PlagueWatch 2020-23 - Coronavirus

[sagegrouse]

Can I ask what we all think of the decision to halt the JnJ vaccine because 6 people out of 7 million got blood clots and 1 person died?

I really want to hear someone, anyone, argue that this was something less than colossally stupid messaging by the CDC and FDA.

There is absolutely no question that stopping this vaccine rollout (and the resulting vaccine hesitancy we will see) this is going to cost hundreds, maybe thousands of lives... if every single person in America got the JnJ vaccine, this blood clot problem would (in theory) result in 47 deaths.

Someone please explain to me how this is not the single stupidest decision by US health experts since, "wearing a mask won't help you, but it helps people around you."

There was a specific reason to link the vaccine to the six cases of clots, and there was a decision for a "pause" in administering the J&J vaccine to figure out what was going on. There is concern about a Heparin link -- an anti-coagulant used for certain high-risk patients or those undergoing surgery.

The CDC/FDA statement seemed sensible enough -- but, of course, it generated somewhat apocalyptic headlines.

Although I am not a doctor, I did pay for medical school.

Kindly,
Sage Grouse

[WillJ]

I think it's a horrible overreaction. They'll probably release the vaccine next week, but the damage will be done in terms of public opinion.

As noted above and elsewhere on this thread, the AZ and especially the JnJ pause make absolutely no sense from any kind of normal risk benefit analysis. It's absurd. The only caveat is that perhaps, just maybe, the FDA is doing the best they can to manage fears and that, in the long-run, this will result in more people getting vaccinated...but that is a very speculative argument and, in the meantime, hundreds (in the US) and many thousands (in the rest of the world) will certainly die EVERY DAY from Covid to avert a few cases of blood clots. It's very sad.

[BlueDevil2K]

As noted above and elsewhere on this thread, the AZ and especially the JnJ pause make absolutely no sense from any kind of normal risk benefit analysis. It's absurd. The only caveat is that perhaps, just maybe, the FDA is doing the best they can to manage fears and that, in the long-run, this will result in more people getting vaccinated...but that is a very speculative argument and, in the meantime, hundreds (in the US) and many thousands (in the rest of the world) will certainly die EVERY DAY from Covid to avert a few cases of blood clots. It's very sad.

I understand the statistical arguments that people are making, but...I think I disagree here for a few reasons. I don't have time to build this argument out the way that I'd like to, but here's a rough sketch. I'm using round numbers here, but they should be close enough:

- There are around 260 million Americans who are eligible to be vaccinated.
- Per the CDC, over 120 million Americans are at least partially vaccinated - 47.6%
- Those who have had at least one dose are "locked in" to that vaccine
- Of those who have been at least partially vaccinated, J&J comprises a bit about 6% of that population (again, per CDC numbers - 7.5M/120M)
- We know that there's a fair amount of vaccine hesitancy, so the best case appears to be that 70% of the adult population is "in a rush" to get vaccinated, or 180M
- We're currently averaging 1.7M first/only doses per day
- At that rate, everybody who wants a shot will get one in no more than the next 60M/1.7M = 35 days
- My impression is that J&J is struggling with supply, so let's assume that same 6% number is the daily proportion going forward. Take away that 6%, and we go from 35 days to 37 days
- All of that assumes that there's no expansion in Pfizer/Moderna capacity, and it does seem to be growing over time
- The J&J vaccine appears to have similar efficacy to the first dose of Pfizer or Moderna, if not slightly lower

So essentially, we're quibbling over the difference between vaccinating everybody who wants a shot in the next <35 days vs. the next <37 days. Spreading 35 days of vaccinations over 37 gives an average delay of around a day. The argument appears to be that the number of people infected in that one day (using my pessimistic math) out of that 60M adults is so large that it dwarfs the number if people who are affected by the issue with the blood clots.

