COVID-19 Variants Make Road to Normal a Bit Rocky

April 12, 2021
Kevin Kavanagh, MD

Infection preventionists (IPs) are now faced with delivering a difficult message. It is much easier to advocate for vaccinations which prevent disease, than it is for vaccinations which lessen the severity of disease or reduces your chances of becoming infected.

In the United States, life for some is rapidly returning to normal with states reopening and people of all walks of life being liberated with vaccinations. The vaccines have been a godsend, they have been reported to be highly effective in the prevention of illness, up to 95% in clinical trials and 90% in real world testing of front-line workers.

A recent study now affirms that the majority of those previously infected with COVID-19 have lasting antibodies for at least 6 months, possibly longer. Another study has found the vaccine to be 100% effective (although in medicine almost nothing is 100%) in preventing spread in teenagers. This is welcome news, since according to Anthony Fauci, MD, the director of the National Institute of Allergy and Infectious Diseases, teenagers can be a driver of COVID-19, especially when engaging in activities such as school team sports.

Thus, both natural and vaccine immunity appear to provide excellent protection against COVID-19. At least for the original strain or wild-type of the virus.

One must ask, why are some sounding the alarm? Fauci recently has stated that the COVID-19 case rate has creeped up from around 30,000 to 40,000 cases per day to 60,000 cases per day. And he warns we do not want to declare victory prematurely because of the viral variants.

Variants which are of special concern contain one of two new spike protein mutations which can evade immunity. These mutations are suspected to empower the virus with the ability to reinfect those with natural immunity. The first is the California variant’s mutation which is suspected to have caused reinfections in California and a resurgence of COVID-19. The second type of spike protein mutation is the E484K or “EeK” mutation. This mutation is found on the South African, Brazilian and New York variants.

Fauci recently testified that previous infection with the wild-type of virus provides “no protection” with the South African variant. In addition, the Brazilian variant has caused a huge surge in cases in the Amazon city of Manaus, Brazil, during a time that three quarters of the population was carrying COVID-19 antibodies from a previous infection. To make matters worse a double mutation variant has been found in India and now has been detected in San Francisco. This variant has the escape mutations of the California variant and another one which is very similar to the “EeK” mutation, the implications of this are not good. All of these variants appear to be more infectious and lethal than the original wild-type of coronavirus.

It is also becoming apparent that reinfections can occur in those who have been vaccinated. A recent report from Denmark studied PCR test results by matching individuals with positive tests that were at least 3 months apart. The study found that previous SARS-CoV-2 exposure protected against reinfection 80.5% of the time, but this dropped to 47% in those 65 and older. Severity of illness was not controlled for so a number of these individuals may have had a mild or asymptomatic infection with a blunted immunological response.

Post-vaccination infections can also occur. A recent report from Michigan illustrates that vaccination is not a free pass to return to normal. The Detroit News reported that the State Health Department has confirmed that 246 vaccinated residents have become reinfected and diagnosed with COVID-19. All patients developed a positive test 14 or more days after vaccination. Three of these patients have died and of the 117 where hospitalization status was known, 11 were hospitalized. However, it is also noted that post-vaccinated infections were more likely to be asymptomatic or mildly symptomatic compared to infections in unvaccinated individuals. In addition, these infections occurred in a state where over a third of the population, almost 3 million residents, have been vaccinated.

But what is worrisome, is that Michigan has gone through a very large surge which appears to equal that of the one they experienced over the holidays. In addition, the Brazilian variant has been recently detected in that state.

Post vaccination infections have also been observed with the South African variant. The Johnson & Johnson vaccine was field tested in South Africa with 6000 individuals where 95% of the cases were found to be due to the South African variant. The vaccine’s efficacy rate dropped to 64%.(11) An analysis by the United Kingdom’s Scientific Advisory Group on Emergencies (SAGE) concluded that previously infected or vaccinated individuals had a 10-fold decrease in effectiveness of antibodies to the South African variant. This “translates into a potential 30% drop in vaccine effectiveness.” However, this is still well above the 50% efficacy goal initially set for COVID-19 vaccine approval. However, post-vaccination infections can still occur.

Disturbingly, no one is tracking reinfections and there is an unknown numerator and denominator. Nor are we doing nearly enough viral sequencing to track the emergence or spread of variants. In this respect, we are flying blind.

Infection preventionists (IPs) are now faced with delivering a difficult message. It is much easier to advocate for vaccinations which prevent disease, than it is for vaccinations which lessen the severity of disease or reduces your chances of becoming infected; especially when advocating to individuals with all or none thinking. To many, reinfections mean the vaccine is not effective and, thus, they do not need to take it. Conversely too many have concluded, that if the vaccine is effective, then why do they still need to wear a mask?

The science behind this conundrum has found that vaccinations will profoundly decrease (by almost 95%) your chances of developing a symptomatic infection from the wild-type of virus. Even just one dose, of a two-dose vaccine, can reduce infections from the wild-type of virus by 80%. In addition, research has also shown vaccinations can blunt the illness of the South African variant which has the E484K escape mutation, greatly decreasing hospitalizations and deaths. The Moderna vaccine can boost antibody levels 6.5 to 9 times over that achieved by a natural COVID-19 infection. Theoretically this will provide enough protection to mitigate the disease caused by EeK (E484K) variants.

So, what do IPs tell patients and coworkers? I would suggest using a metaphor. If you do not get vaccinated, you are much more likely to develop COVID-19. Vaccination makes this less likely to happen, but it does not provide complete protection. Similar to driving, if you drink and drive you are more likely to be in a severe car accident, than if you follow public health advice and use a designated driver. But this does not mean that your designated driver cannot be in a car accident. Accidents can still occur.

And everyone needs to wear a mask and follow public health advice after vaccination. You can still become infected with variants and infect others; and even if you become less sick, you can still develop severe post COVID-19 sequela, such as long-haulers syndrome. Granted you are less likely to die, but this is a very low bar to measure success and health of a patient. Finally, even if you are asymptomatic with COVID-19, you need to remember that the more the virus spreads the more it will mutate, potentially into a variant which can totally evade the vaccines.

Vaccine boosters targeted against the E484K variants are being developed and tested by our pharmaceutical giants. Until then, our current vaccines will help slow the spread of this variant. The take-home message for patients is simple, continue following public health advice. If your football team is ahead in the final quarter, no one turns off the TV during the last 4 minutes of the game. Get a vaccine and continue wearing masks.