Europe's pause on the AstraZeneca COVID vaccine plays right into anti-vaxxers' hands

Last week, more than a dozen European countries suspended the AstraZeneca Covid-19 vaccine. They claimed it was out of an excess of caution, but instead they played right into the hands of those who continue to spread anti-vaccine misinformation.

On Thursday, the European Medicines Agency announced that there was nothing to worry about, that the AstraZeneca vaccine was safe, and that all countries should resume using it.

Too late, I fear. The harm has already been done.

I’ve been fighting the anti-vax movement for years, as have many other scientists, doctors, and science bloggers. We’ve seen their strategies, and they don’t play fair. They don’t care about facts, and they love to scare people. This latest incident gives them plenty of fodder.

First let’s talk about the “fear” part. A very, very small number of cases were reported in which people had blood clots soon after getting the vaccine. This sounds scary.

But wait a minute. We are giving the vaccine to millions of people. If you look at a group that large, how many of them will have blood clots in a given week? The answer, not surprisingly, is greater than zero.

So the first thing that public health authorities should have asked is, obviously, are we seeing more blood clots than expected? But no, they didn’t do that. Instead, out of an excess of caution (so they claimed), they halted the AstraZeneca vaccine while they investigated. This meant that literally millions of vaccine doses were not administered.

Fortunately the investigation took only a few days. What did they find? Well, here’s the answer, directly from the European Medicines Agency itself:

“the number of thromboembolic events reported after vaccination ... was lower than that expected in the general population.”

In other words, the vaccine clearly doesn’t cause blood clots. If anything, it might even prevent blood clots, because the number observed was lower than expected. (No one is claiming that it actually prevents blood clots; I’m just pointing out how wrong the decision to halt the vaccine was.)

Now the unfounded fear of vaccine-induced blood clots has spread through Europe and beyond. You can’t “unsay” something like this, and anti-vax websites and social media groups are already using it to scare more people. (I won’t link to any of them because I don’t want to give them the traffic.) Indeed, several northern European countries still haven’t resumed use of the vaccine, and Germany, France, and Italy are including a warning (an incorrect one) that the vaccine might cause blood clots. This is just wrong.

Halting the AstraZeneca vaccine without doing some very basic number-checking was a huge blunder. Let’s just hope this decision doesn’t cost too many lives.

We've totally crushed the flu virus this year

 As awful as the Covid-19 pandemic is, it’s given us at least one benefit: we’ve utterly crushed the flu virus.

That’s right–the flu has almost completely disappeared this year. A combination of social distancing, closed schools and businesses, dramatically reduced travel, and high flu vaccination rates has achieved something that most flu experts never thought possible.

Flu levels are so low, in fact, that one has to wonder if the flu will even come back next year. The levels now are far lower than we’ve ever seen in modern history. Let’s take a look at the numbers:

nfluenza cases reported to the CDC by US public health laboratories, 2020-2021 season. Data from the CDC, graph created by the author.

As you can see here, the very worst week had just 24 confirmed cases in the entire U.S. That is truly astonishing. And in 2021 so far, we’ve had 5 or fewer cases in the entire country each week. Basically, the flu is gone. To see how dramatic this is, let’s look at data from last year (the winter of 2019-2020), which was a typical flu season:

Influenza cases reported to the CDC by US public health laboratories, 2019-2020, season. Data from the CDC, graph created by the author.

As you can see above, the U.S. had about 3,000 cases per week in January and February of 2020, with a peak at nearly 4,000 cases.

The rate of influenza this year is over 100 times lower than it’s ever been. Why did this happen? It’s obvious: all of the precautions we’re taking to reduce the spread of Covid-19 have worked wonders to prevent the flu as well. In fact, they’ve worked far better for influenza than for the Covid-19 virus.

No one knows what the flu season will look like next year, but for now, at least we’ve won a clear victory against the influenza virus. That’s a bit of good news.

RNA vaccines have arrived. Let's starting making them for influenza, right now.

The race to end the Covid-19 pandemic will be won by vaccines. We now have at least four approved vaccines, and the first two–the fastest to be developed and approved–were both RNA vaccines, a new technology that has never before been used on a large scale.

As I’ve written before, these RNA vaccines are a scientific triumph. Both the Moderna vaccine and the Pfizer/BioNTech vaccine are 95% effective against the virus. Both were developed in a matter of days–days!–after the genome sequence of the Covid-19 virus, SARS-CoV-2, was first revealed.

Now that we know that RNA vaccines work, what’s stopping us from designing and deploying this technology for many other infections that we don’t yet have under control? Simply put: nothing. We just need to have the will to do it, and it will happen. By which I mean, we need the government to pay for it.

