Corona Daily 118: A Day in the Life of Alison Forde

Alison Forde checked the latest figures before leaving for the Royal London Hospital. At 6 am, 30 patients in a&e (accident and emergency) required a bed, half of them covid patients. Six people had been waiting for more than four hours. An 82 year old man arrived yesterday was waiting for 15 hours. The risk of dying increases if a patient is not treated inside six hours.

Alison’s team was shrinking. Out of her core team of eleven, three were off sick, and one was isolating with covid symptoms. In the early months, the hospital had suspended all routine work, including cancer treatment. In January, the sickest covid patients were earmarked for Royal London.

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As the Head of Site Operations, Alison’s main job is to allocate patients to key areas of the hospital. A&E is the clearing house for admissions. From there, she moves patients to respiratory wards to give oxygen via masks or nasal tubes. Or to intensive care which now has three floors (earlier one). Every day Alison was confronted with a brutal fact. There weren’t enough beds. The hospital chain had only ten spare intensive care beds. The entire system was on the verge of grinding to a halt. People who could be cured in pre-pandemic time may not survive now.

After ten months, survival rates had improved, which had aggravated the situation. People now stayed on life support for long, which made intensive care beds scarcer. Earlier, death was the primary mechanism of discharge.

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08.30 am was huddle time for Alison’s team. Here they planned the day. Now, with social distancing, the team occupied the entire corridor. Some members struggled to hear what was being said.

NHS in general, and Royal London in particular, has set capacity benchmarks. The number of ambulances waiting to offload patients, waiting patients, bed occupancy, staffing rates and such. The system triggers alarms. For example, a patient waiting beyond certain time will be sent to another hospital. But now, with all hospitals overflowing, those alarms made no sense. Alison had simply changed the parameters.

The 82-year old fortunately got a bed at 07.15 after waiting for 16 hours.

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Novel tasks were added as a result of covid precautions. Every day, piles of clinical waste from intensive care, including heaps of soiled personal protective equipment had to be disposed. They packed the store rooms to the ceiling. The logistics of disposing the waste mountains was looked over by Alison.

At lunchtime, Alison felt overwhelmed. She sat in the corner and cried a little. Her team was a little surprised to see her state. She is known as the cool cucumber.

When the pandemic started, Alison was extremely worried about contracting coronavirus. Every day, each doctor would visit her office to get three or four death certificates signed. Some hospital employees died as well. Every time she coughed, she thought she had covid. To avoid the Tube, she started cycling to the hospital. She fell off, fractured her jaw, cut her lip, ligament and wrist, and needed two operations. But her fear of covid disappeared since.                                                                                                                                                                                                                                                                                                                                                                                                                                                            

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The hospital is considering adding another unit. That would mean diluting the nurse-patient ratio further. Normally one nurse for two is the maximum allowed; now one nurse takes care of four.

At 4.30 pm, 31 patients were waiting for more than four hours in a&e. By 8 pm, more than sixty.

Alison’s 12 hour shift finished at 08.30 pm, but she can never leave before 9 pm. She caught the bus home, had a cup of tea, a quick cold sandwich. She did a bit of cleaning, more to distract herself. After checking the morning alarm, she went to bed.

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P.S. For 1843 magazine, Simon Akam interviewed Alison Forde, who described her 15 January 2021. This article presents it in a compressed form. For health administrators in Brazil, India and other developing countries, working days are even more terrible. Fortunately for Alison, the situation in London has now improved.  

Ravi 

Corona Daily 119: The Unusual Royal Funeral

British planners excel at contingency planning for the death of a Royal. When the Queen eventually passes away, the Prime Minister will get a code-worded call saying “London Bridge is down” which will trigger press releases, BBC protocols, the lowering of flags in Canada and New Zealand, and detailed funeral arrangements. Loyal watchers of The Crown know this. The code for Prince Philip’s death was “operation Forth Bridge”. Had the British planners shown such zeal and meticulousness during Brexit or Covid-19 planning, Britain would be a much better place now.

Unfortunately, the best-laid plans of men often go awry in a pandemic.

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The original plan called for the coffin of the Duke of Edinburgh to move through the streets of London on a gun carriage with hundreds of thousands lining up on both sides to bid goodbye. This is normally a journey of 22 miles from Buckingham palace to Windsor castle. Instead, Prince Philip’s converted Land Rover made a trip of only a few hundred yards.

