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Pandemics

One Underwriter’s Story, One Breakthrough COVID-19 Infection, and an Ongoing Conversation

COVID-19 long copy

Get vaccinated or get COVID-19? As life and health underwriters, we know it isn’t this black and white. Some of us may get both. But knowing something, and living it, are two entirely different things.


I am a 54-year-old fully vaccinated, handwashing, mask-wearing underwriter. Still, when I contracted a “breakthrough” case of COVID-19, my harrowing bout caused a breakthrough of a different kind. I gained a sense of gratitude for the protective power of vaccination and a strong commitment to share my personal case with hope that it may help others. As I noted to one friend and co-worker, had I not been fully vaccinated, she would not be forwarding my email; she would be sending my family condolences. 

Even now, on the other side of infection, just recalling my fight against this virus has the power to astonish me. And yet my story starts with happy memories. I spent the weekend watching my grandchildren so that my daughter and son-in-law could enjoy a much-needed weekend away.

Even now on the other side of infection, just recalling my fight against this virus has the power to astonish me. And yet my story starts with happy memories.

Entertaining two very well-behaved and adorable kids was no burden. Due to the pandemic, we stayed home most of the time, with one exception: as a special treat I took the kids to a children’s museum where we wore masks and washed our hands often. We then stopped by a neighborhood restaurant for a quick meal, wearing masks when we weren’t enjoying the food. It was the perfect weekend, but as I started my three-hour drive home, I began to experience a scratchy throat and stuffiness that seemed to signal the start of a sinus infection. This is not unusual after my visits: I lovingly refer to my grandchildren as "my little Petri dishes." 

I woke up the next day feeling a bit sick. Just to be safe, I took a PCR (polymerase chain reaction) test for COVID. By the next morning, I was able to access the results, and my stomach dropped at the matter-of-fact message: “You are positive for COVID-19.” I had to read the news a few times for reality to sink in, and I immediately called my spouse to come home and began letting those I had encountered know they had to quarantine.

PCR Test

Next came the two scariest weeks of my life. My condition rapidly progressed from a cough and congestion to fatigue, joint pain, and a horrible headache. I had never felt so sick. While my situation seemed to slightly improve after a few days, I learned that many experience cyclical flare-ups. So, after consulting a nurse, I decided that monoclonal antibodies might help me recover faster. I got the treatment, but in my particular case, my condition spiraled downhill rapidly. Everything hurt: my skin, my joints, even my teeth. I experienced a stabbing pain behind one eye and severe shin pain, disabling fatigue and brain fog, a chronic deep chest cough, nausea, and more. Even mild exertion, such as climbing a set of stairs, left me slumped over and sobbing with frustration. My personal physician grew so worried she gave me her personal cell phone number.

Next came the two scariest weeks of my life. I had never felt so sick.

The steroids I began taking to ease symptoms sent my blood pressure soaring and left me in the emergency room. I cannot describe this frantic, out-of-control feeling to anyone who has never encountered such a rapid decline.

The nights were the worst. I can still recall the gnawing fear that if I shut my eyes, I might not wake up. I experienced insomnia day after day and lost 11 pounds in the first week. Early on, I constantly worried that I may have exposed my loved ones to this disease. My concern was sharpest over my 79-year-old mother, who was also with me for a period, as well as for my grandchildren, who were too young to qualify for the vaccine. Thankfully, everyone else escaped infection.

I am the only one to get sick even though I took COVID-19 very seriously from the start. I wore my mask everywhere; I washed my hands or sanitized; and I got the vaccine as soon as I was eligible. I received the Pfizer-BioNTech vaccine twice and was two weeks shy of the 6-month threshold when I could qualify for a booster. Before I had the opportunity to get that booster shot, I got COVID. Researchers have found that the vaccine efficacy does decline after six months. 

