Hello,
I’d intended to take this week off, but then the CDC and FDA announced they recommended pausing administration of the Johnson & Johnson vaccine after identifying six cases of a potentially lethal blood clotting syndrome linked to the shot. There’s a lot of loose talk on the internet about what this means and whether it’s being handled properly, and so I wanted to write a supplemental grounded in what epidemiologists and public health folks are saying, in part—to be honest here—as a service to myself, someone who along with their spouse has just gotten the J&J vaccine and is in the window in which they have an astronomically remote but non-zero chance of developing a debilitating or fatal brain bleed because of it.
I should be clear up front that I have neither regrets nor reservations about having gotten the J&J vaccine. The risk presented by the vaccine is minuscule in comparison to the risk of contracting Covid. This isn’t exactly a hypothetical exercise for me — one of my kids came home from school with cold symptoms early this week, and from the moment we realized he was sick until the moment our Covid test results came back negative was a white-knuckle ride far beyond anything our household has worried about regarding these vaccine side effects. But vigilance is really important, for reasons I’ll elaborate below.
/ The problem
The problem with this vaccine is similar to one apparently caused by the AstraZeneca shot in Europe: an unusual type of blood clot that forms in the brain while the level of platelets (little cellular bits that help us form blood clots) in the blood is low. The clot prevents blood from draining out of the brain, and a hemorrhage can result. The condition is called cerebral venous sinus thrombosis (CVST) with thrombocytopenia, or low platelet count. It’s particularly tricky because, thanks to the thrombocytopenia, it can’t be treated like a normal blood clotting problem. The usual blood-thinning treatment can actually make the problem worse by encouraging bleeding (one hypothesis is that it was the use of heparin, a blood thinner, that played a key role in the one death among the six identified adverse reaction cases originally under investigation).
It’s common to say that these six cases came out of 7 million administered doses, but that’s not exactly correct and is somewhat misleading — if it takes 1-2 weeks after inoculation for this condition to develop, then these six cases actually arose from something closer to 2.7 million J&J doses administered, as epidemiologist Caitlin Rivers pointed out. And all of these cases involved women between the ages of 18 and 48, which means the denominator is smaller still. So, yes, it’s rare. Incredibly rare. But not exactly 1 in a million. If you’re a woman under 50 the odds of developing this reaction may be as high as 1 in 250,000, virologist and J&J vaccine recipient Angela Rasmussen estimated, which is still extremely unlikely. For more on the nitty-gritty here, I really recommend this interview with science journalist Kai Kupferschmidt.
/ The pause and investigation
The CDC recommended this pause because it’s a tricky problem, they’re not entirely sure why it’s happening or how best to treat it. And also because more cases will absolutely become public — not only because millions of additional doses of the vaccine were administered after the inoculation of the six people who developed this reaction, but also because now that the problem has been identified, more physicians are likely to make the connection between cases of CVST and the J&J vaccine. The more unsettling counterfactual scenario here, from a public communications standpoint, would be a steady drip of vaccine-related deaths reported loudly in the press while public health officials insist over and over again that there’s nothing to be worried about, it’s a one in a million chance, there’s no reason for concern (which would be true, but not particularly convincing to the people who need convincing).
So the CDC convened its Advisory Committee on Immunization Practices (ACIP), a panel of experts, on April 14th to review the data and make a recommendation on how to proceed. In the interest of transparency, the meeting was live-streamed to the public, and epidemiologist Katelyn Jetelina took a really useful set of notes on the meeting here. The ACIP couldn’t make a decision, because the data are still somewhat murky, and they want to wait to see how many more cases develop before recommending either lifting the pause or extending it indefinitely.
/ The implications
There’s been a fair amount of criticism over this pause. The vaccine works. The brain clotting adverse reaction is rare. Making such a fuss might make people more reluctant to get their vaccine. But it seems like the right call to me, for at least four reasons.
First, it’s our duty to act if we know there’s harm — as Craig Spencer put it, if you were a family member of a person hurt by this side effect, and the CDC/FDA knew about it and didn’t act, you’d be justifiably furious.
