One of the things you didn't hit upon is how wrong we apparently got vaccine spacing. There was an interesting thread yesterday by your boy Topol talking about this.
It's possible that the reason the booster is so important is not because it's a 3rd dose, but because its spaced out from the first dose.
There is such a dichotomy between the awesomeness of our private companies and their ability to leverage science and technology to provide such awesome tools to fight this virus and our government agencies complete inability to adapt to novel situations. Imagine if the CDC and the FDA (more importantly) were able to shed the bureaucratic nonsense the keeps us from using data from foreign countries to make decisions, or to approve challenge trials.
On a political note: I wonder how much patience the public has for a new round of precautions. Seems pretty clear to me that we are about to have a 4th??? wave over the next two months.
Even if hospitalizations are high because of the sheer number of cases, if the severity and individual risk of hospitalization/death is low, you are going to see the public become even more apathetic.
Politically, another wave is going to hurt Democrats if it is accompanied with more school disruptions.
Finally: why are you always up so late dude. Damn. I wake up here in Argentina, and you are still going strong on Twitter.
Maybe he stays up late and sleeps in? That's definitely what I would do if I could. I'm a night hunter, at some deep genetic level -- like I even see well in dim light, and literally can't see (or especially drive safely) without my sunglasses, on a cloudless day. My body wants to go to sleep just before dawn, and wake up around noon. Dealing with realistic office schedules is a perpetual struggle. (Look up "chronotype", this is a thing that medical science has come to understand in the last couple decades.)
> One of the things you didn't hit upon is how wrong we apparently got vaccine spacing.
It's good that long intervals are at least as good or better than short intervals, but that doesn't mean that a short interval was the wrong public health choice.
With routine vaccination, we can afford long intervals because the underlying disease is not rapidly circulating throughout the population. A kid is unlikely to be exposed to measles, so the interval between their first shot and booster does not matter that much.
On the other hand, covid was (and is) still epidemic in developed nations. Long intervals -- especially intervals longer than necessary for a "first doses first" policy -- leave people less immune over the interval, for dubious long-term gain. Vaccine policy twelve months ago could not and should not have anticipated the Omicron or even Delta variants.
Additionally, remember that mass vaccination would only begin after completion of stage 3 trials and authorization. If we insisted on long intervals for the best long-term immunity, those stage 3 trials would have taken considerably longer. First doses wouldn't have gone out (in the US) in December/January, but March/April.
ah... yes. But the information I saw yesterday basically talked about how marginal effect/benefit of the 2nd shot wasn't as high as getting more people the first shot.
I think the first shot took you up to like 90% efficiency, and they the 2nd only gave you and extra 5%. Something like that.
We could of gotten twice as many people up to 90% at the beginning of the vaccination effort.
Also, we had large enough vaccination trials to test several spacing intervals. And even with the 3 week interval, we had data showing that the 1st shot was basically super effective by itself.
Other countries did it... our CDC and FDA are just to inflexible to make decent decisions.
The 3 week/4 week regimen should have been seen as a minimum instead of a maximum. That's what I told patients who worried about missing their specific day. At the vaccine clinics I did early on when supply was limited, we were hyperfocused on specific days because that's when we held the follow-up clinics.
I supported extending the interval at the time and still think it would have been the right move. However, I do understand that the first group was the most susceptible so would benefit from the best "armor." I think there's some unexplored middle ground there but I do see the reasoning: shaving some protection off the highest risk might not be worth the relatively few (at that time) doses that would have been made available.
Turns out, getting 2 doses into people before Delta hit was probably the real goal, although that's not something that could have been known prospectively.
"Vaccine policy twelve months ago could not and should not have anticipated the Omicron or even Delta variants." was the theory of evolution not known earlier this year?
How do we know that the boosters are so great given that it hasn't really been that many months since the first booster was given (so we haven't been able to measure what happens after 6 months and decide that we need a 2nd booster then 3rd and so on)?
To that end, why is everyone speaking about boosters as if they have definitive proof that boosters are the be all and end all of COVID vax?
Not to mention that pretty much every article recommending a booster also says that Omicron is so mutated that it will evade the vax.
Isn't it more logical to give it a month or two and see if omicron is a terrible mutation then retool the vax and then booster with vax 2.0? Otherwise we are either booster-ing with the wrong vax or for the wrong reason.
Which makes total sense. By the way, I don’t think vaccines should be expected to sustain antibodies forever. No one has active antibodies against mumps or measles or polio - just not how it works
I hear that but this is classic extrapolating out of very little history - the vaccine has been around for a total of a year. I don’t know when Israel started boosters but, by definition, they can’t have more than a year’s worth of history. If we say that we have to boost after 6 months for the first one, we are guessing at best and we have even less of an idea what’s next. I’m not against it but this is typical human nature to take the little we know and project it into eternity. I am against the definitive-ness in both directions - that boosters are the best thing since sliced bread and that Covid is the end of the world. There will be so much more to learn over the next year - among that, learn to live with ambiguity and not seek (unattainable) absolutes. So give the scientists some room to figure out Omicron and don’t jump to the only thing we know (the booster) while saying that it works against the mutation which has learned to escape the vax
"I am against the definitive-ness in both directions"
Yeah, it can be exhausting to hear "vax good" vs. "vax bad" camps without reference to any underlying thresholds and tradeoffs. One way to do better would be to use more precommitments. Lay out basic principles, then apply those to our best data (or, if we must, best guesses) for specific interventions.
