Corona Daily 231: Travel Nurses

Laura Liffiton, a 32-year-old nurse, worked in an overrun ICU in a crowded New York city hospital in April. In July, she flew to Arizona, where she lost four patients on her first day. In October, she travelled to Green Bay, Wisconsin. She has been sleeping only four hours a night. In different cities, she has seen overwhelmed doctors and nurses, lines of intubated and dying patients, with no end in sight to the misery of the situation.  

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Laura is one of the fifty thousand or so travel nurses in the USA. They work on temporary contracts, and move from city to city. For some, travelling is the motivation, for others money. Early-career nurses want to work in different places to gain experience. Those nearing the end of their careers, with little family burdens, want to use their last few years of work to increase their retirement savings. In normal times ICU and medical surgical nurses are the highest in demand.

Specialised agencies bill the hospitals and provide the “travelers”, who stay in hotels, Airbnbs or rented apartments. They usually stay in one place for three months. The three months were historically granted as a maternity leave, during which a travel nurse would replace the one on maternity leave.

When natural disasters such as hurricanes or tornadoes strike, travel nurses serve a useful function. They reach the hot spot, work in the disaster zone, and then leave.

What is happening this year is unprecedented. In November, the demand for travel nurses went up by 44%. California, Texas, New York, Florida and Minnesota are the five states with the worst shortages.

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Now, more than 100,000 Covid patients are hospitalized every day in the USA. Ordinarily a nurse, particularly in ICU, serves a maximum of two patients. Now, nurses are looking after eight. The governor of North Dakota has allowed covid-positive doctors and nurses to continue working, as long as they are asymptomatic. The University of Utah hospital has been using 36-hour shifts for nurses and the state of Iowa has run out of staff beds.

In summer, travel nurses were mainly needed to help in operating rooms on postponed cases and backlogs from the spring wave. In normal times, hospitals scrutinized the resumes to carefully select the best candidates. Now they specify only the number. Like the rush to get the vaccines, there is a rush to get the travel nurses.

The dynamic between the staff nurses and travel nurses is complicated. In a Sacramento hospital, only staff nurses were given higher quality equipment such as air-purifying respirators. With travel nurses earning substantially more, staff nurses are bound to feel upset. Some of them have left their permanent staff positions to become travelers.

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The prices for travel nurses are skyrocketing. Before the pandemic, hospitals would pay $75 an hour, now it is three times more. A traveler can earn anywhere from $5000 to $10000 a week. On top of that, now hospitals are asking for travelers for vaccination. Joe Biden wants America to give 100 million shots every month. Rural hospitals are struggling to find money to pay the high rates for travelers.

The never-ending work is risky. One organization has identified 922 frontline health workers who died of covid after helping the patients.

High pay has drawn more supply, but because this profession requires training and qualifications, there is a limit to the supply. There just aren’t enough nurses. The agencies are shuffling nurses in what they call robbing Peter to pay Paul.

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In my view, the USA needs to take the extraordinary step of expanding the travel nurse concept to nurses from overseas. Countries like India and the Philippines, with relatively fewer cases now, would be able to provide a few thousand nurses on an emergency basis.

Ravi 

Corona Daily 232: The Strange Case of Ice Hockey

Against all odds, Canada is hosting the 2021 World Junior Ice Hockey Championship in Edmonton. Starting on Christmas day, and culminating on 5 January, it will be held behind closed doors, in other words no spectators allowed. All teams are held in an Edmonton bubble with strict regulations.

This week, eight German players tested positive. Germany’s training matches against Austria (21 Dec) and Czech (23 Dec) are cancelled. Two members of Sweden are also in isolation. Two American players were sent home. Three weeks ago, Hockey Canada had to suspend its selection camp and quarantine all players for fourteen days, after two players tested positive.  

These are the under-20 players. As we know, the coronavirus has little impact on the young. Moreover, these are some of the fittest kids in the world. But ice hockey has been plagued by an astoundingly high number of cases. 29-year-old Tyler Amburgey was the coach of two hockey teams. In August, he initially caught a cold from the chill of the ice rinks. This was not unusual, he had it every year. It progressed to a headache, fatigue and shortness of breath. Thirty kids he had coached had tested positive. On the third day, 29 August, Amburgey died.

