ST. LOUIS — A nationwide effort to track cases of COVID-19 in fully vaccinated people has gotten a slow and confusing start in Missouri.
At the start of this month, the U.S. Centers for Disease Control and Prevention asked states to instruct their local health departments and health systems to collect real-time information on such “breakthrough infections.” States are to collect the data and enter it into a national database.
But county health departments and health systems in Missouri say they were never given such instructions.
By mid April, when the CDC announced its first tally of breakthrough infections across the U.S. — about 5,800 — it caught a disease investigator for the St. Louis County Department of Public Health by surprise.
“I wasn’t sure how they were following it,” said Dr. James Hinrichs. “I am very confused as to how this is being collected and by whom.”
The county health department has been tracking down breakthrough infections on its own initiative and has been waiting for instruction from the Missouri Department of Health and Human Services on what to do with the data, Hinrichs said.
The latest CDC tally of breakthrough infections is now up to 7,157 out of more than 87 million people in the U.S. who have been fully vaccinated. (Fully vaccinated is defined as two weeks past their last dose.)
The breakthrough number is a tiny fraction and completely expected, as the vaccines are highly, but not 100%, effective. But tracking breakthroughs is needed to identify any unusual patterns — such as trends in age or sex, the batch of vaccines involved or whether a variant is the cause.
“To date, no unusual patterns have been detected in the data CDC has received,” the agency states on its breakthrough infection website.
Of the nearly 7,200 cases in fully vaccinated people across the U.S., nearly a third had no symptoms. Just 7% (498) ended up in the hospital, and 1% (88) died.
The federal report states that in the coming weeks, the CDC will focus on investigating breakthrough infections that result in hospitalization or death “to help maximize the quality of the data collected on cases of greatest clinical and public health importance.”
Last week, St. Louis County shared that it had come across 71 breakthrough infections out of about 226,000 fully vaccinated people. Staff discovered the infections through the department’s own routine case investigation of those with positive COVID-19 test results. Two of those people were hospitalized.
A reporter’s inquiry to the Missouri health department about other such cases revealed that only 14 had been collected across the state and reported to the CDC national database.
“Much like all states at this time, we continue to work to enhance surveillance for vaccine breakthrough cases,” Missouri DHSS spokeswoman Lisa Cox wrote in an email.
The CDC report uses data from 45 U.S. states and territories. The report is not broken down by state, and a CDC spokesperson would not reveal which states had not yet submitted data.
When asked why only 14 had been reported when 71 had already been identified in one county alone, Cox said in an email, “At the state level, we are vetting the information received from the county level to confirm the information provided and that it meets the case definition. There are many more currently under review than the 14 confirmed.”
Illinois by comparison, with slightly more than double the population of Missouri, has reported 918 breakthrough infections to the CDC out of its 3.5 million fully vaccinated people, an Illinois Department of Public Health spokesperson said a week ago. About 1.6 million people are fully vaccinated in Missouri.
When asked how the Missouri health department was collecting the data, Cox said local health departments are to report breakthrough cases using EpiTrax, the state’s software system that collects COVID-19 test results. Fields listing a person’s vaccination status were recently added.
Health department confusion
Hinrichs said the state would never know about the county’s breakthrough infections through EpiTrax. The county only uses EpiTrax to receive notifications of COVID-19 test results within the county. The county, by far the largest health department in the state, uses another more robust system to manage data from case investigation and contact tracing. EpiTrax is mainly used by small health departments without their own systems, Hinrichs said.
Jefferson County health officials say the state has only instructed the health department to send reports of breakthrough infections if there are clusters or an outbreak. Jefferson County voluntarily uses EpiTrax to track the breakthroughs for its own use, but officials say they are unaware if the state is accessing the data.
“We can state that as soon as we, as a local agency, became aware that we could access the data, we began to look into how we would be able to analyze it and translate it for community use,” said Kelley Vollmar, Jefferson County Health Department director. “We are unaware of the intentions of the state system, because they have not been communicated to us at the local level.”
Doug Bolnick, spokesman for the St. Charles County Department of Public Health, said disease investigators there would discover breakthrough infections through contact tracing of new COVID-19 cases. Through April 22, investigators had not discovered any breakthroughs, Bolnick said.
If they do, they would share the findings directly with state officials, he said. “Our staff is in contact every day with individuals from DHSS and would communicate that information through these contacts.”
Before publicly sharing information about 71 breakthrough infections the county had discovered, Hinrichs said after the first 50, he voluntarily emailed his contact with the Missouri health department about the findings. She thanked him but provided no further instructions, he said.
After the CDC came out with its nationwide report, Hinrichs said he’s tried to get clarification from the state contact on what to do with the data.
“I tried to call her today as to what they really want, and how the CDC is getting their data if the state is not sending it,” Hinrichs said on Tuesday. “I was tempted to just to call the CDC and say, ‘Do you want us to send it directly to you?’”
On Wednesday, the county’s tally of breakthrough infections in fully vaccinated people reached 96, including an additional case that required hospitalization, Hinrichs said.
He also heard back from state officials. “They are planning on updating their reporting recommendations on Friday, in regards to reporting these cases to the state and then to the CDC,” Hinrichs said.
He was also finally directed on Wednesday to start entering data on the breakthrough infections into the EpiTrax system, which he and another staff member began to do on the county’s 96 cases.
Hospital systems in the St. Louis area have on their own also started tracking breakthrough infections among patients showing up in their emergency rooms with COVID-19.
On April 20, the St. Louis Metropolitan Pandemic Task Force created a process to survey all of the 217 COVID-19 patients in the hospital that day and found seven had been fully vaccinated. The count serves as a baseline to track changes, said task force director Dr. Alex Garza.
The task force hospitals — which include BJC HealthCare, SSM Health, Mercy and St. Luke’s hospitals — are finalizing a process to gather vaccination data on COVID-19 patients going forward, Garza said.
The state health department has not asked for breakthrough infection information from the health systems, he said.
Despite the hospitalizations discovered by the task force and St. Louis County, Cox told a reporter in an email on Tuesday, “So far, none of these cases resulted in hospitalizations or deaths which is what CDC will be focusing on.”