IM Doc pt23
Nov. 12th, 2021 11:40 am![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
temporaryreality***
The following comments relate in some way to this post on NC
Hospital ‘Trauma Centers’ Charge Enormous Fees to Treat Minor Injuries and Send People Home
IM Doc quotes another comment (the original post and the comments are all worth reading)...Our Medical for-profit-system has gone completely off the rails and I find it more than a little frightening.
You do not know how frightening I find it. And the very sad thing for me is I have living memory of what it was like 30 years ago before all this stuff really got going.
I tell people all the time that I work in the biggest wealth extraction machine that ever existed.
I would make sure everyone knows about another huge scam. In big non-profit systems, for every single visit from a physical to a sore throat, you as a patient will get to sit through a litany of someone asking you have you had this done or that done…..
The doctor you are seeing, let’s be clear, has a huge part of his income riding on whether or not he/she has strong-armed you into getting these things done. Whether the evidence is flimsy or not matters not. And you as a physician get monthly reports on how you are doing – and what your bonus will be and you better pick up the pace.
It would be one thing if these things were dietary education, elder care, mental health care, obesity training, exercise programs. I would be the first in line for that. BUT as you can tell, every one of those things is going to cost the system lots of money.
What are the things you get asked about? Colonoscopy, PAP smear, Mammogram, vaccine status, PSA, Lipid panels, bone density studies and on and on. They laughingly refer to these as “Quality Care Indices”.
Can you tell the difference? Every single one of the things they do are cash machines. Some of which are very iffy on the evidence. All the others I mentioned previously would be cash vacuums.
Let me make sure all understand what I am saying – THIS IS NOT ABOUT YOUR HEALTH – this is about maximizing every dollar from every “profit center” they can.
This is all the doing of the MBAs who started taking the system over in the 90s – they are now so entrenched it will take a nuclear bomb to get them out.
I see no hope for the entire system until it finally meets the brick wall. Not sure how long it will take – but I know for sure it is on the way.
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re: a link provided in the day's NC entry,
About the US County Case count map – Area of Concern Continuum. The numbers are assuredly very unreliable because the CDC is not counting the vaccinated positives – but it is what it is.
Is it just me – or is there a rather obvious contingent of Blue State America represented there in red or orange? All the places we have been hearing from our media that are so much further along because they have so many more vaccinated….
I see LA and all of Southern California, The Bay Area, Portland, Seattle, Las Vegas, Phoenix, Denver, Austin, St Louis, Chicago, Detroit, Philadelphia, Boston, New York, DC and Atlanta all in red or orange. Blue areas all. Even blue counties in red states like Dallas and Harris ( Houston) in Texas are red. And yes – there are plenty of red areas that are red on these maps too. But it is certalnly not lopsided like the media would suggest.
I have been a physician for 30 years. I have never seen a campaign in public health pitting one political faction against the other – like our media and politicos and health officials are doing now. And now the White House has admitted they are doing things with Facebook that would make Joseph Goebbels green with envy. This is simply unprecedented. I think we can all face reality and allow that the strategy is clearly not working and is indeed making things worse.
This is a test for this nation. I can assure you that the vaccine balkers in Seattle are a much different crowd than the vaccine balkers in LA or Dallas or Kansas City or Miami. We must begin to realize that a one size fits all approach is just not going to work. And coercion and threats are certainly not the answer. From a physician of 30 years, threatening people in any way about health decisions is just a complete imbecile move. You will completely alienate the patient, you will illicit extreme anger or other bad emotions – and you will almost assuredly make things worse.
We have limited time to get this right – but from the tone of the past few days it is clear to me that we are headed right to the brick wall.
I am hoping that the days ahead are not fraught. This may all very well blow over. But it may not. And if this does get ugly – we are going to need one another and not to be at each other’s throats blasting off blame cannons. I simply cannot believe that our health officials and media and politicos cannot see this – and by their actions over the past year allowed it to happen in the first place.
Gods, these people:
“We have come a long way in our fight against this virus,” Jeffrey D. Zients, the administration’s Covid-19 response coordinator, said at the briefing. “Because we have fully vaccinated more than 160 million Americans, we’ve fundamentally changed the course of this pandemic, from one that puts the lives and livelihoods of all Americans at risk, to one that predominantly threatens unvaccinated people.”
So I can think of no bigger moral failing here, than leaving unvaccinated people to die, as this administration is content to do through the CDC and OHSA; Federalism aside, there is still much that could be done/undone at the federal level, from proper mask guidance, to workplace safety requirements, to funding for recovery from side effects for workers, to universal health care (ha). Not to mention study of treatments.
As the highly contagious Delta variant of the coronavirus fuels outbreaks in the United States, the director of the Centers for Disease Control and Prevention warned on Friday that “this is becoming a pandemic of the unvaccinated.”
And just who exactly gave that outcome a huge assist, with nonsensical masking policy?
These people are just nuts. And I’m sure they’re saddened, just saddened, by all this needless suffering. Whatever could have been done?!
Thank you kind Sir –
I could not have said this better myself.
“Leaving the unvaccinated to die.”
Here is the thing – I have been to this rodeo before with two different viruses – and this is not going to be pretty.
As a young intern, I was on the AIDS wards in a big urban American hospital. I would often sign 8-9 death certificates a day. COVID has nothing on that. Yes – it was that bad. To make things much worse – they were all young 20 somethings. They were for the most part completely abandoned by their families, left blowing in the wind. I have seen the evil that happens to people when we decide as a culture that x-group has it coming and just needs to die. I had believed that we had gotten past that as a culture. I was clearly wrong. It is more disturbing that the side that I thought I was on is now the one perpretating the shame on the country.
There have been two rather large flu epidemic years that have happened in America in just the past 15 years. Many hundreds of thousands died both times, hospitals and ICUs packed, millions sickened. I need to refresh my mind on the numbers but I believe in general the 2009 epidemic was a bit worse than COVID has been as far as deaths (not certain about that). Believe it or not, the amount of patients that just flat out refuse flu shots is staggering even in those horrible flu years. And even when weeks or months later the unvaccinated came into the hospitals sick as a dog, neither myself, the nurses, nor their culture at large treated them with disdain or as deplorables. The unvaccinated issue never was even mentioned. They certainly were not being maligned on TV by Rachel Maddow et al every night.
I often look in the mirror every day in the AM , and think to myself – What has happened to us? What has happened to my profession? How is this all going to end?
On the Ivermectin study. The fact that the Elgazzar study was included in the meta analysis (especially with a low chance of bias rating) does not speak well of the meta analysis’s quality. Their stock has definitely gone down in my opinion.
I will state this in their defense however, (assuming they all aren’t grifters) they have come across a treatment method, which on, alot of the data, suggests it can safe lifes. The response from authority hasn’t been to quickly ramp up large RCT trials to quickly either confirm or deny, it hasn’t even been quiet indifference. It has been to attempt to stamp out this particular treatment. I personally think that people would be able to think a lot more clearly if needless pressure were not being applied.
On a related note https://bbcgossip.com/health/remdesivir-does-not-improve-covid-19-mortality-rates-study-finds/. Nobody is talking about removing the EUA on remdesivir. Nobody is talking about making it illegal for a doctor to prescribe it to their patient out the cost of $3000 for a cause.
IM Doc I agree with every point you make.
I do not believe any of these people are grifters. There really is not an ounce of grift in ivermectin to be had.
And you are correct in your suspicion of remdesevir. I have not seen personally in any patient any benefit at all. I have maybe used it 40 times. The same can not be said for ivermectin where I have seen people improve dramatically.
Unfortunately, we have had to start using it again the past two weeks. I had a husband and wife on Tuesday. Both vaccinated both positive and both having coughing SOB and fever. Husband took ivermectin and improved in one day. Wife did not and is still sick as of last night.
I have too many stories like this for this to be just random chance.
I have a moral and sworn obligation to my patients health. Not Fauci. Not Pfizer. I will continue right on using this until there is clear data not to. The safety profile is just too good and the risk benefit ratio is overwhelming.
That is called the art of medicine.
I know these fits and starts are frustrating. I take it in stride because I have seen this all before several times.
Bactrim is now standard of care for PCP in AIDS. When I was a young Doc that was not the case. The evidence for its use came bubbling up from below and took years of bad trials and good trials and tons of obsstruction from Fauci et al before the proof was finally there.
Ivermectin is almost the same story. Both drugs were considered “out there” at first. But Ivermectin has actually a much better safety profile. Medicine was not enthralled to the “RCT only” fetish back then so the thinking by medical practitioners on the ground was much more clear and ethical than it is now. That to me is the big problem we are facing other than the obvious stonewalling by our agencies.
This remains a clear no brainer until there is real evidence either way.
Pedro Anecdotes are not data.
First do no harm.
The ‘I will use until I have evidence it is bad’ makes me think of lobotomies.ambrit That’s a false equivalence.
The cases of Ivermectin versus lobotomies are vastly different. The Ivermectin use actually saves lives. The other side of the equation does not “lose lives.” Lobotomies are medical intrusions aimed at changing personality permanently. For that purpose, it works. That it does so with significant side effects is another issue, separate from the original design. Either way, lobotomies or their non-use do not lose lives. To turn your argument ‘on it’s head,’ we can compare the use of lobotomies with the non-use of Ivermectin. Lobotomies have gained their negative reputation because they often destroy psychic lives. The non-use of Ivermectin also destroys physical lives. People die due to the blocked use of the drug. Do no harm indeed.
Stay safe.IM Doc The problem with your reasoning is this drug has harmed less than a few dozen out of the billions that have taken it. The same could never have been said about lobotomies.
And since there is virtually no harm issues and multiple very strong signals that it is at least helpful somewhat by medical ethical standards it must be given.
I learned this lesson well in the AIDS pandemic with drugs of unknown efficacy then that are the standards of care now.
This line of reasoning is especiallly germane during a worldwide pandemic.
Phillip Cross Mentos mints are very safe to ingest, but no statistically significant evidence exists that they help cure or prevent Covid.
Wouldnt it be a serious ethical issue if you tell people they work, and prescribe them anyway?
What of the high risk people who hear you and then go to Safeways and buy Mentos, thinking it will protect them. They feel safe and then put themselves in harm’s way, and end up dead after getting Covid19?
IM Doc The problem with this reasoning is that Mentos mints do not have dozens of studies out there already showing some efficacy.
This is both in clinical medicine as well as bench research showing in vitro effectiveness that ivermectin has against SARS COV2.
In other words, there are multiple studies that seem to suggest it does work.
I guess I would remind you that the standard of care right now for people that real doctors are telling people to do all over this country is to go home and come back if you turn blue.
In that kind of environment with no good options – I am willing to give my patients a safe compound that does seem to have some effect. As I have stated above – what I have seen with my own eyes seems to be more than random chance.
In light of the Israeli government admitting the vaccines don’t work as advertised, maybe we can ask why our regulators and public health authorities ignored the substantial evidence that the mRNA vaccines are nowhere near as effective as has been repeatedly parroted for the last 6 months.
Furthermore, it appears that spike protein specific immunity induced by the ‘vaccines’ might be creating the next covid wave
https://twitter.com/holmenkollin/status/1415989536933490688?s=19
IM Doc I would like to give credit where credit is due.
There is an obvious statistical manipulation among the treatment arms that is evident in the original Pfizer trial. It greatly puts into question the results of the study. It would tend to make the touted relative risk reduction of 95% much lower – but it is impossible to know how much lower unless one has access to the primary data.
I will repeat once more – I do not recall a single time in my life that the relative risk reduction has been used a a primary statistical endpoint for vaccine efficacy. My experience with that statistical contrivance is that is mainly used by Pharma for their glossies to bamboozle people. The RRR rarely comes up in journal clubs. It has very limited utility. But it sure looks good – even when the reality-based results are not so good.