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Scientists are studying hockey-related outbreaks to learn why hockey players are getting infected so often. Several theories have been suggested.

Hockey players are sprinting the whole time on ice. This leads to heavier breathing resulting in more particles being inhaled and exhaled.

One theory is that the spaces occupied by the rinks keep the virus suspended, possibly at the height of six to nine feet above the ice. Similar outbreaks were documented at other super-cold venues like meat processing factories.

This is an indoor game. The rink is surrounded by plexiglass to prevent errant pucks and keep the game dynamic (unlike soccer which pauses once the football goes beyond the marked line). The plexiglass keeps the airflow stable, and ice cold. Ice rinks are designed so that there is little ventilation or humidity. It seems like an ideal ground for the coronavirus.

Lab experiments have shown that at 86F (30C) the airborne virus takes 52 minutes to decay, at 50F (10C), it takes 109 minutes, more than double the time.

When humidity is high, the virus attaches itself to bigger droplets and falls to the ground due to the heaviness of the humid drops. (if true, I am happy about the high humidity levels in Mumbai). When the air is dry, the droplets evaporate into small size particles and stay in the air. Lingering at a height of six feet above the ice, they can easily enter the nostrils of the hockey players. Research has also shown that in general, cold temperature and low humidity can make some people more susceptible to viruses, possibly because of lowered immunity.

I must emphasise these are theories and speculations at this stage. But the high number of cases among the ice hockey players is a fact. The tragic death of a 29-year-old coach is also a fact. Ice hockey involves vigorous physical exertion accompanied by deep, heavy breathing. During the game players frequently move from the ice surface to the bench while still breathing heavily.

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Although the International Ice Hockey Federation has cancelled most events by now, the World Junior Championship starting next week is an exception. Governors of seven American states, including New York, New Jersey and Connecticut have banned competitive hockey until the end of January.

Investigating the case of ice hockey is essential because it may offer valuable clues about the behaviour of the virus. It may explain why things are so bad in Europe and America in winter time, and so dramatically improving in hot and humid Mumbai.

Ravi   

Corona Daily 233: Executions in a Hurry

America eagerly waits for 20 January; the day Joe Biden will be sworn in. Three Americans; Lisa Montgomery, Cory Johnson and Dustin John Higgs most anxiously await the Biden inauguration, although they realise their chances of witnessing it are slim. The Trump administration has set their execution dates on 12 Jan, 14 Jan and 15 Jan respectively.

USA, Japan and India are the only three democracies that have retained capital punishment. USA executes the most. In the USA, 22 states have abolished the death penalty. Twelve other states have not executed anyone in the past ten years. Other than the states, the US federal government justice system can also impose a death penalty.

For the last 17 years, not a single federal execution had taken place. With great vigour and enthusiasm, Trump set about changing all that. In July 2019, his Attorney General announced the resumption of federal executions. This year, the virus spread is rampant in the prisons. Nationwide, more than 6000 inmates and 1700 prison staffers tested positive. But without losing focus, during the pandemic, the Trump government carried out more executions than all states combined, a first such instance in history.

As per an unwritten convention, during the transition time, the outgoing president pauses all executions. In fact, Clinton and Obama commuted some death sentences to life imprisonment. Trump broke the tradition of 125 years. Since his losing the election in November, three men have been executed, two of them last week. Trump will also have the honour of facilitating the federal execution of the first woman since 1953.

Lisa Montgomery’s life has been prolonged by the coronavirus, which by infecting her attorneys, caused the postponement of the execution date to 12 January. Dustin John Higgs, due to be executed five days before the Biden inauguration is now corona positive himself. He doesn’t even know the method of his execution.

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A three-drug cocktail delivered through a lethal injection was commonly used in the past. Barbiturate acted as a sedative and painkiller, vecuronium bromide was the neuromuscular drug and potassium chloride was added to stop the heart. The problem with lethal drugs is that no human trials can be conducted. In 2014, Oklahoma officials gave Clayton Lockett an untested cocktail of drugs that tortured him for 43 minutes.

