Threats vs. Science in Public Health Policy

Threats vs. Science in Public Health Policy July 29, 2021

NPR reports that the Biden administration is about to lay down vaccination requirements for federal employees:

He is expected to announce that federal employees will need to confirm they are vaccinated — or face regular testing and be required to wear masks at all times while on the job. The federal government is one of the largest employers in the nation, and the move could spur private sector companies to take similar steps. Some already have.

Reminder: The vaccines in question have not even been fully vetted by the FDA.  (Recap: I’m fully vaccinated, freely chose it, am positive I made the right decision given my medical history, even though, of course, no decision is without risks. I think for most American adults, under present conditions getting vaccinated is probably the best choice. I also admit I’m not omniscient, so that judgment could be proven wrong.)

So why would a vaccine-supporter have objections to the Biden policy?  Because it ignores the current science.

Pause and go read this op-ed by Jeremy Faust at Inside Medicine: “Delta breakthrough cases: rarely deadly but equally contagious.”

Things had already begun to change for me last week when two acquaintances tested positive for coronavirus despite receiving two doses of an mRNA vaccine this spring. Neither of them particularly enjoyed being sick, but both were at home, rather than hospitalized. What probably sounded scary to some—breakthrough infections—to me actually looked to be reassuring examples of the vaccines doing their job by preventing critical illness and death. But one of the two cases took me aback. She had tested positive via a rapid antigen test. That piece of information had important implications about her contagiousness.

To understand why, let’s refresh on test types. Most tests administered are PCR tests. PCR tests check for the genetic material of SARS-CoV-2, the virus that causes Covid-19. A positive result means the person was infected “sometime recently,” but does not indicate contagiousness. In fact, many people remain positive on PCR tests for weeks, well after a person has won the initial fight and ceased being a danger to others. Rapid antigen tests work by detecting a particular protein on the surface of the virus. Only viable contagious virus harbors enough surface antigen to mount a positive test. A person only tests positive on a rapid test at times when they are contagious. That means my second friend, the one with the positive rapid antigen test, was vaccinated, infected, and contagious. So far, that combination is unique to the Delta variant.

For a popular press version, here’s a local media report from Madison, WI.

“Someone who’s vaccinated and has a breakthrough infection, and is walking through a crowded building, is potentially going to be exhaling a lot of virus and is potentially going to be putting others at risk . . .”

I’m sure you can find many others.  This one is of particular interest because of the relatively high vaccination rates (70%) in the affected area.

This isn’t the press glomming onto the latest fad in fear-mongering, it’s just a thing, and not even a surprising thing.  Viruses mutate randomly, but the mutations most likely to get passed along are those which favor the survival of the virus.  Not a shocker. To be expected.

Some studies of interest on the question of breakthrough infections and re-infections:

So.  Back at policy prescriptions.  There is growing evidence that:

  • Vaccine effectiveness decreases over time.
  • Vaccinated persons can get infected and be contagious.
  • Previous COVID-infection appears to function similarly to being vaccinated, though I’ve been struggling to find more-recent studies examining this question.
  • Reinfection and breakthrough infections are both associated with improved outcomes compared to first-time infection in an unvaccinated person.

So what does this mean for vaccine mandates? What does it mean for mitigation efforts?  A handful of thoughts:

#1 Vaccination or previous COVID infection are only partial mitigation measures.

They do indeed “flatten the curve.”  Remember that?  It’s still important, ask an ICU nurse.  However, both of these (and both of them are pertinent, we think), though very helpful, will not end the disease. There is every indication that COVID-19 is going to become endemic.  The current state of medical technology allows us, we’re pretty sure, to make the disease less-deadly, but eradication does not appear to be on the table at this time.

#2  Your colleague’s or classmate’s or caregiver’s vaccination status will not protect you from the disease.

Implementing policies that require disease prevention and detection measures only for the unvaccinated is disastrous.  Even though an unvaccinated, never-infected person is more likely to become infected, a vaccinated person with a breakthrough infection appears, with the Delta variant, to be just as deadly to a COVID-vulnerable person.

