Why The Vaccines are a Home Run Despite the Yankees’ Outbreak

But why the way the Centers for Disease Control removed mask requirements wasn't.

On Thursday, the CDC abruptly declared that it was removing mask and distancing mandates for the fully vaccinated. On the one hand, I do agree that it’s been clear for a long time that the vaccinated are essentially back to baseline-risk (everyday risks), and CDC is also implicitly asserting that transmission risks can be considered to be vanishingly low. But the CDC’s announcement was sudden and not at all presaged. And in my view, it did not take the sociological aspects of guidelines into consideration, meaning that there are collective consequences to all this. Mandates are more about the risk to the least vulnerable.

I know we are all tired of criticism of decision-makers, but I do not understand the underlying theory of the CDC doing it this way.  So I wrote about this in the New York Times:

In the early days of the pandemic it made sense for everyone to wear a mask, not just the sick — as the C.D.C. and the World Health Organization were recommending — if only to relieve the stigma of illness. Now, as we head toward the endgame, we need to apply the same logic but in reverse: If the unvaccinated still need to wear masks indoors, everyone else needs to do so as well, until prevalence of the virus is more greatly reduced.

Just two weeks ago, we were being told the vaccinated should wear masks even outdoors in crowds. Now, the vaccinated are told there is no need for masks at all, anywhere. It’s not even that I disagree about the lack of risk to the vaccinated, but such dramatic, rapid shifts need explanation. 

Plus, why not tie the policy to pre-announced benchmarks, and give states and workplaces and people time to get ready? 

One argument seems to be that this new policy is an incentive for people to get vaccinated. I’m all for incentives, but I don’t see this announcement as helping to either get people to sign up for their shots or safeguard those people who are still at risk from the virus. We don’t have vaccine passports in this country, so essentially we just made it difficult for employees at private companies to wear masks, and the stubborn unvaccinated aren’t volunteering to mask-up. 

It sounds easy to declare that employees should just get vaccinated. But even that works best if there is a heads-up for it. Since writing my piece in the Times, I got a lot of messages from people who are somewhere in their vaccination process—even some people who started as early as they became eligible but are still not yet fully vaccinated. Plus, there are many people who want to get vaccinated as soon as possible but haven’t yet been able to-- Hispanic adults, especially those of working age, are particularly represented in this category. We haven’t yet resolved the problems around access, outreach, and people getting time off from work to get the shots. 

It would have been far better for the CDC to set a few benchmarks, give a bit of heads up to people, provide guidance for the immunocompromised— then make this announcement. I’d be very much in favor of this policy shift if the CDC had prepared for it that way. 

Finally, why not take advantage of a few more weeks of stronger exponential decay?

Another objection I’ve been hearing is that the risk to the vaccinated might be overlooked by this latest CDC shift. People have been pointing to breakthrough cases among the vaccinated, even without masks gone. That’s the part I’m not worried about, not even the latest high-profile one among the New York Yankees that a lot of people have been writing to me about. Here’s what happened:

Gleyber Torres, the Yankees’ two-time All-Star shortstop, became the eighth person involved with the Yankees organization to test positive for the coronavirus this week, the team announced on Thursday. But what has caught the attention of many outside of the baseball world is that Torres, three coaches and four support staff members had all been fully vaccinated.

So, yes, it does feel quite unusual for eight vaccinated people to test positive. That is almost certainly a cluster. Here’s what we know: it got detected after a coach, who had some mild symptoms but now no longer has any, tested positive. Then they found seven more people who tested positive, all of whom were completely asymptomatic. Here’s how the testing is done.

Everyone in the Yankees’ traveling party of 50 to 60 people is being tested three times a day using polymerase chain reaction, saliva and rapid tests. Thursday was the first day of no new positive test results since the outbreak began, Cashman said. “Maybe it’s slowing down,” he said.

For one thing, they should sequence these cases so we know if it was a variant or not, but the incident is still not a cause for worry. Here are some of the possibilities:

1-They are all positive because of a common source, likely a highly infectious individual. These people all got a bit of the virus, and the virus was able to replicate just enough to be picked up by PCR tests that are very sensitive and can pick up even very small amounts. They are testing people three times a day with PCR tests! They’ll pick up anything and everything, even the tiniest viral amount. The virus was obviously stopped in its tracks, so almost everyone is without symptoms. That sounds like a great outcome to me. 

A case of vaccine breakthrough is not the same thing as an unvaccinated or non-immune person catching COVID-19. Personally, if I had tested positive while unvaccinated, I’d be worried until it played out. Post-vaccination? For me, testing positive would be but a curiosity unworthy of my anxiety. There’s a reason that vaccine trials and real world data show so few severe cases, let alone hospitalizations or deaths. Post-vaccination, the virus would no no longer be able to surprise my immune system as a novel pathogen, and I’m not that worried whether it replicates just a bit in my nose before getting shut down.

The virus in the Yankees case might even have been a variant with some antibody evading features which gives the virus a bit more time to replicate (the mutations act like a disguise that slow down but don’t eliminate its eventual recognition) before the rest of the immune system shuts it down. None of the variants we have are in “disguises” (antibody evading mutations) that are 100% effective in hiding from the totality of the immune system, and it’s quite likely they never will get there. 

2-The Yankees all got vaccinated at the same place (they are on a team), and there might have been a mishap like a fridge error (i.e. they aren’t vaccinated). I think this is quite unlikely, but I’d check to be sure,  because this is a cluster. 

The virus may well evade the immune system enough to cause real problems in some people. a The two most likely groups to face this issue are the elderly and the immunocompromised. They are more vulnerable to many pathogens exactly because they have a less robust immune system, and this is one more such threat to them. 

And here's the final point. Always pay attention to the denominator:

Dylan Morris @dylanhmorris

The more people we vaccinate, a higher *percentage* of all new infections will be breakthrough infections (provided VE < 1, which it is). This doesn't mean the vaccine is failing. It means the denominator is changing.

Dylan Morris @dylanhmorris

So why does vaccinating more people lead to a higher percentage of new infections being breakthroughs? Basically, it's that a small percentage of a big group of people can still be quite a few people!

Dylan Morris @dylanhmorris

So if, say, 10 in 100 unvaccinated people get infected on a given day, we'd expect only about 1 in 100 vaccinated people to get infected.

Dylan Morris @dylanhmorris

So 1% of the vaccinated getting infected becomes a bigger and bigger number of actual people, and 10% of the unvaccinated getting infected becomes a smaller and smaller number of actual people. So the percentage of infections that are in the vaccinated goes up.

As the percent of vaccinated people go up, of course these “breakthrough” cases will increase, simply because we have an ever-increasing group to draw from. We need to stop reporting on every breakthrough case or even cluster as if it were newsworthy news, unless it is to celebrate how rare and inconsequential these incidents are.

If we start seeing severe cases go up, yes, we can start thinking about booster shots. But until then, the takeaway from this incident is that people were exposed to COVID-19 and we found a few cases where it replicated just enough to be picked up by our tests in a population we test a lot. Even then, the virus couldn't replicate enough to cause any symptoms in all but one person, and even there it was brief and transient., That outcome is exactly what we hope for from these amazing vaccines.