H5N1

WHO: Global immunization efforts have saved at least 154 million lives over the past 50 years

WHO has published a news release: Global immunization efforts have saved at least 154 million lives over the past 50 years. Excerpt:

A major landmark study to be published by The Lancet reveals that global immunization efforts have saved an estimated 154 million lives – or the equivalent of 6 lives every minute of every year – over the past 50 years. The vast majority of lives saved – 101 million – were those of infants.  

The study, led by the World Health Organization (WHO), shows that immunization is the single greatest contribution of any health intervention to ensuring babies not only see their first birthdays but continue leading healthy lives into adulthood.  

Of the vaccines included in the study, the measles vaccination had the most significant impact on reducing infant mortality, accounting for 60% of the lives saved due to immunization. This vaccine will likely remain the top contributor to preventing deaths in the future.  

Over the past 50 years, vaccination against 14 diseases (diphtheria, Haemophilus influenzae type B, hepatitis B, Japanese encephalitis, measles, meningitis A, pertussis, invasive pneumococcal disease, polio, rotavirus, rubella, tetanus, tuberculosis, and yellow fever) has directly contributed to reducing infant deaths by 40% globally, and by more than 50% in the African Region.  

"Vaccines are among the most powerful inventions in history, making once-feared diseases preventable,” said WHO Director-General, Dr Tedros Adhanom Ghebreyesus. “Thanks to vaccines, smallpox has been eradicated, polio is on the brink, and with the more recent development of vaccines against diseases like malaria and cervical cancer, we are pushing back the frontiers of disease. With continued research, investment and collaboration, we can save millions more lives today and in the next 50 years.”  

The study found that for each life saved through immunization, an average of 66 years of full health were gained – with a total of 10.2 billion full health years gained over the five decades. As the result of vaccination against polio more than 20 million people are able to walk today who would otherwise have been paralysed, and the world is on the verge of eradicating polio, once and for all.  

These gains in childhood survival highlight the importance of protecting immunization progress in every country of the world and accelerating efforts to reach the 67 million children who missed out on one or more vaccines during the pandemic years.

The global community needs to do more to tackle the inequality crisis

Via The BMJ, an opinion piece by Sir Michael Marmot, Monica Geingos, and Joseph E. Stiglitz: The global community needs to do more to tackle the inequality crisis.

Progress on health inequalities is now at risk, argue Michael Marmot and colleagues, the chairs of a new Global Council on Inequality, AIDS, and Pandemics.

The climate emergency and the global rise in inequalities are putting us all at risk. Both will damage health. The global community, with successive climate change conferences (COPs), is taking faltering steps to tackle the climate emergency but is doing little about the inequality crisis. In some countries, political and economic forces are increasing social and economic inequalities, with potentially dire consequences for health inequalities and for people’s vulnerability to pandemics. Unfair distribution of power, money, and resources are driving inequalities in health. 

We’ve been through a good period. Global progress in improving health has been impressive throughout the 20th and early 21st centuries, and health inequalities between countries have diminished. Within countries, too, absolute inequalities in health have lessened, although that picture is more mixed.   

But this progress is now at risk. If the AIDS and covid-19 pandemics did nothing else, they showed how fragile these health improvements are. These pandemics have, to some extent, been driven by social and economic inequalities, and their effects have been to expose and exacerbate health inequalities. The effects of the pandemics have also been disproportionate in some communities and related to socioeconomic circumstances, gender, LGBTQ+ identities, and race and ethnicity.  

To deal with the effects of inequalities on pandemics and of pandemics on health inequalities, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has convened the Global Council on Inequality, AIDS, and Pandemics. We are the co-chairs of this global council. The announcement of the new council was made in Brazil at a meeting hosted by the Brazilian Ministry of Health. Our backgrounds as co-chairs are highly relevant to the council’s mission. We seek to bring the perspectives of international and national economic arrangements, social determinants of health, and human rights to bear on our central questions. The need is great as the following examples show.  

Analyses indicate that countries with greater income inequality have higher rates of HIV infection and of death from AIDS and covid-19. In most, but not all, African cities the urban poor are much more likely to live with HIV than those from higher socioeconomic groups.

HIV and AIDS have also exposed gender inequalities. In the west African countries of Cote d’Ivoire, Ghana, and Liberia, HIV prevalence in people aged 20-24 was five times higher in women than in men.

