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This Is Not a Pandemic of the Unvaccinated

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Some politicians speak about the “pandemic of the unvaccinated.” But fully vaccinated individuals can harbour high viral loads, spread SARS-CoV-2 and cause severe and fatal Covid-19, also among other fully vaccinated individuals. Social cohesion should not be jeopardized because of an erroneous and narrow view of the epidemiological situation.

At the beginning of the pandemic, large numbers of Covid-19 patients in China (79.8%) felt discriminated against. They were seen as a threat to others. Once the vaccination became available, they were less frequently seen as a threat presumably because the vaccinated felt safe (1).

Currently, however, unvaccinated people are increasingly being blamed for the pandemic. In July 2021, U.S. President Joseph Biden made the following comments: “Look, the only pandemic we have is among the unvaccinated“ (2). Germany’s health minister Jens Spahn said in August 2021 that they are currently seeing a “pandemic of the unvaccinated.” Between 90% and 95% of Covid-19 patients in intensive care units are unvaccinated, he said (3). 

The Austrian chancellor Sebastian Kurz used the same wording in September 2021 (4). Even the German TV channel ZDF used this wording as a news headline. After high-ranking politicians released this choice of words for use in public, individual scientists followed suit a short time later. 

Goldman recently blamed the unvaccinated to serve as a pool for variants and that the unvaccinated threaten the vaccinated. Only one part of the population is seen by him as a threat when he describes the unvaccinated as a “breeding ground for the virus to continue to generate variants” and speculates that “lockdowns and masks will once again be required” and that “many more who are currently protected, especially among the vulnerable, will die” because some people do not get vaccinated (5). 

These are serious accusations from a scientist against a part of society. But are they justified?

What is a pandemic?

The International Epidemiology Association’s Dictionary of Epidemiology defines a pandemic as “an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people (6). The definition has never been restricted to a specific part of the population like the unvaccinated, the elderly or the obese. The term “pandemic of the unvaccinated” is therefore not an epidemiological or scientific term but rather a political one.

The increasing stigmatization of “the unvaccinated”

Unvaccinated citizens in Germany experience increasing stigmatization and separation from the rest of society. In a number of federal states, the legal basis has been established allowing restaurants to exclude unvaccinated people to eat inside even if tested negative for Covid-19. Attending cultural events organized by the local authorities is not allowed in some cities in Germany. In these settings, vaccinated and recovered citizens, however, do not need to keep physical distance from others and do not need to wear a mask. 

Decisionmakers assume that they cannot really be a source of transmission. In the federal states of Lower Saxony and Hessen the governments now even allow supermarkets to deny shopping to the unvaccinated with a negative test result.

Vaccination offers only partial protection

The phase 3 trials of Covid-19 vaccines clearly show that vaccination results only in a partial protection for Covid-19, not in a full protection (7-10). More and more reports are published providing epidemiological evidence for only partial protection of the vaccinated. In Massachusetts, a total of 469 new Covid-19 cases was detected during various events in July 2021, of which 346 cases occurred in those who were fully or incompletely vaccinated (74%). 274 of these affected individuals were symptomatic (79%). Ct values were comparably low in all groups (median: 21.5 to 22.8), indicating a high viral load, even among the fully vaccinated (11). 

The largest evaluation of breakthrough infections to date comes from the United States. There, a total of 10,262 Covid-19 cases were reported in vaccinated individuals by April 30, 2021, of which 27% were asymptomatic, 10% were hospitalized, and 2% died (12). In Germany, the rate of symptomatic Covid-19 among the fully vaccinated (“breakthrough infections”) is reported weekly since July 21, 2021, and was 16.9% at that time among patients of 60 years and older (13). 

This proportion is increasing week by week and was 57.0% on 20. October 2021, providing clear evidence of the increasing relevance of the fully vaccinated as a possible source of transmission. Similar findings on the number of Covid-19 cases among the fully vaccinated were reported from the UK (14).

