Recently, one of my colleagues took a trip to Florida. He went to see family, in a long-awaited visit that he had previously only managed to make once during the pandemic, driving the whole way from New York while “peeing behind dumpsters.” Now that everyone was fully vaccinated, it seemed totally reasonable to fly there and to have everyone gather, unmasked, together. It was a relief and a joy. They even went to a hockey game indoors with thousands of people.
When my colleague got home, he started to feel like he had a cold. He didn’t think much of it—until he got a call from one of his family members in Florida who had tested positive for COVID-19. Eventually, all the adults who gathered on that trip got sick, including my colleague’s mother-in-law and father-in-law. My colleague’s wife also tested positive; he didn’t, but given his symptoms, including loss of smell, it seemed like a probable COVID case.
As I spoke to my colleague about it, he was still sifting through exactly what he was feeling. He’d forgotten how miserable being sick is, for one thing, and his case—a “mild one” by medical definitions—knocked him out for about a day and a half. He, his wife, and his father-in-law still had a lingering cough, and he was worried about long-term effects, particularly because his father-in-law is undergoing treatment for a serious health issue.
Mostly, he felt frustrated. He’s a journalist—he’s pretty tuned in to the news. He knew breakthrough cases were possible, but he had seen many assurances that they were extremely rare and not that big of a deal. “I feel like I had very inaccurate information,” he told me, “and I would have made my decisions in a very different light if I knew what I know now.” He would have worn a mask at the hockey game, for example—even though no one was wearing a mask at the hockey game, and the Centers for Disease Control and Prevention said it’s fine for vaccinated people not to wear masks inside.
He acknowledged it might be possible that he and his family just got really unlucky—and maybe a year from now, as long as everyone recovers fully, he’ll be able to look back on this and say “OK, well, the vaccines still did their job.” But right now, he feels worried—worried that breakthrough cases are more common than we think, that vaccinated people will get sicker than they think, that fears about the delta variant are not overblown, and that it might still get worse. Mostly, he’s worried that vaccinated people are not quite as in the clear as many of us seem to think we are.
He’s not alone. The day we spoke, the Dow had its worst day in months as the markets seemed to ingest that same fear, that we’re not as close to the “end” of the pandemic as it seemed. COVID cases are spiking in many parts of the U.S., especially in places like Missouri and Arkansas, which are lagging behind in vaccination rates and experiencing severe outbreaks fueled by the delta variant. Last week, Los Angeles mandated that people wear masks when indoors in public spaces again, regardless of their vaccination status. All of this is enough to be thoroughly freaking plenty of people out. Many of them are people like my co-workers, who also heard my colleague’s story—scary stories travel widely!—but know the gist of the vaccine science and now are wondering what to believe. The story sparked a slew of questions that essentially boiled down to the same ones we have all been trying to answer for ourselves since the start of this pandemic: How can I keep myself and my loved ones safe? How much do I have to give up to do so? And what am I supposed to do to keep everyone else as safe as possible, too?
The most important answer to these questions ought to be very familiar by now: The vaccines work. Most importantly, the vaccines are very effective at doing the main thing these vaccines are supposed to do: prevent severe illness and death. My colleague didn’t enter (and overburden) the health care system with his disease, which is still essentially the point. And in the midst of a lot of eye-popping numbers being tossed around—cases growing by 50 percent sounds scary, a low number of cases doubling less so—I think this chart is striking enough to be useful:
But I also don’t think that this chart means things are simple, or that my colleague’s fears are overblown. The bars on the right side of that second chart are not zero. Even with these very effective vaccines, there are still going to be infections—herd immunity is a long game, not a short one—and some of those infections are going to be severe. There are even going to be a very small percentage of vaccinated people who die—according to the CDC, as of July 12, 5,189 vaccinated people have been hospitalized with COVID-19, and 1,093 have died. (Even that somewhat scary number has caveats: 1,456 of those hospitalized were reported asymptomatic, or were hospitalized for something not related to COVID.) There is still plenty we don’t know, including precisely how much worse delta is, and how much worse whatever comes after delta will be. We do know that vaccinating as many people as possible is our best path toward minimizing the badness of whatever that is, and that in the U.S., we are doing better than many of us seem willing to accept.