The unequal effect of the AIDS pandemic on men who have sex with men is a political choice. In Thailand, for example, where identifying as LGBTQ+ is not criminalised, the prevalence of HIV is 12 times higher among men who have sex with men than among other adults. In Malaysia, where identifying as LGBTQ+ is criminalised and subject to arrest, the HIV prevalence rate among men who have sex with men is more than 70 times higher than among other adults.

In Brazil, where racial inequalities were not openly acknowledged for a long time, the evidence of the effects of this on health inequalities is stark. Rates of new HIV infections have been falling among white people, while rising among black people.

The United States provides an important case study of the role of socioeconomic influences and racism on health, including during the covid-19 pandemic. Life expectancy had been falling in the years 2016-18, in part owing to deaths of despair, which show a social gradient—the fewer the years of education, the bigger the effect. The decline stopped, and life expectancy rose slightly in 2019, but then fell sharply in the first two years of the covid-19 pandemic. Covid mortality was higher among socioeconomically disadvantaged communities and black people. In New York City, in the first year of the pandemic, life expectancy fell by three years among white residents, 5.5 years among black residents, and six years among Hispanic residents.

The AIDS and covid-19 pandemics send two clear messages, and hopefully the global community is open to receiving them. The first is that inequalities drive the likelihood and consequences of pandemics, and pandemics amplify health inequalities. This is the problem that this global council is set up to tackle.

The second is that medical and technical responses are crucial but are only part of the story. Inequities in access to care are needless, harmful, and immoral, and should be relatively easy to solve. Could there have been a global rollout of covid vaccines, entailing higher levels of production? Most certainly. Technically, it should be possible in future pandemics to have the capacity to vaccinate the world as needed. The money is certainly there. In the first year of the covid-19 pandemic, the rich world found $18tn to protect the economies of high income countries. Against this amount, $25bn for a global rollout of the vaccine is coffee money. And the technology that would have made it even easier to rollout the vaccine more widely wasn’t shared, even though governments had put up the vast majority of funds for vaccine development. As the old saying has it, this was penny wise but pound foolish because everyone would have benefited from dampening down covid-19 globally.

The effects of transnational economic inequalities are striking. During the covid-19 pandemic, high income countries put trillions into health and social spending to fight the pandemic’s effects, including supporting their economies, but low and middle income countries lacked the fiscal resources to make this choice. In 2021, almost half of all low and middle income countries cut healthcare spending, and about 70% cut spending on education.

The clear lessons from pandemics are that paying attention to the social determinants of health, respecting human rights, and involving communities are critical. Inequalities in health this vast are not inevitable. They are the result of policies—both what we do and what we fail to do. To achieve a world with better health and fewer health inequalities we need knowledge, resources, and political will. One of the tasks of the Global Council on Inequality, AIDS, and Pandemics is to synthesise the knowledge we already have. As the example of the money found by high income countries to protect their economies shows, “we”—the global community—also have the resources. The problem is the skewed distribution of financial and other resources. Political will is the great challenge. The global council will work with partners in governments, agencies, and communities to build the political will and public demand for change. Social justice requires it.

Is the Covid pandemic finally nearing its end?

In The Guardian, Aris Katzourakis writes: Is the Covid pandemic finally nearing its end? Excerpt:

More than two years on from the realisation that we are dealing with a novel pandemic, we are still nervously wondering what comes next. In the UK, Covid infection rates appear to have fallen to their lowest level since the summer of 2021, as has the number of deaths the virus is causing, but we know that new variants are still likely to emerge. So when will the end of this pandemic come, and what might it look like?  

This is a very difficult question, because we won’t know we have passed the end of the pandemic until some time has elapsed. The expectation is that eventually the disease will reach endemic levels, meaning immunity in the population will balance out the reproduction of the virus, resulting in a stable level of infection year on year. That stability could include regular, repeatable fluctuations such as seasonality, but we won’t know that stability has been achieved unless the same pattern of infections is observed for more than one consecutive year.  

There are two big unknowns in attempting to determine how soon the end of the pandemic may arrive and what it might look like. The first is: how durable will our immunity be, particularly against severe disease but also against infection? And the second is: how fast will the Sars-CoV-2 virus evolve, in particular with respect to overcoming our immune defences? To answer these questions, we need to look at the lessons the pandemic has taught us so far.  

The year of the Sars-CoV-2 virus was very much 2020, when it caused high levels of mortality and disease, and changed lives around the world. We saw a virus transmit into humans and began to observe some evolution, but thanks to the relatively slow rate of evolution of Sars-CoV-2 compared with other RNA viruses, we did not observe much change beyond the immediate public health impact until the very end of the year, with the emergence initially of the Alpha, Beta and Gamma variants.  

