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Why did the UK switch to a 12 week dosing schedule for COVID-19 vaccines?

by Eli Tyre4 min read20th Jun 202122 comments

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On December 30, 2020 Boris Johnson gave a speech in which he announced that the UK would follow a COVID-19 vaccination dosing schedule with a twelve week gap between first and second doses, instead of the 3 weeks that is standard in the US (and the rest of the world? [edit: Orual reports that Canada also used a dosing schedule that prioritized first doses]).

Verbatim: 

And there is one important development that’s helping us to accelerate our vaccination programme across the whole of the UK:

We’ve had new advice from the Joint Committee on Vaccination and Immunisation that the first dose can protect people against the worst effects of this virus because the benefits kick in after two or three weeks.

And so from now on we will give a first dose to as many vulnerable people as possible, with the second dose to follow twelve weeks later.

And what that means is we can vaccinate and protect many more people in the coming weeks.

As near as I can tell, this is a straightforwardly good policy in terms of public health, because it increases society's total heard resistance to the virus faster. But it also entails deviating somewhat from the specific conditions of the trials in which the vaccines were tested. If it turns out to be a bad idea somehow, you can't fall back on saying that this plan was standard practice, and you couldn't have done any better." So in some sense, it's a risk.

I would really like to know what causal factors were upstream of this decision. Why did this happen in the UK, but not in the US or elsewhere?

Are there specific individuals, in the limelight or behind the scenes that pushed for this outcome? Is the difference that, in the UK, someone was in the right place at the right time?

Is this a cultural thing? Does the UK government feel more comfortable choosing policies that make analytic sense, but which don't have the social stamp of approval of "The Science"?

And if it is cultural, what is the difference? Do UK politicians reason from physical models of the virus more than US politicians? Does the UK government expect that if they're attacked for a decision like this, that voters (or someone else?) will back them up, while that's not the expectation in the US? Does the UK government feel like it has credibility, and therefore can make strong, reasoned, recommendations, while the US feels like it doesn't have the slack to do that? [1]

Insofar as Britain was marginally more sane, on a societal level, than the rest of the world, it seems important to find out what made the difference. 

Some additional relevant information: 

Wikipedia says that there was some push-back against this decision by the British Medical Association, and Brittan's Chief Medical Officers published an open letter defending the decision. 

That open letter is here.

It briefly expresses a simple argument for prioritizing first doses, of the sort that I and most Less Wrong readers would make. (There is a limited amount of vaccine; most of the immunizing effect comes from the first dose; it is more beneficial to public health for a marginal person go from 0% immunized to ~75% immunized than to have one go from ~75% to ~90%; therefore, given the tradeoffs, it makes sense to focus on first doses for the time being.) 

We recognise that the request to re-schedule second appointments is operationally very difficult, especially at short notice, and will distress patients who were looking forward to being fully immunised. However, we are all conscious that for every 1000 people boosted with a second dose of COVID-19 vaccine in January (who will as a result gain marginally on protection from severe disease), 1000 new people can't have substantial initial protection which is in most cases likely to raise them from 0% protected to at least 70% protected. Whilst the NHS, through all of your work, has so far vaccinated over 1 million UK patients with a first dose,approximately 30 million UK patients and health and social care workers eligible for vaccination in Phase 1 remain totally unprotected and many are distressed or anxious about the wait for their turn. These unvaccinated people are far more likely to end up severely ill, hospitalised on in some cases dying without vaccine. Halving the number vaccinated over the next 2-3 months because of giving two vaccines in quick succession rather than with a delay of 12 weeks does not provide optimal public health impact.

This letter seems notable to me for being basically lucid and sensible, in contrast to much of what the CDC, for instance, has said this year.

 

 

[1] - In this post Zvi quotes Dr. Fauci (from here), saying that the US switching to first doses first would hurt credibility, because it would entail sending mixed messages:

“There’s risks on either side,” Anthony S. Fauci told The Washington Post, warning that shifting to a single-dose strategy for the Pfizer-BioNTech and Moderna vaccines could leave people less protected, enable variants to spread and possibly boost skepticism among Americans already hesitant to get the shots.

“We’re telling people [two shots] is what you should do … and then we say, ‘Oops, we changed our mind’?” Fauci said. “I think that would be a messaging challenge, to say the least.”

(Note that the quoted article was published in March, more than two months after the UK announced their dosing schedule. Switching in March does seem more confusing than using a 12 week schedule from the get go.)

