the UK. - It's situation is that one
of the things that we do have, the reason why I think it's
been so amazing in schools here is because the adolescents
are so highly vaccinated too. So you have this, a bigger wall of immunity
around the kids under 12 in SF versus like many other
places around the country where they're doing less
than 50% of the adolescents. Whereas in SF, it's like more than 90%. Can you believe that? - And teacher mandates-
- Yeah. essentially for vaccines. I mean, I know you can test out, but that's essentially as much as you can trying to go towards a
mandate for teachers, which if anywhere there's
gonna be a mandate besides healthcare workers, it seems like that's where it should be. - And this test to stay strategy. I mean, one of the
things we're running into in a healthcare workforce is, you know, we're telling people, "You have a sniffle,
you got to stay home." Should we be doing
antigen testing on people? - Yes. - And if you have sniffle,
you do an antigen test. If you're negative, it's okay to work. - We need to stay at work. I mean, there was some
real problems when we had some breakthroughs here and some school general. So I mean that test to
stay strategy right now, what we're going to Delta in
any situation is a great idea. - Okay.
- Yeah. I mean, it doesn't need to
necessarily be antigen testing. If you have all the money in the world, you could do PCR testing. That's fine too. - I do like antigen though, for the reasons you said, that essentially it's more
likely to say you're infectious, which is the entire point-
- Yeah. - Of why you would keep
someone out of school is they could be infectious because a PCR test will
give you one dead virus in your nose, remember that. - Yeah.
And also it's cheaper. It's, you know-
- Right away. - Of scale.
- Yeah. - And yeah, and point of care. - Okay. Let us switch to vaccine efficacy. Is it waning? Is it waning for symptomatic? Is it waning for severe? Is it waning differently for Pfizer, Moderna, J&J, for natural infection?
A lot of stuff to cover, and then we'll obviously get to boosters. And somebody wanna summarize what they think the literature shows in terms of is the vaccine efficacy waning for both symptomatic
and overall infections? George, you hinted at this a little bit. Anybody else wanna weigh in on their take on the literature? Go ahead, Monica.
- I can do this quickly is that I think that in general, you have to divide it
in two, like you said, severe disease and symptomatic disease, where you can get like a quarter of flu. So let's go back to severe disease. I think the data's very consistent that we are not having
waning effectiveness of this, against severe disease in general. And that means from
the UK, Canada, the US, there was a CDC New York study, 20.2 times more likely to be hospitalized if you're in LA. So lots of really unvaccinated
people being in the hospital, not vaccinated as much. So I think we have good severe disease that actually maps on to one
arm of our immune system, which is T-cells, and they tend to stay up for a long time. So then what's going on with
more breakthrough infections? I do think the Pfizer vaccine, because it was given three weeks apart, at least in one study in a German study, comparing to Moderna had
lower antibodies than Moderna, and it could have been
that shorter interval let alone Moderna's three times the dose. And remember Israel where we're
seeing most of this waning against mild disease only used Pfizer. And then there was a Mayo Clinic study that said that people
who had more reinfection in the Mayo Clinic system, they got the Pfizer than
the Moderna vaccine. So I think that's three
weeks apart, maybe too short. I think a lot of
vaccinologist were saying that even at the beginning, you said that Bob. So because of that, it's possible that if you
have the Pfizer vaccine, you may be more likely
for a mild breakthrough, which is I think it's
prudent to put back masks while we're on the Delta
surge in the inside setting. But whether we need to boost or not, I know we'll get into that. But I will say that mild
and severe are different and they're armed by, they're protected by different
arms of the immune system. Antibodies from B-cells protect
you against mild disease, and they do wane with time, it's totally natural. It's what the immune system does. Those you'd be too, you couldn't move, you have too much protein, and so it's normal for that to happen. And it really is mild disease, that severe disease is being protected. So we have to talk about that. - Okay. Anybody wanna add
anything or disagreement? - Yeah. I mean, I agree with Monica, and I mean, for me, that data is very robust. No matter how you slice and dice the pie, that severe disease hospitalizations, and that's a spectacularly prevented by the current vaccine strategy. I am very intrigued by the
idea of interval between doses. And of course, you and the audience
will probably remember that in UK, they had no other choice, but to delay the second doses. And they retrospectively looked at people who got the delayed doses
versus people got it in time. And at the time, I didn't really know what to make of the data, because it was antibody levels, but they showed that the
people who got delayed had higher antibody levels and the people who got it naturals. - Even with Pfizer?
