Dr. Monica Gandhi, Professor of Medicine and Associate Chief in the Division of HIV, Infectious Diseases, and Global Medicine at the University of California, San Francisco (UCSF), joined the February 2, 2022 LeadingAge Coronavirus Update Call. She responded to questions from Ruth Katz and from callers. The interview is summarized here.

Q: Well, it’s Groundhog Day and we’re in pandemic year three. Where are we, and are we going to see cases go down?

A. Omicron is an interesting variant as it is highly transmissible. While this meant that many people got cases, it is less virulent. Even in the unvaccinated, it does not seem to affect the lungs in the same way as earlier waves. Our case numbers are coming down. We are seeing people in the hospital who have COVID, but about half the time that is not the primary reason they are there. We should be through the worst of this wave by the middle or end of February.

Q: I’ve read your Tweet that Denmark and the U.K. are moving to endemic management. Please tell us more.

A: Yes, and France will be going to endemic management in a week and Finland will do it in a couple of weeks. Early on, there was a hope that with masking, distancing and vaccinations we could eradicate this virus. That is never going to be true due to the features of the virus itself like existing in animal reservoirs, contagion before symptoms, etc. We are now talking about control. Control means you have enough immunity in the population that you can “live with it”.

Q: What exactly is endemic management?

A: Endemic management is basically the way we now manage flu. We track it and we monitor hospitalizations and deaths, but there are no restrictions on the public. There are no mask mandates, no asymptomatic testing, no quarantining, and masks are optional. You stay home when you are sick, and life becomes normal. But all of the tracking will continue. We would be monitoring and reporting cases, hospitalizations and deaths to health departments rather than the public. Of course, we would still keep on vaccinating and also make use of good therapeutics such as monoclonal antibodies and oral medicines like Paxlovid.

Q: The omicron variant snuck in and triggered a new wave. How do variants relate to the move to endemic management?

A: Good question. The 1918 flu went from pandemic to endemic when deaths fell. There is a new model that looks like deaths will start falling worldwide in February, and by May death rates will have tapered significantly. At this point, 50% of the world’s population has been infected and we are continuing to vaccinate, so we are achieving endemnicity through natural immunity and vaccination.

Q: How does a country move to endemic management? Does the government have to declare it?

A: Yes, it is a very deliberate process and must be declared nationally. In this country we will likely wait until after the omicron surge recedes. It is my hunch that then the President would consider moving to endemic status. We would keep vaccinating and people could wear masks if they chose, but there would be no vaccine passports. So many people have gotten omicron that there is a level of immunity across the population. Of course, we will need to track hospitalizations and deaths and respond as needed.

Q: What is the current status of vaccines for little kids?

A: It is a little confusing. In the Pfizer trial for children 6 months – 5 years old, they used a small dose and that 3 microgram dose, administered twice several weeks apart, only generated response in the smallest children – not in 2-4 year olds. Pfizer said they are going to request authorization anyway thinking they could do a third dose. So, they could authorize the Pfizer for children who are 6 months-2 years old. We could also vaccinate 2-4 year olds with Covaxin. It is a more traditional vaccine and is widely used in India. But we will need to wait for further study and authorization.

Q: Speaking of children – what should schools be doing now?

A: In many places they are no longer doing asymptomatic testing in schools and some schools are moving more to endemic management. As far as masks go, we are hearing more news media and experts saying let’s get masks off of kids. The CDC would need to endorse that, but there is active discussion in many quarters suggesting no masks on kids.

Q: So, back to Groundhog Day – will we get to endemic status soon?

A: It will be policy decision and will involve changing mindsets – not just hospitalizations and deaths going down.

Q: Are there changes in nursing home practices in the countries moving to endemic management?

A: Nursing homes stopped asymptomatic testing. Everyone in a nursing home should get a booster. But many restrictions have been dropped. In Denmark and the U.K. there are no visitor restrictions. Mask wearing is optional.

Q: In light of that, should we be changing policies for nursing homes in the U.S.?

A: The defanging of the virus came from vaccines and we need to give them more credit. The people who are at risk for breakthroughs are immunocompromised, but there is still very low risk for hospitalization and death. If you are over 75 and have four or more comorbidities you would continue to be at risk. So before going to endemic management we would need to have adequate access to Paxlovid or other effective therapeutics.

Q: Is there still discussion of natural herd immunity and whether it is durable?

A: We know that antibody levels wane over time. However, T cells and B cells are still there and they still work and seem unphased by the omicron variant. People may get more mild infections but not severe disease.

Q: When will we need additional boosters?

A: People who are vaccinated and who are infected get even more immunity. That should stand us in good stead for additional mutations as it confers immunity across the whole virus. I am pushing for a vaccine that crosses the whole virus spectrum that we could administer next year.