Like, "I support any intervention that reduces risk of severe illness by one case per million per month," or wherever the line is.
For the data out of Israel -- they did have a large study population that was vaxxed early, with enough outcomes to measure. Obviously we can't extrapolate this to the omicron variant, or two years in the future. But first things first.
The key takeaway for me is that for a 65 year old, the reduction in severe illness from a booster is very apparent. (That benefit undoubtedly dwindles for younger cohorts, who have a lower base rate, and those groups aren't included in the study.)
The results section is a bit annoying to reconstruct, but if you extrapolate...
Looking across a hypothetical 1,000,000 doubly vaxxed unboosted 65 year olds for one day: 91 of them will get covid, 30 of those cases severe. If the same group was all boosted, you would instead see 84 of them get covid, with only 2 cases severe.
In their results section they jump to "factor reductions," which means they're hiding the base rate, which is incredibly annoying when the entire point of this analysis is to determine how many outcomes across a population we're improving with some intervention. It's like saying you discovered a way to cut deaths by 30%, but forget to say whether it applies to car accidents or shark attacks.
Regardless of the presentation, 28 / million / day fewer cases of severe disease meets my personal threshold as a worthy intervention, even if it only lasts six months. I'd recommend it for all 65 year olds, and maybe err on the side of caution and go a decade or two younger.
But the risks as you get a decade more youthful seem to drop by an order of magnitude with this disease. So for double vaxxed 25 year olds, it's much less clear cut for me.
Even if we aren't targeting severe illness with 25 year olds, maybe we just want boosters everywhere, to slow the spread. Ok. Note though that the ability of boosters to reduce infection is real but much smaller than their impact on severe illness.
So... what reduction in infections per million days should we be targeting in order to recommend this as a public health intervention to 25 year olds? What reduction in cases are we forecasting if we get 70% of this cohort to take a booster?
Maybe the answer is that risks from vaccines are low, so why not... but we might be better off just taking more swings at first shot messaging instead. If we could get everyone over 50 who is turned off by the two shot series to just get one of the two shots, we would likely have a larger impact on hospital burden.
Or just authorize paxlovid as fast as possible I guess.
Omicron may upend this further. I think another exercise is trying to forecast what something like the Israel study will say about the effectiveness of boosters against severe illness and infection after O becomes dominant. Note that it's technically possible that the booster may even increase in relative effectiveness in a world with Omicron, if the base rates of reinfection go up enough. So like, you could get 300 breakthroughs, 150 of which severe, meaning the percentage effectiveness of the booster drops per breakthrough, but across the whole population it actually improves outcomes for 150 instead of just 30 person days.
tl;dr Boosters seem definitely worth it for 65 year olds to me. The case for 25 year olds seems weaker to me. I'm not fixed in opposition to boosters for that cohort, but would like to see more analysis of the specific impact on spread if we apply boosters to that group.
First - I generally agree with the logic that boosters are good for you with the caveat that we have. K idea if they work against Omicron so we shouldn’t say ‘get a booster bec of Omicron - the variant that has mutated enough to escape the vax which we ask you to boost”. That just makes no sense and that is exactly what every article out there preaches (the part in quotes)
Second - if you’re going to do it, do it all the way. In other words, yes a single shot is better than no shot but it shouldn’t be a selling point that people should take it because it inconveniences them less. That’s kinda like saying go in the ocean with a punctured life preserver bec you will last an hour longer and I’m that time you just might make it to shore.
Paul Offit and the crew on the TWiV podcast aren't convinced about boosters. Quite the battle going on in the public health and virology space. Just about as a bad as the mask and test battles early on. Unfortunate.
You sound smart and thoughtful when you talk about the science, but once you start opining about group process you are substantially less impressive.
"In other words, this looks to have been an elite virtue signaling campaign that ended up costing a significant number of lives." This sentence really made my opinion of you plummet, and I am not a member of the group you're accusing of virtue signaling. I personally never managed to decide whether I thought the US should forgo boosters so as to have more vaccine to send to countries with low vaccination rates. What I find lame about your view is that you're missing something that's self-evident, if you just stop and think: The booster shot issue is complicated enough that many fair-minded, non-virtue-signaling people might easily have concluded that we should be sending any spare doses abroad rather than using them for US boosters. Their reasoning might have been that even if we only consider our own welfare, we're better off getting more first doses into the population at large than more third doses into US arms. Or they might have thought that the ethical thing to do is to help non-US citizens get a first dose so that they have better odds, even if one consequence of that choice is that the average US citizen's odds become somewhat worse. Would the people who were swayed by these ideas have been right? Maybe not, but the point here isn't that they were right, the point is that they may well have arrived at their opinion by thinking over the info they had, not by having a virtue-signaling attack.
When you start thinking about the people who reached a conclusion different from yours, you slip into the illusion that you can see right through them, you know just how their tiny little minds were working. You do not know that. You are mistaking your annoyance at these people for insight. In doing so you are engaging in the same kind of process an anti-vaxxer does when he concludes that the people who want him to wear a mask are libtard nazis whose agenda is to take away his God-given rights.
