The Executive Briefing - Friday, August 6th

The truth about breakthrough infections

August 6, 2021

COVID Recap

New COVID cases are at a six month high. The fourth wave continues to crash across the country, with the United States reporting 103,445 new cases on Wednesday. (CIDRAP)
You may have heard about a CDC study from Cape Cod where nearly 74% of the people in an outbreak were vaccinated - but that does NOT mean 74% of vaccinated people will get COVID! That’s a huge misinterpretation - it’s more like 2% of vaccinated people got COVID compared to 13% of unvaccinated people! (MedPage Today)
There’s no doubt: the COVID vaccine doubled the protection for those previously infected. So even if you had COVID you should still get vaccinated! (MMWR)
Full FDA approval for Pfizer may come by September. (New York Times)
The drummer for the band Offspring has been ousted because he was unvaccinated. (The Guardian)
The WHO is calling for a moratorium on booster doses until vaccines are more equitably distributed around the world. (CNBC)
Meanwhile, in San Francisco, one hospital is “accommodating, but not recommending” a dose of mRNA vaccine for staff who got the J&J shot. (MedPage Today)
CVS will no longer be offering the J&J vaccine. (CNBC)
Vaccination rates are finally rising again in areas hardest hit by this latest Delta surge - like in Louisiana where demand for the shot has nearly quadrupled in the past week or so. (New York Times)
There’s a new line of Barbie dolls in the likeness of scientists, including one who helped develop the COVID vaccine. (NPR)
Regeneron’s monoclonal antibody cocktail may work prophylactically, meaning it may prevent COVID symptoms after exposure. (CIDRAP)

Today’s Health News

The U.S. once again ranked last in healthcare among high income countries. (CNN)
Taking too many cell phone pics might actually reduce your memories of an event or occasion. (NPR)
A blood test in mid-life may accurately diagnose Alzheimer's years before symptoms appear. (MadPageToday)
An outbreak of bubonic plague in chipmunks has forced several sites to close to visitors near Lake Tahoe. (The Guardian)
Four cases of Legionella are being investigated in Maine. (WABI)

Best Questions

If a vaccinated person is exposed to someone with a breakthrough COVID infection, can they really still work?!

Yes, though they should wear a mask. Breakthrough infections happen, but despite how much you’re hearing about them they are actually still VERY rare. According to a report from the Kaiser Family Foundation last week, of the 25 states reporting on breakthrough cases, the average share of overall cases among those fully vaccinated was just 1.6%. Even in AZ, the state with the highest rate of breakthrough cases, 94% of all cases were in people who were unvaccinated. So while it feels a little counterintuitive to let someone work after exposure to someone who got sick after being fully vaccinated, it’s important to remember that they still have a much lower chance of getting sick themselves. Still, vaccinated people should wear a mask for 14 days after exposure and monitor themselves very closely for symptoms, and stay home if any develop, even if they’re mild.

Can we rely on a rapid negative test?

Unfortunately, not really. Rapid tests are designed for symptomatic people, and they work best when that person has a high viral load and is at the height of their contagious period, usually in the first few days of symptom onset. While a rapid positive is almost certainly a true positive, a rapid negative is much more likely to have missed someone who’s actually positive but doesn’t have a very high viral load - like someone who is asymptomatic or someone whose symptoms haven’t started yet. In one CDC study published in January, rapid antigen tests missed one in five symptomatic COVID+ people, and missed three out of 5 (more than half!) of asymptomatic COVID+ people. The technology is improving over time, but it’s absolutely not there yet for asymptomatic people, which is why PCR tests remain the gold standard.

Are you seeing a slow down in PCR turnaround times? Should we be discouraging PCR tests because they take 48 hrs?

Actually we’re seeing PCR tests consistently come back in under 48 hours for the most part. As this surge takes off and testing sites are inundated with sick and exposed people, there’s been a bit of a slowdown, but we’re talking a matter of hours rather than days. Most are still coming back in under 48 hours. Again, rapid tests are much less reliable for asymptomatic people, so we definitely don’t want to discourage PCR tests since they’re still the most accurate test by far. One good solution if someone has symptoms and wants to know if they’re positive ASAP could be to arrange both a rapid and PCR test - if the rapid comes back positive, you can bet the PCR will, too. If the rapid is negative, that doesn’t mean anything yet - the person should still isolate and wait for those more-accurate PCR results. This method is less reliable for those who are asymptomatic because of the low sensitivity for rapid tests in those without symptoms.

Any update on the 90 day period where someone is at low risk for reinfection?

There’s been no update from the CDC at this point. As time goes on, we have seen studies that indicate there might be a longer period of protection for those who had the virus. But at the same time, we’re seeing the Delta variant explode out of control and seeing breakthrough infections in those who are fully vaccinated and in those who recently had COVID. Our own clinical team has seen a number of cases where someone appears to have been re-infected within the three month window, including one where the doctor believes they were infected with two different variants of the virus. Public health officials are keeping a close eye on this and will likely share updated recommendations as more studies are completed on natural immunity and the new variants.

Should you wait 14 days to be vaccinated if you’ve had close contact exposure like CVS’s website says?

Yes. If you’re exposed and unvaccinated, you should be staying home in quarantine for the full 10 days and monitoring for symptoms for a full 14 days after your exposure. The reason the CVS and other pharmacies tell you to wait is more about protecting their staff and customers than about you. You can go to be tested because their testing staff are wearing full proper PPE and prepared for infectious people coming there, but their vaccination clinic is not set up for infectious people. If you do end up getting sick with COVID from your exposure, your new vaccine isn’t likely to help since it takes a while to kick in, anyway. It’s better to wait the 14 days and then go get vaccinated so you can protect the health