Covid-19: Limbo between soaring cases and the hope of vaccines - Prof Alan Whiteside

People around the world have pinned their hopes on the arrival of effective Covid-19 vaccines. Now that regulators have begun to approve the inoculations for use, the next hurdles have become clear. The rollout of Covid-19 vaccinations is a complex process, affected by socio-economic intricacies and economic restraints. The process can easily be portrayed as a political one by those who choose to do so. A rocky start to the new year has made it clear that some countries, like South Africa need to be more cautious in their planning of vaccination rollouts, long before they have the vaccines in hand. As the virus sees a resurgence around the globe leaders need to balance speed with practicality at the risk of rendering the vaccines ineffective against the second wave. Professor Alan Whiteside writes about where we are, where we need to be, and what we need to do to get there, in the race to get people vaccinated. – Melani Nathan

Covid-19 watch: A rocky start to the year

By Prof Alan Whiteside*

Introduction

The most depressing day of the northern hemisphere year is reputed to be the third Monday of January. The Independent reports, ‘the formula is essentially pseudoscience and has urged Brits to “refute the whole notion” of Blue Monday’.¹ However, as I sit in my shed, faced with grey skies and temperatures just above freezing, and Covid-19 numbers rising I wonder. We are breaking records for the number of cases and deaths. On the other hand, when I step outside into the garden there are signs of life and renewal. The green shoots of the snowdrops are pushing through the earth, the birdfeeder is visited by wrens, blue and great tits. The blackbirds eat the seed off of the ground. When there is sunshine, it looks full of promise.

The situation regarding the coronavirus pandemic is bleak. A new lockdown has been introduced in the UK, and there is talk of tightening the regulations further. We are being warned to stay at home; that the situation is at its worst for hospitalisations and deaths; and the future is said by the politicians ‘to be baked in.’ The legislation that gave the English government power to introduce new rules specifies these do not have to be reviewed before 31st March 2021.

I don’t want to be too much of a Cassandra.² There has been rapid progress in understanding the virus and developing vaccines. Treatments are evolving and improving. Vaccines are being rolled out in an ever-increasing number globally. Many more are in development. My prediction is a year from now the pandemic may be medically under control. The social, economic, political, educational, and psychological effects will still be evolving. This Covid-19 communique, the first of 2021, focuses on vaccines, and has a guest article from friend and colleague Simon Dalby, ‘Seeing 2020: COVID, Climate and the Failure to Anticipate’.

The numbers

On 12th January 91,027,775 Covid-19 cases and 1,948,236 deaths had been recorded globally. There seems, from the data, to be a clear pattern of new cases continuing to rise steadily. The graph shows an interesting pattern of reported cases being highest in the middle of the week and falling at the weekend. The USA continues to lead the global league table with 22,619,030 cases and 376,283 deaths. To date the US record for daily cases was on the 21st December 2020 with 302,506 cases reported, the highest daily death toll was 4,194 deaths on the 7th January.³

It should be noted there are countries where the data shows the epidemic seems under control: China reports 96,941 cases; South Korea has fewer than 70,000. The leader board has barely changed in the past month: the USA, India, Brazil, Russia, and the UK have more than three million cases. Countries with between two and three million cases include France, Turkey, Italy, and Spain. Germany, Colombia, Argentina, Mexico, Poland, Iran, and South Africa have between one and two million. Most other countries are seeing increases, as is shown on various websites.

The US epidemic is quite unbelievable. The 16th of December saw the highest number of deaths on a single day since the epidemic began, with 3,668 people losing their lives according to the John Hopkins website. With the political upheavals in the USA, the focus has been on Donald Trump and his behaviour during and after the election. He has allowed the virus to spread with great speed. The events in Washington may have given it an additional spurt. It is the biggest challenge Biden faces.

Vaccines

Vaccination is not simple. First there must be approved vaccines. They must then reach people and be accepted. There should be a prioritisation of who gets vaccinated first. Shabir Madhi, professor of vaccinology at the University of the Witwatersrand and the director of the South African Medical Research Council: Vaccine and Infectious Diseases Analytics Research Unit notes

‘the search for Covid-19 vaccines has been “phenomenally successful”. … However, each vaccine faces four “valleys of death”, … The first is getting licensed. The second is scaling up manufacturing to meet global demand – this is where it is at, right now. The third is affordability and access. The fourth is the implementation of an immunisation programme. … he explains. “You can have the greatest vaccine but if you can’t eventually get people immunised then those vaccines count for very little.”’⁴

In the west the first to be approved and administered was the Pfizer/BioNTech vaccine. It has been endorsed in the US, UK, European Union (EU) and Canada. The drawback of this vaccine is that it requires very cold storage. The cost is €12 per dose. The UK was the first country to inject patients. As an aside, I was surprised to see my colleague, Martin Kenyon (91), interviewed on CNN. He is a remarkable man, who played an important role in the fight against apartheid and getting Waterford School established in Swaziland. It was a delightful surprise.