- We're seeing ~700 American deaths per day across the entire population
- 60M/320M x 700 = 131 excess deaths due to that one day of delay, if those who are about to get vaccinated are a cross section of the population**
- That 131 is a very pessimistic number, because it's backwards-looking in terms of infections. By prioritizing vaccinating the highest risk Americans first, it should be the case that the death rate is lower for those who are infected today than for those infected weeks ago and dying today.
- That number is also pessimistic because I'm firmly convinced that the people getting vaccinated are generally also being more careful than those who are not, and their infection rate is somewhat disproportionately lower than the general population
- As a result, I question the statement that "hundreds will certainly die EVERY DAY" - I'm not sure that we're talking even 100 people total. Yes, every death is tragic, but we already have at least one death due to a blood clot that appears to be related to a J&J vaccine...and statistically, probably others to come.

On the flip side, maybe the J&J pause convinces some fraction of the 30% of vaccine hesitant Americans to actually get vaccinated? And by getting vaccinated, perhaps that reduces future deaths by some amount? Maybe even more than 100? I truly believe that in most places, we're about to reach (or have already reached) a tipping point where the supply exceeds the demand for vaccines*. We're all used to a mindset of scarcity due to the last four months, but I think we really should be changing our thinking to encourage as many people as possible to get vaccinated so as to help consume the excess supply. I suspect that the conservative nature of the J&J pause will be more helpful than harmful.

I'm sure that there are some flaws in my math...any thoughts on where I've gone wrong here?

*One data point - I got my first Pfizer shot 16 days ago, and the site ran out of their allotment (Groups 1-4) despite minimal advertising. They had another event last Friday (Groups 1-5) and did not come close to exhausting their supply despite more advertising outreach. It's just a gut feel based on the news of the day, but this feels like it's fairly representative of what's going on in the Triangle. I realize that other states aren't there yet, but they will be very soon.

**I realize that this math isn't quite right - those who were vaccinated a while ago are underrepresented in the daily deaths. I don't have time to go clean this up, but I don't think it skew the approximations enough to change the core argument.

[WillJ]

I understand the statistical arguments that people are making, but...I think I disagree here for a few reasons. I don't have time to build this argument out the way that I'd like to, but here's a rough sketch. I'm using round numbers here, but they should be close enough:

- There are around 260 million Americans who are eligible to be vaccinated.
- Per the CDC, over 120 million Americans are at least partially vaccinated - 47.6%
- Those who have had at least one dose are "locked in" to that vaccine
- Of those who have been at least partially vaccinated, J&J comprises a bit about 6% of that population (again, per CDC numbers - 7.5M/120M)
- We know that there's a fair amount of vaccine hesitancy, so the best case appears to be that 70% of the adult population is "in a rush" to get vaccinated, or 180M
- We're currently averaging 1.7M first/only doses per day
- At that rate, everybody who wants a shot will get one in no more than the next 60M/1.7M = 35 days
- My impression is that J&J is struggling with supply, so let's assume that same 6% number is the daily proportion going forward. Take away that 6%, and we go from 35 days to 37 days
- All of that assumes that there's no expansion in Pfizer/Moderna capacity, and it does seem to be growing over time
- The J&J vaccine appears to have similar efficacy to the first dose of Pfizer or Moderna, if not slightly lower

So essentially, we're quibbling over the difference between vaccinating everybody who wants a shot in the next <35 days vs. the next <37 days. Spreading 35 days of vaccinations over 37 gives an average delay of around a day. The argument appears to be that the number of people infected in that one day (using my pessimistic math) out of that 60M adults is so large that it dwarfs the number if people who are affected by the issue with the blood clots.

- We're seeing ~700 American deaths per day across the entire population
- 60M/320M x 700 = 131 excess deaths due to that one day of delay, if those who are about to get vaccinated are a cross section of the population**
- That 131 is a very pessimistic number, because it's backwards-looking in terms of infections. By prioritizing vaccinating the highest risk Americans first, it should be the case that the death rate is lower for those who are infected today than for those infected weeks ago and dying today.
- That number is also pessimistic because I'm firmly convinced that the people getting vaccinated are generally also being more careful than those who are not, and their infection rate is somewhat disproportionately lower than the general population
- As a result, I question the statement that "hundreds will certainly die EVERY DAY" - I'm not sure that we're talking even 100 people total. Yes, every death is tragic, but we already have at least one death due to a blood clot that appears to be related to a J&J vaccine...and statistically, probably others to come.