I have watched in horror as this RRR number has been touted to the American people for the past 6 months – giving them a completely false feeling that they are “95% protected”. That is just not what that number means. The fact that our public health authorities were not out in front of this misrepresentation and explaining this to the people will be an indelible mark.
But who was it in my world who first noticed the problem with the management of the trial participants that could really goose the efficacy numbers?
Why – that would be Yves. And she put these concerns in comments and maybe even a post. I just cannot find it now. Yves is one very intelligent person – but forgive me – if Yves can see it – why can not medical statisticians? Well – Dr. Doshi – whose blog you highlighted in your comment came out with a blog post discussing this issue in the BMJ a few weeks after it was noted here – and was laughed and censored out of the room by “experts”.
I think we can look right now at the vaccine efficacy issues – and ask ourselves who was right?
Citizens of the world, do you want your medical experts and medical debated muzzled by Big Tech under the direction of Big Pharma and governments? Is it becoming clear why this is a very bad idea?
I sure hope so.
IM Doc, your comments have been a quite an education for me, and I’m sure for this whole community. Thank you! But I am still confused about what is wrong with RRR as a measure of effectiveness, and what is the better alternative? I’m not a dummy about statistics, but I’m missing something here.
IM Doc I have been teaching medical statistics for 30 years – so I will be happy to do my best here for the commenters.
This is usually done with graphical tables and white boards – trying to do this in text will be interesting but I think it can be done.
This is probably going to be a bit long – so grab some coffee.
I start off every group of students I have ever taught with a simple statement – “Statistics are very simple if you do not turn off your common sense.” If one is trying to be dishonest or to make his claim look better that it actually is – it is often very easy to find all kinds of statistical contrivances to do that for you. My job for decades has been to show students every dirty trick in the book. The relative risk reduction trick is one such thing that Pharma uses constantly to overstate their results. In and of itself it is not a problem, as long as you know exactly what it means and what you are looking at.
In the original mRNA vaccine trials, the endpoint in the analysis was the relative risk reduction of about 95%. That does mean something. But it is not what is being presented to the American people. How do I know? I talk to them multiple times daily. They clearly have not a clue what this means. They are being told the vaccines are “95% effective” which is interpreted as you take the vaccine and you have a 95% chance of not getting COVID. THIS IS ABSOLUTELY NOT TRUE. That is a blanket efficacy statement and has nothing to do with the relative risk. This has never that I can tell been explained – and I can see easily how uninformed laymen can make this assumption.
The original Pfizer trial had more than 40000 participants. For simplicity sake for your understanding, I am going to make the denominators a round number and make sure the numerators are ratioed exactly the same as the Pfizer endpoints. That way you can understand better and wrap your mind around the numbers easily.
Let us say that the vaccine arm had 1000 participants and 1 got COVID.
The placebo arm had 1000 participants and 20 got COVID.So actually in the vaccine arm 999 people did not get COVID – so the efficacy number if we were doing this by the blanket approach that the vast majority of Americans would understand is that vaccine actually has a 99.9% effectiveness. That is correct. But wait a minute – that is not 95%.
BUT THIS IS THE CATCH and this is the IMPORTANT part. When you make this blanket kind of comparison – you then have to have a second sentence. That would be the following – However, THE PLACEBO in the other arm prevented 980 people from getting COVID. That is right – a saline injection prevented 980 out of 1000 or 98% from getting COVID.
IN OTHER WORDS, using a SALINE INJECTION has a 98% effectiveness for preventing COVID – if you use the numbers the way this is being presented to the American people.
But the difference between the two arms is really quite minimal when you put them side by side:
99.9% in the vaccine arm ———- 98.0% in the placebo arm –
An actual reduction in risk (known as the absolute risk reduction) of 1.9% The actual number is 0.019.The relative risk reduction is a statistical contrivance – generated by taking the number of events in the placebo group (20) and subtracting from that the number of events in the vaccine group (1) – and placing that number (19) – over the placebo number ( 20)
20-1/20 19/20 0.95 95%
That is where the 95% comes from.
The way most normal people think, again because I talk to them daily, they would understand the absolute risk ratio – the vaccine prevented 1.9% more COVID than the placebo. That is right 1.9%. The relative risk though is 95% – and that is what Pharma uses all the time in its glossies and ads. Please note (think about this the way the American people are being led to believe) the placebo success is 98% – which is even higher than 95%.
Because of this discrepancy – another way to look at the data has been derived from statistics – and it is called the Number Needed to Treat – in other words in this case – how many people need to be vaccinated to prevent one person from getting COVID. This is very easily calculated by this equation 1/absolute risk reduction — in this case it would be 1/0.019 which works out to 52.63. 52 people are being vaccinated with no benefit for every 1 person that gets benefit..
The big problem here is that relative risk reduction becomes more worthless the higher the number of subjects are compared to the actual signal. Having a placebo group of 20/1000 and a vaccine group of 1/1000 really skews the value of the relative risk reduction because they are so close together in a sea of people who were never affected. Accordingly, it is a very very poor way to describe efficacy in any vaccine trial – not just COVID. But they used it because it sounds so good. 95% sounds so much better than 1.9% ( They have been doing this for years – trust me).
Let me give you two simple examples from history about drug efficacy and these numbers.
In the early 1950’s a drug called isoniazid – or INH for short was introduced into the market for TB. In one of the very earliest studies done by researchers to Tulane in a Louisiana TB asylum, there were 70 patients (not 40000 as in the COVID trials). They were split into two blinded groups – 35 given INH for 6 months – 35 given a placebo for 6 months.
The end goal was eradication of TB from the sputum..
In the INH group – 33 out of 35 had eradication. 94% or 0.94
In the placebo group 1 out of 35 had eradication. 3% or 0.03The absolute risk reduction is 91% or 0.91
The relative risk reduction is 33-1/33 32/33 97%.
The number needed to treat is 1/0.91 0r 1.1
So in other words 1.1 patients needed to be treated for every 1 with benefit. The drug is a magic bullet – almost everyone benefited.
And the absolute risk reduction (which most people would understand) and the Relative risk reduction were both above 90. An absolute stellar performance – and the drug was indeed foundational for TB therapy.
Now – let’s do another drug that is not so successful – but was profoundly marketed by pharma using the relative reduction.
That would be FOSAMAX for osteoporosis.The original study came out in the 1990s. There were 560 women on the drug – and 542 women on the placebo. The endpoint of the drug was prevention of hip fractures or vertebral compression fractures.
In the FOSAMAX arm – 22 fractures out of 560 patients – 22/560 4% 0.04
In the placebo arm – 36 fractures out of 542 patients – 36/542 7% 0.07We have an absolute risk reduction of 0.03 or 3%
We have a relative risk reduction of 36-22/36 or 0.39 – 39%
There is a number needed to treat with this drug of 1/absolute risk reduction – 1/0.03 of 33. What does this mean? 33 women had to take the drug – pay the 900 dollars a year, endure the side effects of GI issues, and brittle bones, and jaw necrosis, teeth falling out – for 1 women to avoid a fracture. Not too impressive.
But all the while – Pharma glossies – and the TV were screaming at women – there is a 40% improvement in your bones. Oh yes, oh yes they did. If you look at ads from the era the 40% is big and bright and there is a little footnote – with microscopic type telling you this was a relative risk reduction as if your average American had a clue what that meant. It really is a scam. And the same thing has been done with statins, with psych meds, with diabetes meds, you name it. I can pick up any pharma ad right now – and this tactic will be there.
I am very sorry that is so long – I know no other way of doing this. I have gotten to the point that I have written out a handout for my patients. I feel it is imperative that each and every one understands exactly what these numbers they are being shouted down with daily mean.
Vaccines are usually measured on how they affect the immune response and how they affect morbidity and mortality. The only other one I can think of that ever used Relative risk reduction of case numbers is the shingles vaccine – and for obvious reasons – that disease process really is a case number kind of thing.
The relative risk reduction of case numbers is a very very poor measurement of any other type of vaccine because we are usually dealing with tens or hundreds of thousands of subjects and cases that may number in the dozens. The more stark this contrast is the more useless is that relative risk number.
The other important thing to realize is that because the way the relative risk is calculated, small differences in the numbers are actually quite large on a population basis. So when Israel came out this week and announced that the Pfizer vaccine is only 64% effective against Delta – I want everyone to understand – that is a HUUGGE discrepancy – far more than the “31%” implied. (I am assuming that the 64% is actually the relative risk reduction they are seeing in their current numbers – they never actually said – which is another entire issue that I am getting really tired of).
I am mortified that our agencies are playing this Pharma game of using these statistics to goose their vaccine’s efficacy in the public mind. I really should not be though – this has been standard operating procedure for as long as I have been a physician.
ambrit Thank you for the lesson. I’m printing this out to keep handy for when I see similar tactics tried.
Carolinian I follow what you are saying but leaving aside the vaccines and their marketing it all circles back to the original debate about whether the danger posed by this disease is at all proportionate to the overwhelming response that has resulted. If society is going to heroically intervene to make sure covid is reduced to zero then even that 1.9 percent is significant. Perhaps it’s the goal itself that should be debated but this of course will get you kicked off Youtube.
Myself, I’ve given up on arguing about this but just want to make that point.
Sorry, for some reason the formatting stopped being carried over starting here - hopefully it'll be obvious which comments refer to which.
IM DocI have been a Dem my entire life.
I have seen the major transformation of my profession into a wealth extraction unit.
In almost every case, it was my Dem party that initiated these changes and could not wait to make it worse.
Probably the worst that occurred was the dismantling and centralization of our public health system that the Obama administration was largely in charge of.
We are now paying for this dearly.
In the early stages of this pandemic In feb and March of 2020 when things that would have helped to cause the virus to go to extinction, Trump was stymied at every turn.
Close international travel to China.
You’re racist screamed Biden.
Go eat in Chinatown said Pelosi.
That is when it really mattered.
Now we are just figuring out the best path to endemic status.
Yes I cannot stand Trump. With regard to Carlson – he has had on guests that at least make you think.
I quit listening to Rachel Maddow last year. The constant “all truth only flows from the government sctick” got really old and Chairman Mao and the Red Guard were so much better at that.
What I am saying – there is no debate on the left – seemingly only suppression and towing the line.
That is so not what I wanted in a liberal progressive party.
I do despair sometimes. It seems every part of our polity is headed for disaster.
I guess my rage is so much more focused on dems because I expected so much more.
LifelongLib Most of the so-called PMC live off paychecks and can be fired. That makes them “workers”. Yes, there are social/cultural barriers between (say) “physical” and “mental” workers, people who went to college as opposed to trade school, and managers vs the managed. But all are very much in the same economic boat, and float or sink together. Separating out the “PMC” as a separate group with unique economic interests obscures more than it reveals.
Ahimsa @IM Doc
Thank you so much for this!
I have been pulling my hair out trying to explain this to friends and family about the Vaccine Efficacy numbers that are repeatedly touted and how BOTH the Absolute Risk Reduction AND the Relative Risk Reduction are critical to understanding.
If you will allow me a short trivial example I use to when speaking to friends:
Imagine an unvaccinated control group of 1 million where 10 people get a fatal disease infection.
Now imagine a vaccine test group of 1 million where 1 person gets the fatal disease.Relative Risk Reduction 9/10 = 90 % (looks great, right!?)
Absolute Risk Reduction 9/1,000,000 = 0.0009% (absolute effect is much less impressive)Therefore, it is critical to know the Abolute Risks involved before you can make an informed choice around a vaccine touting Relative Risk Reduction.
(Note: Obviously, the numbers used above in my trivial example do not relate to Pfizer’s actual numbers but are designed to highlight the potentially misleading nature of RRR values.)
