COVID-19 & VACCINES – “With a fast-moving pandemic, no one is safe, unless everyone is safe”

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As of 7 January 2021, there were 85,929,428 confirmed cases of Covid-19 internationally, including 1,876,100 deaths reported to WHO. Data by region can be found here.

In 2020, the pandemic doubled the number of people who needed humanitarian aid worldwide, according to the UN, and is driving record-breaking humanitarian needs in 2021, according to the New Humanitarian.

Since April 2020, the Access to COVID-19 Tools (ACT) Accelerator partnership, launched by WHO and partners, has supported the fastest, most coordinated, and successful global effort in history to develop tools to fight a disease. With significant advances in research and development by academia, private sector and government initiatives, the ACT-Accelerator is on the cusp of securing a way to end the acute phase of the pandemic by deploying the tests, treatments and vaccines the world needs. But…

Donors have committed to fund the scale-up of the ACT-Accelerator but warn that major additional funding is critical to its success. As of 22 December 2020, contributions brought the total committed to over US$ 5.8 billion – but an additional US$ 3.7 billion was needed urgently, with a further US$ 23.7 billion required for 2021, if tools are to be deployed across the world as they become available.

The vaccines pillar of the ACT-Accelerator, convened by CEPI, GAVI and WHO, is supporting the building of manufacturing capabilities, and buying supply ahead of time, so that 2 billion doses can be fairly distributed to poorer countries by the end of 2021.

Announcements of effective and safe vaccines for Covid-19 were greeted with enthusiasm. But discussions continue about the ethical challenges of ensuring fair access to Covid-19 vaccines within and across countries, and which groups should be prioritised. (Lancet 397:10268, 10 December  2020) Thus: “Concerns about equity in access to the vaccines are growing. Estimates as of 2 December 2020 suggested direct purchase agreements had allowed high-income countries to secure nearly 4 billion vaccine doses, compared with 2·7 billion secured by upper and lower middle-income countries. Without such agreements, low-income countries would probably have to rely on COVAX, which would achieve only 20% vaccination coverage.

“While COVID-19 vaccines bring potential hope for a return to some kind of normality, vaccine-based protection is contingent on sufficient population coverage and requires effective governance, organisational, and logistical measures within a wider Covid-19 control strategy that includes continued surveillance and appropriate countermeasures. Successful vaccine roll-out will only be achieved by ensuring effective community engagement, building local vaccine acceptability and confidence, and overcoming cultural, socioeconomic, and political barriers that lead to mistrust and hinder uptake of vaccines.”

The World Health Organization announced in December 2020 that it had signed agreements to reserve some 1.3 billion doses for low- and middle-income countries under the COVAX programme, which was created with the goal of ensuring equal vaccine access.

The Pfizer/BioNTech vaccine, developed in Belgium, was the first vaccine to receive emergency validation from WHO on 31 December 2020 since the outbreak began a year ago. This opened the door for countries to expedite their own regulatory approval processes to import and administer the vaccine. It also enabled UNICEF and the Pan-American Health Organization to procure the vaccine for distribution to countries in need. However, this vaccine requires storage using an ultra-cold chain; it needs to be stored at -60°C to -90°C degrees. This requirement makes the vaccine more challenging to deploy in settings where ultra-cold chain equipment may not be available or reliably accessible. SOURCE: WHO, 31 December 2020

Two other vaccines have been approved as well: The Moderna vaccine, produced by Moderna in Spain, was authorised across the European Union on 6 January 2021; it also requires cold storage. And now there are several other vaccines making their way around the world as well.

The Astra-Zeneca vaccine, developed by Oxford University and Astra-Zeneca in the UK, has been approved in the UK, India and Mexico. Unlike the Pfizer and Moderna brands, it can be stored at higher temperatures and costs less to produce. India has an Astra Zeneca production facility in the country so it is said they can start producing vaccine and vaccinating people.

AstraZeneca’s vaccine costs providers about $4 per dose, while Pfizer’s costs $20 and Moderna’s costs $33, Al Jazeera reports. These prices will most likely fluctuate as time goes on and the vaccines evolve.

All three of these vaccines’ side effects are similar, including potential injection site pain and flu-like symptoms, including fever, fatigue, headaches, and muscle pain, which are to be expected when the immune system is first primed. Because all of these vaccines require two injections spaced several weeks apart, because none of them is 100% effective, and because it takes time for the protection to reach its height, wearing a mask and physical distancing after vaccination is still recommended. (Prevention, 4 January 2021)

Which countries have begun to roll out one or more vaccines?
The following is not an exhaustive picture but gives an idea of what is happening globally, including a sometimes chaotic situation and the fact that often unfair access issues that are emerging. It shows that having produced a vaccine versus successfully vaccinating a population are two very different things indeed. The one does not always lead smoothly to the other. This is proving to be true in the USA and UK, for example, where serious problems are emerging. The prospects for countries with weaker health systems are therefore concerning.

