PlagueWatch 2020-23 - Coronavirus

[YmoBeThere]

Are people really claiming that the vaccines are “perfectly and equally effective at preventing hospitalization and death?” Seems like a strawman to me.

"Gandhi has been updating her table as more data come in, and now pegs Moderna’s efficacy on that front at 97 percent; Jha has since tweeted that “nothing is 100 percent … But these vaccines sure are close”; and Topol told The Atlantic that the numbers in his tweet are not a sufficient basis from which to draw “any determination of magnitude of effect,” though the fact that they all point in the same direction is “very encouraging.” Still, the message of perfection that their initial tables and tweets spawned—the gist, for many readers, of all those 100s and zeros—has since been picked up far and wide, and misinterpreted along the way."

[johnb]

Has there been much public discussion of the US’s role in getting the world vaccinated? Obviously, the first goal is getting most of the US vaccinated, but that’s likely to happen within a couple of months. Soon after, we’re going to, presumably, be able to grind out a massive amount of vaccine. I understand contracts are in place for the first wave, but going forward, do these vaccines go to our geographic neighbors, the highest bidder, longtime Allies, likely vacation destinations for Americans, or to wherever Big Pharma decides to sell them? Do we have a plan for paying for vaccines for less prosperous countries, and if so, has there been discussion of how much profit these companies get to make? Or how much vaccine should be stored in case we need a booster shot? Or if say, 30% of the country refuses the vax, do we start selling it to Mexico ASAP?

I figured I’d try to answer my questions.
Pew recently found the % of likely vaxxers has slowly crept up to 69% (Blacks 61%, older people 85%, Democrats 83%, men 72%). https://www.pewresearch.org/science/...-already-have/

World vaccine map, updated today. Huge disparities, as expected. Americans have received 1/3 of the world’s vaccines, though we trail a handful of countries in percentages (eg, Israel, UK).
https://www.nytimes.com/interactive/...s-tracker.html

Vaccine distribution seems to be organized by several organizations, with Covax running point. A December article indicated that Canada and France intended to donate excess vaccine to the group. Current distribution is primarily Astra Zeneca/Oxford, produced by the Serum Institute of India. An article from last week indicated that first vaccines had gone into arms in Ghana and the Côte d’Ivoire. At the same time, Pfizer vaccines have gone to Korea.
https://www.who.int/news/item/01-03-...ered-in-africa

A recent article from Korea indicates that the large majority of their vaccines are also Astra Zeneca. This article from Seoul leads with the assertion that 2 nurses got covid after receiving the vaccine; it’s ambiguous, but the reader is left with the idea that they got the virus from the vaccine, which is unfortunate. http://www.koreaherald.com/view.php?ud=20210307000253

Anyway, I assume Biden’s team is developing a plan for international distribution but intends to keep its eye on the American ball for at least another 6-8 weeks, which seems to be when every American who wants a vaccine will be able to get one—actual insight welcome!

[CDu]

"Gandhi has been updating her table as more data come in, and now pegs Moderna’s efficacy on that front at 97 percent; Jha has since tweeted that “nothing is 100 percent … But these vaccines sure are close”; and Topol told The Atlantic that the numbers in his tweet are not a sufficient basis from which to draw “any determination of magnitude of effect,” though the fact that they all point in the same direction is “very encouraging.” Still, the message of perfection that their initial tables and tweets spawned—the gist, for many readers, of all those 100s and zeros—has since been picked up far and wide, and misinterpreted along the way."

Seems like an EXTREMELY small nit being picked by the Atlantic article to me.

[budwom]

Haven’t read the article but I know that ‘crowded and poor’ countries also tend to have a much younger population than more developed countries. Young people are likely asymptomatic or barely symptomatic and, especially in a poor country with limited testing, unlikely to ever get counted as a ‘case.’