I am very aware that many may take exactly the wrong lesson from this irony. The first thing I would state emphatically is that had I not benefited from the protection of the vaccine, I truly believe that I would be dead or in an ICU given the severity of my symptoms. In fact, breakthrough cases like mine only reinforce scientists’ statements that COVID-19 vaccines are doing exactly what they were designed to do. The jab is not a shield that just repels coronavirus particles. Instead, it’s more like a fire extinguisher that equips the inoculated to quickly douse the first sparks of infection.

Fire extinguisher


This vaccine is no different from vaccines for influenza, mumps, measles, rubella, or any number of others. This is to say that the vaccines don’t prevent all vaccinated persons from getting the infection, but rather they make the symptoms and/or duration of illness much less severe.

The vaccines don’t prevent all vaccinated persons from getting the infection, but rather they make the symptoms and/or duration of illness much less severe.

Among the vaccinated people with breakthrough cases, the vast majority are either asymptomatic or suffer very mild or moderate symptoms. I was among the minority who reacted to infection like a house on fire. I credit the vaccine with saving my life by ratcheting up my immune system just enough to beat back the flames. I’m a little singed still, but I remain eternally grateful for both shots.

I really am one of the lucky ones. My breakthrough case opened my eyes to the importance of eating well, exercising more, and investing in my health. It reinforced my enduring faith in vaccination and my gratitude for all the family members, friends and healthcare providers who were there to carry me through the darkest days. It also left me with many more questions than answers.

Life underwriters and medical directors almost never have all the facts – instead we must arrive at conclusions through a combination of evidence, experience, logical deduction, and a bit of intuition. Just as every file we see is different, every COVID-19 case is unique and dependent on individual physiology and circumstances. To answer some of the questions each of us has about SARS-CoV-2, I have turned to colleagues on the RGA Medical Team.


A Conversation on My Case

Explain the symptomology of COVID-19. Were my symptoms typical of what has been documented with this disease?

The clinical manifestations of COVID-19 disease most often include cough, headache, and myalgias. Other commonly reported symptoms include diarrhea, shortness of breath, nausea, vomiting, loss of sense of taste or smell, runny nose, fatigue, chills, confusion, and chest pain or pressure. Various dermatologic, rheumatologic, and ophthalmologic symptoms have also been reported with COVID-19 disease. Additionally, some individuals are asymptomatic and never develop any outward symptoms of COVID-191.

Most cases of COVID-19 occur within four to five days following exposure, with an average incubation period of fourteen days after exposure. Symptoms generally progress over the course of a week. Shortness of breath develops around five to seven days following symptom onset and hospital admission occurs after a median of seven days2. There are many potential severe complications of COVID-19 disease, including respiratory failure in the form of acute respiratory distress syndrome (ARDS), deep vein thrombosis (DVT) and pulmonary embolism (PE), encephalopathy, cardiac arrhythmias, myocardial injury, heart failure, shock, and systemic inflammatory response3.

Recovery from COVID-19 follows a variable course. Many individuals with mild infection recover within two weeks, while those with severe disease can face recoveries that span months. Some individuals can experience lingering symptoms that can lead to a diagnosis of Post-acute Sequelae of SARS-CoV-2 Infection (PASC).

Recovery from COVID-19 follows a variable course. Many individuals with mild infection recover within two weeks, while those with severe disease can face recoveries that span months.


The World Health Organization (WHO) released a clinical case definition of post COVID-19 condition in October 2021. It is “a condition that occurs in individuals with a history of probable or confirmed SARS CoV-2 infection, usually three months from the onset of COVID-19 with symptoms that last for at least two months and cannot be explained by an alternative diagnosis4.”These symptoms may be new following initial recovery from acute COVID-19 or persist from the original illness and commonly include fatigue, shortness of breath, cognitive dysfunction, and functional abnormalities.

 

What type of follow-up should someone who has experienced moderate to severe COVID-19 expect in the convalescent phase? Are there tests that can detect lung or organ damage?

