As the nation heads into the 17th month of living amid a pandemic, Maine residents should probably be forgiven for feeling a bit … confused, flustered, or downright fed up.

Daily counts of new COVID-19 cases are once again in the triple digits, after falling into the teens and even a few single-digit days in June. Things that finally felt almost safe again thanks to Maine’s high vaccination rate – like wandering into a crowded restaurant or catching an indoor concert – now suddenly seem questionable.

And to top it off, county-specific recommendations on whether fully vaccinated folks should mask up again before heading into the grocery store or post office can change daily. York County, for instance, flip-flopped between “masks recommended” and “masks not needed” four times over 11 days.

“It seems like throughout the pandemic, we have all become adept at drinking water from the proverbial firehose,” said Dr. Nirav Shah, director of the Maine Center for Disease Control and Prevention. “But it seems like even that pace of information has ramped up even more.”

To help navigate this latest stage of the pandemic, several experts discussed what is driving concerns about the delta variant, why mask recommendations are shifting, and what is – or isn’t – safe to do in this latest stage of the COVID crisis.

Why is the delta variant such a concern, even for the fully vaccinated?

Basically, evolution.

Viruses mutate all of the time, and RNA viruses such as the coronavirus that causes COVID-19 are particularly “notorious” for their replicate-and-mutate capabilities, said Dr. Sten Vermund, dean of the Yale School of Public Health.

About 99 percent or more of those mutations will not necessarily be beneficial to the virus’s survival or ability to spread. But it’s that tiny remaining percentage of mutations that leads to a slightly tweaked virus that can, say, more easily recognize and attach itself to a cell wall in order to cause an infection, Vermund said in an interview with the Portland Press Herald/Maine Sunday Telegram.

“What came out of the replication is a more efficiently transmitted virus,” he said of the delta variant.

More efficient transmission means more infected hosts, which means more replication and mutation, which means more opportunities for the virus to do an end-run around a vaccine.

“We know for a fact that there will be new variants – that’s the name of the game,” Vermund said. “Our goal is vaccinate enough of the human race to reduce the degree of transmission or replication of this virus. And the fewer viruses being replicated in humans, the fewer mutations.”

What about vaccinated people? How worried should they be about the delta variant and “breakthrough” infections?

“If you are fully vaccinated, and you generally are hanging out with other people who are fully vaccinated, your likelihood of getting COVID and/or having a case so severe requiring hospitalization is extremely rare,” Shah said.

That said, the recent U.S. CDC recommendations that fully vaccinated people resume wearing masks in areas with higher case rates is a reflection of the fact that the delta variant changed the game.

Emerging research shows delta is at least twice as contagious as earlier strains of the coronavirus because it can produce 1,000 times the amount of infection in a person, which is frequently referred to as the “viral load.” Even more concerning, fully vaccinated people can have just as high a viral load as the unvaccinated.

Now, the vaccine may prevent a person from even feeling sick and should allow them to fight off infection faster, thereby helping to avoid severe illness in all but a small percentage of cases. Public health experts say that is clear evidence the drugs are working as intended – because vaccines essentially teach the immune system how to keep the little invaders from establishing a beachhead in the body that would allow the virus to replicate to the point of serious illness or death.

But because fully vaccinated individuals can still harbor so much of the virus during the early stages, they can still potentially pass it along to others, particularly the unvaccinated or immunocompromised individuals. The more people infected with the delta variant, the more likely it is to mutate again into a new variant that could pose problems for both the vaccinated and unvaccinated alike.

“There is a very, very longstanding tenet in virology that viruses cannot mutate unless they replicate,” Dr. Anthony Fauci, the federal government’s top infectious disease expert, said last week during a White House COVID-19 Response Team briefing. “And so the easiest way to prevent the scenario … would be to get as many people vaccinated as quickly as we possibly can to not allow the virus to continue to circulate in the community, giving it ample time to mutate.”

If I can still get infected, why bother getting vaccinated?

Well, the risk of developing a symptomatic case of COVID-19 decreases 18-fold if you are vaccinated when compared to an unvaccinated person, while the risk of being hospitalized or dying of COVID goes down 25-fold, according to the most recent data. Plus, getting vaccinated protects others around you, particularly children too young to be eligible (under age 12), the immunocompromised and folks who can’t get a shot.

“What I usually tell folks is you yourself may be just fine – but can you say that about everyone around you?” Shah said.

The masking recommendations keep changing. How is that good public health?

“It feels like we are all being whipsawed – I get that,” Shah said. “A lot of it is the fact that the rates are going up.”