There are a number of factors that are getting attention, and average age is one of them. Another is underreporting(which can't account for the major differences by any means)...a more fascinating one is that lots of people, including older ones in crowded slums, seem to have antibodies from other similar viruses which may be giving them some protection...I'd also imagine that many of these people are not obese...

The author is Siddhartha Mukherjee who does have some serious credentials, including a Pulitzer for The Emperor of All Maladies, an MD from Harvard, and other trinkets. Really a great read...

[Bluedog]

There are a number of factors that are getting attention, and average age is one of them. Another is underreporting(which can't account for the major differences by any means)...a more fascinating one is that lots of people, including older ones in crowded slums, seem to have antibodies from other similar viruses which may be giving them some protection...I'd also imagine that many of these people are not obese...

The author is Siddhartha Mukherjee who does have some serious credentials, including a Pulitzer for The Emperor of All Maladies, an MD from Harvard, and other trinkets. Really a great read...

NY Times said something similar this morning. They added two more possible explanations in addition the ones you mentioned: Western cultures have large nursing homes which aren't a thing in Asia and Africa. And people basically "live outside" in much of Africa and Asia with open air buildings, etc. So, ventilation and weather is much different than North America and Europe.

However, Latin America hasn't fared as well and has those same characteristics...

[camion]

NY Times said something similar this morning. They added two more possible explanations in addition the ones you mentioned: Western cultures have large nursing homes which aren't a thing in Asia and Africa. And people basically "live outside" in much of Africa and Asia with open air buildings, etc. So, ventilation and weather is much different than North America and Europe.

However, Latin America hasn't fared as well and has those same characteristics...

I've heard that there is a dearth of Neanderthals in Africa. How would Latin America stack up Neanderthalwise?*




"Neanderthalwise" - I think I just built a new word.

[Bluedog]

I've heard that there is a dearth of Neanderthals in Africa. How would Latin America stack up Neanderthalwise?*




"Neanderthalwise" - I think I just built a new word.

I read the same article. It stated that SE Asia, however, has a large prevalence of Neanderthal DNA, with Bangladesh in particular...and their numbers are still low (and it's a poor country).

I don't know the percentage of Neanderthal DNA in Latin America, but I feel like that finding is not very predictive, and is more "on the fringe" as it relates to impact. I'm sure the relative age of a country's residents, being outdoors, low obesity rates, etc. play a much larger role. But it's also still a mystery to some extent.

[mph]

Seems like an EXTREMELY small nit being picked by the Atlantic article to me.

This is from a NYT email that Jason posted in the COVID sticky thread:

As Dr. Ashish Jha, the dean of the Brown University School of Public Health, told me this weekend: “I don’t actually care about infections. I care about hospitalizations and deaths and long-term complications.”

By those measures, all five of the vaccines — from Pfizer, Moderna, AstraZeneca, Novavax and Johnson & Johnson — look extremely good. Of the roughly 75,000 people who have received one of the five in a research trial, not a single person has died from Covid, and only a few people appear to have been hospitalized. None have remained hospitalized 28 days after receiving a shot.

To put that in perspective, it helps to think about what Covid has done so far to a representative group of 75,000 American adults: It has killed roughly 150 of them and sent several hundred more to the hospital. The vaccines reduce those numbers to zero and nearly zero, based on the research trials.

I've seen similar reporting of the trial results from many other reputable sources. This report and others like it don't make the precise argument that there is no difference in the vaccines' ability to prevent death but they are creating that perception. And, obviously, perception matters a great deal in a pandemic.

Anecdotally, I've run across many people who believe that there is no difference between the vaccines in the prevention of hospitalization and death. I welcome the Atlantic's attempt to add some nuance and detail to the discussion.

[Bostondevil]

I keep telling people the primary goal of a vaccine is not to prevent you from getting a disease, it's to prevent you from dying from a disease.

I keep pressing that particular LEARN button. I've been making the same argument about flu shots for decades.

