Why You Should Be Happy About the Third COVID Vaccine

I am VERY excited about the Johnson and Johnson COVID vaccine being approved by the FDA for emergency use. It started shipping today, and hopefully will be making its way into people's arms this week! This is great news, in terms of getting more people vaccinated, and I wrote a lot about the importance of that in my last email. Not only will vaccination save lives, it will probably help move us back towards “normalcy”. But I want to address one EXTREMELY important point of confusion about this vaccine with all of you.

We lived in a culture that is obsessed with ratings and rankings. You can read the US News and World Report ranking of colleges, and you can decide that your kid should apply to Princeton instead of Harvard, because this year Princeton is #1 and Harvard is #2. You can determine that Black Sabbath is #85 on Rolling Stone’s top 100 list, but The Temptations are #68, so they are objectively BETTER and you should listen to them more. There is even a ranking for artists, where I found out that Andy Warhol edged out Pablo Picasso for the number one spot, but poor Henri Matisse is stuck at 34.

My point is that while numbers are great for some things, they don’t always tell the whole story. They reduce complicated situations to oversimplified conclusions. And sometimes, they are dangerously misleading if you don’t make the effort to learn more.

I’m worried about the way that we are told that the Pfizer and Moderna vaccines have around 94% efficacy, while the Johnson and Johnson vaccine is “only” 72%. Specifically, I'm worried about the public health and educational impact of that impression. Focusing on that means that people who are offered the J&J shot may feel that they are getting substandard care, which can make them question the whole effort. That narrative, with or without good intentions, makes vaccine hesitancy worse, and undermines trust in medical science and health policy, just when we need it most.

In reality, that "efficacy" concern is overblown and mostly unfounded, as I will explain below. The J&J vaccine is a powerful and necessary weapon in the fight against this pandemic. It’s fine to educate yourselves and learn about the various tradeoffs of different interventions, but if you do that, you need to really learn more than just one isolated number.

The most important thing to understand is what that efficacy number means and what it doesn’t. And you also need to understand why we are giving vaccines in the first place.

As I wrote previously, we are vaccinating people against COVID-19 to save lives. There is some early evidence that vaccines also stop or slow the transmission of the virus to other people. But the studies to date have focused on whether or not they stop people from getting infected themselves. "Infected" can mean anything from asymptomatic infection to death - those outcomes are the "endpoints" that the studies look at.  When studies compare all endpoints, they include even mild cases of COVID, and that’s the difference in “efficacy”. All the vaccines are great at keeping you from dying or getting hospitalized, but there may be some difference in your chance of getting mildly sick.  The important point is that ALL of the vaccines in current use have essentially ELIMINATED hospitalization and death caused by this virus.
That is a HUGE achievement, and one to be celebrated!

This table makes the point very clearly.

The second thing to understand about the 94% vs 72% comparison is that to some degree, it’s comparing apples and oranges. The trials were done at different times with different populations, and the J&J trials included populations with more disease and more variants. For example, the Pfizer and Moderna trials weren’t tested against the South African and Brazilian strains, but J&J was. So even though overall efficacy isn’t the most important number, the different vaccines may be even closer in efficacy than those numbers imply.

There are also some real advantages of the J&J vaccine. First of all, it is extremely effective with only one dose, and that’s VERY important, especially for those who have a hard time making it to a second appointment. People in rural communities living far from vaccination pods, people with difficulties getting time off from work or other obligations, incarcerated populations, homeless populations, people who struggle with the normal activities of daily living, etc… This is also much less of a burden on the health care system, since there is no need to ensure that people come back for their second shot.

Second, it is much more stable - unlike Pfizer and Moderna, you can store the J&J vaccine for months in a regular refrigerator, which makes distribution easier. Third, there seem to be fewer immediate side effects than with the other two, so that makes it a good candidate for drive through vaccination stations, where you don’t have the option of monitoring people after the injection.

So if you have the opportunity to get the Johnson and Johnson vaccine, take it. Sooner or later, you will hear about people who died of COVID after they passed on J&J in hopes of getting a “better” vaccine in the future. If you don’t believe me about all of this, ask Dr. Fauci:

“Don’t get caught up... on the number game, because [J&J] is a really good vaccine, and what we need is as many good vaccines as possible… Rather than parsing the difference between 94 and 72, accept the fact that now you have three highly effective vaccines. Period.”

Another person to follow (on Twitter, or elsewhere) is Dr. Ashish Jha, the dean of the Brown University School of Public Health, who has done a great job of explaining things like this:

“The challenge here is, we focus on these top-line numbers of 65% effective, 75, 85,….What we really care about is avoiding hospitalizations and avoiding deaths. That’s what matters, and we have not seen a single person die who’s been vaccinated with one of these vaccines, and it’s controversial whether anybody’s even been hospitalized or not… So the bottom line is: These vaccines are incredibly effective at preventing bad outcomes…They may vary a little bit on whether they impact your ability to get infected, but what we really care about is those bad outcomes.”

We are probably never going to eliminate SARS-CoV-2 (the virus that causes COVID-19), like we did with smallpox. We missed that chance, and for a variety of reasons, it is likely to be with us for the foreseeable future. The goal now is to make death from COVID-19 so uncommon that we live with it like we live with the flu. We realize that some people with underlying risk factors will die of the flu every year, but other than getting vaccinated regularly for new variants, it doesn’t affect our behavior. If anything, THAT will be the end of the pandemic, and that depends on lots of people getting one of these vaccines. Which is why I’m writing to you! Here are some good articles that explore these points in more detail, from Vox and from the New York Times.

I know that it has been hard to get appointment spots for the shots… I have been working at a few pods around the city giving vaccinations, and I try to post links to helpful sites on my Instagram @snotdoctor as I find them. As of February 15th, New York State added a number of conditions to the existing 1B eligibility group, so many more people are now looking for spots. Keep trying.

Spring is coming. We can do this.