I hate being ill - and on those grounds alone I’ll continue getting vaccinated, paying if necessary, because it somewhat reduces my chance of getting Covid, and probably I’ll be less unwell if I do get it, and so for me it’s definitely worth it.
A risk-based approach could be OK if done well. But the actual risk-based approaches implemented in the real world have serious flaws. In particular, people with long COVID have not been recognized at being at risk of relapse or increased severity from re-infection, nor have people with ME/CFS from other causes, because only reducing hospitalization and not long COVID nor its intensification are considered goals. Furthermore, those deemed at risk are only allowed annual boosters, although the evidence of waning supports every 6 months, or potentially more often in the immunocompromised.
A bigger picture issue is that risk-based approaches send the message that the costs and benefits of vaccination in "low risk" individuals are narrowly balanced. But they aren't - the benefits in terms not just of long COVID risk but also just days off work come down overwhelmingly in favor of vaccination (as they also do for influenza). If you want to send a clear public message that vaccines are a good thing, an easy way to do that is say "Get them every 6 months if you want, they are safe! Although we aren't going to force you, you are welcome to them if you like." By saying "we only think high risk people should be allowed access", you are sending the message that you agree that the vaccines are dangerous.
But with respect, these are mostly points about how exactly a risk-based system should be implemented, not about the principle itself. The Biden administration could have moved to any kind of sensible risk-based system at any time between 2022 and 2024, and made it much less likely that the incoming Government would have been able to throw out the baby with the bathwater.
And "only high risk people are allowed access" is not the position in the UK - it's that as with all medical interventions, there is some kind of cost-benefit analysis done to decide if the taxpayer should pay for it for everyone. Anyone (over 12) has access, the question is who pays for it https://pharmadoctor.co.uk/patient/service/covid-vaccination
I agree it's a question of implementation, but it's important context that there isn't (yet) a good example of good implementation to copy, and the US is hardly likely to supply one right now.
Thanks for the pointer on UK access - the situation in the US is that a long COVID patient, or household contact of an immunocompromised individual, or nursing home worker, would already all need to lie to the pharmacist and pretend to be immunocompromised to access vaccination more than once a year, even at own cost. Or cross the border to Canada or Mexico, and pay there.
It's a lousy cost-benefit analysis to include only deaths and hospitalization "for" COVID, excluding not just long COVID in its ME/CFS form, but also the excess clots (strokes, heart attacks, embolisms etc.) whose incidence is unambiguously elevated by COVID, as well as similarly elevated rates of diabetes. As well as excluding days off work and general misery.
While definitely not implementable in the US, it would also be interesting to see a cost-benefit analysis on universal twice-yearly COVID vaccination, which by reducing community transmission would be very different in nature to individual-based analyses. There is evidence from Japan for yearly universal influenza jabs, and it is rather positive: https://www.nejm.org/doi/full/10.1056/NEJM200103223441204. Using Novavax instead of mRNA vaccines would greatly reduce unpalatable side effects.
And then there are the unknown unknowns. It turns out Spanish flu caused Parkinson's. It turns out EBV causes MS. It turns out that shingles vaccines reduce dementia. HPV causes cancer. It's well known among immunologists that CMV is an important cause of loss of diversity in the immune system (ie immunological aging). A general recurring pattern to discoveries is that viruses are worse than we think.
I'm sorry you think it's a lousy analysis, but it can hardly be a surprise from things I've written here and elsewhere in the last three or so years. But I'm happy to save you the trouble of reading more in the same vein
I thought you were a numbers person and "open-minded as to what such an analysis [of broader infection harms] might conclude". Which is why I am disappointed that out of hand dismissal is your only commentary on the Japanese influenza study?
I think we need to be careful about what we mean by waning immunity. Certainly immunoglobulin levels decline enough over about 6 months such that they are less likely to immediately neutralise an infection. However memory B and T cells generally persist over much longer periods such that a response to a secondary infection is very rapid.
When targeting household contacts / carers of the immunocompromised or other clinically vulnerable individuals, the point is not to cause less severe disease, but to prevent infection that could be transmitted to the vulnerable individual. The UK vaccinates such people only once a year, where 6 months would be much more in line with the goal of reducing onward transmission to the vulnerable.
