Americans face a two-track pandemic — with very different risks

In a speech Tuesday, President Biden drew a stark distinction that has become all too clear to those who, like myself, treat COVID-19 patients regularly. What is occurring in the U.S. is a two-track pandemic:

1) The majority of the vaccinated are on a track devoid of risk for serious illness.

2) Those high-risk individuals who are not vaccinated are on a distinct track that entails a significant risk of serious illness, hospitalization and death, all the while holding hospital capacity hostage.

(For those who are immunosuppressed and have suboptimal responses to vaccine, products such as the long-acting monoclonal antibody Evusheld can augment their protection against serious illness). 

The goal of the first-generation COVID-19 vaccines that we now have, primarily, is to prevent serious illness, hospitalization and death. The goal has not been to prevent every illness like a magic forcefield. A mild infection that occurs post-vaccination is a victory, and the appearance of the omicron variant has laid bare the endgame that has been apparent, but poorly communicated, since the beginning of the vaccination program.

SARS-CoV2 is the seventh human coronavirus discovered and four of those coronaviruses cause about 25 percent of cases of the common cold. Those coronaviruses routinely reinfect us and evade prior immunity quite easily. That the omicron variant evolved immune evasive properties that allow it to get around the protection afforded by vaccines and prior infection is not surprise to infectious disease physicians, microbiologists and epidemiologists.

This is the natural biological progression. Immune evasion is not something to panic about because, in the vaccinated, protection against severe disease (conferred by other arms of the immune system such as T-cells) is able to almost entirely blunt the ability of the virus to cause significant health damage. Mild infections in vaccinated individuals — which constitute the majority of infections in this group — should be considered in a different light than severe infections, which principally occur in the unvaccinated. 

As Biden stated, those of us who are vaccinated face a very different fate when we are inevitably infected with SARS-CoV2 and that should not induce fear or major curtailments in our activities. The value of vaccination is that it allows one to more easily risk calculate and navigate the post-pandemic world in which COVID-19 will always be ever-present, but increasingly more manageable as the threat of severe disease no longer exists. 

As Biden stated, “There will be positive cases in every office, even in the White House, among the vaccinated, from omicron. But these cases are highly unlikely to lead to serious illness.” 

The emphasis should be on the severity of infection occurring rather than the sheer number of infections (cases) occurring. There will always be COVID-19 cases that ebb, flow and surge. However, if those cases are not sending patients into hospital beds they are of a different caliber as they are largely indistinguishable from mild disease that has traditionally been caused by the other coronaviruses. Vaccination decouples cases from hospitalizations and deaths. Just as other respiratory viruses cause countless cases per year that are largely decoupled from hospitalization and death, so too does COVID-19 in the vaccinated. 

Now, we need a precision-guided retooling of isolation periods for cases occurring in the vaccinated. COVID-19 in the vaccinated is not only a milder illness but also a shorter illness with a resultant truncated contagious period. Studies show that viral loads, somewhat a marker for contagiousness, rapidly crashes in the vaccinated. Tools such as rapid diagnostic tests can be used to specifically tailor and pare back an isolation period of 10 days to one guided by antigen positivity as a marker for the presence of contagious amounts of virus.

Therefore, the remaining task left to achieve is the shoring up of a beleaguered hospital system that has been inundated with unvaccinated individuals coming for care. This is critical if hospitals are to be able to deliver the everyday care we all rely upon. As such, it is important to minimize the COVID-19 cases that land in the hospital and ensuring hospitals have the ability to function. This is achieved by encouraging high-risk individuals to be vaccinated, accelerating the approval and availability of the promising antiviral Paxlovid and ensuring a ready supply of monoclonal antibodies.

At this point in the pandemic when we are bombarded with negative headlines, the president’s reminder that “this is not March 2020 — 200 million people are fully vaccinated” is important to internalize.

Amesh Adalja, M.D., is an infectious disease physician and a senior scholar at the Johns Hopkins Center for Health Security. Follow him on Twitter: @AmeshAA