Understanding Why Breakthrough Covid Occurs
This article (MedPage Today) popped up in my In-Box and I believe it is a good average – person on the street (high school education?) read if you want to understand “why,” why getting vaccinated is not a failsafe solution. You still have to socially distance, stay out of bars even if the owner is an ass, wear facemasks amongst other people, etc. so as not to catch Covid.
The article explains why you should be vaccinated even if the vaccine is not the 100% impenetrable Covid – proof – jacket many people believe it should be. Checkout the multiple comments made by doctors, nurses, etc. too in the comments section. This article was well-received by medical personnel.
We Can All Benefit From Helping Patients Understand Breakthrough COVID | MedPage Today, Gary C. Steven, MD, PhD August 27, 2021
Why am I posting this commentary???
The recent change in masking guidance from the CDC and reinstated public health measures from local and state governments have been met with frustration and defiance. Understandably people are questioning why they got vaccinated if they have to go back to masking and distancing anyway. The answer is in the degree of exposure to SARS-CoV-2, and the explanation lies in the way vaccines work.
We (the doctors (not me) can help patients (us) understand this by using three talking points:
(This follows what I [the blog author] know to date and is difficult for me to explain. I am hoping to clear up some misunderstanding by quoting the doctors version of this which I am sure Joel and also Daniel Becker would agree on it.)
Three Points of why we should still mask up, socially distance ourselves, etc.
- The antibody levels in the bloodstream gained from vaccination are completely helpless at preventing infection.
Simply, vaccination is not a guarantee to prevention. Vaccination neutralizes virus particles from the environment which is the result of the vaccine-induced antibodies in our respiratory, GI, and ocular secretions. Or our “frontline” defensive antibodies in our saliva, tears, nasal secretions, and pulmonary mucus.
When exposed to airborne virus particles, antibodies attach to the spike protein of SARS-CoV-2, physically preventing it from latching on to the ACE2 receptor on the surface of our respiratory epithelium and gaining entry to those cells to cause an infection. This is all we have.
If we are exposed to so many virus particles that all the antibodies in these secretions have attached themselves to virus particles and we continue to be exposed to new particles in greater numbers than we can transport more antibodies into these secretions; our antibody defense becomes overwhelmed when we inhale or come in contact with more virus particles than we are able to neutralize. The end result is becoming infected.
- Circulating antibodies help to contain the infection
The vaccine introduces antibodies to help contain Covid. Once infected, the virus takes over the machinery of our cells to make more virus particles and release them. The circulating vaccine-induced antibodies latch on to these newly minted particles preventing them from infecting adjacent cells and from being exhaled.
One of the Delta variant’s strong suits from the beginning is Covid -19’s ability to reproduce itself so rapidly our antibodies are overwhelmed and do not slow it down much. Ultimately, infected vaccinated people shed virus similarly to unvaccinated folks.
- Our vaccine-induced T-cell immunity limits disease severity
The third element of the response to the vaccine is the induced T-cell immunity. Our immune system kills off infected cells which are a lost to Covid and will need to be replaced. This limits the extent of disease. (To my limited knowledge, pre-vaccine T-cells would over react and flood the lungs).
Vaccines are effective at limiting the severity of disease, and is the reason why we do not see many vaccinated people among the hospitalized even as the number of vaccinated people infected with the Delta variant increases. This is also why it is critical to get vaccinated. The vaccines are extremely effective at preventing severe illness and death from COVID-19.
It is not in the T-cell job description to prevent viruses. Vaccine-induced T-cells do not provide protection against getting infected. They only mitigate severity once infected.
More and more vaccinated people are getting infected because they are interpreting vaccination as a carte blanche to return to pre-pandemic life without restriction. They (we) are exposing ourselves to massive viral loads overwhelming the immunity gained from vaccination.
We still need to practice social distancing and masking after vaccination to minimize and/or prevent infection even after vaccination.
What doctors wish patients knew about breakthrough COVID infections
A breakthrough case is defined as “detection of SARS-CoV-2 RNA or antigen in respiratory specimen collected from a person 14 days after receipt of all recommended doses” of one of the three vaccines authorized in the U.S., said AMA member Devang Sanghavi, MD. …
No vaccine is perfect
One reason why fully vaccinated people might develop breakthrough COVID-19 infections “is the characteristics of the vaccine itself and how efficacious the vaccine is, because there is not a single vaccine that we know of that is 100% effective,” explained Dr. Sanghavi. “We know from initial trials from both mRNA vaccines that the effectiveness was somewhere around 94% and 95%—slightly lower in the Johnson & Johnson vaccine.”
