An Open Letter to Chris Witty (England's Chief Medical Officer) on Vaccine Hesitancy

On Thursday, Chris Whitty, England’s Chief Medical Officer (CMO), attended a select committee hearing where he was questioned on Omicron.  During the discourse, the CMO discussed vaccine hesitancy in the population, which he said was approximately 10%.  I’m assuming he meant 10% of the adult population because it’s much higher if under 18s are included.  He made some valid points as to why people are hesitant and I transcribe his response below.

“There are basically four things people want to know and that we have to and make sure are culturally relevant as well and that doesn’t just mean ethnically / culturally I mean making sure every bit in society feels that we’re talking directly to them in a way that they feel comfortable with and trusting of. 

First thing is they want to know that the disease is a big enough threat that it’s actually worth doing anything at all that’s a really critical thing.

Secondly, they want to know that the vaccines actually work and on both of those we have incredibly good evidence.  We know that this is a big threat and we know that the vaccines do work.

The third thing is they’d want to know that the side effects are proportionate to the benefit that the vaccine is giving them.  That one we have to keep on going at because there are huge numbers of myths out there, these are not people who believe them who are anti-vaxxers, the anti-vaxxers start them but they’re not the people who believe them, they just read something on the internet, they’re worried and they need to have serious information put to them.

The final thing is we need to make it convenient.  Convenience makes a very big difference.  I found it very striking when I was last on the wards that the people who I spoke to who had not had the vaccines, who were disproportionately there, unsurprisingly, an awful lot of them said I hadn’t got around to it yet, it wasn’t that they weren’t there, there were a few of them you’d meet who just believed all sorts of nonsense, but for the great majority it was I hadn’t got around to it yet“

As the CMO made some valid points, I thought I would write an open letter to him to address the issues he raised. 

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Dear Chris Whitty,

Further to your attendance at the select committee hearing on Thursday 16 December, I decided to write to you to address your points made about vaccine hesitancy.

Firstly, thank you for distinguishing between true anti-vaxxers and the majority of the population who have decided not to get the COVID vaccine so far.  It is unhelpful and divisive to ‘other’ people and label them as anti-vaxxers when in reality they want the best for themselves, their families and society as much as anyone else does.  It is also likely to further entrench their positions when they feel demonised and so unable to discuss these extremely important issues with others (including with medical professionals who are often even less considerate than the general public).  It is also clear that you and others have thought about why people have made the decisions they have, as the four points your discussed broadly cover most issues which make people hesitant.  I would like to go through these in order.

Firstly, you say people want to know “that the disease is a big enough threat that it’s actually worth doing anything at all”.    The former Public Health England stated that the infection fatality rate (IFR) is 0.096% or to put it another way, a survival rate of 99.904%.  Oxford University produced a tool to calculate an individual’s risk of SARS-COV-2 early on in the pandemic.  Using that tool my own personal risk of dying from COVID-19 is 0.0005% or 1 in 200,000.  For relatively young, healthy individuals would you concede that there is no big threat and the decision to be vaccinated is purely a societal one?

Looking at the question from a societal point of view, can you still say the threat is big enough?  The age-standardised mortality rate for 2020 (before vaccinations) was 1,043, which was undeniably higher than the last few years but less than 2008 (1091) and any year before that.  If your counter-argument is it would have been worse had it not been for lockdowns, then how do you explain countries such as Sweden or states such as Florida or Texas which barely locked down at all?

Is it not the case that the societal risks versus the benefits are much higher when mass vaccinating?  I think the new vaccines are fascinating and am in no doubt that they will revolutionise a whole area of medicine over the years.  However, there is no denying that this is a new technology (I know they have been used in other settings, e.g. for treating cancer) and with all new technologies, there are risks involved.  If younger, healthier individuals are at very low risk from COVID, then why not only vaccinate people in the higher risk categories? 

The counter argument over the past year has been that there is still a small risk after vaccination and that some of the most vulnerable can’t be vaccinated.  Therefore, if everybody gets vaccinated, transmission will be low and a vaccine induced herd immunity will protect them.  However, it has been quite obvious from fairly early on that the vaccines don’t prevent infection and barely reduce transmission (if at all).  The vaccine companies themselves said that their products were to reduce severity of disease and death, not transmission.  That means, that however many people you vaccinate, the same vulnerable people you were trying to protect will always be exposed.

As soon as it was possible to analyse these new vaccines, concerns were voiced about a number of things.  Firstly, with the narrow targeting of antibodies to the original spike protein.  Concerns about this included evolutionary pressures on the virus to mutate so that new vaccine resistant variants would emerge.  There were also worries that such narrow targeting would not produce a broad immunity, which would be gained through natural infection or traditional vaccines, meaning citizens having to be constantly vaccinated to top up antibodies or develop new ones against new variants.