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Dominic Cummings (who is a keen LW reader and agrees with Zvi's most cynical takes about the nature of government) is likely a major factor, although he was gone at the time the first doses first issue arose, the overall success of the UK's vaccine procurement can be credited to the vaccine taskforce which was an ad-hoc organization set up to be exempt from much of the usual rules, partly due to his influence and that of Patrick Vallance, the UK's chief scientific advisor - that way of thinking may well have leaked into other decisions about vaccine prioritization, and Vallance certainly was involved with the first doses first decision. See this from Cummings' blog:

This is why there was no serious vaccine plan — i.e spending billions on concurrent (rather than the normal sequential) creation/manufacturing/distribution etc — until after the switch to Plan B. I spoke to Vallance on 15 March about a ‘Manhattan Project’ for vaccines out of Hancock’s grip but it was delayed by the chaotic shift from Plan A to lockdown then the PM’s near-death. In April Vallance, the Cabinet Secretary and I told the PM to create the Vaccine Taskforce, sideline Hancock, and shift commercial support from DHSC to BEIS. He agreed, this happened, the Chancellor supplied the cash. On 10 May I told officials that the VTF needed a) a much bigger budget, b) a completely different approach to DHSC’s, which had been mired in the usual processes, so it could develop concurrent plans, and c) that Bingham needed the authority to make financial decisions herself without clearance from Hancock.

(I see the success of the UK vaccine taskforce and its ability to have a somewhat appropriate sense of the costs and benefits involved and the enormous value of vaccinations, to be a good example of how it's institution design that is the key issue which most needs fixing. Have an efficient, streamlined taskforce, and you can still get things done in government.)

Other differences that may be relevant: this UK Government arguably has much more slack than the US under Biden or Trump. The UK's system gives very broad powers to the executive as long as they have a majority in parliament, this government is relatively popular due to the perception that it followed through on getting Brexit done, and we were in the middle of an emergency when that delay decision was authorized. Also, vaccine hesitancy is significantly lower in the UK than the US, and therefore fear of vaccine hesitancy by policymakers (which seemed to be driving the CDCs intransigence) is also significantly lower.

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The UK Government apparently has a small team of PhDs tasked with translating complicated papers and other data for the leadership. This team was assembled by rationalist-adjacent Dominic Cummings, who has since left (essentially the Prime Minister stopped listening to him).

If UK Government policy appears sensible and forward thinking, this team is likely the source. I fear with the removal of their patron they may not last long.

 

For those curious about what happens when a LessWrong reader gets close to power:

Some people have mentioned Dominic Cummings' role as former advisor to UK Prime Minister Boris Johnson, describing him as rationalist-adjacent.

He recently gave >7 hours of testimony (available on Youtube, 26 May 2021) to a UK Gov Select Committee, giving his perspective on the UK Covid19 response from within Government. He uses terms familiar to rationalists, meaning I found it useful and the politicians he spoke to largely failed to grasp it. (Eg "Cummings: Politicians operate under perverse incentives," "Politician: Are you saying people were bribed?")

I should note, Cummings does appear to be playing politics in parts of his testimony. He is scathing in his comments on some people (Matt Hancock, Health Secretary), and describes others in glowing terms (Rishi Sunak, Chancellor).

My personal interpretation is that he knows this testimony will cause trouble, and is trying not to hurt people who may yet do some good. 

 

(This is my first LW post. Lets see if the formatting works...)

I think that this is far more parsimoniously explained by the existing mechanisms working as intended. This decision was made by the JVCI, which was established (according to Wikipedia) in 1963, and having existed for some time before that as a polio advisory board. So there's a well-established group of experts who have been looking at immunisation schedules for all sorts of diseases for decades.

Ah, thank you. I was unaware.

 

I've been thinking about the Cummings testimony for a while, considering whether to draw attention to it. I've been (unwisely) seeing all recent UK Gov. activity through that lens.

There are already posts pointing to it on LessWrong. Listing to a 7 hour testimony is however a lot of effort. Having a post that summarizes the most important parts would be valuable.

I should note, Cummings does appear to be playing politics in parts of his testimony. He is scathing in his comments on some people (Matt Hancock, Health Secretary), and describes others in glowing terms (Rishi Sunak, Chancellor).

Yeah. I want to emphasize this to everyone in the Less Wrong sphere who is causally aware of Cummings. He is interested in a lot of the same kinds of things that we are, but he doesn't hold to exactly the same epistemic mores. There are lots of videos of him on youtube in which he is obviously trying to win arguments / score points, instead of straightforwardly say what's true. 

