7 ms·

The paper is thoughtful. The reporting on it is reckless. An accurate headline would be: "Vaccine experts: Widespread booster mandates aren't needed now," or pe

by blagie 5y ago

The paper is thoughtful. The reporting on it is reckless. An accurate headline would be: "Vaccine experts: Widespread booster mandates aren't needed now," or perhaps "recommendations" There's a line between: * Mandatory. * Recommended. * Allowed. * Banned. If I am flying to do humanitarian work in Vietnam tomorrow, I absolutely need a booster shoot. Right now, the only way to get that is to go to a state which doesn't require ids for vaccines, and get a shot. The article discusses that boosters are clearly still appropriate in some circumstances: "Boosting could be appropriate for some individuals in whom the primary vaccination, defined here as the original one-dose or two-dose series of each vaccine, might not have induced adequate protection—eg, recipients of vaccines with low efficacy or those who are immunocompromised2 (although people who did not respond robustly to the primary vaccination might also not respond well to a booster)."

LurkingPenguin 5y ago
Why do you "absolutely" need a booster shot? Are you immunocompromised? How do you know what your level of protection currently is? Even if you did a test to look at your antibody titers, antibody titers aren't the end all and be all of immunity (think T-cells).
- blagie 5y ago
  Well, I'm not flying to Vietnam tomorrow, so I'm not claiming I personally need a booster shot. However: - Vietnam is an epicenter right now, so my odds of catching COVID would be high. - They are well beyond hospital capacity, so if I do have a serious case, it's uncertain I'll receive quality care (and if I do, I'm taking a bed from someone else) We don't have full data, so the right way to think about this is with expected outcomes based on best available data. Best available data, in this scenario, places the likely reduction of risks of COVID19 as a much greater risk reduction than any potential risk of vaccines: - We do have multiple studies about how immunity wanes over time from vaccination. Those provide better ground-truth data than theoretical arguments. - We also have some estimates of breakthrough rates, and severity of infection We don't have good data on long COVID post-vaccine, so that's a place we need to make an educated guess and rely on theoretical arguments. You can plug whatever sane numbers you want, but in this scenario -- humanitarian work in an epicenter with limited hospital capacity -- a booster shot makes sense. For other scenarios -- for example general population -- whether a booster makes sense is still often within the very large error bars of the limited data, and reasonable people can disagree, much as the authors of the Lancet article and the CDC currently do. Once more data rolls in, we'll know.
  - theptip 5y ago
    Mostly in agreement - I would note that the Lancet article gives a few arguments with citations as to why the vaccine efficacy decreases might be statistical artifacts, and so I think you may be a little over-confident on your bullet there. But I agree that there is data on both sides, and strongly agree with your general approach of accounting for the possibility that vaccine efficacy could be waning in your risk model and updating behavior accordingly.
  - LurkingPenguin 5y ago
    > We do have multiple studies about how immunity wanes over time from vaccination. Those provide better ground-truth data than theoretical arguments. I believe the studies you're referring to are those that address efficacy against symptomatic infection, not severe illness. Unless you're in a high-risk group because of age or comorbidities, with two doses of an mRNA vaccine within the past 8 months, to my knowledge all studies to date indicate that the average person's protection against severe illness and hospitalization is exceedingly high. This is probably related to the T and B cell immunity created by your body's response to the vaccines, which are more difficult to measure than antibody titers. I traveled to/from a hotzone in Asia at the beginning of the pandemic and from Asia to the US and back to get vaccinated. My opinion as an expat and avid traveler is that if you have any concerns about your ability to receive adequate care in the case that you get sick, you should reconsider travel at this time. Since the vaccines clearly do not provide sterilizing immunity and everyone's immune response is different, there really are no guarantees, especially if you're going to be in environments where your exposure is high (both in terms of number of contacts and contacts that could lead to exposure of high viral loads).
    - paulmd 5y ago
      This is my clear (amateur) conclusion as well. The exposure amount and dose varies, exposure in high-density hot zones is high risk and the cumulative dose does seem to pose some additional risk, as does the risk that you may not be able to receive a high level of clinical care in various areas. I'm not necessarily talking about adventures in southeast asia there either.
    - 5y ago
mzrk 5y ago
