By Sept. 3, 2021, the COVID-19 pandemic had produced a staggering 220 million cases worldwide and claimed some 4.5 million lives. Just in Shelby County, there have been more than 127,500 confirmed or probable cases of COVID-19 and nearly 1,900 deaths.

But in these 18 months, uncertainty has been as prevalent and transmissible as the virus itself. Even now, as vaccines provide a shield often preventing the worst consequences of the virus, questions about the disease, its origins and safety measures ranging from inoculation to masking don’t always come with definitive answers.

The combination of a virus with chameleon-like tendencies – mutations and the variants they can spawn – and misinformation camouflaged as fact often has left the public unsure where theory ends and evidence begins.

In an effort to bring some clarity, The Daily Memphian conducted extensive interviews on the pandemic’s past, present and future with two of Tennessee’s foremost physicians. 

One is Dr. Jon McCullers, who is on the Shelby County Board of Health and chief operating officer for the College of Medicine at the University of Tennessee Health Science Center. He has been a frequent voice since the first case here.

The other is Dr. William Schaffner, an infectious disease specialist at Vanderbilt University Medical Center, a regular guest on CNN and a source cited in many Daily Memphian stories.

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DM: Let’s walk through some different vaccination scenarios. First one, the person had COVID in 2020 and hasn’t been vaccinated because they are banking on protection from natural immunity. When is that clock going to run out?

Schaffner: Vaccines provide a higher level of antibodies than the infection. That comes as a big surprise to people.

McCullers: And we still don’t know how long natural immunity and immunity from vaccines last. I suspect it’s years to decades in both cases.

DM: Despite the breakthrough infections?

McCullers: Yes. Immunity’s never perfect. So let me make a distinction here for you. There’s a lot of talk about antibodies – your antibody levels are waning at six months or eight months or 10 months or whatever. What they are talking about are these antibodies that circulate in your blood and come out onto mucosa surfaces, like in your mouth or your lungs, and can neutralize and block the virus from infecting you entirely. Those, for most if not all viruses, do wane over time, usually in a year to two years. The ability to detect those after natural infection or vaccinations will wane.

So at that point, it’s much more likely you’re going to be reinfected if you’re exposed to the virus again because the infection’s not being blocked at your mucosa surfaces. What happens next is the question, right? If you then have robust immunity in your B cells and T cells, you’ll start making new antibodies. And within a few days, you’ll have made a bunch of new antibodies and new T cells. Your circulation will be full of those neutralizing antibodies, and they’ll eliminate the infection.

So yes, you got reinfected, but you don’t have the normal disease course because your body has responded.

And we think that immunity lasts for years or decades or maybe your whole life, as it does for many viruses. And we know the vaccines induces more, and better, antibodies so that blocking the infection is much better with the vaccine. Probably it lasts longer, and it takes longer for breakthrough infections to start occurring. But in both cases (natural immunity and vaccination), you’re still gonna be protected from severe disease and you’re gonna get better quicker.

DM: Is it true that if a person had a rougher ride with COVID, they maintain more residual protection than someone who was asymptomatic or had a mild case?

Schaffner: Very good question and there’s a tremendous amount of overlap. A lot depends on you, and the strength of your immune system. Some people who have mild infections get a lot of antibodies. Some people who have serious infections have only a little bit of antibodies. So, you can’t say that definitively.

DM: OK, so let’s say a person had COVID in 2020 or early 2021, and then received the first dose of Pfizer or Moderna. Some physicians have said that combination was sufficient for good protection and a person did not need the second dose. There have been studies that indicate that, and Dr. Anthony Fauci has said as much. Do you believe this to still be the case, that the second shot is not needed yet?

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McCullers: The idea of getting a third booster, whether it’s natural infection plus two, or three doses of vaccine, I still have not seen data that support that. Certainly, if you’re immunocompromised, it makes all the sense in the world to get a third dose. I have seen no data to suggest healthy adults need a third dose.

The Biden Administration recommended that based on two things. One was the waning of the antibodies and to me, that’s not the important piece of it. It’s the built-up immunity that’s going to make new antibodies when you get reinfected that’s important. And then they’re seeing a decreased effectiveness of the vaccine, but the decreased effectiveness is because the vaccine is less effective against Delta.

