While fully vaccinated people are a small percentage of those who contract COVID-19, some researchers are worried that racial disparities may persist among so-called “breakthrough” infections.
One major challenge, these experts said, is that many state and county health departments do not track breakthrough cases. And even when they track breakthrough cases, they often don’t track those cases by race.
Last month, in an opinion piece in The Washington Post, two researchers at Boston University and a prominent New York physician warned that the lack of data could hinder public health officials’ efforts to combat the coronavirus, particularly in communities of color that have been hit hardest by COVID-19.
“That there would be potential racial and ethnic inequities in COVID-19 outcomes among vaccinated people should be no surprise,” wrote Dr. Oni Blackstock, a New York HIV physician and founder of Health Justice; and Alexandra Skinner, a research fellow, and Julia Raifman, an assistant professor, both at Boston University School of Public Health.
“Historical and present-day policies, driven by structural racism, have created striking racial and ethnic inequities in wealth, health, education, work, housing and medical care,” they wrote in The Washington Post.
“Non-white Americans are thus more likely to hold front-line jobs, less likely to be able to work from home and more likely to live in crowded homes or neighborhoods,” they wrote. “These factors increase the risk of coronavirus exposure regardless of vaccination status.”
All of the COVID-19 vaccines have proven to be extremely effective at preventing severe illness and deaths. Still, breakthrough infections have gained the spotlight with high profile cases like that of Dallas Mayor Eric Johnson, 46, who said last week that while he is fully vaccinated, he has tested positive for COVID-19.
Last month, Colin Powell, the nation’s first Black secretary of state, died at 84 from COVID-19 complications. His age and underlying health conditions may have put him at higher risk.
Public health experts say it’s important to monitor data to help identify which populations may continue to be more vulnerable to infection.
“COVID hit [our society] in the context of structural racism and structural inequities in the United States due to historical policies and modern day policies,” said Raifman.
“This is a very important time for policies to counter structural inequities as well as to counter the immediate effects of the COVID pandemic,” she said.
Cecilia Tomori, the director of global public health and community health at Johns Hopkins School of Nursing, agreed that it’s important to monitor disparities. “The equity dimension consistently gets overlooked until people point out that it needs to be tracked,” she said.
At the national level, the Centers for Disease Control and Prevention transitioned in May to tracking only breakthrough infections that resulted in hospitalization or death.
New CDC data compiled from 14 states and two cities shows how often coronavirus infections occur in vaccinated and unvaccinated people. People who were not vaccinated were six times more likely to catch COVID-19 than people who were vaccinated. These unvaccinated people were then 12 times more likely to die from COVID-19 than those who had been vaccinated.
The federal data separates breakthrough infections and their outcomes by age group. Older people who were vaccinated were much less likely to die from a breakthrough infection than their unvaccinated peers. But age is a big risk factor for dying from a breakthrough infection, according to reporting from the New York Times.
Dallas County is one of the few in Texas tracking coronavirus infections in people who have been fully vaccinated, and that data is broken down by race.
“We definitely want to see if there are any particular subgroups that may have more breakthrough [infections] for whatever reason,” said Dr. Philip Huang, director of Dallas County Health and Human Services.
As of mid-October, a cumulative total of 11,300 people have tested positive for COVID-19 despite being fully vaccinated, according to data from Dallas County Health and Human Services. Of those, 528 people who were fully vaccinated had to be hospitalized, and 123 people who had breakthrough infections died.
Huang emphasized that although the number of breakthrough infections sounds large, it represents a very small proportion — only 2.8% — of total cases in Dallas County. The county has had a total of 402,023 COVID-19 cases.
He said county health officials are also monitoring any differences on the basis of which vaccine an individual received.
Raifman said that tracking the data and looking for any disparities is the best way to manage these disparities. When made aware of Dallas County’s data, Raifman said that, to fully evaluate any disparities, the county would need more data on hospitalizations and deaths resulting from breakthrough infections, broken down by race, ethnicity and age.