Moderna was the second approved vaccine. Currently it is cleared in the US, UK, the EU and Canada, this costs €14.68 per dose. Moderna and Pfizer use a new approach involving messenger RNA and are believed to be 95% effective. The most recently approved vaccine is from AstraZeneca/Oxford. It is available in India and the UK, is estimated to be 70% effective, and costs €1.78 per dose. This is the vaccine pushed by Boris Johnson, the links to Oxford lead to a burst of patriotism from him. All these vaccines require two inoculations to give the maximum protection. There is one Russian vaccine being distributed, the Gamaleya known as Sputnik V. It is said to be 91% effective. The only other vaccine to have approval, to date, is the Chinese Sinopharm which was said to be 79% effective. The price for the Russian and Chinese vaccines is not known.

There has been a suggestion in the UK to increase the gap between the two doses, thereby increasing coverage. This has no basis in the science, nor has it been approved by the manufacturers. The government logic is:

“Given the high level of protection afforded by the first dose, models suggest that initially vaccinating a greater number of people with a single dose will prevent more deaths and hospitalisations than vaccinating a smaller number of people with 2 doses. The second dose is still important to provide longer lasting protection and is expected to be as or more effective when delivered at an interval of 12 weeks from the first dose”.⁵

The website goes on to say the Joint Committee on Vaccination and Immunisation (JCVI) advises prioritising delivery of the first dose, as this will have a greater short term public health impact and reduce preventable deaths from Covid-19. I hope a change in dosing does not happen.

There are numerous other vaccines in various stages of development mainly in Europe, the USA, and China. The best vaccine tracker I have come across is produced by Bloomberg, a financial information, software and media firm.⁶ This tracks the biggest vaccination campaign in history which is now underway. On the 12th January more than 29 million doses in 43 countries had been administered, and as of 11th January there had been 9.27 million doses given in the US, with health-care workers prioritised. My Covid communique that covered this in depth was at the end of November.⁷ Also of interest is a January article in the New York Times.⁸

Demand and Supply

We are pinning our hopes on vaccines for a return to a more normal life. The critical questions are:

Can enough vaccine doses be manufactured?
Can the vaccines be distributed from manufacturers to the recipients?
Will these doses be fairly distributed?
Will the vaccines be affordable to governments and individuals?

There are also questions around the efficacy of the vaccines. We may know what level of protection the vaccines offer, but we do not yet know how long this will last. Will there need to be a new vaccine every year, as with the current influenza shots, or could it last for years as with the yellow fever vaccines? There are questions about whether the vaccine will provide protection as the virus mutates. These are distractions, the key is to get as many people as possible immunised.

The anti-vax movement is an issue. There are people who don’t want to be vaccinated for a range of reasons, from not trusting the government to not believing it will work. The issue of vaccine scepticism in South Africa was well covered in the Daily Maverick, where

“there are high levels of anti-vaxxing sentiment. It’s not just Chief Justice Mogoeng Mogoeng, who last year voiced his concern that a Covid-19 vaccine might demonically scramble DNA. This week, Cosatu president Zingiswa Losi said while chairing an event that South Africans didn’t want “non-organic” vaccines. And former ANC MP Tony Yengeni posted on Twitter that he would never accept the “stupid vaccine” for his family.”⁹

The Ministerial Advisory Committee (MAC) on vaccines wrote in December 2020:

“The issues around science denialism, anti-vax sentiments and vaccine hesitancy in South Africa should be addressed through an understanding of the main drivers of the hesitancy and the development of effective local responses.”¹⁰

In my view this is a distraction, vaccination programmes should be rolled out as rapidly as possible, following a priority list. People who refuse the vaccination can be passively sanctioned. If you are not immunised you could be denied access to public transport, refused admission to public facilities including education, or not allowed to cross borders.

The South African priority list is:

Phase 1 Healthcare workers;
Phase 2 Essential workers (including teachers, police, miners, retail workers), People in prisons, shelters and care homes, People in the hospitality and tourism industry. People 60 years and older, People older than 18 with comorbidities; and
Phase 3 Other people above 18 years.

The UK’s order of priority is:

Residents in care homes for older adults and their carers;
80-year-olds and over and frontline health and social care workers;
75-year-olds and over;
70-year-olds and over and clinically extremely vulnerable individuals;
65-year-olds and over;
16- to 64-year-olds with serious underlying health conditions;
60-year-olds and over;
55-year-olds and over; and
50-year-olds and over.

Once these groups are done the vaccine will be rolled out across the rest of the population.

There are a number of helpful websites for looking at vaccines.¹¹ The latest Economist has considerable coverage on the virus, it’s epidemic and the vaccines. They said that their coverage of coronavirus (which is excellent) is free. I have yet to work out how to access it, which means that all I can do is point you to the magazine. The key message on vaccines is they are the good news of the crisis. The rollout gives us a way back to a semblance of normality, although nothing is ever totally simple.