> If I am flying to do humanitarian work in Vietnam tomorrow, I absolutely need a booster shoot. You are saying that like its a shot of espresso... What is yourthough process to think that is good idea to take N-shots of vaccine that clearly is not working as it was prommised... I dont remember any1 talking about 3 dose in Jan/Feb. Narration was you take 1 shot of J&J or 2 Pfizer or other
mercy_dude 5y ago
> “ recipients of vaccines with low efficacy or those who are immunocompromised2 (although people who did not respond robustly to the primary vaccination” How do we measure it? Like is there a way to know through antibody tests?
- exhilaration 5y ago
  If you want to know whether you need the booster or not, and you're in the US, the spike antibody test ("COVID-19 Blood Spike Protein AB") falls under Covid testing, so if you have insurance it's covered with no out of pocket expense. You can get it at most urgent care clinics, and then you can find out exactly what your antibody levels are. I got my Moderna 2nd shot in February and my antibody levels are 1483 (out of 2500) so I am satisfied and not in any hurry to get the booster.
  - LurkingPenguin 5y ago
    1. Determining how much real-world protection you have against infection, hospitalization and death is a lot more complex than antibody titers. Everybody is different, every infection is different and even in the healthy population, everyone's immune response to the vaccine will be somewhat different. My understanding is that it's entirely possible a person with antibody levels lower than yours might be at lower risk than you in the real world because of their health compared to yours, the strength of their immune system compared to yours, etc. 2. Antibodies are only one part of the immunity equation. In the long run, T and B cells are probably just as important if not more important than antibodies. This is another area where it's reasonable to expect that YMWV when you get vaccinated. 3. My understanding is that in the context of vaccines these tests are used primarily to assess whether an individual had an immune response to the vaccines, not to make a meaningful determination of how much protection they have (because there's no "formula" for this). 4. It appears from the Delta-related data that any relationship between antibody titers and risk is influenced by variants. 5. We shouldn't rule out environmental factors in the protection equation. For example, if you work in an environment where you're exposed to high viral loads on a regular basis, it seems possible that you could be at higher risk than somebody who isn't even if you have higher antibody titers.
MomoXenosaga 5y ago
Not all reporting there are good journalists out there. Headline from RTL: Gezondheidsraad: derde prik alleen zinvol voor mensen met afweerstoornis Listen to the experts, write down what they say. Basic journalism.
emn13 5y ago
The most important trend (IMHO) they point out is that effectiveness vs. severe disease does not drop or barely drops. They claim: To date, none of these studies has provided credible evidence of substantially declining protection against severe disease, even when there appear to be declines over time in vaccine efficacy against symptomatic disease. However, the graph they provide doesn't seem to be based on data that appears reasonably chosen (that could be my limitaiton, sure). They refer to appendices (which are here: https://www.thelancet.com/cms/10.1016/S0140-6736(21)02046-8/attachment/7bf05be1-6ccd-406c-a3a7-300cdf0eeb66/mmc1.pdf https://www.thelancet.com/cms/10.1016/S0140-6736(21)02046-8/...), and specifically table S4 appears to be the basis for their graph D. In it, they split same-paper sources into early vs. late effectiveness with respect to hospitalization. Four sources are relevant. - #5: Health IM of. Two dose vaccination data. 2021. 2021 - I can't find this source. - #41 https://pubmed.ncbi.nlm.nih.gov/34401884/ https://pubmed.ncbi.nlm.nih.gov/34401884/ - ...but this paper has huge error bars and additionally the average effectiveness jumps up and down just to underline that the source not only claims to be noisy but appears to be so too. There's just not enough clean data here for any conclusion (wrt to a declining efficacy vs. severe disease). - #42 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8389393/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8389393/ - this paper seems to have solid data, but it simply doesn't include data on when people were vaccinated, and it uses definitions like this: "Hospitalizations among persons with breakthrough infection were defined as new hospital admissions among persons fully vaccinated on the reporting day." - in other words, a mixture of people that are vaccine-protected, and those that have had the jab but not the time to become protected. And the paper does not track how long ago people were vaccinated - so how does the lancet article then try to split this into early vs. late groups? Presumably by calendar date, which I don't think is reasonable; at least not reasonable enough. - #43 https://www.medrxiv.org/content/10.1101/2021.08.24.21262423v1.full.pdf https://www.medrxiv.org/content/10.1101/2021.08.24.21262423v... - and I'm just going to believe they copied the results correctly, but notably that paper concludes: "The efficacy of the vaccine