Another example is a professional soccer team in Germany where 12 new cases were recently detected. Some players showed relevant symptoms of Covid-19. Ten players were vaccinated, most of them fully vaccinated, one player was recovered and one player unvaccinated. The football club was perplexed and could not really explain the outbreak. 

The public discussion was conducted in a manner that the unvaccinated player was suspected as the source for viral spread. But he had the lowest viral load of all players; the viral RNA was barely detectable in his two samples suggesting that other players are much more likely to be the source of the outbreak (15).

Recently, an outbreak occurred in Münster, Germany, among 380 people who were either fully vaccinated or recovered from Covid-19. They attended a club resulting in at least 85 new Covid-19 cases (16).

Recent data on the number of new Covid-19 cases in various US counties with different vaccination levels indicate that there is no discernible relationship between the percentage of population fully vaccinated and new Covid-19 cases. Of the top five counties that have the highest percentage of population fully vaccinated (99.9–84.3%), the US Centres for Disease Control and Prevention (CDC) identifies four of them as “high” transmission counties (17).

In Israel a nosocomial outbreak of Covid-19 was reported involving 16 healthcare workers, 23 exposed patients and two family members. The source was a fully vaccinated patient who was diagnosed to have Covid-19. Under all exposed individuals (151 healthcare workers and 97 patients) the vaccination rate was 96.2%. Fourteen fully vaccinated patients became severely ill or died, the two unvaccinated patients developed mild disease (18).

Fully vaccinated persons with a Covid-19 infection were still able to excrete infectious SARS-CoV-2 six to seven days after the onset of symptoms in half of the cases (19). Even transmission from fully vaccinated Covid-19-infected persons has been described (20). Finally, the CDC reported that the delta variant appears to produce the same high levels of virus in both unvaccinated and vaccinated individuals (21).

Vaccinated people may even accelerate the spread of SARS-CoV-2

One benefit of vaccination is that severe courses of Covid-19 become less likely and thus the symptoms of infection are milder in vaccinated individuals. Thus, some vaccinated patients will have only mild symptoms who would have experienced severe symptoms without vaccination. Other vaccinated patients will have no symptoms who would have experienced only mild symptoms without vaccination. 

Vaccinated people usually behave in a more risk-taking way, they have more contacts, go to concerts and parties more often. They are no longer tested in Germany and are not quarantined. It is a carte blanche for an almost normal social life. If they become infected, they often have no or only mild symptoms and thus do not recognize their infection or recognize it too late. As a result, the expected wave among the vaccinated would hardly be visible. It is to be feared that infections in Germany will spill over from there to the currently 3.4 million unvaccinated people over 60 (22).

The phase 3 trial with AZD 1222 showed already that the proportion of asymptomatic Covid-19 cases is similar among both the vaccinated and unvaccinated study participants (1.0% versus 1.0%) underlining the relevance of asymptomatic vaccinated individuals as a potential source for transmission (7). The increasing proportion of breakthrough infection in countries with a high vaccination level shows in addition that the virus multiplies in both the vaccinated and unvaccinated.

The vaccinated may contribute to variants

In the world of bacteria, Darwin’s principle of the survival of the fittest is known that any selection pressure caused by antibiotics and biocidal agents enhances tolerance, finally resulting in a cellular adaptive response which enables the cell to survive in a rather hostile environment (23). If this principle is transferred to viruses, it may well be that the vaccinated with a partial immunity for Covid-19 could have better contributed to the development of variants that can at least partially escape human immune responses (24). 

Given the emergence of immunity-evading variants even before vaccines were broadly deployed, it is hard to implicate vaccines or vaccine deployment strategies as the major drivers of immune evasion (24). That is why it seems to be possible or even likely that the infected vaccinated can also be a pool for variants and thereby continue to contribute to the pandemic.

Side of effects of stigmatization

To stigmatize people is deeply discreditable or undesirable. It is a social process of labelling, stereotyping, and prejudices that lead to segregation, devaluation, and discrimination. Stigma may also be a barrier to help-seeking. People may not use services such as diagnostics, prevention, and/or treatment in order to avoid stigma. 