- Yes. - Even with Pfizer, yeah. - Okay. If you told me, so I'm 63 year old guy, I got Pfizer eight months ago. If you told me I could go to the Walgreens and get my booster now. I would leave this call and get it, because I still don't want
even quote, "mild disease" because it's quote, "mild disease" that, you know, you lose
your sense of taste or smell for a month, or you feel like garbage for several days. You can transmit the infection, although at a lower rate than, probably a lower rate than
an unvaccinated person. We don't know the probably of long COVID. And Monica sort of made some
comments about what that is, and maybe we have more
information on that. I even want mild disease
if I can avoid it. When I hear people say, the vaccines were never designed
to prevent mild disease, I don't really care what
they were designed for. If they did it before and
they don't do it anymore. I want them to do it again, unless the treatment carries some risk, which as far as I can tell a third dose carries next to no risk. So talk me out of why I
should stay on the call, if I got a call from Walgreens, now that I can get my
third shot right now. Monica, do you wanna tell me why that's not the right thing to do? - Yes. So I think that it is a couple of reasons. So one is that essentially, your possibility of getting
a mild breakthrough infection depends on the prevalence in your area. And 1 in 10,000 is very low, right now in San Francisco, and that will go lower with
time as the cases come down. And it's just a temporary fix, because it's really just treating like the antibodies coming up in your nose, but they're gonna go
right back down again. And what really matters is
what's called your memory, your cellular memory, your B-cells and your T-cells are there. We know it, we'd like biopsy people's
lymph nodes and bone marrow. And we know that these
memory B-cells are there, we know the T-cells are there. And if you see that virus again, you'll fight it hopefully, in your antibodies will
come right back up. Second reason is really, and we have to be fair about this, right? When Dr. Tedros from the
WHO reiterated yesterday, that please don't give
third shots to rich people while we are waiting for, just at least get 40% of people vaccinated in low-income countries. He's speaking to the fact that 2%, 2% of people in low-income
countries have been vaccinated in Sub-Saharan Africa. And you can just argue that, what you just said is
saying you get a third shot, Americans get a third
shots to prevent a cold, but there are people who
are dying every single day in massive amounts, because we have no global vaccine equity. And the US is sitting on upwards at that, by the end of the month of
the billion surplus doses. It is geopolitically. I just can't imagine how
that's gonna look for anyone, if we do this. And then the third thing that
I really wanna say is that and I can wear a mask right now, prevent myself from being around someone where I can get
a mild breakthrough. So I just need to wait a couple more weeks until those cases go down more, and then it's going be 1 in 40,000 chance. And finally, again, don't treat, I would just take those
severe rates of infections, there's 7,000 in this
country out of 173 million fully vaccinated. Figure out the demographics. It's so easy. Are they all Pfizer patients? Then give it to Pfizer people. Are they all immunocompromised? Are they all 63, and otherwise healthy? Are they 70, and have
two medical conditions? Start with that group, and if they need to be in
long-term care facilities, older people, immunocompromised, people with multiple medical conditions. Start with that group
while we're sorting it out. - I wanna layer some thoughts on Monica's comments as well too. And, you know, I'm sort of
mixed about the booster shot. On one hand, there are lots of other
disease vaccination paradigms when we do a prime on boosts and the prime is zero in one month, and then the boost is like six months, at six months, hepatitis B, HPV, et cetera. So it makes kind of sense, biologically, but then on the other hand, I'm looking at the data. So I think it all depends
on if you wanna be proactive or reactive. Right now, we're looking at the data and everything looks good, you know, is that slight waning and the older population
for severe disease and hospitalizations and death in Israel. Maybe 91% in the 80s, if you believe that data, which hasn't been peer reviewed, in the older population. You know, are we going to do, you know, optimize immunization in that group? Nursing home residents, older individuals, so they don't get into
something in the future. Maybe that might be the solution, but regardless, you know, I agree with Monica about the optics, even though we might have enough vaccines to kind of, let's just
lay out boosters for all. And I felt this way also
because over the weekend, the Israeli Minister of
Health started talking about a fourth booster, a fourth shot for the future, and maybe the green pass might expire after two or three doses and they could program it that way. So I think that gave me
some more room for thought, because again, if you think
about antibodies going down to protect against mild disease, you probably have to get
a boost every six months to really keep that up or
develop a nasal vaccine. - George, any thoughts on this? - Well, I mean, they're so enlightened. There's global equity and there's
enlightened self-interest. We have a border with 3
million people who live on it, who are all unvaccinated. That would strike me as
something that would be within our kind of our purview to wanna take care of that little problem before we start passing out their doses to people that don't really need them. So, I mean, I think you can, I mean, the global equity thing is fine, and if I were Dr. Tedros, I'd be saying the same thing, but I think if you wanna look at it from a purely US perspective, there are countries from which we have tremendous amount of immigration, including Haiti and the DR and Mexico, and we should be helping them with their vaccination programs. I think, and that's what really directly within our self-interests. - I guess I'm still struggling
with a couple of things. One on the equity side, you know, you can see the arguments
quite clear morally, but same thing is true for the way we manage
hypertension, diabetes, cancer. You know, we don't say maybe we should, that you're treating this cancer with this very effective
