Let’s clear up the confusion over talk of a ‘preferred’ vaccine

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by Raywat Deonandan
May 5, 2021

This article was published in The Ottawa Citizen on May 5, 2021.

I’m fond of citing a paper from 2007 about lessons learned from SARS that we should apply to the next pandemic. Its number one recommendation was that there should be transparent communication between all parties, including to the public. And yet this is where we have stumbled throughout every step of this emergency.

The latest such stumble comes from NACI (the National Advisory Committee on Immunization), who stated that the mRNA vaccines (Pfizer and Moderna) are “preferred” but that those who “do not wish to wait” for an mRNA could accept one of the viral vector vaccines — AstraZeneca or Johnson & Johnson — if “the benefits outweigh the risk for the individual.”


NACI’s role is to quantify risk and reward with respect to vaccination, and to advise decision-makers via the Canadian Immunization Guide, which is a guidance document meant for use by health-care professionals and vaccine program managers. In times of pandemic, however, NACI’s words are being parsed and interpreted in real time by an audience with whom the committee had never before had to deal directly: the general public.

Communicating with the public is starkly different from offering guidance to health-care professionals. Words such as “preferred vaccine” are, frankly, triggering, and introduce an element of classism into the fracas. Who mostly got the “less preferred” vaccine? Essential workers. Poor people. Racialized people.

Predictably, those Canadians who had dutifully accepted the AstraZeneca vaccine, after having been told by health leaders to “get the first shot that is offered,” feel betrayed. As someone tweeted to me, it’s like the Boomers made GenX take all the risks while keeping “the good stuff” for themselves — like wanting others to eat the no-name cookies before opening up the Oreos for themselves.

I have four immediate thoughts about this latest episode in the ongoing daytime soap opera that is our vaccine rollout and its endless communication missteps.

First, it’s important to take a moment to appreciate what an astonishing thing it is to have a choice of which life-saving vaccine to accept in the middle of a deadly pandemic. Most parts of the world don’t have that luxury. So while the government messaging is often confusing, let’s be thankful for the luxury of that confusion.

Second, “preference” isn’t simply a matter of choice. It’s also a matter of circumstance. The AstraZeneca jab is in many ways the vaccine of the world. It is inexpensive, easily made (compared to the mRNA doses), and can be transported and stored with less consternation. For many parts of the globe, it is the preferred vaccine as it will drag large populations out of this crisis.

Similarly, the Johnson & Johnson vaccine famously only requires one dose, so is ideal for the homeless, the nomadic, or migrant workers — any group for whom scheduling the second dose could be difficult, if not impossible. Clearly, for them J&J would be the preferred vaccine.

Third, preference and choice are luxuries not only for those with access to multiple formulations, but also to those who can afford to wait for their favoured brand. Many communities in Canada cannot wait. Hot-zone neighbourhoods, essential workers, and poor and racialized people who are at great risk of COVID infection cannot afford to wait.

Maybe you prefer Perrier to tap water, but when you’re dying of thirst, you’d best take the first glass of water offered.

Fourth, those Canadians who received the AstraZeneca vaccine should not feel cheated or coerced. Every day spent unvaccinated is a day in which they could have contracted COVID and possibly be fighting for their lives in an ICU ward. This is especially true if they live in a hot zone or are essential workers.

The lesson from all of this, as it has been from the very beginning, is that the pandemic is all about equity. Some groups are more likely to be exposed and infected, to be rendered unemployed, to be hospitalized and die, to lack access to a vaccine, and now to be unable to wait for a “preferred” vaccine, however problematic and incorrect that term might be. Ill-considered messaging does not alleviate the strain of inequity, and might indeed serve to exacerbate it.

There are no second-class COVID vaccines in Canada. They all get the job done.

 

Raywat Deonandan is an Epidemiologist and Associate Professor with the Faculty of Health Sciences, University of Ottawa.

