Dig Into Delta
One of my vaccinated patients has COVID-19. This is a modern-day story of bad luck, emotional whiplash, and the wonders of modern medicine all in one.
She didn’t get COVID because of vaccine failure. Nope! All of the vaccines continue to work well against death and severe disease from COVID-19. My patient, a woman in her mid-50s, had two doses of Pfizer in March. (The latest real-world vaccine effectiveness data out of Italy, where Delta accounts for approximately 60% of all infections, is nicely summarized here.)
She didn’t get COVID because she did anything wrong. Nope! Vaccinated people needn’t mask outdoors because the risk of outdoor transmission remains vanishingly small. Vaccinated people also needn’t mask indoors unless desired or recommended by their physician — or both. My patient was fully aware that while these COVID vaccines are stunningly effective, no vaccine is 100%. She appropriately had confidence in the vaccine’s ability to do its main job: to keep her out of trouble even if she was in the unlikely small percentage of people who did get infected. (Atta girl!! Realistic expectations: check! Appropriately balancing risk and reward: check! Following the facts: check check!)
Side note: why might a vaccinated person decide to mask indoors? (After all, per the most recent CDC data, the risk of a severe outcome from COVID-19 in a vaccinated person is 0.0029% - or 1 in 34,000 people.)
Because they want to — no explanation needed!
If they are immunosuppressed, older, or have underlying health conditions such that a rare breakthrough case of COVID-19 could potentially result in a severe outcome.
If they live in an area with low vaccination rates and where the more contagious Delta variant is surging.
If they simply aren’t willing to tolerate the small risk of getting mild or moderate COVID. (The overwhelming majority of people who get COVID-19 after vaccination have the kind of “bug” we’ve all had many times; the overwhelming majority of people who’ve been vaccinated don’t get COVID at all.)
If they live with high-risk unvaccinated people who run the miniscule risk of getting infected by a vaccinated person (see below for more on this.) Note that an easy solution here is to vaccinate that high-risk person if possible!
My patient got COVID because she traveled to visit extended family in a state where vaccine uptake is low and where, as a result, case rates are increasing largely due to Delta. She dined inside a restaurant and, four days later, she started to feel sick.
How did we make the diagnosis? With a rapid antigen test (aka a “contagiousness test.”) It was immediately positive.
She has a cold. She feels feverish, achy, and crummy — the kind of “bleh” that some of us, pre-COVID, might have powered through and even gone to work with. She’s currently taking Advil, drinking lots of water, and resting at home. It’s worth noting again that most people with symptomatic breakthrough infections (which themselves are rare) have symptoms like this. To echo my friend Monica Gandhi, MD, the vaccines “de-fang” the virus; they turn coronavirus into its wimpy cousin — if anything at all.
My patient’s family members aren’t sick, which isn’t terribly surprising given that they are vaccinated! The likelihood of a sick vaccinated person transmitting the virus to other people depends on a number of factors including the viral load — i.e. the “dose” of inhaled virus — which often correlates to the severity of symptoms, but of course it’s a heck of a lot less likely if the contact is vaccinated.
In other words, we already knew from real-world data that the vaccine powerfully protects the recipient from asymptomatic infection and from “silently spreading” the virus to other people. But when vaccinated people are actually sick with a cold or cough or any other manifestation of mild COVID, of course that person can transmit the virus. This is true for people sick with most viruses: that when we are actively sick we are also contagious to other people to varying degrees.
The solution to not sickening other people when we are sick ourselves? We stay home! We don’t mingle and make out with other people! This is where we get to employ our good old common sense — to dust off that trunk full of no-nonsense intuition that we stashed in the attic in March 2020! (I say this with all due respect for people who have excellent common sense but whose brains are fried from mixed messages about COVID. Trust me, I’m with you!)
What’s the upshot? My patient’s bout with COVID is a vaccine success story. Had she not been vaccinated, she could have gotten extremely sick — or even died — particularly because she has underlying health conditions that put her at higher risk for poor outcomes from COVID-19. Had she not been vaccinated, she also might have spread the virus to others. Had she not been vaccinated, she wouldn’t have risked taking a trip to see her beloved family — the joy of which is difficult to measure.