The UK was the first country to start administrating a Covid-19 vaccine, soon followed by over a dozen other countries. The following mainly well-off countries had approved and started administrating one or more vaccines by 29 December 2020:

Belgium, Canada, Chile, Costa Rica, Croatia, Cyprus, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary Israel, Italy, Kuwait, Malta, Mexico, Oman, Poland, Qatar, Romania, Russia, Saudi Arabia, Serbia, Slovakia, Spain, Switzerland, United Arab Emirates, UK, USA.

On 28 December, Sputniknews quoted the  Russian Health Minister, Mikhail Murashko, as saying to the Russia-24 broadcaster that the Health Ministry had approved the Sputnik V vaccine for use in persons aged 18 and over. Thus, citizens over 60 years old could now be vaccinated against the new coronavirus infection. He added that the Sputnik V vaccine was considered to be safe and effective for older people. Vaccination began. Argentina also initiated the vaccination process using the Sputnik V vaccine, having received a first batch of 300,000 doses. (Pharmaceutical Technology, 28 December 2020) On 29 December 2020, Belarus also started administering the Sputnik V coronavirus vaccine to its population.(Moscow Times, 29 December 2020)

In Russia, compulsory vaccination of frontline health, education and social workers was already underway, but some members of the medical profession with priority access to Sputnik V are deeply sceptical of it. The Moscow Times interviewed 12 medics based in the capital, most of whom expressed reluctance – or outright refusal – to accept this vaccine as it had not yet been through sufficient trials for international clinical approval but was given a green light based on results from much smaller groups of volunteers than its Western counterparts. Some said their managers told them they could be sacked for refusing to be vaccinated. However, it was also reported that ongoing difficult relations between the medical profession and the Health Ministry, and anger at being forced to accept vaccination, may be playing a bigger role in this dispute than mistrust of the vaccine itself. In any case, data from clinical trials have not yet been published, but more than 50 countries have already asked to buy or produce Sputnik V, presumably because they will not get access to the more expensive ones any time soon. (Moscow Times, 29 December 2020)

Chinese pharma are also working on a number of vaccine versions. The Chinese authorities have given conditional approval for general public use of a vaccine called Sinovac, developed by the state-owned company Sinopharm, though published data about it are also limited. Other vaccines from other Chinese companies are said to be in the pipeline. Meanwhile, the Sinopharm vaccine is already being administered to in the United Arab Emirates and Bahrain, and Pakistan is said to have bought 1.2 million doses. Shipments of Sinovac have also arrived in Indonesia and deals with Turkey, Brazil and Chile are said to have been secured already one month ago. (BBC News, 3 December 2020)

Pfizer’s Covid-19 vaccine research trials were conducted with volunteers in Argentina, South Africa, Brazil, Germany and Turkey, as well as in the US. But Argentina, South Africa, Brazil, and Turkey have learned that they will have to be satisfied with Pfizer’s gratitude for their participation, because (like most countries in the world) they won’t be receiving enough of the vaccine to inoculate their populations sufficiently, at least not anytime soon. Producing enough vaccine to cover a large majority of the world’s population – 70% is said to be the optimum (minimum?) total – is not going to be a speedy affair. A UNICEF dashboard shows:

Meanwhile, the USA and Germany – along with Canada, the UK and the rest of the European Union – have contracted to buy enough doses of various Covid-19 vaccines to inoculate their populations several times over. But even that is proving not to be enough. The USA, for example, is struggling with the logistics of its vaccine rollout, which is taking much longer than was expected. (See also The Intercept, 31 December 2020)

Then there is what happens when deliberate discrimination for political reasons dominates vaccine rollout: There are reports that Palestinians living in the occupied territories are being excluded from Israel’s Covid-19 vaccine rollout and may have to wait months for vaccination, while injections go to Jewish settlers. (Guardian, 3 January 2021)

Negative consequences of not meeting unrealistic but powerful public expectations
What is most worrying is if people start thinking that the only thing they need now is to be vaccinated, and refuse to continue to endure lockdown and keep each other safe through masking and physical distancing, assuming even those preventive actions are both possible and happening adequately now (which they are not). The fact is, no matter how much demand there is for vaccination, most people will not be vaccinated immediately or soon, let alone necessarily during 2021.

In the UK, due to the massive failure to implement an effective test–trace–isolate programme in order to prevent the spread of the virus, a mutation of Covid-19 that was discovered some weeks ago has spread rapidly. This is happening in many other countries as well, not least because far too much unchecked international travel is also still taking place and being promoted. On one UK television station last night, an advertisement offered a 40% discount on 600,000 seats!

