Med Journal Nov 2021 Final 2 | Page 4

Commentary by Manish Joshi MD , FCCP ; Thaddeus Bartter , MD , FCCP ; Anita Joshi , BDS , MPH

Delta Variant Surge and Covid-19 Surveillance Gaps - A Step Backward ?

When studying any matter , ask yourself two things : what are the facts and what is the truth that the facts bear out . Never let yourself be diverted by what you wish to believe , or what you think would have beneficent social effects if it were believed . Look only and solely at what are the facts .”

- Bertrand Arthur William Russell , logician and Nobel laureate on evidence and data analysis ( 1959 ).
As the delta variant surges in the U . S . and across the globe , we are at another crossroads with this pandemic . There may be more to come ; the pandemic is not over , and assiduous data collection would arm us to better prepare for the next variant or the next virus . We are dismayed by recent reversal by the Centers for Disease Control ( CDC ) on testing and surveillance recommendations for vaccinated individuals . 1 The decision not to collect data on breakthrough COVID-19 infections ( unless associated with hospital admission or death ) will leave gaps in our data base . Data is the lifeblood of scientific truth , and we believe that the CDC is going in the wrong direction with this change in policy .
Breakthrough infections are expected from every vaccine . Gathering data from breakthrough infections – in terms of incidence , transmission ( from vaccinated to vulnerable and vice versa ), variants , and hospitalizations – is paramount for public health efforts . To best understand infection and transmission , we need to look at several categories : those who are 1 ) previously infected and fully vaccinated , 2 ) previously infected and unvaccinated , 3 ) previously infected and partially vaccinated ( one dose of a two-dose regimen ), 4 ) fully vaccinated and never infected , 5 ) partially vaccinated and never infected and 6 ) neither infected nor vaccinated . Ignoring these categories generates misinformation . For example , data to date is highly suggestive that prior infection confers immunity equal to ( and perhaps better ) than that from full vaccination ; 2-6 the insertion of persons previously infected in the unvaccinated group will falsely lower the benefits from vaccination and , vice versa , including those individuals in the vaccinated group leads to overestimation of vaccine effectiveness .
We also need to further investigate and refine our understanding of individuals for whom vaccination is not effective . Per available last detailed data in May 2021 from the CDC , > 10,000 breakthrough infections ( two or more weeks after full vaccination ) have been reported in the U . S ., with a mortality of ~ 2 %. 7 The cumulative data from individual states , however , estimates that the number currently exceeds 100,000 breakthrough cases and over 1,000 deaths . The data raises important questions . 8 , 9 Can a lack of vaccine efficacy be documented by a lack of antibodies after vaccination ? What categories of patient – immune status , age , etc . – are associated with ineffective immunity leading to breakthroughs ? These questions directly impact patient care and advice .
Public messaging and scientific endeavor are entirely different . While messaging is a crucial aspect of the communication of scientific information to the public , messages need to be simple , consistent , and repetitive . In generating these messages , subtleties and some truths at times must be sidestepped . On the other hand , the scientific approach cannot be based upon a simplification of data collection . As noted above , ignoring prior infection in a study of COVID-19 can distort the data ( and do it variably , dependent upon the incidence of prior infection in a population ). Findings and data about vaccination should be “ pre-tested ” and “ post-tested ” with a rigor not evident in subsequent public messaging . Emergency approval of vaccines by the FDA was based upon pre-testing . Assiduous surveillance is now needed . A decision by the CDC not to track all breakthrough cases deprives us of foundational knowledge .
The CDC is uniquely qualified for the task of detailed data collection . As the delta variant currently surges in all 50 U . S . states , we hope the CDC will reverse this decision , as it impairs our capacity to understand , anticipate , and advise .
References
1 . Interim Public Health Recommendations for Fully Vaccinated People . https :// www . cdc . gov / coronavirus / 2019-ncov / vaccines / fully-vaccinated-guidance . html
2 . Vitale J , Mumoli N , Clerici P , et al . Assessment of SARS-CoV-2 Reinfection 1 Year After Primary Infection in a Population in Lombardy , Italy . JAMA Intern Med . Published online May 28 , 2021 . doi : 10.1001 / jamainternmed . 2021.2959
3 . Harvey RA , Rassen JA , Kabelac CA , et al . Association of SARS-CoV-2 Seropositive Antibody Test With Risk of Future Infection . JAMA Intern Med . 2021 ; 181 ( 5 ): 672 – 679 . doi : 10.1001 / jamainternmed . 2021.0366
4 . Turner , J . S ., Kim , W ., Kalaidina , E . et al . SARS-CoV-2 infection induces long-lived bone marrow plasma cells in humans . Nature 595 , 421 – 425 ( 2021 ).
5 . Gazit S , Shlezinger R , Perez G , et al . Comparing SARS- CoV-2 natural immunity to vaccine-induced immunity : reinfections versus breakthrough infections . MedRxiv 2021.08.24.21262415 ; doi : https :// doi . org / 10.1101 / 2021.08.24.21262415
6 . Shenai MB , Rahme R , Noorchashm H . Equivalency of Protection from Natural Immunity in COVID-19 Recovered Versus Fully Vaccinated Persons : A Systematic Review and Pooled Analysis . MedRxiv 2021.09.12.21263461 ; doi : https :// doi . org / 10.1101 / 2021.09.12.21263461
7 . COVID-19 Vaccine Breakthrough Infections Reported to CDC — United States , January 1 – April 30 , 2021 . https :// www . cdc . gov / mmwr / volumes / 70 / wr / mm7021e3 . htm
8 . https :// www . rockefellerfoundation . org / blog / the-us-can-lead-the-way-in-vaccine-breakthrough-reporting-will-it-squander-this-opportunity /
9 . https :// www . nbcnews . com / health / health-news / breakthrough-covid-cases-least-125-000-fully-vaccinated-americans-have-n1275500
The Journal of the Arkansas Medical Society encourages commentary from all members . The commentary content does not necessarily reflect the views or opinions of the staff or officers of the membership in general .
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