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COVID-19 Update 7/21: Delta Variant, Breakthrough Infections, J&J, and More

July 21st, 2021 | 9 min. read

By Steve E. Bishop, M.D.

COVID-19 Update 7/21: Delta Variant, Breakthrough Infections, J&J, and More

On this COVID-19 update, Dr. Steven Bishop discusses what's going on with the delta variant and increasing cases; breakthrough infections; Johnson & Johnson vs. Pfizer/Moderna; and more. Watch the video below and read on for a recap. 

Delta Variant and Increasing Numbers

So first topic, what's going on with numbers? And does this make sense? Is it surprising? Is it concerning?

It's a little bit of all of those things and a little bit expected. Let's break that down just a smidge. Over the last couple of weeks, the number of COVID cases has started to creep up nationwide. We're nowhere near the numbers that we were seeing back in, say the fall and the winter, but the numbers are increasing.

Now, what's good news is that that is not currently being matched by a commensurate increase in hospitalizations or commensurate increase in fatalities. There is an increase in hospitalizations, but it's not as high as the increase in case numbers. And the fatality rate has stayed very low.

I think what you're seeing there is a couple of different things. I went back and looked at some of the numbers from last summer, and I think what you're seeing is kind of what we talked about many months ago.

As people get vaccinated slowly, which, you know, the vaccine roll-out has been slow and we've kind of stalled out around 50% of the population, a little less in some areas, you're going to continue to see small waves of viral infection. This is how viruses work. This is the natural history of them. We're going to continue to see these small waves.

As more and more people get vaccinated, hopefully the waves become lower and lower amplitude, meaning, if you think of it like a sound wave, right, amplitude is tied to the height. Hopefully over time as you have each of these waves, the amplitude gets smaller.

If you go back and look at the wave that we had in July or August of last year, which we did have a bump up in that time, and that's when a lot of the decisions were being made around schools and people, a lot of places decided not to reopen the schools, et cetera.

We were having a wave at that time, too. It was a lower amplitude wave than we had in the spring, but it was there. And I think we're the same phenomenon now because there's this wave/seasonality to the virus.

So we're seeing a little bit of an uptick now. And the amplitude of that wave does appear to be smaller than what we had last summer, but it's still there. And that's because, we only have half the adult population vaccinated. The number's going up, and I'm not totally shocked by that.

I am glad to see that the hospitalization rate and the fatality rate has stayed low. I think what you're seeing there is the fact that the vaccines, while very good, are not perfect.

Concern for Breakthrough Infections?

And this is going to get to a question that Andy Carpenter sent into us on another post, which is, he said, "Dr. Bishop, how concerning are the number of breakthrough infections?"

Breakthrough infections meaning people who are vaccinated getting sick with the virus. And we're hearing about this more and more.

"Are they at the level we expect given the number of fully vaccinated individuals in the greater prevalence of the virus, or do the numbers suggest that one or more of the vaccines may not be as effective against the Delta variant as we had thought?"

I think there's probably a couple of things going on there. I remember back to the data when it came out, the vaccines are only about 95-ish percent protective against infection. Meaning that still somewhere between 5% and 10% of people who get vaccinated are still going to be vulnerable to get sick.

They are close to 100% effective at preventing severe COVID, meaning COVID resulting in hospitalizations and fatalities. My guess is what's happening is the big surge in cases matched with the still-low hospitalization rate and the still-low fatality rate is why you're seeing breakthrough infections, because a certain percentage of people who are vaccinated are still going to get sick with the virus.

They're just not going to get very sick. They're going to be mildly ill, cold, minor flu, something like that, which is what the vaccine is really designed to do. I think the case numbers you're seeing are probably the Delta variant proliferating and hitting people, but they're still having good protection from the Pfizer and the Moderna, especially. We'll talk about J&J vaccine in a minute.

They're still having good protection in terms of they're not getting so sick they have to be in the hospital and they're not dying, but they are still getting ill. So you're seeing that wave.

And I think that the wave you're seeing is that 5% to 10% of people, of breakthrough infections, plus the group of population that hasn't been vaccinated at all.

My guess, and this is a hunch, is that the vast majority of the hospitalized patients are unvaccinated and those who are dying are probably mostly unvaccinated as well. You're going to have some bleed over on each side.

Some people who are hospitalized and have died, probably have been vaccinated and, for whatever reason, the vaccine did not take with them. No vaccine is perfect. And you're always going to have a small number of people where the vaccine just does not take, for whatever reason. I've had a few patients like that myself, where they've been vaccinated, we've checked them and they just don't have antibodies.

All vaccines work this way, that they all have some small number of people where the vaccine just doesn't take for whatever reason. So I'm not surprised by that, in general.

Johnson & Johnson Vaccine

The J&J vaccine, I'm getting a little concerned about it based on the data we're seeing. And an article came out this week, it was a small lab test study, showing that there's some concern that it may not be providing protective antibodies for the Delta variant for one reason or another.

Combined with that and some of the safety issues that have been cited with the J&J vaccine, I'm starting to lean more and more toward telling people, if you haven't been vaccinated yet, and you're looking for a vaccine, I would really prefer the Pfizer and the Moderna vaccine.

That's what I'm telling my patients to do. I know that one shot is convenient and great. And if that really works for you, that's fine, go ahead and do it. You're going to get some protection. Some protection is better than none.

But I think that that vaccine is not as good as the other two. I would take that into account if you're still trying to decide which one you're going to get. I would lean more toward one of the mRNA vaccines.