Definitely agree on JCVI being highly deserving of praise. Gavin Yamey did make the point a while ago that the different healthcare system in the US makes it harder for them to adopt a similar approach to European countries, although I couldn't give chapter and verse on the details. And of course if your system doesn't let you do certain things, an option is to change the system.
An interesting essay and commentary. As a US citizen, the troubling (one among a gazillion) trend in the US is privatization -- which always ends up meaning $$$$$ to the average citizen. So when one sees the "relaxed" apprroach to vaccine administration: targeting only "at risk age groups", that's all fine and good in those settings with some form of Standardized/regulated/universal delivered medical care. In places without reasonably even access to healthcare. (Can we actually call what the US has, for a significant portion of the population, healthcare??? It's medical services. Sometimes it helps the ongoing health of people. More, often than not, it's REACTIVE care only.)
In the US, the cost of obtaining vaccinations is going to be excessive; the cost of getting sick is going to be excessive: both in dollars and general life impacts. I guess I'm just concerned that only the elite (certainly in the US) will remain viably healthy.
And the rest of the world??? I am perplexed why it is so difficult for so many to understand that sharing tools to health (vaccines, etc) is a benefit to all.
I am horrified by so many people who (RFK, Jr) demonize vaccines. They are the beneficiaries of the very vaccines they demonize. My parents and others of that age group happily embraced getting their children vaccinated for measels, polio, mumps, smallpox, TB. Horrifying to see children dying from measels today because their parents demonized the vaccine.
I'm probably just speaking into a void here. I am happy to get it out. Thanks.
A risk-based approach to vaccination is good, but I do have a few minor thoughts:
1. Society is too COVID-centric, whereas "SARI" (Severe Acute Respiratory Infections - incl. 'flu and RSV, and possibly hMPV too) would be preferable, given the impacts (Days Off, Post Acute Sequelae, Mortality) are the same, as are the Interventions (generic Air Quality improvement, appropriate Vaccinations, and prevalence+environment aware Masking)
2. A challenge is that Public Health focus is always "macro-epidemiological" (impact on society), whereas individuals need the "micro-epidemiological" view, to make the personal risk variables (mainly age and co-morbidities) much more obvious
3. As you identified, the evidence base for reductions in Day Off and Post Acute Sequelae, so the use of Hospitalisation / Mortality as a Proxy is precarious (e.g. for Sequelae, using 'flu as a baseline, SARS-COV-2 is significantly worse, RSV is significantly better)
4. A challenge with the Vaccine Injury topic you mentioned is also a paucity of information (both macro- and micro-epidemiological) relating to prevalance and consequences
For items (3) and (4), an obvious take away would be the line from many -- perhaps most! -- academic papers, "more research needed"😉
I don't disagree with much of that - I'm sure a full analysis would need to consider more diseases and so on, but there's only so much space in a Substack post!
Ditto on fluoridation. I had naively assumed that all UK water was fluoridated, on public health grounds. Listening to The Studies Show podcast on the subject, it turns out there should be more than enough fluoride in toothpaste, and otherwise putting it in everyone’s water is (a) a waste of money and (b) flouride isn’t entirely benign, so the risk/cost/reward benefit only applies to deprived areas where not enough children are brushing their teeth regularly. So only about 10% of the population gets artificially fluoridated mains water - exclusively in England.
RFK Jr has enough crackpot ideas to disqualify him anyway - his stance on fluoride is probably not the best stick to beat him with.
So let’s imagine assessing the risks of smoking using hospitalisations as the central metric too. I think this piece normalises what was a political hijacking of public health, to use hospitalisation as the measure of how serious a pandemic is. Acute SARS-Covid-2 infection is just the on-ramp to the real public health story.
I’m not saying your piece is having some wide impact on the public health response, it’s more about the idea that acute harm is a useful measure of risk, for infection. If we use the politically-motivated metric of hospitalisations as the measure of harm, which we did with Covid, we would never have tackled smoking. Or drinking for that matter. or pretty much any other infection that we already control.
Totally agree, the JCVI still seems mercifully free from ideological agendas when making its recommendations, and let’s hope it stays that way!
I hate being ill - and on those grounds alone I’ll continue getting vaccinated, paying if necessary, because it somewhat reduces my chance of getting Covid, and probably I’ll be less unwell if I do get it, and so for me it’s definitely worth it.
Well that's your prerogative of course!