Vaccination program goals in order of priority (at the level of the individual):

1) Prevent death.
2) Prevent severe disease.
3) Prevent infection.

OK? Folks about here at least should understand that by now.

There are other goals that are population based. They have to do with lowering hospitalizations and lowering infection rates and lowering costs and other economic factors but I think mastering the order of priorities at the individual level is sufficient for most of us. Plus, the population based goals are not always the same for every disease, and they can change over time.

[sagegrouse]

NY Times said something similar this morning. They added two more possible explanations in addition the ones you mentioned: Western cultures have large nursing homes which aren't a thing in Asia and Africa. And people basically "live outside" in much of Africa and Asia with open air buildings, etc. So, ventilation and weather is much different than North America and Europe.

However, Latin America hasn't fared as well and has those same characteristics...

In Latin America the population is often living at altitude, so it may not be comparable to Sub-Saharan Africa. Largest cities are Sao Paolo (2,500 feet), Mexico City (7,400 feet), Bogota (8,675), Caracas (2,953), Santiago (1,900), La Paz (11,900), Quito (9,350), San Jose (CR) (3,850), San Salvador 2,200, Tegucigalpa (3,250), Monterrey (1,800), Guadalajara (5,100).

The shorter list of sea level cities include Buenos Aires, Rio, Lima, Guayaquil, Panama, Tijuana, Veracruz, Montevideo, Asuncion, Maracaibo.

[YmoBeThere]

I keep telling people the primary goal of a vaccine is not to prevent you from getting a disease, it's to prevent you from dying from a disease.

From whose perspective?

[Bostondevil]

From whose perspective?

Good question. From public health professionals' perspective. My career in patient safety has always viewed the category of preventable death as the one that should be lowered first. Death from an infectious disease where we have a vaccine is considered preventable.

[budwom]

Not sure we can paint all vaccines with that same brush...how about polio? Sure are a lot of hideous outcomes there that fall short of death...throw in some others like shingles...

[Bostondevil]

Not sure we can paint all vaccines with that same brush...how about polio? Sure are a lot of hideous outcomes there that fall short of death...throw in some others like shingles...

See priority number 2.

Also - there is a reason why we developed a chicken pox vaccine before a shingles vaccine. People are more likely to die from chicken pox. Rare? Yes. But it happens.

[CDu]

I've seen similar reporting of the trial results from many other reputable sources. This report and others like it don't make the precise argument that there is no difference in the vaccines' ability to prevent death but they are creating that perception. And, obviously, perception matters a great deal in a pandemic.

Anecdotally, I've run across many people who believe that there is no difference between the vaccines in the prevention of hospitalization and death. I welcome the Atlantic's attempt to add some nuance and detail to the discussion.

Relatively speaking, there appears to be no meaningful difference between the Pfizer and Moderna vaccines' ability to prevent hospitalization and death. They almost certainly aren't exactly equivalent. But they are all REALLY good, and thus it's kind of silly to me to nitpick at the small differences between them. Given how much they improve a person's chances of avoiding serious disease, one really doesn't need to focus on the minor differences. If one is available, take it. And for almost everyone, there won't be a choice between vaccines; you will have access to whichever one your provider has.

That said, the article was not at all focused on the differences between the vaccines (other than the throwaway sentence quoted) but rather the argument that the vaccines aren't really 100% effective against hospitalization and death. Which is, in my opinion, a really small nit to pick. Given the substantial reduction in risk of "severe" disease (note: "severe" is a pretty low bar), one would expect that the reduction in risk of really severe disease is as good or better. They mention the 15% fever rate after dose 2 of Moderna, but that's such an incredibly minor thing to nitpick.+

