Getting to Herd Immunity ASAP

By Paul E. Lemanski, MD, MS, FACP

 In my first eight articles on Covid-19, lifestyle-based risk mitigation strategies – including masking, social distancing, hand washing, targeted quarantine, and, when necessary, lock downs – were recommended to keep the population well, until a safe and effective vaccine was developed and “in the arms” of 70-75% of Americans. In this way, vaccination would result in so called “herd immunity” (see Non-Medicated Life, February 2021) and stop the transmission of the virus to those who were not vaccinated. 

Currently, after a dramatic decrease in the numbers of cases, we are again seeing a rise in cases, fueled by the Delta variant, a mutation of the original virus that is more easily transmitted. While the available vaccines, and probably a prior natural infection with Covid, protect against Delta causing severe disease and death, we have still not reached herd immunity – in which enough individuals have antibodies to the virus that transmission to those not vaccinated is stymied. Thus, to end the pandemic we must vaccinate another 10-15% of those not currently vaccinated BEFORE another variant emerges that can escape the vaccine entirely. But how can this be accomplished?

Those currently not vaccinated fall into two groups: 1) those who are adamantly opposed, and 2) those who are unsure or awaiting more information. The first group comprises about 15% of the population and has remained fairly constant since the vaccines became available. The reasons are numerous, but in my own patients those reasons do not appear to be influenced by information science can provide. Moreover, the mere fact that they have survived to date, without infection or a vaccine, seems to reassure this group that they can continue their current practices and continue to expect the same outcome. 

Unfortunately, the Delta variant is so easily transmissible that prior distancing and masking guidelines may no longer work. It is highly probable that those who are not vaccinated will eventually contract Covid by natural infection. In my opinion, after making reasonable attempts to persuade them, these individuals need to be respected in their decision. Those that contract Covid and survive will help with herd immunity and this contribution should be valued.

The second group who are unsure or awaiting more information may have a more immediate impact on herd immunity through timely vaccination. Such individuals should be questioned closely so that the reasons they have remained unconvinced are understood and addressed explicitly. Probably the best person to address these individuals is their primary care physician, who understands each individual’s personal risk with a natural Covid infection, and is also well versed in the most recent data. 

For example, with my own patients who fall in this group, I have been able to reiterate that risk of a bad outcome with Covid increases with age and certain medical conditions. I have also been able to reassure them that upwards of 165 million individuals – including myself – have received either the Moderna or Pfizer vaccines and the data demonstrate an excellent safety profile, as determined by very sophisticated tracking tools of all untoward events related to vaccination. These vaccines have been better-vetted than almost all other vaccines in existence. They may have been approved under emergency authorization, but they are decidedly NOT experimental.

Recently, the CDC has changed masking guidelines for those who are vaccinated. CDC is now again recommending masking indoors, even for those who are vaccinated, because of data that those who are vaccinated and have “breakthrough” disease may still transmit the virus. Breakthrough disease has been known to occur in 5% of vaccinated – although these individuals will avoid severe disease, hospitalizations, and very rarely die. Unfortunately, the new information is that this 5% may still transmit the virus to the non-vaccinated. 

While masking for the vaccinated may represent a responsible scientific recommendation on the basis of new evidence, from a public health perspective, in my opinion, it has complicated and undermined confidence in the CDC. People are completely fatigued with masks. One of my best and most reasonable patients was absolutely livid with the directive to continue to mask in the office after he has gotten his vaccination. It took the better part of 20 minutes to calm him down. 

Suggesting that the vaccinated should mask to protect those not vaccinated and raising the specter of mask mandates detracts from a major incentive to vaccinate: finally giving up the loathsome mask. After explaining the rationale and encouraging the vaccinated to voluntarily comply with the CDC recommendation, rather than trying to somehow force masking, I think our efforts would be better spent getting as many folks vaccinated as quickly as possible and achieving herd immunity as soon as possible.

To this end, I think one of the strategies proposed by French President Emmanuel Macron make some good common sense. If you want to go to a bar, restaurant, nightclub, sports match or any large gathering (and who after this miserable past year doesn’t?), you need to prove vaccination status or prove you have a recent negative PCR test for Covid. Such proof does not require ongoing compliance with masking and provides a higher degree of enforceable safety. Moreover, it does not impinge on anyone’s right to refuse a vaccine. It provides a powerful incentive to vaccinate, as repeat Covid testing is onerous. While there have been protests in France, in polls the majority of the French support this approach. In my opinion, such an approach should be considered soon in America, before a new variant resistant to available vaccines emerges. Time, unfortunately, is truly of the essence.

In summary, in order to end this pandemic, we need to get to herd immunity before a new variant arises that is resistant to the current vaccines. Mask mandates while offering some protection to those not vaccinated may prove counterproductive. Focusing on those not vaccinated who are unsure or awaiting more information, identifying their individual concerns, and addressing those concerns should be the responsibility of their primary care physician. Concerned family and friends should encourage these folks to speak with their physician ASAP. 

Additionally, using a combined carrot and stick approach to prove vaccination status or a recent negative Covid PCR test in order to gain access to public venues and gatherings may be helpful. Vaccines are safe and highly effective. Incentives and strategies to get the group not vaccinated, who are unsure or awaiting more information to accept vaccination, should be our first urgent priority. 

Paul E. Lemanski, MD, MS, FACP is a board-certified internist practicing internal medicine and lifestyle medicine in Albany (centerforpreventivemedicine.com). Paul has a master’s degree in human nutrition, he’s an assistant clinical professor of medicine at Albany Medical College, and a fellow of the American College of Physicians.