Once Covid-19 fades, as it will, we’ll still have to deal with influenza, which sweeps through the population every year, often mutating significantly from the previous year. That’s why we need a new flu vaccine every year: the flu itself mutates to escape the protection we have from last year’s vaccine.

(Aside: we’re in the midst of the mildest flu season in decades, perhaps ever, thanks to the Covid-19 restrictions. The CDC reports fewer than 100 confirmed cases of influenza in the entire country, at a time when we’d usually be seeing thousands of cases per week.)

RNA vaccines are remarkably easy to design, and they’re much cheaper than conventional vaccines too. We should be thinking about making them for a raft of illnesses now: not just flu, but malaria, HIV, and others. But let’s start with the flu.

We already know that we need a new flu vaccine every year, so here’s a not-so-radical proposal: let’s create an RNA vaccine for the flu, right now, paid for by the government. It’s almost certain to work, and it will likely work far better than the current vaccine. Here’s why.

For the current flu vaccines, we create a new vaccine every year based on what’s currently circulating among humans. For the Northern hemisphere, we choose the vaccine strain right around now (late January or early February), because it takes 6 months to prepare the vaccine for the following fall.

The flu vaccine production uses a crude, decades-old process. After choosing a vaccine strain, the manufacturers (GlaxoSmithKline is one) isolate the virus and then inject it into chicken eggs, where they let it grow for 4-5 days. The virus is then extracted from the eggs, killed, and stuck into a syringe. That’s basically it. (This is why people who have egg allergies are sometimes warned not to get the flu vaccine.)

There are loads of problems with this process. First, it often turns out (and this is not widely known) that the first choice for a vaccine strain doesn’t grow well in eggs. In those years, the manufacturers move on to a second, third, or fourth choice, until they find one that grows in chicken eggs. These inferior choices, in turn, lead to vaccines that are less effective at conferring immunity.

Second, the process requires huge, messy chicken farms, which means it is slow and costly. Third, even though the virus is a killed virus, there’s always a small chance that some live virus will survive and infect people.

RNA vaccines, in contrast, can be manufactured precisely to match the virus that you wish to target. There’s no need to grow it in chicken eggs. And it’s far cheaper to make. In addition, you only need a fragment of a virus to make the vaccine, so there’s zero chance that anyone can ever be infected from the vaccine. And we know exactly what to target on the influenza virus: the hemagluttinin and neuraminadase proteins that cover the surface of the virus.

If RNA vaccines are so good, one could argue, why not allow the free market to produce them? Because it just won’t happen: the flu vaccine is not very profitable, and getting an entirely new vaccine approved is very expensive. Private companies just aren’t going to do it; on the contrary, several past flu vaccine manufacturers dropped out of the business because it just wasn’t profitable.

(Interesting story: about 15 years ago, I attended a talk by Anthony Fauci about influenza. At the time, I was leading a large-scale effort to sequence thousands of influenza viruses, a project that continues to this day and that is run by Dr. Fauci’s institute, NIAID. At the end of his talk, I asked Dr. Fauci why the NIH itself couldn’t sponsor flu vaccine development. He answered that it just wasn’t done that way–that NIH handled the basic research, but left vaccine development to industry. Well, Covid-19 has changed all that.)

We don’t have to create a new government-run facility to make the vaccines in order for this to work. Instead, we can do exactly what we did for Covid-19: pre-purchase a large supply of RNA-based flu vaccines, and provide generous funding to pay for the vaccine development and testing. Then companies like Moderna and Pfizer will have proper incentives to use their technology on influenza.

The health benefits of new, better vaccines are far too important to leave this to private companies, who are motivated more by profits than by an interest in public health. Let’s use the scientific success of RNA vaccines to change the way vaccine development works in a big way. We can save untold numbers of lives if we do.

Should we pay people to get vaccinated? Well, maybe.

This past week, a major US retail company, Dollar General, announced that it would pay its employees the equivalent of four hours’ salary if they would get the Covid-19 vaccine. That’s about $40, based on the average pay at Dollar General. The idea is to give employees an additional incentive, and also to cover the time they might need to take off work to get vaccinated.

This is an excellent idea. Let me explain why.

First, though, I should point out that several prominent economists, including Harvard’s Gregory Mankiw and the Brooking Institution’s Robert Litan, have already proposed paying people to be vaccinated–but their proposal is, frankly, terrible. So let’s start with that.

Now that we have two vaccines, from Moderna and Pfizer/BioNTech, with more on the way, we can finally see an end to this awful pandemic. At the moment we have a supply problem: there aren’t enough vaccines to go around. But soon, perhaps in a few months, we’ll have plenty of vaccines. Then the problem becomes getting enough people vaccinated to create “herd immunity.”