Trump’s Attorney General announced federal executions will now use pentobarbital. This is not without problems either. Lundbeck, the European manufacturer, has not sold the drug to the US since 2011. Last year, Texas inmates injected with locally made pentobarbital writhed on the floor, screamed in pain and felt themselves burning. America can detonate atom bombs and kill 200,000 people, but it struggles to execute individuals on the death row.

Undeterred, the Justice Department last month issued new regulations that allow more methods for federal executions including electrocution and the firing squad. In case suitable killer drugs are not available, the planned January executions may happen through any of the other methods.

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Under Operation Warp Speed, correction officers are included in the first round of vaccine distribution along with health care workers. (I wonder if death row inmates are given vaccines).

Prisons continue to test death row inmates and are isolating those who test positive. Dustin John Higgs is now isolated. The priest who talks to him regularly said Higgs won’t be able to meet his relatives during the final weeks of his life.

Joe Biden has declared he is opposed to the death sentence. If the lawyers of the three inmates manage to delay the executions beyond 20 January, the three may live a long life. To prevent that, Trump will try to be precisely punctual and efficient.

Ravi 

Corona Daily 234: Women Less Keen to Get the Vaccine?

An interesting article in yesterday’s Washington Post talks about three US surveys published this month asking Americans about their intentions to get vaccinated. Surprisingly, all three, the Pew Research, the National Geographic Survey and the Gallup poll concluded women were less likely than men to get the vaccine. In a fourth poll, the Reuters/Ipsos poll, 35% of women said they were not very or not at all interested in getting vaccinated. The NatGeo survey had the largest gender gap (men 69% likely vs women 51% likely). All four surveys were American, but the reasons could be universal.

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Cary Funk, the author of the Pew research talks about unrelated past studies. In them, men were generally very enthusiastic about new genetic technologies. Women adopted a wait-and-watch approach. It is possible, Cary Funk says, the doubting women may get vaccinated eventually, but not now.

Most trials exclude pregnant and breastfeeding women. Young women who are or want to be pregnant think about their babies as much as about themselves. In most societies, women don’t get credit for conception, but are blamed for miscarriages. This is one possible reason why many young women would stay away from the unproven vaccines.

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Ruth Faden, a bioethicist at Johns Hopkins, describes women as the guardians of the family. It is the mother, rarely the father, who makes sure the child takes the right vaccines on time. Mothers are particular about visits to the pediatrician. Their maternal instinct makes them read up on new research, and discuss it with other mothers.

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Nancy Tomes, a history professor offers a history perspective. Like Ruth Faden, she confirms women were historically responsible for protecting their families against microbe threats. Women, more than men, wear masks to protect others. But they are discerning when it comes to drugs and vaccines because most medical experience comes from a “male perspective”, medicines created by men, for men. Tomes gives the example of the early birth control pills (invented by men) that had much higher hormonal doses than needed. Women on pills complained of nausea, headaches, dizziness for which men called them hysterical.

Women were excluded from HIV drug trials. Only as late as in 1993 did the US congress pass a law, making women’s inclusion in clinical research mandatory. Light female bodies may react differently to vaccines and drugs than heavy male bodies. Women have had many reasons to distrust medical science. I earlier wrote about the syphilis experiment conducted on black men. Gynecological procedures were forced on enslaved black women.

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The incredible speed with which 95% effective vaccines have appeared has not helped. Since no long-term effects are known, I believe some women may want to wait long enough to monitor the safety record.

The Pew research also found a correlation between the possibility of covid-related hospitalization and vaccination intent. People worried about landing in hospital (and then who knows what) showed greater willingness to get the vaccine. It is well known that in this pandemic men are getting hospitalized and dying in far greater numbers than women. This could be a reason why women are less willing. The risk-benefit analysis in their mind makes the vaccine not worth the risk yet.