So you don’t put those together and say you need a third dose because a third dose is just going to boost you against the Wuhan, and the (lesser) effectiveness against Delta is because it evades the antibodies, not because you’ve lost some sort of protection over time.

Schaffner: It actually takes time for the immune system to evolve and respond adequately to that booster. I got my two shots early because I’m a health care worker. I’m in no hurry to get my booster. I’m gonna wait a little bit longer because longer won’t hurt you. Closer in, you’ll get a less optimal response. What’s the best timing? We’re not sure yet.

DM: Does that mean at some point that we need a new vaccine, so to say, to protect against one or more future variants?

McCullers: Yeah, we need a booster this winter to protect against the Delta variant. And I’m sure Pfizer and Moderna are putting that together right now. We don’t need a third dose against Wuhan, we need it against Delta.

DM: So that changes your answer about getting a booster?

McCullers: Yeah, if they put out a booster for Delta or one of these other variants, I would absolutely recommend everybody get that for the improved protection. And ACIP (Advisory Committee on Immunization Practices), a group put together by CDC, met in the last week and ACIP said the same thing I told you, that a third dose is not needed in healthy adults. I think we’ll see the Biden Administration take a look at that recommendation and probably change their guidance before the Sept. 20 deadline.

DM: How does all this fit with the coming flu season?

Schaffner: Well, it’s going to be a mess. Last year, we had less influenza, lowest flu season anybody can remember and has recorded. And that’s because we were all doing social distancing, masking, staying at home.

And kids weren’t in school. Kids have the distribution franchise. They spread it among themselves, give it to Mom and Dad, the grandparents … each year, flu causes many hospitalizations and deaths.

We’re going to have to promote influenza vaccine as we never have before because there is vaccine fatigue out there. And I think we’ll be doing more testing for flu and COVID this fall.

DM: Even some people who are vaccinated, and almost certainly many of those who are not, still don’t believe that the COVID death numbers are accurate. That they have been exaggerated or counted in a deceptive way given that so many of the deaths have involved co-morbidities and people who were very old. In fact, this belief may contribute to both vaccine hesitancy and a refusal to embrace masking. What can you say to all that?

Schaffner: First, there’s an element of willful disbelief that is very powerful. And then it’s difficult for some people to understand that, yes, the person was 72 years old, and had obesity, diabetes and high blood pressure and got COVID and died. We do this with influenza, same thing. Had they not had COVID, they would be at breakfast this morning with their diabetes, obesity and high blood pressure still reading the morning Daily Memphian.

It was the COVID that kicked them over, the final straw. And when you fill out the death certificate, the cause of death is COVID. There are associated contributing conditions. You fill that in – diabetes, obesity, high blood pressure. But it was the COVID that was the killer.

And it is true that COVID, and influenza, can take a normal, healthy, robust 33-year-old and put them in the intensive care unit all by itself within 24 hours.

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DM: So, given where we are, how should we be living? Should we be doing more testing? Should we send our children to school? Should we be going into our offices? Should we be avoiding restaurants? Should we go to that Memphis Tigers football game, but sit off somewhere by ourselves? Should we not go to that Grizzlies game in November or to an indoor concert?

What would you suggest?

McCullers: It’s very difficult to make a blanket assessment. There’s a personal assessment of risk that you can make if you’re informed enough. If you’re vaccinated that clearly helps, but it’s not perfect.

If the level of community transmission is really high (Shelby County’s current risk level is labeled as ‘severe’), then your risk tolerance needs to be lower. If you’re vaccinated, you can take more risks.

If you’re immunocompromised, obviously you want to do a lot less. And then look at the characteristics. Outdoor is better than indoors. No crowd is better than a big crowd.

With high transmission, nobody should be going to a sporting event and sitting shoulder-to-shoulder with people.

DM: Indoors or outdoors?

McCullers: Indoors or outdoors. Now, if three weeks from now community transmission is much lower, I may change the calculus there because then what are my odds of being next to someone who is infected at the football game?

But during periods of high community transmission, we need to be living our lives in a way to mitigate risk. Which means work from home when you can. Wear a mask when you’re around people from outside of your household, particularly indoors. Avoid crowds. When we have the winter wave, we’re going to have to go back to these behaviors.

