With new infections rising around the country due to the delta variant, reports of breakthrough cases among the fully vaccinated can be worrisome. Mario Tama/Getty Images
There have been a number of recent reports of fully-vaccinated people testing positive for the coronavirus — at the White House, Congress, the Olympics, and major league baseball. And with the fast-spreading delta variant driving up infections, hospitalizations and deaths, a lot of people are wondering whether the vaccines are as protective as we thought.
But the current crop of vaccine "breakthrough cases" don't surprise or alarm public health experts. "I haven't seen any signals in the U.S. indicating that they are occurring at the levels that would give us concern that the [vaccine] effectiveness is going down," says Saad Omer, director of Yale Institute for Global Health.
In all of these settings, from Capitol Hill to professional sports, nearly everyone is vaccinated, he points out, and people are subject to frequent, asymptomatic testing. "It is not surprising to see a substantial number of cases in the vaccinated when the vaccination rate is high," he explains.
Still, people who've been vaccinated may rightly be asking: Are breakthrough cases becoming more common because of the delta variant? Could I get sick or get a family member sick?
Here's what to know about breakthrough cases in the context of delta, and what scientists are doing to track the vaccines' efficacy.
You can get COVID even if you're vaccinated, but it's rare and likely to be mild
Bottom line: Don't panic. So far, research shows the current vaccines are holding up very well against the delta variant. For instance, a June study from the U.K. found that the Pfizer vaccine is 96% effective against hospitalization from the delta variant after two doses.
If you do get infected (which is not likely, but possible), the vaccine should help you keep from getting seriously sick. "Breakthrough infections, they tend to be mild — they tend to be more like a cold," says Dr. Carlos del Rio, professor of medicine and infectious disease epidemiology at Emory University.
"Those mild breakthroughs, according to a New England Journal study three weeks ago, are accompanied by lower viral loads and less — much less — symptoms," adds Dr. Monica Gandhi, infectious disease physician at UCSF. In particular, the study "showed that if you get a mild breakthrough with any variant, you have a 40% lower viral load in your nose after vaccination than you do if you had a natural infection," she says.
Severe cases among vaccinated people are possible, but extremely rare — the vaccines dramatically reduce the risk of serious illness that leads to hospitalization or death. And 97% of those currently hospitalized with COVID-19 are unvaccinated, according to CDC director Dr. Rochelle Walensky.
For context, as of July 12, out of 159 million fully vaccinated people, CDC documented a total of 5,492 cases of fully vaccinated people who were hospitalized or died from COVID-19, and 75% of them were over age 65. It's not clear how many of these breakthrough infections were caused by the delta variant, but that's now by far the dominant variant in circulation.
The chances of getting seriously ill after being vaccinated are higher for those with certain health conditions that affect the immune system. Dr. Marc Boom, president and CEO of Houston Methodist says that at his hospital, 90% of the patients with COVID-19 are unvaccinated. The small percentage of vaccinated patients who do end up hospitalized, he says, "have underlying significant health risks — like cancer, like [organ] transplants — that probably prevented them from mounting a full immune response to the vaccine."
Some argue asymptomatic breakthrough cases shouldn't even count
"I think we are misusing the term breakthrough," says Dr. Paul Offit, director of the Vaccine Education Center at Children's Hospital of Philadelphia. "If someone who is fully vaccinated is subsequently hospitalized or killed by the virus, that's a breakthrough case." He says he wouldn't call an "asymptomatic or relatively mild case" a "breakthrough case."
What matters, he says, is "the vaccine is still doing what it is designed to do — keep people out of the hospital and out of the morgue."
In fact, CDC doesn't even recommend routine testing of asymptomatic vaccinated people for coronavirus. As Gandhi of UCSF explains, positive tests might just be picking up "dead viral particles in your nose," she says. "Vaccinated people may get it in their nose, but they're going to kill it — that's actually what the immune system does."
CDC can't track all breakthroughs but it's using modeling to estimate the risk
There's no exact number of breakthrough cases, for several reasons. First of all, there would be no way to count the asymptomatic breakthrough cases, because the U.S. isn't testing nearly enough to catch them all. And in fact, CDC stopped keeping a running tally of mild breakthrough cases in May.
But that's not necessarily a problem, says Emily Martin, epidemiology professor at the University of Michigan. "You don't want to test everybody — you don't need every positive to be identified," she explains. "You just need to understand how the positives that you're finding represent the whole pie that you're not seeing."