Looking back, 2021 appears to have been the year of the variant. The Alpha variant rapidly displaced the initial strain of the virus: it was more transmissible and more likely to cause severe disease and death, necessitating far more robust public health responses including the reimposition of restrictions in the UK and elsewhere. The degree of adaptation was staggering; the Alpha variant was more than 50% more transmissible in humans compared with the original virus, a leap of adaptation that has never previously been observed in real time.  

The Beta and Gamma variants also displayed a degree of immune escape, a brief glimpse into the possibility that these viruses might be able to, at least in part, evade defences we had built against previous forms of the virus, whether by infection or vaccination. And of course, these variants were succeeded by the Delta variant, which was about 50% more transmissible than the Alpha variant, and also more severe, bringing another wave of disease and devastation.

Towards the end of 2021 we were hit by another variant, Omicron, which brought its own unique challenges and lessons in viral evolution. Omicron is highly evasive of the antibodies that vaccination and prior infection confer, and thereby can breach our immune defences. Fortunately, protection against hospitalisation and disease is not eroded to the same extent, though protection against severe disease has declined. And of course, Omicron is capable of reinfecting individuals who have previously been exposed to other forms of the virus. The idea that viral infection is a “one and done” risk – that you can get it over with by being infected – has well and truly been dispelled by Omicron. Thus, if 2021 was the year of the variant and the vaccine, 2022 so far appears to be the year of reinfection.

Defining immunization: Types, statistics, and resources

Thanks to Regis College Online for sending the link to this resource just before World Immunization Week: Defining Immunization: Types, Statistics, and Resources. Click through to see the very good infographic on immunization. The introduction:

Immunization prevents an estimated 2 to 3 million deaths per year, according to the World Health Organization (WHO). The administration of vaccines has increased significantly over the last century, and developments in the field continue to improve and strengthen them. It’s important for every individual to understand the different types of vaccines and stay aware of recommendations for immunizations put forth by public health organizations.

WHO: Democratic Republic of Congo declares new Ebola outbreak in northwest province

A news release from WHO AFRO: Democratic Republic of Congo declares new Ebola outbreak in North West Province.

Brazzaville/Kinshasa, April 23, 2022 – Health authorities in the Democratic Republic of the Congo declared an Ebola outbreak today after the confirmation of a case in Mbandaka, capital of Equateur province (north -west). This is the third outbreak in this province since 2018.  

So far, only one case has been confirmed. The patient, a 31-year-old man, began experiencing symptoms on April 5 and after more than a week of home care, he sought treatment at a local health facility. On April 21, the patient was admitted to an Ebola treatment center for intensive care but died later that night. After recognizing the symptoms, health workers immediately took samples for laboratory testing for Ebola virus disease. Investigations to determine the source of the outbreak are ongoing.  

“Time is not on our side,” said Dr Matshidiso Moeti, World Health Organization (WHO) Regional Director for Africa. “The disease has taken a two-week head start and we are now playing catch-up. The good news is that health authorities in the Democratic Republic of the Congo have more experience than anyone else in the world in rapidly controlling Ebola outbreaks."  

The Democratic Republic of Congo is experiencing its fourteenth Ebola outbreak since 1976. The current outbreak is the sixth since 2018 alone, the most frequent event in the country's Ebola history. In Equateur province, previous outbreaks date back to 2020 and 2018, with 130 and 54 cases recorded respectively.  

Efforts to stem the current outbreak are already underway. The deceased patient received a dignified and safe burial, which involves modifying traditional funeral ceremonies in ways that minimize the risk of contagious fluids infecting attendees.   

Anyone who has been in contact with the patient is also identified and their state of health will be monitored. The health facility where the patient received care has been decontaminated.  

WHO experts based in the Democratic Republic of the Congo are supporting national authorities to strengthen key areas of outbreak response, including testing, contact tracing, infection prevention and control, treatment, as well as risk communication and engagement with communities to support public health measures to prevent infections.  

Vaccination should start in the next few days. The country already has stocks of rVSV-ZEBOV Ebola vaccine available in the cities of Goma and Kinshasa. The vaccines will be sent to Mbandaka and administered using the "ring vaccination" strategy - where contacts and contacts of contacts will be vaccinated to curb the spread of the virus and protect lives.  

"Many people in Mbandaka are already vaccinated against Ebola, which should help reduce the impact of the disease," said Dr Moeti. "All those who were vaccinated during the 2020 epidemic will be revaccinated."  