Still, just because we can hold onto the knowledge that the vaccines are working (they are) doesn’t mean we shouldn’t strive to get a clearer understanding of breakthrough cases. What my colleague’s story underscores is that we need to reorient how we think about these cases, how likely they are, how problematic they are if they happen to you, and whether it all means we’re backsliding into another lockdown. The bad news is that reporting this article has changed how I’ve thought about the risk of breakthrough cases (I now suspect it’s higher than I had thought) and what it would be like to get one (worse than I had thought). The good news is that I don’t think that means we’re heading back toward lockdown, even though I think we are, once again, going to be tasked with having to think a little bit more about our personal risk calculus—especially if you want to avoid COVID entirely. But the most interesting thing I’ve learned is that if you are fully vaccinated, avoiding a “mild” case of COVID, even if it sucks, might not actually be as important as you think. Given that we have just spent a year and a half dramatically altering our lives to avoid COVID, reorienting in this way is understandably going to take a little bit of time. But it’s worth the effort.
The most important thing to realize is that breakthrough cases are going to continue to surface in our lives. “The goal was never to eradicate COVID from being annoying—it was to eradicate it from being a killer,” said Dara Kass, an emergency medicine physician in New York. (She emphasized, again, that the vaccines are very good at doing the latter.) And so even while you have likely heard that breakthrough cases are “rare,” that’s a subjective assessment that is probably worth adjusting upward. There hasn’t been a firm percentage available beyond these vague characterizations—and the CDC is only tracking breakthrough cases that result in hospitalization or death, a decision a Harvard doctor called “disappointing” on the medical school’s blog. But medical professionals are starting to think about this more and more, and the suspicion is that they will happen with increasing frequency—and we shouldn’t be surprised when we do.
“Breakthrough is the next frontier,” Bill Hanage, an epidemiologist at Harvard, wrote to me. Kass affirmed what many doctors have been reporting anecdotally—that the vast majority of patients ending up in hospitals with COVID are unvaccinated. But, she added, “more and more vaccinated people will keep getting positive COVID tests. We really don’t know how many officially or what that means.” We know breakthrough infections are not as serious or deadly in most cases, but we simply don’t know how common they currently are—or will be as delta continues to spread.
Another disconnect is what we think of as “severe illness” and what is actually severe illness. My colleague said he could not imagine describing the illness he had experienced as anything other than “severe”—he was unable to do anything for 36 hours and said it was on par with having debilitating food poisoning. But when I asked a couple doctors about this, they disagreed with his ranking. “Technically, it sounds like he had a mild bout of COVID-19, by strict case definitions,” emergency physician and sometime Slate contributor Jeremy Samuel Faust wrote to me. “Mild does not mean pleasant. In fact, you can have fever, chills, body aches, and feel downright terrible for a week or more and still be categorized as ‘mild.’ ”
To approach even a moderate (or severe) case of COVID, “there must be significant lung involvement as evidenced by low oxygen levels, for example,” Faust said. “It really can be miserable. But you’re at home, not in the ICU.”
Hanage told me that a vaccinated friend of his had just had a mild case that lasted four days. And that still means the vaccines are doing what scientists like him believed they would. “Vaccination effectively removes the threat of nationally overburdened healthcare—even though locally serious outbreaks remain not only possible but likely,” he said.
If the “mild” cases of COVID that can break through are more severe than the colds we used to accept as a normal consequence of traveling, that is worth being clear about. So, yes: Vaccines greatly reduce the severity of illness. But you can still get very sick, in layman’s terms. It can be much more than a sniffle. (Frankly, the fact that you can get that sick from mild COVID should be yet another reason to avoid getting what doctors call severe COVID.)
My colleague was also frustrated by the fact that everyone in his group got sick—he had believed that because they were all vaccinated, perhaps only one person would get ill if they came into contact with the virus. Hanage said that wasn’t quite true, either: “I’m not that surprised that breakthrough infections cluster, given the very pronounced clustering of transmission in general,” he said. Even if just one person picked it up at the hockey game, they continued to spend time together indoors afterward and experienced sustained exposure.
