All people age 5 and over are now eligible for vaccination in Maine. And, any Mainer age 18 and over who is 2 months out from a single dose of the Johnson & Johnson COVID vaccine or 6 months out from the second dose of either the Moderna or the Pfizer vaccine is now eligible for a booster dose. Maine CDC is advising everyone to be vaccinated, unless they have one of the very rare legitimate medical contraindications. It is a critical time to get as many people vaccinated as possible because there are still enough unvaccinated people around to keep the pandemic going, and to run the risk of new variants forming. As I will discuss, unvaccinated people place everyone at risk, even those who are vaccinated.
At the latest weekly address on November 17, 2021, Dr. Nirav Shah, Maine CDC Director, noted that we were seeing the highest day of new cases in a 24 hour period, with 1042 new cases. He reported that 280 Mainers were in the hospital that day (another record), and that five of them were under the age of 18. This total was up from 212 people just two weeks prior. On November 17 critical care (or ICU) beds with COVID cases in Maine totaled 77, two of whom were children, and 36 of whom were on a ventilator. The seven-day positivity rate (the percentage of positive tests from all taken) had also hit a record at 8.9% (up from 5.9% two weeks prior). In the prior two weeks the percentage of tests done daily in the state had increased by nearly 20%.
Looking at the number of cases overall, as of the data available today at the Maine CDC website, in our state we have seen 115,857 confirmed cases of COVID-19, and 1,271 deaths since testing began in early 2020. This amounts to a current case fatality rate of about 1.1%. The highest case rates are currently seen in Androscoggin, Oxford, and Somerset counties, and all Maine counties are reporting significant numbers of cases. Nonetheless, as discussed last week by Dr. Dora Mills, Chief Health Improvement Officer of MaineHealth, and Dr. James Jarvis of Northern Light Health on the Maine Public radio program Maine Calling, the current surge of cases is being driven by unvaccinated people from primarily rural areas that had been largely spared from prior surges. These areas contain reservoirs of people who have no immunity from either prior infection or vaccination.
On November 17, Dr. Shah noted 71.6% of the entire population of Maine was “fully vaccinated,” meaning they had received a single dose of the Johnson and Johnson, or two doses of the Moderna or Pfizer vaccines, and 79.5% had received at least one dose of a vaccine. This also means that nearly 270,000 Mainers are not vaccinated. Statewide, about 8,800 doses were being administered daily (including first, second, booster, and pediatric doses), an increase of 21% in the prior week. As of that that day 14,209 kids in the age 5-11 group had gotten their first shot (about 14% of the kids in that group).
So, looking at those numbers, in a state of about 1.34 million people, we can calculate that 71.6% full vaccination would come to 959,440 people. Maine CDC states that there have been 12,681 breakthrough cases (COVID infections in fully, not partially vaccinated people, at least two weeks out from vaccine completion). This comes to a breakthrough rate of about 1.3% among fully vaccinated people. That is not bad, but we should keep in mind all of these numbers might miss people who have tested at home (or not tested at all), and not reported illness to the state. So, it is almost certainly an underestimate.
Last week on the Osterholm Update from CIDRAP (the Center for Infectious Disease Research and Policy), Director and epidemiologist Michael Osterholm, Ph.D., made several important points. He noted that there is some loss of protection from the vaccines starting at 6-8 months after a full vaccination, and that there is some initial data that the third dose may be effective for at least 9-10 months. He discussed the point that some people have thought the presence of increasing percentages of breakthrough infections was evidence that vaccines do no good. I have heard the same thing from patients. In this case, the opposite is actually true.
Breakthrough infections around the country are relatively rare (as we just calculated for Maine above), but the proportion of them will rise as more people are vaccinated, which is confusing to some. This is because, while the vaccines are good tools, they are not perfect, and don’t work 100% of the time. The percentage of breakthrough infections increases with the number of vaccines given because more and more people are vaccinated (and fewer and fewer people are unvaccinated). It is a proportion problem.
Think about it this way (and bear in mind I am not really using statistics to calculate this, but am going to keep it sort of simple to show the point). If there were an imaginary city with 1,000,000 people, and the overall risk of becoming infected were 5%, you would expect 50,000 people to become infected over some period of time. If a vaccine came along that was very effective, but still allowed breakthrough cases in 2% of the population, then then only 20,000 people would be infected. To understand the percentage of breakthrough cases going up, consider this. Without vaccines in our imaginary city 5%, or five out of every 100 people would become infected-and there would be 0% breakthrough cases because there would be no vaccination. With a vaccine 2%, or two out of every 100 people vaccinated would become infected. Then we could start to figure out if breakthrough case percentages going up are a good or a bad thing. If you vaccinated half the population 500,000 people would get the vaccine and 500,000 wouldn’t. You would still expect 5% of the unvaccinated people to become ill, which would come out to 25,000 cases. With the 500,000 vaccinated people there would be 2% breakthrough (10,000 cases). If you add the cases up, you have a total now of 35,000 cases, and 40% are breakthrough cases. We just went from 0% breakthrough before the vaccine, to 40% after. It’s going up, right? If that was your take-home message, take a look at the total number of cases. They just dropped from 50,000 before a vaccine to 35,000 when half the population was vaccinated. The percentage of breakthroughs went up, but the total number of cases went down. If you had vaccinated the entire population of 1,000,000, you would expect 2% breakthrough, or 20,000 cases. Because everyone was vaccinated in this scenario the unvaccinated infections were 0%, and vaccinated breakthrough infections 100%. The total number of cases dropped from 50,000 without a vaccine to 20,000 with a vaccine. That is what we want with a vaccine that has a 2% breakthrough rate.
So where am I going with all of this? If you have not been vaccinated yet, please do get the vaccine. If you are eligible for a booster, now is the time. Holidays and indoor gatherings are coming. We will will almost certainly see case numbers rise. The vaccine is an important tool to avoid illness. Keep mind of course, that no vaccine is 100% effective. Minimize your risk of having a breakthrough infection in every way that you can. Avoid dicey situations. If you must attend some indoor event or holiday gathering, make it one where everyone is vaccinated. Your risk of catching COVID-19 when you and everyone around you is vaccinated is exceedingly low. However, if you are inside with a sick or pre-symptomatic person who is exhaling air filled with virus, you are at risk, as I have discussed in several other posts. Because of that I don’t think it is wrong to tell unvaccinated people that you cannot see them at gatherings. It has been reported again and again that unvaccinated family members have spread disease when they have come into contact with family and friends. Those people raise the risk of infection for everyone around them, even vaccinated people, especially those with underlying risk factors. And, if you are eating with others it is still a good idea to spread out the seating during the meal. Let’s do what we can to avoid spreading or catching COVID-19. Finally, please also get the flu and pneumoccal vaccines.