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Ecological fallacy: When a scientist (inadvertently, I hope) uses a favorite antivax form of study

A longtime favorite technique of antivaxxers has been to do bad ecological studies to imply that vaccines cause harm. Why is a Harvard investigator inadvertently using the ecological fallacy the same way antivaxxers used to do before COVID-19?

Longtime regular readers might remember the various times over the years that I discussed bad epidemiology papers by antivaxxers that claimed to have found associations between various vaccines and bad outcomes. You know the studies, for example, the study ten years ago by Neil Z. Miller and Gary S. Goldman that claimed to find an association between the vaccination schedules of various countries and infant mortality rates. (Yes, they incorrectly claimed that schedules with more vaccines were associated with higher infant mortality rates.) A couple of years before that, antivaccine activist J.B. Handley had published a report that used a cherry picked group of nations to try to argue not only that nations that require more vaccines have higher rates of infant mortality but higher prevalence of autism in children under five. A year before even that, in 2008, the father-son duo of antivaccine quack activists Mark and David Geier had tried to use a similar technique to “show” (incorrectly) that increased vaccine uptake was associated with and increased prevalence of autism. The flaw at the heart of all of these studies was the ecological fallacy. Sure, there were, as you might imagine, many other problems with these studies, such as failure to control for confounders and cherry picking nations used in the analysis (they were done by antivaxxers after all), but the main problem always came back to the ecological fallacy.

Unfortunately, COVID-19 cranks and antivaxxers have also been engaging in the ecological fallacy. For example, believers in hydroxychloroquine as a miracle cure for COVID-19 tried to correlate the use of hydroxychloroquine in various countries with the death rate from COVID-19 in an astonishingly bad pseudo-study. (Well, it was astonishing then. No study, no matter how bad, about COVID-19 or COVID-19 vaccines astonishes me any more.) Later last year, antimaskers and anti-lockdown activists tried to correlate the use of public health interventions with COVID-19 death rates, again falling prey to the ecological fallacy. As I wrote at the time, anti-lockdown ideologues’ “science” had become as bad as antivaccine “science.” Unfortunately, this trend continues, but this time not from antivaxxers but rather from people who should know better but apparently do not. I’m referring to a new paper published in the European Journal of Epidemiology that has gone viral and is being promoted by cranks like “inventor of mRNA vaccines” Robert W. Malone:

I’ve discussed Dr. Malone, his conspiracy theory that Wikipedia is “erasing him,” and his wife’s antics editing his Wikipedia entry to try to falsely portray him as the primary inventor of the technology used to produce mRNA-based COVID-19 vaccines like the Moderna and Pfizer/BioNTech vaccines before. Let’s just say that it’s odd how much he now demonizes those same vaccines as someone who believes that he invented the technology behind them. I will also express some surprise that I was unaware of this study, which had been spreading in the antivaccine and anti-mask crankosphere for at least a few days before I learned of it yesterday morning. I guess there’s just too much misinformation. Indeed, I thought of just letting this cup pass because there is so much misinformation, but I thought that I could add to the discussion what no one else was likely to: A discussion of this study in the context of what antivaxxers have long been doing. Yes, it’s true that a certain ancient reptile who likes to combat pseudoscience has already discussed this study this week, and there is a PubPeer comment that much more succinctly sums up the key problems with this study, but, as my fans know, only rarely have previous criticisms of bad science stopped me (or even slowed me down) when it comes to applying a bit of ultra-Insolence to that very same bad science.

As another prelude, let me just point out that I don’t think that the authors, S. V. Subramanian and Akhil Kumar, are antivax. I do find it rather odd, though, to read that Akhil Kumar is apparently a Canadian high school student at Turner Fenton Secondary School in Brampton, ON. As for S.V. Subramanian, I had never heard of him before; so I Googled him and moseyed on over to his faculty webpage, where I discovered:

S (“Subu”) V Subramanian is a Professor of Population Health and Geography at Harvard University, and chair of the Faculty Advisory Group for the Center for Geographic Analysis at Harvard University. He is a Primary Faculty in the Department of Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health, a Core Faculty of the Harvard Center for Population and Development Studies, and a Faculty Affiliate of the Harvard Department of Sociology.

These are not exactly what I would consider good qualifications to do a study of this type. He’s a geographer, not a statistician or epidemiologist, much less an infectious disease epidemiologist. Still, he does have a few COVID-19 publications, such as being co-author on this one finding that mobility restrictions were associated with reductions in COVID-19 incidence early in the pandemic and this one urging mass vaccination and other public health interventions in India at the time the pandemic was producing mass illness and death there. In any event, given that Subramanian is faculty at the T.H. Chan School of Public Health at Harvard University, you would have thought that he’d have known better than to mimic the sort of analysis that antivaxxers have long favored since before the pandemic, either to associate harm with vaccines or to imply that they don’t work. Apparently you’d have been mistaken. Unfortunately.

Before I dig into the study by Subramanian and Kumar that Malone was promoting a week ago, let’s revisit the ecological fallacy again, so that you don’t have to click on links to previous discussions by me and others. An ecological trial is a form of epidemiological study in which the unit of analysis is not the individual person, but rather the group. I’ve discussed this issue before (here and here, among other times), in particular the “ecological fallacy,” which states that ecological studies are particularly prone to false positives (although they can also obscure actual correlations as well, depending on the specific analysis).

One of the best explanations of the ecological fallacies I’ve seen is from an epidemiologist by the ‘nym of EpiWonk. Unfortunately, the article is no longer there. Fortunately, there is the almighty Wayback Machine at Archive.org, where EpiWonk defines the ecological fallacy as “thinking that relationships observed for groups necessarily hold for individuals.” It’s worth citing again, even though I have cited this definition before:

The ecological fallacy was first described by the psychologist Edward Thorndike in 1938 in a paper entitled, “On the fallacy of imputing the correlations found for groups to the individuals or smaller groups composing them.” (Kind of says it all, doesn’t it.) The concept was introduced into sociology in 1950 by W.S. Robinson in 1950 in a paper entitled, “Ecological correlations and the behavior of individuals,” and the term Ecological Fallacy was coined by the sociologist H.C. Selvin in 1958. The concept of the ecological fallacy was formally introduced into epidemiology by Mervyn Susser in his 1973 text, Causal Thinking in the Health Sciences, although group-level analyses had been published in public health and epidemiology for decades.