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The two most effective vaccines so far, Pfizer and Moderna, are based on mRNA, a new technology. The credit for its creation goes to Katalin Kariko, an American woman of Hungarian origin. The technology of another vaccine, Novavax, is invented by a team of all-women scientists. The leader of that team is Nita Patel, an Indian who emigrated to the USA.  Women like them can be invited to campaign for creating more trust in the vaccines. Vaccines are no longer made by men, for men.

Ravi 

Corona Daily 235: Antacid Shortage causes Heartburn

In April this year, developed countries faced shortages of a variety of products. Supermarket shelves were empty of toilet papers. The reason was hoarding, rather than increased use, of toilet paper rolls. Demand for hand sanitisers, masks, bottled water, thermometers suddenly shot up. They were out of stock at different times. One more product has been frequently in short supply.

Antacids.

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Heartburn occurs when acid in the stomach flows up into the esophagus (food pipe) and causes pain that moves from the stomach to the chest. For a variety of symptoms such as heartburn, acid reflux, indigestion, gases, bloating, stomach ulcers and gastritis; antacids are offered as a medical remedy. They contain calcium, magnesium, aluminum salts which work to neutralize the acids in the stomach. Antacids are sold in a variety of forms – tablets, liquids or chewable gummies. Gelusil, Eno, Gaviscon (India), Tums, Pepcid and Famotidine (USA) are well known antacid brands.

What causes heartburn or acidity? The list is long: Fried and fatty foods. Acidic foods (like lemons or tomatoes). Chocolate. Alcohol. Peppermint. Caffeine. Sodas (carbonated drinks). Acidic juices. Table salt. Spicy food.

In short, any food and drink we love is liable to give us some form of acidity, indigestion or heartburn. Mental stress can also cause all of these symptoms.

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In April, as we all remember, the world was frantically conducting studies to find out what may work against the coronavirus. In a hospital, a set of researchers administered nine times the usual dose of famotidine (antacid) intravenously to covid patients. All 187 patients were in a critical stage. The crude study found out that covid-19 patients on famotidine were dying at a rate of 14%, those without at 27%. After the news of the study became public, American pharmacies like Walgreens and CVS sold all antacid stocks within two days.

Before that, on 1 April, FDA banned Ranitidine, popularly known as Zantac. It was an easy to buy, over the counter drug. Investigation showed it can cause cancer if stored for a long time before consumption. Americans were asked not to buy Zantac, and throw away whatever stocks they had at home.

Over the next few months, the pandemic stress grew. Diet composition changed dramatically. Working from home and little exercise meant extra kilos that caused heartburn and acid reflux. Under depression and a cloud of fear, people who could afford it increased the consumption of booze, sweets, comfort food, takeaway pizzas and fizzy drinks. Johnson & Johnson, makers of Pepcid, confirmed sales of Tylenol, Pepcid and other antacids grew by 30%.

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India is known as the pharmacy to the world. Antacid tablets are unusually cheap – one US dollar can buy 200 tablets in India.  Sun Pharma, Cadila, Torrent sell about 70 million tablets annually. Thanks to Trump who was busy advertising a variety of quack treatments, India managed to produce and export large quantities of hydroxychloroquine (now rejected by both FDA and WHO), paracetamol and famotidine. In October, when Trump was infected, White House confirmed he was taking famotidine along with Zinc and Vitamin D. After that announcement the sales and shortages of famotidine suddenly grew. (Don’t forget 74 million Americans voted for Trump).

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The November elections caused unbearable stress and fear about Trump not winning (Trump supporters) and fear about Trump winning (Biden supporters). With the winter wave in North America and Europe, stress levels are sufficiently high for antacids to be out of stock once again.

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Antacids may have only a short-term effect. Several stomach discomforts are aggravated by continuously thinking about them. In my view, it is better to accept the reality of the pandemic stress and lifestyle, learn to live with the heartburn, rather than get addicted to any form of antacids.

Ravi 

Corona Daily 236: Fruits of Lockdown Gardening

In 1526, the English king Henry VIII and his chief advisor, Cardinal Thomas Wolsey, reformed England’s coinage to regulate the kingdom’s economy. In that project, the Tudor king introduced gold crowns, with a difference. They bore the initials of the queen, Catherine of Aragon.

