An Epidemiologist Answers Questions About The Delta Variant, Booster Shots And More
Dr. Melanie Wellington is an epidemiologist at the University of Iowa Hospitals and Clinics, an associate hospital epidemiologist and a pediatric infectious diseases specialist. Wellington joined River to River to discuss the precautions the public — vaccinated or not — ought to take and the remaining threat that COVID-19 poses in Iowa.
This transcript has been edited for length and clarity. You can listen to the full interview here.
Kieffer: “You were last on our program July 2. Now, approximately three weeks later, the delta variant is even more of a threat. I want to get your thoughts on where we find ourselves in this pandemic. According to The New York Times, tracking as of today, July 22, case numbers are climbing rapidly in the country, (though) well below peak levels. Hospitalizations, deaths are also increasing, but at a slower pace. New cases rising in all 50 states. We have this delta variant, infection level soaring in parts of the U.S. — Louisiana, Florida, Arkansas and our neighbor to the south, Missouri. If you look at those maps, it's really got some infection rates that are worrying. Vaccines widely available, have been for some time, effective against the delta variant, but we still have fewer than half Americans fully vaccinated. Let me quote briefly from The New York Times Thursday:
"'Eighteen months after the coronavirus first emerged, governments in Asia, Europe and the Americas are encouraging people to return to their daily rhythms and transition to a new normal in which subways, offices, restaurants and airports are once again full. Increasingly, the mantra is the same: We have to learn to live with the virus. Yet scientists warn that the pandemic exit strategies may be premature.'
Do you agree with that, Dr. Wellington?”
Wellington: “Well, that's a tough question. It is definitely premature to say the outbreak is over. I think we can all agree on that. And I do want to point out that it is the delta variant that we're seeing, it's associated with this infection rise right now, but it's not just rising because of the delta variant. Infection rates are rising because people who are not vaccinated are getting exposed through behaviors that are causing increased exposures. So we need to keep our wits about us. We do need to keep our caution in hand. And ‘do we need to open up? Or not open up? Or something in between?’ becomes, really, a local decision.
"It's not just rising because of the delta variant. Infection rates are rising because people who are not vaccinated are getting exposed through behaviors that are causing increased exposures."
“What we all need to keep in mind, though, is the outbreak is not over, and it is a community issue. It’s one thing to say 'I'm not at risk,' but everybody is at risk, and everybody has someone they care about who's at increased risk. So we need to act as a community to keep our caution, keep our safety measures going, and make sure that anyone who can be vaccinated gets vaccinated, because that's really how we're going to keep cases down.”
Kieffer: “Right. What do you make of the fact that even more local Republican leaders are pleading with their supporters to get vaccinated? We know that you can look at a map of the U.S., of Iowa counties that most supported former President Trump in the last election, are the ones that are struggling with vaccination rates...unusual as it is for epidemiology, the spread of the disease to be tied up with politics. There you have it. Right?”
Wellington: “Right. I think that it's great that anybody who is a leader and who can be part of a community and lead them towards increased vaccination rates should work as hard as they can, because we really need that right now. You're absolutely right that there are some trends and politics has been tied up in this pandemic, but we can be better than that. And I think that's what's happening now. And we're all realizing the biology of the vaccine doesn't care about politics at all. We all need to be working towards getting rid of this thing.”
Kieffer: “Right. And the one fact that should convince the unvaccinated to get vaccinated, I have to believe, correct me if I'm wrong, but almost all hospitalizations and deaths from COVID currently are among the unvaccinated?”
Wellington: “I think the exact number depends on individual hospitals and which patients have which risk factors. But it's absolutely true that you could say almost all of the people who have severe disease, who are being hospitalized or who are dying from COVID are unvaccinated. Every now and then someone who was vaccinated isn't able to make as strong of a response and they can be vulnerable to severe disease. But that's very, very unusual.”
Kieffer: “What is the picture for the community you serve there at the University of Iowa hospitals and clinics in Iowa City?”