"The booster shot issue is complicated enough that many fair-minded, non-virtue-signaling people might easily have concluded that we should be sending any spare doses abroad rather than using them for US booster"
But that's precisely what Noah is rightly calling out a performative moralism. "Should the US do boosters for all or do more vaccine cosmopolitanism" is a classic compatriot priority vs global equality normative policy puzzle, entirely suitable for week 8 of your Global Justice seminar at Princeton. But it's also completely irrelevant for the situation those bureaucrats faced. It's perfectly clear at this point Biden is choosing compatriot priority, and there's obviously nothing CDC/FDA bureaucrats can do about it. The two options are "more booster doses in arms, fewer on pharmacy shelves" and "fewer booster doses in arms, more on pharmacy shelves." That's it. Pretending otherwise doesn't make it so, and shame on the various bureaucrats who've taken steps to deliberately create confusion and leave millions in danger they never should have been in, just so they can posture for an Extremely Very Moral position they have no power whatsoever to create.
I genuinely don't care a whitt about performative moralism on twitter. A perfectly fine venue for it, people seem to enjoy it. I expect more professionalism and moral and political seriousness from high-level public administrators.
I had a similarly negative reaction to this. Notably, I *am* a member of a community where we have been very critical of the inability to get doses out to developing countries, and many of us have talked about the moral complication of the question of getting a booster when our friends and coworkers in X country have not even had one shot. But, all of us got shots! I do not know anyone who has actually not gotten a booster for this reason, because all of us also know that a) our getting a booster still helps, b) the real bottleneck is manufacturing and it's isn't really a question of give me a booster versus give someone else a first shot, but how do we build the political will to bust through the manufacturing shortfall. Which you agree with, but for some reason see progressives as unawake to, when that's the only venue I've heard that message consistenly sent from. (Maybe I belong to a different group than what Noah is really referring to, but I have not met the group he's referring to of progressives who refuse to get boosters on a sort of Singerite utilitarian ground!)
I could tell you as a healthcare worker, if the CDC director didn't overrule the panel recs and ok boosters for us, we would have fucking revolted. Whatever the panel's reasoning, it came across as a big middle finger to us dealing with it.
Especially knowing that increased production is the key to meeting global demand, the whole "global equity" argument just felt like us being asked to make another sacrifice because we were "the troops" or something.
One thing I'm wondering about the measurements of the speed of spread is, how much are we over-sampling the populations that are likely to have Omicron? My understanding is that in the US and Europe, officials are prioritizing the sequencing of cases related to travel from Africa. Thus, if Africa is in fact the main source of infections, then we are likely over-estimating the fraction of current cases that are Omicron, and if Africa is not the main source of infections, we may be over-estimating the correlation between Omicron and travel with Africa. (This is analogous to the problems facing exit polls after elections that over-sample minority populations, and thus initially seem more favorable to candidates that minorities prefer than the actual results are.)
This is a good point. However, one would certainly hope that the this would be a familiar situation to the people running the numbers and that they would therefor account for it. One would hope......
I think the chart of UK sequencing is just the raw data without any adjustments for the fact that they are intentionally sequencing more cases that are suspected of being omicron. It might be better to try to estimate omicron prevalence by looking at s-gene dropout.
Lots of excellent info in your update, but I confess to appreciating the beginning (bunny taking on 'covid') and the end (Noah highlighting yet another failure of our increasingly failed state) the best. Thanks!
How is it "symbolism and signalling" to suggest it's immoral to push boosters for those not facing a large risk of hospitalization and to vaccinate young children when each of those doses could be going to people elsewhere in the world who have no vaccine at all and are in countries where the virus is raging out of control? Even leaving aside the increased risk that variants will emerge through under-vaccinated countries, this is just gross on the face of it. Also see...
Omicron is the variant that finally convinced me that we're all catching this thing eventually. Hopefully, early reporting that it causes milder illness will pan out as new therapeutics come online. A rapidly spreading, milder virus isn't the best possible outcome (or even a good one) but it's probably one of the better outcomes currently available to us. We'll find out what we're dealing with soon enough.
What’s the evidence connecting progressive politics to anti booster mentality? I know some folks were talking about not getting boosters so other countries could get them, but I’m not aware this actually changed when boosters were made available. Are other countries so far ahead of us in delivering boosters?
Man, another wave is a huge bummer. I can’t blame anyone for their apathy anymore. I’ll be getting my booster shot, but I’m not sure it’ll be the last shot I get before this is all over.
I'm not clear from this what was actually wrong with the argument that boosters trade off against giving vaccines to the developing world? Is there a distribution issue, or was there just not political will to actually do it.
There's not a fixed stockpile of vaccine doses out there waiting to be allocated. When Americans get fewer boosters, manufacturers make less, unless someone is paying them to make doses for other users (such as people in the developing world). By the same token, if we pay manufacturers to make more doses, we can give everyone boosters AND give doses to the developing world. So it's all about production capacity; we're not allocating a fixed number of existing doses.
This makes sense, but I feel like you’re talking about a different time scale (the Econ textbook “long run” where capital can adjust) and a different world (where congress can get it together to allocate funds for mass vaccination). Might it still be true that there is a trade-off between boosters in the USA and first doses in other countries over a shorter timescale (some kind of “right now”)? You have asserted that there is no trade off and I want what you’re saying to be true but the case isn’t closed. (You’ve provided much more evidence than I have, but I’m just an internet rando and you’re just a columnist. I would like to see more explanation by industry production experts.)