The CDC runs carefully designed surveillance systems (which try to find pie slices that are representative) and does burden estimation (calculations you use to fill in the rest of the pie). It's a process that's already done every year with the flu, Martin explains, to assess how well the flu shot is working when the vast majority of people who get the flu are never tested.
Now, CDC is doing the same thing to monitor COVID-19. Hospitals and health departments are sending CDC detailed information about certain cases of vaccinated patients who are hospitalized with COVID-19.
"We'd like to have a sample of the virus so that we can understand the viral load, so that we can sequence it, we can understand their symptoms and their risks that potentially put them in that situation," CDC director Walensky told a senate panel on Tuesday.
At the same time, the agency is doing ongoing vaccine effectiveness studies, at long term care facilities, academic medical centers, hospitals, and among health care and essential workers. "We're doing many of those studies across the nation," Walensky said and explained that these allow CDC to get an accurate picture of the real rate of breakthroughs among vaccinated people, and whether that's changing over time.
"That is a more systematic way of measuring breakthrough cases," explains Martin. Realistically, health officials can't count every case, so this careful, long-term surveillance, along with calculations to extrapolate those findings, gives a fuller picture of how much virus is really out in the community.
The number of breakthrough cases is growing and that's expected
There's basic arithmetic at play: as more people get vaccinated, even if breakthroughs are rare, a rising number of cases will be among the vaccinated.
"Even with a 95% efficacious vaccine, you will have 1 in 20 vaccinees who are exposed get the disease," explains Dr. Kathleen Neuzil, director of the Center for Vaccine Development and Global Health at the University of Maryland. The important thing to note is that "the overwhelming number [of cases] are among the unvaccinated," she says.
Certainly, with the delta variant taking over — which spreads about two to three times faster than the original strain — there will be more cases among everyone, vaccinated and unvaccinated, says John Moore, professor of microbiology and immunology Weill Cornell Medicine.
"But, its ability to infect fully vaccinated people is much less than those who are not vaccinated," he explains. "In other words, the vaccines still work, just a bit less well."
Epidemiologist Emily Martin adds that there's no clear data yet to show that delta is to blame for a big rise in breakthrough cases in the U.S. "We are still watching carefully, though!" she adds.
It's not known yet whether you can spread the coronavirus if you get a breakthrough infection
In general, people who are vaccinated and get infected have less virus. "That lower viral load makes it less likely for you to transmit — not impossible by any means, but less likely," says Gandhi.
Dr. Anthony Fauci, chief medical adviser on COVID-19 for President Biden and the nation's top infectious disease expert, told reporters Friday that research on "whether or not the transmission occurs is a large study that's ongoing right now," referring to Prevent COVID U, a study of transmission among about 12,000 college students vaccinated with the Moderna vaccine.
While there aren't yet results from that study, Fauci added, the lower viral load in breakthrough cases suggests "it would be less likely that that vaccinated breakthrough person would transmit, compared to an unvaccinated person."
Even so, with cases rising and the vaccination campaign in a slump, a growing chorus of health experts are recommending using masking and other mitigation strategies to prevent spread, just in case. "I think that the prudent thing at this point in time — and what I'm doing personally," says del Rio of Emory. "If I'm going to a place that it's crowded where there are multiple individuals, including people who are likely not vaccinated, I am wearing a mask."
Vaccines likely lessen the chance of getting long COVID
"We have not seen reports yet of breakthrough cases causing long COVID, thank goodness,"
says Gandhi of UCSF. One reason for that, she says, could be that long COVID involves "a very dysregulated inflammatory response that you get with natural infection," she says. "What you get with an infection after you've been vaccinated, it's what we call a more regulated response or adaptive immunity," she explains.
However, virologist Angela Rasmussen of the Vaccine and Infectious Disease Organization at the University of Saskatchewan in Canada, notes the data on this are limited so we can't completely rule it out.
"The safest thing to do is to avoid being infected altogether, and that's why I think it is appropriate for people to employ additional mitigation measures" she says.
That might mean — in addition to vaccination — breaking out masks again, re-upping good hand hygiene, and getting more air circulating when gathering indoors. "The mitigation measures that we have put in place previously will still work against the delta variant — it's not being transmitted by some other route," she adds.
Allison Aubrey contributed reporting.
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