‘Post-Vax COVID’ Is a New Disease

Katherine J. Wu wrote . . . . . . . . .

Boghuma Kabisen Titanji was just 8 years old when the hyper-contagious virus swept through her classroom. Days later, she started to feel feverish, and developed a sparse, rosy rash. Three years after being fully dosed with the measles vaccine, one of the most durably effective immunizations in our roster, Titanji fell ill with the very pathogen her shots were designed to prevent.

Her parents rushed her to a pediatrician, worried that her first inoculations had failed to take. But the doctor allayed their fears: “It happens. She’ll be fine.” And she was. Her fever and rash cleared up in just a couple of days; she never sickened anyone else in her family. It was, says Titanji, now an infectious-disease physician and a researcher at Emory University, a textbook case of “modified” measles, a rare post-vaccination illness so mild and unthreatening that it doesn’t even deserve the full measles name.

The measles virus is ultra-infectious, much more so than SARS-CoV-2, and kills many of the uninoculated children it afflicts. But for those who have gotten all their shots, it’s a less formidable foe, which we’ve learned to live with long-term. That’s the direction that many experts hope we’re headed in with SARS-CoV-2 as it becomes endemic, as my colleague Sarah Zhang has written.

We’re not yet at the point where we can officially label post-vaccination COVID-19 cases as “modified”; maybe we never will be. Some immunized people are still getting dangerously sick. But the shots are softening COVID-19’s sharp edges: On average, breakthrough infections seem to be briefer, milder, and less contagious. Among the fully immunized, catching the coronavirus doesn’t mean the same thing it did last year. “It’s a very different kind of infection than in people who are immunologically naive,” Lindsey Baden, an infectious-disease physician and COVID-19 vaccine researcher at Brigham and Women’s Hospital in Boston, told me.

If this virus becomes as inescapable as the culprits behind the colds and flus that trouble us most years, we could all have to grapple with one of these infections, and learn that lesson on a personal level. That’s the social tax of a forever virus: Nearly everyone may eventually know what it is to get COVID-19—but a tamer, more domesticated version of its pre-inoculation self.

Since the start, COVID-19 has been tough to define.

Part of the problem is that COVID-19 is the disease, not the virus. Actual microbes, compared with the problems they cause, are arguably neater conceptual packages. SARS-CoV-2 is a knowable pathogen, a tangle of genetic material swaddled in a protein coat; COVID-19 has fuzzier boundaries, dependent on both the virus and how our bodies react to it. To understand that interaction, researchers had to, unfortunately, wait for a decent number of people to get sick—to observe the virus screwing with us in real time.

Next to other airway-loving viruses, such as the ones that cause the flu and common colds, SARS-CoV-2 can be a bit of an oddball. It lopes almost indiscriminately throughout the body, invading a plethora of tissues; it winds up certain immune responses, while dialing others down, sparking bouts of inflammation that can afflict everything from brain to toe. COVID symptom lists that at first focused on the virus’s ground zero—the respiratory tract—eventually ballooned to include nausea, vomiting, changes in mental status, and chest pain. Infection severity operates on a continuum, and SARS-CoV-2 occupies its spectrum fully. Many people never realize they’re infected; others might have a two-day tickle in their throat, while some weather the disability of long-haul COVID for months; a fraction end up ventilated in the ICU.

The experience of having COVID is now poised to splinter further, along immunological boundaries largely defined by vaccines. Inoculated bodies are less hospitable to SARS-CoV-2, making it harder for the pathogen to infect them; when it still manages to, it seems to be purged much faster, affording it less time to cause symptoms—especially the bad ones—and fewer opportunities to hop into other hosts. “I think about it as defanging the virus,” Natalie Dean, a biostatistician at Emory, told me.

A recent study from the United Kingdom illustrates this well. Researchers surveyed nearly 4.5 million people through a cellphone app, asking whether they’d tested positive for the virus, and if they were experiencing any of about two dozen symptoms. Roughly 1 million of them had received at least one vaccine dose. Among the fully immunized, nearly all the symptoms—including fever, nausea, and brain fog—were rarer. Many of the cases were totally asymptomatic. Even rates of long COVID, which can sprout from initially silent infections, seemed to be substantially slashed by shots.