A risk-based approach could be OK if done well. But the actual risk-based approaches implemented in the real world have serious flaws. In particular, people with long COVID have not been recognized at being at risk of relapse or increased severity from re-infection, nor have people with ME/CFS from other causes, because only reducing hospitalization and not long COVID nor its intensification are considered goals. Furthermore, those deemed at risk are only allowed annual boosters, although the evidence of waning supports every 6 months, or potentially more often in the immunocompromised.
A bigger picture issue is that risk-based approaches send the message that the costs and benefits of vaccination in "low risk" individuals are narrowly balanced. But they aren't - the benefits in terms not just of long COVID risk but also just days off work come down overwhelmingly in favor of vaccination (as they also do for influenza). If you want to send a clear public message that vaccines are a good thing, an easy way to do that is say "Get them every 6 months if you want, they are safe! Although we aren't going to force you, you are welcome to them if you like." By saying "we only think high risk people should be allowed access", you are sending the message that you agree that the vaccines are dangerous.
But with respect, these are mostly points about how exactly a risk-based system should be implemented, not about the principle itself. The Biden administration could have moved to any kind of sensible risk-based system at any time between 2022 and 2024, and made it much less likely that the incoming Government would have been able to throw out the baby with the bathwater.
And "only high risk people are allowed access" is not the position in the UK - it's that as with all medical interventions, there is some kind of cost-benefit analysis done to decide if the taxpayer should pay for it for everyone. Anyone (over 12) has access, the question is who pays for it https://pharmadoctor.co.uk/patient/service/covid-vaccination
I agree it's a question of implementation, but it's important context that there isn't (yet) a good example of good implementation to copy, and the US is hardly likely to supply one right now.
Thanks for the pointer on UK access - the situation in the US is that a long COVID patient, or household contact of an immunocompromised individual, or nursing home worker, would already all need to lie to the pharmacist and pretend to be immunocompromised to access vaccination more than once a year, even at own cost. Or cross the border to Canada or Mexico, and pay there.
It's a lousy cost-benefit analysis to include only deaths and hospitalization "for" COVID, excluding not just long COVID in its ME/CFS form, but also the excess clots (strokes, heart attacks, embolisms etc.) whose incidence is unambiguously elevated by COVID, as well as similarly elevated rates of diabetes. As well as excluding days off work and general misery.
While definitely not implementable in the US, it would also be interesting to see a cost-benefit analysis on universal twice-yearly COVID vaccination, which by reducing community transmission would be very different in nature to individual-based analyses. There is evidence from Japan for yearly universal influenza jabs, and it is rather positive: https://www.nejm.org/doi/full/10.1056/NEJM200103223441204. Using Novavax instead of mRNA vaccines would greatly reduce unpalatable side effects.
And then there are the unknown unknowns. It turns out Spanish flu caused Parkinson's. It turns out EBV causes MS. It turns out that shingles vaccines reduce dementia. HPV causes cancer. It's well known among immunologists that CMV is an important cause of loss of diversity in the immune system (ie immunological aging). A general recurring pattern to discoveries is that viruses are worse than we think.
I'm sorry you think it's a lousy analysis, but it can hardly be a surprise from things I've written here and elsewhere in the last three or so years. But I'm happy to save you the trouble of reading more in the same vein
I thought you were a numbers person and "open-minded as to what such an analysis [of broader infection harms] might conclude". Which is why I am disappointed that out of hand dismissal is your only commentary on the Japanese influenza study?
I think we need to be careful about what we mean by waning immunity. Certainly immunoglobulin levels decline enough over about 6 months such that they are less likely to immediately neutralise an infection. However memory B and T cells generally persist over much longer periods such that a response to a secondary infection is very rapid.
When targeting household contacts / carers of the immunocompromised or other clinically vulnerable individuals, the point is not to cause less severe disease, but to prevent infection that could be transmitted to the vulnerable individual. The UK vaccinates such people only once a year, where 6 months would be much more in line with the goal of reducing onward transmission to the vulnerable.
Definitely agree on JCVI being highly deserving of praise. Gavin Yamey did make the point a while ago that the different healthcare system in the US makes it harder for them to adopt a similar approach to European countries, although I couldn't give chapter and verse on the details. And of course if your system doesn't let you do certain things, an option is to change the system.
