The Delta Variant Surge and the New COVID-19 Vaccine Mandate

On July 30, the MMWR (Morbidity and Mortality Weekly Report) released an early report (A) on a series of BT (breakthrough) COVID infections in fully vaccinated persons.  These cases occurred at large public summer gatherings on Cape Cod, Massachusetts.  The Delta variant was sequenced in 89% of the cases that were sequenced.  Of the 469 cases linked to these events, 74% were BT cases.  Real-time PCR cycle times (Ct) of 127 fully vaccinated persons were similar to those of 82 unvaccinated persons, suggesting the high viral load in the nose was similar and meant that fully vaccinated persons can not only acquire the Delta variant, but also can transmit it to others.  Recognizing this reality, the CDC has now again recommended universal masking in indoor public places.  

On the CDC/IDSA (Infectious Disease Society of America) clinician call of 7/31/21 (B), this Variant was noted to have >1,200 times the viral load of the original Wuhan variant, which may account for its much greater transmissibility.  The R0 has increased from 2-3 for Wuhan to 6-8 for Delta, which is similar to what is seen for more highly contagious illnesses like chickenpox.  This means that for every person infected, we can anticipate 6 or 8 new infections.  These factors help explain its rapid explosion to become the dominant variant in our country over June and July.  

In my community, we have had a 10-fold increased COVID testing prevalence from 2.2 to 21 cases/100,000 persons, and an increase in COVID-related countywide hospitalizations from 8-12 in early July, to 77 as of August 11 (our peak hospital census was 102 in January).  Our mortality has increased from 1 in May to 4 in June to 11 in July.  As of 8/10, we have had 1,149 BT cases, but only 3.2% have required hospitalization.  This means the vaccines remain very effective for preventing serious illness.

From a public health perspective, our team anticipates the Delta surge will further worsen without stricter infection prevention and public health measures.  When the efficiency of masks has been assessed, the most effective mask for preventing transmission and acquisition of this variant is the N95 mask (loops behind head) which are now readily available at Costco and other businesses.  Child-sized N95 masks now exist and are recommended for use at school, since our children have proven very susceptible to this variant.  The next most effective mask is the KN95 mask (loops over the ears).  While not as effective as N95's, these are usually more comfortable and are much more effective than cloth or other medical masks.  For myself, I will be wearing a medical mask with an overlying KN95 (improves the seal) when I’m indoor in public spaces or outdoors in public spaces where there’s singing, boisterous noise, or crowding.  Our time in these high risk settings should be minimized.  See the outcome of the outdoor crowd during the Milwaukee Bucks Championship games where over 500 cases of COVID likely occurred (C).  The outdoor space is not as safe as we once thought.  Multiple other outbreaks have now been reported that have been attributed to an outbreak in a crowded outdoor public gathering.  

On 8/5, our State Public Health Officer issued an order (D) mandating currently available COVID-19 vaccines for all HCP (Health Care Personnel).  The order is broad, including any health care entity in our state, any worker employed by a health care entity, and any contract worker/volunteer that does work for a health care entity.  Full vaccination status must be achieved by September 30 or that person cannot work or volunteer at a health care entity, unless they have an approved exemption (medical or religious).  Even with an exemption, the unvaccinated workers must be tested twice weekly (PCR or antigen test) if working at an acute health care or SNF setting and once weekly for other health care settings.  In addition, they must continuously wear an N95 mask while at work.  This vaccination order applies to those who have had COVID, since the COVID-19 vaccines have been proven to enhance natural immunity and further reduce the risk of acquiring the Delta variant by about 50% (E).  

Exemptions are allowed for medical, disability, or religious reasons.  The worker must complete and sign a declaration indicating the reason for exemption and must provide a written statement from a licensed physician, NP, or other licensed professional stating they qualify for the medical exemption.  A local CDPH  representative clarified on 8/12 that a declaration of a religious exemption could require an attestation from the HCP’s religion affirming their declination.  Your HR (human resources) department should study this order and develop acceptable processes for these exemptions that are consistent with the order and overall HR regulations and policies.  In addition, your HR department should update policies that codify expectations for your contractors, students, and other related entities..  

On 8/5, our State Public Health Officer also issued an order (F) regarding requirements for visitors to Acute Health Care Facilities, SNFs, and ICFs (Intermediate Care Facilities).  The order applies only to indoor visits.  These visits are only permitted if the visitor is fully vaccinated (verified by facility) or, if unvaccinated or incompletely vaccinated, the entity must verify documentation of a negative SARS-CoV-2 test (PCR or antigen) within 72 hr for each visit.  Facilities must track and file these tests and vaccination documents so that they are available for local health department case investigation. Visitors for a patient actively dying may be exempted from these requirements, but must wear a well-fitting mask (N95 – my perspective) upon entry and at all times within the facility.  The other prior indoor visitation requirements continue.  Outdoor visits that don’t require entering the facility are still permitted without these new visitor requirements.  

With the necessity for full vaccination of your work/volunteer force by September 9/30, now is the time to inform the unvaccinated of these new state orders and expectations.  It’s also the time to provide helpful information that may help those previously resistant to vaccination, to see the reasonableness of these orders.  To that end, I’ve attached a well-done and up-to-date 14-minute video on common COVID-19 Vaccine FAQ’s posted by JAMA Network 8/10 (G) and have also linked 2 excellent free articles (H, I) from the Annals of Internal Medicine in July that provide good reasons for mandating HCP receive a COVID-19 vaccine. Facilities should consider enlisting the support of their medical directors in having one-on-one conversations with vaccine-hesitant staff.

This Delta variant surge and the need to tighten our private and public health care measures is not the news we anticipated or wanted, based on the receding pandemic metrics of early June.  However, it’s our unfortunate reality.  Our vaccines are still very effective and by far our most effective intervention for preventing serious acute illness, long term disability, business shutdowns, and the unnecessary overload of our limited acute health care resources.  Please encourage the full support of your team and community for these necessary new measures.   

Reference links for above articles

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