The sad thing about this outrageous false Government communication scandal is that an opportunity was squandered to make the important point that immune compromised patients including those with blood cancer are the only members of the clinically extremely vulnerable group where there are significant concerns about vaccine efficacy. Reassurance for the majority could have been combined with warning for the minority.

Immune compromised patients make up only around 500,000 people in the UK. This is well under 1% of the general population so it is no wonder that even large population surveys cannot provide accurate data about this group, especially when you consider it includes anyone with any blood cancer and many other conditions. Some within this group will only have a mildly affected immune system. Others will have almost no immune response at all. It is grossly inaccurate to pool this group and treat them as a single entity.

The Government have repeated their misinformation campaign targeted at blood cancer patients and other immune compromised individuals in yesterdays revised Clinically Extremely Vulnerable guidance document.(CEV).

The promotion of all medical interventions is heavily regulated here in the UK. People are not meant to make misleading, exaggerated, or false claims about any medicine or indeed any vaccine. It is against the law. In theory medical directors of pharmaceutical companies could face prison for misleading the public.

I am therefore this morning extremely alarmed to read that the Government itself has doubled down on a very erroneous and appalling misinterpretation of a recent study performed by PHE. They have now made a number of claims in official documents including the CEV guidance that simply are not true.

These claims can lead to people who are immune deficient for whatever reason, including blood cancer, being falsely reassured that the vaccine has worked for them.

Today I reported @PHE_uk to the @MHRAgovuk for making dangerous claims on vaccine efficacy in #bloodcancer and #immunocompromise. No @ABPI_UK Pharma company would do this. But why have @ASTRAZENECAUK @Pfizer_UK and @moderna_tx remained silent & not corrected @CMO_England ? https://t.co/krocUjbvz1

— Adrian Warnock (@adrianwarnock) July 13, 2021

I am not prepared to sit by and let this happen. I am thinking of what remedies are available to us. The first that I can think of is to report this behaviour to both the MHRA (the UK’s FDA equivalent). I am directly referring the Government as you could any other individual or public body for promoting a medicine in an illegal and false manner. This is my letter to them:

The ABPI’s code of practice authority (the industry self regulation body) has authority over the Pharma companies. I believe these companies have a duty to publicly correct these misleading comments and yet have not done so. Here is the letter I sent them:

I have also written to the CMO Prof Chris Whitty who is ultimately responsible for the actions of PHE. I am aware that the CEO of Blood Cancer UK wrote to him a few days ago, but this has not in my view had an adequate public response. I am today acting entirely on my own initiative and have not discussed my actions with them or anyone else for that matter. Not even the other authors of Blood Cancer Uncensored. But as a patient and previously having worked in the pharmaceutical industry I believe I understand the issues well enough to make this intervention. Here is my email to the CMO:

In addition I would be interested in suggestions of any other actions we can take, not just for this but for the Government’s utter failure to do the following for all of us with blood cancer or other immune compromise. Please do note that this group does not include everyone who is in the Clinically Extremely Vulnerable (CEV) or shielding list as the majority of them WILL respond to the vaccine:

• Warn a much smaller specific group of around 500,000 patients with blood cancer and other causes of immuno-compromise that vaccines often do not work for us
• Test us all for antibodies generated by the vaccine so we can know how well our individual immune system has responded.
• Protect us by taking appropriate steps when we have not responded to vaccines, such as giving us the legal right to continue to work from home or be furloughed, and continuing to insist legally on masks for everyone on public transport and in certain crowded indoor areas. At this point EVERYONE with an immune compromise is probably also feeling the strain mentally and so should be offered psychological and other support in order to continue to at least partially shield until the infection numbers are lower. The Volunteer weekly phone calls have been a lifeline for many, but should be freshly directly offered to this new more specific group. Other support such as prioritised grocery deliveries is crucial and must be enhanced not withdrawn.
• Treat us. Convalescent plasma and monoclonal antibodies have both been shown already to help those of us who have no antibodies of our own to fight COVID19 if infected. Data is currently emerging that they may also help us if given even before we have been infected. And yet a specific monoclonal antibody (made by Regeneron) has had an emergency use authorisation in the USA for over a year (it was given to Trump). This drug is still not available here. And this is even after the results of a UK trial further confirming its efficacy was made available.

