Who Should Get the Covid Vaccine?

A Worst Case Analysis

Summary: 

The Covid vaccines seem to have higher risks than previous vaccines. However, Covid itself is still killing many people. Even with increased risks compared to previous vaccinations, most Americans over 30 have a much greater risk of dying from Covid than vaccination, even under the worst possible assumptions.

If you’ve been hesitating, and you’re a man 20 years or older or a woman 40 years or older, it’s almost certainly to your benefit to get vaccinated unless you are one of the exceptionally healthy people I describe below.

I wish the medical establishment would be less defensive and admit the increased risk, while still encouraging vaccination among those better off taking the risk. Their obfuscation and denial are probably killing more people than generalized vaccine skepticism.

Full Report:

It’s been a strange year. Many of us feel like, for good reason, we can no longer trust the institutions in our society. I’m not generally a vaccine skeptic, but I was cautious at first regarding the Covid vaccines because of the relatively low risk of Covid in non-geriatric populations.

One frustrating thing is no one seems to be able to think critically as Covid true believerism or skepticism has become a religious marker for people’s political leanings. On the one side, there are people who give blind trust to medical authorities without bothering to do basic math. On the other, you have ideological anti-vaccination people who are intent on using any anecdote they can find to advance their cause.

Given the relatively small risk of Covid for healthy, non-elderly, fit individuals, I have mostly ignored the debate on vaccination. Having heard several arguments against, and then hearing of very vulnerable individuals refusing vaccination based on these risks, I think it is time for me to apply the same independent analysis to the vaccines as I did to the pandemic itself. 

So how has my original analysis worked out? I was able to determine within the first couple of months that coronavirus was a) a relatively small risk for most people and b) that the lockdowns would be more harmful than the alternative. I predicted national deaths of around 700,000 (0.2% of the population), an estimate that is very close to actual numbers. 

However here are things that can all be true at the same time:

1. The virus was hyped and we did way more damage to our society locking down versus allowing the virus to run its course. The presidential election of 2020 was seen as an existential threat by most institutions in our society and they did not let this crisis go to waste.

2. The coronavirus vaccines appear to be more dangerous than previous vaccines by at least an order of magnitude. This is not due, I believe, to any strange biological mechanisms of the vaccine (the spike protein shedding hypothesis, see here: https://www.deplatformdisease.com/blog/spike-protein-circulating-in-the-vaccinated-what-does-it-mean). It is likely due to the fact that developing a vaccine for what is likely a novel, bio-engineered virus requires novel technologies to stimulate a robust immune response, and the necessary immune response is more likely to overreact with this vaccine than previous, more conventional vaccines. 

3. The vaccines are less effective than other, more conventional vaccines. Breakthrough infection rates are relatively high, though vaccination does offer at least 95% prevention of severe cases and death.

4. The vaccines are still way safer than risking an infection for most people.

5. The best estimates of herd immunity, natural and vaccinated, are about 65% nationally right now. The odds of infection rise in conservative areas with more vaccine skepticism.

6. If you respect the right of people to remain unvaccinated, and live in an area where others agree, it might be even more important to be vaccinated now, before winter, given the increased risk of infection living in such an area.

The potential increased risk of the Covid vaccines can be assessed through FDA data:

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/adverse-events.html

According to official FDA reports (updated July 2021), there have been 6,340 deaths reported after around 342 million vaccine doses. That last number is a little misleading, since most of the vaccines require two doses, and what we really want is the risk for each total vaccination. Assuming the one-shot JNJ vaccine has a 5% market share, which is probably an understatement given some of its perceived issues and manufacturing problems, the 342 million doses represent something like 180 million total vaccinations. So this is a post-vaccination death rate of something like 0.0035%. That’s 35 deaths per million vaccinations.