The protocol number of attendees is 800. The pandemic reduced it to 30. That meant mainly the immediate family. Queen Elizabeth and Prince Philip are third cousins, with Queen Victoria as their common great-great-grandmother. That could have eased some pressure on the list. Boris Johnson wisely withdrew, and pregnant Meghan was advised not to travel by her doctors and counsellors. The vacant seats allowed the Queen to invite the German relatives of Philip (his mother was German). In 1947, as a consequence of WWII, Germans could not be invited to the royal wedding. The German royals and Harry flying from abroad went into quarantine. There were enough palaces for each of them to isolate in. A small print exception allows mourners to exit quarantine on the funeral day.

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The Queen had to decide on the dress code. Usually, male royals wear military uniforms. The Queen opted for civilian clothes. Black. Black. Black. Queen Victoria, after her husband’s death wore black every day for forty years.

Avoiding military uniforms, though prescribed in the planning book, was a shrewd decision. Harry has sort of renounced royal life, so despite serving in Afghanistan he was no longer eligible. And Prince Andrew exiled for his association with a sex predator didn’t qualify either.

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When operation Forth Bridge was activated, on BBC, presenter Martine Croxall interrupted the programme to announce the Duke’s death. While the channel showed his photographs, she quickly removed her necklace, and changed into a black dress.

Over the next week, you could switch from one BBC channel to another, but couldn’t escape knowing more about the life of the Royal Consort. The civilized kingdom has a platform for people to complain about BBC. This week BBC received more than 100,000 complaints, an all time record, for its wall-to-wall coverage. Some people, presumably anti-monarchists, likened the programming to what might be expected in North Korea.

This is surprising. The Duke’s death was a respite from the wall-to-wall coronavirus coverage. Like sport events played to empty stadiums, but televised worldwide, the BBC coverage offered the worldwide mourners a live viewing opportunity.  

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Inside the castle’s St George’s chapel, every attendee was required to wear a black mask, and not sing. They needed to keep a gap of two meters. The queen dressed in black, wearing a mask, sitting alone in a corner, looked more a widow than a queen.

There was no eulogy and no sermon. A choir of four, the number cut seriously by the pandemic, standing far from the attendees, sang hymns.

Viewers glued to their TVs scrutinised the royal family members to see how much each of them was faithful to the Netflix series.

Prince Philip’s casket was lowered in the royal vault. Only a living royal or a dead royal is allowed to enter the vault. This is a transit stop for Philip. When his wife dies, he will be moved and the couple will be buried side-by-side at the King George VI memorial.

Ravi 

Corona Daily 120: Patents Kill Millions

In 2021, the USA would have produced and reserved one billion doses to vaccinate its 260 million adults. Biden administration has said such large quantities are essential to have vaccines for children, booster doses for variants, and any unforeseen events.

Currently USA is holding 30 million doses of AstraZeneca, not even approved yet. To its south, Brazil is losing 4000 people daily to covid-19, and has approved AstraZeneca, but has no access to these doses.

Of the vaccine doses given globally, 75% have gone to 10 countries. Africa has 17% of the world’s population, and has barely administered 2% of vaccine doses. A healthy 20-year old American can soon be fully vaccinated; whereas hundreds of unvaccinated doctors and nurses have died in Kenya, Mozambique, Nigeria and Zimbabwe.

All this can be understood, if not admired. America’s vaccine nationalism wants to make America absolutely safe, before doing anything for outsiders.

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Poor countries will not be able to vaccinate their populations before 2023 or 2024. And if vaccination becomes an annual requirement, it will be a race that can never be won.

What is less known is that vaccine production can be dramatically expanded across the world. Millions of vaccines can be produced in Bangladesh, African countries or developed countries like Canada. Over the years, Asia and Africa can produce enough vaccines to vaccinate their entire populations. Why is this not done?

Because Pfizer, Moderna and other vaccine manufacturers refuse to share their patented technology and know-how. Their patent restrictions prevent other countries from producing their vaccines.

