By Rose Hoban
This week, the North Carolina Department of Health and Human Services announced that the state had the highest day over day spike in intensive care admissions one day this week since the start of the coronavirus pandemic in early 2020. On Monday alone, 55 people landed in ICU beds, and the data show that last week, there were 547 people aged 25-49 who ended up hospitalized, a record.
It’s hard to believe that on July 1, North Carolina had only 391 people in the hospital with COVID-19, and only 53 people on ventilators. Fast forward to August 11, more than 2,300 people are hospitalized and 586 people are in ICUs with 280 of them on ventilators.
The Delta variant of COVID has exploded at a time when people are planning vacations and planning to get their kids back into school. NC Health News reached out to David Wohl, an infectious disease doctor at UNC Health Care and one of the country’s leading HIV researchers and practitioners. Wohl has been focused since early 2020 on COVID and he talked with us in between seeing patients. (Answers have been edited for brevity and continuity.)
Got a question for Dr. Wohl? Join us on Thursday morning, August 19, for Health Care Half Hour, when he will answer reader questions live. Send your question(s) to firstname.lastname@example.org
NCHN: This summer was so nice, not having to wear masks all the time, but now the word is coming that we should mask up again. Can you help us make sense of this?
David Wohl: Yeah, the reason why masking now is as important, or maybe even more important than ever, believe it or not, is that the Delta variant, this new version of the COVID-19 virus has this unfortunate feature of being able to replicate in our noses and mouths really well. You get very high levels of virus in those spaces, which means you’re much more infectious if you’re vaccinated or not, at least initially.
It doesn’t seem to matter as far as how much virus you’ve got in your nose and throat in the beginning. Vaccinated people seem to shed it for a shorter period of time and [they] don’t then let the virus go down into their lungs and cause pneumonia and get them really sick. It just stays there and goes away. But for a short period of time, both vaccinated and unvaccinated people are shedding this virus. That means, unlike before where my vaccinated friends and I would get together indoors, and maybe even share a meal, now that is unkosher.
Now with this Delta variant, they could be harboring – unknowingly because they’re vaccinated and feel great – the virus in their nose and throat and could shed it to other people. That’s why I wear a mask around anyone who is not my wife, daughter or son, if I’m indoors,
NCHN: It feels like we’re losing that freedom that we were starting to get back this summer. You mean we have to just not do this anymore?
Wohl: We can’t, as we’re learning on so many levels, play with Mother Nature, and not, you know, get burned. We can’t predict what’s going to happen in nature and the Delta variant is something that came along. It’s not an administration’s fault, it’s not the CDC’s fault, it’s not the FDA’s fault, it’s not my fault. The Delta variant came along because viruses will mutate to get around whatever is impeding it and right now, the number one thing impeding this virus are the antibodies we produce.
The great majority of people in the world are not vaccinated and that means the virus is replicating, it’s bouncing from person to person. People’s immune systems are trying to get rid of it, to neutralize it. The virus that survives is the virus that can evade those antibodies. So, this virus evades our initial salvo of antibodies and can perpetuate and replicate and be happy as a clam in our nose and throats for a longer period of time than previous variants. If we had vaccinated the entire planet within about three months, we would not be in this situation.
NCHN: But what if my friends and I are all vaccinated? You mean I can’t have them over for dinner? I still have to worry? Why am I having to worry?
Wohl: I hate to be the negative person or Cassandra of doom, that doesn’t make me happy! But I’m an infectious disease specialist, that’s my job. And we do know that the Delta variant is much more catchy. And we do know that people who are vaccinated while protected – amazingly well from getting really sick – are not protected from having the infection come into their nose and throat.
No vaccine makes you impervious to a germ. [Vaccination] doesn’t mean germs bounce off of you or avoid you because they know you’re vaccinated. The way that a vaccine works is like a smoke alarm, when there’s smoke, the alarm is triggered and reacts. When the germ comes into our body when we get infected, the vaccine has taught our immune system to pounce on the germ and get rid of it.
There should be no thoughts of, ‘Well the vaccine failed, because now I have the germ in my nose or throat.’ No! That’s the whole design. These germs do get into our system, and then we get rid of them when we’re vaccinated. But for a short period of time, vaccinated people can shed the virus and infect other people.
NCHN: What about people over for dinner on your deck?
Wohl: Outside. I’m all good. Anyone will tell you I am a huge advocate for outside and I will jump to the conclusion right now that Delta, even if more infectious, outdoors still doesn’t do a great job of being transmitted.
I keep a pretty healthy distance around people. I work out in the morning with a group of guys we meet outdoors, we’re not in each other’s face. We don’t touch each other. I feel comfortable with that, with some distance between us. I don’t wear a mask when we’re exercising.
Same thing if I have my neighbors from down the road come over, we can eat outside, we’re, you know, feet apart. I think that that is safe, or is it 100 percent safe? I think it’s highly unlikely and again, with enough distance and enough outdoors and yes, I’m totally okay with doing that.