On the flip side, maybe the J&J pause convinces some fraction of the 30% of vaccine hesitant Americans to actually get vaccinated? And by getting vaccinated, perhaps that reduces future deaths by some amount? Maybe even more than 100? I truly believe that in most places, we're about to reach (or have already reached) a tipping point where the supply exceeds the demand for vaccines*. We're all used to a mindset of scarcity due to the last four months, but I think we really should be changing our thinking to encourage as many people as possible to get vaccinated so as to help consume the excess supply. I suspect that the conservative nature of the J&J pause will be more helpful than harmful.

I'm sure that there are some flaws in my math...any thoughts on where I've gone wrong here?

*One data point - I got my first Pfizer shot 16 days ago, and the site ran out of their allotment (Groups 1-4) despite minimal advertising. They had another event last Friday (Groups 1-5) and did not come close to exhausting their supply despite more advertising outreach. It's just a gut feel based on the news of the day, but this feels like it's fairly representative of what's going on in the Triangle. I realize that other states aren't there yet, but they will be very soon.

**I realize that this math isn't quite right - those who were vaccinated a while ago are underrepresented in the daily deaths. I don't have time to go clean this up, but I don't think it skew the approximations enough to change the core argument.

I sincerely appreciate the pushback. Here's how I think about it...and I'll return to some complicating factors later:

We were administering roughly 500k JnJ vaccines per day.
A 3 day halt will mean that we are 1.5 million vaccines behind the path we would be on absent the halt, until such time as supply fully meets demand. Let's say that's 1/1/2022.
So there will be roughly 375 million (1.5 million vaccines delayed * 250 days until supply catches up) unvaccinated-person-days caused by the halt.

There are roughly 250,000,000 unvaccinated people in the US and, as you note, roughly 700 deaths from covid per day. That implies a daily death rate among the unvaccinated of .00028 percent.

If we multiply the 375 million person-days times the .00028 daily chance of death, we get 1,050 extra deaths due to the halt. That's the cost of the halt.

What's the benefit? Assuming that 1 in 1.5 million of the vaccinated get a fatal blood clot (probably an overestimate of the risk), then the halt *delays* one death for 8 months. It is a delay and not an avoidance under the assumption that the halt does not alter year-end vaccinations...i.e. if we ultimately distribute the same number of vaccines, then we'll get the same number of blood clot deaths.

That is the math that leads me to say that it's "absurd." If my math is roughly correct, then that is not hyperbole, IMO. Making the halt longer only makes it more absurd.

All of this could be overturned if - and it's a big if, IMO - the halt reduces vaccine hesitancy. I'm not convinced that it will. All medications have side effects and some popular ones are far more dangerous than the JnJ vaccine. I think it would have been much better to put the risk in context.

[BlueDevil2K]

We were administering roughly 500k JnJ vaccines per day.
A 3 day halt will mean that we are 1.5 million vaccines behind the path we would be on absent the halt, until such time as supply fully meets demand. Let's say that's 1/1/2022.
So there will be roughly 375 million (1.5 million vaccines delayed * 250 days until supply catches up) unvaccinated-person-days caused by the halt.

Thanks - our big difference lies in the quoted/bolded line. I think we're hitting the point where supply fully meets demand right now and are within 4-6 weeks (max) of having so much supply that we're begging people to consume it. That changes the math substantially...

ETA: Pfizer is saying that they're going to deliver 220M doses by the end of May. 65M Americans have received first doses, so they account for 130M. That means that 45M more Americans can be fully vaccinated via Pfizer by roughly early June. That alone accounts for 45M/140M = about a third of the unvaccinated adults and 45M/60M = three quarters of those who appear to be interested in being vaccinated at all. And that's just Pfizer, not factoring in Moderna or J&J.

