The Provincetown cluster

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Sean Rameswaram: Welcome to Today Explained. I'm Sean Rameswaram.

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Sean Rameswaram: Provincetown is this little community up on the tip of Cape Cod. The New York Times called it a vacation mecca for the LGBTQ community. And so Fourth of July weekend, everybody's excited. about 60,000 people came into town ready to party. The bars were open. The clubs were open. And this is, you know, a community. One of the local leaders said they thought about 90% of people there were vaccinated against COVID-19. The guidance from the CDC at that time said, you know, if you've been vaccinated, you can go out without a mask. You can go to a bar. You can go to a club and dance with your friends. On the 4th in early July, the area around Provincetown was reporting zero COVID cases. So this really seemed like a post-COVID world. But as it turned out, COVID-19 and the Delta variant specifically was still lurking. A week, two weeks after the 4th of July, after everybody went home, some cases started to pop up around Provincetown. The local authorities there started doing some contact tracing. They had this team of nurses who were calling people up asking, all right, so what were you doing a week or two ago? And as it turned out, there were a lot of people who were infected with the coronavirus who had been partying in Provincetown on 4th of July weekend. So at this point, I think we're up to nearly a thousand cases that have been linked back to the 4th of July festivities at Provincetown. And this was obviously like a pretty scary case study because, you know, here's a highly vaccinated community, people, you know, who were living by the CDC guidance at the time, and suddenly you've got this major cluster of cases. So that data and this whole story of Provincetown, I think, really fundamentally shifted how the CDC and public health authorities in general are thinking about the COVID-19 pandemic right now.

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Dylan Scott: What are the new guidelines that just came out from the CDC last week? So the CDC said if you've been vaccinated, you don't need to wear a mask anymore in basically any setting. Right. That was back in May. What are they saying now?

Sean Rameswaram: Well, last week, the CDC walked back that guidance pretty significantly. It's not the kind of news we hope for from the CDC these days, but today it was the news we got. The CDC has just changed its current guidance about when Americans should wear masks in response to the alarming spread of the highly infectious Delta variant of COVID-19. And so last week, the CDC said actually, in places that have high rates of coronavirus spread, high rates of new infections, we would recommend everybody wear masks indoors, in public settings, including vaccinated people, because there is some risk that they could contract the virus with the new Delta variant becoming more dominant. And there's some risk that they could spread it to other people, too. So this was, if not a total about-face, a pretty significant revision. If you're indoors in a place where there's a lot of COVID spreading around, you should probably wear a mask.

Dylan Scott: Did they say why they were updating their guidance? So initially, no. If you want to at least make a recommendation on policy, you cannot lie about the data or provide us no data and then expect us to follow your all-knowing guidance. Initially, it seemed kind of, other than the general, you know, the Delta variant is taking hold in the U.S., we have seen cases rising for the last few weeks, hospitalizations rising. Other than the big picture was clearly getting worse, it wasn't actually obvious at first why the CDC was changing its tune on masking for vaccinated people specifically. But then on Thursday night, the Washington Post broke a story about an internal CDC document that explained the agency's reasoning in more detail. The Post writes tonight, quote, The document is an internal Centers for Disease Control and Prevention slide presentation shared within the CDC The document strikes an urgent note revealing that the agency knows it must revamp its public messaging to emphasize And it became pretty clear that Provincetown, Massachusetts, and the outbreak that had been sourced there and from its 4th of July celebration was a really highly motivating factor for the CDC to revisit the guidance. We now see in our outbreak investigations that have been occurring over the last couple of weeks, in those outbreak investigations, we have been seeing that if you happen to have one of those breakthrough infections, that you can actually now pass it to somebody else. So I think it's certainly more complicated than just Provincetown, but I think all of that put together is what motivated the CDC to say, look, we should probably ease back a little bit and recommend that people wear masks more often than we were before.