NCHN: So here it’s mid-August and here’s the big question: What about kids going back to school?
Wohl: You know, this is really not rocket science. If we were as objective and scientific as possible, and we were able to get the politics and wishful thinking and inconvenient truths out of the picture, we would all recognize that younger children are unvaccinated, younger children can get infected with the Delta variant, and younger children can even get sick with the Delta variant, maybe more likely than with previous variants.
Schools are a place where we’re likely to see transmissions.
It would make sense then, what’s the next best level of protection, or a complimentary level of protection? The next level is can we create a barrier that keeps the virus from leaving my mouth and entering into your nose or throat, and we have those barriers, and you know what? They’re simple, they’re cheap, they’re easy. They’re called masks and we have great data.
I think most people have probably heard folks from Duke have done an amazing job in studying this. They had a very nice piece in The New York Times on August 10, that showed after studying basically, a million kids masks universally applied in schools do reduce the rate of transmission. That was pre-Delta mostly, but it’s gonna stand up to Delta, maybe even more so.
Masks work. Kids in school should be wearing masks universally, it should not be an optional thing, that will not work to protect themselves and protect adults in their lives.
I’m vaccinated, I do not want a little kid to cough on me and make me even just sick a little bit. I don’t want to be sick for three or four days, I don’t want to be isolated and not able to get to work for 10 days. For vaccinated people, COVID-19 – for most of us – is a nuisance. For unvaccinated people, it could be deadly.
Johnston County just announced, and other counties or school systems are announcing, mandatory masking in school. That is very, very smart and follows the science.
NCHN: Speaking of schools, you know, the CDC has said that three feet apart is enough for kids in schools. Is it enough?
Wohl: What’s really interesting about the Duke data is that masks kind of took care of the distance thing, the distance thing has always been a little thorny. Certainly pre,-Delta is different than post-Delta or during Delta.
I worry that a lot of factors have to do with this distance thing. One is ventilation in the room. People don’t talk about it as much, but not every room is created equal, and not every room is ventilated the same way. I feel really we can’t have an ironclad rule about distancing, we all know in schools distancing is really tough.
Thus the very safest scenario that we can do is one, kids wearing a mask and another, kids double masking. That’s where you’re going to see opportunities for transmission minimized regardless of the distance. We should always encourage people not to be right in each other’s faces as much as possible.
You know, schools should do what they can, but the mitigation strategies in schools that include universal masking are effective.
Look, my 17-year-old is going to go back to school. He will wear a mask. Is the risk zero? No. But I think the risk is low enough that we’re willing to take that chance. And we know the adverse effects of him being home last year were significant.
As a community, as a society, I think people are realizing kids should go back to school. But we should stack the odds in their favor and stack the odds in our favor, that we’re not going to have school closures, or that a staff member is going to get sick and hospitalized, or that a kid’s going to bring home the virus to infect somebody.
NCHN: What about during lunch?
Wohl: The Orange County schools are really thoughtful about this, and they are going to try to provide opportunities for kids to eat out of doors as much as possible. They’re even, I think, erecting tents, which makes a lot of sense.
When I meet with people and I have to meet with them face-to-face, I meet with people outdoors under tents. You can do that in a variety of ways. When it’s not possible, the school system is going to come up with other creative solutions. That involves distancing in large spaces that I think will help mitigate some of the risk.
There’s no such thing as zero risk. And I come from a background of HIV and there are some similarities in which we use barrier methods, basically condoms, to prevent transmission sexually.
That makes sense. We don’t have a vaccine [for HIV]. Most people would agree condoms work because they’re a physical barrier that doesn’t let the virus go from one person to another. It’s really perplexing to me that some folks don’t believe that masks work, because it is a physical barrier, in a very similar sort of manner, they physically prevent transmission from one person and then receipt from the other person.
NCHN: You mean masks are almost like a face condom?
Wohl: (laughs) They sort of are, but, you know, are a little bit more breathable.
That’s the key thing, they allow you to be able to breathe, they allow you to be able to talk. In some ways, there are analogies where a barrier doesn’t have to be something that stops you from functioning but it’s something that makes sense. It keeps you and those around you safer.
A lot of this mask resistance is wishful thinking, or symbolic, or political, and there are people who will benefit from our pandemic not being well-controlled during this administration. I don’t want to be super-cynical but I think we have to be very cautious about people who are telling us to do things that science tells us are risky. We need to understand, either they are misinformed or they are malignant in that they have objectives which are not good for our health and our well-being.
I really ask consumers of information to be aware of the [information] source and what their motives are. I don’t get anything from telling people to wear masks, I don’t have stock in mask companies. What I want people to do is not get sick, not get in the hospital, not infect me or my family or others in our community or state or country.
We want this pandemic to end. We want to get back to normal, why not use the tools that are available?
NCHN: Another question about kids that we’re hearing from some folks is that right now the vaccine is approved for kids who are 12 and older, what if my kid is 11-and-a-half, could I just take my kid to the doctor and get her vaccinated?
