Notes on how not to figure things out
Happy new year!
First, a few brief updates.
Last week, I wrote an article warning people over the apparently more transmissible lineage that’s emerged in the U.K. Since then, there’s even more evidence that this variant is indeed more transmissible. I’ll get back to this topic soon, but for the moment, let me say this: I believe everyone should up their precautions. We’re so close with the vaccines, despite their frustratingly slow rollout. But until we have more clarity, it’s best to assume that while our precautions should remain categorically the same (masks, ventilation, distance, disinfecting, avoiding indoors/crowds), they should be even stricter and improved: better masks, more distance, stronger ventilation, disinfecting high-touch surfaces in places where households mix, etc.
There have also been developments with issues discussed in the “Counters” installments published on Insight. The question about advocating research into the single-dose/delayed booster debate has been almost completely upended by the developments. The United Kingdom is forging ahead with some delayed dosing (without a trial—I certainly hope they collect data) and I wouldn’t be surprised if other European countries facing shortages and huge spikes in infections and strain on their health-care systems follow suit. Vaccine prioritization certainly remains a crucial story, and it’s just not possible to summarize my thoughts in a passing sentence, so I’ll soon do a full response-to-counter on that.
Similarly, the coup/democracy argument needs more detailed updating (a brief update can be found here on why I think clumsy does not mean performative), and I’ll do that as the presidential transition date is nearer but I think this picture may well be the best update to that one (going on as I type this update):
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On to today’s topic: what we lose with the polarization and moralization of what are actually scientific questions that need to be handled with nuance and recognition of the trade-offs.
I’m going to give an example, not because it’s the most consequential example but because it’s both easy to explain and pretty representative.
Backdrop: as mentioned, towards the end of last year, faced with a surge in infections that seems at least partially-driven by the new lineage, the United Kingdom made an announcement. They declared that they would focus first on vaccinating as many people as possible, before turning their attention to boosters—delaying the boosters perhaps as much as 12 weeks.
As I wrote earlier for Insight, delaying the booster is not a strategy without downsides or risks, but there are many leading scientists—including those with significant expertise in virology, public health and vaccination—who think this is the correct path. They hold that view, especially given the crisis; broader vaccination is essential, so it’s sensible to prioritize that first before turning to the booster, which should help especially with the durability of the immunity. It’s also true that there are many who are concerned. For example, some fear the U.K.’s strategy may erode public trust by deviating from the exact rules of the trials. Others worry about vaccine escape scenarios where delaying the boosters helps other variants emerge. These are all perfectly important considerations, with both science and public health on both sides of the equation.
It was against this backdrop I first noticed an eye-popping story in the New York Times, the headline blaring that, “Britain Opts for Mix-and-Match Vaccinations, Confounding Experts.” The subtitle continued, “If a second dose of one vaccine isn’t available, another may be substituted, according to new U.K. guidelines.”
The experts quoted were livid.
“There are no data on this idea whatsoever,” said John Moore, a vaccine expert at Cornell University. …
“This option is preferred if the individual is likely to be at immediate high risk or is considered unlikely to attend again,” the recommendation said. Because both vaccines target the spike protein of the coronavirus, “it is likely the second dose will help to boost the response to the first dose.”
But it is far from certain that the vaccines are so interchangeable, several researchers said.
“None of this is being data driven right now,” said Dr. Phyllis Tien, an infectious disease physician at the University of California, San Francisco. “We’re kind of in this Wild West.”
Without evidence to back it, the hybrid vaccination approach seems “premature,” said Saad Omer, a vaccine expert at Yale University. Still, it’s not without precedent: Health authorities like the C.D.C. have previously said that if it’s impossible to give doses of a vaccine from the same manufacturer, “providers should administer the vaccine that they have available” to complete an injection schedule.
It did all seem unusual, and the article was widely shared on social media to much outrage. Scientists, journalists and others condemned what appeared to be yet another unscientific, haphazard step by the U.K. government. It was shared by astounded UK journalists as well as legislators.
The article was also shared by leading US science journalists and others, almost all expressing their outrage and shock at this abandonment of science.
So it was in this context that I clicked on the UK guidelines that had allegedly switched to mix-and-match to see if they contained any explanation for this unusual move and quickly realized that... they contained no change in strategy, to one of mix-and-match.
In pretty plain language, the guidelines clearly meant the mix-and-match vaccination as an extreme practice, a last-resort scenario expected to be quite rare. Cases in which a person showed up where the doctors did not know the first dose or have the correct type, and especially if the person was "at immediate high risk or is considered unlikely to attend again" for another round of vaccination. In such cases, rather than leaving the person with no booster, the guidelines sensibly pointed out, it was better to give a booster anyway.
