An analytic approach for understanding mechanisms driving breakthrough infections

Real world data is an increasingly utilized resource for post-market monitoring of vaccines and provides insight into real world effectiveness. However, outside of the setting of a clinical trial, heterogeneous mechanisms may drive observed breakthrough infection rates among vaccinated individuals; for instance, waning vaccine-induced immunity as time passes and the emergence of a new strain against which the vaccine has reduced protection. Analyses of infection incidence rates are typically predicated on a presumed mechanism in their choice of an "analytic time zero" after which infection rates are modeled. In this work, we propose an explicit test for driving mechanism situated in a standard Cox proportional hazards framework. We explore the test's performance in simulation studies and in an illustrative application to real world data. We additionally introduce subgroup differences in infection incidence and evaluate the impact of time zero misspecification on bias and coverage of model estimates. In this study we observe strong power and controlled type I error of the test to detect the correct infection-driving mechanism under various settings. Similar to previous studies, we find mitigated bias and greater coverage of estimates when the analytic time zero is correctly specified or accounted for.