This is probably appropriate and adaptive for his context in the world, but it does make me cringe, and if I observed my friends and coworkers engaging in moves that were that straightforwardly un-epistemic, I would be shocked and disturbed. 

The UK Government apparently has a small team of PhDs tasked with translating complicated papers and other data for the leadership. This team was assembled by rationalist-adjacent Dominic Cummings, who has since left (essentially the Prime Minister stopped listening to him).

If UK Government policy appears sensible and forward thinking, this team is likely the source. I fear with the removal of their patron they may not last long.

The way this is phrased, you make it sound like Cummings put such a team together, but it is still there, after his departure, at least for the time being.

I had assumed that when Cummings was ousted everyone that he was working with went with him, and therefore, whatever team of people he assembled was also out of the job. 

Do you have any additional information here? Do you know which it was?

I had assumed that when Cummings was ousted everyone that he was working with went with him

He was in charge of the whole civil service! But "working with" is debatable. A local MP scare quotes the "with".

Do you have any additional information here? Do you know which it was?

 

Based on what Cummings said, I believe the team survived his departure.

As ChristianKl suggested, I wish I'd made notes when listening to it. I've since thankfully found a transcript of the evidence. My beliefs about the team he assembled are based largely on:

  • A recruitment drive (02 January 2020) on his blog, which looks like the work of someone who took Inadequate Equilibria seriously:

"‘This is possibly the single largest design flaw contributing to the bad Nash equilibrium in which … many governments are stuck. Every individual high-functioning competent person knows they can’t make much difference by being one more face in that crowd.’ Eliezer Yudkowsky, AI expert, LessWrong etc."

"I don’t want confident public school bluffers. I want people who are much brighter than me who can work in an extreme environment. If you play office politics, you will be discovered and immediately binned."

"People in SW1 [centre of London] talk a lot about ‘diversity’ but they rarely mean ‘true cognitive diversity’. They are usually babbling about ‘gender identity diversity blah blah’. What SW1 needs is not more drivel about ‘identity’ and ‘diversity’ from Oxbridge humanities graduates but more genuine cognitive diversity."

 

(I'm not happy with these quotes; I tried to find statements representative of the whole, but failed. To summarise, he's looking for multidisciplinary talent in a range of areas which look promising to a layman rationality enthusiast.)

 

  • The following quotes from Cummings' testimony:

06:08.56-06:09.15 "The heart of the problem was, fundamentally, I regarded him as unfit for the job and I was trying to create a structure around him to try and stop what I thought were extremely bad decisions and push other things through against his wishes, and he had the view that he was Prime Minister and I should just be doing as he wanted me to, and that's obviously not sustainable for very long."

06:14.26-06:14.42 "My goal in January was to try and recruit a whole bunch of people who were much smarter than me and much better able than me to deal with government problems so that I could make myself redundant, which I said publicly, and which I believed."


Q963: "After the election, I hired a guy, a physicist called Ben Warner, and brought him into No. 10 to try to start to build a proper data and analytical office in No. 10. Because one of the great problems that No. 10 had in 2019 when I was there was a huge lack of those kinds of skills."

Q1154: "The data team did not really exist in February/March, it was Ben Warner, but by now, there was a really, really good team of a mix of officials and SPADs in No. 10. They crunched all of these numbers with SAGE data and other stuff over that weekend. Then on the Sunday evening there was a meeting with a combination of SAGE scientists and some external people."


Q1154: "We set it all out to the Prime Minister. Remember, there is a huge contrast at this point with what I was describing in March. In March, there was no testing data, no proper data system, me with an iPhone scribbling things on a whiteboard. By now, we have got a completely professional team, really on it, and they had all the testing data and all the NHS data. It is all really clear. They set it all out."

December 30th was shortly before the UK's third peak of infections, the one caused by the emergence of the UK/Kent/Alpha variant. The more infectious virus put the government under pressure to come up with good ideas to keep R down in the future. 

The UK also has a political tradition of scientists being closed involved in some policy decisions. (Another commenter mentions Cummings being involved with that, and that may be partly true, but I think the tradition to have scientists closely involved is much older.)

The UK also has a political tradition of scientists being closed involved in some policy decisions.

Insofar as this is true, I want to know why, and why the US doesn't have a similar tradition.