And as you alluded, the metric of Number Needed to Treat has been completely underreported.
I really recommend an article currently in WIRED magazine which is highly critical of the CDC and its director Rochelle Walensky. It goes into some detail on the nuances when considering the individual risk-benefit analyses for healthy teenagers. IM Doc will appreciate that the article also challenges the very idea of “mild” myocardiatis cases in teenagers. https://www.wired.com/story/the-cdc-owes-parents-better-messaging-on-the-vaccine-for-kids/The CDC Owes Parents Better Messaging on the Vaccine for Kids
The agency’s strange math and blunt statements are missing key nuances—and may be underplaying myocarditis cases in teenage boys in particular.…Walensky cited a string of statistics that showed “the benefits of vaccination far outweigh any harm.” But some epidemiologists, public health experts, pediatricians, cardiologists, and other scientists dispute the CDC’s numbers, characterizations, and conclusion. The agency, they variously contend, is both exaggerating the risks of Covid-19 to young people and underplaying the potential risks of the vaccine to them.
…The absolute risk of the vaccine still appears to be extremely small for young people but, on balance, when the data are seen through a different frame, the relative individual risk from vaccination, particularly for healthy young males, may be higher than it is to not be vaccinated at this time.
…frankly, being in the hospital at all, is not a condition most people would associate with the word “mild,” even if some clinicians may describe it this way. Even on that point there is some dispute. Anish Koka, a cardiologist in Philadelphia, put it plainly: “There is no such thing as mild symptomatic myocarditis that puts a young person in the hospital.” He continued, “If you want to redefine ‘mild’ in the context of the pandemic, fine, then say you are doing that. I’m not against vaccines. But we need to be nuanced about how we talk about this.”
Ahimsa To follow up on something IM Doc alludes to – there is a perhaps non-intuitive progression of Vaccine Efficacy.
99% Vax Efficacy means 1/100 risk ratio (between unvaxxed and vaxxed
95% Vax Efficacy means 1/20 risk ratio (tho’ only a drop of 4% in VE)
90% Vax Efficacy means 1/10 risk ratio
50% Vax Efficacy means 1/2 risk ratio64% Vax Efficacy (as reported in Israel this week) means ~1/3 risk ratio.
And another bug bear of mine is that Vax Efficacy numbers are differentiated against a specific outcome. That is to say, the Efficacy varies depending on whether we are talking about efficacy against infection/symptoms/hospitalisation/death!
Brian Beijer Thank you for this! I am also going to save this for the future. The only thing I didn’t quite understand is:
the Pfizer vaccine is only 64% effective against Delta – I want everyone to understand – that is a HUUGGE discrepancy – far more than the “31%” implied.
So, are you sayiing that Pfizer had implied that their vaccine was only 31% effective against Delta and that Isreal was disappointed it was only 64% effective? Where does the 31% come from? Sorry if this is a stupid question. I just can’t get my brain to understand that sentence.
Stephen the tech critic Thank for your this detailed explanation of your reasoning about relative vs. absolute risk reduction and how Pharma uses the former to promote drugs which are not necessarily in the best interest of patients.
The two examples you gave make clear that relative risk reduction (RRR) is not the “end of the road” for deciding whether a particular treatment is medically indicated. Now please correct me if I’m wrong, but I believe that the Number Needed to Treat (NNT) isn’t really the end of the road either. The real goal is to balance the potential treatment benefits with the potential treatment risks (from side effects, among other things). NNT directly indicates the proportion of patients who benefit from the treatment *over the trial period*, but careful consideration of those words I just wrote points to some crucial caveats, a couple of which I will highlight here as both are relevant to the vaccines.
First, with regard to the FOSAMAX trial, while I’m inclined to be highly skeptical of the drug’s utility, given the data you provided, I’d want to know other things before reaching a firm conclusion. (I’m speaking rhetorically here. I’m not requesting anything more from you.) I’m not just talking about rates of side-effects but also, the *duration of the trial*. Why? Because the longer the trial, the more likely patients will fracture their hips or vertebrae during that period. So if the trial period was only 1 year long, the benefit (if any has to be had) may not be nearly as apparent as it might be after 10 years when a lot more hips will (hypothetically) have been saved from fracture. The absolute risk reduction (ARR) often increases with duration in this way unless it’s normalized with respect to time somehow, for example in the way economic stats, collected at different intervals, are often “annualized” to make them easier to compare.
Recall a few months ago all those extremely rosy “breakthrough ratio” figures like 0.04% that the CDC and others were hyping through the media to show “how well” the vaccines were doing. The problem? The trial period, between when each subject became “fully vaccinated” (plus two weeks) and the end of the sampling period was extremely short for most subjects. Most fully vaccinated people had just gotten their shots, which was clearly evident by looking at the daily vaccine trends. Furthermore, by the time most people had become “fully vaccinated”, the daily case rate had already plummeted from its wintertime high, meaning people were encountering the virus in the environment much less as well. Both the duration of the data collection period and the daily case rate (effectively, the *baseline risk* of catching COVID) impact those percentages substantially. The hyping of these figures was extremely misleading to the public. In fact, I attempted to estimate the *real* breakthrough ratio (which is just 100% minus the RRR, I think) using a crude model, and time series data of daily cases and vaccinations. I came up with around 75-80% RRR, but then I noticed that the two datasets I was using had major consistency problems that I could not reconcile. Hence, I did not bother to publish my work here.
So not just the trial period but also the background risk of catching COVID affect the absolute risks and the ARRs where the vaccines are concerned. The latter is very much in contrast to the two examples you gave. In the TB trial, everyone was already sick and not likely to recover without intervention. Their “baseline risk” was almost 100%, so any relative reduction translated readily to absolute reduction as well. In the FOSAMAX trial, the baseline risk of fractures (normalized for time) likely remained fairly consistent between the trial and “real life”. Unless older women collectively engage in an extreme sports fad or go through other major nutritional or behavioral shifts, the baseline risk of fractures likely remains about the same between the trial and the “real world” at times in the near future.
Contrast this with the pandemic and the vaccines. In the pandemic, the baseline risk is extremely variable depending on the prevalence of COVID (modified by some NPIs like masks/ventilation) wherever you are at any given time. Not only were the vaccine trials short in duration but they occurred during a time in which baseline COVID risk was actually quite low compared to where things went in the winter. Suppose we kept in place all the NPIs like distancing, contact tracing, restricted travel, masks, etc. which were widespread then and we managed to keep variants from evolving too much. This would keep the baseline risk low enough as to make the net benefits of the vaccines questionable. Until recently, places like Australia continued to follow stringent elimination policies, and for them, the vaccines made essentially no sense—that is until their recent public policy changes that is!
Now, with the public policy shift toward ending all NPIs, and given that the vaccines don’t stop transmission, we are basically being subject to or about to be subject to a very high baseline COVID risk. If the virus is allowed to spread everywhere, which is where policy in the US and other places seems to be taking us to, then we’ll be more like the TB patients, and even “65%” effectiveness will mean a lot if it means staying out of the hospital. Let me emphasize that this “benefit” from the vaccines is entirely contingent upon the highly dangerous and irresponsible public policy that we have!
Think about that for a moment. The assault on our health by TPTB through our corrupt and negligent government is what is enabling Pharma to “save us” with their “technology miracle” vaccines (or so we hope). When the vaccines were first being hyped, I speculatively compared them to the Boeing 737 MAX debacle and suggested there was a high likelihood of a catastrophic outcome. I am still in wait-and-see mode in that regard, but I nevertheless “boarded the MAX” myself (via Moderna) as I could see where the public policy was going. I saw the metaphorical gun barrel being turned on me.
I likely caught COVID back in March ’20, and the “95% efficacy” reported by Pfizer was based on a very narrow definition of “symptomatic” disease which did not include *any of my symptoms*. (I couldn’t get tested then because I didn’t have the “right” symptoms and it was early. More recently, I spoke with the people I think I caught it from and they too suspect they had COVID but couldn’t get tested to confirm.) Furthermore, the “not symptomatic” case I suffered was followed by waves of additional symptoms over the year. Both the acute and extended phase of symptoms were mild relative to what a lot of people suffer, but they were still substantial. Some were quite concerning, such as numb toes (which I eventually traced to muscle and/or joint inflammation in the leg and ankle), brain fog, multiple episodes of conjunctival bleeding (“Pence eye”), and fits of dizziness after eating (which in hindsight may have been indicative of hyperglycemia). By the time I got vaccinated in May, I had been feeling almost back to normal for a few months, but unfortunately the vaccine triggered both a strong acute reaction (~75% of the original symptoms plus a new fever delirium) and more long-haul symptoms (mostly the muscle / joint inflammation, fatigue, brain fog, and disturbed sleep patterns). These persist to today.
So on a very personal level, that 95% figure is pretty much rubbish because it says nothing about protection from what I experienced, which has definitely degraded the quality of my life more than a cold or flu would have. I presume that, in general, reducing the severity of illness also reduces the severity of after-effects, but I think we’re all in the dark as to how well the vaccines really work in this regard as well as with regard to how long these symptoms will typically last in people and how they will affect morbidity in the long-run. The recent numbers I saw suggesting (IIRC) ~0.6% morbidity after 6 months in *all* COVID recovered patients were not encouraging. Many of those who made it to 6 months may still end up prematurely dying given more time, and it wouldn’t surprise me if ultimately “long COVID” ends up being the more deadly form of the disease.
IM Doc All of your comments are very important.
I hope you can understand how complicated medical statistics are and the care which must be taken when interpreting and sharing them with patients.
Hence my extreme disappointment with the way we have just been throwing numbers around.
What I did above is just the basics. Going into the woods is not appropriate for this kind of forum.
With regard to your last paragraph. My biggest fear after months of taking care of covid is actually long covid. Unfortunately, I am now beginning to see many patients with similar symptoms after the vaccines. We have a lot to learn about covid and we have a lot to learn about this first if its kind in world history vaccination program.
A 24 year old whom I know through zoom church meetings has caught covid. He does not seem to be having a terrible time; he is mainly coughing a lot, but of course who knows if there will be long term effects. He’s in England; he was not vaccinated due to the shot not yet being available to him. He was working as a substitute mailman so he was out and about, but I’m sure he wasn’t partying in big groups. But here’s the thing – he has infected both his father and his boss. They were both fully vaccinated (I don’t know which vaccine), but they caught it from him anyway. I don’t yet know how sick they are. I presume this is the Delta variant.
This anecdote has sunk into the consciousness of an older church member I know here in Silicon Valley. He really felt as if being fully vaccinated made him safe; last week he went to a graduation party. It was outdoors, but it’s been clear for a while that being outdoors doesn’t help as much with Delta. I’ve told him countless times that he can still catch and transmit, and he’s well educated and otherwise rational but he just didn’t “get” it. He also read about the Texas Democrats on the plane and that helped open his eyes as well. Now he does “get” it.
Now people like him are bargaining with fate – “but it won’t be a serious case!” I hope they’re right but looking at who is hospitalized in Israel I don’t think they will be.
Mikel Outdoor events…no one mentions that they all had to go to the bathroom.
Not event talked about much in return to office conversations.
What kind of air filters and other ventilation is being talked about for restrooms? What about lids for toilets foe when they are flushed?
Lambert Strether Fomites are a logical concern, but there is no epidemiological study I know of that shows actual transmission, even if not the main means of transmission.
I would have expected a study to have shown up from India at this point, given that they have big problems with sanitation.
I think it’s good to be careful in general, but the days where we were obsessively cleaning our doorknobs and washing vegetables are gone.