Seven years later, Henry VIII wished to divorce his wife. This desire changed the course of England’s history. Since pope Clement VII wouldn’t allow him to divorce, Henry VIII formed his own church: The Church of England. He became its supreme head. Many catholic convents and monasteries were dissolved. The king proceeded to marry Anne Boleyn, and the Royal Mint issued a new set of coins with the letter “A”.

Three years later, Henry VIII accused his wife of adultery, incest, witchcraft and conspiracy to kill him, and arranged her infamous beheading. Having gotten rid of her, he ordered the mint to produce “J” initialed gold coins, dedicated to his new wife, Jane Seymour. She died in a year’s time, in the process avoiding both a divorce and beheading.

Henry VIII married three more times, but the Mint was not able to keep pace. There is no record of this numismatic novelty for the last three marriages.

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During the April lockdown, with nothing better to do, a New Forest family in Hampshire, UK was weeding their flowerbed. All of a sudden, they discovered 63 gold coins and one silver coin from King Henry VIII’s reign. The treasure included coins with the initials of the king’s wives.  

The Museum experts have offered two possibilities. It could be a merchant’s hoard. This part of the world was wealthy. Wool trade was important. The New Forest is close to the coast, so someone involved in maritime trade could have hidden it.

The other possibility is the monasteries. When Henry VIII started dissolving or demolishing them, some monasteries and churches tried to hide their wealth in the hope of recovering it after several years. They didn’t, but some lockdown gardeners recovered the gold pot after almost five hundred years. The total value of the gold coins is more than 14,000 pounds in today’s money.

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Another gardener found a mystery hoard of 50 gold South African Krugerrands from the 1970s, worth about 75,000 pounds. This was discovered in a Milton Keynes garden. How the coins ended up there will be determined by the coroner.

The British museum has said more than 47,000 treasures were unearthed in pandemic times. They include a unique Roman furniture fitting with the well-preserved face of the god Oceanus and a medieval forgery of a bishop’s seal matrix. In Herefordshire, one resident dug out a snake-shaped belt hook from the post-medieval period. Another local found a late medieval ring on top of a molehill.

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England has a law about “Treasures”. If you find something in the garden, or anywhere else, that contains gold or silver, and is at least 300 years old, you must report it to the coroner of the district within 14 days. Not doing so can attract an unlimited fine or 3 months of prison. On the other hand, you may get a share of the reward, if you are the finder and had the permission to be on the land and acted in good faith. (Archeologists are not entitled to any reward, because it is their job).

England now wants to expand the definition of treasure to include other items. For the benefit of society, it is important the items land up in museums rather than private collections. In Scotland, you must hand over whatever you find, and the authorities decide whether it can be considered a treasure trove.

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Those who live in city apartments have little chance of digging in the lockdowns. I suggest they clean the house in the lockdown. It is surprising how many treasures one comes across during the cleaning.

Ravi 

Corona Daily 237: Displaced People of the Developed World

The Sydney opera house has reopened. Nearly 40,000 spectators attended Sydney’s rugby league grand final. India and Australia are playing cricket in front of filled stands. Australian workers are being urged to return to their offices.

Australia is considered a real pandemic success story. However, at least 36,875 Australians wouldn’t agree with that assessment.

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In February, Kate and David Jeffries travelled with their infant son from Perth to Canada to care for David’s elderly mother. She was diagnosed with ovarian cancer. Today, ten months later, the Jeffries are still stranded in Canada.

Desalyn Bowyer, 40, moved from Sydney to Hong Kong last December for work. Her office allowed her to return to Sydney every two weeks to spend time with her kids. She has not met her children since February. In July, her father died. She couldn’t attend the funeral.

Yuvraj Krishna, a four-year-old boy with autism is stranded with his mother in India. His mother had air tickets to return to Sydney in April. She checks the booking sites three times a day. Yuvraj’s case is concerning. He has missed his therapy sessions since March, and has lost his faculty to speak. A therapist attributed that to his closeness to his father. His father, Rahul, alone in Sydney, is now on medication for depression and high blood pressure.

Australians are stranded in Canada, USA, Europe and India. They are the displaced people of the developed world.