These qualitative shifts aren’t easy to capture, especially with the studies coming out now that measure vaccine effectiveness in the real world. Most of them gravitate toward metrics at two opposite ends of the SARS-CoV-2 spectrum—how well the vaccines protect against all infections, or against severe disease, hospitalizations, and death—with less precision around the murky hinterlands of mid-level symptoms that exist in between. (The most serious outcomes are, to be fair, what vaccines are intended to prevent, and what inoculated immune systems are best at staving off, making that metric a pretty good one to concentrate on.)

Focusing on the extremes, though, blurs the texture in the middle. In studies of effectiveness against severe disease, anything too “mild” to be considered a serious illness—warranting hospitalization, for instance—ends up collapsed into a single category. At the other end of the spectrum, counting all infections equates every positive test to a case of concern, regardless of how gentle the viral encounter was. All of this makes it very difficult to characterize what post-vaccine COVID actually is—and to know whether immune responses are diluting the disease’s sting. “Just looking at the rate … loses that point,” Holly Janes, a biostatistician at the Fred Hutchinson Cancer Research Center in Seattle, told me. The experience of infection can be “considerably different for someone who was vaccinated.”

This isn’t an easy dilemma to solve. During the vaccine makers’ clinical trials, researchers were able to study participants closely enough to examine how well the shots were blocking any symptomatic cases of COVID-19. (Studying only the severest disease, which are relatively rare events, wouldn’t have been feasible without making the trials even larger, or stretching them out longer.) “Real-world studies are like the wild, wild West,” Dean told me. Researchers often have to wrestle evidence out of electronic medical records, which aren’t logged consistently, or they have to depend on people to seek out tests and accurately remember their symptoms. They might monitor only the worst infections, because they’re more likely to prompt people to seek clinical care and are easier to document and study. Milder cases, meanwhile, are squishier, more subjective; not everyone will interpret an ache or a pain in the same way, or follow up on it with a professional. The studies that have tackled the task of measuring real-world vaccine effectiveness against all symptomatic disease may not always count the same COVID-19 symptoms, experts told me, potentially inflating or deflating numbers. Thorniest of all may be the data investigating long COVID, which still lacks a universal case definition, after vaccination, Lekshmi Santhosh, a critical-care physician at UC San Francisco, told me. “Most studies aren’t even looking,” she said.

Important variations exist, even at SARS-CoV-2’s extremes. Some hospitalized patients might be admitted for just a couple of days, while others need weeks of critical care or die. Early evidence hints that vaccines are batting away the worst blows here as well, another nuance lost when hospitalizations are lumped together. Positive test results, too, can be misleading. Tests, which hunt for precise pieces of the pathogen, can’t distinguish between viruses that are intact, or that have been blown to smithereens by a protective immune response; SARS-CoV-2 carnage, especially in a person who’s immunized and asymptomatic, doesn’t guarantee disease or transmission. “It doesn’t mean the same thing to test positive if you’re vaccinated,” Julie Downs, a health-communications expert at Carnegie Mellon University, told me.

Still, some infections among immunized people will pose a low-but-not-nonexistent transmission risk, especially to the vulnerable among us, and we can’t yet afford to tune the milder cases out. A much larger fraction of the global population will need protection before COVID-19 can truly be considered mellower than before. But the fates of the inoculated and the uninoculated are clearly already forking, a potential preview of what’s to come, Baden, the Boston physician, told me. “If I were a betting man, I’d say, years from now, this will be another common cold.” Titanji, of Emory, has already confronted the likelihood that her childhood bout of modified measles might foreshadow her experience with the coronavirus. When she sees patients in her clinic in Georgia, she tells them, “We’re all very likely going to have COVID, including myself. But it is okay. I have a vaccine that will prevent me from landing in the hospital.”

