Alabama currently ranks last the nation in COVID-19 vaccination rate, with only a third of the state population fully vaccinated and the Delta variant running rampant.

Vaccinations in Alabama have slowed to a near standstill. As of late week, Alabama’s positivity rate ranked among the top five in the nation. Hospitalizations have doubled. The Alabama Department of Public Health resumed its daily updates due to the surge, and all the while, the Delta variant is here, accounting for 85 percent of COVID-19 cases at one Alabama lab.

We asked Dr. Michael Saag, director of the Division of Infectious Disease at UAB, several pressing questions about our current COVID situation, which he considers a major emergency in our state and country.

Below, he discusses Alabama’s vaccination rate, why people remain reluctant to get vaccinated, what people should know about the Delta variant, why there’s nothing political about protecting yourself from a deadly virus and how we are making the same mistakes we did when COVID was peaking by rushing back to normal life.

You say the timing in discussing COVID is critical right now, that we are beginning to see yet another surge, almost exclusively among non-vaccinated people. First of all, before we dive a little deeper into some of this, why is the timing so critical, and what is the message you want to get out to people about this potential surge?

Dr. Michael Saag: We’re seeing the consequences of a wide open July 4th holiday weekend. People who are vaccinated appropriately were going around without masks and congregating. But people who are not vaccinated were basically behaving as if this was all over, the COVID experience was done and we can just get on with our life. Meanwhile, the Delta variant had other plans. That’s exactly what happened. We are seeing, as a consequence of the unvaccinated folks congregating without masks and in large groups over that weekend, huge numbers of new cases like we haven’t seen since February and March of last year. And it’s rising exponentially. So now is a time for everyone to hit the pause button and rethink how they individually are responding to this pandemic.

The amount of hospitalizations statewide is up. The number of infections reported is also rising. Alabama hasn’t seen this many COVID-19 hospitalizations reported since March. Why are we trending in this direction?

I think the single cause is that two-thirds of our population are not vaccinated. Full stop. That’s enough to explain everything. And the Delta variant is 10-times more infectious than the original SARS virus. To put that in real terms, back when I got infected in March 2020 with the original virus, you would have to be in a closed space within three or four feet of someone for about 10 minutes to be assured of picking up the infection. With the Delta variant, all you have to be is in contact with them for about one minute, maybe a little less, and you’ll pick up this virus. I don’t think the public has quite understood that yet, but we’re finding out in a real way. Our numbers are up over 330 percent from two weeks ago. So this is just the beginning. It’s not stopping today simply because we’re talking about it. It’s going to get worse. And as it gets worse, what’s different this time around is that this is affecting mostly 20, 30, 40-year-old people. The older folks in the state of Alabama, about 80 percent of them, have been vaccinated, compared to about 20 percent or a little less of the people between the ages of 18 and 35. So the 18-35-year-old folks are saying “Well why should I worry about this? Even if I get it no big deal.” But that’s not true. The hospital is now becoming full with people in their 20s, 30s and 40s, some of whom are on ventilators, some of whom are dying.

In May of 2021, in the united states, 18,000 people died from COVID. 17,850 of those folks were not vaccinated. That 99.2 percent. In June, same story. Ten thousand people died, 99.2 percent were not vaccinated. And among the people who were vaccinated and died, those individuals were mostly immunocompromised, meaning they had solid organ transplants where the immunity from the vaccine wasn’t strong enough to protect them from progressive disease. For those who were unvaccinated, that have no pre-existing immunity, so they’re totally vulnerable. This is a public healthy emergency right now — a true emergency. I know you’re tired of hearing that, but that’s what we’re dealing with. And people with public health expertise would be derelict in our duties if we didn’t sound the alarm. This is an emergency right now.

While the Delta variant doesn’t appear to be more deadly than the initial strain of coronavirus, health experts say it is more contagious. What do people need to know and consider about the Delta variant?

That it’s 10-times more infectious than the other virus, and if you were able to dodge the bullet last winter, you are much less likely to be able to dodge it this time. And here’s the thing. Once you get it, you lose control of how your body responds. I’ve heard over and over again: “Well I’m a healthy person. I’m not worried about getting it.” Some of those healthy people end up in the hospital and some of them on ventilators. This virus doesn’t care what your health status is too much. It’s going to infect you, and once that happens, there’s no do-over button. You can’t hit reset like it’s a video game. It’s going to run its course, and you don’t want to be in its way.