Traditionally, when a new US administration comes to power they are able to exchange a lot of people in the civil service. In the UK a new administration can change the minister of a department but not the permanent secretary of a department.

I would expect more positions being political appointments leading to less scientists being involved in decisions.

The UK government also has many non-ministerial departments:

A hypothesis I had was that the US was sticking to an exact formula due to higher vaccine hesitancy, in order to "play it safe" and give less for anti-vaxers to criticize. After looking at a small handful of countries, I think this is not a significant cause of the difference in responses.

If this were true I would expect countries that have higher vaccine hesitancy to be less likely to do first doses first.

Checking [this data](https://www.thelancet.com/cms/10.1016/S0140-6736(20)31558-0/attachment/720358f5-8df0-405b-b06f-7734cf542a58/mmc1.pdf) which was near the top of search results, and using eyeballed values of strongly agree to "I think vaccines are safe" as the measure:

Canada: 75%, Yes FDF (March 3)

US: 66%, No FDF

Mexico: 60%, Yes FDF (Jan 22)

UK: 50%, Yes FDF (Jan 4)

Germany: 50%, Yes FDF (March 5)

Obviously a really small sample and I am being loose with the data, but it does not support this hypothesis, with no obvious correspondence between vaccine-confidence and when FDF started. I chose the countries in question off the top of my head.

Dates and sources were found by searching online, I have not carefully checked them.

https://www.statista.com/statistics/1195560/coronavirus-covid-19-vaccinations-number-germany/ This graph looks like there is about a 3-week lag in 2nd doses.

https://www.thetimes.co.uk/article/germany-follows-uk-by-delaying-second-dose-of-covid-vaccine-mk65kkh9w March 05, Germany starts FDF.

https://abcnews.go.com/Health/wireStory/mexico-russias-sputnik-shortages-limited-2nd-doses-77617433 Mexico does first doses first due to supply issues with the Sputnik vaccine; the first dose can be produced faster. The article does not mention the save more lives argument.

https://www.nasdaq.com/articles/mexico-may-delay-second-vaccine-doses-and-allow-private-orders-to-tame-raging-pandemic The tone of this piece seems to suggest FDF out of desperation.

Minor correction. The UK is not the only country employing the delayed second dose strategy. Canada has done so as well, as a way of maximizing and front-loading the benefit of its relatively limited supplies of vaccine, and I believe we started doing so fairly quickly after the UK, before the effectiveness was clear. So whatever answer explains the UK's willingness to take that risk has to also explain Canada's similar decision.

Similarly in Slovakia. Our government doesn't really bother to communicate its strategy clearly; it's more like "we will send you an SMS when it's your time to get a shot", but I got my first shot in mid-April, and am still waiting for the second one.

An important note!

From my understanding of the Canada situation, it may have been motivated by less access to vaccines initially. The US did very well in terms of getting lots of vaccines soon (https://ourworldindata.org/covid-vaccinations) while Canada took about 4 months after the US to really get going. Canada may have been more desperate to prevent Covid (or have their numbers stop lagging the US), and thus been less risk-adverse.

This argument does not work for the UK, as they have been ahead of the US the whole time.

https://www.msn.com/en-ca/news/canada/vaccine-panel-says-canada-can-delay-second-dose-of-covid-19-vaccine-if-shortage/ar-BB1cIJaG This article cites the decision being partly justified by limited supplies and how bad things were.

Also, note that the UK recently decreased the time range from 12 weeks to 8 weeks: UK reduces gap between two covid vaccine doses from 12 weeks to 8 weeks (livemint.com).

I'm not clear on the reason, but they have vaccinated 80% of adults with 1st doses, so perhaps they've decided that the need for 1st doses is dropping:  Vaccinations in the UK | Coronavirus in the UK (data.gov.uk).

I think the switch to 8 weeks was at least in part driven by the different characteristics of the Delta variant. Whereas for the previous variants the two doses of the vaccine did something like 70% and 90% protection, for the Delta variant it's more like 35% and 80% (vague hand wavey numbers). So now there is similar marginal benefit to getting second doses into people, and because the roll out has been by age category, getting (say) 60-year olds from 1 dose to 2 might well be more beneficial than getting 20-year olds from 0 to 1.

It's quite unclear to me why they not just switch the spike protein to the one of the Delta variant if that's the main reason for chaing how they vaccinate. 

they have vaccinated 80% of adults with 1st doses, so perhaps they've decided that the need for 1st doses is dropping

That was my impression.