Follow-up for individuals with moderate to severe/acute COVID-19 disease will evolve, guided by patient history, physical examination, and clinical findings. Early during recovery, the focus is on identifying and managing acute COVID-19 related complications. Following recovery, the focus is on the management of persistent symptoms to optimize function and quality of life.

This can be achieved in many ways. For example, laboratory testing may be selectively required to follow-up abnormal test results from acute illness and evaluate the presence of ongoing symptoms6. Additionally, symptom assessment tools may be completed to help establish the status of post-COVID conditions and help drive rehabilitation needs5. A similar approach is taken for individuals with ongoing organ specific complaints, such as cardiopulmonary or neurologic sequelae. Post-COVID testing may include chest radiography (CXR), chest computed tomography (CT), six-minute walk test, electrocardiography (ECG), echocardiography, pulmonary function tests, or Holter monitoring, however this list is not comprehensive7.

Specialty assessment may also be necessary depending on the severity of symptoms.  The approach to post-COVID-19 sequelae is currently based on the methods by which similar illnesses are managed because long term data informing the management of persistent COVID-19 symptoms are limited. 

Studies show that monoclonal antibody treatments help many people recover more quickly. What is the reason for the use of monoclonal antibody therapy?

Monoclonal antibody therapy, including the use of casirivimab-imdevimab (Regeneron), has been shown to be effective in the treatment of mild-to-moderate COVID-19 in those patients who are at high risk of progressing to severe COVID-19. Treatment with monoclonal antibodies have shown a decrease in both hospitalization and death rates in these patients4.

Monoclonal antibodies are laboratory-made proteins that mimic the immune system’s ability to combat pathogens such as viruses. This treatment, that targets the receptor binding domain of the spike protein of SARS-CoV-2, is currently under EUA (Emergency Use Authorization) by the U.S. Food and Drug Administration (FDA)1.

Some corticosteroids have anti-inflammatory effects that are thought to prevent or mitigate lung and organ injury from COVID-19. What are some effects of steroids? What are other treatments being used currently?

Systemic glucocorticoids such as prednisone and dexamethasone are currently recommended for use in patients with severe or critical COVID-19 (e.g., those hospitalized with COVID, those requiring supplemental oxygen treatment, and those with comorbidities such as asthma or COPD). Steroids can reduce inflammation but can also suppress the immune system. They have been shown to be effective in those with severe COVID (requiring oxygen or ventilatory support), with improved survival seen in treated patients9. Adverse effects of short-term use include hyperglycemia, hypertension, GI upset, increased infection risk and mood swings. 

Other treatments for COVID currently in use include supplemental oxygen monoclonal antibodies, immunomodulatory drugs, and antiviral medications such as remdesivir. Recently, Merck and Pfizer have filed for EUA from the FDA for, respectively, molnupiravir and Paxlovid, antiviral medications that inhibit viral replication.

What is a breakthrough infection and what are the misconceptions about breakthrough infections?

A vaccine breakthrough infection occurs when an individual is infected after being fully vaccinated. It’s a common misconception that a vaccine has failed if one becomes infected after vaccination; no vaccine is 100% effective, so breakthrough infections are to be expected.

The rate of breakthrough infections is related to the effectiveness rate of the vaccine against original and variant viruses, waning immunity, as well as prevalence in the community.

It’s a common misconception that a vaccine has failed if one becomes infected after vaccination; no vaccine is 100% effective, so breakthrough infections are to be expected.

 

Data for breakthrough infections can be misinterpreted: The denominator matters. Instead of using the denominator of fully vaccinated people having breakthroughs (which would be more accurate), some reports state the number of breakthrough infections out of those that had COVID-19 infections or were hospitalized for COVID-1913. Breakthrough infections still occur at a much lower rate than infections in unvaccinated individuals. The U.S. Centers for Disease Control (CDC) has noted that, as of August 2021, unvaccinated individuals had 6.1 times greater risk of testing positive and 11.3 times greater risk of dying from COVID-19, compared to fully vaccinated individuals14. Due to evidence of waning immunity from the initial two-shot series of available vaccines, the FDA recently recommended boosters for all adults aged 18 and older at least six months after having received second doses.

