Playing With Fire

How has it come to pass that vaccines, once heralded as miracles of modern medical science, with people lining up in droves to take shots and sugar cubes that would prevent them and their children from getting polio, measles, diphtheria, tetanus, whooping cough and many others, are now suspect and avoided by a significant number of people. First it’s necessary to clearly understand the different groups people fall into with respect to their views about vaccines, and recognize that many people labeled Anti-vaxxers are nothing of the kind. There are many quite rational people who willingly accept most vaccines, but believe that a specific vaccine is not appropriate for them based on any number of reasons ranging from vague intuition, anecdotal experience, social media interactions, or occasionally highly informed or even expert level knowledge and review of the scientific data. Then there are the people who generally accept the majority of recommended vaccines, but don’t receive them at the prescribed schedule, either because of some belief that the vaccines are safer when spread apart, or through complacency. Finally there is the group who believe that basically all vaccines are either un-needed or more dangerous than the disease they are designed to prevent. That tribe is the true Anti-vaxxers, and for the most part unreachable by discussion or persuasion—and terribly misguided. All of the forgoing of course applies only to people with simple access to vaccination.

A recent opinion piece in the New York Times by a New York City primary care doctor discusses the very low uptake (27% of eligible persons) of the currently recommended COVID booster, and her thoughtful approach to encouraging vaccination. The vast majority of the currently unvaccinated fall into the first group discussed above—they will take a vaccine if it makes sense to them, and that includes most recommended shots. 68% of the US population was fully vaccinated for COVID, but a lesser number took the 2022 fall booster, and many fewer again took this year’s booster. Pandemic fatigue is frequently blamed for this, but many of these same people willingly take their flu shot every year—why don’t they have Influenza fatigue? It’s not the go to red versus blue politicalization explanation. It’s not that these previously vaccinated people suddenly have been touched by social media anti-vaccine disinformation. Human beings make risk-benefit decisions all day long all the time; and currently it is just a fact that in aggregate people are viewing Covid risk, after multiple vaccinations, multiple rounds of infections despite vaccination, and observation that the majority of infections in normal risk individuals today result in just a cold, as a very low priority. Sometimes there is collective wisdom in human herd decisions, sometimes not; we have seen quite a few instances of the negative outcomes in recent years.

So how effective is this year’s fall booster, which you might have skipped? The CDC just answered that with a study published February 1 in MMWR. Over a 3 month period the vaccine was 57% effective in preventing symptomatic disease in the 18-49 yo. group and 46% for people over 50 yo. There are some caveats to keep in mind. The older people are, the less well they respond to the vaccine, so it’s reasonable to assume that the much older individuals in that wide age range of over 50 yo. will have less than 46% protection from symptomatic infection. The second caveat is the vaccine effectiveness drops dramatically after the first 60 days and that trend was observed with this booster dropping from 58% in the first two months to 49% in the third month, and it will continue to drop. The final point of interest is that this data was collected primarily in the time frame before JN.1 became the only COVID game in town, and subgroup analysis of small numbers of people shows the booster was less effective against JN.1 than the immediately preceding variants. The group at real risk for severe disease could improve their chances of not being among the 1500 still dying every week by taking the new booster— other data is clear on that issue.

https://www.cdc.gov/mmwr/volumes/73/wr/mm7304a2.htm?s_cid=mm7304a2_w

Perhaps group cognition is fairly accurate in this instance for the majority of the population who have passed on the booster. Would we have done better convincing the high risk elderly group to take the booster if the CDC had chosen to recommend it only for them, and concentrated the messaging efforts, like some of the European countries? I think so. Instead the CDC recommended it for everyone 6 months and older, and the perceived value in the general population is extremely low. Much has been made about the erosion of public confidence in Science and expert recommendations, and certainly a good deal of this is due to rampant mis-information, and conspiracy theories. On the other hand, it isn’t lost on lay people that one country’s government will recommend the vaccine for almost every living human, and other advanced, medically sophisticated countries will recommend it only for the elderly. Science educated folks can generally understand that many “recommendations” forming the basis for orders and mandates are simply best guesses based on current knowledge, and subject to revision based on new data. Many Public Health officials, politicians and media, utterly failed when they articulated these recommendations as the true Science which must not be questioned. People without extensive backgrounds in the scientific method were understandably dubious and incensed when down the road many of the pronouncements were shown to be false, or even worse based on the flimsiest of evidence. Preventing mis-information and conspiracy theories in a free society is difficult or impossible, and the people in charge of such adventures have already overstepped reasonable bounds, and been found at times to be entirely dictatorial and wrong. What should be possible is for Public Health figures and scientist-physicians to learn from the events of the Pandemic and have their communications make it immediately clear, what is a best guess based on little to no scientific data, and what recommendations are supported by strong evidence. As far as politicians and the media, I have no expectations of their ability to learn and modify behavior.

When people fail to vaccinate their children for serious childhood illnesses the following scenario plays out. Childhood vaccination rates declined during the Pandemic and have not sufficiently rebounded. The UK is currently experiencing a serious measles outbreak in the west Midlands, and there is great concern it may move to the large cities. The UK National Health Service reports that an astonishing 3.6 million children under the age of 16 are unvaccinated—this is a powder keg looking for a match. The WHO is describing an “alarming” 45 fold increase in measles across the EU in 2023 with 42,200 cases compared to 941 in all of 2022. The WHO estimates 1.8 million EU children missed their measles vaccination during 2020 through 2022, leading to 21,000 hospitalizations last year. Measles is a very serious disease with 1 death for every 500-1000 infections, and many more cases of severe morbidity from encephalitis, pneumonia, deafness and secondary bacterial infections.

I knew that as bored as you are with COVID, you were waiting with baited breath for follow up on Mpox (monkey pox—you knew I would supply the decode). The 2022 world wide outbreak of the virus which primarily afflicted the promiscuous male/male sex population receded nicely with vaccinations, and perhaps some modification of behavior, and then promptly faded from the general public consciousness. But the reality on the ground in Africa is that the largest ever epidemic of monkey pox is progressing without the fanfare that involvement of rich, jet setting, party animal, first worlders attracts. As you may recall, the outbreak of monkeypox which spread around the world was caused by the less severe clade 2 of virus, (which may have acquired some factor facilitating it’s sexual spread). The more virulent clade 1 of the virus is the pathogen that has circulated below the radar in the jungles of central Africa for many years. This iteration of the virus is primarily spread by nonsexual physical contact, and children are the most common victims. The epidemic in the Democratic Republic of Congo has continued to accelerate so that cases rose from 5,600 in 2022 to 14,600 last year and deaths increased from 213 to 900 in that year. If pre-symptomatic spread of this clade 1 is demonstrated, as was found during the recent epidemic of the clade 2 monkeypox virus, then it certainly could be problematic if it manages to spread out from central Africa. But it won’t be the next pandemic, that honor is almost certainly reserved for a virus with respiratory spread, an influenza A, corona virus, adenovirus, or unknown virus X—or perhaps a prion which insinuates itself into the food chain and has more general penetration into humans than Mad Cow Disease. Right now the cervids (deer, elk, moose) of North America are suffering from this type of molecular killer, Chronic Wasting Disease, which is 100% fatal after infection. The deer pictured below is not a Hollywood deer on Ozempic.

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