(Aside: herd immunity has been discussed ad nauseum this year, so I won’t get into any details, but it essentially refers to the situation where so many people are immune to the virus that it doesn’t spread any more. We probably need 60% of the population to be immune (estimates vary) in order to reach herd immunity.)

A well-informed person might think this won’t be a problem: billions of people are desperate to get the vaccine right now. But the anti-vaccination movement has been spreading misinformation about Covid-19 vaccines since the beginning of the pandemic, long before we even had a vaccine. (Yes, I know it’s patently ridiculous to make claims about a non-existent vaccine, but they did, aplenty. I’m not linking to any of their claims here because I don’t want to give them the traffic.)

As a result of the relentless anti-vax propaganda campaign, a substantial portion of the population is at least “vaccine hesitant,” meaning they’re not sure if they want the vaccine. They are worried primarily about safety, even though the data is very clear that these vaccines are remarkably safe. (It’s true that a tiny number of people have had allergic reactions, but this data is public and no one’s hiding it.)

So we need to convince some people that it’s in their own best interests to get vaccinated. A small number of deeply confused anti-vaxxers, such as the people behind the mis-named NVIC, are probably unreachable. They simply won’t listen, preferring to believe their own misinformation and conspiracy theories. But for the large number of people who are merely hesitant, a positive incentive might be just the thing to convince them to get vaccinated.

Enter the economists. Robert Litan first proposed paying people to take the vaccine back in August, and Gregory Mankiw strongly endorsed the idea, writing:

“what’s the best way to achieve herd immunity? Again, simple: Once a vaccine is approved, pay people to take it.”

Such confidence! Actually it’s quite a good idea in principle. But Litan and Mankiw then went off the rails, proposing that we pay everyone $1000 each to get the shot. Litan admitted that he didn’t have any data to support this particular amount, but he called it a “strong hunch.”

That’s a $300 billion program. Neither Litan nor Mankiw was bothered by this.

There are some gigantic problems with this proposal. First, because it’s such an enormous amount, it’s extremely unlikely that it will ever happen. It’s just the kind of hypothetical, pie-in-the-sky proposal that gives academics a bad name. Because it will never happen, Litan and Mankiw will never have their idea tested in real life, and no doubt they will continue to claim it would have worked.

Second, though, is a much bigger problem, as pointed out by economists George Loewenstein and Cynthia Cryder in the New York Times, and by medical ethicists Emily Largent and Franklin Miller in JAMA. The problem is that if you offer to pay a lot of money to do something, then people conclude “this is something you would not want to do without compensation.” In other words, it’s dangerous or somehow bad.

Thus a large payment may merely heighten people’s suspicions that the government (or “Big Pharma”) is up to no good, and that’s why they have to bribe people to take their suggestions. The last thing we need right now is to increase people’s mistrust of vaccines.

In addition, paying so much money for each shot is, as Largent and Miller point out, a bad investment. Sure, $300 billion is much less than Covid-19 is costing us right now, but it’s still a huge sum, and those funds could be better spent on many other things, such as helping to support states that are still struggling to set up facilities to administer the vaccine.

Now let’s go back to the Dollar General plan. Dollar General is paying the equivalent of four hours’ worth of salary, about $40 on average, to each employee who gets vaccinated. As I said above, this is an excellent idea.

Why is this better than the $1000 per person plan from the economists? First of all, it costs far, far less than the economists’ plan, which makes it far more likely to happen. Second, Dollar General is paying people to defray the actual costs–in time–that they will incur in order to get the vaccine. So it’s not so much a bribe as it is a modest reimbursement. Third, by providing a modest payment, they provide a relatively bigger incentive to low-income groups, and they avoid paying billions of dollars to high-income people who are already highly motivated to get the vaccine.

I suggest we adopt a version of Dollar General’s plan for the entire U.S. population. Why not offer a cash payment of $20 to everyone who gets the vaccine, and pay it immediately? Obviously there would be some logistical challenges to this–we’d need security procedures to make sure the $20 payments were actually handed out and not stolen–but it would be far simpler than arranging the $1000 payments so blithely proposed by the academic economists. And it would only cost $6 billion rather than $300 billion.

A payment of $20 provides a small positive incentive, and it can be justified as paying people for the time they spend getting the shot. Because it won’t seem like a bribe, it will be much less likely to raise suspicions that the vaccine is harmful (which it isn’t, I hasten to add).