Secondly, signals of a 2/3 week period of immunosuppression after vaccination was identified.  This meant it was more likely to catch SARS-COV-2 in the short window after vaccination.  If correct, vaccinating during the winter periods would mean more people getting ill than if they had been vaccinated during the summer.  The same concerns are still there with the booster campaign.

Another concern was that, with mass vaccination, the virus could evolve to affect children or unvaccinated people. A similar occurrence happened in chickens developing Marek’s disease.

Were these risks every considered, if not, why not and if they were what were your reasons for dismissing them?

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Your second point about vaccine hesitant individuals was that “they want to know that the vaccines actually work and on both of those we have incredibly good evidence”.  Most of the evidence for the efficacy of the vaccines has occurred during the warmer part of the year when cases, hospitalisations and deaths were relatively low.  However, on the face of it, the evidence for the vaccines working is strong (for a short period of time anyway), with rates for hospitalisation and death per 100,000 lower in vaccinated individuals.  Nevertheless, it has been pointed out that the unvaccinated population can include a lot of people who are too ill to be vaccinated and so can skew the figures.  This concern would be dismissed if more data were released breaking down infections, hospitalisations and deaths by age and vaccination status.  Without that, Simpson’s paradox means any interpretation of the data is unreliable.  The limited data that has been released has shown a potential mis categorisation issue further skewing the data.  Public health is about trust and without trust more and more people will become hesitant (not just about these vaccines) so transparency with data is fundamental.  

It was also a major concern early on that vaccines would only generate short-lived antibody based responses rather than long lived T cell ones.  With increasing data from the UKHSA showing this may be an issue and booster campaigns to try to alleviate this problem, why would it not be more sensible for younger, healthy individuals to get a broader and longer-lived immunity via natural infection? 

Even before Omicron, infection rates in the vaccinated population were going into negative efficacy.  This negative efficacy is now in all age groups over 18, except for the older age groups where boosters have turned this around for now.  If the main reason for a young, healthy person to get vaccinated is a societal one, then having a large chunk of the population in negative efficacy for infection invalidates this argument.

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Your third point was that people “want to know that the side effects are proportionate to the benefit that the vaccine is giving them”.  As mentioned above, my own personal risk of dying is 1 in 200,000.  Therefore, the risks associated with the vaccines need to be at least this or lower for someone similar to me in age and health.  It has not helped public trust when it was obvious early on (from studies undertaken in other countries) that clotting issues were a problem.  This was just brushed under the carpet for a few months until it was recommended under 40s not to have the AstraZeneca vaccine.  By then, a lot of trust had been lost.  The same thing happened with myocarditis and other issues which were freely being discussed in other countries. Furthermore, trust started to vanish as vaccines were given temporary authorisation (rather than being licensed), liability for the pharmaceutical companies removed and trials unblinded and placebo groups vaccinated before the end of the trials.

However, short term side effects are relatively rare and a lot of people are more worried about the potential medium to long term risks.  We are constantly told that the vaccines are safe but how could you possibly know that with such warped sped trials.  There are plenty of previous coronavirus trials in animals that didn’t go as planned so what can you say to convince people that any previous issues have been resolved?

Medium to long term risks could include Antibody Enhanced Dependency (ADE), which could already be showing its ugly head in some of the UKHRA data.  Original Antigenic Sin (OAS) is another concern, where vaccinated individuals will only ever produce antibodies to the original spike protein and so therefore be more susceptible to future variants.  These may be crackpot ideas to you but a simple explanation why these issues won’t occur would encourage a lot of people.

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Your final point was that “we need to make it convenient”.  That may be the case for some people (e.g. older people with transportation issues or people in rural areas) but I would hazard a guess that for the majority of vaccine hesitant individuals, this isn’t really an issue.  The fact that patients tell you “they haven’t got around to it yet” indicates, to me, two things.  Firstly, that they are open to the idea of vaccination, they aren’t anti-vaxxer conspiracy theorists, they just haven’t been convinced it’s the right option for them yet.  Secondly, they are made to feel like anti-vaxxer conspiracy theorists, so try to alleviate this idea by saying the word “yet”.

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I have no doubt that all policy decisions made, with regard to the vaccine rollout, have been undertaken with the best intentions and to save as many lives.  I am guessing that the decision was taken early on that public health policy would provide a strong, clear and focussed message to get the highest footfall of people through the vaccination hall doors.  This policy may work initially but when it is evident that information is being supressed, data is not as transparent as it should be, critics are censored and issues not talked about, public trust is eroded very quickly and it takes a lot to regain this. 

You could start to regain this now and I would be grateful if you could address all the points made in this letter. As you said in the select committee, “people are worried and they need to have serious information put to them”. Please put some serious information to everyone and in doing so I am sure you would convince a lot more people to get vaccinated.

Yours sincerely,

The Naked Emperor