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Govind Persad Profile picture
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15 Apr, 9 tweets, 6 min read
A lot of praise for #ACIP's transparency

But de facto pausing for 7-10 days got the *substance* wrong, as @ashishkjha et al. observe

Understanding the expertise of ACIP members (deep but too narrow) can help understand why these decisions need diverse experts, not just MDs

1/6
For vaccine allocation, CDC/NIH called on @NASEM_Health committee: nationalacademies.org/our-work/a-fra…

Not just MDs but:
- health econ (@healthecon_dan)
- behavioral health (@abuttenheim)
- literally wrote the book on "nonmaleficence" (Jim Childress)
- tribal health (@echohawkd3)
et al

2/6
In contrast, every #ACIP voting member (exc 1 community member) is a MD/DO/RN. Couple w/a MPH. But no health econ. No ethicists. No behavioral sci. No tribal health experts.

Great group for indiv patient care & virology expertise

Not for managing trade-offs in a pandemic

3/6
There were warning signs

For vaccine allocation recs, #ACIP drew on outside ethics consultants. Not there yesterday

Overlooked several of NASEM's good equity recs, like CDC social vulnerability index

Best questions about tradeoffs yesterday came from the nonvoting members

4/6
I wholeheartedly agree with @ashishkjha @thehowie and others that sadly #ACIP failed us yesterday by deciding not to decide

But I also think their composition set them up to fail, by depriving them of relevant expertise to deal with hard tradeoffs

5/6
A prominent theme yesterday in support of an extended pause: "nonmaleficence" "do no harm"



Having Jim Childress to explain why "nonmaleficence" isn't enough in public health decisions helped NASEM ethics.org.au/big-thinkers-t…

Having nobody like him hurt ACIP
I realized I forgot to link the ACIP bios: cdc.gov/vaccines/acip/…

Amazing (but duplicative) medical & infectious disease expertise. Little other expertise.

Compare to NASEM:
nationalacademies.org/our-work/a-fra…

ACIP needed some of these folks, not just great MD/inf disease experts

7/6
Another limitation: many ACIP folks specialize in *childhood* vaccines.

Dr Long, who wanted 1-month(!) pause, is a pediatrics person:

Pausing pediatric rotavirus vax in 2010 was sensible

Pausing J&J in a pandemic way different.
Point that rotavirus pause had a *very* different background context than pausing a vaccine in a pandemic nicely made by someone with relevant expertise here:

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More from @GovindPersad

Govind Persad Profile picture
13 Apr
I agree that a pause isn't permanent & the FDA should track safety concerns

But forced "pausing" (AKA cancelling people's J&J appointments) isn't the right move

People should be given the info & allowed to choose

Deaths from Covid b/c you weren't vaccinated are permanent

1/3
This feels like Germany's mistakes on AZ's vaccine

I thought the "precautionary principle" popular there might be why nytimes.com/2021/03/19/wor…

But it seems telling people stuck on the trolley tracks they can't use a ladder to get out isn't confined to that side of the pond

2/3
Imagine if we'd had a J&J vaccine that was 10% less *effective* than our current one, but didn't potentially have any rare side effects

That vaccine would lead to more deaths than the one we have

Yet I'd guess FDA would have no problem letting people choose to use it

3/3
Read 4 tweets
Govind Persad Profile picture
10 Apr
This mechanistically backs up the evidence of vaccine benefits 10 days after *first* dose from the original Pfizer trial

Underscores the extremely strong precautionary and benefit maximizing case for surging vaccines to Michigan
We have the luxury of two very good options

We have enough supply that we could send MI more vaccines. Only Jeff Zients’ bizarre burden-insensitive conception of “fairness” prevents this

Or we could let MI extend dosing intervals by 2 weeks to get first doses to more people
But apparently sticking w/an ethically ungrounded Trump Admin holdover policy of giving vaccines only proportional to population (which many states aren’t doing intra-state), & an arbitrarily selected dosing interval, is more important than letting people in MI protect themselves
Read 4 tweets
Govind Persad Profile picture
20 Dec 20
For those following #ACIP vaccine prioritization debate - proposal to have 75+ alongside frontline workers in phase 1B is interesting, and different from prior discussion. But there are still pitfalls with any age cutoff, whether 75 or 65, as I explained in a comment to ACIP /1
Down Syndrome deaths are disparately high and happen before 75. 54%, 61%, and 69% of Black, Hispanic, and AI/AN deaths (respectively) happen before 75. I haven't seen US data on income x age at death, but a similar gradient is plausible, and may help explain the race data. /2
So I continue to think #ACIP should encourage states & localities to look at overlapping risk factors like housing+age as LTCF priority did and @CDCDirector suggested, rather than using age cutoffs that sweep in ppl at very different risk & exclude some /3
Read 6 tweets
Govind Persad Profile picture
20 Dec 20
Last (grumpy) thread about #ACIP vax prioritization before bed. Sure, there are some hard tradeoffs, though looking for overlapping risk should make it easier, & ACIP could have had better framing. But critics have been a real mess. Exhibit A, dishonest quoting (aka lying): 1/6
Redfield: need to"demonstrate that we as a Nation also prioritize the elderly (>70 yo) who reside in multi-generation households. Often our Hispanic, Black and Tribal Nations families care for their elderly in multigenerational households and they are also at significant risk."2/
Here, current @CDCDirector Redfield (hardly "Mr. Woke"), after endorsing long term care priority, is sensibly arguing for another multi-factor (age+housing risk) priority similar to LTCF, which would also address disparities for "Hispanic, Black, and Tribal Nations families" 3/6
Read 7 tweets
Govind Persad Profile picture
19 Dec 20
Thread on interconnected #bioethics problems in #COVID19 vaccine allocation: (1) the Stanford med center allocation debacle, (2) Rupert Murdoch, and (3) high-profile calls for age-only (“oldest first”) allocation policies. If you like (3), unfortunately you get (1) and (2). 1/7
People are right to be upset w/Stanford: see @CarolineYLChen excellent piece . But it’s not “algorithms”, it’s inputs. If your inputs are too simplistic (age-only, ignore exposure or medical risk), you get bad outcomes, e.g. no residents, senior WFH 1st 2/7
Same w/ Murdoch: . People are right to be upset. But age-only priority like the UK (start w/85+ or 90+), ends up prioritizing Murdoch over a 60 yo bus driver. Who lives to 90? We know the answer: more often, wealthier people. Need to consider other risk 3/7
Read 9 tweets
Govind Persad Profile picture
16 Apr 20
This op-ed by Harald Schmidt @PennMEHP is a hugely valuable contribution to the #bioethics debate over ventilator allocation, & would have applications to other scarce resources as well. Some thoughts /1
Modifying SOFA score w/"weights" based on race would be struck down in federal court (& certainly by this SCOTUS) under #ParentsInvolved precedent scholar.google.com/scholar_case?c…. Not endorsing that precedent, but crucial to recognize it. Area Deprivation Index is better approach /2
Rather than using Area Deprivation Index "weights" to adjust SOFA scores, it would be better to use the Area Deprivation Index as a tiebreaker within each SOFA-score group ("red" to "green"). Would likely save more lives of disadvantaged patients /3
Read 9 tweets

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