Q&A: The Old Normal Will Return (in January 2022)

October 23, 2020
Frank Diamond

Monica Gandhi MD, MPH: “We will get to the end of this [COVID-19]. We will get to a combination of vaccine and natural infection, enough people getting herd immunity that this will stop. This will stop and we will get back to normal.”

We’ve made tremendous strides against coronavirus disease 2019 (COVID-19), and that can be seen just in how the mortality rate has plummeted and how doctors around the world have polled data to share the best methods for treating those most severely infected. Monica Gandhi MD, MPH, an infectious disease expert and a professor at the University of California, San Francisco, wants people to know that we will indeed get out pre-COVID lives back, but it’s going to take some time. Still, her message for infection preventionists and everybody else who may be listening is a hopeful one. “I think we’ll be going to movies,” Gandhi tells Infection Control Today®. “That people will be going to the theater. People will be going to sports events will hug each other, will hang out. We’re going to get back to normal, but it’s going to take a year and a half.”

Infection Control Today®: What has surprised you the most about the COVID-19 pandemic?

Monica Gandhi MD, MPH: What has surprised me about SARS-CoV-2 is the range of clinical manifestations that you can get. You can be completely asymptomatic, as shown by antibody studies that people have had it, they had no idea. And then how ill people can get. And I think what this has revealed to me is that we have to think about that interplay between host and pathogen better. And how to decrease and mitigate any viral factors that could be contributing to the severity of disease. And also, how to protect hosts that are more vulnerable. I think there are ways to decrease the severity of this infection by working on both virus and host.

Infection Control Today®: Where do infection preventionists fit in here?

Gandhi: I think when you said treatments; by the time we get to treatments, the cat is out of the bag in the sense that obviously someone already has SARS-CoV-2 and the only treatments we have right now are for very severe disease. That’s why outpatient treatment, we don’t have anything yet. It really is about—speaking of infection control—it really is about all of these public health mitigation measures to even prevent people from getting to that point of getting infected. This is all about five things now. They’re very rote. They’re very tiresome. It’s very hard to do all of this. But it’s about social distancing. It’s about universal facial masking. It is about isolation and quarantine if you do get sick. It’s about contact tracing at that point, if there is someone who is exposed to someone who gets sick. And it’s about selective testing. And finally avoiding large problems. With these techniques, we can keep ourselves in some sort of equilibrium until we get to the vaccine. Because by the time we get to treatment, someone is very ill. And that’s what we want to prevent.

ICT®: What are some of the hurdles with contact tracing? That that can be a pretty difficult thing to do.

Gandhi: Actually, that’s why I'm so much more interested in facial masking to not even get to contact tracing, because again, by the time we get to contact tracing someone’s been infected. But you’re right, it is a huge hurdle to contact trace. And what’s going on in the White House right now is a very good example that you don’t know how long someone’s been infectious. You don’t know when they started having symptoms, because symptoms can be subtle, or people may not want to tell you. And all those reasons, it’s hard to trace back who could have been exposed. One thing we’ve been working on is this concept that the dose that you get, or the viral inoculum, how much virus you get, is related to how sick you get. And there’s evidence for that. We’re putting out a paper now that’s showing that masking may be decreasing the severity of illness you get. Our idea is let’s work on how we keep away from each other and wear our masks and block viral particles from getting in so that you may not even get to that point where you get sick. You’re right that contact tracing is hard, and we can’t do it on everyone, which is why we’re asking so many people to stay home.

ICT®: Is it true that mortality figures are going down even as the number of people who have it are going up? And does that give you any hope?

Gandhi: I definitely think the mortality is going down from the infection. Why? I think there are six possible reasons. I think that one is that people are getting exposed and infected at younger ages. They’re less likely to die from it and get very sick. The second is that I do truly believe that we are doing a better job at infection control and universal testing in nursing homes, which we did an abysmal job at the beginning. And so, our elderly are more protected. And unfortunately, many of the vulnerable have already been sick. The third reason is that I think that we have better treatments. So, if you do get into the hospital, there are better treatments. We’re more prepared in the hospitals. Fourth is that I think that this universal masking has a lot to do with it. I really do think that a mask reduces the particles that you get into your nose and mouth. And if you get in less particles, you get less sick. And that’s the data we’ve been working on about masking and severity of illness. And then the final reason—I said there are six reasons—I do think that there is beginning to be more immunity in the population. Unfortunately, there has been a lot of exposure, the recent WHO report is that probably 10% of people in the world have been exposed. That means that we have some short-term immunity, which even if we get exposed again, we’re not going to get sick.

ICT®: Are you talking about herd immunity?

Gandhi: There’s a difference between herd immunity. Herd immunity means that you are at the point where the virus is going around, and they can’t even find anyone to infect because so few people are susceptible. The way that we’re going to get to herd immunity is more through vaccination, because we don’t want the virus to be completely unleashed. We don’t want to mingle and get people sick. There’ll be too much mortality. But even less than herd immunity, even having some of the population either not be susceptible or have antibodies that fight off an infection or T cells that fight off a new infection. Even if they get it again, they get reinfected. It’s asymptomatic. So, it’s not exactly herd immunity. It’s just slowly developing immunity.

ICT®: Which country in the world handled COVID the best?