incredibly expensive chemotherapy, and you're not doing that to
people in India or Africa. And so obviously, your argument
is somewhat different here that somehow it's in our
self-interest at some level or in the world's interest
to get everybody vaccinated and that's different than
treating everybody's cancer. - That's true, right? With the global pandemic, that's true because a variant will emerge like it emerge India with 4%
of the population vaccinated. It will emerge elsewhere. So take morals and ethics out of it. It's a public health
imperative to get vaccination. - But don't you, I guess the question is, no, the question is, is it really, are we framing? We're framing this as or versus and, you know, we were talking
about a billion extra doses, you know, to use a hundred million of them to give high-ish risk people a third dose. Are we really in a material? Is this as a symbolic act or is it really materially
gonna change the nature of the risk of a variant
over the next year? - I would give all 60 year olds a booster, 60 and above, 'cause that way we get you. - Thank you. It makes
me feel better. (laughs) Obviously, it's not all that, maybe. - I'm serious actually. - I see myself as a sort
of reasonable test case where we draw the line. - That's what Israel did was 60 and above. - I mean, I really kind
of mean that like, I mean, like draw a line.
- A risk level. - Because number one
right now I'm implying looks really strange
from the administration. - Right.
- FDA saying one thing, HHS saying one thing, it's embarrassing. Like we need to come together
and just draw a line. If it's over 60, then do that. And that kind of, you
get it all in that way. - But the line is, I mean, it's got to be some, what's the evidence behind the line? The line is that there's a risk level of a certain population-
- Yeah. - Whether it's comorbidities
or age or whatever that does say that the
risk of a breakthrough is meaningfully, can lead to a bad outcome in some way at a higher prevalence. I mean, part of what persuades me here is that we're talking about something that is very low
risk and very low cost, and so it has a different feeling, trying to sort of figure out, why not give it to people.
- Yeah. - I understand when I
hear people say, you know, we should be concentrating, sometimes it make the domestic argument. We shouldn't give it to a third dose for a person's already been vaccinated. We should concentrate on
giving it to the unvaccinated. I'm trying to figure out,
like what does that mean? Have we been concentrating
on that for six months? - But it's like Bob-
- Well. - Bob, I do think one thing to
not lose in the shuffle here, is that, you know, people
who are immunocompromised, who are solid organ
transplants need a third dose, period over now. - They're may need a
fourth dose or fifth dose. - They gonna need more, yeah. They may need a fifth dose.
- No doubt, yeah. - Peter, what is the evidence in terms of them getting their third dose and that meaningfully creating immunity? - Yeah.
- How well is it working? - There are twos of groups
of evidence right now, most studies have been done. One, from France, and then one from the Hopkins Group. There's also one in University of Toronto, but essentially it's after the, if you are not, first of all, about 50% of people for more severely immunocompromised will develop an antibody response. And of those unvaccinated people, if you give them a third shot about anywhere from 30 to 50%
of that group will respond. So again, there's, you know, 50 to 70% of people who may not respond even after third shot. So that's where the
interesting idea about using monoclonal antibodies as bridge in some individuals might
be interesting as well. - Okay. We're gonna run out of time. I wanna cover a few other
issues in terms of efficacy and boosters. So how about Moderna, if let's say Monica has
agreed that it's over 60, let's say as the number who got Pfizer, based on what we know about Moderna and some uncertainty about
what the third dose should be. Should we hold off on them until we figure out what the right doses? - I think we're trying
to figure that out now. - You're right. They're debating between 150 micrograms. The dose for the first two is a 100, because there are two possibilities why Moderna have had higher antibodies, and also the lower re-infection rate in the Mayo Clinic system, which is the higher dose is three times as high as 30 micrograms which is Pfizer, or it is that longer duration, even one week makes a difference. And I think that I, fundamentally have you ever had a vaccine that's three weeks apart? There's not a single vaccine. - Rabies. - One month is minimum to
find the immunoresponse. So I think it has a lot
to do with duration. So to me, it makes it seem
like maybe it doesn't matter 'cause when you get the booster of Pfizer, it's gonna be way spaced
out from your second dose. But the Moderna is interesting. There was some data that it, it really produces long
lasting CD8 cells over time. So I kind of liked Moderna. I got Pfizer. - I got the Moderna. - So but are you saying that
Moderna might not need it because it may be produces
longer lasting immunity either because we gave you a
bigger dose than you needed, or we spaced it an extra week? - Yes. That's the question. I mean, 'cause when we
can talk about antibodies and B-cells and T-cells
all we want, right? But we really wanna look
at reinfection rates, that's the clinical
outcome that's of imports, and that's why I'm asking, everyone's asking the CDC, please take those severe breakthroughs and tell us if they're all Pfizer, tell us they're all Johnson and Johnson, because for Johnson and Johnson people always feel that they're
being left out of the time, but non of them are. - So at this moment, if
you were a Moderna person, let's say you're 70, and you're are at higher risk. And the Pfizer people are gotten their vaccine boosters endorse. You would say, based on what we know now, I would hold off on Moderna, partly because you might
still be better protected and partly because we don't actually know what dose we should give you. Is that accurate? Peter, is that where you would be? - No, I actually would. I think if you're older than 60 and there's a booster approved, I might tell you to just
go ahead and get it, because I'm not sure when
that data will come out. - Right.
