We Need to Start Thinking Differently About Breakthrough Infections

Avoiding the new coronavirus was the main focus of nearly all public-health advice for 2020. Americans got their lives back thanks to vaccinations. In the first months of mass vaccination, breakthrough infections were rare. Only about 10,000 people—or 0.01% of the 101 million U.S. adults who had been fully vaccinated—reported one by the end of April 2021, illustrating that post-vaccine infections were possible, but unlikely.

That changed when the more contagious Delta variant began spreading over the summer and sickening more people who’d had their shots. Now—though vaccinated people remain far more protected than those without their shots—the highly transmissible Omicron variant may force a complete rethinking of breakthrough infections.
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Rare is no more

Omicron remains elusive. The U.S. Centers for Disease Control and Prevention (CDC), however, has cautioned that Omicron may cause breakthrough infections. Initial studies show that COVID-19 vaccines are able to prevent Omicron-related symptoms, although they will still be effective in controlling severe illness and death. The variant also arrived at an inopportune time, when vaccine-related immunity was starting to wane for people who had gotten their shots early in the year and hadn’t yet been boosted.

New York City, one of the first places in the country to experience a significant Omicron spike, is recording an average of more than 7,000 cases per day, despite 71% of the city’s population being fully vaccinated and about 1.7 million people receiving boosters. As of Dec. 4, the case rate among fully vaccinated New Yorkers was 97 per 100,000 people—far lower than the 804 cases recorded per 100,000 unvaccinated people, but roughly double the rate observed among vaccinated people a month earlier.

“Even in quite vaccinated parts of the country, [we should expect to] break records in the numbers of new daily cases confirmed because of Omicron,” says Anna Bershteyn, an assistant professor of population health at the New York University Grossman School of Medicine.

COVID-19 vaccines weren’t built to stop all infections, but rather to stop those infections from turning severe or fatal. They’re still doing that job very well, which should relieve the 61% of Americans who are fully vaccinated—and particularly the 30% of that group who have received a booster. Studies have shown that booster shots significantly increase the levels of antibodies.

Although breakthrough infections are not a risk for millions of people vaccinated, they can still pose a threat to the U.S. overall. Nearly 40%, all children younger than 5, remain unvaccinated. There are millions of people who are immunocompromised or elderly that face a higher risk. Our health care systems have been stretched for nearly two years and additional burdens could be disastrous.

“We look at COVID as an individual disease that affects an individual person when infected,” says Nir Menachemi, a professor of health policy and management at the Indiana University School of Public Health. But “it’s also a disease that affects a population.”

A fragile health system can be protected

Now that the world has largely reopened and a new, highly contagious variant is here, avoiding COVID-19 completely is no longer a realistic long-term plan, says Dr. Megan Ranney, an emergency medicine physician and associate dean of Brown University’s School of Public Health.

“There is a high likelihood that most of us will catch COVID at some point,” Ranney says. “The goal of the vaccines is to delay that as long as possible, and then to make it so that, if and when we do catch COVID, it is as mild as possible.”

But that doesn’t mean we should abandon every precaution, Ranney says. For one thing, we’re still learning a lot about what Omicron can do. Omicron’s ability to treat breakthrough infections and Long COVID is still unknown.

The most urgent issue is, however, the stress on the healthcare system. This has been unsustainable for two years. “Our system has no slack right now,” Ranney says. “An extra 10 or 20 hospitalizations is having the same effect on the system as an extra 50 hospitalizations had a year ago.”

COVID-19 vaccines have such a high success rate that it is unlikely that any breakthrough infections will cause severe diseases. But Omicron is capable of causing such large spikes in cases that even a small percentage could translate to a relatively large number of people—potentially more than the system can handle, particularly on top of all the unvaccinated people likely to get sick.

Bershteyn’s projections show that hospitals in high-vaccinated parts of the country will be able handle the Omicron wave. Hospitals in lower-vaccinated locations may experience larger surges. She warns that hospital staffing can become problematic in any region if there are many medical professionals who get sick simultaneously. Due to the high rate of resignation and burnout, many hospitals are already operating with small staff. And that means care is in jeopardy across the board—not just for COVID-19 patients, but also for people who need to be treated for injuries, strokes, heart attacks and other emergencies.

You need to be more vigilant in order to avoid infection.

To get past the Omicron surge, all Americans need to once again aim to flatten the curve—this time, with the help of vaccines, boosters and rapid tests, as well as masks, physical distancing and ventilation. The policymakers have the ability to guide this process through the implementation of vaccine mandates and improved access to shots, as well setting standards for building ventilation. Ranney also says that it is necessary to rebuild the health care system by taping the U.S. Public Health Service Commissioned Corps, National Guard, as well as by rapidly training individuals to fill non-physician positions.

But there’s a long way to go. There are many factors that contribute to the overcrowding of hospitals. In some areas, there are also overwhelmed testing centers. At-home rapid tests can be expensive and difficult to obtain. “It’s the same problem we had back in March of 2020,” Ranney says. “If you can’t test people and tell them whether or not they have COVID, then you can’t tell folks who needs to stay home.”

People living in areas with high levels of the virus may have to resort to taking more severe precautions. Although the lockdowns in 2020 will not be reinstated, measures such as indoor masking or avoiding large crowds might still prove to be useful, at most, temporarily.

“We need to do what we can to flatten the curve,” says Dr. Rebecca Wurtz, an infectious disease physician and associate professor of health policy and management at the University of Minnesota School of Public Health. “I’m thinking it’s going to be 10 weeks, 12 weeks until we’re able to relax a little bit and move into a normalized response.”

Living with COVID-19

By a “normalized response,” Wurtz means that, eventually, COVID-19 breakthrough infections may be treated like “any other respiratory viral infection.”

A person with COVID-19 should isolate within 10 days of developing or testing positive for symptoms. However, recent research suggests that people who have been vaccinated may be able to clear the virus more quickly. Before too long, she says, we’ll probably scrap that policy and move toward a more familiar approach, in which people stay home while they’re symptomatic but don’t necessarily pause their entire lives for 10 days. Wurtz states that people might not need to be tested or treated if they have only mild symptoms.

Wurtz emphasizes that we’re not ready to abandon preventive tactics yet, given the number of people who remain vulnerable to the virus, the strain on our health care systems and the unanswered questions about Omicron, including its relationship to Long COVID and other serious outcomes.

How can we make COVID-19 a part of everyday life once we have gotten past the Omicron surge?

Menachemi says that policymakers need to focus long-term on solving many socioeconomic issues that enabled COVID-19’s success, such as insufficient access to healthcare and unsafe housing. The public also needs better communication about “why everyone’s effort contributes to us returning to normal” and clearer guidelines for when certain restrictions are or are not required, he says.

Menachemi states that as the COVID-19 threat to the entire population decreases, breakthrough infections will become less scary and more routine.

“We need to start preparing people for the understanding that they will probably, at some point, get COVID,” he says, “and if they’re vaccinated and up to date on their boosters, it’s probably not going to be a big deal.”


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