NOTE Fomites were, of course, what the
dinosaursexperts at WHO and CDC blamed for tranmission at the famous Skagit Choir cases, but further study ruled them out:At the time of the chorale rehearsal on 10 March 2020, because of emerging concern about SARS-CoV-2, person-to-person contact and touching of surfaces was consciously limited, and hand sanitizer was used. No one reported direct physical contact between attendees to the County Public Health investigators.22 Although some choir members helped arrange the chairs and ate snacks during the intermission, the index case did not participate in these activities, and many other members reported not eating the snacks.22 Thus fomite transmission from the index case via chairs or snacks can be excluded. The index case used one of the bathrooms during the event and thus touched the door handle and other surfaces there, but only about six other choir members used that restroom (see Supplemental Information), and many choir members who did not use any of the restrooms were also infected. Indeed, the clustering of infected cases on the seating chart does not support transmission from a point surface contact(s) unless the people who sat together all touched the same contaminated surface. Thus, it appears highly improbable that the direct and indirect contact routes could account for a significant fraction of the transmission during this event.
drsteve0 I suspect what Mikel meant is that when a toilet is flushed a lot of aerosolization can occur.
square coats I had been wondering about public bathrooms too with regard to aerosols, since it turns out that when you flush a toilet it has an “aerosol effect”.
From webmd: “According to the research team, flushing can generate large amounts of airborne germs, depending on flushing power, toilet design and water pressure.”
Aerosol generation in public restrooms (Phys Fluids, 2021): “Covering the toilet reduced aerosol levels but did not eliminate them completely, suggesting that aerosolized droplets escaped through small gaps between the cover and the seat. In addition to consistent increases in aerosol levels immediately after flushing, there was a notable rise in ambient aerosol levels due to the accumulation of droplets from multiple flushes conducted during the tests.”
(not sure if maybe Mikel was alluding to the aerosol effect as well)
Apparently also known as a “toilet plume”, MIT offers a possible answer: “we have to acknowledge that live virus may sometimes be present in feces, though it’s possible this occurs only rarely or only in the case of very severe illness. This makes it theoretically possible that live virus could be present in a toilet plume, resulting in aerosolized droplets and contaminated surfaces. […] Individuals would also have to inhale a sufficient amount of the virus to become infected, he points out. “Even in the unlikely case that a toilet plume aerosolizes some viral particles, you probably wouldn’t be in the vicinity long enough to come into contact with enough virus to make you sick,” he notes.”
Lambert Strether Yes, I know about fecal plumes and I understand the logic. (IIRC, there was a SARS fecal plume that went up a chase in a Hong Kong apartment building and infected several platforms.)
Put the lid down when you flush!
That said, although again it makes sense to be careful, there are no epidemiological studies that show fecal transmission for Covid.
Keith That’s the thing I have been wondering about. Is the jab really about not getting COVID or just not getting hospitalized from it? I tried looking into it before I got it, but couldn’t really find much, aside from authorities saying to just get it.
I think it is an important issue, if true. I supposed the other issue is the seriousness of the delta variant. Is it as bad as the original, or like others have said, it is much more milder.
Cuibono sadly that was NOT studied in the RCTs. lots of real world data that is subject o all sorts of problems
drumlin woodchuckles That was my understaning. The mRNA neo-vaccinoid was designed to keep you from getting less sick from the covid it was never even intended to actually keep you from getting, technically speaking.
It was only meant to make you get less sick.At my age and with my co-morbidities, I decided it was worth the risk. So I got the moderna brand mRNA neo-vaccinoid.
Milton So it’s less a vaccine and more a prophylactic?
chris The vaccines we have were developed to prevent severe disease and death from COVID-19. It seems that they confer other benefits too, but, they do not provide sterilizing immunity to SARS-CoV-2.
drumlin woodchuckles Its not a classical dead virus or attenuated virus vaccine. Its a new and different technology. So I tried to create for myself a new and different word to describe the newness and difference of this not-a-classical-vaccine.
And “mRNA neo-vaccinoid” is the best I could come up with.
Lambert Strether > Is the jab really about not getting COVID or just not getting hospitalized from it?
To me, the jab is about:
1) Really good odds of not being hospitalized or being very sick
2) Good odds of not getting sick
3) Less good but still real odds of not transmitting.
To me as a personal matter, #1 is sufficient.
As a policy matter, #3 really, really worries me.
Adding, I don’t know if the Delta variant is inherently milder, or (a) we have better treatment now, so people don’t get as sick, or (b) it’s hitting a younger and stronger population.
drumlin woodchuckles Could there also be a choice 4) . . . . that widespreading Delta cases will seemfeel mild in the acute now, but will leave behind body cell microdamage which will show up as “premature onset” chronic diseases of old age or other chronic disease? Or also leave organ systems with zero margin of safety so that an otherwise survivable disease becomes non-survivable?
Like if Delta covid silently attrits my kidney function down to 50% and then I get something else which removes the other 50%, I will be left with 0 % kidney function where otherwise I would still have had 50% kidney function left if not for getting Delta covid?
Is that also a mass-demographic outcome we should expect and will see starting in 25-30 years?
IM Doc I think you are very right.
I studied the stages of grief from Elizabeth Kubler-Ross years ago when I was a medical student. It has served me well with individuals dying or undergoing some other tragedy.
Now, unfortunately, I think we are going to be experiencing these stages as a society the next few weeks. The first stage is denial – I think our media and federal officials are still there – but the people for the most part are beginning to move on. The next stages are bargaining like you stated above and anger/rage. In my experience with individuals those two often happen at exactly the same time. I do think this next few months has the potential to be a very fraught time. Please take care everyone.
I have been providing updates on the situation from my little slice of small town America for the past several months. Since we now seem to be entering an impending wave or at least “something” I am going to write this out in the comments weekly. I do think it is important to know how this virus is being lived out in the real world of flyover country and away from the large metropolitan areas. And the bumbling on the TV is about as alien to what is happening on the ground here as if it were being broadcast from Alpha Centauri.
I live in a county where the vaccination rate among those over 70 is right at 90% and those from 18-70 is right at 50%. That seems to be way better than most of America.
In my own personal practice from the last week – JUL 12th through JUL 18th there were exactly 27 positive COVID patients – 70% vaccinated, 30% unvaccinated. As has become apparent for the past few weeks – the vaccinated patients are more likely to be a bit more ill. They have much deeper coughs, X-ray changes and fever more commonly than the unvaccinated. One thing that has also become clear for the past few weeks is how often the vaccinated come from clusters of groups that have multiple members fall ill – ie social events, civic events, church activities, etc. The unvaccinated are mostly lone events.
Please note – the reason there may be more vaccinated – is the unvaccinated are trending toward younger people – and they may not come to the doctor. But the facts are that there are plenty of vaccinated patients becoming positive as well – and going all over the community sans masks and spreading the wealth.
Not one of my patients has become remotely ill enough to be in the hospital. We had a close call a week ago – but that individual has had a full recovery. In the community, however, we have had 3 vaccinated patients become very ill and need to be transferred to a higher level of care. No one unvaccinated has been in the hospital. All 3 were very high risk, older, obese, diabetic, etc. At the time of this writing, all 3 are doing very well.
The tempo seems to be picking up dramatically, however. So far we have had 11 patients just this AM calling in with colds and coughs and fever. All are being tested – no idea what the results are yet.
As of now, it seems there is a high percentage of vaccinated who are becoming ill and positive – much higher than advertised. At the same time, the level of illness has remained relatively low – so at least we have that good thing.
But there is a bigger problem brewing.
Life in small town America – can be quite clarifying – as in crystal clear.
I have been a denizen of big mega-cities all my life – so this is all new to me. But I am able to see aspects now of why rural America may have a bit more skepticism toward the authorities.
You see, it has been being reported in the local news that we have very minimal cases and all the positive patients are mostly unvaccinated – go and get the vaccine and save your town, etc. All of these positive vaccinated people are just not being counted – but that does not stop them from these misleading statistics being broadcast.
And I know Kamala Harris laments the fact that we in rural America do not have the ability to do photocopies – but trust me – these are among the brightest people I know – they can do math.
So, the Mrs and I were in our Sunday School Class of 150 yesterday. The preacher got done with the lesson early – and looked at the crowd and basically announced that we are going back on the war footing in the church effective today. Absolutely none of his widows, widowers, anyone over 70 or anyone with severe medical problems will be going out for groceries or mail or drugs or anything – we are starting the church plan again where the young people will get their stuff and deliver it. And by the way – those helped will include anyone in the town at high risk. (They did this for 9 months last year – I could not be more proud of these people – there is a reason my county is in the top 5% of mortality statistics).
And then he looked right at me – Doc – do you know why I know of personally more than 20 vaccinated positive patients and our papers are not talking about that? Should we be careful with these people too? —- Jaw dropped to the floor – but for sure – I am not going to get involved in this misrepresentation – I have been pissed for months about the whole situation….. NO SIR – I have no idea why that is happening – but I applaud your efforts. Everyone needs to be told to get out in the sun, VIT D 2000 units daily, exercise, lose weight, get your blood glucose down. The most important thing – LOOK OUT FOR ONE ANOTHER. I want this whole mishmash about vaccinated vs unvaccinated to just pass us by – We need to rely on each other now more than ever. AMENS from every corner.
The issue – the powers that be are just not going to be able to hide anything from people forever – public health is all about brutal honesty – and the blowback will be severe once the deception is obvious and once the storms have passed. Things like this become much more obvious in small towns – way before they do in the big cities where the media denizens are located.
Did I ever think I would live to see an old clergy member making more sense than our federal public health?
Commenters, I do not know what we are going to be facing in the next few weeks. It may be bad. It may be a nothingburger. But please – take care of yourselves. Take care of your families and friends. Look after one another. We are all actually in this together.
Godspeed.
Lambert Strether > 70% vaccinated, 30% vaccinated.
I think that’s 30% unvaccinated?
IM Doc Yes – sorry – 70% vaccinated – 30% unvaccinated
Keith Thanks for all the info you share. Not sure if this is a proper question, but do you notice break through cases happening more with one vaccine than another? Is it even something the medical authorities are looking at?
IM Doc I would guess (and it is a guess) that we are about 50/50 Pfizer/Moderna – there is a very small contingent of J&J. And, no, I am seeing no difference between the vaccines at all.
kazy “the vaccinated patients are more likely to be a bit more ill. They have much deeper coughs, X-ray changes and fever more commonly than the unvaccinated.”
Why do you think that those who are vaccinated are more severely ill when they have the virus than those who are unvaccinated who contract COVID 19? Are you suggesting that something in the vaccination is making them sicker?
IM Doc At this point – I am not suggesting anything –
In my personal dealing with patients – I am observing – and reporting what I am seeing. I am sharing what is happening on the ground in my life. Answers to this would require virology labs and lab staff – completely unavailable to 99% of America. When/if I ever have any clue why this might be happening – I will let everyone know. Or it may change and I will let everyone know this as well.
I am reporting only that which is seemingly happening too often to be random chance.
I am hoping that everyone who is vaccinated (and unvaccinated for that matter) will pay attention and realize that if they are feeling ill in any way they really need to stay at home and call their doctor. And I mean that. Anyone at this point who is having a cough or congestion should be at home and not walking around the grocery store with or without a mask. I think we are all taking this a little too lightly.
Thanks Doc. I join the chorus in praising your efforts.
As the evidence mounts suggesting that there is actually quite good natural immunity derived from having been infected, are you getting any sense of its durability?
Also, is there any way to test for previous, though relatively remote (i.e. many months or greater than one year) infections, without having to accept a syringe through the sternum?
Thank you.
IM Doc Again, I do not have a virology or immunology lab handy in my office so those answers are simply not knowable. I am certain, however, this work is being done all over the country in these types of facilities.