Now, many if not most of these deaths are not caused by the vaccine, as people naturally die all the time. But, we can compare reported Covid vaccine deaths to reported deaths from more conventional vaccines to assess relative safety. With a little Google research I found the data for a normal flu vaccine from 2011:

https://vaers.hhs.gov/docs/SeasonalFluSummary_2011April05.pdf

This seasonal flu vaccine consisted of 163 million single doses, with 28 reports of death. That’s 0.000017%, or 0.17 deaths per million. Hence, it appears the Covid vaccine is associated with about 200 times more deaths than this flu vaccine. We are talking about extremely small probabilities in both cases, but this is concerning.

A recent qualitative study utilized medical experts to investigate VAERS reports of deaths after Covid vaccination:

https://www.researchgate.net/publication/352837543_Analysis_of_COVID-19_vaccine_death_reports_from_the_Vaccine_Adverse_Events_Reporting_System_VAERS_Database_Interim_Results_and_Analysis

Their conclusion was not comforting: 

“We found that in 34 of the 250 deaths (14%) a vaccine reaction could be ruled out as a contributing factor in their death; these were all patients either already bedridden and expected to die from a serious medical condition like lung cancer, or were described as at end of life or receiving palliative hospice care. For 203 of the 250 (81%) the vaccine may have been a factor in their death; however, many of these patients had one or more chronic or age-related comorbid conditions. Finally, for at least 13 of the 250 deaths (5%) the vaccine was the most likely cause of death; these patients had strong reactions soon after vaccination and died either on the same day, or during the next couple of days.”

Covid vaccination is clearly not risk-free, and it appears to be much more risky than other vaccines.

So what’s going on? Here’s my best guess:

Covid is likely a bio-engineered virus accidentally leaked from the Wuhan lab. I say accidental because the Chinese are much more notorious for poor quality control practices than they are for external aggression. The lab leak idea is not a conspiracy theory, but a mainstream hypothesis:

https://www.nature.com/articles/d41586-021-01529-3

The virus seems to be designed to spread quickly and not be too deadly, and not kill directly. Rather, in some portion of the population it provokes an immune system overreaction, a cytokine storm, that is the immediate cause of death. The target of the vaccine is the spike protein, and in fact the vaccines induce the body to produce a small quantity of the spike protein (but not the whole virus) so the immune system can produce antibodies. However, the spike protein itself can set off a reaction similar to the whole virus:

https://www.contagionlive.com/view/spike-protein-of-sars-cov-2-virus-alone-can-cause-damage-to-lungs

Perhaps a future vaccine could target a different, less reactive part of the virus’ anatomy, but the vaccines that exist today key off of the spike protein. Just as Covid infection is a delicate balancing act between too much and not enough immune response, the same holds true for Covid vaccination. The Covid vaccine may be deadlier than other vaccines because of the unique immune response provoked in some by the spike protein.

The vaccine also is less effective at preventing relatively mild breakthrough infections - even being vaccinated, a “mild” breakthrough infection can mean several days in bed, like the flu, not a great experience. The entire Texas delegation of State House Democrats recently left the state to deny the legislature a quorum over voting security legislation they disliked. One assumes all have been vaccinated. Of the 67 House Democrats who flew to Washington, DC to advocate for competing national legislation, at least 6 have now tested positive for Covid-19:

https://www.texastribune.org/2021/07/20/texas-democrats-washington-coronavirus/

That’s a breakthrough infection rate approaching 10%. The two-dose chickenpox vaccine, by contrast, boasts a breakthrough infection rate of only 0.04%:

https://pubmed.ncbi.nlm.nih.gov/30104113/

“The total breakthrough varicella infection rate (BVR) was 0.37% for all the vaccinated children and 0.04% for 2-dose vaccination.” Again, because Covid is likely an unnatural, bioengineered virus, the vaccines are less effective and more dangerous than those formulated against conventional targets.

Clearly, however, the vaccine is saving lives. It offers something like 95% protection from severe Covid infection. In Israel, the world’s most vaccinated country, while cases are spiking right now due to breakthrough infections, deaths remain in the range of 1-2 per day:

https://www.worldometers.info/coronavirus/country/israel/

Israel’s actions and results also ought to give us pause against conspiracy-type thinking regarding the vaccines. There are a lot of reasons to mistrust institutions in American society, but Israel is a country that unapologetically exists to advance the interests of the Israeli people as a permanent Jewish state. That Israel chose to vaccinate early and often is evidence that, whatever the risks of the vaccine, there is no conspiracy to actively harm.