Guest Article: Seeing 2020: COVID, Climate and the Failure to Anticipate. By Simon Dalby, Balsillie School of International Affairs.

Hindsight maybe, as the old but rather inaccurate saying has it, 2020. Looking back over 2020, and the course of the COVID-19 pandemic, much was known about pandemics and the likely consequences of failing to prepare for them. But the clear warnings by health professionals and security planners were ignored until matters were out of hand. In part this has been a failure on the part of politicians and decision makers to clearly understand the context of the new world of the twenty-first century. We live in a globally interconnected economy operating in a rapidly changing ecological context, an increasingly artificial world, the implications of which are not widely understood.

In key places in the United States and elsewhere, including Canada, key agencies and warning systems had been eliminated in recent years. They were judged as surplus to requirements; global matters were of less importance apparently than attending to national priorities. In the United States and the United Kingdom, supposedly among the countries best prepared to deal with pandemics, the death toll rose alarmingly through the latter part of 2020. Partial lockdowns, the policy decisions frequently influenced by business interests, rather than epidemiological knowledge, failed to stifle the spread of a nastily infectious virus in many societies.

As 2020 ended the rapid production of vaccines offered the promise of a technical fix and did so with commendable international cooperation in the scientific community. While this technical fix to the pandemic is clearly to be welcomed, the rapid roll out may yet obscure the more important lessons about the failure to prepare. The rush to “get back to normal” suggests that an opportunity to use government largesse for intelligent planning to deal with climate change impacts and other future threats to human wellbeing will be missed in many places.

Part of this problem of failing to think through future dangers is clearly political; urgent matters repeatedly dis-place attention from important matters. Politicians operate with a focus on short-term issues and crisis management; a week is a long time in politics. But in addition, many politicians and policy makers also operate on outdated geographical premises that assume that we live in a world of relatively discrete spaces, and ones that function in a world where the environment is relatively stable, and where “nature” is mostly separate from important human matters.

The rapid spread of the COVID-19 virus, that jumped species and spread rapidly around the world, belies the first and third of these assumptions. The looming crisis of accelerating climate change gives the lie to the second. We are, as the earth system scientists say these days, living in new circumstances. Humanity is now changing environments, and the climate on such a scale that they suggest we are living in a new geological period, commonly called the Anthropocene. The implications of this new recognition, one that is now beginning to find its way into policy making circles, is that the old assumptions that discrete spaces, those administrative conveniences we call states, are no longer the appropriate mode of governance for these new times. Policies of national security premised on “keeping the bad guys out” don’t work in a globally connected economy where careful coordination of standards, financial arrangements and much else are needed to keep everything moving, and people safe.

If in fact it turns out that the COVID-19 virus did initially spread to humans in the wet markets of Wuhan, then, once again humanity has been plagued by a zoonotic disease, where some entity jumped from one species to another. There is an interesting twist in the human-animal transmission story this time round. In Denmark the COVID-19 virus jumped from humans to mink in the industrial farms there. The resultant extermination of many million animals to try to prevent reinfection in humans drew attention to the links between the artificial environments of factory farming and human populations, emphasizing the point that we all live in increasingly artificial circumstances where assumptions of nature separate from humanity make no sense.

Climate change is an entirely predictable threat, and one caused by industrial activity and the widespread burning of fossil fuels. We know it is accelerating, but we are just not sure which of its symptoms will appear precisely when and where. As the pandemic should have taught us, preparation is better than frantic scrambling to try to regain control once disaster strikes. There is no vaccine for climate disruptions; only prevention will work. We also know from the pandemic that we may suffer nasty consequences of policies trying to deal with disasters if they aren’t thought through properly, or implemented effectively and in time.

The novel threats that the artificial environments of the Anthropocene present to their human inhabitants is now the appropriate contextualization for security policies, health and otherwise. Setting up institutions designed to survive short-term political attention and budget fluctuations, with a focus on the long term to prevent future global disasters, simply must be a policy priority for governments. Educating politicians to understand the complexity of global interconnections may be rather more difficult, but it too is a necessary task in our new circumstances.

Conclusion

A conclusion is hard to write. It is as though we are in limbo between an out-of-control epidemic and the hope of a vaccine. I am going to not even try to write more this week. The thing I take comfort in is knowing people who have received two doses of vaccine and who are now protected. As this rolls out, we must start thinking about the ghastly consequences. My next blog will be on 27th January. I am giving updates on key developments in the epidemiology and science, and will have more analysis.

Useful resources

Transformation, Vol 104, 2020, Special issue Covid-19. https://muse.jhu.edu/journal/198

Thank you for reading, reposting and providing comments. What I write is public domain so please share, forward and disseminate. My contact is: [email protected]
Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal www.alan-whiteside.com

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Covid-19: Limbo between soaring cases and the hope of vaccines – Prof Alan Whiteside