All #bloodcancer and other #immunocompromised MUST be WARNED vaccines may not work for us TESTED for antibody response PROTECTED from infection risk and TREATED with monoclonal antibodies not neglected and left to die https://t.co/3cceR9iNw7

— Adrian Warnock (@adrianwarnock) July 8, 2021

UK Charities have today written to the Government asking them to consider lifting basically all infection control measures next week:

.@ceineken Director @ShineCancerSupp has filmed a short video explaining why the letter we sent today is so important.

Please support by sharing the letter, and tagging your local MP, @10DowningStreet and @sajidjavid

Read the letter here: https://t.co/aWzhjwxfrW pic.twitter.com/EAUzFEQlRI

— National Voices (@NVTweeting) July 13, 2021

Vaccines do NOT work well for the immune compromised!

The misleading information being promoted in various forms by the Government and quietly ignored by the Pharma companies is the claim that a recent Public Health England has clearly demonstrated good COVID-19 vaccine efficacy for immune compromised individuals. This is a gross misrepresentation of the data in that study and also utterly fails to take account of the broader balance of data available.

How and where the claim has been used

The misleading claims first appeared in a Public Health England Press Release. Since this has been revised once already I also attach below the PDF of how it still appears on July 13 2021.

In my previous role as the medical director of a various pharmaceutical companies it was my duty to sign off press statements such as these made by the company themselves as being fair, accurate, and consistent with the legislation and code of practice of the ABPI. It is well recognised that the law also applies to other bodies and clearly a Pharma company should not allow misrepresentation of their product to go uncorrected, especially if this is being done by the Government itself. Here are the aspects of this statement that I could not have signed off in my previous role and which I therefore wish to complain about to the regulatory bodies:

Title: “COVID-19 vaccines highly effective in most people in clinical risk groups”. This is too generic and too exaggerated a claim.

The text of the press release: this makes a false and misleading claim: “for those who are immunosuppressed, vaccine effectiveness after a second dose is 74%, with similar protection to those who are not in a risk group. This rises from 4% after a first dose”. Whilst these numbers are quoted from data discussed in the study text they are NOT based on sufficient data or confidence to allow them to be made as a treatment claim, especially considering the context of other known data as I will outline below.

That claim is intensified by the following quote which is much too positive and constitutes an all-embracing claim that everyone with immune compromise will benefit when this is not the case “It is vital that anyone with an underlying condition gets both doses, especially people with weakened immune systems as they gain so much more benefit from the second dose.”

In a revision made to the initial press release over the weekend of the 10-12 July this statement has been added following complaints:

“Within these clinical risk groups, there will be people with more severe forms of illness – particularly in the immunosuppressed group – who may not respond as well to the vaccines, and we recommend they seek advice from their specialists.” 

Cited in https://www.theguardian.com/world/2021/jul/10/public-health-england-accused-of-misleading-cancer-patients-on-covid-jab

But this statement is not clear enough, particularly as we know that only 20% of a sample of blood cancer patients in contact with Blood Cancer UK have been warned by their doctors that the vaccine may not work for them.

In addition a “source from the PHE” reiterated the same false claim to the Guardian during their research for their story. Comments to the media can often clearly fall within the legal definition of promotion and this statement is again a dangerous misrepresentation of the truth:

“the study that the release was based on did find that for those who are immunosuppressed, vaccine effectiveness after a second dose is 74%, with similar protection to those who are not in a risk group. This rises from 4% after a first dose.”

Cited in The Guardian 10 July 2021

On 12 July the Clinically Extremely Vulnerable Official Advice (CEV) was updated (to come in on 19 July) and the following glaring commissions and omissions were made:

