{"id":10173,"date":"2021-08-02T09:57:41","date_gmt":"2021-08-02T13:57:41","guid":{"rendered":"https:\/\/blogs.nejm.org\/hiv-id-observations\/?p=10173"},"modified":"2021-08-02T15:00:27","modified_gmt":"2021-08-02T19:00:27","slug":"provincetown-july-celebration-a-challenging-stress-test-for-the-covid-19-vaccines","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/provincetown-july-celebration-a-challenging-stress-test-for-the-covid-19-vaccines\/2021\/08\/02\/","title":{"rendered":"Provincetown July Celebration a Challenging Stress Test for the COVID-19 Vaccines"},"content":{"rendered":"<p>When the complete history of the COVID-19 pandemic is eventually written &#8212; and boy oh boy, can&#8217;t wait for <em>that<\/em> &#8212; certain events will feature prominently as sites of notable outbreaks.<\/p>\n<p><a href=\"https:\/\/www.webmd.com\/lung\/news\/20200729\/gene-study-shows-how-coronavirus-swept-through-the-idiamond-princessi#1\" target=\"_blank\" rel=\"noopener\">The Diamond Princess cruise ship<\/a><\/p>\n<p><a href=\"https:\/\/www.statnews.com\/2020\/03\/11\/how-biogen-leadership-conference-in-boston-spread-coronavirus\/\" target=\"_blank\" rel=\"noopener\">The Biogen Leadership conference<\/a><\/p>\n<p><a href=\"https:\/\/www.cdc.gov\/mmwr\/volumes\/69\/wr\/mm6919e6.htm\" target=\"_blank\" rel=\"noopener\">The Skagit Valley Chorale practice<\/a><\/p>\n<p><a href=\"https:\/\/www.cdc.gov\/mmwr\/volumes\/69\/wr\/mm6947e1.htm\" target=\"_blank\" rel=\"noopener\">The Sturgis motorcycle rally<\/a><\/p>\n<p><a href=\"https:\/\/www.vox.com\/coronavirus-covid19\/21499923\/trump-coronavirus-white-house-covid-superspreading-pandemic-amy-coney-barrett\">The Amy Coney Barrett White House reception<\/a><\/p>\n<p>And now:<\/p>\n<p><a href=\"https:\/\/www.cdc.gov\/mmwr\/volumes\/70\/wr\/mm7031e2.htm\" target=\"_blank\" rel=\"noopener\">The Provincetown Independence Week celebration<\/a><\/p>\n<p>So what sets the last one apart from the others? And why did it lead to a change in CDC guidance about <a href=\"https:\/\/www.cdc.gov\/coronavirus\/2019-ncov\/vaccines\/fully-vaccinated.html\" target=\"_blank\" rel=\"noopener\">masking indoors for vaccinated people<\/a>?<\/p>\n<p>The answer to question #1 is, of course, that the other events occurred before we had effective vaccines and the highly transmissible Delta variant.<\/p>\n<p>But what about question #2? Why the reversal on masking indoors for people who have been vaccinated?<\/p>\n<p>In addition to the sheer number of cases that occurred in vaccinated people, here&#8217;s the primary reason, in graphic form from <em>MMWR<\/em>:<img loading=\"lazy\" decoding=\"async\" class=\"aligncenter wp-image-10174\" src=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2021\/07\/Screen-Shot-2021-07-31-at-7.44.10-AM.png\" alt=\"\" width=\"367\" height=\"504\" srcset=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2021\/07\/Screen-Shot-2021-07-31-at-7.44.10-AM.png 526w, https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2021\/07\/Screen-Shot-2021-07-31-at-7.44.10-AM-219x300.png 219w\" sizes=\"auto, (max-width: 367px) 100vw, 367px\" \/><\/p>\n<p>The vertical axis is the cycle threshold value, a measure of how much virus is in the sample (lower is more virus). And as is plainly evident, these results are similar for vaccinated and unvaccinated people.<\/p>\n<p>These <em>suggest<\/em> that vaccinated people with COVID-19 could spread the virus to others as easily as unvaccinated people. It&#8217;s not proof, as it discounts the immune response, which may dampen contagious virus and shorten the duration of viral shedding.<\/p>\n<p>It&#8217;s also in contrast with other studies that do show lower viral burdens over time in people who have been vaccinated &#8212; including this highly relevant recent study from Singapore:<\/p>\n<blockquote class=\"twitter-tweet\" data-width=\"500\" data-dnt=\"true\">\n<p lang=\"en\" dir=\"ltr\">A recent study out of Singapore shows not only does vaccination prevent you from getting sick with Delta (B.1.617.2), but it is associated with faster decline in viral RNA load. What does this mean? Vaccines make you LESS infectious!<\/p>\n<p>&mdash; Chise (@sailorrooscout) <a href=\"https:\/\/twitter.com\/sailorrooscout\/status\/1421499506311548931?ref_src=twsrc%5Etfw\">July 31, 2021<\/a><\/p><\/blockquote>\n<p><script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script><\/p>\n<p>Regardless, it underscores the plain fact that anyone with symptoms consistent with COVID-19 needs to isolate until recovery, vaccination status notwithstanding. For those diagnosed, we may even need to institute different isolation protocols, since the higher viral loads seen with Delta could mean more transmissions further out from onset of symptoms.<\/p>\n<p>Already, the CDC has recommended that vaccinated people exposed to COVID-19 should get tested afterward, a return to pre-vaccine guidance. Should we also recommend antigen testing in breakthrough cases before return to work? (PCR may continue to detect non-viable viral fragments long beyond the contagious phase.)<\/p>\n<p>What the outbreak <em>can&#8217;t<\/em> tell us is how bad this would have been without vaccines at all. Yes, there were lots of cases, but so far relatively few hospitalizations, and no deaths. Yikes, the mind boggles.