against severe disease for the 60+ age group also decreases; from 91% to 86% between those vaccinated four months to those vaccinated six months before the study. The corresponding efficacies for the 40-59 age group are 98% and 94%. Thus, the vaccine seems to be highly effective even after six months compared to the unvaccinated population, but its effectiveness is significantly lower than it was closer to the vaccination date." So when they say this: "Given the data gaps, any wide deployment of boosters should be accompanied by a plan to gather reliable data about how well they are working and how safe they are. Their effectiveness and safety could, in some populations, be assessed most reliably during deployment via extremely large-scale randomisation,17 preferably of individuals rather than of groups." - that makes sense; I can understand that. But this on the other hand: "To date, none of these studies has provided credible evidence of substantially declining protection against severe disease, even when there appear to be declines over time in vaccine efficacy against symptomatic disease." - seems to be contradicted by their own sources. Given the data they themselves cite and in addition the many more sources demonstrating that protection from infection wanes (not just antibody levels), it seems implausible to assume that protection from severe disease won't wane significantly as well, even if they're right in saying we don't know for certain or by how much. However, even the waning already demonstrated in the #43 data set represents approximately a 50% increase in the number of hospitalizations and an increase in transmissibility after less than 8 months. Saying it's "still very high" is surely true, but the way they paint boosters as somehow plausibly unnecessary smells like motivated reasoning to me. They clearly make the case for greater third world vaccination; as an ethical argument that makes sense. But the claim that boosters likely won't be useful strikes me as being a little creative with their sources. Furthermore, while the article goes to great lengths to question the utility of booster shots, it does not similarly make the case that avoiding booster shots will actually materially increase vaccinations elsewhere. And while that seems plausible at first glance, there are also reasons to think that's not really true: e.g. are the boosters going to be diverted from production or will they simply be usage of already distributed shots that weren't taken up by the vaccine hesitant (which could be logistically impossible to redistribute in time)? How many people will be both eligible and willing to take a booster, and how does that compare to the number of exported doses - it might not amount to much? Is the timing of the boosters early enough that there will still be a significant export crunch? Is there really a tradeoff here at all, or will by the time boosters are used in significant numbers (say 100 million) other production be ample too? I don't think the article really makes a very thoughtful case, at all. It doesn't really support the notion that boosters will impact supply elsewhere by the time they're deployed, and it's claiming evidence supporting booster utility is slim, but it's not quite as slim as they make out, and again - by the time boosters are widely used, if the evidence we do have so far continues to build in that vein - there will be ample evidence then. Sure, there is a plausible future in which boosters have unexpectedly low utility, yet high uptake, and are mostly doses from new production as opposed to older, already locally distributed doses, all while third-world vaccination remains highly supply constrained. That's a future to avoid. But the paper doesn't make the case it's a likely future, nor even that it'd be hard to see it coming and thus needs action today.
neximo64 5y ago
Not quite sure why you absolutely need the booster shot, could you explain more there? Is that personal preference. Having both almost entirely eliminates the risk of hospitalisation from the other strains.
- causi 5y ago
  People who got vaccinated five or six months ago are seeing their immunity rate drop to around eighty percent. That's double the risk compared to a fresh vaccination.
  - standardUser 5y ago
    Studies have primarily observed a modest decline in effectiveness among older people and the immunocompromised, which is why some jurisdictions have recommended boosters for these people (Israel, California). There is a reason boosters have not been approved anywhere for the general population, and that is because so far the data does not indicate they are necessary.
    - causi 5y ago
      Necessary and useful are two vastly different things. My state is throwing expired vaccine into the garbage. I'd take a booster even if it only made me five percent safer.
      - shotta 5y ago
        The meme of people sticking themselves with every needle they can get ahold of is real? I think this is a bad idea, to make this booster decision on your own. Talk to your doctor first.
        causi 5y ago
        I never said I was making a booster decision on my own. I said I'd be willing to accept a booster shot even if it only somewhat increased my immunity.