I'd also point out that the authors appear to be overstating their argument against when referencing the "600,000 person study in Israel" which had an 87% effectiveness against hospitalization 7+ days after the second dose. In that study, only 8600 had 14 days of data following the second dose (the study was based on vaccinated folks beginning Dec 20 and up through Feb 1, and the pre-print was Feb 24, meaning very few of the participants even had a chance of completing 28+ days of follow-up from first dose). So the study actually had a smaller relevant sample size than the trials the Atlantic article said were insufficient; Moderna had over 27,000 patients with at least 40 days of followup, and 2600 with over 110 days of followup. This is important as the differentiation between vaccine and no vaccine will only grow over the months after the second dose, so not only does the study they reference have a smaller sample, it also truncates the vast majority of the benefit of the vaccine. So OF COURSE the results look worse, but the authors conveniently don't point this out and run with the 85% effectiveness for the rest of their argument.

The 87% that the Atlantic reference was based 2 vaccinated people having a case after 7 days compared with 13 nonvaccinated hospitalizations. So not exactly the compelling argument against that they think they are making. When you add it to the trial data (which again is in a much larger sample and over a much longer period of time, the results still look amazing. In the Pfizer, Moderna, and JnJ trials which to date ONE vaccinated patient has had a COVID hospitalization following the second dose. So add the 2 cases in the study, you wind up right back in the 95+% effective against hospitalization (3 in the vaccine arms, 62 in the nonvaccinated arms). Probably closer to 100% if that Israel study continues to follow up beyond the short window that they've considered.

So, again, I think it's an incredibly small nit to be picking. These vaccines (Pfizer, Moderna, and JnJ) all appear to be spectacular at preventing hospitalization due to COVID. And the differences between the effectiveness against hospitalization appears to be really small. Basically, between the small argument AND the mischaracterizations they make, I think it's a pretty crappy article.

[Bostondevil]

So, again, I think it's an incredibly small nit to be picking. These vaccines (Pfizer, Moderna, and JnJ) all appear to be spectacular at preventing hospitalization due to COVID. And the differences between the effectiveness against hospitalization appears to be really small. Basically, between the small argument AND the mischaracterizations they make, I think it's a pretty crappy article.

Who are the authors?

[CDu]

Who are the authors?

It's one author: Hilda Bastian. Who should know better.

[Bostondevil]

It's one author: Hilda Bastian. Who should know better.

Yes, she probably should. I've looked at her background and she's very much a healthcare consumer advocate but I don't see much infectious disease experience, so, maybe she doesn't have adequate experience to write this particular article.

[CDu]

Yes, she probably should. I've looked at her background and she's very much a healthcare consumer advocate but I don't see much infectious disease experience, so, maybe she doesn't have adequate experience to write this particular article.

Yeah, it probably isn’t fair to expect her to be an expert across tons of disciplines. But if she doesn’t understand infectious disease research and vaccine trials well enough, she really shouldn’t have written this article (not arguing with you, as I think we agree; just saying it out loud).

In summary, I think:
1. No, these vaccines aren’t 100% effective against death and hospitalizations. However, they are proving to be really close to it following the second dose. Arguing over the minor difference is very nit picky, especially when one misinterprets the evidence.
2. No, they aren’t identically effective, but they appear to be close enough to each other in prevention of truly severe disease that these differences aren’t really worth noting. See point 1.
3. No, they aren’t identical in AE risks. But the differences in risks and severity of the AEs experienced is small enough that it doesn’t really make much difference.
4. Most importantly, the consumer isn’t likely to have a choice on vaccine. Especially not the consumer who would benefit most from the vaccine. So it seems silly to even argue about the differences between them. If one is available to you, you should take it ASAP.

The one thing that WOULD have been a sensible argument would be to focus on the first month following the first dose. There IS a meaningful discussion to be had in pointing out that you don’t see much benefit in the first few weeks after the first dose. So it IS important to emphasize that you aren’t suddenly in the clear, especially after the first dose. But that isn’t a real differentiator between vaccines, rather a limitation of all of them.

The framing of the article makes sense from the lens that she is a consumer advocate. But her argument in this setting feels pretty hollow and her references to the data seem flawed.