Now that does leave us with conundrum, which is, you say, "Okay, Dr. Bishop, I already got the J&J vaccine, and I'm worried because now the state is coming out saying, well, maybe I'm not protected or as protected as I thought I was. Should I get a second vaccine, like Pfizer or Moderna, on top of the J&J or just a second J&J booster?"

And the answer to that question is we don't know just yet. I think medically, probably, that's where we're going to be heading. I don't think there's enough data yet to definitively say get a second vaccine type because that hasn't been tested or evaluated. We're at a point again where we’ve sort of run out of science road.

There's no science to guide us here in terms of is it safe to get a Pfizer vaccine or a Moderna vaccine after the J&J. We don't know. Is it safe to get a second J&J dose? We don't know.

I think that the FDA and the CDC are really, and the, the industries of the Pfizer and Moderna and J&J are going to have to really put some studies together here pretty quickly and get us some data on these questions, because I think we're going to have to figure this out by the fall. Especially because the Delta variant is now making up about 83% of all new infections across the US. We're going to have to answer these questions here pretty quickly.

But that being said, in the meantime, while we wait for that information, you know, I think you're going to, if you're someone who wants to get a second vaccine from a second vaccine type, I think you're going to have a hard time getting that done just from a practical standpoint, because most places that are giving vaccine are not going to give you a second vaccine if you've already been vaccinated.

It goes against the FDA approval of the emergency authorization. It's not approved for people to get two different types of vaccine, and it's not contemplated in the CDC or health department guidance anywhere at this time.

What I'd say is stay tuned. Don't panic, but be smart, be safe. If you're someone who has only had the J&J vaccine and you are at high risk, continue to be safe in terms of your mitigation measures and keep your ear to the ground for more data over the next couple of months.

I think the pressure is building on FDA and CDC where they're going to have to give us an answer on this question here pretty quickly because of the numbers increasing. I think we will hear more on this by the end of the summer is my guess. 

Third Shot for Moderna and Pfizer?

"Do you see a third shot needed in the fall or winter for those that had two shots in the spring?"

At this time, I don't think so, because as far as I can tell for now, the Pfizer and the Moderna vaccines both are good in terms of Delta variant and the others that are out there. I think probably we won't need a booster of those at this time.

J&J vs. Moderna/Pfizer

"Every doc I saw on TV today regarding the J&J did not take a stand on which vaccine was best. I'm very surprised you took a stand with data not all in yet."

Yeah, you know, I wouldn't describe it as a strong stand. What I'd say is that that stand is based on the data that I have seen with some safety issues, safety questions. There've been questions for several months now about the overall efficacy of the J&J vaccine compared to Pfizer and Moderna. It's clearly lower. There's not really any question about that in the literature. It's clearly lower efficacy than the mRNA-based vaccines. And now we have questions about the Delta variant efficacy.

The reason that a lot of docs aren't going to take a strong stand on this is the same reason that I kind of muted my comment at the end, which is we don't want to discourage people from getting vaccinated, right? If people want to be vaccinated, we want them to get vaccinated.

And I want them to get whatever shot they're willing to get. So J&J is still better than no vaccine, right? If you're only willing to get one shot and do it one time, then please, by all means, get the J&J vaccine.

But if you're contemplating between the two types, then I think at this point, based on the data we do have, I think it's a very reasonable choice to prefer having one of the mRNA-based vaccines over the J&J. And that's just my medical opinion based on the data I've reviewed. So, you know, talk with your own doctor about it and review and make a decision that makes sense for you.

Length of Protection from Vaccines

"What does the data show so far about how long each vaccine seems to be effective? Is there one showing that has more longevity than the other?"

No, we do not know at this point. Latest data is at least six months. I suspect you're going to find that the immunity is fairly long-lived. And again, it depends on a little bit on these variant issues. So as long as the variants that show up, we keep testing them and making sure that the current vaccines work, then we should be good. And I think that the immunity will be long lasting as long as the virus doesn't change too much.

Concerns for this Fall

“Do you see any concern for kids in school or for travel, large events, et cetera in the fall and winter?”

Yeah, good question. My stance on the kids' issues has stayed pretty consistent, based on my review of the data that is coming out, which is kids continued to be at generally very low risk, not zero risk, of course, very low risk for getting COVID, for having severe COVID, and for being hospitalized or dying from COVID. Very low risk. Overall very, very low.

Of course, not zero. And it depends on if your child or the child has an underlying health condition, right? If we're talking about a child with cystic fibrosis or some other condition that is making them medically fragile or ill, then that's a different calculus, right? That child almost certainly probably needs to be vaccinated as soon as the vaccine is available to them.

Healthier children, you can take a little bit more of a cautious approach if that's appropriate from your perspective as a parent on the kids.

But the data that's come around with come out from schools with kids is that schools are generally not a source of transmission for the virus. And that the transmission that does occur in schools happens between the adults.

So between teachers, essentially, which is why I think it is imperative that any teacher that wants to get vaccinated that hopefully they've been able to do that at this point and get that protection that they need. I think that's good.

And in terms of travel and large events, I think same thing that the biggest risk is to the adults and the older you are, the higher risk you are.

If you're 30, 40, 50, and up, especially if you have a medical problem, I definitely think you should get vaccinated, especially if you're going to be out and about doing things. If you're not getting vaccinated, I would continue to avoid those crowded events, things like that.

Steve E. Bishop, M.D.

As a board-certified internist and concierge doctor in Richmond, VA, Dr. Steven Bishop is passionate about helping his patients improve their lives through better health. He helps healthy adults adjust their lifestyles as they age and helps patients with complex medical diseases manage and improve their health.