What was most upsetting to my colleague was the other people he might have put at risk while thinking he was doing the right thing—his father-in-law, who had higher risk due to his illness, and his nanny and his mother, both of whom are at higher-risk ages. The word he used the most to sum up his feelings was embarrassed. While no one should be blamed for getting sick during a pandemic, I could certainly relate—there’s still an element of all of this that feels deeply and darkly connected to our personal decisions, which is tinged with a sort of problematic morality. It’s almost worse in the post-vaccine landscape, when deciding to mask or not can also be read as a judgment on how much you believe in vaccines, or how much you are still making taking COVID precautions your personality. Anyone who has been in a scenario where you recently would have worn a mask but now suddenly no one is wearing a mask anymore can likely relate.
Kass had a useful way of framing this feeling. She thinks it’s yet another example in the pandemic of some people trying really hard to do everything right, while others aren’t even bothering to get vaccinated. As my colleague Shannon Palus put it in March, “The wrong people are heeding the calls for more caution.” Thinking back to my colleague’s hockey game, the CDC still recommends that anyone who is unvaccinated wear a mask whenever they are indoors in public. I am willing to bet that not everyone in that stadium was vaccinated.
All of this is making people—yes, probably mostly vaccinated people—rethink the basic questions they thought their vaccine had answered for them: Can I go to restaurants and bars unmasked? Can I go back to the office? Can I see my grandma? Can I go on vacation? Can I unmask at my people-facing job? Can I have a wedding, or a party? The answer to those questions is not quite as easy as “yes, if you’re vaccinated.” It depends partly on how many in your group are vaccinated, but the actual answer is basically the same as it’s been all pandemic: It depends on your risk tolerance, it depends on what is happening with case counts locally (though, as more people travel, this might become a less reliable tool), and it depends on any unique risk factors in your group. Kass’ perspective felt novel to me: She said she suspects that in the end, a lot of people are going to end up boosting their immunity by suffering through a mild case of COVID. So no one should feel that bad about getting sick after they’re vaxxed. What matters is getting the order right: “If everyone who gets vaccinated still gets COVID but doesn’t die, that’s a success,” she said. The issue is that it doesn’t feel like a success for vaccinated people. Plus, “if you get infected after you’re vaxxed, it’s all you talk about,” she said. And right now, that’s understandably freaking out a lot of vaccinated people who thought they were in the clear.
But vaccines—as much as we want them to and as much as we maybe were even promised they would—have not wiped out the risk of any illness at all, and therefore they have not wiped out the need for personal risk calculus. “A lot of people getting breakthrough disease won’t be fun, even if they don’t end up in hospital,” Hanage said. There are still good reasons to want to avoid COVID, even a milder, vaxxed version—if you are spending time with higher-risk people, like the immunocompromised who can’t get the same efficacy from vaccines; if you have unvaccinated kids you’re worried about (though kids are a slightly different situation). But you already know how to limit your chance of exposure—you’ve had plenty of practice at that. Pay attention to case counts (and vaccination rates) if you travel. Even though the CDC says you don’t have to, maybe still mask up in specific situations, like indoor situations where there might be lots of unvaccinated people. “I think in areas with high case counts (or some combination of cases and low vaccination rates), masking indoors in public makes a great deal of sense,” Faust said. “Even here in Boston, where the case counts are low, I would mask in indoor settings where everyone’s vaccination status is unknowable.”
You also don’t have to do this—as ever, living through this pandemic means taking the risks and precautions that are reasonable to you. (Obligatory caveat: Get vaccinated if you can.) The reason why everything feels so confusing right now is because we’re getting closer and closer to the point where COVID is something that we just have to live with—just as we live with a million other things that are risky but make us happy, like driving or eating meat from a questionable restaurant. Many people take different approaches to these things. That’s what we’ll eventually have to settle into with this risk, too. There will be guidance, and some of it will be evidence-based and some of it won’t, and maybe it will shift over time, and we will all have to decide how much to take it into account. Like we do with everything.