To show you one example of the ecological fallacy, let’s take a brief look at H.C. Selvin’s 1958 paper. Selvin re-analyzed the 1897 study of Emile Durkheim (the “father of sociology”), Suicide, which investigated the association between religion and suicide. Although it’s difficult to find Selvin’s 1958 paper, the analyses are duplicated in a review by Professor Hal Morgenstern of the University of Michigan. Durkheim had data on four groups of Prussian provinces between 1883 and 1890. When the suicide rate is regressed on the percent of each group that was Protestant, an ecologic regression reveals a relative risk of 7.57, “i.e. it appears that Protestants were 7½ times as likely to commit suicide as were other residents (most of whom were Catholic)….ln fact, Durkheim actually compared suicide rates for Protestants and Catholics living in Prussia. From his data, we find that the rate was about twice as great among Protestants as among other religious groups, suggesting a substantial difference between the results obtained at the ecologic level (RR = 7.57) and those obtained at the individual level (RR = 2).” Thus, in Durkheim’s data, the effect estimate (the relative risk) is magnified by 4 by ecologic bias. In a recent methodological investigation of bias magnification in ecologic studies, Dr. Tom Webster of Boston University shows that effect measures can be biased upwards by as much as 25 times or more in ecologic analyses in which confounding is not controlled.

More recently, Gideon Meyerowitz-Katz described the ecological fallacy thusly in the discussion of one of the aforementioned bad studies, and it’s worth citing his description again:

The basic idea of the fallacy is this: you cannot directly infer the properties of individuals from the average of a group. Sounds complicated, but what that means is that if you measure something about lots of people — say, height — you can’t take the average measurement as an indication of any particular person’s status.

There’s a really simple example of this to do with means, or averages. Imagine you’ve got two groups of ten people, A and B. Group A has an average height of 170cm, and group B has an average height of 168cm. If you randomly select one person from each group, who is more likely to be taller, someone from group A or B?

The intuitive reaction is to say that someone from A is going to be taller than B, because the mean height is higher. However, this is not necessarily true. You can have a mean height of 170cm caused by two 200cm giants and eight 162.5cm people, and a mean of 168cm with six 170cm people and four 165cm people. In this case, 80% of group A is shorter than everyone in group B, which means that you’ll almost always get a taller person in group B if you pick randomly.

In other words, the average of a group isn’t always representative of the individuals.

Unsurprisingly, there are a lot of examples of the ecological fallacy from the nutritional literature, as Meyerowitz-Katz noted:

That’s the ecological fallacy in a nutshell. There are dozens of examples, many of them to do with countries and states. It commonly pops up in nutritional epidemiology — if we do a study and find that people who eat vegetarian diets are more likely to be depressed, it actually tells us very little about an individual vegetarian and their risk of depression. Similarly, even though people who eat more red meat tend to be less healthy, we can’t necessarily say that at an individual level eating more red meat is a good or bad thing.

With that in mind, let’s look at what Subramanian and Kumar did in their study. Looking at his faculty webpage, unfortunately I rather can’t escape the conclusion that the ecological fallacy is a big part of what he Subramanian has been doing recently, as the study under discussion seems to use similar methods to a lot of his more recent previous studies.

So let’s look at their findings before going back to discuss the methods:

At the country-level, there appears to be no discernable relationship between percentage of population fully vaccinated and new COVID-19 cases in the last 7 days (Fig. 1). In fact, the trend line suggests a marginally positive association such that countries with higher percentage of population fully vaccinated have higher COVID-19 cases per 1 million people. Notably, Israel with over 60% of their population fully vaccinated had the highest COVID-19 cases per 1 million people in the last 7 days. The lack of a meaningful association between percentage population fully vaccinated and new COVID-19 cases is further exemplified, for instance, by comparison of Iceland and Portugal. Both countries have over 75% of their population fully vaccinated and have more COVID-19 cases per 1 million people than countries such as Vietnam and South Africa that have around 10% of their population fully vaccinated.

And here’s Figure 1:

Ecological Fallacy scatterplot
This is not how to do a good scatterplot.

As our good reptilian buddy noted, the inclusion criteria are not exactly clear. The authors state that they included nations and counties that met the following criteria: “had second dose vaccine data available; had COVID-19 case data available; had population data available; and the last update of data was within 3 days prior to or on September 3, 2021.” As our friendly reptile with sharp pointy teeth noted, though, for some reason France, the United Kingdom, and Germany were not included, and those are some seriously glaring oversights, particularly given that the authors actually mentioned Germany and the UK in the very first paragraph:

Vaccines currently are the primary mitigation strategy to combat COVID-19 around the world. For instance, the narrative related to the ongoing surge of new cases in the United States (US) is argued to be driven by areas with low vaccination rates [1]. A similar narrative also has been observed in countries, such as Germany and the United Kingdom [2]. At the same time, Israel that was hailed for its swift and high rates of vaccination has also seen a substantial resurgence in COVID-19 cases [3]. We investigate the relationship between the percentage of population  fully vaccinated and new COVID-19 cases across 68 countries and across 2947 counties in the US.

Even more interestingly (for me, anyway) the references used were not scientific ones, at least references 2 and 3. Reference 2 points to a news article about Germany mulling over restrictions for the unvaccinated as their caseload soared in July, and the article doesn’t even mention the UK other than in passing because there were antimask protests in London. (It does mention France and Greece.) Reference 3 is to an NPR story about how Israel was suffering from a new surge in COVID-19 cases in August, despite a highly vaccinated population. This is generally not how you do scientific papers and references. The article also mentions potential causes: the Delta variant, waning immunity, and how Israel’s population, even though very highly vaccinated, is not vaccinated enough to produce herd immunity against a much more transmissible variant like Delta. I mean, seriously, have Subramanian and Kumar not heard of measles or watched how measles outbreaks could occur in areas of low vaccine uptake, even in a highly vaccinated population?

Then there are issues of potential confounding. Carl Bergstrom pointed this out on Twitter:

And:

The idea is simple: Government entities (be they counties or countries) with better public health infrastructure will have better case reporting and more robust testing. Our reptilian friend noted this too, observing:

They include low GDP countries where vaccination rates are low, but testing levels are similarly low. Using data from these countries may provide with a unreasonably low level of COVID-19.