COVID-19’s march toward diminution won’t be linear or uniform. Immune cells forget; viruses shape-shift; our vaccines will need touch-ups or boosts. Behavioral slipups—vaccine refusals, spotty masking during outbreaks—will create cracks for the pathogen to wriggle through. But on a population level, our future could look quite good. Most people will end up getting COVID-19 in their lifetime. In most cases, it won’t be so bad. Eventually, silent or mild infections will feel less catastrophic, because many of us will have confidence that they are unlikely to progress. Outbreaks might be smaller and slower-spreading, and breakthroughs will no longer be headline-making news. Positive test results, in the absence of symptoms, could generally be shrugged off, and infection will no longer feel quite so synonymous with disease. Our bodies will come to see the virus as familiar—not necessarily a welcome guest, but not quite the intruder it was before.

Data alone won’t define our experience here; our understanding of post-vaccination infection will need to come firsthand, too. For me, the pandemic anxiety that dominated much of 2020 is slow to fade, and the idea of getting COVID-19 still feels far worse than getting the flu, even if the symptoms were identical. “It takes time to get over that,” Downs told me.

A small number of post-vaccination infections are now trickling into my social circles, and it’s actually been sort of comforting to hear some of the stories. A few days ago, I talked with Jayne Spector, who just became mother-in-law to one of my best friends. Spector tested positive for the coronavirus a couple of weeks ago—shortly after attending her grandmother’s funeral, where she’d hugged and kissed dozens of family members. Among them was her daughter, who was, at the time Spector received her test result, about to have her wedding, just 11 days later.

“I was really worried I had infected my soon-to-be-married daughter,” Spector told me. And had Spector not been vaccinated, “I think it would have been a disaster.” But Spector was vaccinated. So were almost all the family members she mingled with at the funeral—her daughter included—and not a single one of her contacts has tested positive. (They also kept a lot of the interactions outdoors, and wore masks inside.) Spector isolated at home, where she dealt with what she compares to a nasty but relatively fast-resolving cold—a paltry echo, she suspects, of the sickness she would have had, if not for her shots. “The fact that I’m vaccinated means that it’s tolerable,” she told me. “I took the precautions; I stayed away from others. Now I’m going back to my life.” Her daughter’s wedding was this past Saturday. All 18 people in attendance were fully vaccinated, and tested negative before the ceremony. Spector was one of them.

Source : The Atlantic

Early Data Shows Rise in Breakthrough Infections Among the Vaccinated

Robin Foster and Ernie Mundell wrote . . . . . . . . .

Preliminary data from seven U.S. states show that the arrival of the Delta variant in July may be fueling a rise in breakthrough infections among the fully vaccinated.

At least 1 in every 5 new COVID-19 cases in six of these states have involved vaccinated people, with higher percentages of hospitalizations and deaths among these folks than had previously been seen in all seven states, The New York Times reported.

Still, the absolute numbers of vaccinated people made sick by COVID-19 remains very low, experts said, and the vaccines are still very potent weapons against severe disease.

If breakthrough infections are becoming more common, “it’s also going to demonstrate how well these vaccines are working and that they’re preventing hospitalization and death, which is really what we asked our vaccines to do,” said Anne Rimoin, an epidemiologist at the University of California, Los Angeles, told the Times.

Importantly, a vast majority of vaccinated people who are hospitalized for COVID-19 are likely to be older adults or those who have weakened immune systems. CDC data show that 74% of breakthrough cases are among adults aged 65 or older.

The numbers suggest that people who are at higher risk for complications from COVID-19, and anyone who lives with a high-risk person, “really needs to seriously consider the risks that they’re taking now,” Dr. Dean Sidelinger, a state epidemiologist and state health officer for Oregon, told the Times.

“Remember when the early vaccine studies came out, it was like nobody gets hospitalized, nobody dies,” Dr. Robert Wachter, chairman of the department of medicine at the University of California, San Francisco, told the Times. “That clearly is not true.”

“If the chances of a breakthrough infection have gone up considerably, and I think the evidence is clear that they have, and the level of protection against severe illness is no longer as robust as it was, I think the case for boosters goes up pretty quickly,” Wachter added.