"The people who are not vaccinated are having a surge in disease, and the behaviors of everybody, as we loosen up our restrictions, are causing a surge in children as well.”
Wellington: “Well, I'm a pediatrician at heart and by training. And I think it's important also as we start thinking through the issues here, we need to remember: there is an entire large chunk of our population who cannot yet be vaccinated. If I'm reading the population statistics right, somewhere between 20 and 25 percent of Iowans are children. And of those children, only children 12 and older can be vaccinated. So all of the kids out there, zero to 11, can't be vaccinated yet at all. And so the situation that we're looking at right now is, at least in our very, very local area, we have reasonably high vaccination rates, but not everybody is vaccinated. And so what we're seeing is the same thing everybody else is seeing. The people who are not vaccinated are having a surge in disease, and the behaviors of everybody, as we loosen up our restrictions, are causing a surge in children as well.”
Kieffer: “OK, let's go to our phones. Elizabeth is calling from Urbandale. Welcome to the program, Elizabeth.”
Elizabeth from Urbandale: “Yes, thank you. We are about to host a family reunion. Families coming from Virginia and from Texas, they are flying, so there's airports. We have a couple of elderly people in the family and one unvaccinated three-year-old. What's the protocol for us all getting together and being safe?”
Kieffer: “I'm sure your story is repeated in different variations all around the state, and the country. Dr. Wellington, what do you have to recommend?”
"It's not time to give up the masks yet. I know we all wish we could, but this is really our second best strategy for protecting each other."
Wellington: “Absolutely, Elizabeth. I actually get this question from our doctors that work here next to me all the time. You're spot on about this being a key point. And before we go into sort of the protocol of how to protect yourself, I want to emphasize with everyone, there is risk in everything we do, and there's benefit in everything we do. And even in the middle of a pandemic, we have to weigh those benefits and risks. And in Elizabeth's case, her family has really embraced the value and the need in their life to be together as a family. And so I love that you're calling to say 'we know this is a benefit that we want to work towards and how can we decrease that risk?' So it's always that balancing act. So I love this question. Well, I don't love it. I wish we didn't need to have it all. But I think it really is one of the best questions out there.
“A few simple things can really keep things protected. And one is any event that you can hold outdoors, hold outdoors. If you can't hold it outdoors, if you could hold it in an open space, like an open garage or a house with the windows wide open or a tent, anything you can do to keep things as much outdoors as possible, or with as much ventilation as possible, is going to decrease the risk of transmission. It's great to hear that most of the people at this event will be vaccinated. And that also is a real key to protecting yourselves.
“Past that, your next most important thing is masks. It's not time to give up the masks yet. I know we all wish we could, but this is really our second best strategy for protecting each other. The problem with an event like this, of course, is that our culture shares at these events, food and drink and all sorts of things, that you can't do with a mask on. And so what a lot of people that I know have done has been to sort of make a segregation of areas of the event. So the majority of people at any one time will be in an area where there's no eating and drinking, and they have their masks on. And there's another area for eating or drinking, where you keep the number of people in that area low, so that you can keep the distance between people, so that they can eat and they can drink, with their mask off, of course, but still have safety measures around them.”
Elizabeth from Urbandale: “Well, this was fine for like the family reunion, but this is a group of 12 people who will be sharing a house.”
Wellington: “Yeah, that definitely adds another dimension. It's very difficult. A couple of things you can still do would be — I think the phrase people use now is 'lay low before you go.’ So if you have some time before this event, everybody who is coming should do everything they can to avoid getting exposed out in public. The people who are coming to the event should be extremely careful any time they're out in public, especially if it's indoors, to always wear their mask. While they're traveling in through the airport and on the plane, they want to keep their mask on all of the time if it's possible. If it's not possible, when they take their mask off, they should distance themselves from other people as much as possible. So the idea being that you have the lowest risk possible, that someone's coming to this house with the infection.”