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The Australian economy depends a lot on China. That could be one reason why Australia took the coronavirus very seriously right from the start. Their closing of the borders was draconian. Since 20 March, residents need a permit to leave or enter the country.

Arrivals are capped. Anyone flying in to Australia has been subjected to a 14-day quarantine at their own expense in specified hotels. The arrivals are therefore limited by the capacity of quarantine hotels. The weekly cap has slowly gone up to 8000 now. In January, 2.3 million people flew into Australia. In September, only 16,720.

Mr Den Heten, one of the stranded Australians started a website removethecap.com. It visually conveys the trauma and delays experienced by Australians trying to return home. The website already has stories of 2831 families from 170 countries.

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Several flights were cancelled. Those that operated offered only first class or business class tickets. An America or Europe ticket to Australia would cost $15000. Some airlines played the game of selling tickets for flights that were cancelled, and then taking months to process the refunds. To add to it, every person arriving must pay $3000 for quarantine. Desperate Australians offered to wear electronic ankles at home instead. That suggestion was rejected.

Since July, stranded Australians should register themselves at DFAT (department of foreign affairs and trade). Unless notified, they can’t leave for Australia. The number of stranded is of those who have registered. Every month the number grows because more people register. In India alone, 10000 are reportedly stranded.

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The right to enter your own country is considered a human right. In 1980, Australia signed the International Covenant guaranteeing such a right. Separation of children from parents is considered another breach of human rights.

Australia’s Prime Minister Scott Morrison has promised to get back all stranded Australians by Christmas. That is now unrealistic. Many Australian homes will have empty chairs at Christmas gatherings. The problem is now compounded. Those stuck in North America or Europe are unable to leave their houses because of the new lockdowns. They are unable to make it to the international airport.

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If Australia is a pandemic success, it has come at a high price. It is the only place in the developed world whose citizens are displaced as a result of the actions by their own government.

Ravi 

Corona Daily 238: The Costliest 8 seconds

A New York Times article from this week throws light on the type of punishments served for flouting coronavirus regulations.

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In May, Prince Jochim of Belgium, 28, landed in Spain.  Perhaps he assumed the 14-day quarantine was not for the royals. He took a flight from Madrid to Cordoba to meet his girlfriend. The couple attended a party with 27 people. After that he tested positive.

The Belgian Prince was fined 10,400 Euros ($12,600). As expected, he deeply regretted his actions. Spain has fined more than a million people for breach of quarantine.

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Last month, an unnamed 48-year-old Italian had an argument with his wife and left home to “clear his head”. He is from Como, in the north of Italy. A week later, he was found in the coastal town of Fano, 280 miles away from his home. His wife had reported him missing to the police. He had apparently walked 40 miles every day, with strangers feeding him on the way. He was called the Italian “Forest Gump” on social media. His wife was allowed to drive and pick him up. She had to pay 400 Euros ($485) before taking custody of the husband, who was charged for breaking the curfew rules.

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Taiwan places arriving workers in quarantine hotels. A migrant worker from the Philippines was asked to spend 14 days inside a hotel room in Kaoshing, the south of Taiwan. He wanted to give something to his friend quarantined next door. The video shows the man in shorts and flip-flops leaving his room for 8 seconds. He takes just six strides and returns to his room. When CCTV caught those 8 seconds, he was charged $3,550, each second costing him more than $400.

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Australia doesn’t shy away from naming men. Noel Atkinson, 48, is a construction worker. His mother was born in India. Craving Indian curry one night, he drove 20 miles to reach an Indian restaurant for butter chicken. He was fined $1,230 for breach of lockdown.

Mr Atkinson, an essential worker, drives 50 miles to work every day. Why was he fined for driving 20 miles? You are allowed to drive for work, not for takeaways, he was told.

The owner of Desi Dhaba, the curry place, has taken pity on the fined man. He has offered Mr Atkinson free butter chicken for his orders next year (presumably after the restrictions are lifted).

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Mr Atkinson was the lucky one, he got away with a fine. Yusuf Karakaya, 31, used a ladder to sneak in and out of his quarantine hotel to see his girlfriend. He was given a six-month jail term. The magistrate said a jail term was needed to send a strong message to the community.