The seven states analyzed by the Times — California, Colorado, Massachusetts, Oregon, Utah, Vermont and Virginia — were chosen because they are keeping the most detailed data, the Times said. It is not certain whether the trends in these states would hold across the country.

The increases seen are largely due on the mathematics of mass vaccination: Scientists have always expected that as the number of vaccinated people exponentially grows, vaccinated people will show up more frequently than before in tallies of the severely ill and dead.

“We don’t want to dilute the message that the vaccine is tremendously successful and protective, more so than we ever hoped initially,” said Dr. Scott Dryden-Peterson, an infectious disease physician and epidemiologist at Brigham & Women’s Hospital in Boston. “The fact that we’re seeing breakthrough cases and breakthrough hospitalizations and deaths doesn’t diminish that it still saves many people’s lives.”

The states’ data do confirm that vaccinated people are still far less likely to become severely ill or to die from COVID-19. In California, the 1,615 hospitalizations of people with breakthrough infections as of Aug. 8 represents just 0.007% of nearly 22 million fully immunized residents, and breakthrough deaths constitute an even smaller portion, the Times reported.

But in six of the states, breakthrough infections accounted for 18% to 28% of recorded cases in recent weeks, the newspaper said. These numbers are likely to be low, because most fully immunized people may not feel ill enough to seek a test.

Breakthrough infections accounted for 12% to 24% of COVID-19 hospitalizations in the states, the Times found. The number of deaths was too small to arrive at a solid number, although it does appear to be higher than the CDC estimate of 0.5%.

The latest numbers make a good case for booster shots, and a recent survey showed that seniors can’t wait to get one: Among vaccinated Americans, 72 percent of those who are 65 or older already say they want a booster shot.

Source: HealthDay

Study: Fully Vaccinated People with “Breakthrough” COVID Delta Infections Carry as Much Virus as the Unvaccinated

Tucker Reals wrote . . . . . . . . .

A study by University of Oxford scientists has found that people who contract the Delta variant of COVID-19 after being fully vaccinated carry a similar amount of the coronavirus as those who catch the disease and have not been inoculated. The researchers stressed that vaccination still offers good protection against catching the disease in the first place, and protects against getting seriously ill with it.

The survey of real-world U.K. data indicates, however, that vaccinated people with “breakthrough” infections could still pose a significant infection risk to those who have not been vaccinated.

“With Delta, infections occurring following two vaccinations had similar peak viral burden to those in unvaccinated individuals,” the study, which has not yet been peer reviewed, concludes. Viral “burden” or viral load refers to how much coronavirus-infected people carry and thus “shed,” or release into the environment around them, where it can potentially infect others.

The survey compared U.K. government data on more than 380,000 people who tested positive for the coronavirus between December and May of this year, when the first-discovered Alpha variant accounted for most of the cases in Britain, with figures for more than 350,000 people infected over the following four months, when Delta was dominant.

Oxford’s lead researcher, Dr. Sarah Walker, told The Telegraph that the study shows two doses of the Pfizer/BioNTech, Moderna or AstraZeneca vaccines “are still protective. You are still less likely to get infected – but if you do, you will have similar levels of virus as someone who hasn’t been vaccinated at all.”

The data used for the study do not show how likely it is that a fully vaccinated person with the Delta variant can pass on the infection to another individual, compared to an unvaccinated individual with the virus. But the high viral loads found in the study are a strong indicator that the risks of transmission from both vaccinated and unvaccinated people with the Delta variant could be similar.

Biden to tie vaccines for nursing home staff to funding
The findings could have implications for policy makers who’ve banked for months on hopes that by vaccinating a large proportion of any given population, they will also protect people who cannot or will not get inoculated themselves by reducing transmissions overall.

“The fact that they [fully vaccinated people] can have high levels of virus suggests that people who aren’t yet vaccinated may not be as protected from the Delta variant as we hoped,” Walker told the British newspaper. “It comes back to this concept of herd immunity, and the hope that the unvaccinated could be protected if we could vaccinate enough people. But I suspect the higher levels of the virus in vaccinated people are consistent with the fact that unvaccinated people are still going to be at high risk.”