Kieffer: “Following up on mask-wearing — I don't know if you noticed, doctor, but I certainly did, suddenly this week, after weeks of seeing few masks in public, I'm seeing more of them in grocery stores and so forth. Let's say you want to go to see a show. What should I consider when I'm thinking of wearing a mask to a theater? Maybe it's an open air theater, maybe not, hopefully open air, or whether I should go at all? Perhaps I'm immune compromised.”
"Even when you're vaccinated, you still have to look at the situation, thinking, what's the risk here? Am I willing to take that risk for the benefit of this activity?"
Wellington: “I agree with you that the best and safest thing to do, of course, is to stay home. But again, we need to live our lives, too. So that's always that balancing act. If you can find a show that is what you're looking for, that is an open air show or even one of these ones where there's a shell with a cover but the sides are open, that is your safest bet. If you're going to go out — always open air is the best...I agree, I see more people wearing their masks lately, and I'm very reassured by that. If it's going to be an indoor show, then you have to really start thinking, what are my risks? What is the benefit of the show to me? Because any time you're indoors, there is a chance of being infected. Even people who are vaccinated can be infected. It's called a breakthrough infection. It does happen. It's very rare. And when it does happen, those people usually do not get into serious trouble with the virus. But that can happen too. So even if you're vaccinated, you are still at some risk from the virus, and so the vaccine doesn't give you a free pass. It does give you a lot of protection, an extremely large amount of protection. I don't want to make it sound like it doesn't work. They work great. But even when you're vaccinated, you still have to look at the situation, thinking, what's the risk here? Am I willing to take that risk for the benefit of this activity?”
“So if it's an indoor venue, is it a venue where people have reduced capacity? Have they come up with a way to maintain distance between people? How crowded will it be? Are they asking that everybody at the venue be vaccinated? If I'm remembering right, I heard on the news last night there was a Bruce Springsteen concert where you had to prove that you've been vaccinated before you could go to the concert. Obviously, that's a unique scenario. We can't do that with every event we do in our lives. But those are the kind of things you're looking for. What kind of safety measures are in place, and is that enough for me? Depends on what your personal level of risk is. And you also hit the nail on the head, too. If you're immunocompromised, if you're on a medicine that might decrease your response to vaccine, even though even those folks, if they're vaccinated, still have a higher risk than the rest of us.”
Kieffer: “Let's go to another caller. Jackie is joining us from Sac City. Jackie, welcome to the program from the northwest part of our state.”
Jackie from Sac City: “Thank you. The quick question I had is: I'm vaccinated and, if I should get a breakthrough infection, could I end up with long-hauler effects?”
Wellington: “We don't know quite enough about what happens with disease in vaccinated people yet, thank goodness, actually. It means not that many people are getting infected, which is great news. But there are people who do get the full-blown infection. So we presume, we don't have great data on this yet, so I would love to be wrong, but we presume that those people who do get a full infection could develop the long-term post-infection effects such as that long-haul syndrome.”
Kieffer: “OK, quick questions as our time is rapidly disappearing here, Dr. Wellington. Let's say you've been infected and recovered, but have not been vaccinated. Do you need to be vaccinated, since, evidently, probably you have some immunity from having the COVID-19 disease?”
"Being infected and then getting better is not, alone, enough to protect you as much as we can protect you. And we want to give everybody the best protection possible."
Wellington: “Yes. You should absolutely still get vaccinated. You're going to have more immunity after the vaccine, and you may end up being one of those people who is ultra-protected. But being infected and then getting better is not alone enough to protect you as much as we can protect you. And we want to give everybody the best protection possible.”
Kieffer: “A lot of talk about booster shots. For some of us, it's been many months since we got our second shot, became fully vaccinated. Will we need booster shots? If so, when? This is being debated right now, isn't it?”
Wellington: “It is being debated right now. We suspect there will be a booster shot. Remember, at its heart, the coronavirus is a common cold virus. And we all know you can get that over and over again. So we think we'll need a booster shot, but we don't know when or what it will look like.”
Kieffer: “Is it possible to make a version of a booster shot? Will it be different than the original, or perhaps a variation of the original, that can target the delta variant for, for instance?”
