Monica Gandhi, MD, MPH, is associate division chief of the HIV, Infectious Diseases, and Global Medicine at UCSF/San Francisco General Hospital. She has followed the COVID-19 pandemic closely. Hospital Employee Health sought Gandhi’s thoughts on the end of the Public Health Emergency. The following interview has been lightly edited for length and clarity.
HEH: There seems to be a general consensus that we will never be rid of SARS-CoV-2. In a commentary, you explained the pandemic virus will endure due to its high level of transmissibility, the commonality of symptoms with other respiratory infections, and the fact it can be transmitted asymptomatically.1 Can you speak to this a little further?
Gandhi: The virus does not have features that allow for eradication, unfortunately. Therefore, we will always have to manage COVID in the medical system. In fact, the World Health Organization [WHO] started discussing downgrading from the emergency response to COVID-19 on March 30, 2022. The International Monetary Fund estimated on April 5, 2022, that ongoing investment in COVID-19 for endemic management would be $10 billion per year. The WHO then ended the global health emergency of international concern on May 5, 2023, and the U.S. ended the Public Health Emergency on May 11. COVID-19-related deaths in the world and in the U.S. are the lowest than they have been since March 2020. Data from the National Institutes of Health SeroHub from November 2022 show that 99.9% of Americans had anti-spike antibodies — showing that they had been exposed to either infection or vaccination — and 89.4% had anti-nucleocapsid antibodies, which means they had been exposed to infection.2 We do not know the numbers now, but they are likely even higher.
HEH: Is this endemic phase of COVID-19 kind of an epidemiological judgment call, or must other determinations be made?
Gandhi: To determine if we are in an endemic phase, we should look to whether our excess mortality from respiratory pathogens still is higher now than it was in 2019, but the CDC has not been able to appropriately adjudicate that burden with their current data transparency issues. The reason I would look to overall respiratory pathogen burden is that SARS-CoV-2 has been shown to cause “viral interference” with other respiratory viral infections. The burden of other respiratory pathogens — influenza, adenovirus, rhinovirus, other coronaviruses, human metapneumovirus — decreased during the COVID-19 pandemic in the U.S. It is difficult to get that comparison data to 2019. Moreover, some hospitals continue to swab everyone who is admitted for SARS-CoV-2, as we did at the beginning of the pandemic, for infection control purposes, which can lead to misclassification of a COVID-19 hospitalization. The reason to classify COVID hospitalizations and deaths accurately at this point is that many who test positive in the hospital are asymptomatic or swab positive without being sick with COVID. Moreover, chart review studies show that vaccines work very well if we actually classify hospitalizations properly as being “for” or “with” COVID as shown in a study earlier this year.3
HEH: Some have expressed concern the public has pandemic fatigue and will say the pandemic is — for all practical purposes — “over.”
Gandhi: Instead of over, “control” is the best term in infectious diseases epidemiology to describe our current state. The discipline of infectious diseases has strict definitions for the level of containment for a communicable disease. “Control” means that a disease has been brought down to low levels of circulation with the help of public health interventions such as vaccines. “Elimination” means the incidence of disease has been reduced in a certain geographical region to zero. “Eradication” means the incidence of the disease worldwide has been reduced to zero. “Extinction” means even remaining stocks of the pathogen kept in secure laboratories have been destroyed. With the lowest rate of mortality from COVID in the United States since the beginning of the pandemic — if we adjudicate deaths accurately — it is accurate to say that the U.S. is in the “control” stage of the epidemic. We have excellent tools at this point in the pandemic, including vaccines and therapeutics, to keep us out of the worst phase of the pandemic. These have to be applied equitably, and the federal government says they will still be available for low-income patients until the supply runs out, and then go over to commercial insurance. We should target those for boosters and therapeutics who need them most, which are patients over 65 and those who are immunocompromised.
HEH: How concerned are you about the emergence of new variants of SARS-CoV-2?
Gandhi: A working knowledge of immunology should reassure us about variants. Antibodies are one arm of the immune system that are generated by infection or vaccine. Antibodies wane with time — or our blood would be thick as paste with antibodies from all the vaccines and infections we’ve seen. Luckily, vaccines or infections also generate something called cellular immunity in B and T cells, which are much longer lasting, and protect against severe disease in a more enduring fashion. Memory B cells — generated by the vaccines or as a result of a prior infection — have been shown to recognize the virus, including its variants. Think of memory B cells as a recipe that can make more antibodies if they see the virus in the future. If memory B cells see a variant, they are able to make antibodies adapted to the variant in front of them, like a baker adjusts the amount of yeast in a cake made at different altitudes. Although we do not know how long these memory B cells to COVID-19 last, survivors of the 1918 influenza pandemic were able to produce antibodies from memory B cells when their blood was exposed to the same strain nine decades later.
The vaccines or natural infection also trigger the production of T cells. While B cells serve as memory banks to produce antibodies when needed, T cells both help B cells make antibodies and help recruit cells to attack the pathogen directly. Memory T cells generated by COVID-19 infection may last a lifetime, according to a study that examined participants with varying degrees of initial disease severity.4
During the omicron subvariant surges in spring of 2022, we did see a greater chance of reinfection compared with previous variants, but not in severe disease across the general population. This defanging was even more significant upon closer analysis of hospitalization data. In states like Massachusetts and across other health systems that track hospitalization in detail, there was a clear trend showing the majority of hospitalizations are for patients who incidentally test positive for COVID.
REFERENCES
- Gandhi M. We won’t eradicate covid. The pandemic will still end. The Washington Post. Sept. 21, 2021. https://www.washingtonpost.com...
- National Institutes of Health. COVID-19 SeroHub. Data last updated Nov. 21, 2022. https://covid19serohub.nih.gov...
- Moffa MA, Shively NR, Carr DR, et al. Description of hospitalizations due to the severe acute respiratory syndrome coronavirus 2 omicron variant based on vaccination status. Open Forum Infect Dis 2022;9:ofac438.
- Dan JM, Mateus J, Kato Y, et al. Immunological memory to SARS-CoV-2 assessed for up to 8 months after infection. Science 2021;371:eabf4063.
Monica Gandhi, MD, MPH, is associate division chief of the HIV, Infectious Diseases, and Global Medicine at UCSF/San Francisco General Hospital. She has followed the COVID-19 pandemic closely. Hospital Employee Health sought Gandhi’s thoughts on the end of the Public Health Emergency.
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