[WillJ]

Thanks - our big difference lies in the quoted/bolded line. I think we're hitting the point where supply fully meets demand right now and are within 4-6 weeks (max) of having so much supply that we're begging people to consume it. That changes the math substantially...

ETA: Pfizer is saying that they're going to deliver 220M doses by the end of May. 65M Americans have received first doses, so they account for 130M. That means that 45M more Americans can be fully vaccinated via Pfizer by roughly early June. That alone accounts for 45M/140M = about a third of the unvaccinated adults and 45M/60M = three quarters of those who appear to be interested in being vaccinated at all. And that's just Pfizer, not factoring in Moderna or J&J.

I agree that your points change the costs of halting to being roughly what you describe. But note too that it reduces the benefits substantially, since if we get to the same number of total vaxes in 5 weeks then we only delay the blood clot death by that same five weeks. I still think it miserably fails a cost/benefit test.

I also think that we'd agree that, ultimately, the really important effects of the halt will be embodied in its effect on hesitancy, which could be big in either direction. I think that FDA - and other regulatory bodies - have done a very bad job of it and that they should have emphasized the low risks of the vaccines relative to the higher risk of many already-accepted treatments, but I could of course be wrong. Whatever the effects of delay are, they are going to be much smaller in the US than in the rest of the world.

[BlueDevil2K]

I agree that your points change the costs of halting to being roughly what you describe. But note too that it reduces the benefits substantially, since if we get to the same number of total vaxes in 5 weeks then we only delay the blood clot death by that same five weeks. I still think it miserably fails a cost/benefit test.

I also think that we'd agree that, ultimately, the really important effects of the halt will be embodied in its effect on hesitancy, which could be big in either direction. I think that FDA - and other regulatory bodies - have done a very bad job of it and that they should have emphasized the low risks of the vaccines relative to the higher risk of many already-accepted treatments, but I could of course be wrong. Whatever the effects of delay are, they are going to be much smaller in the US than in the rest of the world.

I do think we mostly agree, with the caveats as stated above. One other difference - I'm suggesting that even if no American got the J&J vaccine ever again, we'd hit the point where everybody who wants a vaccine could get one within a few weeks. I believe the supply vs. demand curve is about to be that inverted - the extra J&J supply might make a few days of difference for some people, but its absence won't be statistically that significant.

[cato]

I’ve seen quite a few opinions stated about the “pause” in use of the J&J vaccine, but am not sure who has analyzed the data that is available to the people making these decisions. Is that data publicly available?

If I were at risk of the blood clotting issue, I would certainly want to know more about the risk before taking the vaccine. There is a lot of discussion of the public health aspect, but every person receiving the vaccine is making an individual choice to do so. The public health officials making these decisions are not in an enviable position.

[tbyers11]

I’ve seen quite a few opinions stated about the “pause” in use of the J&J vaccine, but am not sure who has analyzed the data that is available to the people making these decisions. Is that data publicly available?

If I were at risk of the blood clotting issue, I would certainly want to know more about the risk before taking the vaccine. There is a lot of discussion of the public health aspect, but every person receiving the vaccine is making an individual choice to do so. The public health officials making these decisions are not in an enviable position.

here is a pretty good "cliffs notes" version from an epidemiologist who attended the ACIP meeting yesterday
https://yourlocalepidemiologist.subs...ng-cliff-notes

She is a really good follow on Facebook as Your Local Epidemiologist for vaccine info

[cato]

here is a pretty good "cliffs notes" version from an epidemiologist who attended the ACIP meeting yesterday
https://yourlocalepidemiologist.subs...ng-cliff-notes

She is a really good follow on Facebook as Your Local Epidemiologist for vaccine info

Thanks. This is an excellent and brief summary. Interesting that this informed individual following this closely seems to endorse the process that is being followed here.

My dumb take is that for a healthy woman in the applicable age bracket, taking the J&J vaccine may be riskier than not taking any vaccine. Obviously there are other factors to consider (is the woman able to social distance or is she an essential worker that is exposed to others, etc.), but caution does seem appropriate here.