[mph]

Relatively speaking, there appears to be no meaningful difference between the Pfizer and Moderna vaccines' ability to prevent hospitalization and death. They almost certainly aren't exactly equivalent. But they are all REALLY good, and thus it's kind of silly to me to nitpick at the small differences between them. Given how much they improve a person's chances of avoiding serious disease, one really doesn't need to focus on the minor differences. If one is available, take it. And for almost everyone, there won't be a choice between vaccines; you will have access to whichever one your provider has.

That said, the article was not at all focused on the differences between the vaccines (other than the throwaway sentence quoted) but rather the argument that the vaccines aren't really 100% effective against hospitalization and death. Which is, in my opinion, a really small nit to pick. Given the substantial reduction in risk of "severe" disease (note: "severe" is a pretty low bar), one would expect that the reduction in risk of really severe disease is as good or better. They mention the 15% fever rate after dose 2 of Moderna, but that's such an incredibly minor thing to nitpick.+

I'd also point out that the authors appear to be overstating their argument against when referencing the "600,000 person study in Israel" which had an 87% effectiveness against hospitalization 7+ days after the second dose. In that study, only 8600 had 14 days of data following the second dose (the study was based on vaccinated folks beginning Dec 20 and up through Feb 1, and the pre-print was Feb 24, meaning very few of the participants even had a chance of completing 28+ days of follow-up from first dose). So the study actually had a smaller relevant sample size than the trials the Atlantic article said were insufficient; Moderna had over 27,000 patients with at least 40 days of followup, and 2600 with over 110 days of followup. This is important as the differentiation between vaccine and no vaccine will only grow over the months after the second dose, so not only does the study they reference have a smaller sample, it also truncates the vast majority of the benefit of the vaccine. So OF COURSE the results look worse, but the authors conveniently don't point this out and run with the 85% effectiveness for the rest of their argument.

The 87% that the Atlantic reference was based 2 vaccinated people having a case after 7 days compared with 13 nonvaccinated hospitalizations. So not exactly the compelling argument against that they think they are making. When you add it to the trial data (which again is in a much larger sample and over a much longer period of time, the results still look amazing. In the Pfizer, Moderna, and JnJ trials which to date ONE vaccinated patient has had a COVID hospitalization following the second dose. So add the 2 cases in the study, you wind up right back in the 95+% effective against hospitalization (3 in the vaccine arms, 62 in the nonvaccinated arms). Probably closer to 100% if that Israel study continues to follow up beyond the short window that they've considered.

So, again, I think it's an incredibly small nit to be picking. These vaccines (Pfizer, Moderna, and JnJ) all appear to be spectacular at preventing hospitalization due to COVID. And the differences between the effectiveness against hospitalization appears to be really small. Basically, between the small argument AND the mischaracterizations they make, I think it's a pretty crappy article.

We will probably have to agree to disagree about what constitutes a nit, but I think it matters that prevention of hospitalizations and deaths were not included as primary outcomes in any of the trials and were secondary outcomes in only two of the trials (J&J and AZ). Given the relatively small number of hospitalizations and deaths in the placebo groups, we probably shouldn't be telling people that the studies indicate that the vaccines create near-100% protection against death. Yes, we have good reason to believe that all of the vaccines are very effective at preventing hospitalizations and deaths but that's not what the studies were designed to measure, so some modesty is warranted.

One person's nit is evidence for another person's conspiracy theory. If we start seeing sporadic reports of people dying after full vaccination there will be a chorus of "I told you so's" from anti-vaxxers. FWIW, it's been one week since my first dose of Pfizer and my wife gets the J&J vaccine tomorrow. My wife had a choice of Moderna at a CVS 45 minutes away or J&J at a CVS 1:45 away. She chose J&J for the convenience of not having to schedule a 2nd shot but both of us would have happily taken any of the 3 vaccines.