Ebola is a potentially deadly disease, affecting humans and other primates. Case fatality rates have ranged from 25% to 90% in past epidemics. Effective treatment now exists and if patients receive early treatment, as well as supportive care, their chances of survival improve dramatically.

China’s zero-Covid policy is a pandemic waiting to happen

An op-ed in The New York Times: China’s Zero-Covid Policy Is a Pandemic Waiting to Happen. Much as I respect Drs. Emanuel and Osterholm, I'm nervous about their use of terms like "have to live with it" and "endemic." They sound at this point like acceptance of high mortality and morbidity rates, which will be endured much more by working-class people and people of colour. Excerpt:

As the Winter Olympics approach and some 3,000 athletes, their retinues and the media converge in and around Beijing, the Chinese government has gone to extraordinary lengths to prevent the 24th version of the games from becoming a Covid super spreading event. 

Though athletes and coaches will be required to be vaccinated, they will face severe restrictions. Those who receive a medical exemption from vaccination are being required to quarantine for 21 days after entering the country. Even the vaccinated will have to present two negative tests. Olympic participants must submit to daily Covid tests and will be restricted to an Olympic bubble where they will be confined to prevent spread to the local population.  

These extreme measures are in line with China’s zero-Covid policy. President Xi Jinping and his government seem to believe that the country can be sealed off until the virus is eradicated around the world.  

But that goal is unattainable with the highly transmissible Omicron variant and has set the nation up for disaster. The coronavirus is not going to disappear — the world will have to live with it. Making matters worse, China’s vaccines are much less effective against Omicron. And the Chinese health care system simply is not equipped to care for millions of people sickened by the virus.  

Yes, China has weathered the pandemic well so far. Even with about four times the population of the United States, China has had fewer than 140,000 confirmed Covid cases and fewer than 6,000 deaths since January 2020, according to the World Health Organization. A vast majority of factories continued to operate. Early in the pandemic, China added thousands of hospital beds to its health care system in days.  

All of this seems like an enormous success when compared with the messy and often chaotic response to the virus in the United States, where more than 860,000 people have died and some 2,000 more die each day. Many hospitals are under siege. The economy has been disrupted.  

But this may very well be the future China is facing. Its pursuit of zero Covid will prove to be a huge mistake. The policy has left it wholly unprepared for what will become endemic Covid.

Static socio-ecological COVID-19 vulnerability index and vaccine hesitancy index for England

Via The Lancet Regional Health: Static Socio-Ecological COVID-19 Vulnerability Index and Vaccine Hesitancy Index for England. The summary:

Background  

Population characteristics can be used to infer vulnerability of communities to COVID-19, or to the likelihood of high levels of vaccine hesitancy. Communities harder hit by the virus, or at risk of being so, stand to benefit from greater resource allocation than their population size alone would suggest. This study reports a simple but efficacious method of ranking small areas of England by relative characteristics that are linked with COVID-19 vulnerability and vaccine hesitancy.  

Methods  

Publicly available data on a range of characteristics previously linked with either poor COVID-19 outcomes or vaccine hesitancy were collated for all Middle Super Output Areas of England (MSOA, n=6790, excluding Isles of Scilly), scaled and combined into two numeric indices. Multivariable linear regression was used to build a parsimonious model of vulnerability (static socio-ecological vulnerability index, SEVI) in 60% of MSOAs, and retained variables were used to construct two simple indices. Assuming a monotonic relationship between indices and outcomes, Spearman correlation coefficients were calculated between the SEVI and cumulative COVID-19 case rates at MSOA level in the remaining 40% of MSOAs over periods both during and out with national lockdowns. Similarly, a novel vaccine hesitancy index (VHI) was constructed using population characteristics aligned with factors identified by an Office for National Statistics (ONS) survey analysis. The relationship between the VHI and vaccine coverage in people aged 12+years (as of 2021-06-24) was determined using Spearman correlation. The indices were split into quintiles, and MSOAs within the highest vulnerability and vaccine hesitancy quintiles were mapped.  

Findings  

The SEVI showed a moderate to strong relationship with case rates in the validation dataset across the whole study period, and for every intervening period studied except early in the pandemic when testing was highly selective. The SEVI was more strongly correlated with case rates than any of its domains (rs 0·59 95% CI 0.57-0.62) and outperformed an existing MSOA-level vulnerability index. The VHI was significantly negatively correlated with COVID-19 vaccine coverage in the validation data at the time of writing (rs -0·43 95% CI -0·46 to -0·41). London had the largest number and proportion of MSOAs in quintile 5 (most vulnerable/hesitant) of SEVI and VHI concurrently.  