Dylan Scott: So that Provincetown cluster where there were like hundreds of new COVID cases among thousands of mostly vaccinated people, what did the CDC learn from that cluster? So I think there were a couple of things. One was there was a high rate of breakthrough infections compared to what we might have expected when we've heard, you know, that these vaccines are 95% effective at presenting any illness. You know, we're talking about up to a thousand cases now. And three-fourths of those, according to the CDC study, were vaccinated. And beyond that, something that they found when they did some genetic analysis of the virus that people were carrying. vaccinated people who were infected appeared to be carrying as much of the virus as people who were unvaccinated. And so that could indicate that a vaccinated person is just as contagious as an unvaccinated person. And that, I think, is a pretty fundamental shift in our understanding of the Delta variant and how much it could drive spread. Vaccines, there's still a good protection against severe illness and death, really strong protection against those worst outcomes. But we are seeing more breakthrough infections. You know, people who are vaccinated could still transmit the virus to others. And I think that the Provincetown case study, more than anything else we've seen thus far, really helped drive those points home for the CDC. And now they're starting to adjust their guidance accordingly. So vaccinated people can spread this Delta variant just as well as an unvaccinated person, which is why we should be masking up when we're indoors all over again.

Dylan Scott: Yeah, it appears so. You know, there's a lot of uncertainty, if you're just because a vaccinated person is carrying as much virus as an unvaccinated person, does that mean they're still as contagious as an unvaccinated person? You know, I think the public health world is still working through some of the minutia and trying to figure out, yeah, exactly how infectious vaccinated people might be. But I think the big picture takeaway is clear. Vaccinated people who can track the Delta variant certainly appear like they can transmit the virus to other people, maybe just as much as an unvaccinated person. And do we know how much more transmissible this Delta variant is than the OG coronavirus? It certainly appears a lot more transmissible. Again, with all of this stuff, it's hard to be super precise. Our understanding is evolving. Like I said, just a few weeks ago, I was on a call with the CDC official where it sounded like, you know, vaccinated people probably wouldn't transmit the virus. So our understanding of the virus and the Delta variant specifically is evolving all the time. So I would be hesitant to, like, take any of these numbers to the bank. In this internal CDC document that The Washington Post published, the agency actually said that the Delta variant might be as transmissible as the chickenpox. which to me felt like a kind of outdated reference because we vaccinate against the chickenpox now. But I guess for old folks like you and me, it still means something. I remember getting the chickenpox. I also got the chickenpox. But so yeah, it's clearly much more transmissible than the original coronavirus that obviously wreaked havoc on our country last year. And so again, that requires a lot more vigilance even for the vaccinated. And it's all a little scary and certainly uncertain, but bring this back to Provincetown for a minute. How did people fare there? Did anyone die? Was anyone hospitalized with serious COVID? So this is the good news. The CDC study covered about 500 cases that were linked back to Provincetown. Of those, only a very small number of people, like literally a half dozen, I think, maybe just five, people were hospitalized with COVID-19 and nobody died. So that is certainly an argument for the vaccines working. There were only a minuscule number of people who had severe enough symptoms that they needed to go to the hospital. And even those people, you know, survived and came out the other side. Nobody is dying from this outbreak up in Provincetown. So, you know, that's kind of the new reality that I think we're shifting into where, yes, there are going to be breakthrough infections. You know, the COVID-19 has not disappeared. I do think it kind of requires a bit of a mental shift from like, all right, we can lock down and get rid of this virus, to like, the virus is going to be out there, but we just you know we need to be sensible It a weird time because I feel like for so long understandably people just wanted to be like told what to do Like, what can I do to be safe? And I feel like we're shifting now into a new period where it's like, you know, all of us are going to have to make our own risk assessments. Because I don't think there's any appetite for like business closures, stay at home orders. Like those ships have sailed. And I just think that's a real mental shift for people. How to help people make mental shifts in a pandemic in a minute on Today Explained.

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Sean Rameswaram: CDC recommends fully vaccinated people wear masks in public, indoor settings to help prevent the spread of the Delta variant and protect others. No one could blame you for finding the CDC's recent recommendations a little confusing. In fact, a lot of people are accusing the CDC of doing the confusing. What we very well might have here is failure to communicate, which is why we reached out to science communicator Jessica Malati Rivera. I'm a scientist by training. I studied microbiology and immunology and public health. And being a science communicator means being able to translate that. She's one of the people who's finding all of this a little confusing. It is confusing. And I kind of went on the record this week by saying that the May 13th update to the guidance for vaccinated people to take their masks off was premature. Sure. I think we got a little bit too excited to claim a victory. And I think that it was in many ways kind of like giving folks who've been really working hard and had done their job of getting vaccinated, kind of giving them a cookie of sorts by saying you could take your mask off. But I don't think we were ready. I think we needed to see two things, which was low transmission and high vaccination. And we just weren't seeing that. We were seeing a bit lower transmission. But vaccination even up today is not where it should be, where we can be kind of getting an edge over the virus and now the variants. And so they've had to kind of course correct a few times. And I understand that they were trying to base it on the data as it was available then. But it's still, in my opinion, and in the opinion of I think a lot of other public health experts, was a little bit too early.