So Litan and Mankiw were sort of right: paying people might encourage more people to get vaccinated. But they’re wildly wrong about the size of the payment, which other economists and bioethicists have pointed out would likely create distrust. Dollar General is getting it right: let’s offer everyone a small cash payment if they’ll take the time to get the vaccine. It might just work.

A meditation on the year to come

A mountain in the Eiger valley, Switzerland.

So we've just experienced one of the hardest years in the past 50. The world is still reeling, but we have reasons to hope that our lives on this planet will get better–much, much better–in 2021. Entering the new year, I'm offering this brief meditation (a technique that I would have dismissed in years past, but that I've discovered during the pandemic) with my hopes for better times ahead. Vaccines will soon free us, at long last, from the prison of social distancing that the virus has imposed on the entire population. Emerging from our months of isolation, what will we do first? Next?

Let's imagine, as we meditate, that we will travel, as many of us desperately long to do. On a train, or a plane, or just in a car, finally going somewhere far away with a close companion, with no masks required. Viewing the sights, taking photos, eating at a crowded restaurant, or just walking through a shopping district filled with people. Enjoying the freedom that we took for granted for our whole lives, until the pandemic shut everything down in March of 2020. Sipping an Aperol spritz on a terrace with a scenic mountain view.

Everything we've lost will return again. Let's imagine, closing our eyes for a few moments, what we'll do once we get beyond these last months of the pandemic, once we are free again. Anything is possible, and the future will be better.

Closing the barn door after the virus has escaped

When will we learn? For the past two or three weeks, the world has been fretting over a new Covid-19 virus variant, one that UK Prime Minister Boris Johnson announced was significantly more transmissible than other variants.

Johnson’s announcement has led multiple other countries, including the U.S. and France, to temporarily ban travel from the UK. As scientists began testing for the new variant, at least 3 states in the US–California, Colorado, and Florida–have already reported that they are detecting the new variant too. Expect many more states (and other countries) to report finding the variant in the coming days.

In the UK, the new variant was first detected in September, and by November one-fourth of the cases in London were caused by this variant. That does seem worrisome.

My first reaction upon hearing of this new variant was to ask whether it really is more transmissible or not. The evidence is very preliminary, and it’s still not peer-reviewed, but a very new study from a week ago says that yes, the new variant is 56% more transmissible.

Okay then, that’s not great. But there’s no evidence that the new variant (known variously as B117 or VOC 202012/01) is more deadly, or that the vaccine won’t work against it. It just spreads faster.

My second reaction was about these new travel bans. Why would anyone think that the variant was only in the UK, merely because the UK was open about reporting it? Unless we really know that to be a fact, travel bans are a classic case, as the adage goes, of closing the barn door after the horse (the virus) has escaped.

So has the B117 virus has already spread well beyond the UK? Yes, it appears so.

In a new study released just two days ago on medRxiv, scientists at Helix, a company that has tested millions of samples for the presence of the SARS-CoV-2 virus, looked back at their testing data over the past several months. They found that evidence of the B117 virus in the US extends back at least to October. They also found that the variant is now spreading in the eastern US, in Massachusetts, Ohio, and Florida.

An important caveat is that Helix’s tests weren’t specifically looking for the B117 strain. They instead looked at two key deletions in the spike protein (which I’ve discussed before) that the B117 strain contains, and that their tests can also detect. It might be that they found slightly different strains that shared these deletions, but even if the strains they detected weren’t identical to B117, it’s possible they were equally infectious.

So yes, the new strain seems to be in the US already, and it seems that it’s been here since October. And if it’s been in the UK since September, and the US since October, well then it’s a darned good bet that it’s pretty much everywhere. Banning travel from the UK not only punishes the UK for openly sharing its findings, but it also may prevent other countries from sharing information about newer strains of the virus, should those emerge.

What should we do in response to the new strain? The most effective action will be to roll out vaccines even faster, something that public health authorities across the US are trying to do. So far it is not going well, in part because we have no consistent national strategy. It’s not too late to fix that.

But let’s not pretend that travel restrictions now will do anything to keep this new strain locked up. They’re just closing the barn door after the horse has escaped. Or “Vijgen na pasen” as they say in Flemish, or “arriver apr├Ęs la bataille” in French. There’s an idiom for this behavior in every language, it seems.

These new RNA vaccines are a triumph for science and medicine

This week the FDA approved a second vaccine against SARS-CoV-2, the virus that causes Covid-19. We now have two highly effective vaccines, one from BioNTech and Pfizer, and the other from Moderna. A third vaccine, from Oxford University and AstraZeneca, is very close to approval.

The two new vaccines, both based on RNA, are both remarkably effective. Below I’ll summarize some of the numbers, which have been published for the world to see.