Gandhi: I think it is important to give New Zealand credit. They are an island, but they did a great job in terms of making everyone stay home. And then they got the prevalence so low that when they went out, they didn’t have very many cases. However, the Asian countries—and I mean, Singapore, Hong Kong, Thailand, Vietnam, South Korea, and Japan—these are countries that never had an issue with masking. Not even one. No one is out on the street protesting facial masking to get through this pandemic. And they have actually been more open. Their economies have not been devastated. Because there’s absolute compliance with public population wide facial masking. And that’s because of [SARS-CoV-1]. Right. They went through this in 2003. They knew how to act. They made it part of their culture. They hand out masks. Taiwan handed out masks starting on March 6. So early in the pandemic, they started making masks and handing them out. I have to give them a lot of credit for how they managed it. You never hear about them, because they’re doing quite well.

ICT®: Do you think this will change the way infection prevention is handled in the United States from here on out? And how?

Gandhi: Yes. I think that if we can—we and other groups are looking at this idea that the amount of virus you’re exposed to is related to how sick you get—then it will keep us away from people. I mean, it’s sad because with a respiratory virus, it means we have to truly socially distance, not have big crowds and facially mask. But I don’t think we’ll ever have this kind of controversy again, where keeping away from each other and doing these social distancing guidelines and hand hygiene and all that is going to be as much of a big problem anymore because people are going to understand it. Same thing with a new bacterial illness, the more you get, probably the sicker you get. I think our hand hygiene, things are going to change forever. I think that how we think about hygiene and approaching each other is going to change for a long time. I think it’s hard. It’s a very hard time in the world. And it feels like it’s going to go on forever, but it’s not. We will get to the end of this. We will get to a combination of vaccine and natural infection, enough people getting herd immunity that this will stop. This will stop and we will get back to normal. I want to give people that ending comment that it’s not going to be forever and just get help us get through this time with you with these kind of public health guidelines.

ICT®: I read a little bit of your biography and know that you specialize in HIV. Do you see any similarities between how these two things progressed in the population?

Gandhi: Yes. I mean, there’s been a lot of similarities to me for HIV and infectious disease. We could say with HIV that it was a sexually transmitted disease, mainly also spread by blood products. And this is a respiratory disease. So, they’re different in that way. They’re different in that the risk factors are different, and who got it, and who could get it was different. On the other hand, what’s similar to me is that I’ve been very unhappy with the kind of stigmatizing aspect of COVID-19 just like HIV was stigmatized. There’s been more of a blaming of the individual. “Oh, how did you get COVID? Are you not doing enough of the public health guidelines? Did you leave your house? Did you hang out with friends?” This kind of stigmatizing language is not appropriate in public health. I think that we need to message to people that of course, you can close down for several months and this has been really hard. Of course, people want to see each other. We have to think about better, gentler, more loving, harm reduction ways of messaging. Yes, see your friends. Use a mask but see your friends. The stigma is reminding me. I have a lot of my patients who are living with HIV, and they say, “This feels like living through HIV all over again.” And then there is this kind of anti-science sentiment that’s going on in this country that also went on with HIV. This kind of resisting of the facts that led the government in the 1980s…. The president didn’t even speak of HIV until 1987. There has been a little bit of that distancing from what’s going on, that reminds me of it. But the thing that makes me positive, is that I’ve never seen progress move this fast as it’s moving with COVID-19. The therapeutics, that vaccines are in phase three, we could get data so soon. Things are moving fast. And that’s why we’ll get through this.

ICT®: Probably many infection preventionists are fearing the fall and winter. Do you have any advice for them?

Gandhi: I am not fearful of the fall and winter because of the public health measures that we’re doing that I think will reduce the severity of cold and flu. Any respiratory virus really is going to be prevented by hand hygiene, social distancing, and facial masking. It’s just that we don’t ask the population to facial mask every winter. But if we did, I think we’d have a lot less influenza. I think we’re not going to see it as bad as we think. I mean, the other thing I’d want to say about infection control is that the surface issue, that it exists on surfaces, has really been receding, has really been going away. There’s been great data over the last couple of weeks, that that risk is greatly exaggerated, because it really is through the respiratory route that we get infected. I think a little bit less emphasis and fear about touching things and the disinfection, and more on the respiratory aspect of infection control.

ICT®: Will we ever get back to the way we were before COVID hit us?

Gandhi: We will. I really mean it. I think we will. I think we’ll be going to movies. That people will be going to the theater. People will be going to sports events will hug each other, will hang out. We’re going to get back to normal, but it’s going to take a year and a half. January 2022. It’s so hard to say. But I do think it’s going to take until January 2022. We need to get the community transmission down. We need to get a vaccine. We will vaccinate the whole populace and then it will stop because it can’t go anywhere because we have immunity and we will get there.

ICT®: Do you think nursing homes should be staffed with infection preventionists?

Gandhi: You’re absolutely right that this pandemic revealed the fault lines in our nursing homes here. Absolutely. We need infectious disease epidemiologists who fast test. We need better protection of our nursing homes. It revealed that we didn’t have a unified regulatory system on nursing homes, where people were kept safe. And I think that’s going to be one of the biggest lessons of this pandemic.

This interview has been edited for clarity and length.