Thread by @ASlavitt

COVID Update: The very unclear story of boosters will become clear.

I will try to sort it out. And attempt to be clear myself! 1/

The evidence for a booster shot is obvious for people as they age or are at risk. The immune response was lower to begin with & after 6 months vs Delta that adds up to risk of hospitalization. 2/

Boosters dramatically increase antibody levels. And the safety profile of the boosters is also pristine. No real side effects.

It’s a no brainer for everyone with immune system issues or a little, ah, age on them. How much age? 65? 60? 50? 40? Will get back to that. 3/

If you are solely trying to prevent serious illness/hospitalization, then there is a good case to draw the line reasonably close to 65 (as the FDA Advisory Committee recommended).

But that’s not the only issue. 4/

Are we trying to reduce spread? Symptoms? Keep schools open? Get the economy & jobs back? What about the impact on global equity?

Well the FDA Advisors didn’t consider any of that in making their recommendation. Just the science. But… 5/

Those things should be considered in the next 3 hoops the decision jumps through— the FDA commissioner, the CDC advisors & the CDC director.

On Monday Janet Woodcock, FDA commissioner, is on @inthebubblepod. The same day she may make her decision. 6/

If you consider those other factors (schools, speeding the pandemic’s end, etc), you would consider the following.

-There is an observed reduction in spread among people w boosters
-The economy is losing 15 million working hours/week w people sick/in quarantine. 7/

Many of those hours are worked by people who work by the hour. They can’t afford to miss work. Do we care about them?

Many are parents of young kids or teachers. 3000 kids/week are being hospitalized. Do we care about them & their exposure? 8/

Most of us can handle a few upper respiratory symptoms? But what about when the virus gets into the lungs & causes longer term symptoms? Do we care about that?

These questions make the case that the age cutoff not just focus on reducing hospitalizations (>~65) but drop lower. 9/

What about the impact on global equity? Should that be in the overview of the CDC to consider? It should.

If the doses that would go to people 30-65 (100-150 million) could get absorbed immediately in Africa, that should be a priority. But let’s look at what’s happening. 10/

The US has donated 500 million doses, 30% of which have made their way into people’s arms. COVAX has another billion-plus going to lesser developed countries by year end.

How does this fit into the global picture? 11/

5.7 billion doses have been administered to date and the wealthy nations are administering about 25 million/day. This is LESS than we are producing as w globe.

So what’s happening? Every continent is above the global average except Africa. Only 6% of the continent is vaxxed.12/

What’s the issue? More vaccines? More money? No to both. Better located factories will help in the future but right now, it’s all about last mile logistics.

To vaccinate the globe quickly we need troops on the ground, PEPFAR resources (from HIV) & help w cold chain & admin. 13/

Adult vaccinations in Africa are trickier than kids. And 2 doses is even harder. Africa has another characteristic that makes it a priority.

A lot of compromised immune systems from HIV in many countries— putting people at risk & also creating a breeding ground for variants. 14/

In a nutshell, the resources needed to vaccinate Africa are not the same as the 100 million odd boosters already distributed in the US (most aren’t eligible for export anyway). Or even boosters in the other 20 or so developed nations. 15/

Many younger people of course haven’t hit their 6 month mark since their second vaccine just yet. So the US has a small amount of time before they have to deal with the full wave of people. 16/

There’s another direction the CDC can go which is to make a rather vague approval for people “at risk,” requiring only attestation at the pharmacy to get boosted. Could be health status, occupation— but not subject to age. 17/

There’s also the question of the people who got the J&J or Moderna shots. Should they get boosted now given that only Pfizer is being reviewed for the time being?

J&J data is being submitted. Moderna decision is expected in a few weeks. What about ppl who don’t want to wait? 18/

Given that there is only very limited mix/match data, I can report the broad consensus. It’s safe & effective to mix/match but with a possibility there could be slightly higher minor side effects.

To me the answer is obvious & I hope it is followed… 19/

Since Pfizer is fully approved by the FDA, a doctor can write a prescription for it if they feel it’s warranted unless expressly limited on the label. A doc may say an 80 YO or immuno-Comp person w Moderna can get a Pfizer booster. But a 40 yo may be advised to wait. 20/

The flaw in that is the flaw in a lot of things.

Not all of us have doctors. Access to care is shoddy where it’s needed the most.

And the take up of boosters is likely to be high among the people who got vaccinated early but boosters are ripe for misinformation spreading. 21/

Already a problem, it’s one that’s bound to get worse.

The politicization isn’t helped by the rancorous process at FDA & CDC advisory committees.

Different votes. Speeches without evidence. Frankly dumb witnesses. But also reasonable areas of disagreement & interpretation. 22/

But in the end I will take our system any day.

The right to dissent publicly is ultimately what persuades me & the public that we will eventually get it right.

Dissenters shouldn’t be hidden from view. Their arguments should be debated but they shouldn’t be marginalized. 23/

This is what puts more burden on the CDC and FDA to get it right and make it clear. Let the advisory committees be advisory.

They don’t carry accountability for public health, public trust, or managing the pandemic. The agencies do. 24/

Next week we deserve to see the arguments but then see them out in perspective with a cogent policy put out & explained.

My recommendation isn’t the only way to go. But make it simple & logical; scientific based but aggressive in bringing us back closer to normal. /end