The biggest difference between last summer and fall and now is that we can do something to prevent this, and that’s get vaccinated. You get vaccinated, not only do you reduce your risk to a very low number. The Delta variant can break through a vaccinated person. About 25 percent of the people who have been vaccinated will get infected with the Delta variant, but the disease is a short duration of mild symptoms, and unless immunocompromised won’t progress to severe disease. But for those people who are unvaccinated, not only are you putting yourself at risk, you’re putting those people who have been vaccinated that are immunocompromised at risk. And that’s, in my view, a tragedy because this is totally preventable. Those deaths in May, the deaths in June and the ones that are happening in July are totally preventable deaths. How can we put up with that when we have readily available vaccine for everyone?

Are children more at risk with the Delta variant? One expert said we don’t have evidence that it infects children to a varying degree than it infects adults. Are you aware of any differences?

Yeah, the Delta variant will infect children much more than the original strain simply because the Delta variant is much more infectious. The question then becomes, “Are they going to get sicker?” The jury is out on that still. There’s a study out of Scotland that suggests they are getting sicker per person infected. We know people under the age of 12 are not eligible for vaccines. They’re the ones who are getting infected in pretty large numbers right now. There are case reports, stories out of Mississippi with 10-12 kids in ICU. We’ve had several cases here at UAB and Children’s Hospital of younger people going into the hospital and ICU. It’s not universal by any stretch, but why take the risk?

Children, if they are not vaccinated and they’re going out into crowds around other unvaccinated children, should be wearing a mask. Period. They should be. I want to see kids go back to school as much as anyone. But I think if I were a parent, even if the schools don’t require it, I would send my child to school with a mask, unless they’re able to get vaccinated. This virus is just revving up right in time for school season. And once this virus gets into a school situation, it’s going to run rampant because that’s what the Delta variant does. Seventy-five to 80 percent of the cases in Alabama right now are Delta variant. It’s here. It’s running rampant.

So you would recommend that all schools require masks, but even if they don’t, you would recommend parents have their kids wear masks to school anyway?

The responsible thing, in my opinion, for school systems to do is to require a mask. And if they won’t step up and do the right thing, then the parents should take care of their own kids by having them wear a mask. I would reiterate, though, that a mask does most of its work covering the mouth and nose of someone who’s infected. So even if your kid goes to school with a mask and they’re not infected, if a child next to them has COVID, the mask on your child will help some, but the best protection for your child is for the child who is infected to be wearing a mask. And the problem is that a lot of times kids are infected for several days before they develop symptoms, spread the virus before they know they’re sick, and so the exposure can happen inadvertently just in the normal activities of what kids do.

What I don’t understand is why there is so much political pushback for mask requirements or for that matter, vaccine mandates. Somehow this has become so political that people are talking about in some states making it illegal to have mask mandates in their state. I don’t understand. I guess they just want to see people die. But it doesn’t make sense to me why they would have prohibition on a mask mandate when you’re dealing with a public emergency. It’s indescribable to me.

There are a lot of people who are hesitant about getting vaccinated, where perception about COVID is in stark contrast to reality. We just published a story that says the overwhelming majority of Americans who said they won’t receive a vaccine fear side effects more than the virus itself. It also says more than 25 percent of fully vaccinated people believe the dangers of COVID-19 were exaggerated for political reasons. In this time you consider so critical for proper messaging and making sure as many people as possible are vaccinated, what is your message to people who remain on the fence about getting the shot?

The first thing to think about is this is not a question of get the vaccine or don’t get the vaccine. This is a question of the relative risk of a side effect from the vaccine versus a relative risk of getting COVID and getting very sick and dying. That’s what we’re weighing out here. We’ve had well over 400 million doses of these vaccines that have been given, and there’s no surprise. It’s exactly what we thought we would see. Side effect profile is among the best for any vaccine we’ve ever had, and the efficacy (the effectiveness of the vaccine) is about as good as you can ever expect, much better than we ever had for the influenza vaccine. So that’s the risk of the vaccine and the benefit.

Once you get COVID, you just have to experience whatever is going to happen. And it’s a heck of a lot worse than getting a side effect from the vaccine, I can promise you that. There aren’t people coming into the hospital and going on ventilators from a vaccine. And there are plenty of people having that happen when they get COVID. Imagine the world if we did not have a vaccine. What would we be going through right now with Delta variant? At least the older folks are being protected because they were wise enough to get the vaccine. It’s the younger populations and people who have dug their heels and said “I’m not getting the vaccine.” Well, you’re putting your life on the line. You’re putting yourself in harm’s way, in my view, unnecessarily.