This is usually justifiable because innovation is rewarded by legally enforceable patents. But in this case, the US and the European governments gave those pharma companies billions of dollars. These were not loans, but grants. If the vaccines had failed, the governments couldn’t recover that money. The sponsoring governments should have either kept the patents to themselves, or included a clause in the contracts making them available equitably. When the Gates foundation gives grants, it includes such clauses. Moncef Slaoui, the head of Operation Warp Speed said the program was US-centric. Patent sharing was never discussed.

Last year, WHO tried to create a “Covid-19 technology access pool”, a platform to help developing countries make coronavirus vaccines. Not a single vaccine manufacturer agreed to join it. Albert Bourla, the CEO of Pfizer, called the concept “nonsense”.

India and South Africa have pushed for patent waivers. Biden has sided with the drug companies. In March; USA, Britain, the EU and Switzerland rejected the push for waivers.

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In effect, you have rich nations investing billions in Pharma companies, letting them retain the patents and block production expansion around the world; and allowing them to reap profits year after year. Moderna was entirely funded by taxpayers’ money, but is most restrictive on sharing knowhow. The Trump administration’s badly drafted contracts allowed this.

US federal law permits the president to seize patents and use them as it sees fit. Last month, Biden “persuaded” Merck to make Johnson and Johnson vaccines. He used wartime procurement powers. Of course, this was done because Merck was American. But if Biden wishes to think globally, he can apply the same powers to let a Bangladeshi factory acquire the knowhow free, and produce American vaccines.

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This week, dozens of Nobel Laureates and former heads of states have written an open letter to President Biden urging him to waive IP rules for covid vaccines. Hundreds of thousands of African lives were lost because of patents on HIV lifesaving drugs. In 2001, WHO had successfully managed to procure an exemption for public health emergencies. That was in the context of HIV.

Is Covid-19 not a grave enough public health emergency? It is equivalent to a World War. And in World Wars, nobody should talk about patents. Does America really think it will remain absolutely safe, while the rest of the world remains unvaccinated? American Pharma giants wish to protect American innovation. They should note that most innovators of the current vaccines are immigrants. (Pfizer’s Bourla who called patent waivers nonsense is also an immigrant).

If nothing is done, just like the coronavirus, American patent laws are likely to kill millions in the pandemic.

Ravi 

Corona Daily 121: Utopia 56

This is why I love France.

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Aziz and Sima fell in love in Teheran. Both had fled Afghanistan as children. Aziz’s father was killed and Sima’s family threatened by the Taliban. In 2017, in their early twenties, they decided to marry. Sima’s family refused because Aziz as a construction worker didn’t earn much. If you try to run away with him, we will find you and kill you, Sima’s parents told her.

A year later, they secretly married and with enough savings to pay a smuggler, fled Iran. A 500 mile risky journey brought them to Turkey. Within a few months, they smuggled themselves into Greece, where Sima gave birth to a daughter. Over the next eighteen months the homeless family travelled through Bosnia, Croatia, and Slovenia to arrive in Paris. It was January 2020, Paris was cold and rainy.

They spoke only Dari, and knew of the landmark: Eiffel tower. They joined the thousands in Paris who sleep under the bridges, in the metro stations, on the pavements.

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As a rule, the residents, the sons-of-the-soil hate illegal immigrants, asylum seekers and refugees. They often forget that many refugees were driven away from their homes by violence perpetrated by the rich countries. A wave of refugees has arrived in Europe from Syria, Iraq and Afghanistan – countries occupied, bombed and terrorized by the USA and NATO.

Asylum supporters are often asked: You are talking about the country taking them in; will you take them in your house?

Well, in France, in Paris, they do.

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Every evening, hundreds of refugees spend the night out in the open, in Paris, Calais and all over France. The vulnerable crowd includes single women, children, families, unaccompanied minors. With or without the pandemic, they try to hide themselves from the gaze of the police.

Yann Mazi, his wife and son have founded a voluntary organization called Utopia 56. They never doubted the generosity of the French. Through their website and WhatsApp groups they began asking Parisians and others: Do you want to open your door? For one evening, for a week, for a month?

Like Airbnb, Utopia 56 has created a framework to match the hosts and the guests. When someone volunteers to take people in, Marwan Teiebi, the coordinator makes a home visit. He conducts background criminal checks on the hosts. The hosts also must sign a form absolving Utopia 56 in case they or their guests contract covid-19. Hosts usually share meals.