“The study environment is different because these are patients who were carefully selected when the trial rolled out. After the FDA gave its EUA [emergency use authorization], and it was given to a lot of the general population, we found that the real-world effectiveness of the vaccine is lower at around 90%,” he said. “That means that there are inherent characteristics of the vaccine itself when it reacts with the patient and the comorbidities of the patient that would itself lead to ineffective immunization in certain populations.”
Discover what to tell your patients when they ask which COVID-19 vaccine to get.
Efficacy depends on the individual
“To add to the vaccine characteristics, you also add patient characteristics,” Dr. Sanghavi explained. Patients with immunosuppressed status after organ transplantation, those who are post-hematologic malignancy, or those who are older “have higher chances of getting COVID-19 despite being fully vaccinated,” noting that “we see a lot of these patients in our practice.” …
The unspoken part about how little the vaccines do to reduce the spread of Indian Delta is that it will never be possible to return to what used to be ‘normal’ life again. Indian Delta is unmanageable without vaccination, social distancing, and masking. Take away any one leg of that triad–now or ever–and Indian Delta overwhelms societies.
Indian failure to manage SARS-CoV-2 has created an apocalyptic virus that has ended our way of life.
Never forget which government deserves the blame.
India is very crowded and it is difficult to distance one’s self from others. The vaccine will help as well as masking.
While the points are real, what the correct interpretation of them for the vaccinated person has to be arrived at by the individual I think. Knowing the way the vaccines function to mitigate serious illness if infected might be plenty for many people to stop masking and social distancing. Heck, we know that simply the basic risk profile is enough to get a whole lot of unvaccinated thinking that way. It is notable that each of these points circles back to the idea that the vaccines are fundamentally a personal protection step that people ought to want to do, but less of a collective step to stop the virus from circulating (particularly the second point highlights the similarity in viral load in unvaxxed and vaxxed). When OSHA releases an emergency workplace safety rule it is going to be interesting to see what they say. The President was explicit that the measures were at least partly motivated by the idea of protecting the vaccinated from the unvaccinated. But the the infected vaccinated present the same risk of transmission as the unvaccinated, so the better safety would be test all employees regardless of status. That would undermine the potential of the rule being an incentive to vaccinate, but it would provide better workplace safety against the risk that has been pointed to as the reason for the rule. I’ll let OSHA make their rule, but the suspicion that this is not about workplace safety so much as control is not that unreasonable. Likewise, prior infection generates the responses highlighted in the second and third point.
In response to nobody and Eric377: See this piece, “No, Vaccinated People Are Not ‘Just as Likely’ to Spread the Coronavirus as Unvaccinated People,” in the Atlantic.
Yes, but in a minor manner when you consider transmission as a workplace safety issue as the exposure is repetitive and for many hours a day. If the risk of transmission to a vaccinated coworker working among untested, unvaccinated colleagues is X% after a week, then it is going to be X% after a few more weeks with untested, vaccinated workers. But if running X% risk is not acceptable, well you better test all who might be infected. COVID is definitely going to be spread by vaccinated individuals at work.
To me the issue is whether or not this is actually a safety problem. The President’s statements make me think his administration believes it to be a specific safety issue for vaccinated individuals even though vaccination greatly diminishes personal risk of severe illness. But their safety is not dependent on the vaccine status of the person who transmitted the virus to them but only on whether they are being exposed to the virus in the workplace. This is why I think testing will quickly either run to everybody or the measure will fail as a safety measure if safety actually means exposure prevention. And since I think this is darn obvious, I think considering this as a real safety measure might be wrong, depending on what the rule is.
Vaccination status here is a proxy for what is presumed to be the response of the individual’s immune system. It is a reliable proxy – although with some duration concerns. But prior infection is also a reliable proxy – again with some duration concerns. So it will be revealing I think to see what OSHA does with this. My sense is that the President wants this to be a control mechanism to force vaccinations and will not allow logic to intrude very much. The vaccinated will be deemed “safe” but the unvaccinated with prior infection will be “unsafe” even if the science says both are reliable proxies for what passes as safety here. Likewise, it will be “safe” to not test vaccinated workers even though they will end up transmitting it to others, because testing everyone seriously hampers the vaccination forcing mechanism of such a rule.