• Misleading information from the press release is included. Use of the phrase “1 million people” particularly makes this sound much more robust than it really is: “A recent study from Public Health England, which looked at more than 1 million people in at-risk groups, found that people who are immunosuppressed are significantly better protected from symptomatic infection following the second dose of a COVID-19 vaccine.”
• The above paragraph contradicts and confuses a statement made in the previous paragraph which itself could be much better worded and include more helpful information since many people will read this document. We can and should say so much more than merely “there is emerging evidence that suggests that some immunocompromised and immunosuppressed individuals may not respond as well to COVID-19 vaccines as others”
• No attempt made to make clear that we now need to consider how to support two different groups: Firstly the wider clinically extremely vulnerable community, many of whom SHOULD be being reassured that vaccines DO appear to work for them very well. Secondly a sub group of the most vulnerable of the vulnerable: those with immune compromise. It is not made at all clear who should consider themselves to be immune deficient. This group is a very diverse group and accurate data actually suggests SOME of them WILL respond to the vaccine by making antibodies. But MANY do not, and as I have argued previously with everything opening up, mask mandates being removed, and the infection rate being allowed to raise, this is actually the most dangerous time for this group.
• In the vaccination section no explanation that vaccines are less likely to work for those who are immune compromised but do work well for most others in the CEV list – a great opportunity to reassure and warn appropriately has been missed here.
• There is no mention of the fact that antibody levels can give at least some indication of whether an immune compromised individual may have responded to the vaccine or not
• There are no requirements imposed on employers to take extra steps to protect those who have not responded to vaccinations and ensure they are not put at risk by being forced to work outside the home or travel in crowded public transport. Certain duties under health and safety legislation could be explicitly stated to apply in this situation to this group of protected individuals who are most at risk and most impacted by the pandemic. The premature ending of social distancing in places of employment is potentially discriminatory against immune compromised patients and certainly puts them at unfair extra risk.
• The following statement is surely putting those who have not responded to the vaccine by making antibodies and do not know this at particular risk “If you cannot work from home, we are no longer advising that you do not attend the workplace”
• The failure to extend a priority booking service for supermarket delivery slots risks putting immunocompromised patients at particular risk.

Media coverage generated by the press statement

The use of careful language and in particular headlines in press releases is crucial as these tend to be exaggerated further in media coverage and the dangerous misinformation is only highlighted further. The title and in particular Dr Ramsay’s quote has found its way into a number of press outlets where it forms a very misleading impression:

BBC “COVID-19 vaccines highly effective in most people in clinical risk groups”

“The study of more than a million people in at-risk groups shows two doses of the Pfizer or AstraZeneca vaccines are needed for this protection. 

Being double-jabbed reduced the risk of symptomatic Covid-19 by around 90%.

One dose cut it by about 60%, says Public Health England (PHE). . . .

Dr Mary Ramsay, head of immunisation at PHE, said: “This real-world data shows for the first time that most people who are clinically vulnerable to Covid-19 still receive high levels of protection after two doses of vaccine, It is vital that anyone with an underlying condition gets both doses, especially people with weakened immune systems as they gain so much more benefit from the second dose.”

https://www.bbc.co.uk/news/health-57781073

Note the way that Dr Ramsay’s comment again is presented in such a way as to promise “much more benefit” to the immune compromised with zero caveats seen anywhere in the article attributed to PHE

Guardian: Covid-19 vaccines offer high levels of protection for those with underlying conditions

Government claims simply repeated and the only context provided in the following quote which doesn’t challenge the data:

“16 health charities joined forces to urge the Government to support around 500,000 people who are immunocompromised or immunosuppressed.

The charities included Anthony Nolan, Blood Cancer UK, Bowel Cancer UK, Cystic Fibrosis Trust and the MS Society. . . The charities said they wanted better communication from the Government and the NHS to inform patients, the wider public and employers about the continued risks that Covid-19 poses to immunocompromised people.

They also want employment protection and access to workplace adjustments for immunocompromised people, including the duty to consider working from home wherever possible and flexibility in start and finish times so as to avoid peak-time travel.”

https://www.theguardian.com/politics/live/2021/jul/09/uk-covid-live-news-updates-coronavirus-nhs-boris-johnson-delta-variant?page=with:block-60e864518f088bdc7639aa4d#block-60e864518f088bdc7639aa4d

The Telegraph: Two vaccine doses give strong Covid protection in high-risk groups

The article begins with the following dangerous misinformation which is a reasonable interpretation of the offending press statement:

“Two vaccine doses are as effective at preventing Covid in those with high-risk health conditions as they are in everyone else, Public Health England (PHE) research suggests.”

https://www.telegraph.co.uk/news/2021/07/09/two-vaccine-doses-give-strong-covid-protection-high-risk-groups/

Pulse: Covid vaccines 74% effective in immunosuppressed after second dose

No context given to the Government’s claims.

Mint – quotes Dr Ramsay’s misleading comment only.

No context again.

