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On digesting the latest pandemic news — and the perils of nuanced public health messaging

Prior claims of vaccine efficacy came from the pre-delta era. When delta rode into town in late May, everything changed. So we need to change.

Photo by engin akyurt on Unsplash

Like so many others, getting the COVID vaccine brought me a sense of relief and release. Best-case scenario, I would be fully immune to the virus. “Least case” scenario, I would be spared the worst of the disease (hospitalization and/or death) and I would be far less likely to pass it on to someone at high risk for those outcomes.

Yes, a booster might be in my future, given the penchant coronaviruses have for clumsily scrambling their RNA, looking for a different, “winning” combination. Millions of people being infected worldwide means COVID is getting a gazillion chances to roll the genetic dice and morph into something different or worse. The arrival of the delta variant, first found in India, fit the bill.

But I remained hopeful, some would say delusional. When the local coffee shop reopened for in-person business, it seemed like a threshold had been crossed. The war against COVID had turned in our favor. Yes, the delta variant was clearly more contagious than its predecessors and was sadly and predictably burning through the dry tinder of the unvaccinated. But “breakthrough infections” in the previously vaccinated were uncommon, and would most likely affect the elderly, whose aging immune systems often prevent them from developing a robust response to vaccines.

Sometimes the latest pandemic news arrives from the CDC, and sometimes from a neighbor.

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Last week a neighbor told me that her family’s reunion plans were in limbo. Her parents, living in Florida, had both developed mild-to-moderate respiratory symptoms and tested positive for COVID. They were in generally good health for their age (early 80s), had been vaccinated early in the pandemic, and looked to be recovering.

The news was disappointing but overall, still good. Except there was another family member who wouldn’t be able to come: a healthy 23-year-old, vaccinated niece. She too had developed a symptomatically mild breakthrough infection.

Then the CDC chimed in. “The war has changed,” they said.

On July 28, the CDC recommended that people living in high-transmission communities wear masks in indoor, public spaces, even if they had been vaccinated. Italics, mine. Disappointment, mine — and so many others’.

The recommendation came after new data showed that those with breakthrough infections carried similar amounts of virus in their nasal secretions compared to infected, unvaccinated people. Presumably, this means that the vaccinated and the unvaccinated can be equally contagious. We, the vaccinated, had gone from being a big part of the solution to being some part of the problem.

Dr. Anthony Fauci
Susan Walsh/Pool via REUTERS
Dr. Anthony Fauci
As Dr. Anthony Fauci, the Oracle of NIAID, put it, “Vaccinated people are transmitting it, and the extent is unclear, but there’s no doubt they are transmitting it. People who are vaccinated, even when they’re asymptomatic, can transmit the virus, which is the scientific foundation of why this recommendation is being made.”

The following day, the Washington Post cited an internal slide presentation from the CDC that struck an urgent and somber tone. Experts like Robert Wachter, chairman of the Department of Medicine at the University of San Francisco, commented, “I finished reading [the CDC slide presentation] significantly more concerned than when I began.”

On July 30, the CDC released both the above referenced slideshow and a detailed report on a COVID outbreak on Cape Cod earlier in July.

The slide presentation, called “Improving communications around vaccine breakthrough and vaccine effectiveness,” trumpeted the efficacy of the vaccine. Based on the most current data, a vaccine reduces the risk of getting infected eightfold and leads to a 25-fold reduction in hospitalization or death. Although vaccines are effective at preventing more than 90% of severe disease, the presentation confessed that breakthrough infections may be as transmissible as they are from unvaccinated cases, meaning the vaccinated could be playing an important role in the delta variant’s rapidly accelerating “Summer of Un-Love” tour.

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Clearly, this was a difficult message for the CDC to put out: moving backwards (masking again) is forward (infection control); and when it comes to spreading the delta variant, vaccines don’t work as well as we had hoped, but it’s more important than ever to get one.

Public health messages with even the slightest nuance are a hard sell — what the slide presentation termed “communication challenges.”

Case in point: The CDC presentation stressed that it was “important to update communications describing breakthrough cases as ‘rare’ or ‘small percentage’ of cases.” The problem is, data from the Cape Cod outbreak —  released that same day — noted that 74% of cases occurred in fully vaccinated persons. The median age was 40 years. Of the 469 cases identified, five were hospitalized (no deaths), and four of those were vaccinated.

Those numbers clash rather awkwardly with what was reported earlier. The number 74% doesn’t seem to qualify as “small” or “rare.” Breakthrough infections were supposed to happen among the elderly, not 40-year-olds. And shouldn’t the majority of hospitalizations be among the unvaccinated?

There are scientifically explainable answers to those questions, and the authors of the study note four major limitations to their study at the end of the report. Suffice it to say, one should be very careful extrapolating data from one particular event in one particular town to an entire country (the infected reported attending “densely packed indoor and outdoor events at venues that included bars, restaurants, guest houses, and rental homes”). And statistically speaking, as more people get vaccinated, we will certainly see increasing numbers of breakthrough infections, even as the percentage remains low (i.e. 1 percent of a thousand is a lot fewer people than 1 percent of a million).

Unfortunately, in an era of billboard-intellect health messaging, and where vitriol is sometimes nefariously used to try to make the exception disprove the rule, the epidemiologic limitations of this Cape Cod study won’t make headlines, but the alarming and seemingly contradictory numbers will. Headlines like “CDC Backtracks on Masks” have appeared, where “backtrack” is kind of a slur, suggesting confusion and “flip-flopping” — even though changing one’s mind based on the latest data is the surest sign of intelligence and clear thinking.

If your physician gets some data suggesting that your heartburn is actually angina — blockage of the heart arteries — you better hope she is prepared to “backtrack” and change her treatment recommendations.

Time to mask up, again, and get vaccinated. It’s still our best hope of shoving this mutant genie back into the bottle and getting back to the life we remember.

Yes, there will be (and probably already are) claims that the CDC lied to the public about the vaccine’s effectiveness, when in fact, they are just being honest. It takes time to accrue data. Prior claims of vaccine efficacy came from the pre-delta era. Take a look at this graph. When delta rode into town in late May, everything changed. So we need to change.

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