And, as noted elsewhere:

And then there was this take that called the study “hot garbage” (an accurate characterization):

The paper presents two main arguments. The first is a scatter plot of the percent fully vaccinated against COVID-19 cases per one million in 68 countries. That’s it. It’s a simple bivariate analysis. To be clear, bivariate analysis isn’t inherently wrong, but it depends on the context in which it is used. A published analysis in a prestigious journal needs to do more than simply plot two variables. This excess simplicity ignores the massive variation between countries in testing, quality of vaccines, nonpharmaceutical interventions, and reporting.

Exactly. And don’t even get people started on this issue:

Another concern I have with Subramanian 2021 is the quality of reporting between countries. Does the data coming out of Brazil, India, Libya, and Ukraine match the data quality coming out of Canada, Germany, and the United Kingdom? In other words, is the reported number of COVID-19 cases as a proportion of the true number of COIVD-19 cases equal across the two groups? We already know deaths are underreported around the globe.

Indeed. If you don’t know how cases are reported and compiled in all the countries included in the analysis, you can’t determine if there are systematic flaws in the data that could either produce a false positive or mask an actual correlation. Zero attempt was made to correct for this.

Another epidemiologist made a complementary observation:

Again, remember the lessons from measles. Cases cluster in areas where vaccine uptake is low, and these areas can be smack dab in the middle of a highly vaccinated population, thus skewing the case count for the entire area. For instance, consider an town in the middle of a county (or country) that has low vaccination rates and a high case count. That will artificially inflate the case count for the entire surrounding area (county or country), even if the averaged vaccination rate of the whole county or country is high. Do these people not know basic epidemiology? We saw this sort of thing the year before the pandemic with all the measles outbreaks among populations with low vaccine uptake! We’re just seeing it now on a grander scale. I can forgive Kumar because he’s apparently a high school student, but there’s no excuse for Subramanian not to have gotten a real epidemiologist involved, along with, preferably, a real statistician before undertaking any analysis, not after.

Then there’s this:

Of the top 5 counties that have the highest percentage of population fully vaccinated (99.9–84.3%), the US Centers for Disease Control and Prevention (CDC) identifies 4 of them as “High” Transmission counties. Chattahoochee (Georgia), McKinley (New Mexico), and Arecibo (Puerto Rico) counties have above 90% of their population fully vaccinated with all three being classified as “High” transmission. Conversely, of the 57 counties that have been classified as “low” transmission counties by the CDC, 26.3% (15) have percentage of population fully vaccinated below 20%.

There is but one reaction appropriate to this paragraph:

Godzilla facepalm

Why? First, these percentages of vaccinated people are vaccinated adults and do not take into consideration children under 16. Remember, in the US, there is no COVID-19 vaccine yet approved (or even authorized for emergency use) for children under 16. The authors do the same thing with Israel, pointing to it as an example of a highly vaccinated country with rising case counts.

The Raptor will have none of that, and I agree:

Even though Israel had a high rate of vaccination, that was for eligible individuals over the age of 12. Actually, only 58% of the population was vaccinated, which is not high enough. It’s hard to tell what the exact herd immunity level is for COVID-19, but it’s probably close ot 88%. Israel may have been highly vaccinated, but not nearly highly enough.

Multiple critics (and now I) note that the primary endpoint examined is case number per unit population. While vaccines are certainly intended to decrease the case number and transmission of the virus if possible, the primary intent is to prevent people from getting really, really sick, winding up in the ICU, and dying. No attempt is made to analyze the data using these endpoints. Then there is the consideration that various countries were in different phases of the pandemic during the time frame used to examine case counts and vaccination rates. Then, for the county-level analysis, one must remember that states are made up of counties, which mean that groups of counties (in the same state) will tend to cluster because they will have similar testing and other policies. Even so, across the US, different counties (mainly in different states) vary widely in their access to testing, public health interventions, and vaccination rates. That’s not even considering differences in population density that can result in higher transmission in more densely populated areas, or weather. The bottom line is that there is so much wrong with this paper that, to put it kindly, the conclusions are not supported by the data.

As I was wrapping this post up, I came across this:

You know, I shouldn’t have used up that facepalm, because this really does deserve a facepalm—or, better yet, two facepalms:

Here’s what I mean:

Anti-vaxxers say they’ve found a smoking gun: a new blue-chip paper that proves COVID vaccines are ineffective.

The vaccine “doesn’t stop you from getting [COVID] at all,” claimed Daniel Horowitz, a senior editor at the Blaze, in a tweet promoting a column he wrote trumpeting the research. The headline: “Harvard researcher finds absolutely no correlation between vax rates and COVID cases globally.” Supporters of Horowitz’s perspective tweeted the piece and posted it on Facebook, where it received more than 4,000 interactions, including 2,600 shares, according to data from CrowdTangle, the Facebook-owned analytics company.

Alas, there’s just one problem for Horowitz and company: S.V. Subramanian, the Harvard professor of population health and geography behind the paper, says the vaccine doubters are completely wrong.

“That conclusion is misleading and inaccurate,” Subramanian told me of Horowitz’s Blaze column over email. “This paper supports vaccination as an important strategy for reducing infection and transmission, along with hand-washing, mask-wearing, and physical distancing.”

Really? It sure didn’t come across that way to me, and I read it before I had seen a lot of antivaccine talking points. Indeed, I’ve never seen or read Horowitz’s article, either. I did do a Twitter search after I had started writing this article, and—surprise! surprise!—virtually every Tweet linking to the study other than the ones I’ve already cited came from antivaxxers touting this study as slam-dunk evidence that COVID-19 vaccines don’t work because there was no correlation between case numbers and percentage of people vaccinated in the country or county analysis. Indeed, what I found was only the top of the iceberg:

Despite the misinterpretation, anti-vaxxers and vaccine doubters like Horowitz have held up and shared Subramanian’s paper as vindication on an array of platforms that have struggled to fight false anti-vaccine information. Horowitz’s own column has been tweeted out to at least half a million users. Posts bringing attention to the paper have done well on anti-vax and right-wing Reddit groups; a summary was posted to more than a dozen subreddit communities with over 34 million followers.

