So you think you can hug? (and other post-vaccination conundrums)
Updated: Jul 9, 2021
Some science communication is simple: trans fats are bad, measles is highly contagious, and smoking is addictive. Answering the question du jour, “What can I do after I am fully vaccinated?” requires more nuance. (N.B. Fully vaccinated means being two weeks or more past your final (or only) shot). Most public health messengers are unfortunately sidestepping this nuance in one of two ways:
Extreme risk aversion
The silent response, reasonable at the start of the vaccine rollout, goes something like this, “While we know the vaccines work very well, the clinical trials were designed to assess efficacy not transmission of asymptomatic disease so we cannot say / need to wait / will get back to you.” Since then, evidence has emerged that points to a dramatic reduction in the transmission of COVID-19 from those who have been fully vaccinated. These data come from places like Israel that are vaccinating quickly, as well as the recent Johnson & Johnson trials. It is early data, yet so far it is offering a consistent message: While it is plausible that vaccinated people can become infected with and transmit asymptomatic COVID-19, the likelihood is low.
The extreme risk aversion approach goes like this, from my amazing (but on this point, I fear unhelpful) local public health department:*nothing* changes after vaccination. This approach suggests the safest approach is abstinence. We could borrow a page from the AIDS epidemic and reconsider how realistic this is. Yes, it would be safer to wait for herd immunity, or for international vaccinations to gain traction, or even variant boosters to be approved and distributed. There will always be more data and more ways to reduce risk. But the “change nothing” approach is not realistic or necessary. Life becomes much less risky after vaccination. Once fully vaccinated, a person is less likely to get sick or transmit COVID-19, and is extremely unlikely to be hospitalized with or die from COVID-19.
Evidence for reduced transmission is inherent in the CDC’s recommendations that someone who is fully vaccinated and then exposed to COVID-19 does not need quarantine within three months* of completing vaccination, unless they have symptoms. If being exposed to known COVID-19 was considered a tangible risk for the vaccinated to transmit to others, this exemption would be hard to justify. Additionally, an Israeli study published last week in the New England Journal of Medicine indicates that full immunization with Pfizer-BioNTech is 90% effective against asymptomatic infection. No infection means no transmission; that is great news and a reason for post-vaccination life to look different.
Not everything is different. Masking in public will remain largely universal. Whether it is Delta Airlines or Trader Joe’s, there is no capacity for businesses to easily separate the vaccinated from the unvaccinated from the partially vaccinated, so universal masking just makes sense. Plus, it’s a nice show of solidarity with the many Americans (myself included) who are eagerly awaiting our turn at the front of the vaccination line.
As vaccines become increasingly common, questions of risk elimination are surfacing. However, these are not necessarily the right questions. Most salient are questions about how well vaccination mitigates risk both for those who are vaccinated and the unvaccinated who are around them. Nothing in life is safe in the absolute sense. From a public health perspective the important question is: safe compared to what? Is it safe to hang out with my vaccinated friends if I am also vaccinated? Indeed, I think that the best available evidence suggests it is. There is some tiny chance of infection but the odds that you are in a serious car accident on the way to this gathering are almost certainly higher than the odds of severe COVID-19 resulting from it. And compared to the risks of a gathering among unvaccinated people, this risk is trivial.
You may wonder, is it safe to hang out with my vaccinated friends if I am unvaccinated? That is where nuance is needed. If I were fully vaccinated, I would be excited to host vaccinated friends and family without concern. I would also consider hosting unvaccinated friends and family, but only one at a time so they do not expose each other. And this is a situation where risks should be weighed against benefits. Should you mask, ventilate, and distance in settings where the vaccinated and unvaccinated mix? I am a big fan of layers of protection, wherever it is feasible (unmasking for a meal in a well-ventilated space, re-masking when the meal is over, for instance). I have confidence in the vaccine; its protection, while imperfect, is potent. And remember – the dose makes the poison -- exposure to at least a minimum infective dose is required to transmit COVID-19. Vaccines greatly reduce the risk of hitting that threshold, and distancing, ventilation, and masks can add to that protection in mixed “vax status” settings that are becoming increasingly common.
Despite our public health silence, the message that vaccination makes a difference is out. The Bank of America I frequent has been virtually empty most of the pandemic. I pulled up yesterday to use the cash machine and had a hard time finding a parking space. I was worried about a line at the ATM but there was none. As I waited for the machine to dispense my cash, I watched who was coming and going. Not a person under the age of 65 was in sight. It was fantastic to see these seniors out and about. They had gotten the message - now that you are fully vaccinated, life, to some extent, can and should return to a new normal.
Vaccination enables us to resume so many essential quality-of-life activities that include friends, family, and community. Sure, anything could happen: a nasty variant could challenge vaccines; a side effect of a newer vaccine could hamper the rollout; vaccine efficacy could decrease over time; and the rare case of vaccine “breakthrough” (where someone gets sick despite vaccination) is possible.
Life is full of risks; that was true before and during this pandemic and it will be true when it is over. But the risks of social isolation, lost fitness routines, and delays in essential medical visits are real and impactful. It is our job as public health professionals to offer the information people need to make the best decision. By not communicating, we ask people to make a less informed decision. Evidence is available and growing that once fully vaccinated, someone is much less likely to be infected with COVID-19 (including asymptomatically) and that the risk of transmission is also greatly reduced. Vaccination is a great reason for so many who have been isolated for so long to see friends and family who are also vaccinated, to consider careful one-on-one interactions with the unvaccinated, and to feel that long-delayed warm embrace of those who care. We are rapidly entering the post-vaccination world. So you think you can hug**? I think so too!
*The three-month window is recognition that we do not yet know the duration of vaccination immunity, but I hope it will be extended if we learn about durable immunity from vaccine.
**Hugging between vaccinated people is extremely low risk; hugging that includes one unvaccinated person is also a very small risk. Hugging in general is a brief duration of exposure. For maximum hug-related risk reduction, turn your faces in opposite directions and keep it short but sweet.