Interpretation  

The indices presented offer an efficacious way of identifying geographical disparities in COVID-19 risk, thus helping focus resources according to need.

Omicron accounts for nearly three-quarters of new US cases

Via The New York Times: Omicron accounts for nearly three-quarters of new U.S. cases. Excerpt:

The extremely contagious Omicron variant is now the dominant version of new coronavirus cases in the United States, according to the Centers for Disease Control and Prevention, and has prompted the resumption of mask mandates in some cities and states in the Northeast, where the growth in new cases has been particularly steep.  

Omicron, first discovered overseas around Thanksgiving and identified in this country on Dec. 1, now accounts for more than 70 percent of new cases in the United States, according to federal estimates released Monday.  

The estimates underscored the rapid spread of the new variant. Two weeks ago, the C.D.C. said Omicron accounted for just 1 percent of U.S. cases; a week ago, it was about 13 percent. Delta, which for months had been the dominant form of the virus, accounted for about 26 percent of new cases over the last week, the C.D.C. estimated.  

Omicron, discovered thanks to its distinctive combination of more than 50 mutations, has turned out to be highly transmissible — two to three times as likely to spread as Delta — and less susceptible to vaccines than other variants. Early cases raised hopes that it may cause milder disease than other variants, but scientists say more research is needed.  

In New York, new cases have shot up more than 80 percent over two weeks. In Washington, D.C., where the mayor reinstated an indoor mask mandate on Monday, more than three times as many cases are being identified each day as at the start of December. In Boston, where cases are also surging, Mayor Michelle Wu on Monday announced proof-of-vaccination requirements for certain indoor spaces like gyms and restaurants.  

In a news conference on Monday, Mayor Bill de Blasio of New York City said that the city must “move faster” in its response to the latest wave of new cases, but insisted that another lockdown “would have horrible impacts on the people of this city.”  

New York’s governor, Kathy Hochul, on Monday called the surge in new cases “a vertical increase” because “it is going straight up,” but she did not announce new restrictions. Ms. Hochul, a Democrat, appeared at her daily coronavirus briefing without the state’s health commissioner, Dr. Mary T. Bassett, who tested positive for coronavirus via a rapid test earlier in the day. 

The tens of thousands of new cases in recent days have included prominent politicians and lawmakers, such as Larry Hogan, the governor of Maryland, and Senators Cory Booker of New Jersey and Elizabeth Warren of Massachusetts.  

The surge is coming as many hospitals have reached capacity and governors in several states have mobilized the National Guard to help with hospital staffing shortages. As Covid-19 cases crowd into hospitals, leaders of health care facilities in multiple states have taken out newspaper ads begging local residents to get vaccinated.

Growth, population distribution and immune escape of Omicron in England

Via the MRC Centre for Global Infectious Diseases: Report 49 - Growth, population distribution and immune escape of Omicron in England. If I'm reading this correctly, Omicron is no "milder" than Delta. That is very worrying news. The summary, with my bolding:

To estimate the growth of the Omicron variant of concern (1) and its immune escape (2–9) characteristics, we analysed data from all PCR-confirmed SARS-CoV-2 cases in England excluding those with a history of recent international travel. We undertook separate analyses according to two case definitions. For the first definition, we included all cases with a definitive negative S-gene Target Failure (SGTF) result and specimen dates between 29/11/2021 and 11/12/2021 inclusive. For the second definition, we included cases with a positive genotype result and specimen date between 23/11/2021 and 11/12/2021 inclusive. We chose a later start date for the SGTF definition to ensure greater specificity of SGTF for Omicron.  

We used logistic and Poisson regression to identify factors associated with testing positive for Omicron compared to non-Omicron (mostly Delta) cases. We explored the following predictors: day, region, symptomatic status, sex, ethnicity, age band and vaccination status. Our results suggest rapid growth of the frequency of the Omicron variant relative to Delta, with the exponential growth rate of its frequency estimated to be 0.34/day (95% CI: 0.33-0.35) [2.0 day doubling time] over the study period from both SGTF and genotype data. The distribution of Omicron by age, region and ethnicity currently differs markedly from Delta, with 18–29-year-olds, residents in the London region, and those of African ethnicity having significantly higher rates of infection with Omicron relative to Delta.  

Hospitalisation and asymptomatic infection indicators were not significantly associated with Omicron infection, suggesting at most limited changes in severity compared with Delta.  