Aren’t risk probabilities are always relative to a period of time or per exposure or some number of multiple exposures. I don’t think you can say that X% probability is an unacceptable risk without attaching a time interval or units of exposure to the number. For example, we talk about the risk of dying in an automobile accident per thousands of miles driven. If that is X%, and X% is acceptable, but 5X% is not, do you say that you are willing to drive 1000 miles but not 5000? To keep the total number of deaths in a country to a number that is considered acceptable, do we say that the total number of miles that people may drive is Y, but we are going to limit them in the aggregate to less than 5Y? I don’t think that that’s the way things work, and it’s certainly not the way people think about these things (reasonably in my opinion).
Thank you for this.
The problem may be my own, but I find the new-days quoting conventions difficult to follow. Old fashioned quotation marks, and “Person XXX said, “…” works better for me than indentations, shaded boxes, etc. expecially when two or three sources are being quoted.
As I said, the problem for me may be my own cognitive limitations, but I think…I can’t really tell… that sometimes the author doesn’t keep track himself of just who is saying what…that is, the author knows, but is not consistent in his style of quotations.
Sorry, really sorry, to be making what sounds like a critical comment about what I think is a really important article. For what it’s worth, I know I have the same problems with my writing.
rereading the post, i find, i think, that the problem is not the quotation confusion. It looks to me like the entire post is Run speaking, with what i took to be a headline for a quote “merely” a reference to the source. So, I still found the post hard to follow, but that may be a more general problem we all have as writers and readers.
There is a link you can use to revert to the original text which I have commandeered and wrote mostly in my own words.
..speaking of writers difficult to follow.
I think you are right about time being an important factor in exposure risks.. the time it takes for immunity reponses vs the time it takes for virus to multiply. this is a point that it seems to me the “herd immunity” folks have failed to understand from the beginning.
but…as in the case of your deaths-per-mile example, we are talking “probabilities” here, and one thing i try to point out is that each person has his own different risks, so that an while an “average” per mile risk may be a perfectly understandable basis for limiitng the total number of traffic deaths in a country, it is perfect nonsense when you recognize that some drivers are drunk, some irresponsibly reckless, some limited in normal attention, perception and reaction. and some drivers can drive with a risk level a hundred or a thousand times less per mile than others.
someting similar may be true of covid risks.
and yes, all day in a crowded room is much riskier than a day on a mountain top alone. and a year of days in a crowded room is riskier than one day…for slightly different reasons.
again, the fault may be mine, but I can’t really understand what you are saying here, and it seems to me you are not really following the “logic” you think is “darn obvious.”
especially if you are saying that the President has a secret plan to force vaccinations. Maybe you mean something reasonable that I am overreacting to because of all the hysteria about secret government plots to deprive us out freedom that I hear about.
I think a few more posts like the one here going into the mechanics, and statistics, of infection and immunity would be very useful.
With herd immunity, you are culling the herd.
Admittedly, we are saying its ok to lose a bunch as the rest of us will survive. With Covid, you do not need to drive fast, be drunk, or all asleep. All you have to do is come in contact with an infected person unbeknownst to you.
That independence is akin to Reagan’s Shining City speech where we will lose some on the way to it. Cuomos response? “In many ways we are a shining city on a hill. But the hard truth is that not everyone is sharing in this city’s splendor and glory.”
I believe the herd immunity supporters are more along the line of the Reagan followers. They are healthy, they are doing well, and they live in areas which are not as over crowed as our larger cities. Wisconsin comes to mind.
Culling the herd through herd immunity is more likely to occur in crowded areas where people have limited capability to distance. Minorities, the poor, etc. are in these areas. So what does it matter if they catch Covid? To many of the fortunate, nothing matters.
Remember, to have herd immunity, you have to be exposed to Covid. If you are amongst the later as opposed to the former healthy, suburban types, and wealthier group; you probably survive the outbreak with 8 months of immunity (the immunity you may gain from infection).
Covid is a rapid infection in which you will be overwhelmed in a matter of days. With the reaction of T-Cells to the virus and without proper care, you will drown in your own mucus created by your body’s response to Covid.
So do we go with herd immunity? Only if you wish (no guarantees), you wish to experience a horrific death. Time is of the essence and Covid can outstrip your body’s ability to fight back or the outcome of your body’s response will kill you also. The vaccine gives you an edge on Covid.
run75441 wrote: “Cuomos response?” I think you are showing your age. How many people younger than 50 remember Mario? When they hear (read) “Cuomo” I suspect that what comes to mind is most likely Andrew or perhaps Chris, the epigones.
Mario’s response to Reagan was one of the greats of our (old guy’s) time. It was the right speech at the right time. I think (and perhaps I am wrong) for someone to say similar to rebut trump and his sycophants’.
Yes. The man had a golden tongue.
