I have a long list of things I wanted to share with you this week, but they mostly feel trivial at the moment. Today's news from CDC is a nightmare. Not so much because of the scientific updates—which are not good, but not revelatory—as for how it's going down.
So this letter is almost entirely going to be about the virus again. I swear it won't always be.
Which is technically true. But also, I worry, misleading.
So, let's step back. What we have is a powerpoint. It says it was written by a pediatrician who serves as a member of the CDC's vaccine effectiveness team, and it's titled "Improving communications around vaccine breakthrough and vaccine effectiveness." (Though I'm pretty sure it did the opposite.) I hesitate to even call this a leak because that implies a trove of classified secrets; it's more of a document that's not written for an audience other than public-health officials, nor finalized enough to warrant publication. In several places it says "CONFIDENTIAL - preliminary data, subject to change" in bold red letters. (As opposed to something like "CONFIDENTIAL - we can't let the public know how serious this virus is.") When data are considered preliminary or unpublished, it's most often because researchers are not yet confident enough that the findings are real and accurate, or public-health officials are not yet convinced that the findings are actionable. Sometimes it's a scandalous coverup, but usually, in my experience, scientists like to have their work published. It's kind of their thing.
In any case, the first and key point made in the powerpoint is that the vaccines are still extremely effective: Getting vaccinated reduces your risk of hospitalization or death 25-fold.
The headline attention came from other bits, some of which are provocative, but not fundamentally at odds with the already widely reported understanding: delta is far more transmissible than other strains of SARS-CoV-2. It is beginning to put our vaccines to the test among high-risk populations, and vaccinated people are susceptible to infection, possibly even transmission of the virus. This variant is dangerous, and it is ruining summer.
But have we not already acknowledged that, as one slide reads, "The war has changed"? Just this week, because of delta, CDC recommended indoor masking once again, in places where transmission is high. (And don't wars constantly change?)
Anyway, I think there are a couple interesting points that do warrant attention, and which I wish the agency would just address and clarify now that this is out in the world. CDC has yet to comment on the powerpoint, as of this writing, which I wish they'd done immediately. That silence invited wild speculation about what to make of this scandalous leak of revelations indicating things we mostly already knew.
So, I'll take part. My read on the noteworthy points, hopefully in very brief:
Though the vaccines seem to still be 95-percent effective at preventing severe illness in most people, there are signs of waning effectiveness among some immune-compromised people, and those in nursing homes. This implies that boosters will be recommended soon for certain high-risk groups. Fauci suggested as much earlier this week. As did I last week.
The most striking bit is about transmission of the virus by vaccinated people. Earlier evidence had suggested that vaccinated people who got infected would carry relatively little virus, and for a short period, and so were extremely unlikely to infect another person. But now, some vaccinated people who have gotten infected with the delta variant have been found to have evidence of a high viral load (the amount you carry). The level appears to be similar to that of unvaccinated people. Again, this is preliminary. We don't know how regularly it is happening. And a high viral load doesn't necessarily mean that you are contagious, only implies so. (It's unlikely that you'd be carrying around tons of virus and somehow not casting it about.)
Finally, maybe the most news-making bit—the headline in The New York Times and Reuters—the powerpoint claimed that the transmissibility of this variant is similar to that of the notoriously contagious chickenpox virus (and even greater than things like smallpox, common colds, or the 1918 flu).
Such comparisons are debatable and imprecise (e.g. there are tons of viruses that cause common colds, and we know very little about the 1918 pandemic since there were no tests and no way to keep track of even the deaths, of which estimates vary by tens of millions of people (you know, plus or minus!), etc). So I read this as a flexible assessment? It's not clear that it was ready for prime time.
It would be good to know more about this, though, because a virus comparable to chickenpox would render some masks less effective than we understand them to be, and that could have practical implications for what's recommended. As it is, it's unclear how firmly it was being made. Because, again, all we have is a bullet point on a slide. As anyone who's made a powerpoint knows, the slides shouldn't tell the whole story or speak for themselves. (If they do, cancel the Zoom meeting and just send the presentation as an email, Steve.)
But absent further context, now, of course journalists and readers were left to err on the side of caution when reading a slide like the one titled "Delta variant vaccine breakthrough cases may be as transmissible as unvaccinated cases," not knowing how much emphasis was to be placed on that crucial may.
On that point we got a little more information this afternoon, when CDC published a study surrounding an outbreak in Massachusetts, implying that there was probably transmission by vaccinated people there, and noting that their viral loads during infection were similar to those among unvaccinated people. But, as in the powerpoint, the limitations are notable. For one, estimations of high viral load are based on "Ct values" from PCR tests that, and the study notes "might provide a crude correlation to the amount of virus present in a sample, and can also be affected by factors other than viral load ... The assay used in this investigation was not validated to provide quantitative results."