I think it might be stuff like this post? https://yourlocalepidemiologist.substack.com/p/be-careful-comparing-the-us-to-other
An interesting essay and commentary. As a US citizen, the troubling (one among a gazillion) trend in the US is privatization -- which always ends up meaning $$$$$ to the average citizen. So when one sees the "relaxed" apprroach to vaccine administration: targeting only "at risk age groups", that's all fine and good in those settings with some form of Standardized/regulated/universal delivered medical care. In places without reasonably even access to healthcare. (Can we actually call what the US has, for a significant portion of the population, healthcare??? It's medical services. Sometimes it helps the ongoing health of people. More, often than not, it's REACTIVE care only.)
In the US, the cost of obtaining vaccinations is going to be excessive; the cost of getting sick is going to be excessive: both in dollars and general life impacts. I guess I'm just concerned that only the elite (certainly in the US) will remain viably healthy.
And the rest of the world??? I am perplexed why it is so difficult for so many to understand that sharing tools to health (vaccines, etc) is a benefit to all.
I am horrified by so many people who (RFK, Jr) demonize vaccines. They are the beneficiaries of the very vaccines they demonize. My parents and others of that age group happily embraced getting their children vaccinated for measels, polio, mumps, smallpox, TB. Horrifying to see children dying from measels today because their parents demonized the vaccine.
I'm probably just speaking into a void here. I am happy to get it out. Thanks.
A risk-based approach to vaccination is good, but I do have a few minor thoughts:
1. Society is too COVID-centric, whereas "SARI" (Severe Acute Respiratory Infections - incl. 'flu and RSV, and possibly hMPV too) would be preferable, given the impacts (Days Off, Post Acute Sequelae, Mortality) are the same, as are the Interventions (generic Air Quality improvement, appropriate Vaccinations, and prevalence+environment aware Masking)
2. A challenge is that Public Health focus is always "macro-epidemiological" (impact on society), whereas individuals need the "micro-epidemiological" view, to make the personal risk variables (mainly age and co-morbidities) much more obvious
3. As you identified, the evidence base for reductions in Day Off and Post Acute Sequelae, so the use of Hospitalisation / Mortality as a Proxy is precarious (e.g. for Sequelae, using 'flu as a baseline, SARS-COV-2 is significantly worse, RSV is significantly better)
4. A challenge with the Vaccine Injury topic you mentioned is also a paucity of information (both macro- and micro-epidemiological) relating to prevalance and consequences
For items (3) and (4), an obvious take away would be the line from many -- perhaps most! -- academic papers, "more research needed"😉
I don't disagree with much of that - I'm sure a full analysis would need to consider more diseases and so on, but there's only so much space in a Substack post!
Ditto on fluoridation. I had naively assumed that all UK water was fluoridated, on public health grounds. Listening to The Studies Show podcast on the subject, it turns out there should be more than enough fluoride in toothpaste, and otherwise putting it in everyone’s water is (a) a waste of money and (b) flouride isn’t entirely benign, so the risk/cost/reward benefit only applies to deprived areas where not enough children are brushing their teeth regularly. So only about 10% of the population gets artificially fluoridated mains water - exclusively in England.
RFK Jr has enough crackpot ideas to disqualify him anyway - his stance on fluoride is probably not the best stick to beat him with.
I didn't know that either - that's very interesting!
So let’s imagine assessing the risks of smoking using hospitalisations as the central metric too. I think this piece normalises what was a political hijacking of public health, to use hospitalisation as the measure of how serious a pandemic is. Acute SARS-Covid-2 infection is just the on-ramp to the real public health story.
I think you're overestimating the influence of a Substack post that's been read by 0.00007% of the world population in normalising anything.
I’m not saying your piece is having some wide impact on the public health response, it’s more about the idea that acute harm is a useful measure of risk, for infection. If we use the politically-motivated metric of hospitalisations as the measure of harm, which we did with Covid, we would never have tackled smoking. Or drinking for that matter. or pretty much any other infection that we already control.
Yeah, I'm not taking lectures about politicising public health from someone who subscribes to the ISAGE Substack (and those of its members).
I have no memory of subscribing to that! If I did it was to just know what was being discussed. My view here certainly wouldn’t match theirs.
My interests have nothing to do with those debates. It’s purely here to question why hospitalisations is suddenly a dominant public health metric.