And reports are being published that vaccination rollout has been slower in many countries than was hoped for, not least because there are simply not enough staff to carry it out. Hence, public health people and governments will have to guard against something akin to panic at government level on how to deal with conflicting demands and limitations.

In addition to imposing a total lockdown in the UK after a far too lax Christmas period, a decision was taken by government public health officials in the first week of January to postpone giving the second injection of both the Pfizer and the AstraZeneca vaccines in order to provide first injections to many more people more quickly. The reasoning was that even one injection provides more protection than none. Then, within a few more days, they went even further and proposed to use the Pfizer vaccine for the first dose and the AstraZeneca vaccine for the second dose, that is, if they did not have enough supply of both to use the same brand twice for each person vaccinated. What was the response? As one expert from the USA said:

“Officials in Britain ‘seem to have abandoned science completely now and are just trying to guess their way out of a mess’.”

These policy decisions have caused major debates amongst the expert scientific community internationally, in which responses have ranged from: “Don’t try it”, to “There are no research data to support this”, and “You don’t know how long the first injection will remain effective if you delay the second injection” and “You need to trial these changes first”. All are absolutely correct. On the other hand, a few experts have acknowledged that the “trade-off” being proposed – under imperfect circumstances in which the health care system is already stretched to its limits of coping – is an understandable one, even if not evidentially supported.

Dr Anthony Fauci, the top expert on infectious diseases in the USA, said he would not recommend following Britain’s lead on this, while reports say Germany and Denmark are now also considering delaying the second Covid vaccine dose, presumably for reasons similar to Britain’s. At this writing, WHO has also stepped in and said postponing the second injection – Britain is proposing an interval of up to 12 weeks – is not supported by scientific evidence; they are also against it.

The US Centers for Disease Control and Prevention has made it clear that the approved Covid-19 vaccines “are not interchangeable,” and that “the safety and efficacy of a mixed-product series have not been evaluated. Both doses of the series should be completed with the same product”. This is a big gamble as none of it is data driven. At the worst, a huge number of first injections may prove useless if second injections are delayed too long, pushing everything back to square one.

Another major concern, just emerging and as yet unanswered, is whether any of the existing vaccines will be as effective against the mutated viruses (of which there are now several kinds reported from different countries) as against the original virus they were developed to block. This is the global situation as we send this newsletter out.

See the following articles, which address this growing list of unresolved issues and problems:

Panic, abandoning the COVAX agreements on equity of access to the vaccines that a large majority of countries supported less than a month ago, rushing to use vaccines whose trial data are still limited and/or have not yet been published and evaluated, ignoring good quality trial data to try and speed up a process that cannot be rushed – all of these are mistakes that in the longer term will not take the world where we need to be.

Prevention of infection remains a global priority
Our leaders need to convince people to hunker down, that this situation is with us for longer than we would all like, and that prevention of the continuing spread of infection from one person to another to another is still needed worldwide, based on what is known about the speed of spread of the mutated virus. Our leaders need to prepare for and put in motion major efforts to strengthen and expand national public healthcare services on a longer term basis.

Meanwhile, prevention includes mandatory masking of adults and children over the age of two in all public places, indoors and outdoors; better promotion of physical distancing – that is, to stay at least two meters (six feet) away from other people in public spaces; handwashing when arriving home and using disinfectants in shops; national lockdowns; effective test-trace-isolate programmes run by local health services in which isolation of everyone who tests positive is enforced and supported; closure of schools and supported home teaching of children; and economic support for all those who have lost their jobs or are unable to work – as well as effective protection for all key workers – are critical to defeating this pandemic.

Not just vaccines. And even with vaccines. Today, someone wrote that to vaccinate the world out of this pandemic, 70% of all our populations will need to be vaccinated. This is a gargantuan task and will take far more than one year, let alone a few months. This needs national and individual discipline and accepting the reality and complexity of disease prevention and control.

Lastly, we need to add public health education to the curricula of schools and the training of politicians, and for all our leaders. Our national media also need an education in how to promote public health far better than most of them are currently doing. We were already warned in 2016 that there were more pandemics to come. Most of our countries did not listen. And today, almost all our countries have proved we are far from ready. The few who were ready, and who have managed to contain and defeat this virus, such as Taiwan and New Zealand, have not been seen to be or used as models to follow by the rest of us. At our continuing peril.

Postscript: This report is of course not about abortion. But I am sharing it because I think everyone with any connection to public health issues needs to be sharing this kind of public health information in order to support control of this pandemic. Our lives depend on it. We also need to know much more about what is happening in the poorest countries, which this report clearly does not touch upon. Further information is more than welcome. Marge Berer

Top image: https://www.innomech.co.uk/covid-19-where-do-we-go-from-here