A vax-only approach leaves the most vulnerable behind

Reinforcing dominant U.S. public health thinking, a recent study said more than 300,000 COVID deaths could have been avoided if everyone in the country got their shots after vaccines became available.

According to the analysis published in May by researchers at Brown University and Microsoft AI Health, if 100% of the state were vaxxed, 2,467 adults in N.M. could still be alive today.

But an epidemiologist says the results are implausible, and a professor of health law and policy comes to different conclusions than the authors about what we should do to fight the pandemic.

It matters because the thinking that underlies this study is repeated by public health officials around the country — including in New Mexico — as they roll back other pandemic protections.

The COVID vaccines work. 

But problems arise when they’re spun as a silver bullet: Vaccine efficacy does not occur in a vacuum, and there are other steps communities can take to stop breakthrough deaths, according to disability and health justice advocates. Plus, public health measures like masking can also keep vaccines effective for longer.

Why the study should be retracted

Justin Feldman is a social epidemiologist studying inequality and state violence at the FXB Center for Health & Human Rights at Harvard University. He says the study should be retracted.

He said it runs into a significant limitation: The researchers did not look at age-specific vaccine effectiveness.

“They assume vaccine effectiveness is the same across the whole population,” he said.

The data upon which the study is based shows that for the oldest people, those older than 80, effectiveness is lower. We know for various reasons that effectiveness is going to be lower for older people, Feldman said, because they are more likely to be disabled, immunocompromised. They also got vaccinated the earliest, he said.

The researchers entirely ignore the question of boosters, he said. It’s in their dataset, it goes into their ultimate calculations, but they don’t explicitly address it in the text or in their analyses.

“They are painting an overly rosy picture,” Feldman said. “It doesn’t pass the sniff test.”

Source New Mexico reached out to seven authors of the study about these potential limitations. Only one responded, Stefanie Friedhoff.

Friedhoff said rates of people aged 65 and older who have gotten a booster shot are very low in some states, which contributes to a large number of breakthrough deaths.

“These are still vaccine-preventable deaths, because as time marches on, many of these deaths can be prevented with a third and now a fourth shot,” she said.

But Feldman points out that the researchers assumed that only 5,000 vaccinated people died in the entire country once vaccines become available.

“That is completely implausible,” he said, because more than 5,000 people who had their primary series and their booster shots have died since vaccines became available — a much smaller group of people than those who have only completed their primary series.

In fact, according to the CDC dataset which provides the best look at the prevalence of breakthrough deaths in the United States, about 60,000 vaccinated people died of COVID. Those data only include about 70% of the U.S. population.

“If you extrapolate to the full U.S. population, that would be about 78,000 deaths of vaccinated people,” Feldman said.

Another problem is that the study does not account for boosters, he said.

“They don’t look at booster status or whether someone is up-to-date in the study,” he said. “Their results are implausible when compared to real-world data. This is 100% retraction-worthy in my view.”

Policy takeaways

The study does not ask how many deaths could have been prevented by public health measures meant to slow the spread of COVID in a community like universal masking or social distancing, or policy supports like paid sick leave or paying people to stay home.

Not talking about the limitations of vaccines, as the Brown study does, makes it seem like there is much less urgency for boosters and public health measures, Feldman said.

Friedhoff said vaccines make many public health measures “unnecessary if the majority of society is vaccinated.” She said she does not think layered protections are necessary right now.

Neither does acting New Mexico health secretary David Scrase, who said on July 14 that state officials are not considering a mask mandate to slow the spread of the new BA.5 variant.

Feldman said the study is part of the common refrain from some public health professionals and the Biden administration that we are in a “pandemic of the unvaccinated.”

“There was a dominant framing — and still is to a large degree — that blames the problem of continued COVID on people not being vaccinated,” he said, “and suggests that if only everyone made the choice to get vaccinated, there would be very very few deaths, there would be very few hospitalizations.”

That’s not true, he said. He points to Cuba as an example, which has one of the best vaccination rates in the world. More significantly, Cuba has one of the highest rates of boosted people in the world, and so did incredibly well even once officials there dropped universal masking a few months ago.

But that’s not the reality here in the United States. A lot of people who were vaccinated initially — a number that would be shocking to most people — still died as a result of COVID, Feldman said.

Vaccines work really well, he said, but the issue is that we have designed all of our policies around the idea that vaccines would offer a near-perfect level of protection.

“What’s happened is that omicron moderately weakened the protection of vaccines,” he said. “Boosters would help, but the U.S. has done a poor job boosting. The combination of omicron, failing to boost most of the population, and failing to implement other public health measures like mask mandates has led to a situation where tens of thousands of vaccinated people have needlessly died of COVID.”

Despite continued vaccine effectiveness, about half of people who die of COVID in the U.S. are vaccinated, Feldman said. That has added up to a very large number, far higher than what is estimated in the Brown study.

“This is not an indictment of the vaccines, which are amazing,” Feldman said. “It’s an indictment of the U.S. approach to the pandemic.”

Julia Raifman, an epidemiologist and assistant professor of health law, policy and management at Boston University, said we should not be pitting mitigation measures against each other, because we have all of them. She also read the Brown study.

We’re in a surge right now. And we have the best policy evidence and logic to show that vaccine mandates and mask mandates during surges are the most important policies, she said.

Ventilation is also important, she said, but it wouldn’t on its own be sufficient to eliminate transmission, when you have such a transmissible virus. Mask mandates can still help protect people in crowded indoor spaces, she said.

The two together, then, are the most effective, Raifman said.

“The vaccine-only approach is clearly insufficient. It’s inequitable,” she said. Even among people who are vaccinated and boosted, a vax-only approach leaves behind essential workers and people of color who experience more work absences due to COVID, according to a study she recently published.

“So it’s not that the vaccines and boosters are explaining all of it away,” she said. “There’s a role of exposure, and we have to account for that.”

The idea that we are in a “pandemic of the unvaccinated” disrupts the spirit of coming together needed to effectively fight the pandemic, Raifman said.

“It really just undercuts the whole of the response,” she said, “and just leaves us with less social cohesion, and more societal dissolution, when we don’t lead on coming together.”