There is simply no justification, given the present state of the research, to regard any given vaccinated individual as “safe” to a vulnerable person.

#3 Policy prescriptions need to distinguish more-vulnerable vs. less-vulnerable persons, rather than fixating on vaccination status.

If you are working with immune-compromised patients? You need to use full precautions to avoid passing on the infection even if you are fully vaccinated.

If a workplace needs to implement precautions such as masks or testing for unvaccinated individuals, it needs to do so for vaccinated individuals as well. Both are sources of transmission of the virus.

#4 Mandated mitigation measures should take into account differences in vulnerability.

Life involves risk.  Mitigation measures are trade-offs.  For a child who is immune-compromised or has a vulnerable (even after vaccination) family member, radical steps to prevent COVID transmission are probably warranted.  For a child who is at low risk of disease complications and whose mostly-healthy older family members are all vaccinated or previously-infected, it is reasonable to transition to classroom precautions more like one would take during an ordinary flu season.

Given that the proportion of children needing full precautions and teachers needing full precautions is probably quite similar, an obvious answer is to group accordingly.  Parents and teachers can self-select after consulting with their medical care team.

Meanwhile, the federal government can lead the way (happy birthday ADA) in providing full accommodations for employees who need to work remote due  to continued risk of COVID morbidity and mortality.

#5 We seriously need to put ventilation on the table as a major mitigation measure.

Y’all.  Your cloth mask is a real but weak mitigation measure.  Six feet? Real but weak.  Plexiglass dividers at check-out? Real but weak.  If you are going to cough in my presence for any reason whatsoever, yes, I would like you to cover your cough.  I would like less of your respiratory-tract contents coming my way.  Every time, full stop.  If you must breathe on me while sick, I would like you to breath on me less.  That’s what these mitigation measures do: Less of your lungs in my face.

Okay that’s good. Reducing viral load matters.

But COVID-19 hangs around.

Think of it like a certain child of mine’s obsession with scented products: It’s not only a question of whether she’s actively spraying you with It’s All Vanilla Now, there’s also the part where you get to breathe in the lingering presence of Vanilla Will Haunt You Forever regardless of whether you were in the room when the wonder-potion was released.  (To her chagrin, we have pretty good ventilation in our house. She has to keep re-applying.  I keep telling her that taking out the trash would be a much better scent-improvement measure.)

So, with regard to protecting federal employees: Where are the ventilation mandates?  Because in terms of your getting sick, it just doesn’t matter whether your now-infected colleague was previously vaccinated or not, what matters is whether you breathe the same air.

Vaccination or previous-infection status are protective against serious disease, and therefore vaccination is a worthy recommendation, despite the lack of full data on their longterm safety and effectiveness.  Previous-infection and vaccination rates are both worth tracking, and vaccinations are worth* encouraging, because both do appear to slow the rate of transmission at the macro-scale.  Averages are improved.

You, however, are not macro.  Vaccination makes it less-likely your colleagues are infected, but what matters to you is a pure binary: Is this one here infected or not?

Thus it is laughable to the point of criminal negligence to claim that vaccination is the make-or-break in any given case of disease transmission.  It simply is not.  Your vaccinated colleagues can kill you.  And when that happens, it’s because you inhaled what they exhaled.

So.  Ventilation. Put it on your radar.

Update 7/30/2021: Here’s the link to the Washington Post’s PDF copy of the CDC’s internal slideshow, “Improving communications around vaccine breakthrough and vaccine effectiveness” July 29, 2021.  Includes some interesting study results, well worth a look.

*By “worth encouraging” I don’t mean “forget everything you ever knew about civil rights” and certainly not “forget every major correction in medical knowledge that’s ever happened.”  It is entirely possible to implement public health policies that encourage vaccination without mandating or coercing.  You don’t have to choose between living in a free republic and having a fully-functioning public health system.  Choosy voters choose both.


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