[MChambers]

here is a pretty good "cliffs notes" version from an epidemiologist who attended the ACIP meeting yesterday
https://yourlocalepidemiologist.subs...ng-cliff-notes

She is a really good follow on Facebook as Your Local Epidemiologist for vaccine info

Can’t spork you, but Your Local Epidemiologist is great.

[tbyers11]

Thanks. This is an excellent and brief summary. Interesting that this informed individual following this closely seems to endorse the process that is being followed here.

My dumb take is that for a healthy woman in the applicable age bracket, taking the J&J vaccine may be riskier than not taking any vaccine. Obviously there are other factors to consider (is the woman able to social distance or is she an essential worker that is exposed to others, etc.), but caution does seem appropriate here.

Most of the experts I have seen endorsed the pause and quick review but were not fans of the ACIP not making a decision yesterday and reconvening in 7-10 days. Because they will likely have very little additional info in that time period. Many like Ashish Jha (a favorite of Bostondevil IIRC) suggested to continue the pause in females 18-49 and resuming for everyone else. Saying that J&J (one shot, does not require freezer storage) is optimal vaccine for many vulnerable/underserved demographics. I tend to agree with them

Ashish Jha's twitter thread https://threadreaderapp.com/thread/1...824738304.html

[richardjackson199]

Update from Dr. Ohl:

He says Adolescents age 12-15 will be able to start getting vaccinated around end of May with Pfizer.

Great news, meaning they will be fully vaccinated by Fall 2021 schoolyear if their parents want. And they should want given efficacy (100%) and saftey data in that age group.

[OldPhiKap]

Update from Dr. Ohl:

He says Adolescents age 12-15 will be able to start getting vaccinated around end of May with Pfizer.

Great news, meaning they will be fully vaccinated by Fall 2021 schoolyear if their parents want. And they should want given efficacy (100%) and saftey data in that age group.

Great news!

[richardjackson199]

Also interesting, to me anyway, is Dr. Ohl said that data shows that screening procedures at workplaces, doctor's offices, schools etc. are essentially a waste of time and resources. Being asked those questions and having temperatures taken he said aren't effective at screening out Covid. So he expects that stuff to rapidly fade away from doctor's clinic visits, schools, etc.

-His rationale is things like 40% of Covid is asymptomatic, so you can ask questions, take temperatures, and screen all you want, you won't catch Covid. Also checking temperatures in the summertime is fraught with error, so not worth doing. My employer has had me do personal screenings answering questions and checking my temperature on an app every day for several months. Our staff also has to do it with every parent and patient. It's time-consuming, and if not useful will be nice to get rid of. He said a more effective thing to do is if you're sick, be a good citizen and stay home away from other people.

--As noted several times above, he re-iterates that extensive cleaning surfaces is not something that time and resources should be dedicated to. Just wash your hands and clean as you normally would.

--For those who want to hear his take on the J & J vaccine pause it's around 22:25. It's really not worth watching with not much new information for me. Basically he thinks the risk is low, about 1/1,000,000; in the population of younger women, and only between days 6-14 after the J & J vaccine. Signs of a blood clot in the brain would include stroke-like symptoms and worst headache of your life so you'd know and go to the ER. He thinks it's tough to prove cause when the rate of background blood clots in the population for those with no risk factors is higher than 1 in 1 Million (about 1 in 400,000). But the AstraZeneca vaccine (same adenovirus vector mechanism) also has this low association due to an antibody activated in the immune response triggering platelets to clot. So it's being looked at closely with J & J where they've found 7 cases after trials. He basically sounds like he thinks it's potentially a bummer for the world population where having a safe 1-shot vaccine with lower refrigeration requirements could make a huge difference. In the US he said we'll still have plenty of vaccine from Pfizer/Moderna where appointments should be readily available now (at least in our area of NC, and hopefully yours too). He emphasizes putting the risk in perspective, which he compares to winning the powerball.

https://www.facebook.com/watch/live/...454&ref=search

[CDu]

The 7-day average daily death rate for the US might drop to a point we haven’t seen since last July. It is roughly equal right now to the lowest point since July. Fingers crossed that this trend continues. Interestingly, both new cases and new hospitalizations have been trending upwards for a month. What isn’t clear to me is whether those cases are people being hospitalized due to COVID or who happen to have COVID but we’re hospitalized for other causes. Presumably it is a fair bit of both; I would have expected the death rate to have started trending back up a week or two ago otherwise. So, again, something to keep an eye on over the next week or two.