This is a scientific triumph. Less than a year ago, no one outside China even knew this virus existed. The genome of the virus was first released in January, and within a few months scientists had designed the first vaccines. Clinical trials were launched immediately, and larger trials followed, leading us to where we are today: two new vaccines, tested and validated in tens of thousands of people, now being manufactured and shipped to billions.

For anyone who might be skeptical, or who just might want to know more, the test results are being published openly. The New England Journal of Medicine has a dedicated website with dozens of papers and audio summaries, including results from the large-scale (Phase 3) trials of the Pfizer vaccine.

Before getting into the numbers, let’s summarize what these two new vaccines are. (I wrote about this in July, if you want to read my previous explanation.) Both of them are RNA vaccines, which is itself a dramatic breakthrough. RNA vaccines have been discussed for years, but the technology was never employed for human vaccines until now.

Here’s how they work: our immune system (which is super-complicated, as Ed Yong explained in The Atlantic) recognizes microscopic invaders and destroys them. Once you’ve been infected with Covid-19, the immune system swarms over the viral particles and basically learns what they look like. SARS-CoV-2 has a protein all over its surface called “Spike,” so that’s what the immune system recognizes.

Once you’ve fought off the infection, the immune system remembers what Spike looks like. If you’re infected again, it can respond far more quickly, so you won’t get sick. This is what we call acquired immunity.

So for vaccines, the trick is to teach your immune system to recognize Spike. One way to do that is to manufacture lots and lots of the Spike protein, and put that in the vaccine (sort of–I’m greatly oversimplifying here).

But with modern genomics technology, we can use a different approach. Every cell in your body has machinery inside it to translate RNA into proteins. As soon as we had the SARS-CoV-2 genome, back in January, we knew the genetic code for Spike. So rather than make the protein, what if you just made the RNA, which is far easier and faster to manufacture, and injected that into people? Do our own cells then translate the RNA and make the Spike protein?

Well yes, they do. And not only that, but–as the Modern and Pfizer clinical trials have now proven–our immune system recognizes that the Spike protein is foreign (it’s complicated) and launches an attack.

So to make an effective RNA vaccine, you simply have to inject enough RNA so that the immune system responds. That’s what both the Modern and BioNTech/Pfizer vaccines have done.

Now let’s look at the numbers. As reported in NEJM just two weeks ago, the Phase 3 trail for the Pfizer vaccine tested 43,448 volunteers, of whom 21,720 got the vaccine and 21,728 got a placebo. At the time of the report, 162 people who received the placebo had become sick with Covid-19, but only 8 people in the vaccine group got sick. That’s a 95% reduction in illness, a remarkably good result. They also reported that 10 people had “severe” illness, and 9 of those ten were in the placebo group.

How about the Moderna vaccine? This vaccine has almost identical efficacy, published in a preliminary report a few weeks ago as 94.5%. Just a few days ago, an FDA review panel approved the vaccine and confirmed that its efficacy was above 94%. And the Modern vaccine doesn’t need the super-cold freezers that the Pfizer vaccine needs, which makes it easier to distribute.

Both vaccines have minimal side effects in most people, mostly soreness at the injection site, and sometimes headaches or chills, which subside within a day. RNA is quickly degraded in the body, so there’s no reason to expect any lingering side effects from these vaccines.

There’s also growing evidence that immunity lasts for many months, if not years. Another report in NEJM, on the Moderna vaccine, contains some of the latest data, which shows that immunity is still strong after 4 months. Of course, with a brand-new vaccine, we simply have to wait to see if the immunity lasts for years, but all signs are positive right now.

So yes, these are really good vaccines. I will get mine as soon as I can, although I expect I’ll have to wait several months because of short supply.

(The Oxford/AstraZeneca vaccine, a more traditional protein-based vaccine, has also shown positive results, either 62% or 90%, depending on the dosage regimen, but the 90% results are based on fewer cases. Even so, it is clearly effective and it should be approved soon, at least in the UK. So we might soon have 3 vaccines.)

A note to anti-vaxxers: no, you cannot catch Covid-19 from these vaccines. They don’t contain the virus! They only have a fragment of RNA from one protein, and the virus has RNA that encodes 28 other proteins. It’s simply impossible for the virus to self-assemble without the rest of its genome.

But hey, if you don’t want the vaccine, go to the back of the line. Most of the world is desperate for it.

The success of RNA vaccines is a huge win for science, but even more, it’s a huge win for the human population. We’re still many months away from vaccinating the whole world, but with two highly effective vaccines, we can finally have hope to end this pandemic.