I really want to see someone do a systematic survey - which countries are limited by available doses, so that they have delivery trucks waiting and pharmacies/vaccination sites waiting for doses to inject into waiting arms? which countries have enough doses to keep up but are limited by delivery trucks or pharmacies/vaccination sites? and which countries have both enough doses and delivery trucks and vaccination sites to keep up but are limited by hesitancy/demand side?
My impression is that most rich countries are in the third bucket now, and most poor countries are in the second, and very few are in the first, but if there are substantial numbers of countries in the first, that would be good to know! That first bucket is doing a lot of the rhetorical work in this discussion.
I've gotten the impression that there is a clear tradeoff (seen the FT chart where there have been more boosters in higher income countries than first shots in lowest income countries), but it's driven by who can afford to buy doses vs who has to have them donated and which manufacture has been approved. Like if Novavax was churning out doses right now I don't think there would be much of an issue (because they had a huge order to be filled by Covax).
Apart from what Noah said, people thought that Covid would only be eradicated once the entire world were vaccinated. This view seems to be something of a hangover from the days when we believed in herd immunity, the rarity of breakthrough infections, and the universal desire to be vaccinated. What once sounded reasonable is now clearly untenable.
I don't think it is untenable. Had we gotten everyone vaccinated, there would not have been a population in which to breed variants. What has happened is exactly what we knew would happen if we _only_ partially vaccinated. If we develop improved vaccines we can, again, either vaccinate everyone, or expect similar results.
Omicron appears to have developed primarily in a single immunocompromised individual who sustained a chronic infection for over a year before it began spreading in other people. (That at least is one natural explanation for why it seems to have many unique mutations, but is closest to some variants that were circulating in May 2020 and doesn't share many of the distinctive mutations of all the variants that have taken over in the past year.)
If that's right, then even largely eliminating all infections over the past year wouldn't have affected the emergence of Omicron. (Though it may well have prevented Alpha and Delta.)
Kenny, I think I neglected to respond to you last time you mentioned _this_ in a discussion we were having. I think that this is a difficult claim to make. However, I also think it is largely irrelevant. Whether it occurred in an infected individual or adjacent to an infected individual, the result is the same.
Every time a virus divides, you have mutations. If there are 10x as many unvaccinated as vaccinated adjacent in a society then by some measures, it is 10x more likely to develop in the unvaccinated population. That it appears to have developed in one of the largest unvaccinated populations on earth leads me to favor this idea.
Regardless of which type of individual it developed in, it must still have maintained its ability to spread outside its host. And in either case, had everyone been vaccinated, the effective R0 would have been low enough that there it likely never would have evolved.
In case I wasn't clear, my thinking is: Evolution in a vaccinated individual is maximized by a large population of vaccinated people regularly exposed (by a small number of carriers). Evolution in an unvaccinated individual is maximized by a large population of unvaccinated exposing (a small number of) vaccinated individuals who would then allow it to spread.
Also, that it is markedly more communicable than Delta in general, also increases the odds that it could have not merely evolved but even outspread Delta in an unvaccinated population.
I don't believe this is true. I'm double vaccinated and recently got Covid. I know plenty of other people in the same situation. Short of a universal vaccine which prevents breakthrough infections, we are bound to catch Covid again and again, and in so doing provide the hosts necessary to breed variants.
If you do the math, the immunity conferred by against the original variant and (I believe) against delta was enough to drop R below 1. That means that the virus would have petered out if everyone had been fully vaccinated. However, they were not and thus the effective R stayed above 1. Delta's contagiousness against the unvaccinated had a particularly high R0.
This is part of why it was reasonable to argue that we should pay to vaccinate 3rd world countries.
While I'm happy to read anything you care to pass along, my understanding was the vaccines were originally believed to confer about 95% immunity, with a 5% chance of breakthrough infections. Booster shots were not generally thought to be needed because we believed that the immunity conferred would last some while. That no longer appears to be the case, and it increasingly looks as if Covid is something we will live with indefinitely. While providing vaccines to the rest of the world is still a goal worth pursuing, there is no longer any realistic chance of it burning out the virus.
The numbers for the vaccines even against delta show about 10x reduction in infection rate. The initial R0 was between 1 and 2(say 1.5) and Delta looks to be 4x worse. So, against delta the vaccinated R0 should be 0.6 and the unvaccinated R0 should be 6. If we were all mixed together evenly, and 93% of the people were vaccinated we would have an R0 of 1. Thus >93% vaccinated would equate to declining infection rates.
Obviously these numbers are imprecise. But clearly the vaccines were good enough against the original variant (R0=1.5). They also appear to have been effective enough against Delta.....
As it turns out we are not evenly mixed and we would have breeding grounds in red states(and 3rd world countries) even with 98% vaccination rates.
One of the things you didn't hit upon is how wrong we apparently got vaccine spacing. There was an interesting thread yesterday by your boy Topol talking about this.
https://twitter.com/EricTopol/status/1467186981327151105?s=20
It's possible that the reason the booster is so important is not because it's a 3rd dose, but because its spaced out from the first dose.
There is such a dichotomy between the awesomeness of our private companies and their ability to leverage science and technology to provide such awesome tools to fight this virus and our government agencies complete inability to adapt to novel situations. Imagine if the CDC and the FDA (more importantly) were able to shed the bureaucratic nonsense the keeps us from using data from foreign countries to make decisions, or to approve challenge trials.