Therefore, fear associated with stigma and discrimination has significantly compromised public health. Stigma is likely to have a negative impact on the quality of life of affected persons, their family, health programs and society. 

Yuan et al. proposed that public health education with scientific-based information and an anti-stigma campaign are probably the most effective ways to prevent social harassment of at-risk groups. They encouraged community leaders and public health officials to avoid using negative languages that may cause stigmatization, and to provide community and social support to challenge stereotypes and stigmatization (25). 

Amnesty International writes that discrimination occurs when a person is unable to enjoy his or her human rights or other legal rights on an equal basis with others because of an unjustified distinction made in policy, law or treatment. This seems to be the case with “the unvaccinated” in some parts of the world.

Conclusion

The vaccinated have a lower risk for severe disease but are still a relevant part of the pandemic. It is therefore wrong to speak of a “pandemic of the unvaccinated.” However, this description seems to be a welcome message for politicians in various countries, on the one hand to further increase the willingness to vaccinate, and on the other hand to blame the recalcitrant unvaccinated for inconvenient measures. 

As a result, these accusations can further complicate the already sometimes difficult dialogue between representatives of different viewpoints and subsequently lead to increased social division. 

Historically, both the United States and Germany have bad experiences with stigmatizing subgroups of the population for their skin color or religion. That is why the term “pandemic of the unvaccinated” should not be used by high level politicians and scientists. Social cohesion is a high value that should not be jeopardized because of an erroneous and narrow view of the epidemiological situation.

References

1. Li L, Wang J, Leng A, Nicholas S, Maitland E, Liu R. Will COVID-19 Vaccinations End Discrimination against COVID-19 Patients in China? New Evidence on Recovered COVID-19 Patients. Vaccines. 2021;9(5).

2. Miller Z. Biden grappling with ‘pandemic of the unvaccinated.’ 27. September 2021. Available from: https://apnews.com/article/joe-biden-health-government-and-politics-pandemics-coronavirus-pandemic-8318e3f406278f3ebf09871128cc91de.

3. Anonym. Germany is seeing ‘pandemic of the unvaccinated,’ says Health Minister 27. September 2021. Available from: https://www.thelocal.de/20210824/germany-is-seeing-pandemic-of-the-unvaccinated-says-health-minister/.

4. Anonym. Regierung legt neue Maßnahmen vor: „Pandemie der Ungeimpften“ 28. September 2021. Available from: https://www.tt.com/artikel/30800507/regierung-legt-neue-massnahmen-vor-pandemie-der-ungeimpften.

5. Goldman E. How the unvaccinated threaten the vaccinated for COVID-19: A Darwinian perspective. Proceedings of the National Academy of Sciences of the United States of America. 2021;118(39).

6. Singer BJ, Thompson RN, Bonsall MB. The effect of the definition of ‘pandemic’ on quantitative assessments of infectious disease outbreak risk. Scientific reports. 2021;11(1):2547.

7. Voysey M, Clemens SAC, Madhi SA, Weckx LY, Folegatti PM, Aley PK, et al. Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK. Lancet. 2021;397(10269):99-111.

8. Baden LR, El Sahly HM, Essink B, Kotloff K, Frey S, Novak R, et al. Efficacy and Safety of the mRNA-1273 SARS-CoV-2 Vaccine. N Engl J Med. 2021;384(5):403-16.

9. Polack FP, Thomas SJ, Kitchin N, Absalon J, Gurtman A, Lockhart S, et al. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. N Engl J Med. 2020;383(27):2603-15.

10. Logunov DY, Dolzhikova IV, Shcheblyakov DV, Tukhvatulin AI, Zubkova OV, Dzharullaeva AS, et al. Safety and efficacy of an rAd26 and rAd5 vector-based heterologous prime-boost COVID-19 vaccine: an interim analysis of a randomised controlled phase 3 trial in Russia. Lancet. 2021;397(10275):671-81.