Francois Lemeille, 26, became a host in the autumn after three of his roommates left Paris during the lockdown. He made pumpkin lasagna for an Eritrean couple. When his roommates returned, they used cupboards to separate the space. They continue to host different families. “It seems impressive, but when you see the reality, it’s not,” said Lemeille. “We offer a comfortable place, a shower and warm tea. That’s it.”

Since the pandemic started, Parisians have hosted more than 3000 people through Utopia 56.

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“Tea Shop” is a place near the Gare d’Austeritz, in the southeast of Paris. It’s a day center where asylum seekers and refugees can shower, do their laundry and eat a warm meal. The refugees call 115, an emergency hotline for temporary accommodation. During the pandemic, the line was overwhelmed with more than 1000 calls a day.

In November, Guillaume and Therese first considered volunteering as hosts. That month the police had used tear gas to evict migrants from roadside tents. At Tea shop, Aziz and Sima were told that a couple across the city would host them. The Utopia 56 volunteer travelled with them by metro for an hour. Around 8 pm, they reached a brick building. Guillaume and Therese welcomed the family. They had prepared rice and lentils for dinner. In the 450 sq ft apartment, they showed Aziz and Sima the living room, where a sofa bed had been prepared for them and their baby. The couple smiled their thanks.

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This is why I love France.

Ravi 

Corona Daily 122: Women Don’t Belong in Science

You can name any inequality, rich and poor, white and black, male and female – the coronavirus pandemic has made it worse. In the last seven days, I wrote about two great women scientists, one credited with mRNA technology, and another a top expert on the role of bats in propagation of coronaviruses. And today, to my surprise, I find tons of articles about how the pandemic has hit women scientists very hard. Women published fewer papers, led fewer clinical trials, and received less or no recognition for their expertise.

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These are not perceptions, but facts based on quantitative studies. In a medical journal medRxiv, the gender gap between authors grew from 23% in January 2020 to 55% in April 2020. Women academicians and scientists were evidently fulfilling the role of caring for children. Women in faculty with children up to 5 years completed fewer peer reviews, attended fewer funding panel meetings, and submitted fewer first authors’ articles compared to pre-pandemic. Male professors with children up to 5 years had hardly any effect on productivity.

Less than one third of covid-19 related clinical trials were led by women, half the proportion of non-covid trials in the same period. It reveals imbalances in women’s access to research activities and funding during health emergencies.

In the coronavirus coverage, female scientists and doctors are cited less, interviewed less, invited less to policy debates. Men continued to be given leadership roles and the job of speaking to the media.

A Gates foundation researcher analysed online corona coverage in the UK, USA, Kenya, South Africa, Nigeria and India. Women were four times less likely to feature as experts or commentators. During lockdowns in France, more than 83% front page photos were of males. Most opinion pieces were written by men as well. In Switzerland, out of the 30 scientists most frequently cited during corona coverage, 28 were men.

This data is particularly interesting, because 69% of health professionals around the globe are women. Since 2000, in the US and most developed countries women have earned more than 50% of the science and engineering degrees, and doctorates. Once women earn their PhDs, they receive 39% of available fellowships and 18% of professorships. In the USA, a typical Health research grant is $41,000 larger for a man. The gender gap is $68,800 at Yale, and $76,500 at Brown.

Women excel in studies, research, medical practice so that men can make more money, more presentations and give expert views on TV.

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In November 2020, a study was published by three scientists, two of them women. The paper concluded that having female mentors would hinder the career of young scientists. It recommended steering graduate students to male mentors. This was like saying no woman can become the president of the USA, because all successful presidents in the past have been males.

A petition signed by 7600 scientists, men and women, was submitted to express their anger and disgust. On 21 December, the paper was retracted, though it continues to be available online.

Rockfeller University has a wall exclusively made of white men affiliated to the university. They are winners of Nobel and other awards. Many such “dude walls” exist in American universities, ignoring women from the same universities who had won prestigious awards.

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In August 2020, Rita Coldwell, a senior scientist shared her experience in the Atlantic. During her six decades in science, she was told sometimes subtly, but often openly that women don’t belong in science. When she applied for a graduate fellowship to study bacteriology, the male professor said the department didn’t waste such positions on women.