If the course is interrupted or delayed, it should be resumed using the same vaccine but
the first dose should not be repeated. There is no evidence on the interchangeability of the COVID-19 vaccines although studies are underway. Therefore, every effort should be made to determine which vaccine the individual received and to complete with the same vaccine. For individuals who started the schedule and who attend for vaccination at a site where the same vaccine is not available, or if the first product received is unknown, it is reasonable to offer one dose of the locally available product to complete the schedule. This option is preferred if the individual is likely to be at immediate high risk or is considered unlikely to attend again. In these circumstances, as both the vaccines are based on the spike protein, it is likely the second dose will help to boost the response to the first dose. For this reason, until additional information becomes available, further doses would not then be required
In fact, scientifically, this isn’t a huge concern in such a context of last-case-administration since a booster of a different type may well work just as well, if not better, though it’s also possible it may be weaker. It remains unknown and it should be studied; however, it is not going to be worse than having no booster. And, clearly, sending home a person “at immediate high-risk” as the guidelines put it, and unlikely to return without any booster is the worse option. The guidelines are conservative and cautious, not some edgy, reckless mix-and-match regime.
In fact, the guidelines are so boring and mundane that the United States has long had the exact same recommendation on mixing-and-matching vaccines from manufacturers. As the article itself noted in passing, but without noting its significance, in the U.S. CDC had issued the exact same recommendation for vaccines and boosters—in rare cases, it’s fine to give a booster from a different manufacturer, if the alternative is skipping the booster.
ACIP [Advisory Committee on Immunization Practices] prefers that doses of vaccine in a series come from the same manufacturer; however, if this is not possible or if the manufacturer of doses given previously is unknown, providers should administer the vaccine that they have available.
Ironically, on social media, it was the political editor of the Daily Mirror—a tabloid not always not known for the most careful publishing—who expressed astonishment, and then did the obvious and reached out to health authorities, who made it clear that no mix-and-match regime was in place.
In fact, many from the U.K. were astonished that they were learning about something so consequential from the New York Times—except for the fact that it wasn’t happening.
The repercussions—damaging public trust in vaccines—got worrisome enough that the editor of the British Medical Journal asked for a prominent correction to help undo the damage. So did other leading authorities from the U.K.:
Dr Mary Ramsay, Public Health England's head of immunisations, said: "We do not recommend mixing the Covid-19 vaccines - if your first dose is the Pfizer vaccine you should not be given the AstraZeneca vaccine for your second dose and vice versa."
Dr Ramsay added that on the "extremely rare occasions" where the same vaccine is unavailable or it is unknown which jab the patient received, it is "better to give a second dose of another vaccine than not at all".
Ms Godlee urged the New York Times to print a "highly visible correction" as soon as possible.
What I noticed was that there was no “highly visible correction,” as of this writing, or any kind of correction. (Disclosure: I also tweeted at the journalist, hoping for a correction or a retraction). There was, instead, a stealth, unnoted editing of the headline. It changed from “Britain Opts For” to “Britain Opens Door to,” and downgrading the objection from “Confounding Experts” to “Worrying Experts.” The article also added a comment—finally—from the health authorities which noted that “said substitutions would occur only on ‘a very exceptional basis, when the alternative is to leave someone with an incomplete course.’” However, the article didn’t add a note of correction or a retraction, let alone add a comment stating the obvious: the article was unnecessary. Plus, the many newspapers around the country and the world who republished the article didn’t even update the misleading headline.
So that’s it. There was no actual controversy, nothing worth a whole article, let alone one that included condemnations of the U.K.’s vaccination guidelines on this topic. There was nothing to confound or even worry the experts. They were the most routine of guidelines, absolutely in line with best practices in other countries. They were obviously meant as a reminder to providers to avoid sending home high-risk patients without a booster, especially if the patients were unlikely to return.
But the story was a vehicle for channeling anger at the United Kingdom, at Boris Johnson, and at the U.K.'s decision to delay the booster—fine to be angry at the first and to disagree with the latter. But what happened instead was just a vehicle for channeling outrage, the way some children act like most food is merely a method for channeling ketchup into their mouth. In fact, the booster delay was mentioned in the same article as if it provided any context to this non-story, also with experts condemning it (without any being quoted explaining or defending it).
What we are seeing polarization and, in fact, moralization of every little thing, turning banal scientific manuals making routine recommendations into fodder for social media dunking and expressions of outrage. These developments have certainly made everything harder, including maintaining trust in public health guidelines. An ordinary person reading the article in the U.K. may leave with the impression that British scientific authorities are completely out of their minds, making outrageous, unprecedented decisions and gambling with public health on everything.The reality is much, much more mundane, and not that related to this most boring of guidelines. We’ve increasingly lost the ability to interpret even the smallest things outside of frameworks of outrage.