The development of the mRNA vaccines during the COVID-19 pandemic has been the single greatest scientific advance of the pandemic, and will lead to a Nobel prize. At the same time, there are many legitimate questions and concerns about the dose, the number of shots, the interval between shots, order of vaccination, and the line between individual benefit, collective benefit, and no benefit at all. What is the for someone who has recovered from COVID-19? Does it vary by age? What is the optimal dosing and schedule of mRNA vaccine for adolescents? Does it vary from boys to girls -- given the massive difference in rates of myocarditis? What evidence is needed to support boosters? And finally, as pediatric trials become available, what evidence is needed for regulators to decide if the risk/benefit profile is favorable?
As I look across social media, I am concerned. Clearly there is a small, but vocal minority of people who are critical -- often irrationally so -- of vaccination. They are wrong. But, what I see more and more, among the ranks of physicians and other professionals, is a growing minority on the other end of the spectrum. These are people who are quick to label legitimate scientific dialog as "anti-vax" or "dangerous misinformation." In many cases, the speakers have little knowledge of the issues themselves. They couple this condemnation with a strong sense that they are "morally" correct, working to purge the world of dangerous anti-vax thinking. Ironically, they are further polarizing an already polarized debate, and worse, they are simply wrong. These are real and live issues. Intelligent scientists have to discuss these policy implications openly. The stakes could not be higher.
As we continue to investigate unanswered questions during this unprecedented pandemic, the tribalism and polarization must end. Simply raising questions about the vaccines isn't anti-vax, so let's not label it as such. Instead, we need to welcome new questions and invite ongoing, open discussions from medical professionals. If not, we risk poisoning progress.
Investigating COVID-19 Vaccine Questions
The questions about vaccines I offer above are not esoteric. These questions have direct implications for millions of people in the U.S. and globally, and have second order implications for the distribution of vaccines across nations.
In order to think clearly about these questions, the first thing to consider is risk that spans several orders of magnitude (or log-fold differences in risk). This is not intuitive. I believe it helps to have considerable data-analysis experience to do this. Here is an example: A shows 28-day mortality after a first positive COVID-19 test per 100,000 individuals in the population by vaccination status (see chart b on page 18). It clearly shows an increase in risk of death with increasing age and significantly greater risk among unvaccinated adults.
These data are as real as it gets: Vaccinated 40-year-olds have higher population risks than unvaccinated kids under the age of 18 for COVID-19. You would not know that from the breathless, innumerate U.S. media landscape, but once you know it you might feel differently about risk. A vaccinated 40-year-old might feel comfortable attending a dinner party without a mask. The same person might prevent their 7-year-old from going to a sleepover at a friend's house. Of course, there are valid reasons for this choice, but, I fear, the choice might also occur because of ignorance of the absolute risks.
Second, in order to think through these issues you need reliable data. Recently a preprint appeared online that sought to estimate the rate of myocarditis after the second dose of mRNA vaccination in the U.S. The final number the was 1 in 6,800. That number is not much different than estimates in , , and .
But on social media, the calls against the authors came vociferously, passionately, and very nearly constantly. Many were skeptical of the study being based on VAERS data, which is self-reported. And, I agree that generally VAERS data is unsuited to draw conclusions about the frequency of adverse events. But there are several unique features here: the authors reviewed all cases by hand, using the expertise of a cardiologist; many cases had features that were challenging for alternative explanations; and finally, the authors acknowledged many limitations in the paper and provided the primary source data for others to code differently in a convenient app. All that said, I am sure there are persistent errors in the paper, both of inclusion and exclusion, and others may wish to make different external comparisons. The paper is not perfect, but it offers something, even if it's not the end of the story.
Yet, others went further to insinuate that these authors were anti-vax, and others insinuated that they should be reported to their state medical boards and lose their license. That's strong language, and language that is chilling for the faithful conduct of science. Even uttering those words may dissuade others from studying this topic. Many demanded that the preprint be retracted (I'm not sure that word choice even makes sense; it's a preprint not a paper), and I saw one person say that he would no longer be willing to share a beer with a study author, whom I presume was once his friend. Wowzers! We can't even drink together? Over a preprint?
Vaccine Tribalism
Here is what I believe is going on. In non-pandemic times, there was a sorting of tribes on social media. Among medical professionals, a consensus grew around the excesses of the pharmaceutical industry, the importance of sensible public health, particularly on issues of social justice, and the importance of childhood immunization. But the pandemic twisted that into knots. The pharmaceutical industry -- of whom I have been a faithful and dogged critic -- performed the single greatest miracle by developing a vaccine in record time. And that intervention -- a vaccine -- like all medical interventions had risks and benefits that varied by demographic categories.
The "tribe" of med-Twitter that had existed before was fractured. Many felt that dogged an unyielding devotion to vaccines (i.e., two mRNA doses has to be good for everyone, everyone must get a booster ASAP) was synonymous with being pro-vaccine, and anti-pandemic. One driving factor has been a new entrant into previously academic debates: the public. As medical and research discussions have increasingly become part of the mainstream during COVID-19, many doctors have been labeled as anti-vaxxers or COVID-deniers because the public will take their questioning of the science and treat it as fact. While I understand the desire to prevent this, we can't neglect the fact that an ongoing and careful reconsideration of harms and benefits is often warranted in this complex and constantly changing pandemic. What works for an 80-year-old might not be right for a 16-year-old boy. Log fold risk by age is not intuitive, not fully processed, nor understood. A tribe that developed a policy platform over years was unable to handle a scientific moment that twisted and fractured the usual rules, especially as the public entered the debates.
Thus, we find ourselves in a precarious arrangement. Many people who view themselves on the side of the moral right are pushing harder and harder against nuance. They are eager to label any investigation or discussion of vaccine safety as "anti-vax" out of fear that it will fuel a public anti-vax agenda. They have asked that other scientists who generate a myocarditis estimate contrary to their worldview or using controversial methods lose their medical license. In doing so, they poison their own cause, and become a threat to science and sound health policy.
Many of these commenters need to be honest and appraise their own skill set. Are you capable and do you have experience quantifying rare harms? Are you certain that the federal agencies tasked with this appraisal -- the same agencies that have made colossal errors -- are not making errors here? For most people on Twitter, the best way to be a science communicator is to sit this one out. When used correctly, science is the greatest lighthouse for human endeavors, but if misused, science has led to some of the greatest errors in our history.
Demonizing people interested in better characterizing vaccine safety signals is not pro-vax; it is pro-ignorance and anti-science. Vaccine tribalism is poison.
is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of .
Disclosures
Prasad has relationships with Arnold Ventures, UnitedHealthcare, eviCore, and New Century Health.