Maine’s mask mandate expired at the end of June with the civil state of emergency. As a result, the state is now only recommending – not requiring – that vaccinated individuals in areas with “substantial” or “high” rates of transmission wear masks in indoor public settings.

Because Maine is a rural state with relatively small populations in many counties, it doesn’t take a large number of new cases for those counties to go from “moderate” to “substantial” or “high” community transmission levels on the the U.S. CDC’s scale. That has happened in Piscataquis, Kennebec, Somerset and York counties during the past week.

Shah said last week that Maine CDC is exploring options to provide residents and businesses with more predictability and stability, potentially by updating the county-by-county designations. But the reality is that most if not all of Maine’s counties are headed toward the substantial or high designations.

Dr. Meghan May, an infectious-disease specialist and microbiologist at the University of New England, said because of the pace of the pandemic, Americans are seeing science unfold in real time rather than learning about it after the research is settled. The shifting recommendations are in response to that emerging research as well as changes in the way the pandemic is playing out.

Unfortunately, all of this coincides with a “very charged environment” politically in the U.S.

“You have to realize that these guidelines can change and can change drastically very quickly, and it has nothing to do with any intentions other than that the science is changing,” May said.

Vermund was even more blunt as he lamented some people’s attempts to politicize public health.

“It’s unfortunate that we have folks in society saying, … ‘You don’t know what you’re talking about,'” Vermund said. “Well, guess what. The virus is a creature of change – literally, a creature of change – so if it mutates and becomes more infective, the public health community would be foolish not to pivot our counsel” to recommend masks.

I’m fully vaccinated. But with the rising number of cases (including breakthrough cases) in Maine, should I change my routine?

Public health experts say that depends on a host of factors, most notably where you live and whether you expect to be around vulnerable people, such as unvaccinated children or the immunocompromised. It also depends on your personal comfort level.

Dr. May said her family is absolutely “scaling back” its activities as cases rise in their area of York County.

Given her profession and the fact that she has several children, May said she pretty much never stopped wearing a mask in many places despite being vaccinated. While one child has since been able to get a shot because he is over age 12, another is still too young. So May said her family continues to wear masks in public settings — including during an entire pre-surge trip to Florida when “it was 112 million degrees … and we were among a vanishing small number of people who wore masks.”

May also recommends that vaccinated individuals carefully consider wearing a mask or avoiding high-risk places if they are around unvaccinated children, people with suppressed immune systems or other potentially more vulnerable higher-risk individuals.

“For the high-risk activities, it is almost like going back to square one – and particularly in the unvaccinated people,” May said. “The highest-risk activities now are the same as they were last winter: indoor dining, and gyms and K-12 schools, particularly elementary schools” where all students are too young to be vaccinated.

What about large gatherings — indoor or outdoor?

The U.S. CDC still says that outdoor activities “pose minimal risk to fully vaccinated people” and that “most indoor activities pose low risk,” particularly in areas with low to moderate transmission levels. As of Friday, Cumberland, Lincoln, Penobscot, Piscataquis and Aroostook counties had “substantial” levels of community transmission, while Waldo County had “high” levels of transmission, with all others in the “moderate” category.

“Fully vaccinated people might choose to mask regardless of the level of transmission, particularly if they or someone in their household is immunocompromised or at increased risk for severe disease, or if someone in their household is unvaccinated,” the U.S. CDC says in its most recent guidance for vaccinated individuals.

For Shah with the Maine CDC, the arrival of vaccines changed the equation so that, unlike in the pre-vaccination days when everyone was vulnerable, “there is no grand unified theory or definition of what is safe.” Instead, Shah said he asks people what are the most important activities in their lives and then makes suggestions on how best to do them safely.

That might mean wearing a mask inside a movie theater if that’s an important activity. Or for a young person who loves the bar scene but still wants to see their vaccinated-but-potentially-vulnerable grandparents, it might mean choosing bars with outdoor service or even wearing a mask inside in between sips even though that may feel awkward.

“That’s the world we are in,” Shah said. “There is going to be a little bit of a tradeoff between being able to see your grandparents and being able to live your social life.”

Vermund, the Yale University dean and physician, said fully vaccinated people are safe and “should not go into some kind of bubble” because of the delta variant. But Vermund said he has started wearing his mask more often in public and practicing hand hygiene even “more aggressively” to reduce the risk that he becomes a carrier that can infect others.

“All of the things we have been doing for the last year and a half are still things that will reduce risk now,” he said. “Vaccination is more effective than all of those together, though.”


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