Viewpoint: Should US Adopt an Elimination Strategy Against COVID-19?

On July 29, 2021, Infection Control Today^® sounded the alarm regarding vaccine breakthrough infections and waning immunity, citing Israeli data which found vaccine effectiveness in the prevention of all infections and symptomatic infections to be only 16% after 5 months from full vaccination. Israeli data also showed that individuals above the age of 60 were particularly vulnerable, with breakthrough infections resulting in an 8.6% incidence of hospitalizations and a 2% incidence of death.

These reports should have spurred immediate action. Instead, what followed seemed to be inaction and a litany of reassurances that the vaccines were effective. The confusion was created by flawed analyses of available research. At issue is the waning vaccine immunity with the delta variant. All too often the variables of which variant the data was derived from along with the time from full vaccination were not taken into account.

Kevin Kavanagh, MD

For example: A new report from Oxford University regarding vaccine effectiveness with the delta variant has been posted as a preprint. It reported high vaccine effectives with some coverage entitled “Don’t Fear Delta: COVID-19 Vaccines Keep The Deadly Variant In Check”. But another analysis in Nature more aptly stated “COVID vaccines protect against delta, but their effectiveness wanes” pointing out that the Pfizer/BioNTech vaccine is highly effective 14 days after the second dose “but the vaccine’s effectiveness fell to 90%, 85% and 78% after 30, 60 and 90 days, respectively.” Although the Oxford report shows good efficacy just after vaccination, it also shows waning starting early after vaccination and, thus, supports the Israeli data.

The Israeli data was also supported by research from the Mayo Clinic, which reported Pfizer/BioNTech vaccine effectiveness in preventing infections had dropped to 42% against the delta variant. Recently, the Centers for Disease Control and Prevention (CDC) reported vaccine effectiveness in preventing infections in health care workers declined by 30% with the delta variant. And the data from infections in LA County reported that 25.3% were in vaccinated individuals. The data also showed that 3.2% of infected fully-vaccinated individuals were hospitalized but few (0.25%) required a ventilator.

Data have been slow to emerge out of the United States, and little if any data on breakthrough cases are available on the Johnson & Johnson vaccine. The lack of data is largely the result of the CDC’s decision not to report all breakthrough infections. Currently only those which result in hospitalizations or death are reportable. This decision limits the US ability to immediately detect waning immunity and to implement timely strategies to protect the public.

It is becoming increasing evident that although vaccines are an important part of our armamentarium, we cannot solely vaccinate our way out of this pandemic. In addition, the implementation of a mitigation strategy to allow us to safely live with the virus may not be possible. The virus mutates and reinfections bring with it the risks of long COVID and death.

Other countries such as New Zealand, Australia, Taiwan, South Korea, Singapore and China have chosen to take another path, one of an elimination strategy.

China had outbreaks of the delta variant in a number of its cities which was traced back to the cleaning of an airplane which arrive from Russia. China along with many other South Asian nations has a zero COVID-19 policy and will lock down entire cities for just 1 or 2 cases. In China, these aggressive tactics have reportedly returned the nation to zero cases. Not only were entire cities locked down for just a few cases, but everyone in the city was repeatedly tested. One city tested their population a dozen times. In Beijing the total cases in the outbreak were reported to be less than 10. China used over 100 million tests to eradicate what would be classified as a very small outbreak by US standards.

It is becoming evident that the narratives asserting those who are vaccinated do not develop symptomatic infections are not true. And those with vaccine breakthrough infections can still become hospitalized, but less often and less severe than those not vaccinated. However, the vaccines are expected to provide less protection in the elderly and those who were vaccinated early in 2021.

In nursing homes, we need to administer boosters to residents who were fully vaccinated early in this pandemic. Nursing home residents are the most frail and highest risk members in our society.

The bottom line is that everyone needs to follow strict public health advice. This means vaccinations, quarantines, widespread testing, and the wearing of medical grade, KN95s or well-fitted N95 masks for optimal protection. Avoidance of indoor settings is of utmost importance, since the delta variant aerosolizes with a higher concentration of viral particles than previous variants. But most importantly, we may need to pivot as a nation to an elimination strategy and break the cycle of repeated waves of deaths and disabilities caused by emerging variants.