by blagie 5y ago

LurkingPenguin 5y ago

Why do you "absolutely" need a booster shot? Are you immunocompromised? How do you know what your level of protection currently is? Even if you did a test to look at your antibody titers, antibody titers aren't the end all and be all of immunity (think T-cells).

blagie 5y ago
Well, I'm not flying to Vietnam tomorrow, so I'm not claiming I personally need a booster shot. However: - Vietnam is an epicenter right now, so my odds of catching COVID would be high. - They are well beyond hospital capacity, so if I do have a serious case, it's uncertain I'll receive quality care (and if I do, I'm taking a bed from someone else) We don't have full data, so the right way to think about this is with expected outcomes based on best available data. Best available data, in this scenario, places the likely reduction of risks of COVID19 as a much greater risk reduction than any potential risk of vaccines: - We do have multiple studies about how immunity wanes over time from vaccination. Those provide better ground-truth data than theoretical arguments. - We also have some estimates of breakthrough rates, and severity of infection We don't have good data on long COVID post-vaccine, so that's a place we need to make an educated guess and rely on theoretical arguments. You can plug whatever sane numbers you want, but in this scenario -- humanitarian work in an epicenter with limited hospital capacity -- a booster shot makes sense. For other scenarios -- for example general population -- whether a booster makes sense is still often within the very large error bars of the limited data, and reasonable people can disagree, much as the authors of the Lancet article and the CDC currently do. Once more data rolls in, we'll know.
- theptip 5y ago
  Mostly in agreement - I would note that the Lancet article gives a few arguments with citations as to why the vaccine efficacy decreases might be statistical artifacts, and so I think you may be a little over-confident on your bullet there. But I agree that there is data on both sides, and strongly agree with your general approach of accounting for the possibility that vaccine efficacy could be waning in your risk model and updating behavior accordingly.
- LurkingPenguin 5y ago
  > We do have multiple studies about how immunity wanes over time from vaccination. Those provide better ground-truth data than theoretical arguments. I believe the studies you're referring to are those that address efficacy against symptomatic infection, not severe illness. Unless you're in a high-risk group because of age or comorbidities, with two doses of an mRNA vaccine within the past 8 months, to my knowledge all studies to date indicate that the average person's protection against severe illness and hospitalization is exceedingly high. This is probably related to the T and B cell immunity created by your body's response to the vaccines, which are more difficult to measure than antibody titers. I traveled to/from a hotzone in Asia at the beginning of the pandemic and from Asia to the US and back to get vaccinated. My opinion as an expat and avid traveler is that if you have any concerns about your ability to receive adequate care in the case that you get sick, you should reconsider travel at this time. Since the vaccines clearly do not provide sterilizing immunity and everyone's immune response is different, there really are no guarantees, especially if you're going to be in environments where your exposure is high (both in terms of number of contacts and contacts that could lead to exposure of high viral loads).
  - paulmd 5y ago
    This is my clear (amateur) conclusion as well. The exposure amount and dose varies, exposure in high-density hot zones is high risk and the cumulative dose does seem to pose some additional risk, as does the risk that you may not be able to receive a high level of clinical care in various areas. I'm not necessarily talking about adventures in southeast asia there either.
  - 5y ago

mzrk 5y ago

> If I am flying to do humanitarian work in Vietnam tomorrow, I absolutely need a booster shoot. You are saying that like its a shot of espresso... What is yourthough process to think that is good idea to take N-shots of vaccine that clearly is not working as it was prommised... I dont remember any1 talking about 3 dose in Jan/Feb. Narration was you take 1 shot of J&J or 2 Pfizer or other

mercy_dude 5y ago

> “ recipients of vaccines with low efficacy or those who are immunocompromised2 (although people who did not respond robustly to the primary vaccination” How do we measure it? Like is there a way to know through antibody tests?