Belfast Telegraph: Covid-19 vaccines offer ‘high levels’ of protection for immunosuppressed

No context except the 16 charities comment seen in the Guardian.

The Clinical Data this erroneous press release is based on

The PHE study has been made available as a preprint. The abstract summarises the data with regard to the immune defiecient in a very different manner than the press release:

“The only clinical risk group with significantly reduced S-antibody response after one and 2 doses was the immunocompromised group who had a 68% (95%CI: 43 to 82%) reduction in the geometric mean titre after 2 doses. Reduced vaccine effectiveness against clinical disease was also noted in the immunosuppressed group after one dose, however, after a second dose of either vaccine, high levels of effectiveness were seen (Pfizer: 73.0%, 95%CI 33.9 to 89.0%; AstraZeneca 74.6%, 95%CI 18.7 to 92.1%).

https://khub.net/documents/135939561/430986542/RCGP+VE+riskgroups+paper.pdf/a6b54cd9-419d-9b63-e2bf-5dc796f5a91f

Note that the conference intervals around many of these data points are rather large in range which is a sign that even this summary may be rather too optimistic. Crucially the data demonstrates a very large reduction in the mean population antibody plasma levels. Clearly this must mean that a significant proportion of this group had dramatically lowered antibody levels and one can assume that some of them had zero whatsoever based on other data which has already been published.

In the paper itself, the Table 1 lists the percentages of people who tested positive following their first dose of the vaccine. Almost group in this table has at least 89% of it’s members test positive after just the first vaccine.

They report that their study only included a tiny number of those in the shielding  group . Just 60 patients in fact. This raises HUGE concerns about the generalisability of this study to those millions of people who were on the shielding list let alone the specific immune compromised group. Of those 60 patients 49 made an antibody response giving a rate of 82%. But remember there are a huge number of conditions that can lead to shielding and only a small proportion of the overall group were in that group due to immune compromise including blood cancer.

Table 1 also lists the “Immune compromise” group but at no point qualifies who this group are. Patients with a wide variety of diseases are listed as immune compromised, and in many cases this can be much milder than would be required to obtain a shielding designation. Perhaps it is not surprising then that the immune compromise group as a whole was larger than the shielding group. So the estimate of efficacy is likely to be much better than for those who are bad enough go be included in the shielding group due to a blood cancer or other form of immune compromise. Nonetheless this table lists 93/132 patients as making antibodies in response to one dose of the vaccine a rate of 70%. This is dramatically and statistically significantly lower than the general population and represents a third of even this broad group of immune compromised patients not responding to the first vaccine dose.

Table 2 shows even smaller numbers of immune compromised patients and 38 out of 39 of them made some antibody response after the second dose although the plasma levels were significantly lower.

The study also tried to make estimates of vaccine effectiveness based on case numbers seen in the GP database. Again the broad non specific definition of immune deficiency was used with no attempt made to subdivide that group. After dose one the vaccines were estimated to have only a 4% efficacy among immune deficient individuals with a wide confidence range that included the possibility that the vaccine might actually increase the number of cases by a third! This may have been due to the risk of exposure seen by a shielding group going out to be vaccinated and getting exposed. There figure of 74% efficacy after the second dose for immune compromised patients has been touted in commentary on this study but this is based on just NINE cases in this group and so is utterly meaningless and has very broad confidence intervals.

These tiny numbers of patients are not sufficient to set aside the growing body of evidence that those with immune compromise are definitely at greater risk of not responding to the vaccine than others. This body of data should have been more adequately reflected both in the explanation in the study itself, and also in the press release.

As a good summary of the emerging body of evidence for blood cancer patients, a key component of the immune compromised group see this Blood Cancer UK summary.

The PHE study discussion section

This section explains the context of the study and important limitations in a way that just simply doesn”t find its way into the misleading PHE press release.