The message from Walker and her team at Oxford was clear: Vaccination remains the best way to protect against infection, and certainly against serious illness or hospitalization with COVID-19, including the Delta variant.

None of the coronavirus vaccines approved for use in the U.S. or U.K. thus far eliminate the risk of infection, but they all reduce that risk by between about 70% and 90% — and they’ve proven much more potent at preventing hospitalizations and deaths.

“There are lots of reasons why the vaccines may be very good at reducing the consequences of having the virus,” Walker told The Telegraph. “You may well still have a milder infection and might not end up getting hospitalized.”

She said that while the results of the ongoing vaccine effectiveness study were important, “they aren’t everything, and it is really important to remember the vaccines are super-effective at preventing hospitalizations.”

Source : CBS

An Epidemiologist Went to a Party with 14 Other Fully-vaccinated People; 11 of Them Got COVID

Allan Massie wrote . . . . . . . . .

I was sitting on an examination table at an urgent care clinic in Timonium, giving my history to a physician’s assistant. An hour later, she would call me to confirm that I was positive for COVID-19.

Given the way that I felt, it was what I expected. But it wasn’t supposed to happen: I’ve been fully vaccinated for months.

Five days earlier, I had gone to a house party in Montgomery County. There were 15 adults there, all of us fully vaccinated. The next day, our host started to feel sick. The day after that, she tested positive for COVID-19. She let all of us know right away. I wasn’t too worried. It was bad luck for my friend, but surely she wasn’t that contagious. Surely all of us were immune. I’d been sitting across the room from her. I figured I’d stay home and isolate from my family for a few days, and that would be that. And even that seemed like overkill.

The official Centers for Disease Control and Prevention guideline stated that, since I was fully vaccinated, I didn’t need to do anything different unless I started developing symptoms. I’m an epidemiologist at a major medical research university, which has a dedicated COVID exposure hotline for staff. I called it, and workers said I didn’t need to do anything.

Then, I started to hear that a few other people who had been at the party were getting sick. Then a few more. At this point, 11 of the 15 have tested positive for COVID.

Fortunately, none of us seems to be seriously ill. When fully vaccinated people experience so-called “breakthrough” infection, they tend not to progress to serious disease requiring hospitalization, and I expect that will be the case for us. But I can tell you that even a “mild” case of COVID-19 is pretty miserable. I’ve had fever, chills and muscle aches, and I’ve been weak enough that I can barely get out of bed. I don’t wish this on anybody.

Our research group at work has shown that the COVID vaccine isn’t always fully effective in transplant recipients. I’m proud of the work we’ve done. But once I got the vaccine, I figured the COVID battle was over for me. Out of an abundance of caution I took an antibody test shortly after my second vaccine dose. It was off the charts.

As much as I hate me and my fully-vaccinated friends being sick, I’ve been thinking about what our little outbreak among means for the rest of us. Here’s what I’ve concluded:

State and local health departments, and the CDC, need to do a better job collecting and reporting data on breakthrough infections. The CDC announced in May that it was only going to collect data on breakthrough infections that led to hospitalization or death, which are fortunately rare. But that means that outbreaks like ours will fly under the radar. Any of us could infect others, apparently including other vaccinated people. It’s not clear if our group got sick because of a particularly virulent variant, because the vaccine is wearing off or for some other reason. Without good data, we’ll never know.

Fully vaccinated people exposed to COVID need to isolate at home and get tested. I thought I might be overreacting by leaving work in the middle of the day and immediately moving to our basement at home. Now I’m glad I did.

Governments and businesses should consider bringing back masking requirements, even for vaccinated people. We’re still at risk of getting sick, and we’re still at risk of infecting others. The CDC recently recommended masks for vaccinated people in areas with over 50 new infections per 100,000 people per week. In the seven days before my exposure, Montgomery County had 19.4 new infections per 100,000 people.

