Life post vaccine if we don't get herd immunity
Are you a bit confused about what’s safe to do after you’ve been vaccinated?
You aren’t alone.
With the news that herd immunity may not be achievable in the US, many of us are left wondering how to live our lives moving forward.
The public health guidance we’ve received since the beginning of the pandemic has been detailed and prescriptive, but it’s also been confusing. Post vaccination guidance follows a similar path.
I think that part of the confusion stems from the fact that “trust the science” isn’t really a thing.
But the bigger reason is that risk exists on a spectrum. So that’s why we have conflicting guidance from state to state, and even from city to city: because values and risk tolerance necessarily become part of any public health recommendation.
As a doctor taking care of patients, I pay attention to the public health guidance, of course, but I also look at the data and talk to my patients about their own personal spectrum of risk.
So let’s keep the focus on what we know and talk about what life post vaccination might look like.
Not reaching herd immunity is upsetting
I’m not an epidemiologist, infectious disease doctor, or a public health official. I have no idea whether herd immunity is an unrealistic target now.
But the argument that increasing vaccine reluctance coupled with virus variants that are more contagious means herd immunity may not be achievable sounds plausible to me.
This is clearly depressing - living with COVID as an endemic part of our lives is much less appealing than eradicating it entirely. But you play the hand you’re dealt, so we should start to think about how to live our lives if COVID never goes away completely.
I think about our risk as existing on a spectrum and your individual decision making should take into account both your own risk as well as your own risk tolerance.
A spectrum of risk means a spectrum of opinions
On one hand, you have people who say “throw out your mask after you’ve been vaccinated” and on the other hand, you have the city of Brookline, Massachusetts continuing to mandate masks outside after the state lifts those restrictions.
We know the data on real world post vaccination is really reassuring:
You are much less likely to get COVID after vaccination, even if exposed
If you do happen to get COVID, you are much less likely to get really sick
If you happen to get really sick, you are much less likely to die
But since it is still possible to die from COVID after you’ve been vaccinated, it makes sense for CDC guidelines to provide nuance across a spectrum of risk.
When I’m counseling my patients on risk mitigation we always have a conversation about a person’s individual risk profile. Risk reduction is much more important if your chance of a bad outcome is 50% than if your chance of a bad outcome is 1%.
So the first place to start when you’re considering your own risk is to think about your own health status:
What’s your metabolic health like? Do you have diabetes, high blood pressure, and heart disease? Are you obese? Would you describe your own health as poor? The more negative answers you have to these questions, the higher your personal risk and the more you benefit from vaccination.
Have you been vaccinated? If so, your risk is really, really low. It’s not zero, but it’s close!
With COVID, risk isn’t just dictated by your own characteristics, it’s also influenced by your environment
Local conditions play a huge role in determining your risk.
I think a lot about how high death rates were at the beginning of the pandemic compared to what’s going on now.
We are better at treating COVID, but the more important factor is that our hospital systems aren’t overwhelmed. Last spring lots of hospitals were stretched to the breaking points - doctors and nurses working out of their areas of expertise, makeshift ICUs, repurposing machines to serve as ventilators.
As COVID numbers have come down and we aren’t overwhelmed, it’s easier to focus on each individual patient. It doesn’t hurt that we’ve learned a lot about what treatments work and what treatments don’t, but lower overall numbers make an impact too.
You need to think about what’s happening in your local environment to even begin to contemplate your own risk with even a semblance of accurately.
Think about what’s happening in India right now
It’s a humanitarian tragedy, with countless lives being lost due to an out of control pandemic and an overwhelmed health care system.
If you were in India, my advice would be to stay home, double mask if you needed to go out, and be as cautious as possible - even if you are the picture of perfect health and you have been vaccinated.
That’s because even if your own personal risk is low on a relative basis, it’s high in the absolute sense. The local environment there means two major things:
There’s a huge amount of spread so your risk of being infected is high.
If something bad happens, your medical care will be suboptimal because the system is overwhelmed, regardless of what your own personal resources are like.
So you need to consider local conditions when you make your own decisions.
The bottom line: the vaccines are great, you should get them, and then you should go back to a mostly normal life
With COVID-zero looking less like a possibility for the near future, we have to make some decisions for ourselves.*
Breakthrough infection post vaccine is certainly real.
But it’s likely to be mild and risk of death - even if your own COVID risk is high - is astoundingly low.
I think that wearing masks outside is fine to stop after you’ve been vaccinated (and was probably even fine pre-vaccine).
Indoors gets trickier, but in most situations you can probably take the mask off.
The key things to consider:
What’s your local environment like - are infection rates and test positivity high? If so, be more careful.
What’s the ventilation like? Poor ventilation increases risk considerably.
How many people are there? More people means more risk
How likely is spread based on the activity? Things that make spittle - singing, talking loudly, breathing heavily, exercising - all increase risk.
There’s isn’t likely to be a point with zero risk anytime soon. But if you’ve been vaccinated, risk is really low and I advocate trying to get back to your normal life as much as you can.
We’ve all been so disrupted by the past year, hopefully we can start to take part in the things that we’ve been missing.
Thank you for reading! Please share on social media and with your family and friends!
I’m curious how you have all been approaching post vaccine life? How much normalcy have you been willing to let into your life so far?
*The CDC guidance isn’t actually all that bad here. You just need to spend a few uninterrupted and focused minutes to understand it:
