Take the Seventh-Inning Stretch
Hooboy! Last week eight Yankees staff and players tested positive for COVID. They’d all had the J&J vaccine. This story has thrown a curve-ball into vaccine optimism. But it shouldn’t.
I get it! We’ve been repeatedly told just how stunningly effective the vaccines are — specifically how our risks of getting COVID-19 and transmitting the virus drop dramatically after the shots.
So what in the (real) world happened here?? How can we possibly have confidence in the vaccines — and even ditch our masks as the CDC has sanctioned — when vaccinated baseball players are getting infected?
As always, let’s start with the facts:
All eight Yankees players and staff had received the single-dose J&J vaccine. Of note, many of them had been vaccinated within two weeks of the positive tests.
A study published last week in the New England Journal of Medicine found what we’d suspected in the past: that the Johnson & Johnson vaccine becomes far more effective after four weeks than two. (Two weeks is still the appropriate waiting period after the Pfizer or Moderna shot.)
Only ONE of the eight people who tested positive actually exhibited symptoms. In other words, seven people had evidence of coronavirus in their nose but did not have COVID-19. (Recall there’s a difference between infection — which can cause symptoms or not — and COVID-19 which, by definition, is infection with symptoms.)
The one person who developed COVID-19 had mild, short-lived symptoms.
The positive tests happened after a group of 50-60 people traveled in tight quarters — on planes, in dugouts, and in the clubhouse
We have no proof that the person who developed symptoms was the person who infected the others.
Breakthrough infections are expected but are going to be rare. As I wrote to you last month, we shouldn’t be surprised when a tiny percentage of vaccinated people get COVID. For more specific data on breakthrough infections: as of April 26, 2021, the CDC was aware of 9,245 breakthrough infections out of more than 95 million people fully vaccinated in the US. Also note that on May 1, 2021, CDC appropriately stopped counting asymptomatic cases as “breakthrough cases” — and only to count and investigate hospitalized or fatal COVID cases. Why? Because a positive PCR test is not the same as having the disease. It does not necessarily mean you are sick or can sicken other people.
In other words, the seven asymptomatic infections would not meet today’s CDC criteria for “breakthrough” infections. No one got sick. And, perhaps most importantly for people worried about catching the disease from vaccinated people, transmission of the virus from vaccinated asymptomatic people is highly unlikely. Is it possible? Sure. Especially if you're hanging out in a dugout, loose-lipped and close-talking only two weeks after a J&J shot. But if you only got a cold — and you were one of 50-60 people in the mix — you might feel pretty good about your immunity.
PCR tests are extremely sensitive tests. They can pick up just 10 viral particles. Recall that people who are sick and contagious have hundreds of millions — even billions — of viral particles in their nose and respiratory tract. In other words, viral load matters. The more viral particles in your nose, the sicker you can become and the more likely you are to transmit the virus. The vaccine drops viral loads with both endpoints met.
The Yankees were getting PCR tests for surveillance (meaning without symptoms) even after being vaccinated when even the CDC’s latest guidance suggests vaccinated people may “refrain from testing following a known exposure, if asymptomatic” and “refrain from routine screening testing if feasible.”
What’s the upshot?
The Yankees story isn’t about failed therapeutics; it’s a story of the vaccine’s success. Had none of the Yankees been vaccinated, more might have gotten sick. And some might have needed hospitalization.
It’s also a story about much-needed context. We should expect reinfections, but as long as they don’t make us sick or allow us to sicken other people, we really needn’t know about them. Tiny bits of virus parked in our nose that are being fended off by IgA antibodies (the kind of antibodies that live in our nose and mucous membranes to prevent invasion by ever-present viruses and bacteria) needn’t be named.
Remember that we live with bacteria, viruses, and other pathogens every single day. Our immune system goes to bat for us behind the scenes every day. Let’s trust it like we can trust the vaccines.
This is also a story about testing. There is no role for PCR testing in vaccinated asymptomatic people. Unvaccinated people with COVID symptoms should indeed get a PCR test. But if you’ve been vaccinated and develop COVID symptoms — a sniffle, cold, cough, or fever — you need an antigen test (which I call a “contagiousness” test) because it will be positive if and when you have enough virus in your nose to be clinically relevant. This fabulous article yesterday featured Michael Mina at the Harvard School of Public Health about the harms of using PCR tests like we have in the US during a public health emergency. It’s a great read if you love nuance like I do. (Thanks to my patient MG who made me the T-shirt I’ve been craving!)
Similarly, vaccinated people need not isolate after exposure to a person who tests positive if they are asymptomatic. CDC agrees and appropriately acknowledged the very low risk of transmission after vaccination.
Just like we don’t live in a germ-free world, no vaccine is perfect. The currently available vaccines are pretty darn close. But if you’ve taken the J&J shot, ideally wait four weeks instead of two before taking off your masks in a sweaty, shouty dugout. In the meantime, let’s rise for the 8th and 9th innings and step up to the plate with science at our back.
I will see you next week. Until then, be well.
P.S. Join me Tuesday May 25 at 8 pm ET (5 pm PT) for a Facebook live interview with Monica Gandhi, MD, MPH, whose recent Washington Post piece summarizing the state of the pandemic is a homerun.