Pharmaceutical companies, research institutions and governments should prioritize research into booster vaccines. At one point it seemed like two mRNA doses or a single Janssen dose might be the answer. But apparently, whether because of variants or fading immunity, being “fully vaccinated” doesn’t necessarily mean you’re immune.

COVID-19 vaccines do an enormous amount of good. I expect a milder course of disease since I’m vaccinated. But COVID-19 isn’t over, even for the vaccinated. As the pandemic continues to evolve, we need to evolve with it.

Source : Baltimore Sun

Vaccinated People Make Up 75% of Recent COVID-19 Cases in Singapore

Aradhana Aravindan and Chen Lin wrote . . . . . . . . .

Vaccinated individuals accounted for three-quarters of Singapore’s COVID-19 infections in the last four weeks, but they were not falling seriously ill, government data showed, as a rapid ramp-up in inoculations leaves fewer people unvaccinated.

While the data shows that vaccines are highly effective in preventing severe cases, it also underscores the risk that even those inoculated could be contagious, so that inoculation alone may not suffice to halt transmission.

Of Singapore’s 1,096 locally transmitted infections in the last 28 days, 484, or about 44%, were in fully vaccinated people, while 30% were partially vaccinated and just over 25% were unvaccinated, Thursday’s data showed.

While seven cases of serious illness required oxygen, and another was in critical condition in intensive care, none of the eight had been fully vaccinated, the health ministry said.

“There is continuing evidence that vaccination helps to prevent serious disease when one gets infected,” the ministry said, adding that all the fully vaccinated and infected people had shown no symptoms, or only mild ones.

Infections in vaccinated people do not mean vaccines are ineffective, experts said.

“As more and more people are vaccinated in Singapore, we will see more infections happening among vaccinated people,” Teo Yik Ying, dean of the Saw Swee Hock School of Public Health at the National University of Singapore (NUS).

“It is important to always compare it against the proportion of people who remain unvaccinated…Suppose Singapore achieves a rate of 100% fully vaccinated…then all infections will stem from the vaccinated people and none from the unvaccinated.”

Singapore has already inoculated nearly 75% of its 5.7 million people, the world’s second highest after the United Arab Emirates, a Reuters tracker shows, and half its population is fully vaccinated.

As countries with advanced vaccination campaigns prepare to live with COVID-19 as an endemic disease, their focus is turning to preventing death and serious diseases through vaccination.

But they are grappling with how to differentiate public health policies, such as mask wearing, between the vaccinated and those who are not.

Both Singapore and Israel, for example, reinstated some curbs recently to battle a surge in infections driven by the highly contagious Delta variant, while England lifted almost all restrictions this week, despite high caseloads.

“We’ve got to accept that all of us will have to have some restrictions, vaccinated or not vaccinated,” said Peter Collignon, an infectious diseases physician and microbiologist at Canberra Hospital in the Australian capital.

“It’s just the restrictions are likely to be higher for those unvaccinated than vaccinated people, but that may still mean they have mask mandates indoors, for instance.”

The Singapore data also showed that infections in the last 14 days among vaccinated people older than 61 stood at about 88%, higher than the figure of just over 70% for the younger group.

Linfa Wang, a professor at Duke-NUS Medical School, said elderly people had been shown to have weaker immune responses upon vaccination.

In Israel, which also has a high vaccination rate, about half of the 46 patients hospitalised in severe condition by early July had been vaccinated, and the majority were from risk groups, authorities said.

It was not immediately clear if the Singapore data reflected reduced protection offered by vaccines against the Delta variant, the most common form in the wealthy city state in recent months.

Two doses of vaccine from Pfizer-BioNTech or AstraZeneca are nearly as effective against Delt

a as against the previously dominant Alpha variant, according to a study published this week.

Singapore uses the Pfizer and Moderna vaccines in its national vaccination programme.

Friday’s 130 new locally-transmitted infections were off this week’s 11-month high. The recent rise in cases prompted authorities to tighten curbs on social gatherings in the push to boost vaccinations, particularly among the elderly.

Source : Euro News