Again, if I’m vaccinated, I’m not worried about getting sick and dying of COVID because the vaccine does a great job protecting people. But I don’t want to get it and pass it on to other people and I don’t want to get ‘long COVID.’

DM: And those ‘long COVID’ symptoms, which can include profound fatigue, shortness of breath and so-called brain fog, among other things, is life-altering while you have it?

Schaffner: It’s absolutely real.

McCullers: There’s a good study out in Lancet Infectious Diseases that looks at incidences of long covid if you’re vaccinated vs. unvaccinated and it’s about half as likely if you’re vaccinated. That’s great, that’s data I’ve been waiting for – I’ve been worried about long COVID, and I don’t need four months where I can’t do my job because I got all these debilitating, chronic symptoms.

DM: Worldwide, the vaccination rate is still low (less than 28% fully vaccinated). Probably not much we can do about that here in Tennessee. But I presume this is a concern?

Schaffner: There isn’t any doubt we need to look beyond our own borders, not just for humanitarian reasons, but self-interest. Because the more COVID there is around the world, the more likely it can come back here. And if it’s spreading elsewhere, that’s where the variants can crop up and one of the variants could evade the protection of the vaccines we’ve been given.

Delta occurred first in India. The original strain came from China. The World Health Organization notwithstanding, we still do not have a comprehensive international program to curb pandemics and distribute pharmaceuticals. The world’s community has got to mature much more than it has at the present.

DM: There also seems to be an attitude among some young people that it just won’t be that big of a deal if they get COVID, so they don’t want to get the vaccine. They’ll be fine. They’re ready to move on.

McCullers: It’s hard to change the mind of a young person. We were both young once and certainly had our rebellious streaks or whatever. Telling stories about 20-somethings who have long COVID or are in the ICU is important because then they’ll say, “I don’t want that to be me.”

DM: So what can we do? On the local level, do we need something similar to a vaccine passport to sort of wrestle the pandemic to the ground?

McCullers: I’ve said since the pandemic started, we need a vaccine passport and that would help get us through this, and I agree with that still now. Businesses are going to take the lead in the private sector. If you’re a concert (promoter), you’re going to say they have to have a vaccine passport because they’re not going to want the liability. Airlines are eventually going to stop letting people travel if they’re unvaccinated. And businesses aren’t going to let people in.

You’re seeing it happens some places faster than others – New York, California, a little bit of it in Memphis … eventually everybody’s going to catch up and that’s going to be the norm. You’re gonna have to show proof of vaccination to do a lot of the things you want to do.

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DM: A lot of physicians have said they feel good about their chances of persuading a vaccine-hesitant person to get the shot, if they can talk to them one-on-one, face-to-face. The problem, of course, is not everybody will get the opportunity to speak one-on-one with a physician. Which sort of puts some responsibility back on leaders to provide a voice on this. And the way our society works, that probably extends to the sports and entertainment worlds, too. There are those rare, famous people who can reach folks who look like them, and people who don’t look like them. Of all ages.

Are these people, and leaders in general, speaking up enough about the importance of vaccination? 

McCullers: It would be great if leaders of all stripes – our public health officials, governmental leaders, our leaders of congregations, our leaders in schools, our entertainers and influencers – were giving that positive message. I think that would do a great deal.

But I think the other side of the coin is the people who are giving the wrong message are just as influential or maybe even more influential in a segment of the society that wants to be the underdog and wants to rebel against authority. And if we had a way to not have those people talking, that would be more powerful. 

DM: At this point, it seems like there might not be a lot that can be said to hardcore vaccine holdouts. So what would you say about the position they’ve taken?

Schaffner: We live together as a society and have given up our own personal inclinations and liberties to do whatever we feel like under certain circumstances. Otherwise, we couldn’t live together.

A very common one is every time we get in a car. Every time we come to an intersection, if the traffic light says green, we continue to drive. But if it says red, I don’t care if I’m in a big hurry or I just want to do it, we stop.

If we drive on the red, that’s our own personal decision and puts us at risk, but it puts everybody else at risk at the same time.

Not being vaccinated is like driving on the red. It’s not just about you.

We’re in a war with this COVID virus. And the war has heated up with this Delta variant. Up till now, we’ve had a volunteer army. People who have chosen to be vaccinated.

But now that we have Delta, we have to have a draft.

And you’re being drafted into being vaccinated.