That said, anyone who wants the vaccine can get it, so there’s no need to pressure those who have little to no need of it, such as healthy teenagers, to get vaccinated. On the other hand, for those of us where it’s a close call, we might ought to get vaccinated to contribute to herd immunity and save the lives of others. 

So who should definitely get vaccinated according to the odds?

Let’s assume the worst, because of the precautionary principle. That is, because we live in a world where breaking things is easier than building them, before we take action under conditions of uncertainty, the burden of proof needs to be borne by those advocating action, in this case getting vaccinated vs. risking a natural Covid infection.  

In this spirit, let’s assume 100% of the reported deaths are caused by the vaccine so we put a robust upper bound on the risk. That is, the absolute maximum risk of making the decision to get the Covid vaccine is rolling the dice on not being one of the 35 deaths per million. That’s about 1 in 28,000. We can use my Covid risk estimation spreadsheet I prepared last year based on Italian mortality data to find crossover points for men and women, and those with and without comorbidities:

https://docs.google.com/spreadsheets/d/1xExEc5e7jtJsQzzUxKmVp9u8qOa8JYFKyfyUeuBBWiE/edit?usp=sharing

Now some will object here that VAERS supposedly only captures a small sampling of data and underreports adverse events, including deaths. We have no way of knowing if this is true. However, the vast majority of adverse events are coincidental anyway. We can check this with common sense. You probably know a few people who died from Covid. Now, think about the vaccine. Do you know anyone who died after getting it? Probably not, most of us just maybe know someone who had a bad allergic reaction and was ok after a few days. In addition, CDC data on excess mortality has only normalized since vaccination began in earnest earlier this year (https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm). If that many people were dying of the vaccine, it would show up in the overall mortality data based on death certificate reporting.

So I think using VAERS deaths is a very safe, very conservative upper bound for actual vaccine risk. Where does the risk/reward start to make sense?

Let’s start with me.

As a 42-year-old male with no comorbidities, my handy Covid risk estimator puts my odds of dying from a Covid infection at about 1 in 12,000. However, estimates say we are at about 65% herd immunity. We need about 80% herd immunity to make Covid infection a negligible risk. So among the 35% without immunity, another 15% will end up getting the virus or vaccinated before herd immunity is reached. Thus, my risk of Covid infection, if I remain unvaccinated, is somewhere around 43%. This means my actual odds of dying from Covid are 43% of 1 in 12,000, or 1 in 28,000. 

I estimate that I am, at worst, about as likely to die from Covid vaccination as I am from Covid infection. Because of my low risk, I am choosing not to vaccinate at this time, though I am monitoring the data closely to see if anything changes. In particular, if more robust safety data emerges on the JNJ option (see below), I might get vaccinated later this summer or early fall.

[Update: this week, I contracted Covid. Symptoms remain mild so far (malaise, GI issues, fever) and I will have natural immunity once done. Though my symptoms are mild, I have lost my sense of smell and it might take weeks to come back. Had I finished this analysis earlier and considered the ongoing inconvenience of the loss of smell, I probably would have chosen to vaccinate. Since even a mild case of Covid will easily kill a week’s productivity, with at worst even odds the possibility of never getting it is a real benefit.]

Playing with my model and adjusting for infection probability we can determine who would definitely benefit from vaccination. This is when the risk of dying from Covid becomes greater than the maximum theoretical risk of dying from the vaccine.

If someone is not medically overweight and has no other comorbidities, vaccination is absolutely a win at age 43 for men and age 55 for women. 

For those who are overweight or have other health problems, about 80% of Americans, vaccination becomes a guaranteed net benefit at age 20 for men and age 40 for women.

The reason for the vast age difference is that men are much more likely to die of Covid because of weaker immune systems associated with testosterone. 