- And we're in the middle of. - And you get the original dose, you get the third full on dose, even though it might
be more than you need. Okay. J&J. Everybody with J&J is like, feeling like nobody's
paying any attention to me. (laughs) So what should they do? You know, a couple of weeks ago, it seemed like it was a no
brainer that if you got J&J you probably get an mRNA, and then a study didn't come out at least preliminary saying the second dose of J&J worked pretty well. So what should a J&J person think and do? Let me start with Peter. - So I think one interesting study that didn't get a lot of press was that J&J study looking
at it was very small. It's 17 people, and they follow them for six months. And it was interesting because their antibody levels were, it was horizontal. They didn't decline
like Pfizer or Moderna, I thought that was very intriguing. And then of course, there's a J&J study showing that the second shot increases antibodies, but that's not surprising. I think if I were a J&J person, I would feel like what, you know, many people believe J&J
is really conceptualize a two dose vaccine series, not as one dose and that mainly pragmatic. So I would probably want them
to get an additional dose depending on who they are, especially if they're over 60. - You would get a second
dose of the J&J not a mRNA. - No, I would get any
dose as a second dose, but I would get a dose. You know, there is mixing
and matching studies. that been talking about.
- Right. - Not J&J, but with AstraZeneca. And it was, you know, it was safe and effective.
- Yeah. - I'm getting this question all the time. So when I get it, 'cause I don't know anything, I'm gonna tell them what you told me. So if you've got J&J as your first dose, and you're over 60, let's say, would you say you should get a booster? And they say, all right, which
of the three should I get? What would you tell them? - Tell him to get an mRNA, just riding off of from what I know. I mean, the mRNA vaccines give you a code for
more of a spike protein than J&J does. But again, that's more not
based on clinical data so far, and again, more speculative.
- Okay. - And then I know that
mixing and matching is safe. - But the one thing-
- Go ahead, Monica. - One thing to weight
on is the ensemble too, which is the two dose Johnson and Johnson. They are saying-
- Yeah, yeah. - We're gonna get data
at the end of this month. That is the two dose, and it have been conducted during Delta. So I probably hold out
and wait for that data. - You tell them to wait, wait for a second.
- Just a little while. - George, anything can coming? - You can do both. You can hold out and get the mRNA vaccine while you're holding out, right? - Yeah.
- There you go. All right. And then big final question, natural immunities. Some studies have come out and said, it works pretty well. So how long is it working for? What are we seeing in terms
of waning immunity for if you had your prior infection, let's say in 2020? - I think the best study for me, recently comes from Kentucky, where they looked at
people a year ago in 2020, who got regular COVID, and they follow them in the same database. And if you are vaccinated,
you would, you know, or if you were unvaccinated, you are twice as likely to, higher odds of getting
reinfected with COVID. So what it says to me is that, yes, you could get reinfected
even if you got it before, and then number two, you know, the vaccines rule, but we knew that already. I think reinfection is not
that commonly described, but at least in this Kentucky study, it's definitely a thing. There are some studies that illustrate that maybe it lasts a year, but there's a thousand fold
difference in some studies, and one individual
response was just another to natural infection. - To be fair that was the case. - Some people have a
vigorous antibody response and some people not so much, and you don't really know who you are. So you could be at reasonably high risk. - Yeah. Just to be careful about
that Kentucky study, that may be on the list of how
not to do case control study. - Yeah. I was going to
say that same thing. I wouldn't pull that
out as the only study. There's plenty of studies. - Although it's quite compelling. I'll give you that. - Yeah. - No, I mean, to be really fair, you've got to look at
the science and studies and prospective studies. Some even show reinfection rates are lower after natural infection. So again, let's be fair. You really wanna be fair when you present, because then you'll be more trustworthy. You don't wanna pull up
like the badly done study. So I would just say,
I don't think we know, but I get one dose, and that's my recommendation because there's so much
data that you know. - If you had a documented prior infection, based on what you know today, you get a single dose of an mRNA. - And that's what Italy, Germany, Spain, France are all doing, and they're smart. They like think about immunology. - And they've been doing
it for a long time. - Yeah.