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COVID-19: Exponential Growth and the Myth of the Balanced Response

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by Raywat Deonandan

April 27, 2021

A slightly modified version of this article was published in The Ottawa Citizen with the title, “Deonandan: COVID-19 — How Ontario fell into the myth of the balanced response” on April 28, 2021.

Earlier this month, Ontario’s Solicitor General Sylvia Jones was asked on a radio show why the province waited so long before enacting the COVID-19 restrictions that doctors and scientists had been pleading for. Earlier, Ontario’s Science Table had observed a worrying growth trend in cases and ICU usage and had forecasted a dire and explosive situation just mere weeks away.

Jones replied, “We wanted to make sure that the modelling was actually showing up in our hospitals.”

This was a curious answer that speaks to the heart of the issue of slow and ineffective government responses to the pandemic. It is also why the so-called “balanced response” advocated by those seeking to calibrate public health responses against real-time data was always doomed to failure.

The problem, simply, is exponential growth. Most of us do not understand it. In a pandemic, that failure of understanding is our undoing.

Investors know it as compound interest. Consider the unlikely but delectable scenario in which you pay a single dollar into an investment fund that guarantees to double your money every three days. How long will it be before you become a millionaire? You might be shocked to know that it would only take sixty days. That is the insidious magic of exponential growth.

Similarly, a small number of COVID-19 cases can explode into a nightmarishly overrun healthcare system in a matter of weeks. If you wait until you see the modelling in the hospitals, it is probably too late to prevent the crisis.

 

The human brain thinks naturally in terms of linear growth, possibly developed through millennia of evolution chasing prey and escaping from predators who tend to move at constant speeds over a given period. It is why we can easily predict where a vehicle or a running animal will cross our path if it does not change course or accelerate.

But we struggle to internalize exponential growth, which can be deadly when responding to an infectious disease. A 2020 paper by German statisticians suggested that, “people mistakenly perceive the coronavirus to grow in a linear manner, underestimating its actual potential for exponential growth.” The authors go on to say that this cognitive failure, “influences political opinions about matters of life and death.”

Exponential growth comes in two phases. As labelled by author Richard Baldwin, the first is the “imperceptible progress” phase and the second is “explosive progress”. In the first phase, growth is acknowledged but easily dismissed. But in the second phase, we are overwhelmed by growth and act surprised that it is happening at all.

 

Futurist Roy Amara lends his name to Amara’s Law, which states, that “we tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run.” This is because technologies tend to grow exponentially, and we salivate over their unrealized potential early on –the imperceptible progress phase– but are shocked when that potential is actualized and overwhelms us in the explosive progress phase.

For example, the growth in the speed of computers in the past couple of years has been twice that of the previous fifty years. Baldwin argues that that is why Artificial Intelligence suddenly seems so daunting, though its rate of development has been steadily on an exponential curve for years.

We can see Sylvia Jones falling into the trap of Amara’s Law. By waiting to see if the explosive growth of COVID-19 shown by the provincial modelling would manifest in the hospitals, the province was in essence doing nothing during the “imperceptible progress” phase of the 3rd wave. So here we are, overwhelmed in the “explosive progress” phase.

The lesson of exponential growth as it pertains to public health is this: When we know it is happening, when we are still in the “imperceptible progress” phase, we must act decisively. If we wait until the “explosive progress” phase, we risk not having the resources to mount a sufficient response.

In other words, our response must always feel like a premature overreaction, or else it will never be enough.


Raywat Deonandan is an Epidemiologist and Associate Professor with the Faculty of Health Sciences, University of Ottawa

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No, you shouldn’t wait for a better vaccine

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by Raywat Deonandan

Mar 15, 2021

This article was published in The Ottawa Citizen under the title, “Deonandan: No, you shouldn’t wait for a better vaccine” on Mar 15, 2021.