exhilaration 5y ago
If you want to know whether you need the booster or not, and you're in the US, the spike antibody test ("COVID-19 Blood Spike Protein AB") falls under Covid testing, so if you have insurance it's covered with no out of pocket expense. You can get it at most urgent care clinics, and then you can find out exactly what your antibody levels are. I got my Moderna 2nd shot in February and my antibody levels are 1483 (out of 2500) so I am satisfied and not in any hurry to get the booster.
- LurkingPenguin 5y ago
  1. Determining how much real-world protection you have against infection, hospitalization and death is a lot more complex than antibody titers. Everybody is different, every infection is different and even in the healthy population, everyone's immune response to the vaccine will be somewhat different. My understanding is that it's entirely possible a person with antibody levels lower than yours might be at lower risk than you in the real world because of their health compared to yours, the strength of their immune system compared to yours, etc. 2. Antibodies are only one part of the immunity equation. In the long run, T and B cells are probably just as important if not more important than antibodies. This is another area where it's reasonable to expect that YMWV when you get vaccinated. 3. My understanding is that in the context of vaccines these tests are used primarily to assess whether an individual had an immune response to the vaccines, not to make a meaningful determination of how much protection they have (because there's no "formula" for this). 4. It appears from the Delta-related data that any relationship between antibody titers and risk is influenced by variants. 5. We shouldn't rule out environmental factors in the protection equation. For example, if you work in an environment where you're exposed to high viral loads on a regular basis, it seems possible that you could be at higher risk than somebody who isn't even if you have higher antibody titers.

MomoXenosaga 5y ago

Not all reporting there are good journalists out there. Headline from RTL: Gezondheidsraad: derde prik alleen zinvol voor mensen met afweerstoornis Listen to the experts, write down what they say. Basic journalism.

