Vaccine tactics matter! Ring vaccination NOW!

In addition to Joe Biden’s Alex Tabarrok’s “First Doses First” plan,i Operation Warp Speed’s “Half-Doses First” plan, and David Friedberg’s “Fuck The Litigious Corrupt Bureaucracy Mobilize The Army” plan,ii given COVID’s well-established and irrefutable ability to mutate faster than we can tie our shoelaces, we would do very well to consider more tactical approaches to vaccine distribution given the incredibly high probability absolute certainty that one dose one time is insufficient for lifelong immunity and that future doses of even newer vaccines against COVID-19 will be required to respond to the thousands of inevitable variants coming soon to a theatre near you.

Why not just mass vaccination for all? Doesn’t “spray and pray” work? Shouldn’t we vaccinate people with the most political pull, like California does by prioritising unionised teachers over its elderly? Well Timmy, I’m glad you asked these thoughtful questions. To start, let’s consider the history of vaccines. Thankfully, this isn’t the first time that humanity has fought off an invisible enemy with a vaccine as our primary weapon and if we dig a bit deeper into the dusty tomes of yore, we’ll find some worthwhile ideas on how to better use our current crop of finite resources, be they vaccine doses or institutional capacity.

Recall that humanity had the smallpox vaccine for 200 years before we eradicated the disease and we had the polio vaccine for 70 years before it too was eradicated.iii Why did these vaccines fail for so long… until they didn’t? In short, they were being implemented poorly… until they weren’t.iv Recall our conversation from last week relating to Israel’s strength with the last mile. If Israel can get to herd immunity in a month or two, it will be because they’re a small, well-trained country that cut the red tape and got to work, but for the rest of the failing/flailing western nations posturing nakedly, the ones who don’t have such a strong military-based do-or-die culture as Israel does, leveraging a little tactic known as RING VACCINATION to contain outbreaks, combined with early vaccination of the elderly and high-risk workers, is our best path forward with our limited resources in Q1/Q2 2021.v

Image via https://www.scq.ubc.ca/smallpox-then-and-now/

Image via Smallpox: Then and Now, by Tyler Hickey. The Science Creative Quarterly, August 2004.

So what exactly is ring vaccination? Dr. William Shiel has it:vi

Ring vaccination: The vaccination of all susceptible individuals in a prescribed area around an outbreak of an infectious disease. Ring vaccination controls an outbreak by vaccinating and monitoring a ring of people around each infected individual. The idea is to form a buffer of immune individuals to prevent the spread of the disease. Ring vaccination was used to control smallpox until the last naturally occurring case in 1977. When an infection was diagnosed, all people who were or may have been exposed were identified and vaccinated. Then, a second “ring” of people who may have been exposed to the first ring were also identified and vaccinated. Ring vaccination was also recommended by the American academy of Pediatrics in 2002 for smallpox, should there be another outbreak (from terrorism or whatever). Ring vaccination has been used successfully as a disease-control strategy under other circumstances, for example, to contain foot-and-mouth disease in livestock in the UK. Also known as surveillance and containment.

Not complicated. Then again, none of this is. For the most part, as much as COVID is the enemy, we’re our own worst enemies… Until we aren’t.

It’s time to get out of our own way and WIN WIN WIN NEVER STOP!
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  1. Alex was there December 8th of last year. Have you heard of anyone there sooner? Sleepy Joe only woke up to the idea of deploying “second” doses ASAP on Jan 8th of this year, granted that’s still faster than The Crazy Train.
  2. VC Bestie David Friedberg has the hot take:

    The Pandemic War is an actual war we must fight and win. the virus is surging, and evolving. we must surge back, and evolve faster than the virus. here’s my proposed plan and analysis… first, in general, perfect has been the enemy of good, that’s why we’re losing this War. perfect test results. perfect vaccine. perfect treatment (no one can die; follow regular standards of care). we must end perfect and get good enough. it’s the only way to win.

    1) eliminate liability
    2) source/staff/operate Covid Care Centers
    3) rapid tests for everyone
    4) immediate antibody therapy for ALL C19+ patients
    5) unrestricted high-volume vaccine rollout

    1) pass Federal law that eliminates all liability for COVID care & vaccine deployment. care providers must not fear legal repercussions in prioritizing speed of care over quality of care. the “no one can die” “by the book” approach must end. we can save lives by taking risk. make it easy for unlicensed volunteers to administer vaccines. nationalize responsibility for testing, antibody therapy, & vaccination administration. eliminate health record keeping/HIPAA reqs for those services. we need throughput; this is in-field battle triage.

    2) for every 100k population, setup 1 Covid Care Center, providing rapid antigen tests (drive up/outside), vaccines (outside) & antibody therapy (inside). surging means we need non-standard improvised care facilities. can’t depend on hospitals/existing infra. take over sports arenas, convention centers, high school gyms. 3,300 Covid Care Centers needed. Natl Guard runs logistics of site selection and crowd control. 10/center = 33k Natl Guard troops (there are 336k members of Army Natl Guard). we can get sites up in ~7-10 days. volunteers provide rapid testing and administer vaccines outside, nurses provide antibody therapy to positive patients inside. severely ill routed to hospitals, where care can be managed w our limited hospital resources. each Center staffed w 3 trained nurses, 1 doc, 30 volunteers per shift, work 12 hour shifts 7 days/week. pay nurses triple OT. source through agencies. open call for docs.. 6k docs, 20k nurses, 200k volunteers needed. there are ~1M licensed physicians + 3.8M nurses in US. each nurse trains/manages 10 volunteers during shift. prioritize EMS/EMT/nurses/police officers/trained teachers/military as volunteers. CDC already has vaccination administration training materials available. 10-30 days to staff Centers.