Once the pandemic is over, female scientists will have to start their battle with the hypocrisy all over again.

Ravi   

Corona Daily 123: More on China’s Bat Woman

On the evening of 30 December 2019, when Shi Zhengli returned from Shanghai, she immediately began work on the unexplained pneumonia samples received from Wuhan Jinyitan hospital. For the next 72 hours, Shi’s team worked without a break. They survived on instant noodles because the institute canteen was shut. By 2 January 2020, the whole genome sequence of the new coronavirus was determined.

By 5 January, the virus strain was isolated. By 7 Jan, Shi’s team had confirmed the new virus had indeed caused the new disease – based on analyses using PCR and antibody tests, full genome sequencing, and the virus’s ability to infect human lung cells in a petri dish. The genomic sequence was 96% identical to that of a coronavirus Shi had identified in horseshoe bats in Yunnan. The virus sequence was submitted to WHO on 11 January. Many non-Chinese experts acknowledge that this work was thorough and extraordinarily fast.

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Since the time she left Shanghai, Shi was bothered about one issue. Was it possible this virus was a leak from the Wuhan Institute of Virology? While her team was analyzing the samples, Shi was frantically but meticulously engaged in another exercise. She went through her lab’s records from the past few years to check for any mishandling of experimental materials, especially during disposal. She was relieved when the results of the new virus came back. None of the sequences matched those of the viruses her team had sampled from the bat caves. This was indeed a novel coronavirus. That night she could sleep for the first time.

When Wuhan lifted its lockdown on 8 April, Shi was in low spirits. Social media in China and mainstream media abroad continued to talk about the possibility of an accidental leak from her lab. On 24 April, the White House recommended stopping funding to the EcoHealth Alliance in New York, a grant that included bat virus research at WIV. “We don’t understand it and feel it is absolutely absurd.” Said Shi.

The biosecurity level 4 laboratory in which she worked was the highest security facility in which work is done on the most dangerous pathogens. The lab never had an incident of accidental leaking. Not a single staff member of the institute or the labs was infected by the new virus. And Shi knew none of the sequences matched the sequence of the novel coronavirus.

Professor Dashak of the EcoHealth Alliance, who has worked with Shi was for a long time describes her as social, open, honest, frank. A sort of goodwill ambassador for China at meetings, Shi speaks in English and French. (She is also a renowned singer of Mandarin folk songs).

To a repeated question about a formal investigation, Shi said, “I would personally welcome any form of visit based on an open, transparent, trusting, reliable and reasonable dialogue. But the specific plan is not decided by me.”

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Other than being termed the “Bat Woman” by the Chinese media, the 55 year old Shi was also included in Time Magazine’s 100 most influential people of 2020. Till today, Shi has published eight articles, the highest in the world, on covid-19 research.

When the pandemic started, she called it the “revenge of nature of human beings”. She still defends that view. Through constant expansion, urbanization and intensive farming the human race has caused damage to the whole ecosystem. The damaged ecosystem makes it possible for a virus from the wild to get transmitted to humans. It is not the virus attacking us, it is our behavior that causes the constant outbreak of emerging infectious diseases, Shi says. 

“The coronavirus is just the tip of the iceberg. If we want to prevent human beings from suffering the next outbreak, we must go ahead and learn about these unknown viruses carried by wild animals. Bat-borne coronaviruses will cause more outbreaks.” Shi said in a TV interview with the tone of a scientist’s certainty.

“We must find them before they find us.” She added.

Ravi 

Corona Daily 124: Batwoman

On 30 December 2019, at 7 pm, the mysterious patient samples arrived at the Wuhan Institute of Virology. Shi Zhengli was at a conference in Shanghai at that time. Her phone rang; it was her boss, the director of the institute. Drop whatever you are doing, and come right now, said the director. Shi apologized to the audience and walked out of the conference. At the Shanghai railway station she hopped on to the next train to Wuhan. On the train, she wondered if the municipal authorities had erred. Shi had never expected to find coronavirus in Wuhan, in central China, in the city where China’s best labs for virus research were located.