Scientists were rendered giddy by the data published by Pfizer and Moderna for their COVID-19 vaccines. Each showed 94-95% efficacy! Canadians now have access to formulations from Astra Zeneca and Johnson & Johnson, as well. But their efficacy scores, while very good, are nonetheless slightly lower than those of Pfizer and Moderna So some Canadians are choosing to wait for “a better option” when given the chance to receive an AZ or J&J shot immediately. Continue reading

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The Saturday Debate: Can the Tokyo Olympics still happen this summer?

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by Raywat Deonandan & Helen Lenskyj

Jan 23, 2021

This article was the “No” component of a two-side debate. The “yes” side was written by Dick Pound. This debate was published in The Toronto Star on Jan 23, 2021.

 

In March 2020, the International Olympic Committee (IOC) reluctantly and belatedly announced the decision to postpone the 2020 Tokyo Olympics to July 2021. Since that time, organizers have addressed the challenges of doing so — in most cases, inadequately. Continue reading

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Delaying That Second Dose Is Not Evidence-Based Medicine But It Still Makes Sense

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by Raywat Deonandan

Mar 5, 2021

This article was published in The Ottawa Citizen on Mar 5, 2021.

 

The clinical trial data describing the safety and efficacy of the Pfizer and Moderna COVID vaccines were probably the most scrutinized science papers in history. They showed efficacy scores over 94% when a prime dose was followed by a booster 21 or 28 days later. Yet the National Advisory Committee on Immunization (NACI) now recommends extending that interval to up to 4 months, a substantial deviation from the manufacturers’ directions. This has upset many who feel that this departure is tantamount to experimentation without consent. Continue reading

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Wearing a face mask is both socially responsible and self-interested

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by Raywat Deonandan

This article was published in The Ottawa Citizen on July 14, 2020. It was adapted from a blog post titled, “COVID19: Heroes Wear Masks.”

In many cities, each night at dusk, grateful residents applaud health care workers. It’s a reminder that in the early phase of the COVID-19 pandemic, doctors and nurses held the front line. All that was required from the rest of us was to stay home, watch Netflix, and learn to bake.

Continue reading

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COVID19 Testing is Our Salvation

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by Raywat Deonandan

This article was first published in India Currents Magazine on April 7, 2020. It is based on this blog post.

We are weeks into widespread social distancing in many parts of the world, though it feels like months. Cases of COVID19 continue to mount, as expected, and we watch Italy and Spain for signs of when our society might be cast into crisis and chaos. Health care workers, the heroes of our time (and of all times, really), gird themselves for a flood of respiratory distress cases, projected to peak sometime in April. Physicians and nurses of all specialties are being asked to update their ventilator training in anticipation of being called to the front lines for service. Yet many fear that they will not have sufficient weapons for this fight, such as masks and ventilators.

At this time, it’s important to remember that COVID19 has a global case-fatality rate of about 2 to 3%lower in the USA, meaning that most people will survive this. In the words of Larry Brilliant, “this is not a zombie apocalypse. It’s not a mass extinction event.” What is it, then? This is, and always has been, a health systems crisis more than simply a health crisis. Continue reading

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COVID-19 is not a health crisis, it is a health systems crisis

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by Raywat Deonandan

This article was published in The Toronto Star on April 7, 2020. It is based on an earlier blog post.

Most models of the COVID-19 pandemic show it continuing for another year or two, with North America stifled beneath the current wave of cases until June at the earliest. With such harrowing realities, it’s easy to mischaracterize this crisis as solely a medical one. Continue reading

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Coronavirus shows the urgent need to invest in health infrastructure

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by Raywat Deonandan

This article was first published in The Ottawa Citizen on Mar 13, 2020. A longer version is available here.

Bill Gates recently speculated that COVID-19 could be the “once in a century” disease whose severity rivals that of the 1918 Spanish Flu. That disease was so dire that it likely played a role in ending the First World War, having removed so many soldiers from the battlefield.

COVID-19 has already caused profound economic, psychological and even climatic impacts. But with a century of experience since the Spanish Flu, how resilient is our health infrastructure against this and future pandemics? Continue reading

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