To be clear: no one is celebrating. Being sick stinks. It means isolating for 10 days and closely monitoring household family members for symptoms. It means missed work and wads of Kleenex. It also means grappling with the frustration of getting sick despite taking the appropriate steps to protect herself and her family.
That said, my patient graciously said to me over the weekend, “At least I’m not in the hospital. I feel like I dodged a bullet.” She is well aware of what the vaccine has done for her. It primed her immune system so that when she was unwittingly confronted with coronavirus, her antibodies, T cells, and memory B cells were ready to fight off the virus and limit its damage.
These stories are happening more and more and naturally are revving the engine of our collective anxiety. For many of us, the mere threat of getting mildly sick with COVID-19 after vaccination can feel like an affront to our sense of safety and security. What’s worse, the headlines can easily trigger our anxiety about our unvaccinated children and high-risk family members.
After a year of hypervigilance, most of us were hoping to reset this summer — to vax and relax. But it’s not that simple.
So why does it feel like deja vu all over again?? There’s one main reason: Because only 49% of Americans are fully vaccinated, and unvaccinated people are sadly getting infected and spreading the virus to other unvaccinated folks (and to a tiny percentage of vaccinated folks like my patient.) Indeed, 97% of people hospitalized for COVID-19 are unvaccinated; 99% of people dying from COVID-19 are unvaccinated.
Let me be clear: vaccinated people are not the main drivers of Delta’s spread. Why?
Vaccinated people are unlikely to get infected in the first place. You cannot spread the virus if you aren’t infected with it.
Vaccinated people who are infected but have no symptoms are very unlikely to transmit. The vaccine does that for us.
Vaccinated people who are sick (aka have symptoms) can indeed sicken others — but hopefully they’re in bed watching the Price is Right.
You may be wondering if there’s any good news at all. Well, there’s plenty:
The vaccines continue to protect us from severe consequences of COVID-19. They all hold up very well against Delta. As infectious disease specialist Celine Gounder at Bellevue Hospital in New York told the New York Times, “The takeaway message remains, if you’re vaccinated, you are protected. You are not going to end up with severe disease, hospitalization or death.”
The UK, which is a month or so ahead of us and where Delta is dominant, has seen a drop in the number of COVID cases for six days in a row as of today. Importantly, this does not seem to be a result of less testing. This suggests that, like a tornado, Delta comes and goes in a flash.
While Delta is more contagious, there hasn’t been any data to suggest Delta is deadlier than previous variants. This means that if you were at low risk for getting very sick from COVID-19 before Delta came on the scene (for example, if you are a healthy youngster), you are still at low risk. Your risk is even lower if you’re surrounded by vaccinated people and you live in an area with high vaccination and low hospitalization rates.
We’re finally seeing increases in vaccination rates in the states that are being hit hardest by COVID. The 7-day average of newly vaccinated Americans is up 28% from the past week.
Kids in general continue to be at relatively low risk — though of course not zero risk — from COVID-19. As Harvard Professor Joseph Allen recently wrote in the Washington Post: “Three major studies over the past year all found the risk of death to be in the range of 1 in 100,000 to 1 in 1 million. Hospitalization rates for school-aged kids younger than 12 (the group that can’t get vaccinated yet) hovered around 3 or 4 per million throughout the pandemic...”
That said, we’re all waiting for a collective exhale. When will the pandemic finally be in the rear view mirror? I’d be lying if I gave you an answer. But I will say this: we’re getting there. With life-saving vaccines and accumulated knowledge on risk mitigation, stratification, and treating our sickest patients, we are light-years away from the shock and horror of 2020. If you’re immune to COVID-19 — either from vaccination or from natural infection — you can worry a WHOLE lot less. You have done the best job you can to protect yourself, your family, and your community.
And if you are unvaccinated and eligible for the vaccine, please re-read this little ditty and consider the incredible public service you’ll be doing by taking the vaccine. Even if you’re low-risk yourself, getting vaccinated helps us all.
This morning I appeared on MSNBC to talk about the state of the pandemic, booster shots, and masking. I hope this is helpful!
I will see you in a week. Until then, be well.