Unvaccinated individuals are likely to differ from vaccinated individuals in an important way. Vaccination coverage shows that individuals aged 90+, aged 65 to 69 and belonging to black, Asian and minority ethnic (BAME) groups, especially black ethnicities, are less likely to be vaccinated. Disparities in transmission rates are understood to exist by these sociodemographic characteristics. Those close to the end of life may be less likely to vaccinate. Those who have had recent infection are expected to wait 28 days from resolution of symptoms before vaccinating. We control for many of these factors, but some residual confounding is likely . . . While the cohort under study is large, once stratifying by clinical risk groups, numbers in some groups remain small and we were unable to further stratify, for example by specific cause of immunosuppression. It is likely that there are differences in immune response and VE according to the severity of immunosuppression . . . The immunosuppressed group stands out as having reduced response to vaccination after one and 2 doses . . . Further research is needed to understand vaccine effectiveness against severe disease among immunosuppressed groups.

https://khub.net/documents/135939561/430986542/RCGP+VE+riskgroups+paper.pdf/a6b54cd9-419d-9b63-e2bf-5dc796f5a91f

Response from others

I have written to CEO @phe_uk about this press release. It is misleading & dangerous. People with blood cancer will read this and think they are likely to be protected, and behave accordingly. The is not what the evidence tells us. @CMO_England please intervene. https://t.co/HOJFNgM8wF

— Gemma Peters (@gemmapeters) July 9, 2021

Blood cancer CEO has been particularly scathing of her criticism of the Government and has written to Public Health England about this. Her public comments have also been quoted in The Guardian as follows:

 “I cannot tell you how disappointed I am to see the public body responsible for protecting people’s health acting in a way that recklessly risks the health of some of the most vulnerable people in our country.

“Given all the above, we believe Public Health England has a duty to people with blood cancer to publicly retract this study as soon as possible, and to contact every journalist it was sent to. For clarity, we have no issue with the study itself, but with the way it has been represented in the press and the subsequent media coverage.”

https://www.theguardian.com/world/2021/jul/10/public-health-england-accused-of-misleading-cancer-patients-on-covid-jab

Initial Conclusion

Far from retracting their false claims the Government have repeated them. I therefore call on the MHRA to investigate the Government for their direct action to mislead patients who are among the most vulnerable of all, and the ABPI to investigate the silence of the Pharma companies which make them complicit in this lie being told to patients, including those with blood cancer, who are immune deficient.

Note: press offices of all organisations referred to in this article have been asked for comment and so comments will be added below as they are received.

Comment from Public Health England

It is interesting to note that many blood cancer patients were included in the study, and of interest that they intend to issue some guidance but the PHE are still here essentially stating that they are doubling down on their dodgy data. Remember this is based on just NINE cases! Immune comprise is a hugely heterogenous term and to use this 74% figure so boldly is really irresponsible. If you look at their paper, even if you accept that to think of this group as a whole is valid the confidence intervals around this 74% number are between 48.8% and 87.0% which shows just how little confidence we can have in this number. Does the vaccine work for SOME people with immune compromise OF COURSE. But even on the basis of what they are saying it does NOT work for all people with immune compromise. This all just shows how crucial it is that we TEST EVERYONE with immune compromise to see if the vaccine has worked FOR THEM as an individual so they can then make an informed decision.

Comment from the MHRA

I received the following email from the MHRA (the UKs equivalent of the FDA). It is interesting that they do not comment on the accuracy of the claims, and could be considered quite remarkable that they suggest that it may be helpful for me to refer the government to the advertising standards authority which I will now do. To them it seems there is a doubt about their jurisdiction in this matter. I will quote their email in full and then my reply.

Dear Dr Warnock

Thank you for this referral.  We have considered carefully the points raised in your email regarding aspects of the government’s campaign to support covid vaccination.

The MHRA is responsible, on behalf of Health Ministers, for administering the legislation on advertising medicines as set out in Part 14 of the Human Medicines Regulations 2012, as amended.  The relevant definition of an advertisement for a medicine is given in regulation 7.  It is the view of the MHRA that materials disseminated by Government bodies in support of a public health campaign are not caught by this definition as they are not ‘designed to promote the prescription, supply, sale or use’ of a specific medicine or medicines.  Their purpose is rather to promote public health by encouraging people to seek appropriate medical intervention, in this case uptake of vaccination against COVID 19.  The regulations provide a specific exemption for an advertisement that may be issued as part of a campaign approved by Ministers (see regulations 292 and 291A).  It was not considered necessary in the legislation to provide an exception for the whole campaign, only to provide a route for materials on specific medicines to be disseminated if Ministers considered it appropriate.

We therefore consider that the materials you submitted fall outside our remit.  If you disagree and have further evidence that this is not the case, please provide this evidence and we will consider again.  