<\/p>\n<p>Because if anyone is under the impression that Provincetown is the kind of sleepy Cape Cod small town made famous through <a href=\"https:\/\/www.google.com\/search?q=edward+hopper+cape+cod+images&amp;sxsrf=ALeKk03-8SNscs0W7x0dQ3_iy_tkyk1sew:1627912482030&amp;source=lnms&amp;tbm=isch&amp;sa=X&amp;ved=2ahUKEwjqut3JvpLyAhUwTt8KHQfNDz4Q_AUoAXoECAEQAw&amp;biw=1851&amp;bih=946\" target=\"_blank\" rel=\"noopener\">Edward Hopper&#8217;s dreamy artwork<\/a>, think again &#8212; this July celebration is the diametric opposite. All who attended reported <a href=\"https:\/\/www.nytimes.com\/2021\/07\/31\/us\/covid-outbreak-provincetown-cape-cod.html?action=click&amp;module=Top%20Stories&amp;pgtype=Homepage\" target=\"_blank\" rel=\"noopener\">plenty of crowded bars, restaurants, and dance parties<\/a>, with many shared accommodations among travelers.<\/p>\n<p>You could hardly imagine a better environment for SARS-CoV-2 transmission. These settings plus the Delta variant provided the ultimate stress test for the vaccines.<\/p>\n<p>What the outbreak also can&#8217;t tell us is how commonly <em>asymptomatic<\/em> people who are vaccinated acquire SARS-CoV-2 and then transmit it onward. This question has been filling up the email inboxes of every ID specialist out there.<\/p>\n<p>I <em>suspect<\/em> it&#8217;s uncommon. But let&#8217;s not be overconfident about anything related to this tricky virus, which has bedeviled us with unpredictable twists and turns from the start. Humility!<\/p>\n<blockquote class=\"twitter-tweet\" data-width=\"500\" data-dnt=\"true\">\n<p lang=\"en\" dir=\"ltr\">This is quite the figure, from a <a href=\"https:\/\/twitter.com\/CDCgov?ref_src=twsrc%5Etfw\">@CDCgov<\/a> presentation. <\/p>\n<p>Further evidence of the critical role of humility when it comes to predicting what&#39;s next in this pandemic, a lesson we all need to learn again and again. <\/p>\n<p>H\/T <a href=\"https:\/\/twitter.com\/washingtonpost?ref_src=twsrc%5Etfw\">@washingtonpost<\/a>  <a href=\"https:\/\/t.co\/1LnqGojF3V\">https:\/\/t.co\/1LnqGojF3V<\/a> <a href=\"https:\/\/t.co\/IlymSsJOOX\">pic.twitter.com\/IlymSsJOOX<\/a><\/p>\n<p>&mdash; Paul Sax (@PaulSaxMD) <a href=\"https:\/\/twitter.com\/PaulSaxMD\/status\/1420923285869563905?ref_src=twsrc%5Etfw\">July 30, 2021<\/a><\/p><\/blockquote>\n<p><script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script><\/p>\n<p>Yes, that&#8217;s a scary figure. What to do in the meantime as Delta is surging?<\/p>\n<p><em>Get as many eligible people vaccinated as possible.\u00a0<\/em>Remember, the vaccines reduce transmission risk in two ways:<\/p>\n<ol>\n<li>Decreasing the probability of infection in the first place, either symptomatic or asymptomatic<\/li>\n<li>Decreasing the duration of infectiousness for those who do get infected<\/li>\n<\/ol>\n<p>That first effect is ironclad &#8212; no virus, no transmission. The second one is a bonus. The evidence is strong that both of these are in play with COVID-19 vaccines, as summarized in <a href=\"https:\/\/academic.oup.com\/ofid\/advance-article\/doi\/10.1093\/ofid\/ofab259\/6278371?searchresult=1\" target=\"_blank\" rel=\"noopener\">this superb review<\/a>.<\/p>\n<p>So approve the vaccines already, FDA! This will allow broader implementation of vaccine mandates in schools and workplaces.<\/p>\n<p>Plus, when possible, we should limit socializing indoors to gatherings with other vaccinated people. Since not everyone can be vaccinated &#8212; kids under 12, for example &#8212; if you&#8217;re planning a large indoor event, go ahead and ask people to get tested ahead of time. We might ask even if everyone is vaccinated, especially if the event has immunocompromised guests. Good tests are widely available over the counter that can give results back in 15 minutes. Let&#8217;s use them!<\/p>\n<p>And whatever is causing COVID-19 case numbers to decline rapidly in the United Kingdom and India, here&#8217;s hoping it happens here as well.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>When the complete history of the COVID-19 pandemic is eventually written &#8212; and boy oh boy, can&#8217;t wait for that &#8212; certain events will feature prominently as sites of notable outbreaks. The Diamond Princess cruise ship The Biogen Leadership conference The Skagit Valley Chorale practice The Sturgis motorcycle rally The Amy Coney Barrett White House [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,5,8,9],"tags":[4601,5374],"class_list":["post-10173","post","type-post","status-publish","format-standard","hentry","category-health-care","category-infectious-diseases","category-patient-care","category-policy","tag-covid-19","tag-rapid-home-covid-testing"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/10173","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=10173"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/10173\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=10173"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=10173"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=10173"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}