Let's Also Talk About Vaccine Hesitancy and Convincing People

 Let's start with the facts: any approved COVID-19 vaccine will be, for sure, safer than getting the disease.  Vaccination remains a public good.  I have told everyone I know they should be vaccinated, and I expect I'll have to argue my mother into it (WHY MOM, YOU ARE A LICENSED MEDICAL PROFESSIONAL).  Also, you don't want to infect your nearest and dearest!  That is not good!

However. If one more person tells me there's totally nothing to worry about and it's definitely 100% safe I will flip a goddamn table. 

First go read this article on all the shady nonsense the FDA has pulled since March, including approving therapies that actually raise the death rate.  

Then you can go read the entire Pfizer trial preliminary results (in two documents!).

First note that the median Phase 2/3 follow-up after the second dose is one month, for a total of two months.  Yes. Two.  When you hear people expressing concern over long-term effects- which there will be, there always are a few- don't bullshit them and say there's plenty of good long term data.  There isn't.  This is a novel technology not previously approved in humans.  But you are less likely to die, or kill others, if you get vaccinated.  There's your talking point. 

Don't tell people that just because the FDA approved something, it's safe and effective. (See above, also, any time these last 100 years.) Say that this disease is deadly, and the trials are pretty large, and COVID definitely will kill you faster than two months.  

When you hear people saying there were Bell's Palsy cases, that is true, and the incidence (over two months) was the same as the normal incidence over a year (though incidence varies widely by sex and age).  Don't bullshit people and say it's totally within normal range.  It may or may not be.  Say that Bell's Palsy mostly resolves, and also, it will not kill you. 

When you hear people saying there is insufficient safety data on people with previous infection, that is also true.  The Pfizer trial gave 670 people (see p. 28) with serological evidence of previous infection their vaccine.  Among these people, adverse events may or may not be more common.  (Also, the US is about to do an accidental trial on all the medical personnel who were infected and didn't know it, so adverse events will show up there.)  But also, please do not try to tell me, personally, that we know 100% for sure it's safe in people with previous infection. You can tell me that by the summer, we will have those data!  We do not have the data now.  But the vaccine still won't kill you.* 

And also, there were at least two credible reports- in hospitals, in medical personnel! - of anaphylactic or anaphylactoid reactions (the latter can still kill you).  The ingredients list is unconclusive as to what might have caused this- basically, PEG, the mRNA itself, or maybe one of the lipid components- but this is a legitimate reason to be concerned.  Again, we do not have enough data now.  For this one, I would say, don't dismiss the concerns of people with severe allergies; tell them to watch for more data.

So, overall: people are hesitant with good reasons.  Some of these reasons can be addressed.  By the time normal people can be vaccinated- in about six months- we will have enough data.  But please don't tell people who legitimately want more data that everything's fine.  That's how the FDA and CDC burned all that trust to start with. 

* There will, eventually, be a fatal adverse event, which will be a one-in-ten-million event.  On average, however, this will remain true.

Grim Guesses, Revisited

The original, from April 22, is here. 

"I think that the true net death rate for coronavirus in an adequately supplied care environment, when we finally compare excess mortality to serology, will be around 1%, no more than 2%"

What's the death rate? The WHO's August estimate is 0.5-1%.

"I think the current fatalities are at least twice and maybe three times what is reported (looking at excess mortality). That's 95,000 deaths as of today. If our terrible healthcare system has a CFR of 2%, that's 4.7 million cases already- ONLY, I will note, 5x as many as reported. Most epidemiologists estimate that we are under counting by a factor between 10 and 40. "

What's the real number? Excess mortality as of August 13 is over 200,000 deaths. We're currently under counting by about 20%; earlier, like in NY, more were missed. Probably not undercounted by half now! But even the CDC thinks we've undercounted cases about 10x. 

I'm not even going to post new commentary for these: 

"I think the second wave will be even worse... I think we will see widespread mask orders coupled with a weak, heartless federal response that will disproportionately impact those living in poverty."

"I think over half the nursing homes and prisons will have outbreaks and tens of thousands of these vulnerable populations will die."

"I think there will be an absolute minimum of 200,000 confirmed covid deaths, and it will be closer to half a million in reality (US alone, that is.)"

"I think colleges and schools may not open in the fall and many colleges will have severe financial difficulties."

"I think that most states won't have the political will to keep stuff closed through August and will have large outbreaks soon.  (6/8: Ta da!!)"

"I think that some of the places (like NZ) that have done the best containment are screwed in the absence of widespread testing - even worse off than NYC- because the moment anything reopens it will spread very fast. If nothing is happening now to prepare for that, they're just making people suffer..."

