How the Delta Variant Is Changing the Public-Health Playbook

In the past few weeks, the U.S. has seen a dramatic increase in coronavirus cases and hospitalizations, the vast majority of them caused by the Delta variant—a mutation of the virus that the Centers for Disease Control and Prevention says is far more transmissible than the original strain. The spike in hospitalizations and severe illness has prompted an encouraging rise in immunizations, particularly in states with low vaccination rates. Still, the U.S. is trailing the European Union in vaccinations, and many Americans, especially white evangelicals and people under seventy-five, remain reluctant to receive the shot.

I recently spoke by phone with Rebecca Weintraub, an assistant professor at Harvard Medical School and the director of the Better Evidence program at Ariadne Labs. Since the pandemic began, Weintraub, who is also a practicing internist, has been working with health officials across the country and around the world, advising them on vaccination efforts. For the past few months, she has been administering shots—and answering questions from skeptical patients—at Brigham and Women’s Hospital and at mobile vaccination sites in Massachusetts. During our conversations, which have been edited for length and clarity, we discussed the best ways to talk to people who lack confidence in the vaccine, the necessity of various forms of vaccine mandates, and why the spread of the Delta variant has forced public-health officials to adopt new messaging.

How would you assess the vaccine campaigns in the U.S. over the past several months?

We knew, like with every other pandemic, that when the vaccines were initially approved we’d be facing vaccine scarcity. This is not a new problem in society. What was new in this moment in many ways was that there was a window for thinking about equitable distribution of a COVID-19 vaccine, and the deployment could be done in a way that could benefit those who are at highest risk of deaths and severe disease. That plan, deployed in early December, was one in which the federal government got heavily involved. And that deployment and that perspective was relatively well received.

What did not happen was a predictable supply to the jurisdictions. So the sixty-four jurisdictions [fifty states, six metropolitan areas, and eight U.S. territories or freely associated states] assumed they would receive, and were told they would receive, certain numbers of doses, and they did not receive that allocation week by week. So you began seeing this second phase of stockpiling so the states could then have that second dose to deploy.

But now obviously we’re in quite a different phase, with sufficient supply. And we have a better understanding of the storage capacity of, for example, the mRNA vaccines, which can be stored in a regular refrigerator for a month—which means we can deploy them in many different types of settings. Most providers have access to a refrigerator, but we haven’t fixed many of the gaps.

What specifically are the types of problems you are seeing?

Early on in the pandemic, we sent the vaccines to health systems, and directly to nursing facilities via retail pharmacies, and then in January and February jurisdictions began deploying the vaccine to additional outlets and different distribution sites. Now there are tens of thousands of distribution sites for the vaccine.

What we’ve been able to show, though, is that there are persistent vaccine deserts—areas of the country where someone needs to drive, walk, or use public transportation for at least fifteen minutes. One reason for that is that most primary-care providers were not equipped to receive the vaccine. They have not been integrated within the deployment. And, when we look at the survey data for primary-care physicians and specialists, they are interested and eager. They want to engage in a conversation with their patients, and then be able to offer the vaccine immediately, so it’s on the menu at all times during the patient encounter.

What you’re saying is interesting to me because all the stories we read about people who are not vaccinated present it as a demand issue, not a supply issue. Even if it is mostly a demand issue, it seems like you’re saying there are also supply issues that could be improved. It’s not just people not wanting to take the vaccine.

That’s correct. We need to be managing and having robust systems for the flow of the product, the flow of information, and the flow of the financing. And we’ve had a bumpy start to all three of those things. We’re concerned about second-dose administration, for example, and then obviously the financing—how to insure that providers are being reimbursed for the time they’re spending on the conversations they’re having and the administration of the vaccine.

What have been some of the issues with second doses?

Let’s say you’re returning to see your primary-care provider or a specialist. They should be able to offer you the second dose as you’re seeing them in a clinic. Or say you’re in the midst of a hospital stay—you could receive the second dose there, and not need to go back to the vaccine site. We’re trying to remind everyone that this should be an essential part of your routine. This vaccine should be offered in all settings, and it’s taken quite some time to expand not only the number of sites but, obviously, to integrate this within health systems and health-care delivery.

What have you learned in your work about the different ways to get people to take the vaccine? Are there certain strategies that you think should be used or should not be used?

In conversations with folks at vaccination sites, all the questions that I’m being asked are good questions. People want to understand immunology. They want to understand how a vaccine is developed, how it’s manufactured, how it’s stored in a vial, what type of syringe I am using. People are asking excellent questions about the safety and efficacy of the vaccine. And they also want to talk about the stressors of the pandemic. And I found that, in all the conversations, people are also looking for a bridge toward wellness, and the vaccine’s just the beginning. It’s not the sole intervention to get back to wellness.

Do you think that that conversation should be different with Delta?