On Facebook, posts sharing a link to the paper’s abstract have also gone viral thanks to similar pages. Bernhard Zimniok, a member of European Parliament representing Germany’s far-right AfD party, shared it to his 24,000 Facebook followers, netting over 1,000 likes, shares, and comments. Slobodny Vysielac, a xenophobic, nativist Slovakian publication which has been likened to Infowars, also shared a link to the study to its 85,000 followers. Across the platform, CrowdTangle analytics show it was shared by pages with over a collective 2 million followers and was interacted with 7,000 times

Subramanian is surprised that his paper was picked up by antivaxxers? How naïve can he be? Also, how clueless can the reporter, Ali Breland, be? He writes the article to frame Subramanian as being unfairly mischaracterized and misinterpreted by antivaxxers. I can see an argument that it is being mischaracterized, but not by a lot. Whether he realizes it or not, Subramanian unwittingly provided a number of antivax-ready quotes in his article.

Go back to the Tweet above by Carl Bergstrom, in which Bergstrom criticizes Subramanian for making prescriptive statements based on a crappy analysis. That whole paragraph basically is, whether Subraminan realizes it or not, parroting an antivaccine talking point, namely that we rely too much on vaccination and that the vaccines are much less effective than advertised. Worse, Subramanian tells us we’re relying too much on vaccination alone (a not unreasonable point)based on an analysis that falls for the ecological fallacy and can very easily be interpreted to suggest that the vaccines don’t work. After all, the key finding of Subramanian’s paper is that there is no correlation between the percentage of the population vaccinated and COVID-19 case counts.

Just look at Subramanian’s concluding paragraph:

In summary, even as efforts should be made to encourage populations to get vaccinated it should be done so with humility and respect. Stigmatizing populations can do more harm than good. Importantly, other non-pharmacological prevention efforts (e.g., the importance of basic public health hygiene with regards to maintaining safe distance or handwashing, promoting better frequent and cheaper forms of testing) needs to be renewed in order to strike the balance of learning to live with COVID-19 in the same manner we continue to live a 100 years later with various seasonal alterations of the 1918 Influenza virus.

Yes, Subramanian states that we should be using standard public health interventions in addition to vaccination to control COVID-19, but then he finishes with a comparison frequently used by antivaxxers, namely likening COVID-19 to seasonal flu and saying that we have to learn to live with it!

If he happens to see this post, I’m sure Subramanian will think I’m being very harsh and very unfair. Maybe. But I don’t think I’m being unfair. Although I don’t think that he or his coauthor are antivaccine, I do think there is considerable value in pointing out how similar the study he did is to the sorts of awful studies prone to the ecological fallacy that antivaxxers did before the pandemic (and still do) to try to attribute harms to vaccines that they don’t cause or imply that they don’t work. Even more importantly, scientists like Subramanian who do studies involving COVID-19 and COVID-19 vaccines really do need to be aware of how their words can be weaponized by antivaxxers and COVID-19 minimizers and conspiracy theorists, so that they don’t craft studies like this one that are so easily co-opted for such purposes.

In fact, I hope that this comparison shocks some scientists. The vast majority physicians and scientists before the pandemic were blissfully unaware of the sorts of distortions of science that antivaxxers routinely engaged in. Some of them were even openly contemptuous of efforts by skeptics to combat health misinformation, quackery, and antivaccine pseudoscience and conspiracy theories, viewing it as beneath them or shrugging it off as unnecessary, not believing that anyone could “believe such nonsense.” I hate to say, “I told you so,” but I told you so. So did a number of others. Unfortunately, we were (and remain) a pitiful band compared to the forces arrayed against us spreading misinformation. It would help if scientists on “our side” didn’t provide ammunition to antivaxxers, which is what Subramanian did.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

76 replies on “Ecological fallacy: When a scientist (inadvertently, I hope) uses a favorite antivax form of study”

I had looked at this paper earlier this week and concluded it was nonsense from beginning to end. One thing we are fully aware of is that COVID-19 testing is uneven across the world. You cannot use reported cases as a proxy for real cases in any comparison between countries. I have previously noted that New Zealand and Australia because of their high testing and low case numbers have probably gone close to identifying the full number of cases. Many other countries are not even close. If the positive test rate is 20% then lots of cases will be missed. Knowing cases are inaccurate, any comparison with vaccination numbers is pointless.

This is without even getting into the problem of ecological fallacies.

And not only that, testing can pick up asymptomatic cases. In my pretty highly vaccinated local area, with school starting, testing has tripled in the last month — and so have detected cases. However, hospitalizations and deaths are still quite low. Anecdotally, my pharmacist says 90% of the tests she is conducting now are for asymptomatic individuals. Anyone looking at just case numbers, though, would think we are having a dangerous surge,

Yep the paper is GIGO.

One additional comment about the following incorrect claim made in the paper:

“Of the top 5 counties that have the highest percentage of population fully vaccinated (99.9–84.3%), the US Centers for Disease Control and Prevention (CDC) identifes 4 of them as “High” Transmission counties. Chattahoochee (Georgia), McKinley (New Mexico), and Arecibo (Puerto Rico) counties have above 90% of their population fully vaccinated ”

The authors picked 3 counties which all show > 99.9% vaccination of eligible population. That looked to me like a data error and the authors should have checked this. For example the official Georgia DPH site lists the current vaccination rate in Chattahoochee County as just 20%. Similarly the official NMDOH site has McKinley county is shown as currently 86%.

Imagine, almost a year into these ‘miraculous’ vaccines and all we find are their backers whining about research suggesting the vaccines are not helping rather than slamming down research of their own saying they are. How low the bar has sunk!

Went over to SR (yes, exercising great discrimination, he banned me), and I can imagine him rebutting me with this:

As for the increase in hospitalization and minor increase in mortality for vaccinated is not the right comparison. You’re taking the numbers in a vacuum, but it should be compared to the risk of hospitalization and death for the unvaccinated. That’s when we see how powerfully successful vaccines have been in this fight.

Indeed, over and over again we hear the vaccine pushers argue that the risk of hospitalization and death is vastly greater for the unvaxxed. What’s wrong with that thinking? It too is taking numbers in a vacuum. For instance, for every unvaxxed person that is hospitalized or die from covid, there are multiple amounts of asymptomatic or mildly affected cases that have acquired the disease naturally and built up superior immunity. Those folks will no longer serve as cases down the road.