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Shi was barely forty years old when in 2004, she first joined an international team to visit bat colonies in caves. The bat caves were near Nanning, the capital of Guangxi. With the sunny and breezy weather of spring, Shi felt it was a holiday trip. Her first cave was large, made of splendid limestone columns. Milky white stalactites hung from the ceilings, glowing with moisture. It was spellbinding, Shi recalls.

But she soon learnt most bats settle in deep, narrow caves on steep terrain. Guided by local villagers, Shi and her colleagues hiked for hours, and then crawled in the caves on their stomachs. These shy, flying creatures can be elusive. After exploring thirty caves, Shi saw only a handful of bats.

That expedition was to find the villain of SARS, the first big epidemic of the new millennium. It was the first emergence of a lethal coronavirus with pandemic potential. Shi Zhengli, a genetics graduate from Wuhan, with a PhD from France, was an early recruit for the expedition.

The SARS virus had jumped from civets to humans, but it wasn’t known how the civets got it. In Australia’s 1994 Hendra virus infections, contagion had spread from horses to humans, in Malaysia’s 1998 Nipah outbreak, from pigs. In both cases, it was later discovered that the pathogens had originated in fruit-eating bats. Horses and pigs were merely the intermediaries. Would that be the same this time? That was what Shi Zhengli wanted to find out.

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During the virus hunting months of 2004, whenever Shi’s team identified a bat cave, it would put a net at the entrance before dusk. When the nocturnal creature tried to leave the cave for food, it was trapped. The researchers took its blood, saliva samples; fecal swabs, usually late in the night. After a quick nap, they returned to the cave to collect urine and fecal pellets in the morning.

Cave after cave, night after night, this yucky exercise continued for eight months. And not a trace of coronaviruses in a single bat. Maybe bats have nothing to do with SARS, thought Shi. But then, another research group gave them a diagnostic kit for testing SARS antibodies. (Now even lay people are well familiar with the distinction between a virus test and an antibody test).

Shi tried the antibody test. Quickly she found three horseshoe bats with SARS antibodies. Shi’s team realised that coronavirus in bats was short-term and seasonal, but the antibodies could last from weeks to years. Shi began roaming mountains, visiting caves around China. The researchers identified one spot: Shitou cave, near Kunming, the capital of Yunnan. The team conducted intense round-the-year sampling in this cave over the next five consecutive years.

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The hard work paid off. Shi’s team discovered hundreds of genetically diverse bat-borne coronaviruses. Constant mixing of different viruses creates a great opportunity for dangerous new pathogens to emerge. It was not necessary to be a wildlife trader to get infected. In 2015 Shi collected blood samples from 200 villagers near the Shitou cave. Six of them had antibodies against bat-coronaviruses. They had never handled wildlife, but seen bats flying in the village.

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In December 2018, professor Shi and her associates published two comprehensive scientific reviews. In them, Shi warned of the risk of future outbreaks of bat-borne coronaviruses.

(The story of China’s batwoman will continue tomorrow).

Ravi    

Corona Daily 125: The Covid-19 Origin Story

With every country in the world now in its second year of the pandemic, the desire to find out exactly how this nightmare started is intense. Last month, Jonathan Perker and others published a scientific report “Timing the SARS-CoV-2 index case in Hubei province” which offers several interesting points.

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Tracing the history of the virus to the start is akin to detective work. Through a virus DNA analysis, it is possible to keep going back on the evolutionary tree. If any places have stored wastewater samples from 2019, they can be analysed to check the presence of the virus. This team of researchers focused on three important pieces of information. (a) How the virus spread in Wuhan before the lockdown. (b) The genetic diversity of the virus in China and (c) Reports of the earliest cases in China.

Their models also ran retrospective epidemic simulations to learn the timing and the scale of the spread.

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The first documented case was on 17 November 2019. The analysis puts the index case in Hubei around 4 November. Retrospective mapping indicates that the earliest case could have happened in mid-October, not before.

The interesting finding of the study is that the virus didn’t originate in the Wuhan seafood market. Because several cases from early December lacked genetic connections to the clusters in the market.

The data and the epidemic simulations show that 70% of the cases with this virus were self-limiting. In other words, the infected person recovered without passing the infection on. Epidemics that go extinct typically produce a single infection, never more than 44 infections, and never more than 14 infections at one time. It seems there is no such thing as a “pandemic virus”; the same coronavirus had infected dozens of Chinese people. In 70% of the cases, the virus was not transmitted further.

