In science and mathematics, the Greek symbol delta represents change — or difference — and the delta variant of SARS-CoV-2 has certainly changed things for Americans and made a difference in hospitals across the county.
Just when we thought COVID-19 was transitioning from a life-altering pandemic to a fact-of-life endemic disease like influenza, the common cold and gastrointestinal viruses, hospitalizations and deaths due to COVID-19 are increasing. The average daily national COVID death count bottomed out at 189 on July 10, and now, only six weeks later, that average is more than four times higher. Daily hospital admissions nationally are up more than five times since that date to over 12,000 compared to a peak of 16,300 in January.
So, what’s different about delta?
While SARS-CoV-2 will become an endemic virus, mostly causing mild infections, we are not there yet. However, we will likely reach an endemic state sooner than later since the delta variant now accounts for about 99% of new infections in America, and because delta-infected patients are almost twice as infectious and shed 1,000-times more virus than people infected with the original strain.
Everyone will eventually be infected — just like with the cold-causing strains of coronavirus — and most Americans have decided whether or not that will be with the protection of a vaccine or without it — and it’s not too late to benefit from vaccine protection! The current surge in hospitalizations and deaths is clearly the result of naive immune systems infected with a new virus.
COVID patients in the ICU are overwhelmingly unvaccinated, and their doctors and nurses are burning out — even protesting — caring for conditions that they see as preventable, as multiple surveys around the country show that more than 90% of ICU patients with COVID are unvaccinated.
One study estimated that the hospitalization of 113,000 Americans in June and July would have been prevented by COVID-19 vaccinations, and this assumed that vaccines are 84% effective at preventing hospitalizations.
What does it mean that one vaccine is fully approved?
What difference will full FDA approval of the Pfizer vaccine make? Moving the Pfizer-BioNTech COVID-19 vaccine from Emergency Use Authorization status to full approval means that the FDA affirms that the vaccine meets its high standards for safety, efficacy and manufacturing quality. It’s taken 60 years since mRNA was first identified as an integral part of the human body to utilize its potential to prevent or treat a human disease. With full approval, will more people get vaccinated?
In May, a Kaiser Family Foundation survey revealed that 32% of unvaccinated adults said they would be more likely to get vaccinated once a vaccine is fully approved. If true, that means another 6 million adults will line up for vaccination, in addition to the 202 million Americans who have received at least one dose of a COVID vaccine.
If there are breakthrough infections, why get the vaccine?
Breakthrough cases refer to COVID-19 infections that take place in people who have received a full series of COVID-19 vaccination. As the percentage of vaccinated individuals increases, the percentage of COVID-19 cases in vaccinated individuals will naturally increase; this is true for all vaccine-preventable conditions. No vaccine is 100% effective. The purpose of the vaccine is to prevent serious disease such as hospitalizations, long term morbidity and death. We wouldn’t have a pandemic if COVID-19 was just a new virus causing the common cold — like several other coronaviruses.
Because of the increased infectiousness of delta, higher percentages of vaccinated individuals are testing positive. Even though vaccinated people can get infected, the outcomes for such people are far better. In a review of nationwide data in the United Kingdom, the Pfizer vaccine protected against any infection for 94% of those with alpha (identified in UK) compared to 88% with delta (identified in India). A year ago, experts thought 70% protection would have been a big win.
A recent analysis of patients in the Mayo Clinic Health System revealed an 81% reduction in hospitalization for Moderna vaccine recipients and 75% reduction for Pfizer recipients. Deaths were reduced 98% for Moderna Recipients and 100% for Pfizer recipients compared to unvaccinated hospitalized patients.
Data from the United Kingdom public health authorities demonstrated 92% protection from hospitalization for Delta variant infections in Moderna vaccine recipients compared to 96% for Pfizer recipients.
How safe are schools?
While tempers are flying around the country over the conversations regarding whether or not students should wear masks, friends have reminded me that we should assume that those on all sides of the debate have the good intention of doing what is best for our children’s health. It also is commonly recognized by teachers that holding class in person has a number of benefits compared to virtual school for those students who normally attend school, and most people believe the goal is to have our school children in school buildings instead of watching their teachers online.