I think you are making the same point I was trying to make. “different covid exposure to risk” taking the place of “different driving exposure to risk.
I limit my driving risk by not drinking. I limit my Covid risk by not insisting on eating in a restaurant during a pandemic.
That and arguing we are all too willing to sacrifice others, the problems so we can have our freedom.
yes, that too. i was afraid to say more because, first, length, and second, i seem to hurt people’s feelings without meaning to.
You are fine . . . Thanks for reaching out.
Long time ago I was called for jury duty. watched the prosecutor question another potential juror, explain the concept of reasonable doubt. “now,” he said, ” if you want to go on an airplane, you know that airplanes sometimes crash, but you get on the airplane anyway, because you have no reasonable doubt you will be safe.”
I was never given that explanation by the prosecutor, because if I had, I would have said, “on the contrary, there IS a reasonable doubt that I will be safe. the odds are in my favor, but it is reasonable to doubt that I will be safe. But more important, when I get on a plane I am betting that the risk is worth the benefit. If I force YOU to get on the plane, I am not betting anything..the risk is all yours. You might not think the risk is worth it, especially if you don’t want to go where the plane is going.
and related to this… i was being told by some expert that the risk of being killed in a plane crash was, passenger mile for passenger mile, less than the risk of being killed in a car crash.
and that is true if you are dealing with large numbers. but it is not necessarily true for YOU or ME. I have some control of the risks in driving. I have no control of the risks of being a passenger in an airplane.
I think these examples exhibit some of the risks of thinking about statistical risks. Or especially, insisting that other people see the statistical risks the same way you do.
Related to this, from a comment above, as “the authority” concerned about the whole population risk of deaths per mile, you can limit the risk per person by limiting the number of miles, or you can spend some money making roads safer..to the point of being idiot proof…as we have done in this country..almost. some idiots always find a way to kill themselves and others.
of course there is always the risk i am misunderstand, it seems to me i see a lot of people throwing statistics in each other’s faces without understand what they are talking about.
As we learn…experience teaches… more about this virus, the “risks” change. (could have said “known risks” but i didn’t want to sound like Donald Rumsfeld.)
tryong to sort some things out here and foment [sic] understanding.
Do we know that the risk of transmission from vaccinated people is the same as risk from unvaccinated? take into account numbers of people, apparent number of new cases/population in communities compared to vaccination rates.
consider mechanisms. i think Run gives us at least a start here to understand why they might be different.
are we sure testing reduces risk…or is it only an after the fact data to help monitor sources and spread? if there is a lag between early positive test and transmissibility, there might be a way frequent testing and quarantine would reduce the rate of spread.
i think you do not know..I do not know…the effect on rate, or ultimate reach…of infection given tests, or vaccination. Biden listens to better people than Trump in y opinion. He is the President and has the well being of the whole population in his hands, so if he thinks “forcing” people to get vaccinated is better for the people as a whole, he is not doing anything nefarious.
personally, i think he is mnaging the issue quite well. outting pressure on people is not forcing. those with trivial or political reasons will find it’s better to get the vaccine than not. people with serious objections will find another job. [yes I know that’s easy fro me to say, not so easy for them.]
vaccinated people may be at lower risk of death. this may or may not affect the spread of the disease. vaccinated people can still get and transmit the disease. it is not clear to me that we are not looking at a virus variant that has evolved to not kill the infected person in the presence of the vaccine, but may therefore live a long time in that person and infect many more other people over that longer time than it would have by killing the person in a short time. we don’t know if this will enable more variants to emerge.. as new variants will be a function of number of living viruses, which might be a function of number of living “survivors.”
in short, we do not know the ultimate value of the vaccine in reducing the total number of serious lllness and death. but the evidnec so far is that it does. that evidence cannot be anecdotal (at first) or based on speed reasoning. I would say that Biden is doing the best he can with present information and the political situation (massive disinformation by Friends of Fox and Trump).
i have “learned” recently that there are limitations to the protections provided by masks which explains some of the confusing advice put out by “experts” about them [holding back the complications because the people are too stupid to deal with complication. doesn’t mean they are no help. they are expecially helful in reducing the spread from you to someone else. and of course from someone else to you. if that sounds contradictory, finger it out. or i’ll explain better when i get less tired.
i suspect your last paragraph transitions from reasonable doubt to political hysteria, but i could be wrong.
i am no better a writer than anyone else, but i did try to be careful here,and i would be sorry if i did not get answers that tried to be careful. we might make progress from there, otheriwse its just a dormitory bull session.