Regarding political agendas, I don’t speak from a political perspective. Some people may question that. Politics has nothing to do with this. This is simply medical science. This is public health 101. There’s nothing political about it. When you see an emerging crisis like this, we use the data that’s in front of us and give advice based on that. No different than if you went to your doctor with chest pain. We know what to do for that. We do an EKG. We run some blood tests. This is going to your doctor, except the doctor is a public health official who knows a lot about how epidemics emerge. There isn’t politics in this. There may be politics in the negative messaging, perhaps. I don’t understand where it comes from. It’s not based in data. This is what’s becoming very frustrating for a lot of us not only in the public health field, but also physicians in the hospital taking care of the new onslaught of cases and looking around and seeing the folks who are coming into the hospital going on ventilators now as people who resisted the vaccine message because they saw the messaging through a political lens. I can promise you there is no politics in this, from the messaging that I’m giving, the CDC is giving, the WHO is giving. They’re giving the advice based on sound public health and medical science advice. End of discussion.

Are there any legitimate medical reasons why a person should not get vaccinated?

There are two. If someone has had an allergic reaction to one of the components of the vaccine, that might be viewed as a medical indication. The good news with these vaccines, especially Pfizer and Moderna, is there are very few components. It’s mostly polyethylene glycol. That’s it. Everything else is just a lipid membrane and a piece of messenger RNA. So it’s unlikely that anybody has had an allergic reaction to polyethylene glycol. The second reason is if somebody from a prior vaccination had a rare, adverse event called Guillain-Barré. But even in that setting, I’ve taken care of several people who have had previous Guillain-Barré, who got the vaccine and did not have a recurrence of it. That doesn’t mean you should just jump right in without talking to your doctor. But that’s about it. Everybody else, if you’re immunocompromised, not only should you get it, you should be first in line. If you’ve got something going on with your immune system, you are a super candidate, not someone for whom the vaccine is contraindicated.

I read a report that said post-immunization COVID cases, these “breakthroughs,” are very rare but also very expected, but I think there is still a perception that if you are vaccinated, you can’t get COVID. But this is obviously not the case.

Correct. With the original viral strain, the breakthrough cases were running around 5 percent in the studies, but in practice it was only running about 1-2 percent. So these breakthrough symptomatic cases were very uncommon. With Delta, we’re seeing more breakthrough symptomatic cases on the order of around 15-25 percent. But the very good news is that even if someone is vaccinated and they develop symptoms from a new breakthrough COVID infection, the symptoms are typically mild and of short duration. Very, very few people are going into the hospital, and even fewer people are dying after they’ve been vaccinated from a second COVID infection. So the vaccine is working incredible well, better than anyone ever imagined or hoped when it was being developed.

It’s been widely known since the vaccines were approved for emergency use that they are not 100 percent effective, but there’s a report out of England that says 60 percent of people being admitted to hospital with COVID-19 have had two doses of a coronavirus vaccine. Why are people who are fully vaccinated being hospitalized with serious illness? That seems like a very high number?

It depends on the country. In Israel, they had a similar report. But remember, in Israel, 85-90 percent of the population has been vaccinated. So as a percentage of people getting admitted, the odds are pretty high that somebody had been vaccinated. Their overall numbers are remarkably low, the actual number of cases. Whereas in the United States, where only about a third of the people in Alabama and less than half the people in the U.S. in general, as far as people going into the hospital or dying from COVID, it’s a very small number because most of the cases in the U.S. are among people who are unvaccinated.

People remain eager to return to what the consider normal life in Alabama. Plans remain for football stadiums to reach full capacity this fall. People are eating in restaurants again. Masks are disappearing. Rushing back into things was already a major concern more than a year ago, but as cases and hospitalizations rise, it appears history is repeating itself, even with more people vaccinated than they were a year ago. What is your sense of our collective caution with COVID right now? Are we making the same mistakes we did when it was at its peak?

Yeah, unfortunately I really do. A lot of the decision-making for this fall, especially with regard to football stadiums and getting back to life as a semblance of normal, was based on the assumption that the vast majority of citizens would be vaccinated. That’s not happened, to a lot of people’s surprise including me. It’s not rocket science. If you put a lot of people in a space, even if it’s outdoors, packed in next to one another and the majority of those people are not vaccinated…if you’re sitting next to someone who’s infected and they’re yelling and screaming like people do at a football game, they’re spewing virus into the environment and almost certainly it’s going to be a Delta variant, which means all you have to do is breathe in that air for about a minute and you’re going to walk away from that football game infected if you’re not vaccinated. This is just common sense and logic.