However, one can assume things in roundabout ways from other evidence. I have been very careful to note if any of the positive patients (both vaccinated or unvaccinated) have been previously diagnosed with actual COVID. In my panel of patients, that number is right at 18% – counting all cases since JUNE 1. So there does seem to be a fairly significant number of breakthrough from previous COVID infections as well. I have not broken this down as far as timing. I have no data if these patients were infected 3 months ago or 18 months ago. But that does seem to be a fairly high amount regardless of the timing.
As I have heard from the beginning from many many virologists, in this family of viruses, and other respiratory viruses as well, herd immunity is just not a realistic endpoint. There are other commenters that can speak to this issue from much better expertise than I.
Aumua I still don’t see that there’s anything new appearing about the vaccines and their effectiveness, that we didn’t know months ago. They don’t necessarily protect you from getting COVID, from transmitting it or even from having symptoms. They do protect from life threateningly serious symptoms. I believe also that they do prevent infection altogether in at least some and probably the majority of exposure cases. Just look at the numbers. Infection and deaths have fallen massively in the U.S. since the vaccine rollout began. Yes in the U.K the cases have rebounded quite a bit, but deaths still remain very low (order of magnitude) compared to Jan and Feb. The vaccine may be less effective against some variants. Also not really a surprise.
The amount of speculation running rampant in the wild is very high about all this, and I would hope that we try and stay as grounded as possible here. I am willing to consider that my beliefs about the vaccines might be wrong, and that even the craziest theories could be true. But just because something could be true doesn’t mean it is true. I’m willing to accept even anecdotal data points too if they are coming from someone who has significant first hand experience like IM Doc. But even so that is still only one data point among many. It’s probably going to take a lot of evidence to move me from my basic position that the COVID vaccines are generally effective and safe, with some exceptions.
Basil Pesto The problem is when you say ‘nothing we didn’t know’, who’s ‘we’? The magic bullet theory of the vaccine was pretty widely disseminated, and was even a future assumption being made last year – eventually vaccines would come and everything would go back to normal. It’s losing steam now, but it had enormous traction for a long time without critical consideration of the unknowns regarding this new treatment. If health authorities and the journalists covering them had been up front about this from the beginning, it would have been better for all concerned, if we go by IM Doc’s formulation of trust being the sine qua non of public health.
The other issue remains over the questions and concerns about immune escape: That a decent vaccine in a population that takes no other controls (because the population has been running with the magic bullet vaccine theory; see eg the CDC’s Mission Accomplished performance) runs the risk of doing more harm than good in the long run, as more virulent and unmanageable variants of the pathogen develop in this amenable environment. It’s this line of thinking that led me to post this comment in Corbishley’s post late last week (reposting because I’m still interested in input):
I remain unvaccinated but am now a lot more interested in getting one as Australia seems to be on a bit of a delta knife edge.
A thought occurred to me this week as to how we might better conceive of the vaccinations, which has been my conception without really realising it until I thought about it this week: Thinking of them as a last line of defence, instead of a (or, in many places, the only) first line of defence. That’s to say, we should think of them, ideally, as a kind of failsafe, after taking various NPIs (border control, masking, ventilation) and prophylaxis (vit D, melatonin and the rest). This is instead of the prevailing “magic bullet” cure theory of the vaccine (although this theory is becoming less prevalent by the day).
I’d be interested in whether you & the other medical/Covid brains trust posters think this line of thinking has any merit/utility from a public health point of view, although I suspect it’s too late to broadly change the messaging now.
All of which is to say, vaccination remains a tool, as you rightly point out, but not the tool (because as it stands, there is no singular tool to bring this under control. The sooner this is understood broadly by the public the better off I think we’ll all be).
The Rev Kev Just had this medico on TV saying that we have to “learn to live with the virus” causing me to using many unchristian-like words. This was immediately after watching people wearing masks, deserted streets, lock-downs, testing ques, deaths, businesses shutting down, cancelled holidays, hospitalizations rising. That to me is what learning to live with the virus looks like. To hell with that noise. When I hear a medico talking that way, I am now never sure if he is talking advice from the medical/political establishment or whether he is talking his stock portfolio. That type of question was never on my bingo card as in ever.
Aumua You are right, when I say “we” I do mean we who are probably exposed to a higher quality of analysis and opinion than many. I suppose I personally never held any “magic bullet” beliefs about that vaccines because of that (still, they are having a positive effect). And I still see the mainstream constantly pushing the idea that continued spread of COVID is all on the unvaccinated, and that “breakthrough” cases in vaccinated people are extremely rare, like this article from today does. I think it’s becoming more and more obvious that breakthrough cases aren’t all that rare.
IM Doc I think what you are saying is generally very correct.
The appropriate studies were never fully and completely done on these vaccines, other than minimal studies about symptom reduction and case numbers. That may be what we are seeing right now.The big problem is that they are clearly non-sterilizing – they do not effectively help to end transmission. The issue there is that with a virus highly efficient at mutating – that allows many many more to be infected to give the virus many many more playgrounds in which to mutate.
We have never really introduced a non-sterilizing vaccine into an acute pandemic before. It is very unclear exactly what all consequences that will entail, if any. There are some concerns about this issue from the veterinary literature – but whether this virus has the ability to do what those animal viruses did in the past is really pure conjecture at this point.
Again – we are all just going to have to realize that this is a WORLD problem – this is not a DEMOCRAT/REPUB problem, an AMERICA/CHINA problem – a world problem – especially now that we are clearly headed for endemic status.
In our media I hear all the time that endemic status is fine – we just have to learn to live with it.
Let me clarify something very clearly – MALARIA is endemic – and it kills millions every year. HIV started as a pandemic and is now endemic – and kills millions every year.
To be “endemic” in infectious disease is not to be a “teddy bear” like it is being presented so often to the American people right now.
The vaccines were very effective against the original variant and the UK one, but less effective against delta. You’d have a lot more very ill and dead people from covid-19 w/o the vaccines. The vaccines targeting the spike protein are a decent short term measure until an effective approach that neutralizes the virus can be discovered.
IM Doc The problem is that if you are indeed allowing a vaccinated person to have minimal symptoms at the same time the virus is not sterilized, you have effectively turned that person into an incubator for more mutant expression.
And then multiply that person by millions. You have to think in large numbers here. Allowing this much genetic mutation capability is a real issue for future variants that could be a lot more toxic.
If the vaccines were sterilizing, the person would have no symptoms AND the virus would be inactivated and unable to change.
That is the concern with non-sterilizing vaccines. It is basically what could happen in the future.
To Lambert and Yves and all commenters here –
Sorry to have another update in just one day – but I think this is so illustrative of what is going on right now that I feel compelled to share.
I did not feel well when I got home from work last night. As the night wore on, I began to have a very severe cough, very loud wheezing (I do not wheeze), a mild headache, and a fever of 101. I knew exactly what was going on. As soon as I could, I called work to tell them I was not going in and headed right to medical care to be checked – and indeed I am now positive for COVID. I was fully vaccinated in mid April.
To me, this day was not and if but when. From the very first day in my internship in the big city in the middle of the AIDS pandemic – one of the leading internists in the country told my class – “We do not run from pandemics, we run into them.” My office of fully vaccinated staff has already had one wave of COVID go through about a month ago that somehow I missed – my time was up last night.
I am in great physical shape for my age – very healthy – and am already feeling much better today – I am going to be fine. But what has happened in the interim since this AM – has been eye-opening.
I was actually called by a health department phone operator within an hour or two of my diagnosis. They then put another administrative person on the line who informed me that I was vaccinated – and therefore no quarantine was necessary. I told them right away that was ridiculous – and I would be staying at home for now. Within 30 minutes, someone from the state health department contacted me – and I will be brief – informed me that it was very reckless for me as a physician to be talking about quarantine of myself a vaccinated person – the CDC has told us this is not necessary – you cannot spread the virus – doing this would potentially discourage others from vaccination – It may cost lives – My response – “so having me, a positive COVID patient, hang out in exam rooms or the grocery store with obese diabetic cancer patients is not going to cost lives? Please if you think I am being reckless – report me to the Medical Board – I will happily discuss this with my peers.”
These are the kinds of things that occur with pathologic lying. People actually begin to believe the accumulated lies are truth. All rational thought is completely clouded. I will state for the record – that neither person who spoke to me today was an MD DO RN or MPH. All administrative. I truly believe that most health care workers are beginning to wake up. I think a real genuine health worker would have rotted in hell before making such statements.
I called one of my old students/residents right after this call. He is currently the head of the Internal Medicine Dept at one of our big universities in Blue America. I was informed that out of the 20 or so faculty members in his division – all 100% vaccinated – 7 of them had become ill with COVID in the past few weeks. We kind of laughed nervously about the 95% number for relative risk reduction – and how we as a profession were about to learn that misrepresenting numbers like this to the public was a very bad idea. Then some profound statements from him ——
“I have been dealing with this nightmare called evidence-based medicine for years. Students and residents both now tell me that only peer-reviewed RCT are what they should be looking at – nothing else matters. They would not know the difference between a relative risk reduction and an incidence if they had to – they do not even bother to look at anything but an RCT – therefore they know nothing of medical statistics. This has been on full display for the world to see the past 18 months. Just look at any Twitter feed. We have a lot of work to do.”
And I, IM Doc, have several times discussed the human theater, the “stupid human tricks” of putting your vaccination photos on Facebook or TV as a motivator. And then spend days talking about the bad reaction you had to your vaccine – “I got really sick – Hallelujah – I know it has activated my immune system”. I got so so tired of that chestnut – but it was all over the Internet for months. Any vaccinologist, immunologist – etc – would tell you that was just horse shit. And now you know why that was a very very bad unprofessional thing to be doing. It literally motivates no one, and now there is going to be lots of explaining going on.
My old student today – “Actually the Facebook vaccination meme was the second worst thing. The absolute worst was the whole health care TikTok Video dancing – often done in ERs where there were lines of sick people waiting. It made me want to punch the wall. But now all these kids that put their Facebook vaccination photos online and bragged about it – are going to get to explain to all their patients and friends how they still got COVID after the vaccines – we have quite a few housestaff and students fully vaccinated becoming positive – not just the faculty.”
“Young Grasshopper – pride goeth before a fall”. There are those of us who have been warning that all was not well with our entire approach for months – and were laughed and scoffed out of the room. We as a profession are going to have a lot to answer for.”
All that is from my old student – now a leader in academic medicine – I am so so relieved – people are starting to wake up.
The take home message from where we are today –
These vaccines are non-sterilizing. That means they may limit or eliminate symptoms – but they do nothing for the spread. There are probably all kinds of vaccinated patients harboring active infections at this very minute and they have no clue – the vaccine is making them not sick. But they are sharing it with all around them. Many if not most of them taking no measures because the CDC told them they did not have to – YOU ARE VACCINATED. The good news for today is that the symptoms, hospital, and death all seem to be low. The bad news is all of these harboring the virus are further playgrounds for the virus to mutate. And when you allow it to become more and more widespread – the more likely a really bad mutant will come to the fore. That is THE danger of non-sterilizing vaccines being used for a virus that is profoundly capable of mutating.
My advice today – DO NOT PLAY INTO THE DIVISIVE UNVACCINATED/VACCINATED GAME – at this point and in the near future – it is going to become increasingly obvious this is just not a hill to die on. TAKE CARE OF YOURSELF and YOUR FAMILY. Find and identify any elders in your community that may need help. Plenty of sleep – plenty of sunshine – lose weight, exercise, eat well – vitamin D 2000 daily. AND SMILE. It does wonders.
God bless us all.
Are many vaccinated people getting sick enough to require hospitalization?