Asher Vander Snaden, instead of staying in her quarantine hotel in Western Australia, left the state by hiding in a car transported in a truck. She was also given a six-month jail sentence.  

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This month, in India, the Gujarat high court was creative in punishing people wearing no masks. The court stipulated that the culprits should be given non-medical community service duty in “Covid Care Centres”. This will make the violators better understand the nature of the virus. To have the desired deterrent effect, those cases should get wide publicity in the media, the court suggested.

India’s Supreme Court, however, has stayed the high court order calling the sentence too harsh.

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In countries with strict regulations, people must understand that it is nearly impossible to break the law without being caught by the omnipresent CCTVs.

Taiwan’s suppression performance is brilliant. It has had just 736 cases, and 7 deaths, the last death on 11 May. Australia is a democracy, but can ruthlessly send people to jail for flouting regulations. Australia is almost free from the virus. Countries like the USA may have something to learn here.  

Ravi 

Corona Daily 239: Sputnik-Oxford - a Bizarre Strategy

Yesterday, British and Russian vaccine makers announced their plan to create a joint vaccine. In a few months, the world may see the sovereign Boris Johnson and the eternal Vladimir Putin triumphantly presenting the Sputnik-Oxford vaccine on TV.

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The Oxford/Astra Zeneca vaccine was leading in the vaccine race for most of the year. It was cheap, traditional, easy to transport and store (at 2c-8c). Britain ordered 100 million doses, 30 million to be delivered by September. India’s Serum institute has gambled and produced millions of doses without any approval. In May, USA’s Operation Warp Speed made its biggest investment. Though AstraZeneca had little experience in vaccines, USA poured $1.2 billion for development and production in exchange for 300 million doses. AstraZeneca’s stock skyrocketed.

The Oxford/AZ vaccine was expected to have 60% worldwide share among the Covid-19 vaccines.

Things went downhill there onwards. A British participant developed neurological symptoms in July. The trial was paused, but FDA not informed. The US trial was halted for 47 days, restarted only by end October. Earlier, I have explained AstraZeneca’s errors and attempts to cover-up things. The Lancet article published last week added another twist. Some participants received the second dose after three months, instead of one month as planned. This shows a high level of carelessness in clinical trials.

What is the solution found by the British company? To join hands with the Russian vaccine maker.

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With Pfizer and Moderna reporting efficacy above 90%, there is pressure on other vaccine makers to produce higher numbers. Oxford/AZ in the best-case scenario is 70% effective. Russia’s Sputnik-V is reportedly 95% effective, though the reports are not backed by any data.

Now, Oxford-AZ wants to mix and match those two vaccines. This concept is known as a heterologous (rather than homologous) boost. A person will receive the Oxford shot first and after a month the Sputnik shot (or the other way round). Oxford uses a Chimpanzee adenovirus, whereas Sputnik uses a human adenovirus. Such diversity, it is hoped, will produce a greater and longer immune response.

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In business, the product itself is only part of the consumer attraction. The price, reputation, advertising and other factors influence demand. The Pfizer vaccine, though possibly an excellent product, suffers from logistical problems. Trust in the vaccine is an important factor. What’s the use of a superlative product, if people don’t trust it?

Russia and Soviet Union before that are not famous for product quality. (Soviet microprocessors were the largest in the world, Zenit cameras the heaviest and watches the fastest). I have already written about the Gamaleya Institute not being able to produce a single effective vaccine.

In one of the great geopolitical puzzles, India has been buying Russia’s Mig fighter aircraft for the past forty years. They fall more than they fly. Every few months, a Mig crashes killing young Indian pilots. (Today, Navy commander Nishant Singh was cremated. He died in a Mig-29K crash). India doesn’t need enemies or wars, simply buying Migs does the job. On the other hand, Russia’s deadliest nerve agent, Novichok, fails to kill the targets. (Instead of using Novichok on them, former Russian spies or opposition leaders can simply be flown in a Mig-29.)