On a political note: I wonder how much patience the public has for a new round of precautions. Seems pretty clear to me that we are about to have a 4th??? wave over the next two months.
Even if hospitalizations are high because of the sheer number of cases, if the severity and individual risk of hospitalization/death is low, you are going to see the public become even more apathetic.
Politically, another wave is going to hurt Democrats if it is accompanied with more school disruptions.
Finally: why are you always up so late dude. Damn. I wake up here in Argentina, and you are still going strong on Twitter.
Maybe he stays up late and sleeps in? That's definitely what I would do if I could. I'm a night hunter, at some deep genetic level -- like I even see well in dim light, and literally can't see (or especially drive safely) without my sunglasses, on a cloudless day. My body wants to go to sleep just before dawn, and wake up around noon. Dealing with realistic office schedules is a perpetual struggle. (Look up "chronotype", this is a thing that medical science has come to understand in the last couple decades.)
> One of the things you didn't hit upon is how wrong we apparently got vaccine spacing.
It's good that long intervals are at least as good or better than short intervals, but that doesn't mean that a short interval was the wrong public health choice.
With routine vaccination, we can afford long intervals because the underlying disease is not rapidly circulating throughout the population. A kid is unlikely to be exposed to measles, so the interval between their first shot and booster does not matter that much.
On the other hand, covid was (and is) still epidemic in developed nations. Long intervals -- especially intervals longer than necessary for a "first doses first" policy -- leave people less immune over the interval, for dubious long-term gain. Vaccine policy twelve months ago could not and should not have anticipated the Omicron or even Delta variants.
Additionally, remember that mass vaccination would only begin after completion of stage 3 trials and authorization. If we insisted on long intervals for the best long-term immunity, those stage 3 trials would have taken considerably longer. First doses wouldn't have gone out (in the US) in December/January, but March/April.
ah... yes. But the information I saw yesterday basically talked about how marginal effect/benefit of the 2nd shot wasn't as high as getting more people the first shot.
I think the first shot took you up to like 90% efficiency, and they the 2nd only gave you and extra 5%. Something like that.
We could of gotten twice as many people up to 90% at the beginning of the vaccination effort.
Also, we had large enough vaccination trials to test several spacing intervals. And even with the 3 week interval, we had data showing that the 1st shot was basically super effective by itself.
Other countries did it... our CDC and FDA are just to inflexible to make decent decisions.
The 3 week/4 week regimen should have been seen as a minimum instead of a maximum. That's what I told patients who worried about missing their specific day. At the vaccine clinics I did early on when supply was limited, we were hyperfocused on specific days because that's when we held the follow-up clinics.
I supported extending the interval at the time and still think it would have been the right move. However, I do understand that the first group was the most susceptible so would benefit from the best "armor." I think there's some unexplored middle ground there but I do see the reasoning: shaving some protection off the highest risk might not be worth the relatively few (at that time) doses that would have been made available.
Turns out, getting 2 doses into people before Delta hit was probably the real goal, although that's not something that could have been known prospectively.
"Vaccine policy twelve months ago could not and should not have anticipated the Omicron or even Delta variants." was the theory of evolution not known earlier this year?
How do we know that the boosters are so great given that it hasn't really been that many months since the first booster was given (so we haven't been able to measure what happens after 6 months and decide that we need a 2nd booster then 3rd and so on)?
To that end, why is everyone speaking about boosters as if they have definitive proof that boosters are the be all and end all of COVID vax?
Not to mention that pretty much every article recommending a booster also says that Omicron is so mutated that it will evade the vax.
Isn't it more logical to give it a month or two and see if omicron is a terrible mutation then retool the vax and then booster with vax 2.0? Otherwise we are either booster-ing with the wrong vax or for the wrong reason.
The Israelis are coming out with data showing the booster antibody immunity is waning at a similar rate to prior immunizations.
Which makes total sense. By the way, I don’t think vaccines should be expected to sustain antibodies forever. No one has active antibodies against mumps or measles or polio - just not how it works
That's not true. Coronaviruses have been difficult vaccine targets.
https://jamanetwork.com/journals/jamapediatrics/fullarticle/569784#:~:text=Main%20Outcome%20Measure%20Measles%20antibody,and%20suggestive%20of%20potential%20susceptibility.
"How do we know that the boosters are so great given that it hasn't really been that many months since the first booster was given "
We look at data out of Israel, where it's been quite a bit longer. The evidence for significant increased protection in Israel is very strong.
I hear that but this is classic extrapolating out of very little history - the vaccine has been around for a total of a year. I don’t know when Israel started boosters but, by definition, they can’t have more than a year’s worth of history. If we say that we have to boost after 6 months for the first one, we are guessing at best and we have even less of an idea what’s next. I’m not against it but this is typical human nature to take the little we know and project it into eternity. I am against the definitive-ness in both directions - that boosters are the best thing since sliced bread and that Covid is the end of the world. There will be so much more to learn over the next year - among that, learn to live with ambiguity and not seek (unattainable) absolutes. So give the scientists some room to figure out Omicron and don’t jump to the only thing we know (the booster) while saying that it works against the mutation which has learned to escape the vax
"I am against the definitive-ness in both directions"
Yeah, it can be exhausting to hear "vax good" vs. "vax bad" camps without reference to any underlying thresholds and tradeoffs. One way to do better would be to use more precommitments. Lay out basic principles, then apply those to our best data (or, if we must, best guesses) for specific interventions.