Sorry, there is evidence from Israel. Covid infections are proportional to the vaccination levels in the population. That implies the vaccines provide no/little protection against getting infected but do blunt severity:
https://twitter.com/itosettiMD_MBA/status/1413922415550291968
The US has no info because the CDC, as we have repeatedly said, is not recording cases among the vaccinated unless they wind up being hospitalized.
IM Doc says that via his regular Zoom meeting with colleagues who are affiliated with a major teaching hospital, that there are many infections among the vaccinated. They are seeing symptomatic cases and in this sample, the vaccinated are on average MORE sick. This may be sample bias, in that the elderly and those with co-morbidities would presumably have higher vaccination rates than the population overall. Recall that the elderly also have weaker immune responses. That’s why the winter flu vaccine has a separate, stronger over 65 version. And the vaccines had thin participation of older patients in the clinical trials.
This MD network is also seeing clusters of cases among the vaccinated (as in pretty much everyone in family groups) while the cases among the unvaccinated tend to be more isolated. That is a soft indicator that the vaccinated are propagating the disease (as in it is more likely that one member brought Covid into a household and it spread there than all members in parallel got it outside).
Now the vaccinated are presumed to be less infectious but there is no data either way due to the US refusal to gather any data. It is looking like they are contagion vectors, so even if less so, it doesn’t appear to be much less so.
Not IM Doc, but this one seems interesting:
RE: CDC Director Says Delta Variant Of COVID-19 Among ‘Most Transmissible’ Viruses Known
As I read CDC Director Dr. Walensky’s comments about the Delta variant, I noticed she was throwing around a lot of percentages, but no raw numbers. IM Doctor recently warned about this very tactic regarding Covid messaging from health officials.
For example, Walensky says:
The number of new cases has risen almost 250% since the beginning of July, and states with low vaccination rates, including Florida, Texas and Missouri, are experiencing some of the worst outbreaks.
Here’s another one:
Walensky said last week about 97% of people who are hospitalized with COVID-19 have not been vaccinated, describing the situation as a “pandemic of the unvaccinated.”
In the embedded video Walensky gets even more vague, saying:
We are at yet another pivotal moment, with cases rising again and some hospitals reaching their capacity in some areas.
It struck me that the CDC is sure interested in using case counts to scare everyone into getting vaccinated, even though they’ve stubbornly stuck to their guns about only being concerned about tracking and reporting Covid-related hospitalizations and deaths.
So this article is a case of the dog that didn’t bark. Why didn’t Walensky climb up on her hobby horse of hospitalizations and deaths because of this terrifying new Delta variant, which she says is the most aggressive and infectious she’s ever seen?
Using the graphs posted by Lambert each day in Watercooler, I took a look at what is going on in the measures the CDC says are so crucial.
Looks like new hospitalizations are about 9 people (18+ years old) per 100,000 the week ending July 17, 2021. They haven’t been that low since March, 2020.
Covid-related deaths are down to a daily rate of .76 per 1,000,000. They haven’t been that low since March, 2020.
Excess mortality rates are down to 2.63%. That is actually quite a bit below the excess mortality rate of 4.36% reported back in March, 2020.
According to the goalposts set by the CDC itself, we are in better shape than we’ve been in nearly 1 1/2 years.
I’m not saying the Delta variant isn’t something to be concerned about; just that the scaremongering from our fearless leaders continues.
I wonder how young doctors feel about their choice of career. I doubt they entered medicine and assumed the large debts to pay for med-school so they could work as employees of firms run by private equity or Corporate managers. I expect it might take some of the profession out of being a medical doctor.
IM Doc I expect it might take some of the profession out of being a medical doctor.
It has taken it right out.
I was in the big city for decades – in a large academic center. About 7 years ago or so – the faculty practices were consolidated into a large “non-profit” run by MBAs. Within a year – I realized I was in a company that may as well be run by vultures. That is literally what they are. The stated goals of the MBA profession are a direct 180 from the MD profession. The fact that these vultures are in charge of everything in a system where the “consumers” or patients are at their most vulnerable is a crime of the ages. My immediate elders when I was a young doctor that are all gone now would have scarcely recognized the current raping mantra employed by these companies. What has allowed this to happen? The pencil necked assholes in the Ivory Towers in Boston and NYC and DC who are MDs who never see a patient but tell everyone how to do it – and then it was hugely made worse by Obamacare.
I cannot stress upon everyone enough – if you have a choice – do not go to any physician that is affiliated with any kind of non-profit. They are often worse than the profit corporations, at least they have some accountability. And I know there are huge swaths of America that have no choice.
My wife was putting constant pressure on me – she was the first to realize that my job was literally killing me. We left the big city – and are now in a very small town in a very remote part of the country. The hospital is run by a board elected by the taxpayers – COMPLETE accountability to the community – and I feel like I have taken a step back in the past when I was young. It has been an incredible change in so many ways. Is it perfect? – NOPE – what in life is? But I can certainly live and thrive here – and not feel I am going to burn in Hell one day.
The elite have completely destroyed the profession of medicine – and have completely dismantled our public health system. Both were once the envy of the world. I hope and pray that we can all see in the past 18 months how vulnerable these losses have made the whole population to the predation of the elites.
I see no solution until we hit the brick wall.
re: Breakthrough Infections of SARS-CoV-2 Gamma Variant in Fully Vaccinated Gold Miners, French Guiana, 2021
About the French Guyana paper from the CDC
This is how science – the actual process – not the Fauci version – should be working.
I have repeatedly stated that I am seeing much much more vaccinated positives than one would ever have expected. As I have stated, they seem to be much sicker (though not critically so) and they tend to happen in clusters. For the past two months, this has stuck out from the dominant media narrative. I have never had to fight the cognitive dissonance between the media and my own eyeballs in my life.
I belong to a large non-public alumni group of my residency program that has literally thousands of IM docs all over America. The first thing a scientist does is to confirm that your observations are general or something you are just seeing. It was quickly obvious from that group that I was far from alone despite the “minimal breakthrough cases” media narrative.
So, then you do everything you can to hypothesize reasons why you are seeing what you are. I have been a physician for 30 years and that experience plays a huge role as well. Having this gigantic number of breakthrough cases just simply does not happen. I continue to see more than half the cases in vaccinated patients and so do many others. UNHEARD OF IN VACCINES BEFORE NOW.
Part of hypothesizing why is looking to the literature for evidence. Seldom is this found in RCT at this stage. Case reports and series like this paper are critical. They are seeing the same breakthrough ratio. And they have done a lot more viral research than you can. This is a gold mine for my own questions.
Is there anything in the paper that could possibly explain what I am seeing. Lots of times, it is not in the headline part but in all the test results and discussion. And yes, there is a very important finding deep in the results.
Why would clustering and sicker patients be so much more common in the breakthrough patients – there must be a reason for that?
If you look at the brief discussion of cT or cycle threshold you will see that the vaccinated patients have a SIGNIFICANTLY lower cT than the unvaccinated. That is the way the PCR test works. It basically means the vaccinated have a much higher amount of viral active particles than the unvaccinated. That would account for the breakthroughs I and my colleagues are seeing being a bit more ill. And it would explain the clustering. THe vaccinated breakthroughs have much higher viral load so they are much more contagious and the higher viral load makes them more symptomatic.
So we now have a suggestion and strong evidence that the vaccinated population may be spreading much more virus than the unvaccinated. I would say that is a critical public health issue and must be further researched immediately.
This Certainly needs much more work. THis is not confirmatory of any conclusions. But it is consistent with observation on the ground – unlike most of what the media has been spewing to the American people. But this is how science works. This paper is about the gamma variant but a conference yesterday with experts discussed that similar findings were being found in delta and lambda. The suggestion in this paper is now on the front of my mind. I am even now thinking of ways to confirm or falsify these conclusions going forward. This is science.
Another issue. The writers make the point that the breakthrough rate is extremely divergent from the expected rate. The difference is this paper documents what is happening in REAL LIFE. So much of what we are hearing on our media about vaccine efficacy is research being done in vitro. It is presented as gospel truth. I just want to scream.
I am doing great and thanks for all the kind words. More about my week later. The commenters here are the best in the internet and I so appreciate my time here.
Shonde First of all, thank you for sharing all your on the ground observations.
A question: You were tested for the virus and found positive. Do you have any idea where your test landed on the cycle range when you were found positive?
Shonde After posting, I realized this is a personal question. I withdraw the question.
IM Doc Because I am a very persistent physician – they did share with me the number – 18. And later this week I did find out it was the delta variant. If the delta variant has reached my remote location – you can be assured it is now everywhere.
The subsequent tests I have done they have refused to supply the number.
I was fully vaccinated in mid April.
The article discusses cT values;
“CT values were not different according to the immune status: median (interquartile range [IQR] of Ct (RdRp1) = 29 (25-35) for non-immune (n = 3),
21.5 (18-25) for vaccinated 1 dose (n=6) and 23 [21-27] for vaccinated 2 doses (n = 13), p = 0.15 with median test. For RdRp1: median [IQR] = 28 [25-33] for non-immune (n = 3), 20 [20-23] for vaccinated 1 dose (n = 5) and 23 (21-26) for vaccinated 2 doses (n = 13), p = 0.09 with median test. For N gene: median (IQR) = 32 (30-34) for non-immune (n = 2), 26 (25-28) for vaccinated 1 dose (n = 5), and 27 (26-31) for vaccinated 2 doses (n = 14), p = 0.30 with median test”
The P values do not show a significant difference. One problem is n is so small it is hard to detect a difference if it exists.
There is this Nature communication:
Initial report of decreased SARS-CoV-2 viral load after inoculation with the BNT162b2 vaccine
IM Doc Yes – these are all true – however – this was a case series – never meant to be a definitive discourse on that issue. If you read what I said – this is a possible signal. Nothing is confirmed. But a very important one. And certainly goes right along with what I am seeing. And a huge swath of my colleagues.The health departments across America should be watching for this right now. But we are not even counting vaccinated positives yet.
There are now press reports showing up about one vaccinated individual being a superspreader person among other vaccinated and unvaccinated. And this goes right to the debate of masking and mitigation. Unfortunately it is also a very important issue for the vaccination of kids in school issue. You have to assume that all the breakthrough cases are all spreading virus – and they have been told not to mask. So they are just walking around everywhere sharing the wealth. Furthermore, if there is even a chance that they may be carrying around a higher viral load – that must be investigated fully. It would in normal times completely change the operating procedure. But again – we are not even counting breakthroughs right now.
In my local area this week, we had a report from the Health Department head about our case numbers. I was on tele because I am in quarantine. It became immediately apparent that they have two books – one with the breakthroughs and one without – Let’s just say they are only sharing one to the public – and I think you know which one. The numbers with the breakthrough cases were very similar to this paper. The media is not really running this down.
Dean I agree with everything in your original comment except the word “significantly.”
The Nature paper and you may both be correct. You are probably seeing the delta variant while the Nature data were collected in February 2021.
I agree that health departments and especially CDC should be monitoring and reporting viral loads for all cases.
Thank you for all the information you provide.
IM Doc I would like to share with you that I used your comments today when I was debriefing the two medical students here with me this month for their rural rotation.
A few things that people may not know – July 1 is the first day of the medical year. These kids are fresh right out of their non-clinical 1st two years and this is their very first rotation. To have their very first clinical experiences be in the middle of the mess we find ourselves in at our hospital – and on top of that having their attending succumb to the contagion and have to be quarantined has been jarring for them to say the least. This is about as “real” as real gets. We did our debriefing today on the computer. I will be back in person early next week.
These kids walked into this morning – 6 COVID patients who were admitted all still in the ER – because there was nowhere for the new admissions to go last night – we are already full. 3 vaccinated/3 unvaccinated. None of these people are horribly sick. But these students are literally scared to death. What a way to start your career. I may be one of the better equipped to guide them through this – because when it was my first day 30 years ago – the AIDS patients were all over the ER.