So, in sum, covid might be killing and hospitalizing a lot of unvaxxed people, but it’s also sparing a lot more; and, the real bonus being, possibly even more than the vaccine. Looking at things this way, trends for countries that give us generalized numbers might indeed be the most accurate reflection of things.

“It’s okay that my unvaccinated travelers die in much higher numbers than vaccinated people, or are hospitalized and left with large medical bills and lifelong damaged, because not everyone dies or is left with harm and then, if they were lucky, maybe they won’t get COVID-19 again” (and at this point, there’s no basis to think COVId-19 immunity from infection is lifelong, and quite a few indications it’s not) is not quite the winning argument you seem to think it is.

Barely superior immunity, tempered with the greater risk of death to obtain it. Maybe not even that. I can’t remember the search criteria I used but I found a study concluding that natural immunity from the original virus gave better protection against variants that develop later. However, vaccinated immunity was far better against the virus variant that the vaccine was designed for. The obvious implication is that creating a vaccine, targeting the newer variants, would be more effective than relying on natural immunity generated previously.

Funny how anti-vaxxers won’t accept any risk of adverse events from vaccines but they’ll happily accept a far greater risk (especially if it’s to other people) from which ever wild virus is circulating. Must be one of those ‘if I die it’s the will of God’ thingies coupled with some kind of eugenics. Kill off the weaklings and create a stronger super-species. Bit of a waste if the natural immunity wanes fairly quickly though.

For instance, for every unvaxxed person that is hospitalized or die from covid, there are multiple amounts of asymptomatic or mildly affected cases that have acquired the disease naturally and built up superior immunity. Those folks will no longer serve as cases down the road

By the same token, for every vaxxed person that is saved from hospitalization and death, there are multiple amounts that are vaxxed that have been robbed of their chance of gaining superior, natural immunity. By vaccinating them, we are permanently placing them at increased risk of sickness and death.. And, I emphasize ‘permanently’ because as I am arguing down thread, by vaccinating people we are screwing up their immunity to the extent that they will never stand a chance of reaping the benefits of natural infections.

So, seeing Covid vaccination as an overwhelming success requires a heavy set of blinders. Unfortunately, they are not in short supply with the vaccine pushers.

Say, Gerg, when did you pick up this shitwitted habit of using no-context blockquote tags for your own remarks?

@Greg How much superior the natural immunity is ? Your Isreali study says 1.5%. This no no reason to get a pssoble lethal infection.
Did you notice that you actually said that vaccines are protective ? (They were robbed the infection.)

@Greg So you are saying that it is actually that OK COVID kills ltoss of unvaxxed people ? You should add that unvaxxed asymptomatic people spread the disease.

Greg So you are saying that it is actually that OK COVID kills ltoss of unvaxxed people

No, Aarno, I am saying it’s great that Covid is saving lots of unvaxxed people, and, consequently, lots of vaxxed people too. I am saying it’s not ok that you guys are actually killing lots of vaxxed and unvaxxed people.

No, Aarno, I am saying it’s great that Covid is saving lots of unvaxxed people….

From what? Breathing?

Greg.

I don’t say this lightly because I’m usually not a fan of psychoactive drugs or counseling unless a person is seriously in crisis. You just might be. I strongly recommend you seek help. I mean it. You don’t have to live life this way. You can break free from this nonsense and live your best life. There must be people who care about you and don’t want to see you behaving like this.

As an aside: I truly hope you don’t have any young children or firearms in your home.

Greg.

I don’t say this lightly because I’m usually not a fan of psychoactive drugs or counseling unless a person is seriously in crisis. You just might be. I strongly recommend you seek help. I mean it. You don’t have to live life this way. You can break free from this nonsense and live your best life. There must be people who care about you and don’t want to see you behaving like this.

As an aside: I truly hope you don’t have any young children or firearms in your home.

Thanks, Medical, for your concern, but what if I enjoy living my life like this. Seriously, I am getting tremendous pleasure participating on this blog. Whatever psychological issues I might have, this blog is addressing them.

You’re all my counselors in assisting me to break free and be my best. Sure I have a wife and kids who love me and care about me, but I also have you guys; you, Narad, Orac, Squirrel, Athaic, Denice… Ok — not Denice! Good gawd — she might just drive me over the edge with her phony therapist spiel. Reading her crap, perhaps if I had a gun in the house I might just use it.

That was a joke Medical, but Denice can be quite annoying. Still, I got the rest of you assisting with my mental health and I am greatly appreciative.

“Whatever psychological issues I might have, this blog is addressing them.”

i do not believe that it has at all. ps your brains and bits of spinal cord are in the bag by the sink. I feel like your SO is not feeling too impressed about all that. Even though you gave it the ol’ college try. Thank you for allowing me to be your excuberant arbiter it has been a hoot. Now please kindly fuck off and die in a fire. Awkward.

Vaccines are saving vaxxed people, and unvaxxed, too,if heard immunity is reached. Vaxxing does not an effect to unvaxxed, but COVID does.

The language about stigmatizing populations also reads as “don’t criticize those who don’t vaccinate.”

If the goal was to help the high school student get a resume bump, by the way, I worry that it will misfire and hurt the kid in ways that writing a flawed paper usually doesn’t hurt high school students, and shouldn’t.

Well I would tell the kid to smoke more pot and not worry about it so much. I know my views are not popular but I have never courted popularity.

–Orac mentions that vaccines prevent ” people from getting really, really sick, winding up in the ICU, and dying” HOWEVER, through what I can only imagine must be deliberate obfuscation, denialists leave out these figures and cite cases “rising” although it has been shockingly easy to find these numbers. For example, where I live, an early hot spot for Covid, the government has provided daily tallies of numbers- positive tests, people in hospital, in ICU, deaths- which I’ve followed. The cases have shown several waves since March 2020 BUT the numbers of hospitalised, in ICU, on vents and deaths has steadily decreased as vaccine coverage increased since April 2021. If you leave out these numbers, you misinform.