You may find it helpful to consider submitting any further complaint to the Advertising Standards Authority (ASA) to see if they can investigate the concerns you raise.  They have a wider remit on misleading advertising and may be able to consider some aspects of your complaint that fall outside the medicines regulations.  You can find details of how to complain to the ASA here.

Yours sincerely

Advertising Standards Unit

Email received 13 July 2021

I decided to reply to them including two copy of the graphic from the tweet I cite earlier in the article.

My main point is that this tweet graphic below looks remarkably like an advert promoting the use of a vaccine to me in a group of patients (who by the way I agree SHOULD use it) but for whom they are basing their assertion that it is 74% effective on just NINE cases and a very heterogeneous sample, and ignoring the background data that says for many groups it is a lot lower than that.

Anyway 74% effective is a meaningless concept when what we really mean is that it is effective 100% for some people but not for others.  In the context of the government REFUSING to warn immunosuppressed patients the vaccine may not work for them and refusing to do tests to see if it has worked for them then I think this is a very dangerous public health message.  

It may encourage people to use the vaccine, yes, but it may falsely reassure people like me who do not make our own antibodies to think that the vaccine has worked for them. Then they may put themselves at risk, something the government is now itself encouraging by removing most of the safeguards e.g. social distancing in the workplace. 

Actually immunocompromised people who have been working in covid secure environments should probably be encouraged to stop doing so if they are about to become covid non secure and the rates allowed to increase.  This irresponsible advert is in my view aimed directly at forcing people who are immunocompromised to get back on with their life without fear of getting covid.  It is a false reassurance not really any better than those people who advertise snake oil as being the cure for cancer.

IF you saw this graphic in ANY other context than on a government based account you would call this an advert for sure and you would come down like a ton of bricks on any  pharma company that was this dishonest and didn’t put the data into the context of the whole background of data on the issue.

Basically what we seem to be saying is it doesn’t matter if the government lies about a claim being made about a medicinal product.  I don’t see how that can be the case.  For some reason PHE do not seem to be able to see for themselves how dangerous this LIE actually could be.  Unscrupulous employers will tell their employees the government says the vaccine works for immunocompromised patients so they cant work from home any more.  Some may die.  Without better communication on this issue we risk a large number of immunocompromised patients throwing caution to the wind and catching covid and NOT being protected.  
Why should the government not be held to the same standard as the pharma companies?  I write as a previous pharmaceutical company medical director who would NEVER have signed something like this off.
https://twitter.com/DHSCgovuk/status/1413495655125995523/photo/1 (original URL) 

Commentary on the same tweet by CEO of blood cancer uncensored (who are not involved in my personal complaint)

Further reply from the MHRA (14 July 2021)

I have to say I am impressed with the speed of the MHRA response to this issue. Here is further explanation from them of why they do not believe that this constitutes an advertisement for a specific medicine within their interpretation of the relevant legislation, although it might well be seen as an advertisement in a more general sense:

Thank you for explaining your point in more detail.  We have looked at the material again but we consider that the material promotes vaccination rather than the specific vaccine products available.  It remains our view that it is designed to promote public health and does not meet the legal definition for an advertisement for a medicine, that the material is “designed to promote the prescription, supply, sale or use of that product”. 

If you want to take this further, we suggested that you consider submitting your complaint to the Advertising Standards Authority (ASA). They have a wider remit on misleading advertising and may be able to consider some aspects of your complaint that fall outside the medicines regulations. You can find details of how to complain to the ASA here.

Email received 14 July 2021

My complaint to the Advertising Standards Authority ” Report a coronavirus ad” form.

It seemed quite appropriate as then webform I used said “Use this form if you’d like to quickly tell us about an ad that makes misleading, harmful or irresponsible claims around the current coronavirus or ‘Covid-19’ situation.” Which is EXACTLY what I believe about this advert and the press release it is based on.

Lets see what they say!

Baroness Stroud Asks the Minister in the Lords about communication with blood cancer patients

Reply from the ABPI Code of Practice Authority

On 5 August 2021 I received a reply from the pharmaceutical industry self regulating body which pointed out that they are only responsible for regulating the actions of the pharmaceutical companies themselves.

Learn More

• PHE Study Preprint
• The Guardian Article
• Mask mandate petition
• Blood Cancer UK Vaccine Efficacy updates