Is there anything I could have done to prevent my infection?

The single most important preventative measure is vaccination (including receiving a booster shot). This will decrease the likelihood of infection, serious illness, hospitalization, and death.

Other public health interventions can also prevent the spread of disease. Given the prevalence and enhanced transmissibility of the delta variant of COVID-19 as well as the ongoing emergence of new variants such as omnicon, measures such as masking indoors, hand washing, and social distancing are vital. The best anyone can do to prevent infection is to get vaccinated and follow common-sense infection control and public health guidelines.

The single most important preventative measure is vaccination (including receiving a booster shot).


An October 2021 study published in the Lancet15 showed that peak viral load was similar between vaccinated and unvaccinated individuals in the household setting, but clearance, or the time required for the virus to become undetectable, was faster in those who were vaccinated. It also suggested that household transmission was similar among vaccinated and unvaccinated individuals. Thus, all preventative measures are essential, especially if one lives in an area where COVID-19 is highly prevalent or surging. There is no single solution to combat COVID-19, but hopefully a combination of measures, including vaccination, goodwill towards one another, and treatment innovations, will help curtail the pandemic.  

 


References

  1. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html
  2. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS, China Medical Treatment Expert Group for Covid-19. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020;382(18):1708. Epub 2020 Feb 28.
  3. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, Wang B, Xiang H, Cheng Z, Xiong Y, Zhao Y, Li Y, Wang X, Peng Z. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020;323(11):1061. 
  4. https://www.who.int/publications/i/item/WHO-2019-nCoV-Post_COVID-19_condition-Clinical_case_definition-2021.1
  5. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/post-covid-assessment-testing.html
  6. Arnold DT, Hamilton FW, Milne A, Morley AJ, Viner J, Attwood M, Noel A, Gunning S, Hatrick J, Hamilton S, Elvers KT, Hyams C, Bibby A, Moran E, Adamali HI, Dodd JW, Maskell NA, Barratt. Patient outcomes after hospitalization with COVID-19 and implications for follow-up: results from a prospective UK cohort. Thorax. 2021;76(4):399. Epub 2020 Dec 3. 
  7. Greenhalgh T, Knight M, A’Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ 2020; 370: m3026. doi:10.1136/bmj.m3026
  8. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-monoclonal-antibodies-treatment-covid-19
  9. RECOVERY Collaborative Group, Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, Linsell L, Staplin N, Brightling C, Ustianowski A, Elmahi E, Prudon B, Green C, Felton T, Chadwick D, Rege K, Fegan C, Chappell LC, Faust SN, Jaki T, Jeffery K, Montgomery A, Rowan K, Juszczak E, Baillie JK, Haynes R, Landray MJ. Dexamethasone in Hospitalized Patients with Covid-19. N Engl J Med. 2021 Feb 25;384(8):693-704. doi: 10.1056/NEJMoa2021436. Epub 2020 Jul 17. PMID: 32678530; PMCID: PMC7383595.