Like, "I support any intervention that reduces risk of severe illness by one case per million per month," or wherever the line is.
For the data out of Israel -- they did have a large study population that was vaxxed early, with enough outcomes to measure. Obviously we can't extrapolate this to the omicron variant, or two years in the future. But first things first.
The key takeaway for me is that for a 65 year old, the reduction in severe illness from a booster is very apparent. (That benefit undoubtedly dwindles for younger cohorts, who have a lower base rate, and those groups aren't included in the study.)
The results section is a bit annoying to reconstruct, but if you extrapolate...
Looking across a hypothetical 1,000,000 doubly vaxxed unboosted 65 year olds for one day: 91 of them will get covid, 30 of those cases severe. If the same group was all boosted, you would instead see 84 of them get covid, with only 2 cases severe.
In their results section they jump to "factor reductions," which means they're hiding the base rate, which is incredibly annoying when the entire point of this analysis is to determine how many outcomes across a population we're improving with some intervention. It's like saying you discovered a way to cut deaths by 30%, but forget to say whether it applies to car accidents or shark attacks.
Regardless of the presentation, 28 / million / day fewer cases of severe disease meets my personal threshold as a worthy intervention, even if it only lasts six months. I'd recommend it for all 65 year olds, and maybe err on the side of caution and go a decade or two younger.
But the risks as you get a decade more youthful seem to drop by an order of magnitude with this disease. So for double vaxxed 25 year olds, it's much less clear cut for me.
Even if we aren't targeting severe illness with 25 year olds, maybe we just want boosters everywhere, to slow the spread. Ok. Note though that the ability of boosters to reduce infection is real but much smaller than their impact on severe illness.
So... what reduction in infections per million days should we be targeting in order to recommend this as a public health intervention to 25 year olds? What reduction in cases are we forecasting if we get 70% of this cohort to take a booster?
Maybe the answer is that risks from vaccines are low, so why not... but we might be better off just taking more swings at first shot messaging instead. If we could get everyone over 50 who is turned off by the two shot series to just get one of the two shots, we would likely have a larger impact on hospital burden.
Or just authorize paxlovid as fast as possible I guess.
Omicron may upend this further. I think another exercise is trying to forecast what something like the Israel study will say about the effectiveness of boosters against severe illness and infection after O becomes dominant. Note that it's technically possible that the booster may even increase in relative effectiveness in a world with Omicron, if the base rates of reinfection go up enough. So like, you could get 300 breakthroughs, 150 of which severe, meaning the percentage effectiveness of the booster drops per breakthrough, but across the whole population it actually improves outcomes for 150 instead of just 30 person days.
tl;dr Boosters seem definitely worth it for 65 year olds to me. The case for 25 year olds seems weaker to me. I'm not fixed in opposition to boosters for that cohort, but would like to see more analysis of the specific impact on spread if we apply boosters to that group.
First - I generally agree with the logic that boosters are good for you with the caveat that we have. K idea if they work against Omicron so we shouldn’t say ‘get a booster bec of Omicron - the variant that has mutated enough to escape the vax which we ask you to boost”. That just makes no sense and that is exactly what every article out there preaches (the part in quotes)
Second - if you’re going to do it, do it all the way. In other words, yes a single shot is better than no shot but it shouldn’t be a selling point that people should take it because it inconveniences them less. That’s kinda like saying go in the ocean with a punctured life preserver bec you will last an hour longer and I’m that time you just might make it to shore.
Paul Offit and the crew on the TWiV podcast aren't convinced about boosters. Quite the battle going on in the public health and virology space. Just about as a bad as the mask and test battles early on. Unfortunate.
Oof.
You sound smart and thoughtful when you talk about the science, but once you start opining about group process you are substantially less impressive.
"In other words, this looks to have been an elite virtue signaling campaign that ended up costing a significant number of lives." This sentence really made my opinion of you plummet, and I am not a member of the group you're accusing of virtue signaling. I personally never managed to decide whether I thought the US should forgo boosters so as to have more vaccine to send to countries with low vaccination rates. What I find lame about your view is that you're missing something that's self-evident, if you just stop and think: The booster shot issue is complicated enough that many fair-minded, non-virtue-signaling people might easily have concluded that we should be sending any spare doses abroad rather than using them for US boosters. Their reasoning might have been that even if we only consider our own welfare, we're better off getting more first doses into the population at large than more third doses into US arms. Or they might have thought that the ethical thing to do is to help non-US citizens get a first dose so that they have better odds, even if one consequence of that choice is that the average US citizen's odds become somewhat worse. Would the people who were swayed by these ideas have been right? Maybe not, but the point here isn't that they were right, the point is that they may well have arrived at their opinion by thinking over the info they had, not by having a virtue-signaling attack.
When you start thinking about the people who reached a conclusion different from yours, you slip into the illusion that you can see right through them, you know just how their tiny little minds were working. You do not know that. You are mistaking your annoyance at these people for insight. In doing so you are engaging in the same kind of process an anti-vaxxer does when he concludes that the people who want him to wear a mask are libtard nazis whose agenda is to take away his God-given rights.
Stop with that shit.