I showed these kids this thread this AM. And told them both that it is very very important to use correct and measured language when we are discussing issues with patients and non-medical folks. Little abbreviations and things we say to one another all the time are often not really going to do the job when discussing with the public. Always always remember that. And this is why I so appreciate this site. It seems like everywhere else is an ad hominem hatchet fest in the comments section – and this is such a relief.
But I ended our talk today with something which I feel is just as important. This is not looking good at all. We may be right back where we were last fall and winter very soon. I urged them both to learn the basic mechanics of medical statistics and medical reasoning. I am afraid we are soon going to be entering territory in the next few weeks when luxuries like RCT and p- and z- scores are not going to be our lot. That is why my teachers trained my brain to look and evaluate things on the fly – ALL kinds of medical research- and to be able to wield it appropriately in any situation – I am going to endeavor to put these kids through the wringer in that regard the next 6 weeks.
The others I am really more concerned about are the nurses, RTs CNAs front desk people, and the housekeepers. This is WWAAYY more stressful on them than any physician. We should all be keeping these people in our thoughts and prayers the next few weeks. I am already seeing severe strain develop in many of them here around me.
IM Doc The article you have given is also from March. So the datasets were likely done in DEC thru possibly JAN They way things are mutating and changing on the ground – and the way we have demonstrated now that the vaccine efficacy markedly decreases in months – I am not sure those conclusions apply. If I am reading it correctly – the patients in that trial had been fully vaccinated within about 40 days. That time window is not valid in our current situation when the vaccinated patients that seem to be the sickest were vaccinated now months ago. Many other things may be going on.
This CDC paper – if I am reading it correctly – all the data was collected within just a few months of vaccination as well – making it even more critical that we study this issue.
I do not know – I will ask friends of mine who are experts. But I am hesitant to put much timber into anything that was done in the early part of the vaccination program. Too much has changed.
antidlc “I have repeatedly stated that I am seeing much much more vaccinated positives than one would ever have expected. As I have stated, they seem to be much sicker (though not critically so)…”
Could you please clarify? “They seem to be much sicker”.
“Much sicker” than what? The unvaccinated positives?
IM Doc For several weeks – dating back to mid May – I was seeing groups of fully vaccinated patients becoming positive – but asymptomatic. Most of these situations arose because one member of the family or group was found to be positive because of foreign travel – or having surgery or whatever.
As this became more and more common – I began to be very concerned about what the future may hold. And the Health Department and CDC were just ambivalent.
The guidance of the local health department was to ignore this – “they are vaccinated – there is no way they can spread, etc.”. Just as the CDC guidance was telling them to do. I do not much like to have armed nuclear warheads sitting around, and I am very persistent – so I ordered the contact tracing on my own – every close family member or close contact was checked. And to my absolute horror – large clusters of them were positive. But at that time, they were asymptomatic- almost every single one. I have been dutifully reporting these numbers to Yves and Lambert for weeks.
Then about a month ago – something changed. People were then starting to become ill – and come to clinical attention that way. There were no longer just the asymptomatic patients. And again – on my own – ordered the contact tracing – and found the same thing. Multiple vaccinated family members positive. Multiple bridge group members positive. Multiple church members positive, etc etc. And lately – socials around the July 4th weekend were also clustered. At that point in time – there was no one sick enough to be in the hospital. But the vaccinated positives were clearly more ill than the unvaccinated positives. Heavier coughs, more SOB, more febrile. This included even the younger ones among them. But again – no one sick enough to be hospitalized.
And then – this week – we have had a seismic shift. We have admitted multiple very ill vaccinated patients – two of which were critically ill. At the same time – we are admitting unvaccinated patients as well. Some of them too are now very ill. We have had deaths this week – all of those patients were unvaccinated. But I am not holding my breath – we now have two critically ill vaccinated patients that I am not sure are going to make it. I do not have the best handle on these situations this week because I am in quarantine. But right at this minute – we have more COVID patients in the hospital since January – and it is right at 50/50 vaccinated/unvaccinated – and I would say they are equally ill.
It has been fascinating to watch this very orderly step up in severity over time. And then this week the bottom dropped out. And I live in a very vaccinated county – the paper reported this AM a 72% vaccination rate. The only stragglers were the 12-18 group which is below 50. The “herd immunity” concept is certainly not working here. And the local medical folks are just horrified that this is getting this bad after working so hard for this really good vaccination rate. It is reminding me greatly of the ramp up we had last summer – it is almost the same in every way – except it got much worse much quicker. I am hoping it will burn out – but not looking like that so far.
I will share something else. I have a very small limited patient size – I am in a small town. But I am very attentive to media reports of numbers from other locations. Big cities and big sample sizes give perspective. When I heard last weekend that there were ZERO vaccinated patients in the hospitals in LA – I grew immediately concerned – because that was not our experience at all – It is basically a WHAT HAVE WE DONE WRONG MOMENT….So I called three of my old students who are now on the front lines in the LA area – to the one – the response was “I have not a clue what they are talking about – that is just not true…”. Among the three of them the averages they were seeing were about 75% – 85% unvaccinated in the hospital – and all had had very ill vaccinated patients. I did not feel so bad then. But My God, the media cannot be trusted with a single god-damn thing. I have never seen such a bunch of liars in my lifetime. It is a real tragedy – when we need them the most they are doing propaganda. And do not even get me started on the Health Dept people who are misleading the population like this.
Wishing IM Doc a speedy recovery and many thanks for the updates.
Reports 72% vax coverage in local area and also a
50:50 ratio of vaxxed to non-vaxxed in hospitalised patients.
Let’s do the math! We would really need the numbers of positive tests in both vaxxed (calling CDC???) and non-vaxxed populations to calculate and compare the hospitalisation rates for both groups in order to then calculate the vax efficacy. Of course the vaxxed population skews older and/or has more comorbidities and/or is possibly taking more risks since vaccination, so it’s not quite so simple, but…
IF we assumed equal rates of infection in both populations (i.e. 28:72)
(a big assumption meaning vax efficacy against infection is null)
Then efficacy against hospitalisation is 61%
IM Doc’s cases:
X = Vaxxed hospitalised = NON-vaxxed hospitalised patients
Vaxxed hospitalisation rate = X/72
NON-Vaxxed hospitalisation rate = X/28
=> Risk Ratio = X/72 ÷ X/28 => 28/72 = ~0.39
=> Vaccine Efficacy = (1 – Risk Ratio) = 61%
LA Story:
Colleagues seeing 75%-85% non-vaxxed in hospital.
LA reports 70% vaccination for >16 yrs old.
Again assuming equal infection rates (i.e. 30:70 non-vaxxed:vaxxed)
Then 80:20 hospitalised patients suggests
~89% Vax Efficacy against hospitalisation, i.e. 1- (20/70 ÷ 80/30)
As you can see from these simple calculations, it is really important to know the vaccination rates AND the rates of infection, otherwise there is no way to make any sense of the no’s in hospital!
Note: to produce the (acceptable?) efficacy rates above, I had to assume 0% efficacy against infection which would make a mockery of the idea of vaccination passports and dropping of masks.
Finally, if the rates of infection are greater in non-vaxxed (presumably so?) then these efficacies really start dropping off.
==
PLEASE REPLY if you see an error!
IM Doc You are very correct on how you did the numbers.
And this type of wide variation is to be expected in the real world – that is the way it goes. And another very severe confounding issue is the absolute gigantic chasm of numbers between these two data sets. I am in a very small area with a very small N. LA is gigantic. So theoretically, the LA numbers would have a much higher statistical power. However, there are an infinite number of confounding variables that must be taken into account in a side to side comparison. I have chills when I hear the media making all these god-like pronouncements about this place or the other. It is just very difficult to compare apples to oranges and they really should not be making blanket statements about every locality based on numbers coming from just one. This habit has been yet another bad side effect of our sterilization of the local health departments and the dependence on one centralized center.
The other issue left off your calculations is the number of people who are very ill and suffering at home. This is not a small number. I know this for a fact because there are about 10 patients on our call list that are COVID positive and very sick and we call them twice daily. They refuse to be in the hospital, largely for financial reasons. That is almost certainly an issue in LA as well.
Another possible confounding issue is if there is a much larger group of younger people who are not nearly as likely to be admitted whether vaccinated or not in either LA or here. The demographics and the attitudes of different age groups vary widely between different parts of the country.
The vaccine efficacy of 61% in my area is much closer to what is being experienced in Israel right now for what it is worth.
And thank you for the efforts to do these numbers – you should be a medical student.
One other little pearl to think about. ANYTIME anyone in medicine reports a 100% rate of anything – assume they are lying until proven otherwise. I would assume that to be the case in every field. There is no such thing as perfection.
When the LA report came out last week that their hospital admissions were 399 and all 399 were unvaccinated, I knew right off the bat that they were lying. That just does not happen in medicine. These people need to find better liars. For instance, if they had said 356 were unvaccinated, which is still a respectable number, I would not have raised an eyebrow. But they went for the gold, and earned hundreds of hilarious comments in my doctor’s forum that evening. The average physician in America who is hip deep into these tragedies is really getting tired of all the shenanigans.
Anyone who states with a straight face that “the safety data is in” on these vaccines should be immediately disregarded and laughed out of the room.
I have had more patients with DVT and PE in the past 8 months than I have had combined for the past 9 years.
I keep very detailed records of diagnoses on computer databases for just such occasions.
Take one guess that fits together with all but one of the patients in the past 8 months.
It will only be the passing of some serious time and the evaluation of morbidity and mortality tables before we know the safety of these vaccines.
I could spend all day reciting the list of medications the FDA has approved and then years later has to pull because these facts become obvious. The difference now is the facts are actually obvious now to anyone with eyes to see.
His hypothesis about the delta variant causing the higher loads may be correct.
There is also another hypothesis now out there gaining some signal every day. Many people I know with expertise discussing it. And that is the increasing evidence that viral loads are much higher in the vaccinated. Since we have so many vaccinated now, it would make sense that the overall viral loads are higher. This elevation may have nothing to do with “delta”.
Again, just another hypothesis out there looking for evidence.
Funny how a board member of Pfizer neglected to mention that alternate hypothesis.
Why he continues to be carted out on national television in his obviously conflicted status is all the proof I need that our media is corrupt to the core. How much did Big Pharma pay CBS in ad revenue last year?
An update today.
I came back today for my first day of work. I am officially present and not on Zoom.
There were 8 COVID patients in the hospital. 3 vaccinated/5 unvaccinated.
I have discharged all but 1. The crush we had last week is now in the rear view mirror. There are no new people in the ER right now. I have stated this for many months, this virus behaves in a very very strange way. I have made this comment before and I will make it again – this type of behavior is just not the usual situation in the middle of any kind of epidemic. The virus is trying to give us clues – are we smart enough to figure this out?
The outpatient patients continue to roll in. Right now it is about 70%vaccinated/30%unvaccinated. No one on the horizon right now needs to be in the hospital.
Overall – good news right now. We are all keeping our fingers crossed in our community. No one is taking their eye off the ball. I truly feel a lot of our seeming improvement here is due to the efforts of the local church officials stepping in and making sure we are doing everything to keep our vulnerable at home. And the civic clubs are helping this out a lot as well. Everyone is stepping up to the plate.
And guess what? We have all decided together this is a community problem. There are GOP and there are Dems doing this altogether. We are ignoring all the crazy messaging coming from the media. I could not be more proud of these people.
Again – good positive developments – we hope it stays that way.
