Time for a Ring/Surge Vaccination Campaign

On Variants and Vaccines

There have been a lot of questions about the variants, vaccines and the surge that’s increasingly apparent in multiple cities and states—New Jersey, Michigan, Philadelphia among others. It’s a difficult, complicated time. 

So I wrote a piece about it all for The Atlantic, which allowed me to also clarify a few more things on my mind, including touching upon some of the questions that came up in the weekly open-thread last Sunday. 

It all feels like an inflection point, with good news and advances as well as inequities variants dominating the trajectory.

First, the vaccine news is getting better everyday. Just yesterday, the CDC released findings showing that vaccinated people are not even getting infected to a large degree (we already knew that they were completely spared death and hospitalizations, and also spared from most symptomatic disease), which adds to similar findings from multiple countries.

It’s pretty clear that large numbers of people in the U.S. already are, or will soon be, protected from COVID-19’s more severe outcomes, such as death and hospitalization, which the vaccines reduce so close to zero that clinical trials have reported hardly any such cases. And it gets better: Yesterday, the CDC released real-life data showing that, just two weeks after even a single dose, the two mRNA vaccines were 80 percent effective in preventing infection. The effectiveness rose to 90 percent after the second, booster dose. People in the study were routinely tested regardless of whether they had symptoms, so we know that vaccines prevented not just symptomatic illness—the vaccine-efficacy rate reported in the trials—but any infection. People who are not infected by a virus cannot transmit it at all, and even people who have a breakthrough case despite vaccination have been shown to have lower viral loads compared with unvaccinated people, and so are likely much less contagious.

Second, B.1.1.7—the so-called UK variant—is bad news. Really bad news. I know the collapse of the hospital system is leading to terrible outcomes, and Brazil has its own troublesome variant. And there has been a lot of back-and-forth about the South African one which showed “immune evasion” to vaccines resulting in more mild/moderate disease even among the vaccinated. But as noted in earlier pieces for this newsletter, such “immune evasion,” or lowering of neutralizing antibodies, does not necessarily indicate that our vaccines are ineffective against severe disease, hospitalization or death, which is fought off by a different kind of immunity (And the surge in South Africa went up and down without even vaccines). It looks like Brazil’s complete lack of national mitigation strategy and lack of vaccines is leading to the collapse of the hospital system—a dire tragedy. 

Compared with previous surges, case-for-unvaccinated-case, this surge has the potential to cause more illness and more deaths, infecting fewer but doing more damage among them. We can also expect to see more younger, unvaccinated people falling sick and dying. We’ve observed this in other places, including the U.K. and Israel, which started vaccinating the elderly after B.1.1.7 had already taken hold and then had many younger victims. This variant is also very hard to dislodge; the U.K., for example, was able avoid more catastrophic outcomes by delaying booster doses to cover more people initially, but still battled lengthy surges, as did Israel. Even with the U.K.’s ongoing vaccination campaign, which started in early December, almost 50,000 people in the country died from COVID-19 in just January and February this year, equal to nearly two-thirds of the total for all of 2020.

Third, I think the discussion around herd immunity has been less than stellar, and overly-binary.   We’re really underestimating how its politics will now be complicated by the stellar efficacy of the vaccines themselves.

Herd immunity is sometimes treated as a binary threshold: We’re all safe once we cross it, and all unsafe before that. In reality, herd immunity isn’t a switch that provides individual protection, just a dynamic that makes it hard for epidemics to sustain themselves in a population over the long term. Even if 75 percent of the country has some level of immunity because of vaccination or past infection, the remaining 25 percent remains just as susceptible, individually, to getting infected. And while herd levels of immunity will eventually significantly drive down the number of infections, this may not happen without the epidemic greatly “overshooting”—infecting people beyond the levels required for achieving herd immunity, somewhat like a fire burning at full force even though it is just about to run out of fuel.

Fourth, a little less spoken but no less real challenge—again something we discussed in previous posts of this newsletter—is playing out right in front of our eyes. If our vaccines were less stellar, perhaps more people would continue to be concerned about the ongoing pandemic post-vaccination. Right now, for many people, it may well appear as a purely moral question since, once vaccinated, they may, not without justification, feel fairly protected from all severe outcomes, if not almost all disease, and also essentially are much much less likely to transmit even in the unlikely case they have an asymptomatic infection. What will move us nationally and also globally to make sure we do not leave billions of people behind?

Finally, the Atlantic piece has a practical component. A ring surge vaccination! Yes, I made up the term, but the concept is well-established in public health. 

The solution is obvious and doable: We should immediately match variant surges with vaccination surges that target the most vulnerable by going where they are, in the cities and states experiencing active outbreaks—an effort modeled on a public-health tool called “ring vaccination.” Ring vaccination involves vaccinating contacts and potential contacts of cases, essentially smothering the outbreak by surrounding it with immunity. We should do this, but on a surge scale, essentially ring-vaccinating whole cities and even states.

A vaccination surge means setting up vaccination tents in vulnerable, undervaccinated neighborhoods—street by street if necessary—and having mobile vaccination crews knock on doors wherever possible. It means directing supply to places where variants are surging, even if that means fewer vaccine doses for now in places with outbreaks under control. It doesn’t make sense to vaccinate 25-year-olds in places with very low levels of circulation before seniors and frontline workers in places where there is an outbreak.

Another sensible step would be to delay opening up—especially places with surges and especially for high-risk activities that take place indoors—until the next 100 million Americans are vaccinated, which could be done as quickly as in a single month. It makes no sense to rush to open everything now, when waiting a few weeks could protect so many. In the meantime, we need to protect frontline and essential workers by providing high-filtration masks and paid sick leave while targeting their workplaces with vaccination campaigns. We have already asked so much of them, and they have already suffered so much.

I understand the impatience with restrictions—I’m fed up and tired, too—but our restlessness risks creating one last set of victims who could easily be spared. We should not condemn anyone to be the last person to die unnecessarily in a war that we will win, and shortly. The vaccinated can clearly do more, and safely, especially two weeks after their final dose. But it’s a particularly perilous time for the unvaccinated, who deserve our attention, resources, and continued mitigation measures as appropriate.

For more details, here’s the whole thing (it should not be paywalled, since it is part of the Atlantic’s pandemic coverage) and as usual, I welcome comments, questions and feedback. How does it look where you are? The United States may well be a “best case” scenario—amidst past tragedy—and may be a harbinger of a near future in which the vaccinated celebrate and get back to life (which I do not begrudge anyone!) while the unvaccinated continue to suffer, a fate increasingly confined to those without wealth or power. That’s what happened after the HIV pandemic, and we should do everything to avoid repeating that moral failure.