emn13 5y ago

The most important trend (IMHO) they point out is that effectiveness vs. severe disease does not drop or barely drops. They claim: To date, none of these studies has provided credible evidence of substantially declining protection against severe disease, even when there appear to be declines over time in vaccine efficacy against symptomatic disease. However, the graph they provide doesn't seem to be based on data that appears reasonably chosen (that could be my limitaiton, sure). They refer to appendices (which are here: https://www.thelancet.com/cms/10.1016/S0140-6736(21)02046-8/attachment/7bf05be1-6ccd-406c-a3a7-300cdf0eeb66/mmc1.pdf https://www.thelancet.com/cms/10.1016/S0140-6736(21)02046-8/...), and specifically table S4 appears to be the basis for their graph D. In it, they split same-paper sources into early vs. late effectiveness with respect to hospitalization. Four sources are relevant. - #5: Health IM of. Two dose vaccination data. 2021. 2021 - I can't find this source. - #41 https://pubmed.ncbi.nlm.nih.gov/34401884/ https://pubmed.ncbi.nlm.nih.gov/34401884/ - ...but this paper has huge error bars and additionally the average effectiveness jumps up and down just to underline that the source not only claims to be noisy but appears to be so too. There's just not enough clean data here for any conclusion (wrt to a declining efficacy vs. severe disease). - #42 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8389393/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8389393/ - this paper seems to have solid data, but it simply doesn't include data on when people were vaccinated, and it uses definitions like this: "Hospitalizations among persons with breakthrough infection were defined as new hospital admissions among persons fully vaccinated on the reporting day." - in other words, a mixture of people that are vaccine-protected, and those that have had the jab but not the time to become protected. And the paper does not track how long ago people were vaccinated - so how does the lancet article then try to split this into early vs. late groups? Presumably by calendar date, which I don't think is reasonable; at least not reasonable enough. - #43 https://www.medrxiv.org/content/10.1101/2021.08.24.21262423v1.full.pdf https://www.medrxiv.org/content/10.1101/2021.08.24.21262423v... - and I'm just going to believe they copied the results correctly, but notably that paper concludes: "The efficacy of the vaccine against severe disease for the 60+ age group also decreases; from 91% to 86% between those vaccinated four months to those vaccinated six months before the study. The corresponding efficacies for the 40-59 age group are 98% and 94%. Thus, the vaccine seems to be highly effective even after six months compared to the unvaccinated population, but its effectiveness is significantly lower than it was closer to the vaccination date." So when they say this: "Given the data gaps, any wide deployment of boosters should be accompanied by a plan to gather reliable data about how well they are working and how safe they are. Their effectiveness and safety could, in some populations, be assessed most reliably during deployment via extremely large-scale randomisation,17 preferably of individuals rather than of groups." - that makes sense; I can understand that. But this on the other hand: "To date, none of these studies has provided credible evidence of substantially declining protection against severe disease, even when there appear to be declines over time in vaccine efficacy against symptomatic disease." - seems to be contradicted by their own sources. Given the data they themselves cite and in addition the many more sources demonstrating that protection from infection wanes (not just antibody levels), it seems implausible to assume that protection from severe disease won't wane significantly as well, even if they're right in saying we don't know for certain or by how much. However, even the waning already demonstrated in the #43 data set represents approximately a 50% increase in the number of hospitalizations and an increase in transmissibility after less than 8 months. Saying it's "still very high" is surely true, but the way they paint boosters as somehow plausibly unnecessary smells like motivated reasoning to me. They clearly make the case for greater third world vaccination; as an ethical argument that makes sense. But the claim that boosters likely won't be useful strikes me as being a little creative with their sources. Furthermore, while the article goes to great lengths to question the utility of booster shots, it does not similarly make the case that avoiding booster shots will actually materially increase vaccinations elsewhere. And while that seems plausible at first glance, there are also reasons to think that's not really true: e.g. are the boosters going to be diverted from production or will they simply be usage of already distributed shots that weren't taken up by the vaccine hesitant (which could be logistically impossible to redistribute in time)? How many people will be both eligible and willing to take a booster, and how does that compare to the number of exported doses - it might not amount to much? Is the timing of the boosters early enough that there will still be a significant export crunch? Is there really a tradeoff here at all, or will by the time boosters are used in significant numbers (say 100 million) other production be ample too? I don't think the article really makes a very thoughtful case, at all. It doesn't really support the notion that boosters will impact supply elsewhere by the time they're deployed, and it's claiming evidence supporting booster utility is slim, but it's not quite as slim as they make out, and again - by the time boosters are widely used, if the evidence we do have so far continues to build in that vein - there will be ample evidence then. Sure, there is a plausible future in which boosters have unexpectedly low utility, yet high uptake, and are mostly doses from new production as opposed to older, already locally distributed doses, all while third-world vaccination remains highly supply constrained. That's a future to avoid. But the paper doesn't make the case it's a likely future, nor even that it'd be hard to see it coming and thus needs action today.

neximo64 5y ago

Not quite sure why you absolutely need the booster shot, could you explain more there? Is that personal preference. Having both almost entirely eliminates the risk of hospitalisation from the other strains.

causi 5y ago
People who got vaccinated five or six months ago are seeing their immunity rate drop to around eighty percent. That's double the risk compared to a fresh vaccination.
- standardUser 5y ago
  Studies have primarily observed a modest decline in effectiveness among older people and the immunocompromised, which is why some jurisdictions have recommended boosters for these people (Israel, California). There is a reason boosters have not been approved anywhere for the general population, and that is because so far the data does not indicate they are necessary.
  - causi 5y ago
    Necessary and useful are two vastly different things. My state is throwing expired vaccine into the garbage. I'd take a booster even if it only made me five percent safer.
    - shotta 5y ago
      The meme of people sticking themselves with every needle they can get ahold of is real? I think this is a bad idea, to make this booster decision on your own. Talk to your doctor first.
      - causi 5y ago
        I never said I was making a booster decision on my own. I said I'd be willing to accept a booster shot even if it only somewhat increased my immunity.