— One f the loons I survey ( PRN) insists that opponents to Covid vaccines and other PH measures are now, NOT alties like him, but the “orthodoxy” itself: MD/ PhDs, esteemed professors, researchers with hundreds of PubMed studies, etc. and he lists people like Malone and McCullough amongst others. I sure that Subramanian will be another.

— Orac says ” ..we may remain a pitiful band..” BUT, of late I have seen encouraging signs- surveys show people accepting vaccines more, supporting mandates more, being harsher on anti-vaxxers, companies mandating vaccines and workers accepting ( high rates of vaccination United Airlines, HCWs, college admissions)
the amount of strong refusers remains below 20%. These figures are easy to find and are mentioned on the news. MSNBC has two powerful advocates in Joy Reid and Chris Hayes who frequently sound like Orac and Company but since anti-vaxxers usually avoid liberals, they won’t be heard by them.

You’re welcome.

I don’t like to leave statements unsourced so..
— NY had to fire 25 000 healthcare workers because they won’t get vaccinated which is 3% of the total NewsDay
— United Airlines let 220 employees go.. OUT OF 67 000 Yahoo News
There are additional similar reports about university students and professors but I couldn’t find them quickly

The last paragraph is where I am day to day. I keep hearing from very woo-ish people how upset they are that there are still so many unvaccinated people and how stupid their reasoning is, but these same people spend their days at the chiro, acupunturist, naturopath or reiki salon. They take masses of suppements, believe our food is poisoned, that Pharma is trying to kill us all, that doctors “know nothing about nutrition”, that GMO’s are a threat to humanity, that “science doesn’t know everything”, that there are numerous types of “energy” that defy scientific explanation, and so on ad infinitum, They see my occoasional interjections of reason as annoying, and at best, amusing. Most of these people are well-educated–in liberal arts. They say they trust science, but most of their actions say otherwise. FB doesn’t get it either. They ban the most egregious but the garbage persists and isn’t even recognized.

A new heroine for antivaxers: California critical care doc Patricia Lee, who’s written a letter to the CDC and FDA (publicized on Twitter and dubious “news” websites) describing horrific Covid-19 vaccine reactions in her patients, including Pneumocystis pneumonia, cytomegalovirus colitis, obstetric complications including chorioamnionitis and septic shock, and quadriplegia. All of these events must have been due to vaccines, although details including time course are largely lacking and we’re supposed to take her word about lack of other risk factors.

Dr. Lee hired a law firm which boasts of taking on numerous cases for the, um, vaccine-hesitant and has also represented Del Bigtree’s ICAN outfit. Her lawyers sent their own followup letter barely a week later to the CDC and FDA demanding action, i.e. a meeting with this doc to discuss her concerns. Both the law firm and the doc urge the feds not to focus on her but on her allegations, which makes one wonder why focusing on her might be detrimental to her cause.*

*which also includes opposing Covid vaccine mandates.

What an interesting list of conditions…all of which would be caused by an unchecked HIV infection. I wonder if that’s where she got her little list from?

Both the law firm and the doc urge the feds not to focus on her but on her allegations, which makes one wonder why focusing on her might be detrimental to her cause.

Unsurprisingly, California has five M.D.’s named Patricia Lee. Triangulation of the USC degree and San Jose practice leads here, if anybody feels like looking around.

I wonder, statistically speaking, what’s the likelihood that one doctor would see all these ‘vaccine reactions’ yet my entire town, of 100,000 people or so, hasn’t had any horror stories making the rounds at all. What, enquiring minds would like to know, does this say about California?

Seriously, look at Worldometer figures for today. Why is lightly vaxxed India with a population of over a billion reporting half the cases of heavily vaxxed UK with a population of over 60 million? This trend of UK reporting more cases has been going on now for months. Really, what’s up there? Does ecological fallacy account, or are Indians just plain bad at counting their cases. Or, is it the case that India went through a brutal delta wave and their population is now reaping the benefits of superior natural immunity? Yes, let’s double — triple!– our efforts to vaccinate the world; we need more UKs.

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

“Yes, let’s double — triple!– our efforts to vaccinate the world; we need more UKs.”

They could put it in half-smoked Pall Mall butts and airburst/carpet bomb the hot spots.

And then give the Pall Malls to the poor and children of the poor. And Jeff and Blue Origin, to congratulate him on making Shatner cry*, and to swear a little for becoming the Ferengi of their own vision.

*** https://www.youtube.com/watch?v=7q6BtcZ7Ugk

Solemn.

If you really believe your sh!t, go get infected, Greg.
There are studies looking for volunteers to study the normal course of an infection.

But you are a coward. We all know it.

If you really believe your sh!t, go get infected, Greg.
There are studies looking for volunteers to study the normal course of an infection.

But you are a coward. We all know it.

So much so that the sphincter seems to have closed right up in response to the question.

Nevermind India, but what is occurring in Brazil, South Africa, and even the US south? All these places had recent surges — largely unvaxxed surges– and their unvaxxed cohort is pretty much now immune and accounting for the drop in their cases

The general worldwide decline in cases that we’re seeing is largely due to this — not from vaccination. Next, look to the virus to start picking off the vaxxed.

Yes, they are now mostly immune, just like most vaccinated people.
They can also be dead, which of course means they will never get Covid-19 again, nor have to suffer from any other illness. Or they suffer from long covid. and don’t forget that having Covid-19 often isn’t a walk in the park either.

There is a certain irony that in the comments to an article about the ecological fallacy, Greg makes an ecological fallacy argument.

Is it “irony” or unfortunate because I can not discern any more and Alanis Morissette is heavily overfitted in here even though I get the idea that she is really Greg level stupid.

These situations cause me discomfort and also Reykjavík Geothermal is starting to pitch a temp about it. She was not supposed to let me in there. I can be pretty persuasive.

And, ask the ‘experts’ why we are still in the midst of a pandemic, and they will likely give you a one word response — Delta! Outside of also blaming the unvaxxed, it’s as if that one word absolves everything, including the vaccines. The pandemic is still raging not because the brilliant ‘vaccines’ failed to prevent Delta or even slow its transmission; the pandemic is still raging because of — Delta! Oh — how easy life is when one word does all the accounting!