    3) we don’t need “gold standard” PCR testing. rapid antigen paper test strip can be printed for literally $.10, we have facilities to do this in US. reactive chemical stripe (changes color if “antigen” is present) is printed like ink in line on paper; paper cut into little strips. rather than use typical rapid test plastic casing ($$$, made in Asia), just use the paper strip, a q-tip (self swab in nose), and saline in plastic tube; dip qtip in saline drip onto paper strip. positive if stripe changes color. self-administered. volunteers explain + support. nasal (front of nose) swabs w rapid antigen tests capture ~74% of true positives. not perfect, but gets enough people ID’d to quarantine + get antibody therapy, dramatically reducing spread + hospitalizations. Likely ~$0.50 all-in cost to make each test. use DPA to force printing. (can get 1B tests printed and delivered in <30 days for $500M. all Care Centers can be fully staffed and resourced in <30 days from today.) if test is negative, you get vaccine shot and/or go home. if positive, go inside and get immediate antibody therapy…

    4) Regeneron has isolated 2 human antibodies to SARS-COV2. antibodies are synthetically produced in fermenters used to manufacture biologic (protein) drugs. 2.4 grams of antibodies w 1 liter of saline given via IV into arm over 60 mins provides artificial immunity. and it works! given early enough, antibody therapy reduces hospital/doctor visits by 70% and mortality by (potentially) 100%! Few to no side effects. It’s only effective if given early; not useful when severely ill after virus has spread in body. however, biologic infusions at hospitals take tons of paperwork, dedicated nurse labor, hours for check-in/vitals/prep/monitor. the “standard protocol” means most hospitals aren’t resourced to give antibodies to early-stage C19 patients, as resources dedicated to the very ill. thus, simplify process- eliminate paperwork/vitals; simple intake q&a, sit in chair, nurse hooks up IV bag; <60min turnaround, parallelized w 40 chairs. 5 mins/patient setup; single nurse = 12/hr; ~800 patients/Center/day capacity; 200k treated in US/day=only 70/Center/day needed. need to make LOTS of antibodies. Can be made in standard antibody bio mfg systems; 2.5M liters capacity in US. production yield likely ~4g/liter/5 days. For 200k patients/day, we need ~25% of US mfg capacity. Regeneron currently only using 140k Liters (5% of US) to produce! Regeneron charging $1,500/dose at 92% gross margin! Actual scaled production cost likely <$5/dose! Can treat 200k patients/day, nearly eliminating C19 deaths for ~$1M/day, saving 4k lives/day. Use DPA to take capacity from biotech companies, force scale up, and deliver free.

    5) vaccination is a group problem not an individual one. If we don’t ALL get vaccinated, the virus mutates and we ALL LOSE. priority isn’t the issue, throughput is the ONLY issue. we’re expecting 100M+ doses of vaccine from Pfizer+Moderna. we can deploy <30 days… 1 shot / 3 mins / volunteer, ~15 vols/Center x 24hrs = 10k vax/Center/day = 33M/day throughput capacity! No ID/paperwork/time wasted. 2 lines: o/u 65yo, 5:1 resource split. stand in line, no ID/paperwork, get shot, done. allergy risk? sit + wait. something happens, doc treats. i am a big believer in market forces. normally, i think if you reduce regulation and enable markets to act freely they will resolve to the best outcome. however, i don’t think market forces work well when the collective interest outweighs individual interest.

    Now, Friedberg nails the treatment and testing angles, but for vaccination, while he’s not wrong in spirit, the long-term efficacy of his approach still depends on simultaneous coordination globally as well as specifically targeting outbreaks (ie. ring vaccination!). Yes, throughput globally is hugely important and will overcome some of the coordination issues (ie. LET VACCINES RIP!!!) but priority also matters a lot. It certainly did when we vaccinated against polio and smallpox, so why shouldn’t it here? 

  3. “Eradicated” should seriously be in air quotes because neither smallpox nor polio have exactly gone the way of the dodo and dinosaurs, being that they can find reservoirs outside of the purview of vaccines and then lie in wait for anti-vaxxing Darwin Award Nominees, but let’s not make the main body any harder to parse than it already is, ya? 
  4. For more on the history of smallpox vaccination success from one of the men responsible, check out Episode 8 of BBC’s “How To Vaccinate The World” (podcast archived here) in which economist Tim Hartford interviews brilliant scientist Larry, er, Brilliant. In summary: for COVID vaccinations, we need to implement RING VACCINATION to contain outbreaks!
  5. From my lips to Hashem’s ears will 100s vaccines be approved worldwide by Q3 2021, each being manufactured in 10s (or 100s!) of millions of doses per month!
  6. Note that Ebola was also contained and controlled in Africa using ring vaccination just a few short years ago. It can be done! It wasn’t a simple undertaking but it was still a lot simpler than quarantining the whole continent. Quarantines work rather well in the short term while vaccines and treatments are developed but they’re certainly not designed to work over years and years, not that our dear western “leaders” have figured this out yet. Of all the things the west chose to borrow from China’s early success in managing this outbreak (eg. crazy fast hospital construction, contact tracing, severe lockdowns, mass surveillance, rapid therapy and vaccine development and approvals), what western countries chose to borrow was… soft lockdowns that bought us a few important months early on so that we could figure out testing, treatments, and vaccines, but that now serve to make everyone fucking crazy without appreciably stemming the tide or buying more time. We’re done buying time in this war! The only thing left is to fight the fucking war!!! Who do these Chamberlain LARPing fucks think they’re appeasing at this point???!!!

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