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To become an epidemic, a virus requires a host, and a superspreader setting. One of the infected people went to the Wuhan seafood market, which offered the virus the lucky break. A crowded, wet, unhygienic market was an ideal setting for the virus to start spreading.

It’s like a smoker throwing a burning cigarette on the road. It rarely causes an incident. But if the same burning stub were to be thrown in a dry forest, it can set the entire forest on fire.

If that infected person, (and scientists haven’t managed to identify him or her), had not gone to the Wuhan market that day, or simply watched TV at home, or hated seafood, or was too ill to leave home, the pandemic may not have happened. The seafood market was not the origin of the virus, it was a spreader.

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Scientists the world over are aware of the pandemic potential of viruses. The common surveillance methods, though, keep an eye on hospitalizations and deaths. In SARS (2003), every tenth infected person died. The action was more immediate. MERS (2012) had a case fatality ratio of nearly 35%. The high death rates could have contributed to stopping the earlier coronavirus pandemics quickly.

Covid-19 is not as deadly. Ironically, that was tragic. Had the covid virus started killing 10% or 35% of the infected, it would have been spotted more quickly. Before the Chinese scientists found enough covid patients in hospitals or morgues, its spread had become unstoppable.

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The study finds that the virus existed initially only in China. The same model of an infected person and a superspreader setting may have played across the world. The virus was introduced several times everywhere (for example, Chinese workers returning to Italy after the Chinese New Year) but it took some superspreader setting for it to spread. Cases were found in France (December 2019) and California (January 2020), but it took many weeks after that for the outbreaks.

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The lesson from the study: If you are infected with an unknown virus, please don’t visit a packed, crowded place. It is as bad as throwing a burning matchstick in a forest.

Ravi 

Corona Daily 126: Sputnik brings down a European Government

For an unknown reason, East European countries are hurting more in the pandemic than West European ones. Maybe like long covid, there is “long communism” that haunts those nations thirty years after communism was abandoned. In Slovakia, one out of 500 citizens has succumbed to Covid. Slovakia is losing every day 13 people out of a million, the third highest rate in the world.

Early this year, Slovakia’s Prime Minister Igor Matovic ordered 2 million doses of Sputnik V from Russia. He must have done it with good intentions. European Union has not approved Sputnik. Slovakia, after Hungary, was only the second EU country to order Sputnik. The Russian media lauded Russia’s humanitarian efforts to save Slovakians when western vaccines couldn’t. On 1 March, Matovic personally went to the airport to welcome the first batch of 200,000 Sputnik doses.

Slovakia’s government is a coalition of four parties. Prime Minister Matovic, for reasons best known to him, had arranged the vaccine deal with Russia in secret, without taking the coalition partners into confidence. In March, the political atmosphere in Slovakia was totally infected. Ministers started to resign one after another. Finally on 31 March, the Prime Minister resigned, and the Slovakian government collapsed.

If Matovic couldn’t survive without the support of the coalition partners, the reverse was also true. In the painful negotiations, it was finally agreed Matovic will become the finance minister and the deputy PM in the newly formed government.

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Meanwhile, SUKL, Slovakia’s medical regulator, issued a statement this week. They claimed Slovakia had received a different Sputnik. In February, the Lancet had published a paper giving Sputnik efficacy as 91%. Since the Lancet is a British medical journal, Russia hailed that paper as the final proof of Sputnik’s eminence.

Now, SKUL said the Sputnik sent to them is different from what is described in the Lancet. The properties are different: lyophilisate versus solution, single dose ampoules versus multi-dose vials, different storage conditions, composition and method of manufacture. SKUL has been repeatedly asking Russia for data, and 80% of the data requested has never been submitted.

One scientist at SKUL said the vaccines received by them were Sputnik V in name only.

(If you like Cadbury’s milk chocolate, no matter where you buy that chocolate, you expect it to taste the same.)

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RDIF (Russian Direct Investment Fund), Russia’s sovereign wealth fund, is responsible for exporting Sputnik. In a tweet, they called the SKUL statement “fake news”, and an act of sabotage. The vaccine was not tested in registered labs, thereby violating the contract. (Interesting, the fund doesn’t argue about the findings, but on the registration status of the laboratory).