It is not delta. Vaccination rate is still not high enough.
There is a paper about COVID among unvaccinasted/vaccinated:
COVID-19 vaccine effectiveness against hospitalizations and ICU admissions in the Netherlands, April- August 2021
View ORCID ProfileBrechje de Gier, Marjolein Kooijman, Jeanet Kemmeren, Nicolette de Keizer, Dave Dongelmans, Senna C.J.L. van Iersel, Jan van de Kassteele, Stijn P. Andeweg, the RIVM COVID-19 epidemiology and surveillance team, Hester E. de Melker, Susan J. M. Hahné, Mirjam J. Knol, Susan van den Hof
doi: https://doi.org/10.1101/2021.09.15.21263613
” For the study period 4 April – 29 August 2021, 15,571 hospitalized people with COVID-19 were included in the analysis, of whom 887 (5.7%) were fully vaccinated.”
Comparing alpha and delta:
“The VE for full vaccination against ICU admission was 93% (95%CI 87-96%) in the Alpha period and 97% (95%CI 97-98%) in the Delta period”

It is not delta. Vaccination rate is still not high enough.

And, how high must it be, Aarno, to start blunting the pandemic? Today Singapore had another record breaking day for cases. This is a country with 84% of its population that is fully vaxxed.

So, are we to believe the unvaxxed 16% is the main driver of their surge? Aarno, I think not because some say around half of a given population already had Covid and is immune, so it must the 8% unvaxxed Singaporeans driving their surge. Oh – those selfish 8%!

https://ca.news.yahoo.com/3445-new-covid-cases-in-singapore-8-more-deaths-151332915.html

This is a country with 84% of its population that is fully vaxxed.

Canada only has just under 73% of its population fully vaccinated. They probably need to get to closer to 80% to stop the pandemic. So greater than 95% of those over 16. You should help out Greg by getting vaccinated. It is people like you who keep the COVID-19 pandemic ticking along.

Canada only has just under 73% of its population fully vaccinated. They probably need to get to closer to 80% to stop the pandemic

Chris, you are missing the point that I made to Aarno. Unvaccinated doesn’t necessarily equate to not immune. Some argue that 50% of the population at some time during the pandemic got Covid and is naturally immune. So, well over 80% of the Canadian population should be immune, whether by vaccination or natural infection or both. So, Chris, why is the pandemic still not in the rear view mirror for us?

You should help out Greg by getting vaccinated.

Does anyone really think that he isn’t? He hasn’t regaled anyone about the smooth sailing of his infection or coughed up labs, nothing.

After all, on his first time around, he insisted that everyone here was lying about being vaccinated, “tee hee”; the hypocrisy would fit right in.

Some argue that 50% of the population at some time during the pandemic got Covid and is naturally immune.

Some might argue this, but they are wrong. If 50% of people were naturally immune to COVID-19, hospitals would not be filling up so fast with the unvaccinated. C’mon Greg, be a man, roll your sleeve up and get the vaccine.

Greg:

some say around half of a given population already had Covid

According to Worldometer, Singapore has had a total of 24556 cases/million population, or about 2.5% with detected infections. Even if the actual rate is double that, it’s still nowhere near half the population.

Worldometer also says that the people of Singapore have, on average, each been tested 3.5 times.

Would you like to cite some of these “some” who say half the population of Singapore has been infected?

https://www.worldometers.info/coronavirus/#countries

I feel greatly complimented to be singled out by Greg whom I “annoy”.. I wonder why that is? There are so many other worthy contributors here like Aarno, Athaic, Renate, Bacon, Dorit, Narad, Medical Yeti and the rest..
No one here is doing therapy with Greg: he, who supposedly has an undergrad degree in psych, should know that. We just give him information after he spreads nonsense to steer him towards reality and although that will probably never occur, it just might instruct a vaccine hesitant reader or two.

There’s a reason that Orac places him in auto-mod- which is a rarity usually reserved for truly outre commenters- he reiterates mistruths from anti-vaxxers and attributes unsourced malfeasance to SBM, doctors and researchers with appellations like “drug pushers”.
A while back, a few anti-vaxxers took issue with my approach especially when I quoted research that cancels their number one issue- that vaccines cause autism.
I repeatedly quoted experts’ work in physiology and neuroscience that effectively disproves this outdated and unhealthy notion. I suppose I “annoyed” them too: facing reality has a tendency to do that. Their all-too-frequent appearances diminished to a paltry, sporadic few. I imagine that they have found other venues where their “wisdom” is tolerated and even applauded but The internet never forgets.

Commenters like these anti-vax mothers are one of the reasons I contribute because they, usually quite uneducated in relevant areas although they mime expertise, blithely recount their tales of “vaccine damage” and quote altie “thought leaders’ and salesmen in order to scare younger parents away from vaccines. Their campaign and programme are aimed at reducing vaccination by any means. Research has shown that parents are more likely to trust advice about vaccines from other parents rather than from medical professionals. Anti-vax blogs, facebook groups and other internet locales are their stomping ground and they stomp out reason and fact extremely well.

No one here is doing therapy with Greg: he, who supposedly has an undergrad degree in psych….

Did this come out back when he trying to deny he was Canadian? (Good times.) Either I’ve forgotten it, or his output was too profligate for me to have noticed in the first place.

At least after this, he can always pack up the family to go tell Africans that “natural malaria” is much better than risking a little help from Mosquirix.

And, another of Greg’s famous prediction? You can’t say you didn’t hear it here first. As time passes and the vaccination failure becomes more pronounced, we will find the least vaccinated countries to be the first to emerge from the pandemic. Ecological fallacy be damned!

Please explain how you think that will work, Greg. Will everyone there just get covid? You really do think that comes with no costs, don’t you?

I would repeat this:
The VE for full vaccination against ICU admission was 93% (95%CI 87-96%) in the Alpha period and 97% (95%CI 97-98%) in the Delta period
In a paper previously cited

In other (related) news: Joe Rogan is now a full-blown antivaxxer. This is a truly sad turn of events, as he has a massive following. I found his podcast interesting and provocative but, for the first time ever this morning, had to turn it off on my drive as the baloney he and his guest were spewing unchallenged was too much. Usually he is great about checking is own opinion and attempting to ironman the argument against whatever he is saying and analyzing that position. Not any more. I just don’t get it.