The largest study with the best data, and reported by the Centers for Disease Control and Prevention, followed more than 90,000 Georgia students in kindergarten through fifth grade in November and December of 2020. Two interventions significantly reduced infections among students: teachers and staff required to wear masks (37% reduction) and increased airflow via open doors and windows, use of fans and/or HEPA filters (35% reduction).
When students were required to wear masks, there was a 21% reduction, but it did not quite reach statistical significance. About 60% of parents of K-12 students support wearing masks in schools now.
Regarding masks for students, the World Health Organization recommendations are less stringent than the CDC, which recommends them for all students over 2 years of age or older. WHO recommends no masks for children 5 and under. For those 12 and over, WHO says to follow local public health guidelines for adults. Masking for children 6 to 11 years old should be based on factors including intensity of local transmission and ability to distance. Countries following WHO recommendations in their schools did not have a higher frequency of cases among children than American schools.
One practical reason I have heard for wearing masks in school is that children will be sent home to isolate if they have any upper respiratory infection symptoms. Last year, all of our interventions — masking, distancing and hand hygiene — led to radical reductions in all respiratory illnesses, including a 99% reduction in influenza compared to the previous year. Practicing those same precautions will likely reduce the amount of time students will be required to isolate or quarantine at home. A concern many have, though, is what would be the end-point for such masking so that it does not become the “new normal.”
What should we do at Mass?
This is a great question. On July 27, the CDC updated their recommendations for individuals to wear masks indoors in areas of high transmission (currently, the vast majority of the country). The delta variant is so infectious that it is acting like an airborne disease such as chicken pox or measles instead of like a droplet-spread disease such as influenza or tuberculosis. Airborne disease particles may stay suspended for hours.
The CDC guidance did not reinstitute any social distancing recommendations after rescinding them in May. With delta acting more like an aerosolized infection, distancing is less likely to be effective. Shortening time indoors and improving ventilation will likely be more effective.
There is a combination of COVID fatigue among people and the unanswered question of how much a difference masks and distancing make. All U.S. citizens age 12 and over have had a chance to receive a vaccine and reduce their risk of serious infection and death. I have heard many ask, “How much more can we do, and what difference would it make?” There are no clear answers. Public health officials often lean on the “precautionary principle” that if something has the potential to help — and minimal to no downsides — then it is worth implementing.
During the pandemic, my colleagues and I have recommended following local public health guidance regarding gathering sizes, masks and distancing. As Sunday Mass is a weekly event for about an hour, there is less potential exposure there than for students who are at school five days a week for seven hours a day. With delta being so much more infectious, a potential 20% reduction in infection rate by wearing masks might be worth it.
Last summer, my colleagues at the Catholic Medical Association and I searched for evidence of outbreaks occurring at Mass when most parishes in the country required masks and distancing, and when the original COVID-19 virus was circulating. We did not find any such outbreaks, although we did find outbreaks associated with wedding and funeral receptions.
Should high-risk people attend Mass?
If the delta surge follows the course of the delta variant in other countries, cases could peak as soon as Sept. 1 and then drop drastically over the next few months. However long that takes, until the delta surge is over, it would be reasonable for those with one — and especially multiple — comorbidities to stay home (for health reasons) from crowded Masses. This might even be true for vaccinated people with significant comorbidities such as obesity, heart disease, lung disease, weakened immune systems and others. When community transmission is no longer high, returning to more crowded gatherings will become safer, and local public health recommendations will reflect that.
On Aug. 19, Pope Francis and six archbishops from the Americas released a video in which the pope gives sound advice for ending this pandemic in the face of highly infectious delta varian. He said: “Getting the vaccines that are authorized by the respective authorities is an act of love — for self, families, friends, all peoples. I pray to God that each one of us can make his or her own small gesture of love, no matter how small, love is always grand.”
Thomas W. McGovern, MD, practices Mohs surgery and facial reconstruction in Fort Wayne, Indiana. He worked for two years at the US Army Medical Research Institute of Infectious Disease before his dermatology training and serves on the national board of the Catholic Medical Association.