With products impacting life-and-death, the reputation of Russian brands is suspect. Vaccines are one of those products.

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That is the reason I find the British company’s strategy bizarre. It is like trying to combine two average minds to create a genius. Oxford/AstraZeneca appears to be confused and desperate. Their vaccine was meant to be the savior of the poor world, the most widely used covid vaccine in Asia and Africa. Sputnik-V has not reported scientific data and is not approved outside Russia. New large trials will need to be run that will take months. In covid times, vaccine manufacturers must keep things simple. Joining hands with Sputnik may discourage regulators to approve it. Many countries may prefer Chinese vaccines. China’s product quality reputation is not as bad as Russia’s.

Ravi 

Corona Daily 240: 15 Minute Observation Rule

An astounding scientific breakthrough can be marred by poor understanding of logistics. The scientist couple who invented the novel technology used in Pfizer vaccines specializes in cancer research. Technology requiring -70C is tolerable for a niche population of cancer patients, but not for national and international rollout. UK is beginning to understand the logistical challenge with several family doctors/ General practitioners now withdrawing from the vaccination rollout.

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To cover its population of 68 million with two doses, UK must deliver 2 million shots every week, which is 400 jabs every minute. Even such a brilliant performance will vaccinate the nation only by the second quarter of 2022.

Vaccination began in 50 hospital hubs this week. Next week, GPs at 280 sites were expected to administer 273,000 doses. But several GPs in Sussex, Lincolnshire, Yorkshire, Thames valley and other places have pulled out. The problem is especially acute in Manchester.

NHS has negotiated a contract with the doctors’ trade union that obliges a GP who signs it to vaccinate 8 am to 8 pm all 7 days, all holidays, for nine months. NHS also has a contractual right to impose new conditions unilaterally.

Because of the freak conditions imposed by the cold chain, each GP site must deliver 975 doses in 3.5 days (or else the vaccine gets spoilt). Rather than pre-filled syringes, the vaccines are stored in boxes of 195 vials containing five doses each, which means they need to be diluted and split into individual jabs.

As if this was not enough, yesterday MHRA confirmed a 15-minute observation rule. This was prompted by the two allergy cases. To rule out anaphylaxis, the vaccinee must wait for a minimum of fifteen minutes under observation.

GP practices have heavy workloads and fewer staff. They know the importance of vaccination, but with their conversion into vaccine centres, they won’t be able to attend to patients. They are at a loss about what to do with the 15-minute wait. The waiting rooms and the car parks will be full, and the process will be slow.  

In an average year, GPs administer 15 million flu shots. But flu shots don’t require 70C storage, two doses, social distancing, and fifteen-minute observation. The second dose after precisely 21 days is another challenge. UK hasn’t rolled out IT systems to individual GPs or pharmacies. They are required to operate their own systems or carry out the process manually. The army has been asked to help, but it has no electronic patient records nor IT access. The GP switchboards are jammed, with people calling the whole day asking when they can get the vaccines.

Many GP practices must hire extra staff, install special super-freezers and reconfigure surgeries to manage the patient flow, at the same time observing social distancing.

There is little compensation for such hardship and loss of regular practice. The NHS and the GPs know the disastrous rollouts of testing and tracing services.  

Oxford/AstraZeneca vaccine is expected to have normal (2c-8c) cold chain conditions. Many GPs would rather wait for that vaccine to get approved, rather than bother about the Pfizer vaccine.

Already more than 100,000 residents must look for alternatives, as a result of their GPs withdrawing.

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The cold chain conditions mean people must go to vaccines, rather than vaccines coming to them. Vaccinations of those in the care homes has been postponed.

NHS doctors, nurses and other frontline staff were supposed to be the first to be vaccinated. In the first week of December, for unknown reasons, it was decided to vaccinate senior citizens (80+) instead. This is like denying a restaurant chef the food he prepares for others. That decision should be reversed. Hospitals with freezers are the best places for vaccinations. Rather than making a mess with GPs and pharmacies, UK should focus on using the Pfizer vaccines for the NHS staff first. If lucky, a logistically normal vaccine may arrive in time for the rollout.

Ravi