It is one thing to discuss complementary factors like overall health, tobacco abstinence (He could use this,) supplementary vitamins (Can’t hurt,) exercise (KEY to overall CV capacity prior to disease,) etc. Instead? He’s basically saying the vaccine is useless based on now well-discredited media reports and fraudulent “Studies.” He argues that ivermectin helped him get over COVID faster and rails against CNN for calling it horse de-wormer. Then he and guest launch into how it is approved for human use, is a great drug, Nobel prize, WHO essential Rx list, etc, etc. That’s all true and it has absolutely nothing to do with viral inhibition.

But India! Ivermectin stopped COVID there! Baloney. That paper was a complete fake. I have an MPH as my primary training in research (Believe it or not, most doctors don’t get a lot of research training) and even I can spot the issues with that “Study.” Indeed, a medical student fist noticed issues with the study data.

Anyway, I just thought this was shame. I know he’s not everyone’s cup of tea but he really has taken a wrong turn here.

I know he’s not everyone’s cup of tea but he really has taken a wrong turn here.

AFAIK, Rogan took a wrong turn when he got behind a microphone. I mean, his arguing with Howard Stern is “news.”

I’ve already mentioned that I had to put up with stuff when I staying with a friend on the North Side, hour after hour. If I sat down with him in the afternoon to try to chat while the program was on, I was constantly scrambling to try to filter what he was getting from the program into something that would yield an opening without pissing him off.

Sort of the reverse of trying to talk about race in a Florida retirement community: Either don’t bother, or try to get one simple concession. At least Morton Downey, Jr., skipped the pretense. The world would be no worse off without any of the programs.

“when I staying with a friend on the North Side”

Well I hope ya’ll are getting just as equally gentrified as the “South Side” because I don’t even live there at all. Only there is a NORD server there I sometimes hit up to stalk an ex. It is a pretty shitty server.

for the first time ever this morning, had to turn it off on my drive as the baloney he and his guest were spewing unchallenged was too much.

That is what I did with Alex Jones in 2014. A bit late, for some.

But Rogan? Yeah, he had a draw for sure https://youtu.be/KzPnihZ41h4?t=24

Yeah, Musk had a role in the whole HCQ early on. But word has it that wasn’t martite sparkling up the test and breaking the ship. I think he may have come around.

I saw this “in the wild” the other day, someone posted it on a friend’s post where vaccine mandates for nurses was mentioned. My impression on reading it was that it looked like a student wrote it and wondered how it passed peer review. It’s ridiculous how people with an agenda will grab anything that supports it no matter how terrible it is.

I have been away from this blog, but I see Gregor Samsa is still here and not dead from Covid-19 – God looks after fools and children.
A common place to see the ecological fallacy is in issues of race, ethnicity, and nationality. Once you ascribe certain qualities to a given group, then you can make a factually untrue syllogism, like the punchline to the old joke, “Very funny, you not look Jewish.” The obverse is the fallacy of extrapolating from one to an entire group.
Gregor, your entire purpose on this blog is to gainsay anything anyone says that is pro-vaccine. Funny, it all started with MMR and when the tiny bit of thimerosal was removed, then it had to be any and all vaccines, and if they happened to correlate with reduced mortality and morbidity from the disease, it had to be due to improved sanitation and nutrition, an idea that falls flat knowing vaccination campaigns eradicated rinderpest from its last endemic areas. No antivaxxer here has ever tried to refute that it was due to the vaccine for it.

Yep, the paper is GIGO. No need to embellish that.

One additional point regarding a claim that was in the paper:

“Of the top 5 counties that have the highest percentage of population fully vaccinated (99.9–84.3%), the US Centers for Disease Control and Prevention (CDC) identifies 4 of them as “High” Transmission counties. Chattahoochee (Georgia), McKinley (New Mexico), and Arecibo (Puerto Rico) counties have above 90% of their population fully vaccinated ”

The authors picked 3 counties which all show > 99.9% vaccination of eligible population. That looked to me like a data error and the authors should have checked this. I did and the official Georgia DPH site lists the current vaccination rate in that Chattahoochee County as just 20%. The official NMDOH site currently reports 86% for McKinley – which too is below the 90% claimed.

Yep the paper is GIGO.

One additional comment about the following incorrect claim made in the paper:

“Of the top 5 counties that have the highest percentage of population fully vaccinated (99.9–84.3%), the US Centers for Disease Control and Prevention (CDC) identifes 4 of them as “High” Transmission counties. Chattahoochee (Georgia), McKinley (New Mexico), and Arecibo (Puerto Rico) counties have above 90% of their population fully vaccinated ”

The authors picked 3 counties which all show > 99.9% vaccination of eligible population. That looked to me like a data error and the authors should have checked this. For example the official Georgia DPH site lists the current vaccination rate in Chattahoochee County as just 20%. Similarly the official NMDOH site has McKinley county is shown as currently 86%.

Sorry for the multiple comment spam. The comment system kept glitching for me and it wasn’t clear that anything had posted. Next time I’ll try waiting longer…

It’s possible, I suppose, that Subramanian didn’t understand how the paper would be picked up and used by anti-vaxers… if he’s really, really stupid. But given that the paper still includes an endorsement of vaccination efforts, albeit a very weak one, I suppose it’s best not to put the authors in the “anti-vax” bucket. I’d say “COVID minimizing” is a more appropriate rubric. What’s telling of the politics here is not just the line about “learning to live with COVID-19” but how they define “non-pharmacological prevention efforts” which amounts mainly to asking people to do keep social distancing and wash their hands more often. That’s some serious, effectively denialist weak-sauce right there. Now, if it’s true that “The sole reliance on vaccination as a primary strategy to mitigate COVID-19 and its adverse consequences needs to be re-examined, especially considering the Delta variant” what “non-pharmacological intervention” may actually “need to be put in place alongside increasing vaccination rates”? Could that be, say, masking mandates? Now why didn’t Subramanian and Kumar mention those? (Nudge, nudge, wink wink…)

And, except for Doug, no one seems to want to take even the tiniest steps towards the dance floor. C’mon you immunology experts, contest my argument that Covid vaccination pror to natural infection will interfere with the benefits of such infections

Which benefits?
The chance of dieing?
The chance of long covid?
The chance of ending in an ICU?
The chance of ending in a hospital for some time?
Or just the chance for sick-leave for several weeks?

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