Wellington: “It is definitely possible, especially with the MRNA vaccines, they're fairly readily adaptable. But the early data we have on boosters is going to be with the same vaccine. And we want to go with this data where we have data so that we can be sure that it's safe.”
Kieffer: “Some in the scientific community, I've read, say we will never need boosters. That's still a question to be determined. I wonder, what is the debate like among infectious disease specialists, epidemiologists right now? What’s the spectrum, the range of opinions about where we are with the current, very successful, vaccines and the possibility that their effectiveness could wane as time goes on?”
Wellington: “The one side says, you know, 'we always have waning immunity to coronaviruses. We're going to need a booster, period.' The other side says, well, 'it's true that you can get the common cold over and over again. You rarely get into trouble with the common cold after you've had it once. Therefore, a booster is not going to be necessary because the single vaccine or the single series of vaccines will protect you from the severe disease.' And then there's a third group that points out that, 'well, we are having a happy amount of vaccine available in the U.S. That is not the case around world. And we should wait on booster shots until we get the rest of the world vaccinated.'”
Kieffer: “And in which camp are you in, if I may ask?”
Wellington: “Oh, boy. I suspect that a booster shot will be given. Let's just put it that way. Okay. I think, though, that we need to think about the ethics of doing that. And I would love to see the whole world vaccinated first.”
"The outbreak is not over, and it is a community issue."
Kieffer: “Right. When we look at data, when you look at data as an epidemiologist and infectious disease specialist, tell us, what is the data that is being used to determine in the coming weeks and months whether a booster is needed? The number of antibodies a person still has, the number of breakthrough infections?”
Wellington: “The most data that we're able to collect right now is the different drug companies who make the vaccines are going back to people who were in the original trials. So those are people who were vaccinated August, September, October last year — and looking at their immune responses and then giving a booster dose of the same vaccine and looking at their immune responses again. So we're looking at what responses we can measure in the lab. We don't have a perfect number that says if you're at this number, you're fine. So it's all sort of lab-based data at this point. So the conversation of whether or not to do booster is going to turn out to be very complex and nuanced. But that's how they do it. They they look at somebody's immune response, say today, they give them a dose of vaccine. They wait four weeks and they look at their immune response again.”
Kieffer: “So it wouldn't be the case that in the future, or would it, that you would go in to see your primary care physician or some other medical professional, they could on the spot see if you need a booster based on antibodies or whatever?”
Wellington: “It's not possible right now, and it's not going to be possible in the close future. But the pandemic has certainly mobilized the power of our scientific research community, and I'm not going to say nothing will ever happen because I would be prideful."
Kieffer: “OK, this is a huge moneymaker for pharmaceutical companies, Pfizer, specifically. Their vaccine, I read, could soon become the all-time best-selling drug ever, and this in the course of only one year. How can we know that big pharma won't be able to convince us that, 'oh, you always need a yearly booster,' even when we might not.”
Wellington: “I think that there's a nice balance in our country between big pharma, academics, and government, and everybody has to be looking at the data. Not just 'does a the booster increase the immune response,' but how will it help the population and the combination of people that are going to need to say, yes, we should be doing this. It should protect us from that conflict of interest, of the monetary impact for the company.”
"The more the virus goes from person to person, the more chances it has to mutate into a new variant that could be even more dangerous. What's happening in Africa can change our health here very quickly."
Kieffer: “Back to something you mentioned just a moment ago — the moral, ethical debate over whether wealthy countries such as ours should be asking drug companies to ramp up production of boosters when, in many poorer countries, there are still very low vaccination rates , places where even elderly people, health care workers even have not yet been vaccinated.”
Wellington: “That is definitely an ethical question, but it's also a biological question, and one that has impact to our health here in this country. Because the more the virus goes from person to person, the more chances it has to mutate into a new variant that could be even more dangerous. So what's happening in Africa can change our health here very quickly. If we don't immunize everybody around the world, then there's going to be this ongoing transmission, and there will continue to be new variants and new mutations that could be more dangerous.”