I’m vaccinated but got COVID-19 anyway. Now what?

With omicron on everyone’s minds, people are concerned about breakthrough infections. How do you proceed if you think you’ve had one?

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A pharmacist prepares a syringe of the Pfizer vaccine for COVID-19

In this Jan. 8, 2021, file photo, a pharmacist prepares a syringe of the Pfizer vaccine for COVID-19, at Queen Anne Healthcare, a skilled nursing and rehabilitation facility in Seattle. (AP Photo/Ted S. Warren, File)

Ask us about COVID-19: What questions do you have about the coronavirus and vaccines?

This is one of a series of articles in which reporters from WHYY’s Health Desk Help Desk answer questions about vaccines and COVID-19 submitted by you, our audience.

You celebrated the holidays with family and friends, and now you have symptoms of a virus. With news about yet another coronavirus variant, omicron, you’re worried that you have a breakthrough COVID-19 infection.

And you might. As of Friday, Dec. 3, 104,379 breakthrough infections have been reported in Pennsylvania, around 1.5% of people in the state who are fully vaccinated. In Philadelphia, there have been 9,307 breakthrough infections, which represents just under 1% of the fully vaccinated population.

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Of the 545,057 fully vaccinated people in Delaware, there have been 7,122 reported breakthrough cases of COVID-19 as of Friday, Dec. 3, which represents about 1.31%. And as of Thursday, Nov. 30, New Jersey Gov. Phil Murphy said of the 5.9 million people vaccinated against COVID-19, there have been 54,260 breakthrough cases, fewer than 1%.

Those numbers are not completely accurate: People are not systematically tested for COVID-19, and specimens are not usually accompanied by vaccination history. Also, many at-home test results are not reported to the states.

“I don’t think [states] should be presenting that data in that manner. I believe it is misleading,” said Dr. Stanley Weiss, a professor of epidemiology at Rutgers University.

Dr. Rick Hong, medical director for the Delaware Division of Public Health, agreed that states are underreporting breakthrough infections because of the barriers mentioned. However, he argued that the trends are more important than the numbers.

“I agree that there is some underreporting with any number we have, including breakthrough cases, but if we see a sudden jump, that’s where we’d be more concerned. And we kind of saw some of that, and that’s why we were pushing for the boosters, because we’re noticing that after six months, we saw a jump in breakthrough cases,” Hong said.

To get a more accurate number, Hong said, everyone needs to get tested. The state of Delaware is tracking vaccination status during its case investigations, he said, but people need to participate in the investigation process.

“But I think we have enough information that we are comfortable with the trend that we’re seeing, whether it’s bad or good, and how to react appropriately when we see those changes and trends,” Hong said.

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What’s the first thing I should do if I have symptoms of any kind? 

Distance yourself from other people, health experts say. Next: Get tested right away.

If you were exposed to someone who tested positive for COVID-19, but you’re not showing symptoms, you should get tested in five to seven days.

Don’t assume that just because you’re vaccinated the symptoms are only a cold, the experts say. Early data suggests that with the omicron variant, for example, you might not experience loss of taste and smell, which often is one of the telltale signs of COVID-19.

“Unfortunately, COVID-19 symptoms kind of mirror a lot of those that you see with the common cold, with influenza. And so the only way that you can know if it’s COVID-19 versus a different virus is to get tested,” said Dr. Michael Coletta, chief physician for Delaware’s Division of Public Health.

I do have a breakthrough infection. What’s next? 

Being vaccinated still protects people from severe illness. Most healthy, vaccinated adults with breakthrough cases should expect that their symptoms will be relatively mild, similar to the common cold, said Dr. John Wherry, director of the Institute for Immunology at the University of Pennsylvania.

People who have mild symptoms typically are advised to stay at home, get plenty of rest, drink plenty of fluids, and take acetaminophen or ibuprofen for fevers and chills.

But if your breathing gets worse over time, if you have a fever that won’t subside, or you’re experiencing difficulty accomplishing day-to-day activities, you should call your physician. Other severe symptoms to look out for are severe body aches, and nausea, and vomiting that prevents you from eating or drinking fluids.

If you have other serious medical conditions, don’t wait to call your physician, Wherry said. There are treatments available to high-risk patients before their symptoms get worse. Even if you’re vaccinated, you might be eligible for monoclonal antibodies.

Other treatments may be around the corner. A new drug from Merck appears to have some effectiveness within the first five days of a COVID-19 diagnosis. It’s currently going through the Food and Drug Administration’s approval process, and a federal advisory committee on Tuesday voted to recommend authorization for its use.

“The evidence is that those therapies significantly reduce the risk of getting seriously ill, reducing both the risk of hospitalization and of death substantially,” Weiss said. “Several of the therapies we have are less effective as the disease and infection progress. So treating early on makes great sense. There are several other types of therapy that the physician may well consider giving based upon individualized medical circumstances.”

If I get a breakthrough infection, should I quarantine? For how long? 

If you’ve been exposed to the coronavirus but have no symptoms, the Centers for Disease Control and Prevention recommends that you wear a mask and get tested within five to seven days. If symptoms occur, you should immediately quarantine (restricting yourself to one location) until a negative test confirms those symptoms are not related to COVID-19.

If you test positive for the virus but show no symptoms, you should isolate yourself (separating yourself from people who are not sick) for five days, and wear a mask around others (in and away from your home) for an additional five days. If you have a fever, remain in isolation until the fever resolves.