So I have started what may be a long journey to find a physician now that I have Medicare. With the exception of an emergency room visit I have not seen a doctor in almost a decade. My previous physician, along with other colleagues from an innovative service once offered through Beth Israel belongs to a newer practice with a $50/month fee. I think it could be considered a PMC upper middle class concierge service. I have now stumbled across a different version of that, one that has gone public on Nasdaq. They only charge $199/year, but there is no indication of that on the listings of their physicians on Medicare.gov. But the Carlyle Group liked them well enough to invest over two years ago. Dropping a Medium column on them here, but what may be of the most interest is the comment from two weeks ago.
Medium on One Medical
This wiped out more than a few on the list I made to call to see about an appointment. Like I said it may take awhile. Sigh.
Pat Correction. My former doctor’s subscription was $50/month last I checked it is now $100 for the first family member with a sliding scale for the rest of the family. All medical care is on top of that. I think they are full on concierge care for the wealthy.
IM Doc I find the whole concierge model to be very troubling.
These physicians often have panels of patients that number only in the 100-200 range. The problem is that 10-15 years ago, the residency slots were numbered and designed for the calculated population that would need them. The average internist has 1500 – 2000 patients in their panel. When these physicians switch to this model, the other 1300 patients that do not stay with them get tossed to the wind. When 20-30 of the internists in a community do this, the chaos is overwhelming. This is happening all over our big cities right now. This is part of the reason why it is so very difficult for Medicare patients to find a PCP.
I get very discouraged at times with the behavior of my colleagues. It is bad enough to do this to all those people, but then we start in with segregated waiting rooms, and “medical spas” and do not get me started.
I just received my final dose of the @pfizer #COVID19 vaccine. I appreciate the medical staff at Baptist South for their service & professionalism. Vaccination is critical to overcoming the pandemic. I encourage those eligible to get vaccinated. #alpolitics pic.twitter.com/KjXMBYYqpI
— Governor Kay Ivey (@GovernorKayIvey) January 12, 2021
About the Joan Walsh/Salon sequence above in the links – about Kay Ivey not being gung-ho about the vaccine.
As usual, these media types never surprise me any more – what a liar!
I am getting very tired of the whole blame the unvaccinated trope. Maybe it is me being a physician for 30 years – having been part of numerous epidemics of the flu which were pretty bad in their own right – and having absolutely no one say a word about anyone’s vaccine status. My job is to take care of people where they are – it is not to judge them when they are ill. The media is doing the devil’s work for sure. Psst – guys – it is not working. I am on the front lines – believe me – you are making things much much worse. It is almost like you want a civil war.
An update for today – I have had a new superspreader event that I am dealing with all morning. So far no one in the hospital – but we are getting close on two different patients. This particular time was a planned event. There were 20 invitees – and part of the condition of coming to the event was all had to be vaccinated. So far we have 12 positives for sure – and 3 more who are sick and likely positive. All fully vaccinated. Again – no one in the hospital. The sick include many 20somethings breakthroughs. Interestingly, many of these people were just vaccinated in the past month in response to being invited to this event. So at least in their bodies, the vaccine has not “had time to wear off” – but positive they are. We even have managed to infect two of the hired staff – both vaccinated. And that was it. There were no others involved. No unvaccinated deplorable to blame. Gee whiz – this virus just does not take the time to read the Salon.com narratives. Multiple others in contact with them are now being tested. I have not had time to deal with the health department yet, but almost assuredly, none of these people will be counted – they are not hospitalized nor are they health care workers.
We still have just the 1 patient in the hospital who is doing better – and there are no new ones in the ER right now. Still pretty quiet.
In my old urban core hospital before I moved to this area, the unvaccinated are about 75% of the admissions. The other vaccinated 25% are mostly diabetic, obese or immunocompromised – mostly elderly. Basically, the same crowd that fell victim last year.
This is the same city whose reddit and twitter feeds are playing one video after another for the past month of multiple gigantic night clubs of all ethnic backgrounds with thousands of people bumping and grinding with no mask in sight. And yet Joan Walsh has the gall to just blame “the unvaccinated” for this situation. There really is no shame – nor is there any medical truths in these proclamations. There are consequences when you put all your eggs in just one basket when dealing with any epidemic. We have NEVER – NOT ONE TIME – deployed this public health strategy in my lifetime.
I am pretty much telling all my patients right now on every visit – It is clear that these vaccines offer you no immunity from getting COVID. It is literally a flip of the coin. They do seem to at this point make the symptoms less. That is all I am willing to tell them – because I am now reporting truths that I am seeing with my own eyes. Long ago I realized that telling even white lies to patients is never a good strategy. So I do not.
For those who are at special risk – the elderly, the obese, diabetics, or immunocompromised – all visits are on tele – and I am encouraging them strongly not to leave the house.
I still strongly feel that high risk patients should be vaccinated – and I go through this multiple times daily.
For everyone else – out in the sun as much as possible, exercise, lose weight, vitamin D, decrease stress, sleep well, and hug your kids and your spouse as much as you can. Do not , like Joan Walsh and many others like her, be the source of contention and strife.
Sorry about the rant – it gets harder and harder to stomach the lies.
Take care and God Bless.
IM Doc In my last paragraph – Should have added – For everyone else – vaccination is certainly OK – I am never going to discourage it. But if you do not – get out in the sun, exercise, etc etc.
This is a decision we are all going to have to make. And I am afraid for all the Joan Walsh types out there that celebrating deaths of unvaccinated patients like I have see in the media repeatedly this past few weeks is unbecoming of a moral person. It is literally ghoulish. And is making things much much worse for those of us trying to do the right things on the front line.
John I had the one shot J&J vaccine because that is what was on offer when I got an appointment in early March when appointments were hard to come by. The J&J vaccine is not mRNA, but the older vaccine making method. All the commentary I see and read refers to the mRNA vaccines. Are there breakthroughs with J&J? Shall I need a booster shot? I am way over 65 and in generally good health. I walk, garden, take vitamin D, hug the kids and grand kids, and am a fan of IM Doc’s commentary. I would really like to hear from the knowledgeable about the prospects for those of us vaccinated with the J&J jab.
IM Doc There are far far fewer people vaccinated with J&J, so with most of the people we are dealing with the other two. But yes indeed, breakthroughs have occurred with J&J that I know of. I just could not even begin to comment on the numbers.
At this point, I just view people as vaccinated fully, vaccinated partially, or unvaccinated.
IM Doc Dr. Walensky’s assertion today was that the virus now has the capability of having as much viral load in the vaccinated as the unvaccinated. She used the word “rare” – but they have used that word in other things this past 18 months that did not end up to be so “rare”. Furthermore, I have heard from other trusted colleagues that this issue is indeed a problem – and the word “rare” never came up in their discussions.
As I have reported earlier, there has been signal in a few case studies released over the past week that this may be the case – and that indeed the viral load may actually be WORSE in the vaccinated. I am talking about SIGNAL in studies, and not statistical significance because the case numbers in these series is so low. But the patterns are defintely there. And I have seen this same pattern in my very own patients when I have their cT numbers before my eyes in the past few weeks. My own vaccinated self had a cT of 18 when I was COVID positive last week. That is a fairly low cT indicating a fairly large viral load.
If this is indeed the case, and when that realization really hits the American public, my prediction is there will be hell to pay. We do not know what “scared and angry” has the potential to be.
Just think about it – the science is giving us at least some signal that the unvaccinated have just as much to fear from the vaccinated as what the media is trumpeting right now about the unvaccinated. Trust me, there is a reason this mask mandate issue is at the forefront again, and it is not just the case numbers.
This is why I have been urging people to knock it off with all the unvaccinated hatred. That ire may end up being misplaced. We are all in this together. This is completely unbecoming of our country.
Think even a bit further down the road. We have now vaccinated most of our entire health care system. These workers are in very very close contact with all kinds of patients daily. Masks are better, but certainly not perfect with aerosolized viruses. If this all holds up to be true, these health care workers may be spewing forth all kinds of virus loads in the hospital.
I do not know about you, but this sounds like a rather potentially explosive situation. I certainly hope this is not the case – but facts must be faced head-on. The hateful rhetoric coming from our media, our politicians, and many of our medical people needs to stop right now. They are just fueling the fire. I truly feel that some of them are doing all they can to start a civil war. I just can no longer fathom what is happening in this country.
Yves Smith To be clear, another reader interpreted the same study differently. I am a little nervous about reaching conclusions based on one paper with a very small sample that didn’t point strongly either way. As reader Dean noted:
The article discusses cT values;
“CT values were not different according to the immune status: median (interquartile range [IQR] of Ct (RdRp1) = 29 (25-35) for non-immune (n = 3),
21.5 (18-25) for vaccinated 1 dose (n=6) and 23 [21-27] for vaccinated 2 doses (n = 13), p = 0.15 with median test. For RdRp1: median [IQR] = 28 [25-33] for non-immune (n = 3), 20 [20-23] for vaccinated 1 dose (n = 5) and 23 (21-26) for vaccinated 2 doses (n = 13), p = 0.09 with median test. For N gene: median (IQR) = 32 (30-34) for non-immune (n = 2), 26 (25-28) for vaccinated 1 dose (n = 5), and 27 (26-31) for vaccinated 2 doses (n = 14), p = 0.30 with median test”The P values do not show a significant difference. One problem is n is so small it is hard to detect a difference if it exists.
What I do get is you’ve seen enough cases of high viral loads in the vaccinated in your own hospital to question the party line.
GM also wondered via e-mail if the causality went the other way:
Regarding the C_t values — this might be a case of a an inverse causal relationship combined with selection bias.
For those vaccinated people to end up in the hospital, the infection has to have overwhelmed the antibodies that they have.
So it might be that it is not the case that vaccinated people have higher viral loads, but that it takes a higher viral load to land a vaccinated person in the hospital than an unvaccinated.
Obviously, that’s a speculation, but it’s the only way I can see to make sense of that observation (which others have made too). Because prior the vaccinated starting to fill in the hospitals, they had higher C_t values
… in effect, some vaccinated were getting themselves in high-contagion settings. You as an MD treating sick patients would be exposed to more virus than the average person. Vaccinated people going to crowded bars (where people speak loudly to be heard) could get themselves in a similar position. The CDC basically told vaccinated people to go do stupid stuff en masse.
IM Doc Yes – I agree with all you said. The one thing I would point out about the above observation as related to the case study in French Guiana miners – is none of those patients were sick enough to be in the hospital and the pattern still held.
I will repeat what I have said before. This situation is getting serious. We may not have the luxury for perfect studies. We certainly did not in the AIDS crisis. I know for sure that well-qualified people are looking into this very situation.
Whatever happens, we must somehow find it in ourselves to stop the blame cannons and start working together as one. Or this is going to get really ugly really quickly.
In my part of the country, the current large contingent of unvaccinated are avocado toast eating man bun wearing deep blue liberal young people.
They simply refuse to think about exposing their bodies to any kind of toxin. In general terms, this is one huge arm of the entire anti vaccine movement.
It is not the elderly Fox News crowd as the vaccination rate in the over 70s here and almost everywhere is 80% or higher.
The other large group are the younger evangelicals who in my experience are far more likely to be convinced to be vaccinated – they are not in general anti vaccine. They have just watched like everyone else the horror of the gross incompetence of the CDC and have trust issues. If they were really serious a move like firing Fauci would do wonders.
And yet another large group of racial minorities who are just not interested in another experiment.
And then the other gigantic group of workers who will be on the streets if they miss a single day of work.
The problem is these two groups for the most part live in very different geographic areas. In days old, the local health departments would employ vastly different outreach programs.
We no longer have local health departments that function alone. We have nationalized everything.
We are now enjoying the feast of consequences.
You can resent all you want but nothing will change the gross incompetence that got us here. I have become increasingly resentful personally about the resentments of the PMC crowd who spew all the time and then do absolutely nothing to help.
The lies that continue to be spewed by our media that this is just a deplorable MAGA problem will be the end of us all.