Having good data on what’s happening with breakthrough cases, Raifman said, is the best way to reduce deaths, keep people in the workforce and keep kids growing up with their parents. This data helps public health officials determine when different population segments would benefit from more vaccines and plan strategies to deliver those doses.
Raifman and many other researchers have documented throughout the pandemic how inequities made people of color more vulnerable to worse COVID-19 outcomes. For example, people of color often face higher occupational exposure to COVID-19.
A study published in the Journal of the American Medical Association: Internal Medicine looked at excess deaths of Latinos in California from March to August of last year. (Excess deaths are the difference between the observed number of deaths in a certain period and expected numbers of deaths in the same period.) The researchers showed that people who worked jobs like cooks and farmworkers had higher exposure to COVID-19 and the highest rates of excess mortality.
But the researchers did not see excess mortality among white health care professionals.
“We know that a lot of what was driving those disparities in the first year was simply access to the means to protect yourself from infection,” Alicia Riley, an assistant professor of sociology at the University of California, Santa Cruz, told The Dallas Morning News. Riley was one of the authors of the JAMA Internal Medicine study.
“Personal protective equipment and N-95 masks helped protect the people with the most privilege, despite their workplace exposure,” she said.
In June, the Occupational Safety and Health Administration finally released an emergency workplace safety rule requiring that health care employers implement an infection-control plan to protect their employees from COVID-19. But, the initial draft of the rule submitted to the White House had been intended to cover all workers, according to reporting from Bloomberg Law.
Blackstock, the New York physician, worries that if structural factors that put people at risk for exposure to COVID-19 haven’t changed, these trends on the disproportionate impact of COVID-19 on people of color could continue.
Other research during the pandemic has also shown that people of color were more vulnerable to severe disease due to higher rates of underlying medical conditions, Raifman said. And people of color who get COVID-19 may have lower quality health care compared to that of white people, she said.
“Policies that control the pandemic are really important for reducing racial disparities,” Raifman said. “When we don’t have policies in place to control the pandemic, it really exacerbates disparities.”
Vaccinated people can still transmit the virus to other people, Huang said. That’s the reason that the county health department recommends that vaccinated people should also still wear masks when indoors and in a crowded setting, he said.
“Even if any one individual’s risk is pretty low, at a population level, [the risk] adds up,” Justin Feldman, a fellow at the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University, told The News.
Writing in Slate in September, Feldman argued that “there are three main reasons I think we need to take breakthrough infections seriously. First, vaccinated people can still transmit the virus to people who are unvaccinated, including children who are not yet eligible for the vaccine.
“Second, there are people whose health conditions put them at high risk of hospitalization and death even if they are vaccinated. This includes people with certain immunocompromised conditions who may not respond as well to vaccines, even with a booster shot,” he wrote.
“Third, we are still learning about the risks of long COVID among the vaccinated. Even if a small percentage of breakthrough infections lead to persisting symptoms, that adds up to a large number of people when infections are widespread,” he wrote.
A CDC study published last month showed that 70% of vaccinated people incarcerated in a federal prison in Texas tested positive for COVID-19. “That is an exceptional circumstance, because these are extremely bad conditions, so the exposure levels are very high,” Feldman said. “But to me, that reinforces the main point of my Slate piece: that if exposure is high, breakthrough infections can be a serious problem.”
“If we continue to allow a lot of deaths to happen and a lot of [community] spread to happen,” he said, “we’re going to have a lot of people who are vaccinated dying of COVID — even if it’s a small percentage [of overall deaths].”
Feldman told The News that officials should be trying to prevent breakthrough infections through non-pharmaceutical interventions, including mask requirements, improved workplace protections and paid sick leave for quarantine.
“All of the [COVID-19] mitigation strategies are stronger together, and policies effectively scale up [these] strategies,” Raifman said. “If we just say we recommend them, then what ends up happening is that the highest-income places have great ventilation and great rapid testing programs and great vaccine coverage.
“I think unfortunately when there’s really widespread community transmission, breakthrough cases are not rare,” she said. “We have to realize that controlling community transmission is good for everyone.”