Close contacts who are unvaccinated, or more than six months out from the second dose of Pfizer or Moderna or two months out from the single dose of the Johnson & Johnson vaccine (without a booster), should quarantine for five days, followed by mask use for an additional five days.

Close contacts who have had a booster, or are less than six months out from being fully vaccinated with Pfizer or Moderna or are less than two months from the J&J vaccine, don’t have to quarantine, but should wear a mask for 10 days after the exposure to someone who is positive.

For vaccinated close contacts who are not yet eligible for boosters, such as young kids, no quarantine is needed.

People who are asymptomatic or have mild symptoms are capable of transmitting the virus to other people, so isolation is important, Weiss said. If you live with others, you should wear a mask and increase air circulation, he said.

Unvaccinated people carry the infection and spread it to others over a much longer duration than vaccinated people, however, Wherry and Weiss said.

“The vaccination clearly helps control the viral infection, reduces the risk of progressing to severe disease or to death, and very likely helps reduce the duration of transmissibility,” Weiss said.

After a breakthrough infection, when should I get a follow-up test? 

The CDC no longer recommends a test-based approach to decide when to end isolation. If you’ve completed your quarantine or isolation period and your symptoms improve after 24 hours, there’s no recommendation for either the vaccinated or unvaccinated to get retested.

“And the reason being is that you can still test positive for 90 days or even longer. That doesn’t mean you’re infectious,” Hong said.

“So that’s why we don’t recommend repeat testing once you test positive, at least within that 90-day window, because you could get that positive test, which means you have some viral genetic material in you, but may not imply that you are infectious,” Hong said. “You should talk to your employer. Some employers do have more stringent return-to-work guidance.”

Contact tracing and breakthrough infections 

The health experts said contact tracing, whether you are vaccinated or not, is an important aspect of preventing the spread of COVID-19. Weiss and Wherry said they don’t believe contact tracing at the state level is as vigorous as it needs to be, and particularly for breakthrough cases.

Hong and Coletta, of Delaware’s Division of Public Health, noted that contact tracing does not differentiate between the vaccinated and unvaccinated.

“The whole concept of contact tracing is we want to let folks who’ve been exposed to a case [know, so] that they can take precautions so that they don’t continue spreading,” Hong said.

During contact tracing, infected people provide a list of people and places they have come in contact with. Contact tracers then reach out to people who have been exposed and advise them what to do next.

If official contact tracing is not being done, Weiss and Wherry suggest that you reach out to the people you’ve been in contact with. If you’ve been to a party, for example, let the host of the party know you’ve tested positive for COVID-19. If you went to a restaurant, let the owner know.

Does a breakthrough infection give me stronger immunity? 

There have been few studies that examine how getting infected after being vaccinated boosts the immune response. The reverse of that scenario has been studied, however, and data suggests that people who are infected with the coronavirus and get vaccinated later do have a more robust response than people who had only two doses of the vaccine.

Though studies are mixed, some data shows that having COVID-19 alone without vaccination does not boost the immune response to the levels that the vaccine does. That’s why health officials still recommend that people who have previously been infected get vaccinated.

If you get a breakthrough infection, the health experts recommended talking to your physician about getting a booster.

“The latest evidence on the boosters from the mRNA vaccines show not only a tremendous increase in the level of antibody protection, but a broadening of the antibody response, so that would cover more variations in the virus to give protection. That is why the booster seems to be giving such excellent protection against delta,” Weiss said.

“We don’t know yet, but we’re hopeful that it may help protect against many other variants,” he said. “In addition, we know that the vaccine boosts the cellular immune system, and we expect that is also substantially contributing to their protection.”

How long after a breakthrough infection should I get a booster? 

There’s no official guidance. Wherry said there’s no harm in getting the booster a month to two after recovering from a breakthrough infection.

“I think it’s going to be important for us going into the winter with increasing spread of the delta variant, with new concerns about the omicron variant, to get those antibody levels boosted to a high level to try to decrease your likelihood of getting infected and also try to decrease transmission and spread in the community,” Wherry said.

Could omicron cause more breakthrough infections? 

Omicron has more than 50 mutations, with more than 30 in the coronavirus’ spike protein, which increases its ability to infect the body. The concern is that those mutations will allow the variant to evade vaccine-induced immunity to some extent. What scientists don’t know yet is how much it’s going to evade that immunity.

“The evasion will likely be at the level of antibody. The vaccines also induce T cells, which are kind of like a backup plan. And so I think a lot of folks in the field are thinking that there will be some level of immunity to omicron. We just don’t know how much,” Wherry said.

“It will likely be immunity protecting you from severe disease and hospitalization. We may see a little bit of an increase in infections because of the evasion of antibody responses, but it’s very early,” he said.

Hong emphasized that though breakthrough cases are possible, it’s important to remember that the vaccines still protect people from severe illness and lower the chances of spreading the virus to others.

“I remember when we started reporting breakthrough cases, people were concerned the vaccine was not working. We never claimed that the vaccine will give you 100% protection. Really, no vaccine does that. However, it does reduce the risk of hospitalizations, death, as well as transmission to others,” he said. “Don’t let the breakthrough cases make you think, ‘Well, maybe I shouldn’t have gotten the vaccine,’ or, ‘It’s not working.’ The numbers clearly show that those who are not vaccinated are at a high risk for everything I mentioned before.”

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