"The booster shot issue is complicated enough that many fair-minded, non-virtue-signaling people might easily have concluded that we should be sending any spare doses abroad rather than using them for US booster"
But that's precisely what Noah is rightly calling out a performative moralism. "Should the US do boosters for all or do more vaccine cosmopolitanism" is a classic compatriot priority vs global equality normative policy puzzle, entirely suitable for week 8 of your Global Justice seminar at Princeton. But it's also completely irrelevant for the situation those bureaucrats faced. It's perfectly clear at this point Biden is choosing compatriot priority, and there's obviously nothing CDC/FDA bureaucrats can do about it. The two options are "more booster doses in arms, fewer on pharmacy shelves" and "fewer booster doses in arms, more on pharmacy shelves." That's it. Pretending otherwise doesn't make it so, and shame on the various bureaucrats who've taken steps to deliberately create confusion and leave millions in danger they never should have been in, just so they can posture for an Extremely Very Moral position they have no power whatsoever to create.
Performative moralism. Performative public busting of performative moralism. Twitterverse.
I genuinely don't care a whitt about performative moralism on twitter. A perfectly fine venue for it, people seem to enjoy it. I expect more professionalism and moral and political seriousness from high-level public administrators.
I had a similarly negative reaction to this. Notably, I *am* a member of a community where we have been very critical of the inability to get doses out to developing countries, and many of us have talked about the moral complication of the question of getting a booster when our friends and coworkers in X country have not even had one shot. But, all of us got shots! I do not know anyone who has actually not gotten a booster for this reason, because all of us also know that a) our getting a booster still helps, b) the real bottleneck is manufacturing and it's isn't really a question of give me a booster versus give someone else a first shot, but how do we build the political will to bust through the manufacturing shortfall. Which you agree with, but for some reason see progressives as unawake to, when that's the only venue I've heard that message consistenly sent from. (Maybe I belong to a different group than what Noah is really referring to, but I have not met the group he's referring to of progressives who refuse to get boosters on a sort of Singerite utilitarian ground!)
I could tell you as a healthcare worker, if the CDC director didn't overrule the panel recs and ok boosters for us, we would have fucking revolted. Whatever the panel's reasoning, it came across as a big middle finger to us dealing with it.
Especially knowing that increased production is the key to meeting global demand, the whole "global equity" argument just felt like us being asked to make another sacrifice because we were "the troops" or something.
One thing I'm wondering about the measurements of the speed of spread is, how much are we over-sampling the populations that are likely to have Omicron? My understanding is that in the US and Europe, officials are prioritizing the sequencing of cases related to travel from Africa. Thus, if Africa is in fact the main source of infections, then we are likely over-estimating the fraction of current cases that are Omicron, and if Africa is not the main source of infections, we may be over-estimating the correlation between Omicron and travel with Africa. (This is analogous to the problems facing exit polls after elections that over-sample minority populations, and thus initially seem more favorable to candidates that minorities prefer than the actual results are.)
This is a good point. However, one would certainly hope that the this would be a familiar situation to the people running the numbers and that they would therefor account for it. One would hope......
I think the chart of UK sequencing is just the raw data without any adjustments for the fact that they are intentionally sequencing more cases that are suspected of being omicron. It might be better to try to estimate omicron prevalence by looking at s-gene dropout.
Yo, Noah, I saw you tweeted about what "bugman" meant. I found a weirdly long piece explaining the term here. you should write an article about this, considering they basically describe stereotypical weebs. https://hackernoon.com/on-the-infestation-of-small-souled-bugmen-6561ae922e07
Lots of excellent info in your update, but I confess to appreciating the beginning (bunny taking on 'covid') and the end (Noah highlighting yet another failure of our increasingly failed state) the best. Thanks!
How is it "symbolism and signalling" to suggest it's immoral to push boosters for those not facing a large risk of hospitalization and to vaccinate young children when each of those doses could be going to people elsewhere in the world who have no vaccine at all and are in countries where the virus is raging out of control? Even leaving aside the increased risk that variants will emerge through under-vaccinated countries, this is just gross on the face of it. Also see...
https://twitter.com/zainrizvi/status/1464348016501043224
Omicron is the variant that finally convinced me that we're all catching this thing eventually. Hopefully, early reporting that it causes milder illness will pan out as new therapeutics come online. A rapidly spreading, milder virus isn't the best possible outcome (or even a good one) but it's probably one of the better outcomes currently available to us. We'll find out what we're dealing with soon enough.
What’s the evidence connecting progressive politics to anti booster mentality? I know some folks were talking about not getting boosters so other countries could get them, but I’m not aware this actually changed when boosters were made available. Are other countries so far ahead of us in delivering boosters?
Man, another wave is a huge bummer. I can’t blame anyone for their apathy anymore. I’ll be getting my booster shot, but I’m not sure it’ll be the last shot I get before this is all over.
I'm not clear from this what was actually wrong with the argument that boosters trade off against giving vaccines to the developing world? Is there a distribution issue, or was there just not political will to actually do it.
There's not a fixed stockpile of vaccine doses out there waiting to be allocated. When Americans get fewer boosters, manufacturers make less, unless someone is paying them to make doses for other users (such as people in the developing world). By the same token, if we pay manufacturers to make more doses, we can give everyone boosters AND give doses to the developing world. So it's all about production capacity; we're not allocating a fixed number of existing doses.