  10. Rochwerg B, Agarwal A, Siemieniuk RA, Agoritsas T, Lamontagne F, Askie L, Lytvyn L, Leo YS, Macdonald H, Zeng L, Amin W, Burhan E, Bausch FJ, Calfee CS, Cecconi M, Chanda D, Du B, Geduld H, Gee P, Harley N, Hashimi M, Hunt B, Kabra SK, Kanda S, Kawano-Dourado L, Kim YJ, Kissoon N, Kwizera A, Mahaka I, Manai H, Mino G, Nsutebu E, Preller J, Pshenichnaya N, Qadir N, Sabzwari S, Sarin R, Shankar-Hari M, Sharland M, Shen Y, Ranganathan SS, Souza JP, Stegemann M, De Sutter A, Ugarte S, Venkatapuram S, Dat VQ, Vuyiseka D, Wijewickrama A, Maguire B, Zeraatkar D, Bartoszko JJ, Ge L, Brignardello-Petersen R, Owen A, Guyatt G, Diaz J, Jacobs M, Vandvik PO. A living WHO guideline on drugs for covid-19. BMJ. 2020 Sep 4;370:m3379. doi: 10.1136/bmj.m3379. Update in: BMJ. 2020 Nov 19;371:m4475. Update in: BMJ. 2021 Mar 31;372:n860. Update in: BMJ. 2021 Jul 6;374:n1703. Update in: BMJ. 2021 Sep 23;374:n2219. PMID: 32887691.
  11. DM, Sivapalasingam S, Norton T, Ali S, Gao H, Bhore R, Xiao J, Hooper AT, Hamilton JD, Musser BJ, Rofail D, Hussein M, Im J, Atmodjo DY, Perry C, Pan C, Mahmood A, Hosain R, Davis JD, Turner KC, Baum A, Kyratsous CA, Kim Y, Cook A, Kampman W, Roque-Guerrero L, Acloque G, Aazami H, Cannon K, Simón-Campos JA, Bocchini JA, Kowal B, DiCioccio AT, Soo Y, Geba GP, Stahl N, Lipsich L, Braunstein N, Herman G, Yancopoulos GD; Trial Investigators. REGEN-COV Antibody Combination and Outcomes in Outpatients with Covid-19. N Engl J Med. 2021 Sep 29:NEJMoa2108163. doi: 10.1056/NEJMoa2108163. Epub ahead of print. PMID: 34587383; PMCID: PMC8522800.
  12. https://news.wfu.edu/2021/08/11/reports-on-breakthrough-covid-cases-causing-confusion-about-vaccine-effectiveness/
  13. https://covid.cdc.gov/covid-data-tracker/#rates-by-vaccine-status
  14. https://www.npr.org/sections/coronavirus-live-updates/2021/11/19/1056832774/the-fda-authorizes-covid-19-booster-shots-for-all-u-s-adults
  15. Singanayagam A, Hakki S, Dunning J, Madon KJ, Crone MA, Koycheva A, Derqui-Fernandez N, Barnett JL, Whitfield MG, Varro R, Charlett A, Kundu R, Fenn J, Cutajar J, Quinn V, Conibear E, Barclay W, Freemont PS, Taylor GP, Ahmad S, Zambon M, Ferguson NM, Lalvani A; ATACCC Study Investigators. Community transmission and viral load kinetics of the SARS-CoV-2 delta (B.1.617.2) variant in vaccinated and unvaccinated individuals in the UK: a prospective, longitudinal, cohort study. Lancet Infect Dis. 2021 Oct 29:S1473-3099(21)00648-4. doi: 10.1016/S1473-3099(21)00648-4. Epub ahead of print. PMID: 34756186; PMCID: PMC8554486.

 

 

The Authors

  • Jennifer Johnson
    FALU, CLU, FLMI, FLHC, ARA
    Executive Director
    U.S. Underwriting Innovation

    RGA
  • Dr. Dave Rengachary
    DBIM, FALU, FLMI
    Senior Vice President and 
    Chief Medical Director

    U.S. Mortality Markets
    Send email >

  • Dr. Preeti Dalawari
    MSPH
    Medical Director

    U.S. Mortality Markets
  • Dr. Megan Leivant
    Vice President and Medical Director
    RGA
     
  • Dr. Maryam Shapland
    DBIM
    Vice President and
    Medical Director

    U.S. Mortality Markets

Summary

A harrowing bout with a breakthrough case of COVID-19 causes RGA's Jennifer Johnson to have a breakthrough of a different kind. She shares her wrenching personal experience, offers some lessons learned, and embarks on a conversation with RGA's physicians about the particulars of her case. 
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