Well? I was wrong about NZ, though even they now have untraceable community transmission, which is Very Bad (means it was circulating undetected this whole time, probably). Everywhere else is, in fact, having outbreaks as soon as people mingle, though of course compared to our dumpster fire it looks like a rounding error.

"I think the US outbreak is un-containable, that a safe and highly effective vaccine will not arrive in time, and that we will see both seasonal transmission and domestic animal reservoirs"

Good news! No evidence of animal reservoirs (yet.)  Bad news: it was uncontained, and now it's uncontainable.

Relative Risk and Kid Coronavirus Infections

This news article from Texas is all over the place lately.  Here is a brief explainer of why it isn't as bad as it seems. (It is not great, but everything is not great.)

The report is that "307 children and 643 staff members" have been diagnosed. Let us posit for the sake of argument that these numbers are real.*

Say also that there are 10 kids for every adult and that today's percent positivity rate (20%) represents the true proportion of infections.**

That means out of roughly 3200 staff members, 20% got infected (643). But there were, say, 32,000 children, and so about 1% of them got infected. 

This is what public health experts mean when they say children are less likely to get sick and less likely to die. (See also the screenshot below from the  'covkid project '. Even if, god forbid, every child in intensive care were to die, the mortality rate would be 2 per thousand cases.)***

Will some people have long term lung damage, weird neurological side effects, and lifelong disability, even children? Yes, and I'm not dismissing the seriousness of those (vote, vote blue, and don't let anyone repeal the ACA!). I'm asking you to read news with a critical eye to whether the incidence is one in a hundred, or one in a million. 

* None of the coronavirus numbers are real except for total excess mortality.
** This is also not true but we need some kind of number. 
*** Yes, I know, these numbers are also fiction, but we have to use something.

Some Grim Guesses on COVID-19

(I may well be wrong about all of these things! I would love to be wrong.)

Here is the only not depressing prediction: I think that the true net death rate for coronavirus in an adequately supplied care environment, when we finally compare excess mortality to serology, will be around 1%, no more than 2%, probably pretty close to the rates observed where there is a competent response, i.e. Germany and South Korea.*

I think the current fatalities are at least twice and maybe three times what is reported (looking at excess mortality). That's 95,000 deaths as of today. If our terrible healthcare system has a CFR of 2%, that's 4.7 million cases already- ONLY, I will note, 5x as many as reported. Most epidemiologists estimate that we are under counting by a factor between 10 and 40.
(4/23: looks like way more than this.... already.)

I think at least half the country will get sick eventually, which is roughly 165 million people.

I think the second wave will be even worse. I think we will see widespread mask orders coupled with a weak, heartless federal response that will disproportionately impact those living in poverty. I think outbreaks in densely populated areas, i.e. cities, will burn faster and therefore be worse overall. (This one is barely even a prediction; look at NYC.) (6/8: Ta da!!)

I think over half the nursing homes and prisons will have outbreaks and tens of thousands of these vulnerable populations will die.
(4/23: this one is now barely a prediction, too.)

I think there will be an absolute minimum of 200,000 confirmed covid deaths, and it will be closer to half a million in reality (US alone, that is.)

I think that the odds of any individual person not getting sick are very poor indeed. A 4-million person outbreak is a wildfire. How long can you stay in your house, never going in a store or office? Is it 18 months?

I think colleges and schools may not open in the fall and many colleges will have severe financial difficulties. (I think if schools don't open I'm going to call the governor's office every damn day.)

I think that most states won't have the political will to keep stuff closed through August and will have large outbreaks soon.  (6/8: Ta da!!)

I think that some of the places (like NZ) that have done the best containment are screwed in the absence of widespread testing - even worse off than NYC- because the moment anything reopens it will spread very fast. If nothing is happening now to prepare for that, they're just making people suffer and delaying the deaths until later. (6/8: New Zealand and South Korea have all managed to actually by-gum quarantine all arrivals - with strict enforcement- and are containing their cases! Most other places..... not so much. My sisters were going on about how great Israel was doing....) (6/20: South Korea, Chinahttps://www.cnn.com/2020/06/18/asia/beijing-coronavirus-reminder-intl-hnk/index.html, and Australia are having resurgent outbreaks now. New Zealand is basically the only place that's okay and I think the island thing is helping.)

I think the US outbreak is un-containable, that a safe and highly effective vaccine will not arrive in time, and that we will see both seasonal transmission and domestic animal reservoirs.

I think that our government is run by sociopaths** who, at any moment, COULD do something (more tests, more aid, more ventilators) but choose, every day, to do nothing.


*I am not, in any way, arguing that this is a good and happy number! And it will kill a lot of elders. This is bad.
**A word I used at dinner and then had to define in a way appropriate for a five year old.