Yes. I think at this stage in the pandemic we have to acknowledge that the Delta variant is different. The variants are behaving like they’re in some type of relay race, in which one loses steam and another one takes over. And what we know today, and why we need to convince people and understand their concerns and questions about the vaccine, is that the Delta variant has a different playbook. Its incubation period is about four days, rather than six. And, when people originally were spreading the coronavirus, they were spreading it to two or three people. Now the folks who are infected with the Delta variant are infecting between five and nine people. The reason we’re very conscious of the speed and the acceleration and progress of vaccinations is that the Delta variant has caused the vast majority of the new infections in the United States. This means there has to be a new message, and we need to think about how we’re communicating.

We have six hundred thousand Americans dead, and we need to convey that the Delta variant is worrisome. What we’ve seen in the past week are local intensive-care-unit doctors and nurses sharing their experiences of patients in the I.C.U. The message right now is: considering the speed at which the Delta variant is spreading, we want to protect you from death. We want to protect the unvaccinated from dying or from experiencing severe disease. There’s been a series of I.C.U. physicians and nurses and patients sharing terrible stories from their bedside. They did local stories about what it means to survive an I.C.U. stay, the ongoing symptoms and P.T.S.D. that patients are experiencing, and the ongoing recovery process and loss of function for those who experience severe COVID-19.

Just to clarify, are you saying that, pre-Delta, the message about getting the vaccine would be something about protecting the long-term health of your family and community, and now the message should be more that people are going to spread this and die very quickly if we don’t do it?

Yes—with, I guess, a bit more subtlety there. The powerful message that we’re seeing coming out of Alabama, Tennessee, Arkansas, and Missouri this week is local providers telling their patients and their local populations, “We are worried about you. You are the unvaccinated, and you, as a young person, are at risk of severe disease or death from COVID-19. This variant is different. We’re seeing younger people needing to be ventilated, having long I.C.U. stays, and we want to help protect you.” That is a different conversation than we were having before. This local message from a local provider is gaining traction, and we’re seeing many folks in these communities get vaccinated. For example, in Alabama, we’ve seen a threefold uptick in people going to vaccines.gov, and we’ve seen a fourteen-per-cent rise in vaccine appointments for the first dose.

When you’re talking to people at vaccination sites and they cite false information about the harm of the vaccines, what are the most helpful ways to respond?

I do think this has to start as a conversation. We need to acknowledge that people are receiving information in channels that look official. And so what resources should you trust? What evidence base are you reviewing? What information are you consuming? What is the background of the individual? But one thing that’s been quite powerful is that at this point millions of people have received the mRNA vaccines, as well as AstraZeneca and Johnson & Johnson, and we actually have a significant data source of very few side effects in the general population that received the vaccine. So it’s important to talk about the millions of doses that have been deployed and the small numerator of side effects.

Is there some way in which full F.D.A. approval of the vaccines could change this? I know most real human beings are not checking the F.D.A. Web site every day for updates. But is there a way in which that would really help? I have seen people suggest that it would.

Well, first I just want to take a step back. Most of the folks that I’m interfacing with, either virtually or in person, want to start a conversation. They are interested in the vaccine. They want to learn more, and I think it’s important to acknowledge that many folks have been isolated from interfacing with providers, and want to be in person with someone that they trust and begin a dialogue about the vaccine. So, yes, I have folks who do come with piles of papers and want to make sure I read what they’re reading, and I am pleased to do that. But for most folks, I find, actually the conversation they want to have is about the stressors of living through the pandemic, and when we begin there and acknowledge what they’re going through then we can proceed forward to the evidence base regarding vaccine safety and efficacy.

That’s interesting, but you didn’t say much about the F.D.A.

So I would say I have not confronted many individuals who are waiting for F.D.A. approval. My take has been that this will be a gateway for certain institutions. I suspect F.D.A. approval will help us add some momentum to the vaccination mandates among employers and institutions, but I suspect we’ve overestimated the effect it’ll have on a large swath of the wait-and-see population.

The way you just alluded to mandates, I assume that you think that they’re a good idea.

Yes.

They seem inevitable and overdue. That being said, I’m curious how you synthesize the need for vaccine mandates with everything else you’ve been saying, which is about meeting people where they are, having respect for their opinions, and talking it out with them. Is there any dissonance between that and having employers and the government say that they have to get vaccinated?

Yeah, this is my daily dissonance. As a provider, I respect and honor the individual in front of me. I want to know their needs. I want to care for their stressors. And, at the same time, the practice of public health requires us to think about public safety in the same way we think about preventing water contamination or a terrorist attack or wildfire, and individuals lack the data and the technology to address these types of threats. This is why we need to invest in our public-health agencies to be that authority. And, at times, in the midst of an emergency, we need to exercise that authority.

