| Last week, I expressed my weariness and disappointment about our return to masking and other restrictions because of the delta variant of the coronavirus. I received an email from a reader who was vaccinated yet told me, "I do not understand all the rage or just frustration at the unvaccinated. What's the hoopla really about?" The email included some misconceptions, so I'm sharing part of my response because I believe we all need to be aware of some very important facts about virus transmission, the impact of not being vaccinated and how viruses mutate. As I write this, data from the past week shows that new daily reported cases rose 5.5 percent and new daily reported deaths rose 29.6 percent. The writer's statement: "Vaccines don't prevent virus transmission, though they do diminish covid disease." My response: It's true that the main purpose of a vaccine is to prevent infection and severe disease. But research has shown that the coronavirus vaccines DO cut down on transmission, though they don't prevent it entirely. According to the CDC: "A growing body of evidence indicates that people fully vaccinated with an mRNA vaccine (Pfizer-BioNTech or Moderna) are less likely than unvaccinated persons to acquire SARS-CoV-2 or to transmit it to others [emphasis mine]. However, the risk for SARS-CoV-2 breakthrough infection in fully vaccinated people cannot be completely eliminated as long as there is continued community transmission of the virus." Unfortunately, because the vaccines were designed based on the original Wuhan version of the virus, they aren't as effective at stopping the spread of variants, and we now know that vaccinated people who get breakthrough cases of the delta variant can have similar viral load in their nasal passages. That is the reason the Centers for Disease Control and Prevention started advising everyone, regardless of vaccination status, to wear masks inside (advice the unvaccinated seem more likely to ignore, because they are often the same people who refused to wear masks). Still, because the unvaccinated are more likely to get infected in the first place, they are more likely to transmit covid-19 than the vaccinated. And they could spread illness to vulnerable people who have tried to protect themselves or who cannot avail themselves of the protection the vaccines offer, such as those who are vaccinated but still at risk of serious disease (the elderly, the immunocompromised) and children who are too young to be vaccinated. The writer's statement: "As stupid as they might be for not protecting themselves from severe disease, that's their choice. They can choose to risk severe disease just as smokers do, unhealthy eaters do, sedentary people do, heavy drinkers do, etc. It's completely wrong to put the healthcare system at risk, but they can risk their own lives for all I care if they choose." My response: Refusing to get vaccinated doesn't just harm the unvaccinated person; as noted above, it risks the lives of others. This is a major difference between unvaccinated people and the unhealthy eaters, sedentary people and heavy drinkers that the writer cites. (In the case of smokers, who can harm others, we have laws against secondhand smoke, which undermines the point the email writer was trying to make.) And the unvaccinated aren't just putting the health-care system at risk, they are completely overwhelming it in places, forcing some hospitals to turn away non-covid patients and forcing some patients to delay getting other kinds of treatment, such as chemotherapy. The unvaccinated are also hurting health-care workers who must endure long, unforgiving hours and deal with the trauma of unnecessary illness or death; costing billions in unnecessary treatment; and prolonging the pandemic. Plus, those who die are leaving behind families. The writer's statement: "I also don't understand the blame heaped upon unvaccinated for potential mutations. The virus has no reason to mutate in easily infected bodies where it can thrive. Mutations have so far developed in bodies (citizenry) who resisted the waves of the earlier, original, initial form — those nations. Because it couldn't get a hold in those regions, it mutated to enable itself to thrive." My response: This is wrong. The more a virus circulates among "easily infected bodies," the more opportunity it has to make errors during the copying process, which is how variants arise. And I don't know where the writer got the idea that the variants developed in nations that had resisted earlier forms of the virus; delta arose in India at a time when it had already been devastated by the alpha variant of the coronavirus and had a low vaccination rate. That means that Americans who refuse to receive easily available vaccines are indeed increasing the possibility of future – and more dangerous – variants. Furthermore, unvaccinated Americans are the reason delta has been able to do so much damage here. If more people had been vaccinated before delta reached us, we'd be much better off because (1) fewer people would be getting ill in the first place, because the vaccines do offer some protection against delta, and (2) we'd mostly be dealing with less-severe breakthrough cases, and our health-care system would not be overwhelmed. So yes, I feel rage and frustration. But mostly I feel deeply disturbed that so many Americans seem to care so little about their fellow citizens that they not only decline vaccines but refuse to wear masks to protect the vulnerable among us. One good bit of news is that their numbers seem to be dwindling: In August, more than 14 million people got their first shot, which was almost 4 million more first shots than in July. Take care. | 
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