While some breakthrough cases among those who are fully vaccinated against Covid-19 are inevitable, they are unlikely to result in hospitalization or death. But one important question about breakthrough infection that remains unanswered is: Can the vaccinated develop so-called long Covid?
Long Covid refers to a set of symptoms — such as severe fatigue, brain fog, headache, muscle pain and sleep problems — that can persist for weeks or months after the active infection has ended. The syndrome is poorly understood, but studies suggest that between 10 and 30 percent of adults who catch the virus may experience long Covid, including those who experienced only mild illness or no symptoms at all.
But the vast majority of data collected about long Covid has been in the unvaccinated population. The risk of developing long Covid for the fully vaccinated who get infected after vaccination hasn’t been studied.
While preliminary research suggests that it is, in fact, possible for a breakthrough case to lead to symptoms that can persist for weeks to months, there are still more questions than answers. What percent of breakthrough cases result in lingering symptoms? How many of those people recover? Are the persistent symptoms after breakthrough infection as severe as those that occur in the unvaccinated?
“I just don’t think there is enough data,” said Dr. Zijian Chen, medical director at the Center for Post-Covid Care at Mount Sinai Health System in New York. “It’s too early to tell. The population of people getting sick post vaccination isn’t that high right now, and there’s no good tracking mechanism for these patients.”
One recent study of Israeli health care workers published in the New England Journal of Medicine offers a glimpse of the risk of long Covid after a breakthrough infection. Among 1,497 fully vaccinated health care workers, 39 of them — about 2.6 percent — developed breakthrough infections. (All of the workers were believed to be infected after contact with an unvaccinated person, and the study was conducted before the Delta variant became dominant.)
While most of the breakthrough cases were mild or asymptomatic, seven out of 36 workers tracked at six weeks (19 percent) still had persistent symptoms. These long Covid symptoms included a mix of prolonged loss of smell, persistent cough, fatigue, weakness, labored breathing or muscle pain.
But the study’s authors caution against drawing too many conclusions from the research. The sample size — just seven patients — is small. And the research was designed to study antibody levels in the infected, said Dr. Gili Regev-Yochay, director of the infectious disease epidemiology unit at Sheba Medical Center. It was not designed to study the risk of long Covid after a breakthrough infection.
“It was not the scope of this paper,” Dr. Regev-Yochay said. “I don’t think we have an answer to that.”
Even so, the fact that one in five of the health care workers who had breakthrough infections still had lingering symptoms after six weeks appears to be the first indication from a peer-reviewed study that long Covid is possible after a breakthrough infection.
“People have said to me, ‘You’re fully vaccinated. Why are you being so careful?’” said Dr. Robert M. Wachter, professor and chair of the department of medicine at the University of California, San Francisco. “I’m still in the camp of I don’t want to get Covid. I don’t want to get a breakthrough infection.”
Dr. Wachter said that despite the many limitations of the Israeli study, the data offer more evidence that the vaccinated should keep taking reasonable precautions to avoid the virus.
“I’m going to take it at face value that one in five people, six weeks after a breakthrough case, continued to feel crummy,” Dr. Wachter said. “That’s enough to make me want to wear two masks when I go into the grocery store, which is not that burdensome anyway.”
Understand the State of Vaccine and Mask Mandates in the U.S.
- Mask rules. The Centers for Disease Control and Prevention in July recommended that all Americans, regardless of vaccination status, wear masks in indoor public places within areas experiencing outbreaks, a reversal of the guidance it offered in May. See where the C.D.C. guidance would apply, and where states have instituted their own mask policies. The battle over masks has become contentious in some states, with some local leaders defying state bans.
- Vaccine rules . . . and businesses. Private companies are increasingly mandating coronavirus vaccines for employees, with varying approaches. Such mandates are legally allowed and have been upheld in court challenges.
- College and universities. More than 400 colleges and universities are requiring students to be vaccinated against Covid-19. Almost all are in states that voted for President Biden.
- Schools. On Aug. 11, California announced that it would require teachers and staff of both public and private schools to be vaccinated or face regular testing, the first state in the nation to do so. A survey released in August found that many American parents of school-age children are opposed to mandated vaccines for students, but were more supportive of mask mandates for students, teachers and staff members who do not have their shots.
- Hospitals and medical centers. Many hospitals and major health systems are requiring employees to get a Covid-19 vaccine, citing rising caseloads fueled by the Delta variant and stubbornly low vaccination rates in their communities, even within their work force.
- New York. On Aug. 3, Mayor Bill de Blasio of New York announced that proof of vaccination would be required of workers and customers for indoor dining, gyms, performances and other indoor situations, becoming the first U.S. city to require vaccines for a broad range of activities. City hospital workers must also get a vaccine or be subjected to weekly testing. Similar rules are in place for New York State employees.
- At the federal level. The Pentagon announced that it would seek to make coronavirus vaccinations mandatory for the country’s 1.3 million active-duty troops “no later” than the middle of September. President Biden announced that all civilian federal employees would have to be vaccinated against the coronavirus or submit to regular testing, social distancing, mask requirements and restrictions on most travel.
Complicating the study of breakthrough infections is the fact that the U.S. Centers for Disease Control and Prevention only tracks post-vaccination infections that result in hospitalization or death. While the C.D.C. does continue to study breakthrough infections in several large cohorts, the lack of data on all breakthrough cases remains a source of frustration among scientists and patient advocacy groups.
“It’s very frustrating not to have data at this point in the pandemic to know what happens to breakthrough cases,” said Akiko Iwasaki, an immunologist at Yale School of Medicine who is conducting studies of long Covid. “If mild breakthrough infection is turning into long Covid, we don’t have a grasp of that number.”
Diana Berrent, founder of Survivor Corps, a Facebook group for people affected by Covid-19 that has about 171,000 members, took an informal poll and found 24 people who said they had lingering symptoms after a breakthrough infection. It’s not a scientific sample, and the cases haven’t been validated, but the poll shows the need for more data on breakthrough cases, Ms. Berrent said.
“You can’t extrapolate it to the general population, but it’s a very strong signal that the C.D.C. needs to be mandating reporting of every breakthrough case,” Ms. Berrent said. “We can’t know what we’re not counting.”
But some experts predict the surge of new cases caused by the spread of the Delta variant will, unfortunately, lead to more breakthrough cases in the coming months. Dr. Chen of Mount Sinai said it will take several months before patients with long Covid from a breakthrough infection are enrolled in studies.
“We’re waiting for these patients to show up at our doors,” Dr. Chen said.
Despite the lack of data, one thing is clear: Getting vaccinated will reduce the risk of getting infected and getting long Covid, said Athena Akrami, a neuroscientist at University College London who collected and published data from nearly 4,000 long Covid patients after developing long Covid herself after a March 2020 bout with Covid-19.
“It’s simple math,” said Dr. Akrami. “If you reduce infections, then the likelihood of long Covid will drop automatically.”