My advice to people: If you’ve been vaccinated, you’ve got a ticket to ride. You can go to the football game. You can go to restaurants, within reason, etc. If you’re not vaccinated, you’re basically putting yourself in harm’s way in a major way because many of the people at the game or whatever location are just like you, unvaccinated. And the odds are pretty high with the numbers rising right now that out of 25 people, at least one would be infected at that moment in time. So you divide 25 into the number of people at the game, and you’re going to have hundreds of people who are going to be infected at the game at any moment in time, spreading virus to the people who are not vaccinated. It’s going to be an interesting fallout that is unfortunate because people are not getting vaccinated. Totally preventable. Totally. And yet, we’re not heeding the warnings.

What is most concerning to you right now? What is something you think we aren’t reporting or that people aren’t considering with COVID and another potential surge?

I think the reporting has been accurate. What we have is a perfect storm of a very contagious virus in the Delta strain, a lot of susceptible people who have not been vaccinated and an attempted return to normal when things are not normal. You put those things together and you’re talking about another surge, only this time it’s hitting the people who had a choice, and they chose not to get vaccinated. The choice is still there. The vaccines are widely available. Now is the time to act and go get vaccinated. Now. Because this thing is exploding, and if you want to be protected and able return to the life we knew before COVID in a safe fashion, the vaccine is the way to protect yourself. In essence, when you’re vaccinated, you’re wearing a biologic mask that’s protecting you from infection, and if you happen to get infected, your disease course will be of much shorter duration and of much less severity. I can’t tell you the numbers of people I’ve seen in the hospital on their way to getting intubated and said, “I had it wrong. I should have been vaccinated.” Frankly, for those folks, unfortunately, it’s too late.

What has it been like to be a doctor for the last year-and-a-half? We’ve all grown up minding doctors orders, but in the age of COVID, this virus that has polarized, been politicized, there has been significant public skepticism cast on medical science. I know you can only speak for yourself personally, but based on what you’ve observed during the pandemic, have you felt stigmatized or even marginalized at all, or do you just focus on doing the best you can in light of the circumstances?

I think I can speak for all the physicians I work with and say that we’re all doing the best we can. I can also say we’re all working with the best of intentions. That said, for me personally, I’ve never been as frustrated professionally as I am right now. I had hoped and prayed for a successful vaccine and was frankly surprised when the vaccine showed its efficacy to the degree that it is and its safety. And I thought, my goodness, there’s a Christmas miracle if we’ve ever seen one in our lifetime. It actually happened. And then to have it not available initially and people clamoring, but finally getting it delivered in sufficient quantities to vaccinate everyone in the United States. And to my surprise and horror, people are not lining up to get the vaccine that’s offered to them free and that works extraordinarily well. People are choosing to remain in harm’s way, but worse, when they get infected, they put people who are vaccinated at risk, at least those who are immunocompromised who could get very sick from this.

And something what I would call the assassination of the trusted voice. People who we normally in the past would listen to and heed because we knew they were giving us sound advice. Those individuals are still giving us sound advice, but they’re being demonized by social media and other places that basically have taken that voice away to the detriment of everyone who lives in our community and to our country as a whole. Other countries are not seeing this. A lot of other countries are moving forward with vaccinations with an aggressive, open mind because they know what the data are. We have the data. The media has reported it accurately. We just have a resistant portion of our population who don’t want to heed the warning.

From my perspective, if people don’t want to use a vaccine, we should start sending that vaccine to other countries before it expires because countries all around the world, especially resource-poor countries, are clamoring for this vaccine while their populations are being decimated by COVID. If our people don’t want it, then fine. We’ll send it before it expires someplace else, but I’d rather see all the people in the United States get vaccinated, protect ourselves, take care of our own, and then we can begin exporting to elsewhere. But it’s really an individual’s choice. We haven’t mandated it. But to me, it’s a tragedy. And it’s extraordinarily frustrating for me as an individual, as a provider, as a researcher to see this happening.

As a healthcare provider, I liken this to being at war. We had servicemen and women who went to Vietnam and fought and put their lives on the line for a greater good, for a cause. And when they came back, they were largely ignored and even ridiculed. It’s beginning to feel that way a little bit in the healthcare community. I see my colleagues running into battle every day. They are taking care of people as they come in, regardless of their vaccination status. But at some point, it feels like a portion of the population is almost thumbing their nose at people who are trying to do the right thing and take care of folks in a professional way, but they are not given any regard when they are trying to protect people from showing up at the emergency room and overwhelming the hospitals again. And that is remarkably frustrating, for everyone.