- That works. All right. Where we're at a time, but I can't tell myself we
can go over a minute to two. Just last question, tell us what the next six
months life is gonna be like, it's sort of the end game now is so hazy and is there gonna be another surge coming or in the Bay Area, we're gonna reach a point where the immunity actually is high enough to beat back Delta. What do you think? What are you telling
people about the future? George, go ahead. Why don't you start.
- Sure. I'd be curious what Monica
and and Peter think about whether we could see a worst variant, a more transmissible variant than Delta. I mean, there are a finite
number of amino acids that can substitute, I don't know, kind of mechanically, whether that's really gonna happen or not. We can reach herd immunity. Herd immunity remembers
R0 minus 1 divided by R0, so that the R0 not for Delta is 6, that means you're gonna have
to get to 84% of everybody, at least everybody over six months of age. So it's gonna take some substantial amounts
of pediatric vaccination to get there. Monica is absolutely correct. You have to add in, and Peter too, you have to add in the natural immunity, unclear whether that wanes or not. But it certainly seems like there's a wall and East Los Angeles and stuff where there's, we're not seeing kind of
ongoing outbreaks of disease. So I think that, you know, I think we're getting pretty close. If I have patients with, who had prior confirmed disease, I'd tell them to get
a single dose as well. I completely agree with that. - But the point is if we
can get to 85% immunity and real lasting immunity, you know, either from vaccines or from a prior infection and it hasn't waned, you think based on what we know today, that will be enough to exert considerable
back pressure on cases and prevent a big surge in the future. But you're still worried
about the next Delta that's even better than Delta, - Delta plus, yeah. Yeah. But it's Miller time than, Bob. - Yeah. Right. Okay. Peter, what's your take on the future? - You know, I agree with George. I'm probably a little more, slightly more pessimistic that we won't necessarily
reach herd immunity because we all borders are so porous, and there are people moving
in and out of San Francisco all the time. And, you know, I just don't know where they're coming from. I'm hopeful that that's the case. I do think that this
winter in particularly is gonna lead to a lot of
confusion with diagnostic tests, because you're gonna have
influenza or COVID potentially, or RSV. And you could have bypassed that sniffle before if we
still are seeing COVID and that will be very
confusing to a lot of people, but I'm also optimistic. If anybody's gonna do it, we are going to do it in the Bay Area. - Yeah. Monica, what's your last word? - Yeah. I mean, I always think about HIV and how it gets hemmed
in by its mutations. I think really important
principle of evolutionary biology is like what George said, you can't keep on going, you can't keep on going. This is a really transmissible variant. I am very hopeful that
this is that variant that was the most transmissible, it's gonna give a lot of people immunity, who decline to get vaccinated. That's not ever how I'd
want people to get immunity, but it will. And I'm actually pretty hopeful, I don't think we're
gonna eliminate it ever. I'm sorry, it's going to be endemic, but it's gonna be low grade
sitting in environment. Outbreak here, because this group decided
not to get vaccinated, up severe disease, but it's gonna calm down and it's gonna be this low level virus. And I think this is
gonna be the last of it. - All right. Well, I hope that turns out to be right. I have to remember our conversation in May where we had a similarly
optimistic outlook and the Delta came along. So obviously, this thing has to continue to humble all of us as time has gone on. Let's keep our fingers crossed that we are getting to that level. Thank you the three of you fantastic and interesting and honest, this is the best information that people can get out there. It's not perfect, 'cause information continues to evolve, but really appreciate
you sharing that with us. Thank you to my team, putting this together. You see them listed up there. We'll be back next week for
a non COVID Grand Rounds. We'll do a clinical case presentation, which will be fantastic with Rabih Geha. And we will go on from there. This will be posted on YouTube tonight. For those that didn't
get a chance to watch. Stay safe, and we will talk to you next week.