To estimate the impact of Omicron on vaccine effectiveness (VE) for symptomatic infection we used conditional Poisson regression to estimate the hazard ratio of being an Omicron case (using SGTF definition) compared with Delta, restricting our analysis to symptomatic cases and matching by day, region, 10-year age band, sex and ethnicity. We found a significant increased risk of an Omicron case compared to Delta for those with vaccine status AZ 2+weeks post-dose 2 (PD2) , Pfizer 2+w PD2, AZ 2+w post-dose 3 (PD3) and PF 2+w PD3 vaccine states with hazard ratios of 1.86 (95%CI: 1.67-2.08), 2.68 (95%CI: 2.54-2.83), 4.32 (95%CI: 3.84-4.85) and 4.07 (95%CI: 3.66-4.51), respectively, where PD3 states are categorised by the dose 1/2 vaccine used. Depending on the Delta VE estimates used (10), these estimates translate into Omicron VE estimates of between 0% and 20% PD2 and between 55% and 80% PD3 against Omicron, consistent with other estimates (11). Similar estimates were obtained using genotype data, albeit with greater uncertainty. 

To assess the impact of Omicron on reinfection rates we relied on genotype data, since SGTF is associated with a higher observed rate of reinfection, likely due to reinfections typically having higher Ct values than primary infections and therefore being subject to a higher rate of random PCR target failure.  

Controlling for vaccine status, age, sex, ethnicity, asymptomatic status, region and specimen date and using conditional Poisson regression to predict reinfection status, Omicron was associated with a 5.41 (95% CI: 4.87-6.00) fold higher risk of reinfection compared with Delta. This suggests relatively low remaining levels of immunity from prior infection.

In New Mexico, the pandemic rages on

Via The New Yorker: In New Mexico, the Pandemic Rages On.

 Excerpt:.

At one of the hospitals where I work, in rural New Mexico, the covid-19 patients are often young. Many are extremely sick, and most are unvaccinated. Not long ago, I walked into a room to find a woman in her mid-thirties. (Patient details have been changed to protect privacy.) She was unvaccinated, and had tested positive the week before. Her oxygen saturation was just fifty per cent, and her chest X-ray looked terrible. She seemed resigned and scared. When I asked her why she hadn’t got the vaccine, she shrugged. 

Down the hall, I visited a man in his early twenties who was breathing forty times a minute. We were still waiting for his test results, but his chest X-ray also looked terrible. When I asked him why he hadn’t got immunized, he said, “I don’t know,” and shrugged, too. Outside, in the hall, I checked our status board. A ten-year-old had been checked in with worsening covid symptoms. Fifteen more patients were waiting to get tested. 

In New Mexico, it doesn’t feel like we’re experiencing a new “wave” of the pandemic—it’s more like we’re in the middle of an endless voyage, in twenty-foot seas, miles from land. 

I’ve been working as an emergency-room physician all through the pandemic, first in Boston and now here. Taking care of unvaccinated patients stirs up complicated emotions in me. Severe covid-19 is now a largely preventable illness, and I often feel anger and frustration: I think, You couldn’t be bothered to do something as simple as schedule two shots, and now you might die—what is wrong with you? I contemplate the risk that each unvaccinated person poses to everyone around, including to me, and my family, and our nurses, and their families, and the hospital staff who will clean the virus-slick rooms, and their families—the risks branch out with dizzying complexity, like ice crystals forming in a cloud. I try to keep these thoughts to myself, for obvious reasons. Who wants to hear, after they’ve totalled their car and broken their legs, that they shouldn’t have been speeding? 

Sometimes, when I stand at the bedsides of young, critically ill patients who shake their heads when I ask if they’ve got the vaccine, I murmur, almost to myself, “I really wish you had.” But their past choices are no longer the most important thing. They are sick and afraid, and need our help as much as anyone else. I tell them that we’ll do everything we can to keep them safe. I never tell them that, for some patients, everything won’t be enough.

By asking people why they have avoided these incredibly safe and effective shots, I’ve learned a lot about how confusing the information ecosystem has become. Patients used to tell me that they worried about adverse effects, such as myocarditis or blood clots. (These effects are vanishingly rare.) 

Then, in September, I started hearing about a new concern: “the VAERS report.” I heard more about it by listening to a conservative talk radio show; listeners kept dialing in to talk about it. They said that tens of thousands of Americans had died after receiving the coronavirus vaccine, and that this report proved it. My patients in the E.R. began saying this, too.