Wohl: I’m all about playing by the rules for this one.
People who know me know that I’m not the biggest rule follower and that I do color outside the lines and try to be creative when I think there is a greater good at stake. But in this case, with the vaccines, I think we should play by the rules and then urge the rules to be changed if they should be changed.
I would not get a booster. If you’ve had the Moderna or Pfizer or a second shot if you had Johnson & Johnson, getting a booster shot, that’s being sneaky. I do agree that there’s maybe some good rationale for boosters although it has to be a little bit better sussed out. But until this is authorized, I wouldn’t cheat.
In the meantime, do what makes sense: be careful around people outside your bubble and be really careful to reduce your risk of exposure.
NCHN: Say I went and got a Johnson & Johnson vaccine and I’m nervous. Can you mix and match vaccines?
Wohl: So right now, I think there are some people who are thinking hmmm, maybe my Johnson & Johnson wasn’t the best vaccine to get, but it’s a really good vaccine! We’re not seeing anything right now that suggests that people who got Johnson & Johnson are getting in the hospital more, or are getting really sick, or that there’s even more of these symptomatic infections that are mild with Johnson & Johnson.
I would not go out and try to get another vaccine right now, but there are really compelling data that mixing the vaccines may actually be a good thing, not a bad thing. Now there are studies from Europe that have looked at this. And I think you will see mixing and matching when we come to the boosters, that will be actually a good thing.
NCHN: If I’m vaccinated, is it safe to travel?
Wohl: Outside of staying at home and being a hermit, everything involves some degree of risk. And so for me, my risk tolerance right now is really not accepting of going on a vacation. That doesn’t pass the threshold of being worth the risk involved in travel right now, even with all the protections in place.
NCHN: What if you get in your own car and go to the house that you’re renting. That’s not a problem, right?
Wohl: I’ve done that. We drove to the mountains, we were in our own car, we stayed in an Airbnb, we didn’t eat indoors.
If you’re getting on a plane, if you’re renting a car, in the places that you’re going, you just have less control over your environment, oftentimes, so people have to make a personal decision. It’s all a risk-benefit calculation. And if the benefit is high enough, it may balance out or surpass the risk, but everyone has to think about it.
I am very worried right now because we have a very, very, very contagious variant that is increasing, not decreasing right now. And if you go about your business as normal, you are like the proverbial ostrich with, you know, her head in the sand and so I think you should not be blind to the reality around you. We are in a crisis right now.
NCHN: So, why are people getting so-called breakthrough infections?
Wohl: It’s not 100 percent of people who get vaccinated that get protected from the vaccine.
Even in the studies, we knew 95 percent efficacy, that means all the COVID symptomatic infections in these studies, 95 percent [of those infections] were in people who are not vaccinated.
What about that 5 percent of people who got vaccinated? They ended up getting a little bit sick. So we knew already there was going to be some breakthrough, if you will, from the beginning. And that’s what we’re seeing with Delta, it’s probably a little bit more.
This is not news, we knew about this. It’s important. I think we should realize that even some of our vaccinated people who are immunosuppressed, whether they know it or not, [from taking] immunosuppressive medicines, and then older people, there can be folks who the vaccine didn’t really take very well. And we can’t identify those folks really well.
NCHN: One of the things I’ve been hearing from folks is that we’re seeing people who are younger, and then they’re coming in sicker.
Wohl: Yeah. In general, in infectious diseases, if you get infected with more of a germ, it generally leads to more severe illness. So I’m not too surprised that when we’re talking about Delta, there’s such an amount of virus present, a larger amount than what we saw before. I think that gives the virus an upper hand to make people more symptomatic and sick.
If you’re not vaccinated, you know, the gates are down, the moat is dry, the doors are open, the windows are open, and you’re just vulnerable. There’s nothing protecting you, your immune system can’t react right away. It takes days, if not a couple of weeks to react. You’re wide open.
With something like Delta, it’s just gonna lay you low. A lot of those folks, especially if you have risk factors for severe disease, even these young people who say, “Oh, my immune system would take care of it,” [it will be] a week or two before that. You’re at the mercy of the virus.
The difference between a vaccinated person and non-vaccinated person is my immune system should be primed. So it doesn’t take two weeks to develop antibodies, it takes a much shorter period of time for my antibodies to be elicited, they may even be circulating around the time the virus comes along. So I’ve got the jump-start.
The other thing was for anyone whether they’re vaccinated or not, they should be aware that there is treatment. Monoclonal antibodies are something that people haven’t heard about. [They] are antibodies not produced by you, not produced by your vaccine, but they’re produced in a lab, and they’re designed to attach and neutralize the COVID-19 virus, including the Delta variant. They can be infused and if they’re infused into your system, they work within minutes, hours.
Getting people to know that there are monoclonal antibodies that are authorized by the FDA for treatment right now is important because I feel a lot of people don’t know about that. Their providers don’t know about it. And we’re missing out on something that in clinical trials has been shown to reduce the risk of people getting hospitalized and probably dying.