Anyone with a previous Covid infection likely doesn’t need vaccination, despite claims to the contrary:

https://www.healthline.com/health-news/new-study-determines-people-whove-had-covid-19-dont-need-to-get-vaccinated

Be careful about assuming you’ve been infected. A lot of people claim they must have had Covid because of a “weird cold” they think they had in 2019, but odds are most of them didn’t. Unless you had a positive test in the past and recovered, or have detectable antibodies now, I wouldn’t assume you’re safe.

Let’s be honest about what it means to be medically overweight. About 80% of Americans have at least one comorbidity, notably being overweight or obese. We have lost track of what normal, medically healthy weights should be. To assess this, instead of BMI I prefer to reference clothing size as a better proxy for body fat percentage, the medically relevant variable. BMI is notorious for underestimating this in most people (see here: https://www.mlive.com/health/2012/04/bmi_underestimates_obesity_esp.html).

Men over 6’ tall and wearing pants larger than a 36” waist probably have excess abdominal fat and should consider themselves to have a comorbidity for Covid purposes. Men less than 6’ tall and pant sizes bigger than 34” are probably medically overweight. Women bigger than a size 10 under today’s inflated sizing are also probably medically overweight. This is not to insult anyone, but to help honestly assess whether a vaccine might be more likely to save one’s life. These are rough estimates, to calculate a more accurate number I recommend the U.S. Navy’s circumference method: https://www.bizcalcs.com/body-fat-navy/.

The reason Covid is so deadly for those carrying any amount of extra weight is because when it attacks the lungs that extra weight means they lose blood oxygen much more quickly than a slim person. It just takes more oxygen to support a higher body weight. This means the medically overweight are more likely to be intubated, and if that happens there is only a 70-80% chance of surviving.

Remember my analysis makes the worst possible assumptions about the risks of vaccination, and so should be seen as a minimum recommendation based on those who are most vaccine skeptical. Overall, Covid vaccination at any eligible age, except maybe for very fit, athletic teenagers, is probably, all things considered, a good decision.

I really hate how politicized the vaccine debate has become. Both sides are behaving like religious fundamentalists. Those who should know better, the public health authorities, have let themselves become overly defensive and refuse to address any of the legitimate concerns about vaccine safety and relative risk. The data show they have nothing to fear other than admitting that Covid vaccinations appear more dangerous, and less effective, than previous vaccines, though they are still beneficial for most Americans.

There are so many wonderful, conservative people I want to encourage to rationally assess their risk, without the misinformation presented by both sides. Another wave is probably coming this winter, so this assessment matters. And with so many vaccinated people getting mild breakthrough infections, we are possibly further away from herd immunity than initially expected. We might need to get to 90-95% herd immunity before it stops spreading.

Which vaccine is safest? Early data hints that the JNJ vaccine might be the safest. As of the latest CDC data I could find:

https://www.cdc.gov/mmwr/volumes/70/wr/mm7018e2.htm

There were 88 deaths reported across 7.98 million doses, or 0.0011%, about 1/3 the risk of the other two vaccines. Since JNJ is a single dose, this is a significantly lower reported death rate than the total risk from the two dose regimen. It’s also more convenient since a single dose and is similar to the technology used in the Russian vaccine, which was the first effective vaccine released in August 2020. Similar to the Ebola vaccine, the JNJ Covid vaccine uses an adenovirus to deliver instructions to the cell to produce a spike protein which stimulates the immune system to generate antibodies. However, there are concerns about very serious blood clots and Guillian-Barre syndrome with JNJ that the CDC considers statistically significant, so while it is associated with fewer deaths it may have more overall serious adverse events. These are relatively small numbers compared to the Pfizer/Moderna vaccines and haven’t been updated with new data since April.

All in all, the risks are small, so the one dose option from a convenience point of view may be attractive. In addition, the JNJ requires less intense refrigeration, which means you are relying less on the supply chain to ensure your vaccine is actually effective by the time you receive it.

That’s it for this report, let me know what you think in the comments, and I hope you found this information helpful.