Second, while pausing administration of the J&J vaccine puts a dent in our vaccine supply, it’s not a critical problem: the vast majority of shots given have been of the two mRNA vaccines, which don’t carry the risk of these side effects. We’re in a moment where we have more vaccine supply than demand, and so we have the slack to be cautious here.
Third, while it’s true that the J&J vaccine can reach people who might not be able to get the mRNA shots, that’s all the more reason to take our time getting it right.
That’s because, fourth, our country’s medical sector is badly damaged after 13 months of dealing with this pandemic, and it’s crucial to get physicians and nurses a clear signal on how to recognize and treat this blood clotting problem before resuming administration of the shot. The nightmare scenario is that we go on as usual, disproportionately giving the J&J vaccine to people who tend to receive less attentive medical care either because they’re in communities with under-resourced health systems or because they’re subject to medical discrimination based on their gender, race, or other characteristics, and some fraction of these people then develop blood clots as a result, which go undiagnosed or mistreated, with fatal results.
/ High reliability vaccination
What we want, especially in a world where emerging infectious diseases will routinely cause outbreaks and occasionally pandemics, is a vaccine system that is highly reliable: that works predictably and, when it fails, fails in a way that causes the least amount of harm. The organizational science of high reliability calls for a preoccupation with failure, for building rules that lower the bar for what are considered to be unacceptable missteps.
The civilian air traffic system is a good analog here, actually. Air travel has become ridiculously reliable, from a safety standpoint. Strict regulations ensure resilient engineering of the aircraft, and high-reliability organizing in the air traffic control system ensures that collisions in the air and on the ground are incredibly rare. Because of this track record of safety, air travel is (was) a routine and unremarkable part of everyday life (with negative consequences for the climate and for, uh, public health given how it enables pathogens to spread with unprecedented speed and geographic scope).
To survive the next pandemic we’ll need to establish a system that can develop and deploy vaccines against newly discovered diseases quickly and safely enough that people won’t hesitate to take them. Not everyone will be convinced — to return to the air travel example, there are plenty of folks who are afraid of flying, and it’s not really the kind of fear that you can dispel by chanting safety statistics to the wary — but a system that’s transparent, regular, and preoccupied with failure will go a long way towards increasing vaccine uptake in the long run.
That system will be working against headwinds generated in part by social media platforms that have shown exactly the opposite approach to information safety, which is to move fast and break things regardless of the consequences. The fact that the most popular article on Facebook about the J&J pause is from an anti-vaccine conspiracy theorist isn’t the CDC’s fault, it’s Facebook’s. One of these institutions is taking its role in safeguarding equitable public health seriously. The other is an advertising firm.
/ What’s next
The CDC’s vaccine advisory panel will meet again April 23rd to discuss the J&J vaccine, and may decide at that meeting to end the pause. In the meantime, the U.S. is vaccinating more than three million people every day, and despite a worrying and completely avoidable partisan gap in vaccine acceptance, the J&J pause doesn’t seem to have mucked up the vaccine rollout in any measurable way yet. And in our household, while we’re watching out for headaches and shortness of breath, in a few more days we’ll be both in the clear with regards to vaccine-related blood clot risk and functionally immune to SARS-CoV-2. All in all, not bad for a week in our terrifying new future.
// Micro Link Roundup
Information infrastructures are out there: This week the U.S. military released some new footage of unidentified flying objects captured on tape by troops on exercise. The constant trickle of UFO footage is one of my favorite subplots of the late 2010s-and-early-2020s, and it got more interesting with this long analysis by an aviation intelligence journalist who thinks the UFOs are most likely a sophisticated intelligence-gathering operation by foreign adversaries (probably Russia and/or China) to probe U.S. air defense capabilities by floating drones and other weird airborne objects near military units in hopes that they’ll attract the curiosity of our advanced sensors. It makes absolute sense from an institutional perspective, if you understand modern militaries as complex, highly technical organizations in continual competition to gain information about their operational environments.
— “Adversary Drones Are Spying On The U.S. And The Pentagon Acts Like They're UFOs.” Tyler Rogoway, The Drive.
That’s it for this supplemental. Make sure to share the newsletter in the chat at your next X-Files watch party, subscribe through the box below, and I’ll see you in your inbox next Saturday.