Vaccine Mandates are Futile in the Omicron Era
Though well intentioned, vaccine passports are futile and counterproductive in the Omicron era
Dr. Larry Istrail is the author of The POCUS Manifesto: Expanding the limits of our physical exam with point-of-care ultrasound. You can get a copy here or watch his grand rounds lecture here.
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As of January 15th, 2022 Mayor Bowser mandated most Washington D.C. businesses to require that residents show their ID and vaccination card to gain entry. As a physician, I struggle to understand the medical or scientific justification for this.
Presumably this well-intentioned requirement is to: prevent infections or transmission (though it perplexingly excludes large gathering sites such as churches, grocery stores, or museums), increase vaccine uptake, and make people feel safe indoors again. Yet the vaccines are not preventing transmission or lowering viral load. And, therefore, we should stop implementing policies that suggest they do. Like judging a seatbelt by its ability to prevent a car accident, judging the mRNA vaccines by their ability to prevent infections has caused enormous confusion and mistrust in the their most fundamental role for which they are doing so well: preventing severe illness.
While there was some evidence that vaccines could prevent household transmission during the initial alpha wave of infections (here and here), this has not held up with Delta or Omicron in a large study from the UK published in the Lancet. It is an unfortunate fact that has become abundantly clear in the states and countries with over 90% vaccination rates co-existing with Omicron-induced, record-setting case counts. In Washington D.C., for example, Omicron has ravaged through the vaccinated, boosted, previously infected, and/or unvaccinated population to the tune of 169 cases per 100,000, the highest rate in the country at the time. This is a population that - according to their own dashboard - for the most part is already highly protected from severe illness with 90.2% of its residents vaccinated with at least one dose and 69% with at least two. This is a remarkable public health achievement with a vaccine that continues to reduce the risk of hospitalization, ICU admission, and death by about 90%, especially in those under 65, at a time in the pandemic when we have multiple effective treatments we did not have two years prior.
Bewildering further is the timing of a such a mandate one week after the case counts have already peaked and started their rapid descent, just as was seen in South Africa or the U.K.
Whether we like it or not, this exponential ascent of the highly contagious, less lethal Omicron variant has provided thousands of daily ‘natural boosters’ to the D.C. residents (over 2,000 per day at its peak, though this offical number is only a small fraction of the actual number of infections at a given time ). And when it comes to future protection from re-infection, hospitalization, or death, this ‘natural booster’ is nothing to sneeze at.
While the concept of natural immunity from previous infection is not discussed by many public health officials in the setting of COVID-19 (presumably to deter people from getting infected on purpose), ignoring its existence is on the flat-earther spectrum of denial. Previous infection (or natural immunity) reduced the risk of reinfection by 93% in a large study in the New England Journal of Medicine, and those that were re-infected had 90% lower risk of being hospitalized. This was also seen in a large Israeli study where the vaccinated (or not previously infected) group had a 13x higher risk of reinfection and 27x higher risk of symptomatic infection when compared to the previously infected group.
“It’s a textbook example of how natural immunity is really better than vaccination,” says Charlotte Thålin, a physician and immunology researcher at Danderyd Hospital and the Karolinska Institute who studies the immune responses to SARS-CoV-2
In another New England Journal of Medicine study, subjects with two vaccines but no previous infection did not produce neutralizing antibodies to Omicron while 90% of those who were vaccinated and previously infected did. And, as Dr. Peter Attia pointed out, based on the CDC’s own data, the risk of reinfection with natural immunity is lower than after vaccination.
There are dozens of other studies that support this.
All this is to say that while we are lucky enough to have vaccines that prevent severe illness, we were not fortunate enough for them to eradicate SARS-CoV-2, an idea that was considered a “pipe dream” by leading immunologists from the start. The mRNA vaccines are high-tech, heavy-duty respiratory seat belts and airbags. But they are not anti-SARS-CoV-2 forcefields, raised draw bridges, or moats, a conclusion even the ‘Israeli Dr. Fauci,’ recently came to publicly. This is how Professor Cyrille Cohen, head of Immunology at Bar Ilan University and a member of the advisory committee for vaccines for the Israeli Government described vaccine pass futility in a candid interview:
Correspondent: “Israel was famous for one of the first countries to introduce the vaccine pass…presumably the principal of it is that you can feel safe in a room full of vaccinated people if it prevents transmission … in a world where it doesn’t prevent transmission very much or at all, vaccine passports are not really very relevant … Has Israel caught up with that fact?”
Cohen: “Oh ya definitely … Especially with Omicron, where we don’t see virtually any difference, there is a very narrow gap between people vaccinated and non-vaccinated, both can get infected with a virus, more or less at the same pace.”
Correspondent: “Are you now of the view that vaccine passports should be phased out because they are not relevant in the Omicron era.”
Cohen: “Ya I tend to think so.”
These inconvenient truths make it hard to justify the onerous, frustrating, and awkward encounters small businesses have to endure as they try to explain to a person with natural immunity, or one who forgot their vaccine ID card, that - despite the fact that there is no difference in transmission risk, and that sitting next to a vaccinated person does not protect you from infection - they cannot enter their restaurant or place of business. Instead of allowing these restaurants to do so voluntarily based on the public’s appetite for such measures, it forces businesses to pay their staff to do extra work, lose potential customers, and creates an incentive for the roughly 1.2 million people in the greater D.C. area who have not gotten two doses, or are naturally immune, to avoid these restaurants all together. This is a gut punchingly depressing thought for the already dilapidated restaurant industry that has suffered disproportionally at the hands of COVID-19 and its resulting policies.
In the 2005 The Great Influenza, an impressive 500-page book describing the 1918 flu pandemic and the resulting government and public health response, the afterward written in 2018 tells us much of what we need to know:
“There was a terror afoot in 1918, a real terror. The randomness of death brought that terror home … But as horrific as the disease itself was, public officials and the media helped creat that terror - not by exaggerating the disease but by minimizing it, by trying to reassure. A specialty among public relations consultants has evolved in recent decades called “risk communication.” I don’t care much for the term. For if there is a single dominant lesson from 1918, it’s that governments need to tell the truth in a crisis. Risk communication implies managing the truth. You don’t manage the truth. You tell the truth … So the final lesson of 1918, a simple one yet most difficult to execute, is that those who occupy positions of authority must lessen the panic that can alienate all within a society … Those in authority must retain the public’s trust. The way to do that is to distort nothing, to put the best face on nothing, to try to manipulate no one … A leader must make whatever horror exists concrete. Only then will people be able to break it apart.”
In the spirit of Mr. Barry’s remarks we should not misrepresent what the vaccine can and cannot do. We should tout its many virtues without ignoring its limitations. In the Omicron era, we should continue to strongly encourage all to get vaccinated, and those at highest risk to consider a booster. But we should not be enticed by a false sense of security by pretending that such mandates will create SARS-CoV-2 free environments. They won’t. The integrity of our public health depends on it.
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Dr. Larry Istrail is the author of The POCUS Manifesto: Expanding the limits of our physical exam with point-of-care ultrasound. You can get a copy here or watch his grand rounds lecture here.