SKUL replied that the laboratories were registered agencies, though not necessarily accredited with the EU. Anyway, the medical regulator was not aware of the contract between the two governments. Not having seen the contract, it was difficult to say whether it was violated or not.

Russia, through Putin’s spokesman and other channels, has now demanded the 200,000 doses are urgently returned to Russia. Slovakia was the 39th country to order Sputnik, and a real breakthrough for Russia, since it is an EU member. Who would have thought Slovakia’s medical regulator would want to check the vaccines they receive?

The compromise reached now is to send the samples to Hungary. The Hungarian laboratory has been asked to test them. Russia would still prefer to have the vaccine doses back.  

The drama is not over yet. If indeed the vials, ampoules, storage conditions, and composition vary from the original specifications, it would be difficult for the Hungarian lab to approve the Slovakian batch. If it confirms what the Slovakian lab claims, Sputnik V will be the first covid vaccine to have mutations.

Ravi 

Corona Daily 127: Breakthroughs

Last week, I wrote about a doctor friend who got infected after being fully vaccinated. Such infections are called “Breakthrough infections”. Not breakthroughs for scientists, but for the virus. As if it has managed to break through the vaccine protection. The Hepatitis B virus that infects one after inoculation is called the “vaccine escape mutant”.

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 One immunologist clarifies: Being vaccinated doesn’t mean you are immune. It means you have a better chance of protection. Vaccine is just one variable in the toolbox available for protection. The goal of vaccination is not eradication of covid, and this may surprise many. The goal is to peacefully coexist with the coronavirus, like we do with flu. Of course, eradication would be nice, but at present that is considered too ambitious.

A breakthrough infection can happen in immuno-compromised people. Age and weight of a person can matter. Doses for flu vaccines differ based on such factors. However, for covid vaccines, an identical dose is given to everyone. This may prove to be insufficient or excessive. The good news is that most cases noticed so far have milder symptoms and a shorter duration.

Virus mutations can be a reason. So far, the main approved vaccines – Pfizer, Moderna and AstraZeneca are working against all variants. (A single exception was AstraZeneca not working in South Africa against the locally identified variant). Ideally, every breakthrough case should be subjected to genomic surveillance. A fully vaccinated person’s positive sample should go for a genome analysis. That will tell us exactly which variants are more successful in escaping the vaccine effect. Unfortunately, such data is not available.

Large viral loads may cause infection. If a fully vaccinated person attends a superspreader event or joins a crowd where the virus is rampant, he or she can get infected because of the sheer viral load. Even in that case, the symptoms are likely to be mild.

Improper storage of the vaccine can be a reason. This is rare. However, in a country like India with unstable power supply, it is a challenge to maintain an uninterrupted vaccine cold chain. Vaccines lose potency if stored at wrong temperatures or used after an expiry date. Moderna allows anyone to check online the expiry date of its vaccine based on the batch number.

Some of those testing positive after vaccination are asymptomatic cases. Including them is a bit unfair. In most vaccine trials asymptomatic cases were excluded. Immunologists distinguish between infection and disease. Whenever someone tests positive, the real question is, are they sick, and how sick are they? They may still be isolated for the benefit of others. But in all likelihood, their asymptomatic infection is a successful outcome of the vaccine.

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USA has already administered 66 million doses. The data of breakthrough infections has started trickling in. Based on the state-wise data I have seen so far, one person out of 10,000 can get infected despite being vaccinated. This is excellent news, because it means 9,999 out of 10,000 are protected.

A study published this week in the New England Journal of Medicine offers another piece of good news. The research found that fully vaccinated people have robust levels of antibodies more than six months later. Those levels subside very slowly, giving hope that the vaccine immunity may last for a long time. The study included mainly those who received Moderna, and it is hoped similar studies will show similar results for other vaccines.

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Breakthrough infections are bound to happen. But they shouldn’t stop anyone from getting vaccinated. One doesn’t stop wearing a helmet just because some biker had an accident wearing it.

At the same time, it is important to track the breakthrough data, to look at the percentage and analyse virus variants where possible. If such infections were to climb to unexpectedly high rates, an additional booster shot or tweaking of the vaccine may be needed to improve the immune response.

Ravi