I'm not suggesting this measure isn't a fair proxy for actual viral load; only that this is the sort of uncertainty that may have made CDC hesitant to say that post-vaccination transmission is definitely happening and that everyone should behave accordingly. As such, today's study's takeaway is still vague: "Jurisdictions might consider expanded prevention strategies, including universal masking in indoor public settings, particularly for large public gatherings that include travelers from many areas."
And, really, that's the news. I'll keep you updated. For most of us, it's not a huge deal to put on masks a little more often in indoor spaces, and the transmission update could have been calmly conveyed.
The fact that it wasn't is, to me, is the actual nightmare. Because the real point of the report is that vaccines are extremely effective. And getting people vaccinated isn't a scientific challenge; it's a communication challenge. The literal premise of the powerpoint was that the agency was that it's important to communicate these updates to the public in a careful, accurate, and deliberate way. And yet the opposite happened.
There are researchers who dedicate entire careers to the study of effective health communication, and how to avoid contributing to problems like unwillingness to get vaccinated. The keys are clarity, transparency, accessibility, and credibility. Messages from health officials should clearly communicate what is known, with what degree of certainty, and what people can do about that. Instead we have a jargon-y powerpoint alluding to preliminary data and suggesting how to frame it in a way that won't dissuade people from getting vaccinated. The message is nebulous, unclear, possibly even reads as sinister or manipulative (among those inclined to see things that way).
I'm not here to take sides on how all this went down. I'm just worried about the effect of it. Communicating well in this moment, about the virus and the vaccines, is the key challenge of the pandemic. Because as bad as the virus is, it's not as dangerous as the breakdowns in trust and communication that cause people to refuse vaccination.
As the CDC powerpoint laid out, it's possible that news of breakthrough illnesses and post-vaccine transmission will lead some hesitant people to think vaccination isn't worthwhile. Others who have gotten vaccinated may feel they've been misled, because they were told that if they got the shot they could ditch their masks. But messages to the public can't be guided by trying to avoid creating such concerns; they can only to be guided by truth. Anything less will ultimately compound the problem.
The fact that the agency didn't instantly share concerning preliminary data, and instead was discussing how to do so, isn't inherently wrong. It's standard practice to be deliberate in communicating public-health updates, and to wait until you're certain enough that you don't often raise false alarms. Just as you don't want a doctor shouting, while you're halfway through a CT scan, "whoa, I haven't seen that before"—even if it's exactly what he's thinking—presenting bad news thoughtfully, and at the appropriate moment, with appropriate context, is central to effective public-health policy.
What's ruinous, though, is being perceived as less than forthcoming. If your doctor murmured "possibly cancer" every time she found a mole or heard you cough, that would be profoundly annoying. But it'd be worse if she thought you might truly have cancer, and she wrote as much in your chart instead of saying anything, for whatever reason, and then someone published your chart online, and you learned about it there. Feeling like you haven't been told the whole story can make people unable or unwilling to fully trust that person, maybe even that whole system, ever again.
Trust is the defining issue of the pandemic. When people refuse to get vaccinated, it's often not actually about the vaccine. The more basic, visceral concern is a feeling of being manipulated, or misled, or a sort of instinctive allergy to being made to do something by someone they don't fully trust. The antidote isn't to try harder to sell them on vaccination by crafting the perfect pitch or convincing them with yet more facts curated to make the case. Even if you're absolutely correct, and your case is objectively as compelling as any ever could be, it can't stand on a shaky foundation. The way forward is to earn their trust; to address whatever it is that causes this person to put up that impenetrable barrier; to prove to them it's safe to let it down and engage earnestly.
I wish this were as easily done as said. But I know it involves authenticity, respect, transparency, and candor about what you know and what you don't. It involves communicating simply, but not simplistically. If you've tried to distill a persuasive message down to something like "Vaccines work!" and people were already hesitant—allergic to any feeling of being manipulated—then every breakthrough illness or piece of data about viral loads now might read to them as proof that you can't be trusted. Even some reasonable people who willingly masked and stayed home and got vaccinated because they trusted you will eventually get frustrated and throw up their hands unless you constantly prove worthy of their trust.
And so that's why it feels like a nightmare to me. I feel like episodes like this chisel away at an already wobbly foundation. But I hope it's useful to talk openly here, about the limitations of vaccines (and everything else), because I think that the only way forward. They're the way out of this. Nothing about this variant makes it unbeatable. The challenge is us.
P.S. My friends Leah Finnegan and Kelly Conaboy started a new web site called Gawker dot com. It's a different version of the old one, where they also worked, in another life. They're very funny writers and I'm looking forward to reading it.
P.P.S. I did comment on the Mila Kunis and Ashton Kutcher showering discourse. (How could I not?) Oh, Wednesday. Simpler times!
P.P.P. The photo at the top of this is the Yukon River delta in Alaska. I'm tired of pandemic imagery, so I went with a better-looking delta.
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I'm a RN vaccinator (I do other things, but this is the relevant bit here). Thank you for your efforts to clearly inform the public about pandemic issues. You're doing a far better job than the CDC, who I know is earnestly trying to be coherent, but...