Conflation

Lumping everyone together when talking about risk does people - and public-health officials - a disservice. It needs to stop.

This was my original post but never sent via e-mail. Enjoy!

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From Oxford Languages:

If I told you that the median adult human was ~170 centimeters (67 inches) tall, is that useful to you? Maybe, but it’s conflated data - it mixes men and women. Wouldn’t it be more useful this way?

The COVID-19 pandemic in 2021 was, to me, far more frustrating than throughout 2020. I know public-health authorities aren’t strategic communicators but we’ve had almost two years to get better at this. I’m just not seeing it, and the messaging now just misses the mark. Why? The inability to delineate risk by population.

In early 2020, we all understood the assignment. A virus is out there, it spreads stealthily, wear some masks to protect others from you, etc. It was easy to tie behavior to risk, as everyone was on the same level. There were no vaccines, options, nor data. If you headed indoors, you were supposed to wear a mask as a best practice. If you didn’t, your behavior was pretty easily tied to outcomes - both for you and those that interact with you. Sure, it got all mucked up by some opportunistic politics but that was the basic message, for better or worse. Simple.

Enter vaccines. For the vast majority of us, they became available in the first half of 2021. These changed the calculus a lot, for while my mask protects you (by stopping me from breathing the virus into the air), my vaccine protects me (by preparing my immune system for an imminent invasion from your virus). You could layer a mask onto that for some marginal benefit to you and others but, really, the risk was to those without their shots, for if I breathe my virus into the air, it’s your immune system that protects you from illness. That was the message after the vaccines.

Or it was for like 6 weeks. Then came the July 4th outbreak in Provincetown, MA. This was essentially the message afterward:

• Vaccinated people can get sick! 80-90% efficacy isn’t 100%, so yeah. Vaccines are fire extinguishers, not body armor (to quote the TWiV podcast/YouTube show).

• They can spread the virus to others! Yeah, if they’re sick they can do that.

• OMG, this is so scary! We’re all screwed now! Masks back on, kids! Why? My vaccines protect me. Who am I masking up to protect? 🤦‍♂️

To visualize this a bit more, you’re in the “inner orbit” if you’re vaccinated but blast into the “outer orbit” if you’re not. Masks don’t change this:

The Provincetown outbreak illustrated this case, too. Nearly all people who tested positive stayed in the inner orbit. From the Barnstable County Department of Health and Environment:

As of July 29, a total of 934 confirmed positive cases of COVID-19 had been officially reported to the Massachusetts Department of Public Health associated with the Provincetown cluster. Of these cases, 560 are Massachusetts residents, 231 of which reside in Provincetown. The remainder of individuals who tested positive reside in other states. A total of 7 hospitalizations have been linked with this cluster. No deaths have been reported.

934 cases, 7 hospitalizations, 0 deaths. In other words, even if we assume all were vaccinated (~70% were), the vaccines were:

• 99.26% protective against hospitalization

• 100% protective against death

We don’t know how many people were exposed, so determining protection against infection was tough, but these are excellent statistics. Given that ~30% of the crowd was unvaccinated, this means the vaccines were even better, as some of those 7 hospitalized could’ve been unvaccinated (can’t tell from the post).

But the message resulting from this outbreak was something close to panic among people who should have known - and are paid to know - better. This became the story:

People can get sick, regardless of vaccination status, so we need to set guidance as if vaccines don’t exist.

This is a mistake. If you’re trying to convey risk to your average person, this makes it seem as if vaccination is pointless. Many won’t do their own research (not that they should) to find out the true risks. I don’t think this is what the CDC and public-health authorities were doing, for what it’s worth - I think they were looking at the macro picture of population spread - but the message was that you are not safe, even with vaccines, because the macro focus wasn’t called out.

Of course, you’re very safe, if vaccinated, on an individual basis. Not only are you far less likely to even catch the ‘rona if you’re fully vaccinated, but you’re even more far less likely (do those words even make sense?) to die if you are. In other words, in a lot of public-health messaging this past summer, there was almost no delineation between the risks to vaccinated and unvaccinated individuals - the risks were conflated. “The Delta variant is dangerous.” OK, to whom? See the orbits diagram above one more time. Don’t take my word for varied risks, either. From the CDC itself, right up until Omicron was discovered:

This translates to a real-world vaccine efficacy against any infection - any positive test - of 83-84%. Add in the fact that deaths are super low among the vaccinated and that deaths for vaccinated individuals skew to those above 80 years old (here’s Oregon’s latest)…

To date, 4.3% of all vaccine breakthrough cases have been hospitalized and 1.2% have died. The average age of vaccinated people who died was 81.

…and you can see that if you are…

1. Vaccinated

2. Not 80+

…your risk of even disease - let alone death - is very low. If you got a mRNA vaccine series, it’s the lowest possible. Let’s go even further and split up risks by age group and vaccination status so we can further de-conflate. Again, from the CDC:

This last graph makes my case. If you’re…

1. Vaccinated

2. Not 80+

…your risk of death is almost non-existent. Been boosted? Holy crap, you’re darn near bulletproof, regardless of your age right now:

Simple message: Get vaccinated and you’re going to, almost without fail, be fine. Sick? Sure. Really sick or dead? Probably not. So, doesn’t this information warrant a couple of sentences in CDC guidance? The vagueness of messaging is blurring the lines and conflating risks, making everything look risky (because you see high case and death counts). Omicron, for example, may be a larger risk to the population, but it probably isn’t overall if you’re vaccinated.

What about “long COVID”? Conflation, this time on the part of the media, and this is but one example. Look at this headline (from Reuters):

Eeeeeek! Vaccines don’t protect me from “long COVID”. But…if you dig into the article, you see these key pieces of info that come from this study (not yet peer-reviewed), which is linked in it:

1. Vaccines do a great job keeping you healthy in the first place, avoiding the whole idea of “long COVID”…but we’re talking about breakthrough infections, so OK.

2. They protect those < 60 from long COVID even after a breakthrough infection

3. The data don’t support that they protect those 60+ from long COVID

The average reader is going to read the headline and not the details, however. So, conflation. Would it have been so tough to write a headline that says “Long COVID risk no lower for those 60+ with breakthrough infection…”? It matches the data and costs 3 extra words. But the editors failed miserably, so we end up with “risk soup” instead, where everything is conflated into a single “vaccines don’t help” type of headline.

Public-health authorities and our friends in the media (and not just the USA) need to do better if we’re ever going to get out of this mess.