This makes sense, but I feel like you’re talking about a different time scale (the Econ textbook “long run” where capital can adjust) and a different world (where congress can get it together to allocate funds for mass vaccination). Might it still be true that there is a trade-off between boosters in the USA and first doses in other countries over a shorter timescale (some kind of “right now”)? You have asserted that there is no trade off and I want what you’re saying to be true but the case isn’t closed. (You’ve provided much more evidence than I have, but I’m just an internet rando and you’re just a columnist. I would like to see more explanation by industry production experts.)
I really want to see someone do a systematic survey - which countries are limited by available doses, so that they have delivery trucks waiting and pharmacies/vaccination sites waiting for doses to inject into waiting arms? which countries have enough doses to keep up but are limited by delivery trucks or pharmacies/vaccination sites? and which countries have both enough doses and delivery trucks and vaccination sites to keep up but are limited by hesitancy/demand side?
My impression is that most rich countries are in the third bucket now, and most poor countries are in the second, and very few are in the first, but if there are substantial numbers of countries in the first, that would be good to know! That first bucket is doing a lot of the rhetorical work in this discussion.
> When Americans get fewer boosters, manufacturers make less,
I thought we were running the factories at maximum capacity. To hear that we're not is saddening and surprising for me.
I've gotten the impression that there is a clear tradeoff (seen the FT chart where there have been more boosters in higher income countries than first shots in lowest income countries), but it's driven by who can afford to buy doses vs who has to have them donated and which manufacture has been approved. Like if Novavax was churning out doses right now I don't think there would be much of an issue (because they had a huge order to be filled by Covax).
Apart from what Noah said, people thought that Covid would only be eradicated once the entire world were vaccinated. This view seems to be something of a hangover from the days when we believed in herd immunity, the rarity of breakthrough infections, and the universal desire to be vaccinated. What once sounded reasonable is now clearly untenable.
I don't think it is untenable. Had we gotten everyone vaccinated, there would not have been a population in which to breed variants. What has happened is exactly what we knew would happen if we _only_ partially vaccinated. If we develop improved vaccines we can, again, either vaccinate everyone, or expect similar results.
Omicron appears to have developed primarily in a single immunocompromised individual who sustained a chronic infection for over a year before it began spreading in other people. (That at least is one natural explanation for why it seems to have many unique mutations, but is closest to some variants that were circulating in May 2020 and doesn't share many of the distinctive mutations of all the variants that have taken over in the past year.)
If that's right, then even largely eliminating all infections over the past year wouldn't have affected the emergence of Omicron. (Though it may well have prevented Alpha and Delta.)
Kenny, I think I neglected to respond to you last time you mentioned _this_ in a discussion we were having. I think that this is a difficult claim to make. However, I also think it is largely irrelevant. Whether it occurred in an infected individual or adjacent to an infected individual, the result is the same.
Every time a virus divides, you have mutations. If there are 10x as many unvaccinated as vaccinated adjacent in a society then by some measures, it is 10x more likely to develop in the unvaccinated population. That it appears to have developed in one of the largest unvaccinated populations on earth leads me to favor this idea.
Regardless of which type of individual it developed in, it must still have maintained its ability to spread outside its host. And in either case, had everyone been vaccinated, the effective R0 would have been low enough that there it likely never would have evolved.
In case I wasn't clear, my thinking is: Evolution in a vaccinated individual is maximized by a large population of vaccinated people regularly exposed (by a small number of carriers). Evolution in an unvaccinated individual is maximized by a large population of unvaccinated exposing (a small number of) vaccinated individuals who would then allow it to spread.
Also, that it is markedly more communicable than Delta in general, also increases the odds that it could have not merely evolved but even outspread Delta in an unvaccinated population.
I don't believe this is true. I'm double vaccinated and recently got Covid. I know plenty of other people in the same situation. Short of a universal vaccine which prevents breakthrough infections, we are bound to catch Covid again and again, and in so doing provide the hosts necessary to breed variants.
If you do the math, the immunity conferred by against the original variant and (I believe) against delta was enough to drop R below 1. That means that the virus would have petered out if everyone had been fully vaccinated. However, they were not and thus the effective R stayed above 1. Delta's contagiousness against the unvaccinated had a particularly high R0.
This is part of why it was reasonable to argue that we should pay to vaccinate 3rd world countries.
While I'm happy to read anything you care to pass along, my understanding was the vaccines were originally believed to confer about 95% immunity, with a 5% chance of breakthrough infections. Booster shots were not generally thought to be needed because we believed that the immunity conferred would last some while. That no longer appears to be the case, and it increasingly looks as if Covid is something we will live with indefinitely. While providing vaccines to the rest of the world is still a goal worth pursuing, there is no longer any realistic chance of it burning out the virus.
The numbers for the vaccines even against delta show about 10x reduction in infection rate. The initial R0 was between 1 and 2(say 1.5) and Delta looks to be 4x worse. So, against delta the vaccinated R0 should be 0.6 and the unvaccinated R0 should be 6. If we were all mixed together evenly, and 93% of the people were vaccinated we would have an R0 of 1. Thus >93% vaccinated would equate to declining infection rates.
Obviously these numbers are imprecise. But clearly the vaccines were good enough against the original variant (R0=1.5). They also appear to have been effective enough against Delta.....
As it turns out we are not evenly mixed and we would have breeding grounds in red states(and 3rd world countries) even with 98% vaccination rates.