11. Brown CM, Vostok J, Johnson H, Burns M, Gharpure R, Sami S, et al. Outbreak of SARS-CoV-2 Infections, Including COVID-19 Vaccine Breakthrough Infections, Associated with Large Public Gatherings – Barnstable County, Massachusetts, July 2021. MMWR Morbidity and mortality weekly report. 2021;70(31):1059-62.

12. COVID-19 Vaccine Breakthrough Infections Reported to CDC – United States, January 1-April 30, 2021. MMWR Morbidity and mortality weekly report. 2021;70(21):792-3.

13. Robert Koch-Institut. Wöchentlicher Lagebericht des RKI zur Coronavirus-Krankheit-2019 (COVID-19). 22.07.2021 – AKTUALISIERTER STAND FÜR DEUTSCHLAND 28. September 2021. Available from: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Situationsberichte/Wochenbericht/Wochenbericht_2021-07-22.pdf?__blob=publicationFile.

14. UK Health Security Agency. COVID-19 vaccine surveillance report. Week 408. Oktober 2021. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1023849/Vaccine_surveillance_report_-_week_40.pdf.

15. Galler S. Hachings Präsident Manfred Schwabl kann sich den Corona-Ausbruch in der Mannschaft kaum erklären 28. September 2021. Available from: https://www.sueddeutsche.de/sport/regionalliga-bayern-zehn-geimpft-einer-genesen-1.5419806.

16. Dolle F. Münster: Inzwischen 85 Infizierte nach 2G-Party im Club 23. September 2021. Available from: https://www1.wdr.de/nachrichten/westfalen-lippe/corona-infektionen-clubbesuch-muenster-100.html.

17. Subramanian SV, Kumar A. Increases in COVID-19 are unrelated to levels of vaccination across 68 countries and 2947 counties in the United States. European Journal of Epidemiology. 2021:1-4.

18. Shitrit P, Zuckerman NS, Mor O, Gottesman BS, Chowers M. Nosocomial outbreak caused by the SARS-CoV-2 Delta variant in a highly vaccinated population, Israel, July 2021. Euro Surveill. 2021;26(39).

19. Pollett SD, Richard SA, Fries AC, Simons MP, Mende K, Lalani T, et al. The SARS-CoV-2 mRNA vaccine breakthrough infection phenotype includes significant symptoms, live virus shedding, and viral genetic diversity. Clinical Infectious Diseases : an official publication of the Infectious Diseases Society of America. 2021.

20. Kroidl I, Mecklenburg I, Schneiderat P, Müller K, Girl P, Wölfel R, et al. Vaccine breakthrough infection and onward transmission of SARS-CoV-2 Beta (B.1.351) variant, Bavaria, Germany, February to March 2021. Euro Surveill. 2021;26(30).

21. CDC. Delta Variant: What We Know About the Science 11. August 2021. Available from: https://www.cdc.gov/coronavirus/2019-ncov/variants/delta-variant.html.

22. Heinze S. Alexander Kekulé: „Ich rechne mit einer unsichtbaren Welle der Geimpften“ 24. September 2021. Available from: https://www.rnd.de/gesundheit/corona-alexander-kekule-warnt-vor-kompletter-oeffnung-im-herbst-MKTLTHYRFJFWLLZ65UAEE5U3KQ.html.

23. Kampf G. Adaptive bacterial response to low level chlorhexidine exposure and its implications for hand hygiene. Microbial cell (Graz, Austria). 2019;6(7):307-20.

24. Krause PR, Fleming TR, Longini IM, Peto R, Briand S, Heymann DL, et al. SARS-CoV-2 Variants and Vaccines. N Engl J Med. 2021;385(2):179-86.

25. Yuan K, Huang XL, Yan W, Zhang YX, Gong YM, Su SZ, et al. A systematic review and meta-analysis on the prevalence of stigma in infectious diseases, including COVID-19: a call to action. Molecular Psychiatry. 2021.

Brownstone Authors and Contributors

  • Prof. Dr. Günter Kampf Consultant hospital epidemiologist and Associate Professor for hygiene and environmental medicine at the University Medicine Greifswald, Institute for Hygiene and Environmental Medicine, Germany.

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