And I think in many ways the state leaders that I interface with who have had the burden with quarantining, masking, schooling, and the vaccine campaign are asking us to estimate the cost of delaying vaccine mandates, or not enacting an indoor mask mandate, or not administering a vaccine mandate. How many folks will end up with severe disease or die? And I think now is one of those pivotal times. The Biden Administration announced a vaccine attestation mandate for federal employees, and I think this is a tipping point. I think there are many who will follow this example from the federal government. It allows the states to then also counsel employers and institutions and schools to think about mandates ahead.

The Biden Administration is having federal workers choose between getting vaccinated and regularly going through a rigorous testing regimen, the idea being, “We’re not going to fire you if you don’t get a shot in your arm, but you are going to have to deal with all this testing.” That seems less harsh to me than just saying, “Get the shot or you’re fired.” Do you have to have some sort of sense of how coercive mandates should or should not be?

I think the first thing public-health agencies need to do is make vaccination highly convenient. Then we need to make it highly inconvenient to be unvaccinated. And you’re seeing today many spins on a vaccine mandate versus testing. So, for example, M-G-M is saying to its employees, “If you choose not to get vaccinated, you pay for your own testing and you will not be paid if you test positive and need to quarantine.”

How does testing fit into that? Are you saying testing should be easy, and, if so, is there a trade-off if people can get tested easily instead of taking the vaccine?

We are at a stage where the more employers and states begin mandates—that’s what we need to counter Delta. I think different employers will do different forms of a mandate. Many of them are going to add the option of testing regularly.

We want testing to be cheap and easy. We want this to be part of your daily life. You vaccinate yourself for the flu, you vaccinate yourself for COVID-19, and can get vaccinated on the way to work or school. We want everyone who is concerned and wants a test to be able to get a test, and you may need to get a test if you are vaccinated. With a vaccine mandate, what is important is employers have the combination of a carrot and stick.

And it’s harder to argue against, “Well, if you want to show up at work and put people in danger, you have to bear the cost of that.” It feels like less of an invasion of privacy or someone’s rights than requiring a shot.

That’s right. And I think what we’re seeing in the case of the University of Indiana, for example, is that we need to remind students and university employees that the university isn’t forcing anyone to get a vaccine. It’s offering you an option. Either you get the vaccine, you apply for an exemption, or you find a new school to attend. Students and staff must be fully vaccinated against COVID-19 unless they qualify for a medical or religious exemption, and students who refuse the vaccine and don’t qualify for an exemption have their classes cancelled and access to the online university system revoked.

People over the age of seventy-five are getting vaccinated at a healthy rate, and we have got to a pretty good level of vaccination among older people. One interpretation of this is that people who are not getting vaccinated are just not scared of COVID, because, if the hesitancy were about injecting the vaccine, we would see similar rates of resistance in older people. Is that also your interpretation?

Yes. Absolutely. And I see this globally as well. Many of our patients over the age of sixty-five remember waiting in line for the polio vaccine, and I’ve been hearing more stories from patients about swimming pools and movie theatres being closed during polio season because of fear. It was referred to as an invisible enemy. And several of my patients reminded me that health workers in New York City would actually remove kids from their homes or playgrounds if they were suspected to be infected. And if you think back, in 1952, the number of polio cases in the U.S. peaked at fifty-seven thousand, and there were three thousand deaths. This generation remembers the paralysis, with kids needing to use crutches and wheelchairs, and classmates who needed to be on an iron lung. Their parents rushed them to get vaccinated, and they were listening to their pediatrician.

We sent a very different message to young people early in this pandemic, but it has to be a different message today with the Delta variant. We need to upgrade the playbook so that young people understand that they should be concerned not only for severe disease and death but for long-haul COVID-19.

Does it work to say to someone, “You may not want to do this. You may not feel you’re at risk, but be a good citizen”? We are in a country where most people pay taxes. Many people are willing to join the military and fight and die for their country. Many people give money to charity to help their fellow-Americans. But I haven’t heard many people say that giving this kind of message is helpful for getting people to take a vaccine. Do you have a sense of that, one way or the other?

A lot of states and jurisdictions are trying to say, “This is how we protect our local communities. Low vaccination rates are a risk for all of us, the vaccinated and the unvaccinated.” But I agree with thinking of this as part of our role. I believe getting the world vaccinated as quickly as possible is the most patriotic act you can do. And, at this stage in the pandemic, we need to change our playbook. It’s like we’re at halftime, and we’re playing against a new team. They have a different offensive play, and we have to upgrade our defensive playbook right now. And that’s going to include vaccine mandates. The virus is replicating, and we’re actually at the point where we have to adapt to the idea that the coronavirus will be a part of our daily lives. We need to adapt and protect and mitigate our risks against infections. There are going to be times when we’ll be masking again or distancing again, but accelerating vaccinations and preparing our immune system for future variants is the most protective act we can do.