On the vaccine front, we should top 200 million doses administered today. 80% of people over 65 have had at least one dose and 63.7% are fully vaccinated. Hopefully in the next couple of weeks we will have 80+% of the elderly fully vaccinated, which would be amazing. Nearly 50% of the adult population (48.3%) have gotten a dose, and 30.3% are fully vaccinated. That is also fairly encouraging as it is seeming like we may well get over 75% of adults vaccinated.

Cautiously optimistic about where things are headed, though certainly wary about the rise in hospitalizations with positive COVID. The next few weeks should be telling.

[Bostondevil]

Most of the experts I have seen endorsed the pause and quick review but were not fans of the ACIP not making a decision yesterday and reconvening in 7-10 days. Because they will likely have very little additional info in that time period. Many like Ashish Jha (a favorite of Bostondevil IIRC) suggested to continue the pause in females 18-49 and resuming for everyone else. Saying that J&J (one shot, does not require freezer storage) is optimal vaccine for many vulnerable/underserved demographics. I tend to agree with them

Ashish Jha's twitter thread https://threadreaderapp.com/thread/1...824738304.html

You remember correctly.

[Bostondevil]

Thanks. This is an excellent and brief summary. Interesting that this informed individual following this closely seems to endorse the process that is being followed here.

My dumb take is that for a healthy woman in the applicable age bracket, taking the J&J vaccine may be riskier than not taking any vaccine. Obviously there are other factors to consider (is the woman able to social distance or is she an essential worker that is exposed to others, etc.), but caution does seem appropriate here.

Nope. It may be riskier than taking Pfizer or Moderna. Way, way, way less risky than coming down with covid. Covid causes blood clotting issues in many patients. Way more than one otherwise healthy woman between 18 and 49 has died from covid as well.

[YmoBeThere]

Also interesting, to me anyway, is Dr. Ohl said that data shows that screening procedures at workplaces, doctor's offices, schools etc. are essentially a waste of time and resources. Being asked those questions and having temperatures taken he said aren't effective at screening out Covid. So he expects that stuff to rapidly fade away from doctor's clinic visits, schools, etc.

-His rationale is things like 40% of Covid is asymptomatic, so you can ask questions, take temperatures, and screen all you want, you won't catch Covid. Also checking temperatures in the summertime is fraught with error, so not worth doing. My employer has had me do personal screenings answering questions and checking my temperature on an app every day for several months. Our staff also has to do it with every parent and patient. It's time-consuming, and if not useful will be nice to get rid of. He said a more effective thing to do is if you're sick, be a good citizen and stay home away from other people.

We are still at 72k cases a day and 750 deaths. You don't get to 580k deaths if everyone is being a good citizen. Those countries are at 4k cases per million population and less. I'm curious because 40% asymptomatic is 60% symptomatic. What % of that 60% will you catch with such tactics? They aren't meant to be foolproof with 100% accuracy, but I do see where they might influence some to be good citizens. Kabuki theater perhaps...

[cato]

Nope. It may be riskier than taking Pfizer or Moderna. Way, way, way less risky than coming down with covid. Covid causes blood clotting issues in many patients. Way more than one otherwise healthy woman between 18 and 49 has died from covid as well.

An excellent response to a point I didn’t make. A healthy woman between 18 and 49 who is able to mask and distance may be better off choosing not to get the J&J vaccine, since she has very effective tools at her disposal to avoid getting Covid.