Jessica Malati Rivera: What do you think their reasoning was for doing it at the time? Was it just let's get back to normal pressure from the new administration, from businesses, from state leaders? Well, I mean, you have to think about the environment and what we were dealing with in the data at the point. This was pre-Delta becoming as disruptive and as pervasive here in the United States. And so what we knew about the original version of SARS was that if you were vaccinated you were very unlikely to get the virus and or transmit the virus that your viral load was really low making you very low risk for transmitting the virus So based on that data it seemed relatively true that if you were vaccinated you at low risk of getting and transmitting it. Now, the game has changed a bit, and that's why we've had to pivot. But even still, I kind of exercised out of an abundance of caution and felt like because I knew there were so many people not yet vaccinated, that even vaccinated people still needed to exercise caution and keep masks on for a bit longer. It created this false dichotomy, right? It made people think that you get vaccinated to take your mask off. And I'm like, no, we're getting vaccinated to end this pandemic. And it has to be this additive approach. It can't just be one or the other. It's layers and layers of mitigation so that we can be better about, you know, slowing this.

Jessica Malati Rivera: How much of this is, you know, a result of a public health crisis, the Delta variant, and how much of it is a result of potentially bad messaging and guidelines from the CDC? Where is that line? It's 100% both, right? It's hard to parse it out and say that it's one and not the other because Delta has changed the game. Delta is 100% more contagious. It is a more complicated variable in this equation. So it's both that and it's like kind of throughout the pandemic failing at communicating, right? We did not see the CDC step up as they should have in the beginning of the pandemic when it came to even just data aggregation. And then beyond the data aggregation, it needed to be communicating what that meant so that there would be streamlined federal and then statewide policies on everything from closures to masks to vaccines, kind of preparing the people that this is where we are, this is where we're going, and we can end it by kind of all aligning on these things.

Jessica Malati Rivera: Going forward, do you think there's a way the CDC could better message around the Delta variant, around the latest on the vaccine, around who knows, maybe a new round of shots if they can convince the rest of the people in this country to get the first round? I think that trust is built over time when you have consistency and transparency and empathy, right? And I think that the CDC is lacking the kind of nuance to say they don't know when they don't know yet, to wait before they kind of change something without all the receipts kind of on the table and available, and to speak in a way that's like inclusive and doesn't exclude people. I've often struggled with how the CDC kind of forgets communities like the medically fragile or the immunocompromised or even kids when they're talking about broader policies because kids are part of the unvaccinated population. I mean, they've obviously talked about kids when they talk in the context of schools and school policies and openings for all that. But it's that kind of, you know, kind of nuance and the granularity of things that are often missing. And we have a long way to go, I think, or the CDC does to unfortunately have to rebuild that trust that's been broken and continues to have these little fractures with this kind of back and forth.

Jessica Malati Rivera: The pandemic isn't over when like every single human on the planet is vaccinated. And, you know, there's zero virus, right? I feel very confident that what we're probably going to be dealing with is a dimmer switch and not an on and off switch. We'll be kind of slowing the way in which the virus has been disruptive to populations and to health care systems. And it'll probably become endemic, meaning it'll be a circulating virus, but it won't be as impairing, right? When we have about half of the country vaccinated, that's not even close to the lowest thresholds that we had for herd immunity. Not even close. And so I think there are some benchmarks that don't seem as kind of pie in the sky or futile that we can obviously achieve if we do stay the course. And it doesn't have to take forever to do that, right? I think getting to 75% is a very reasonable goal, but we have to get there.

Sean Rameswaram: Jessica Malati Rivera is an infectious disease epidemiologist and research affiliate with Boston Children's Hospital. That's in Boston. I'm Sean Rameswaram from Today Explained. Thank you.

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