April update – our crazy COVID world!

SUMMARY

• Optimism is in the air in the UK as cases and deaths drop, but recovery will be complex.
• The B117 variant is driving new waves in Europe and is 64% more deadly
• Vaccines are at least partially effective against all variants due to T Cells which target various sites of the virus.
• Treatments for the infection continue to disappoint with Ivermectin the latest casualty of clinic trials.
• Brexit has not helped pandemic management and global inequity is widening.
• Vaccine hiccups – another needless AZ PR hiccup, but good news too.
• Recovery will be complicated – goodbye to decade of Tory thinking on the NHS and some suggestions on a better society for the post COVID decade.

With spring in the air and with the equinox approaching, is the end of our COVID19 experience in sight? Many of us are genuinely tired of the pandemic, fatigued by the restrictions, the bombardment of data and uncertainty as to where we are and what is going to happen. I feel this myself – how much more is there to say? I’m afraid the answer is quite a lot. Recovery from illness can be tricky, things change after a life changing diagnosis and this will be the same with the pandemic.

The COVID world

It is the total global population of viruses that create variants and the number of viruses replicating and mutating right now is staggering. If its anything like flu, then at the peak of the illness there are 100 trillion viruses in each infected person. Multiply that by the 650,000 current cases for the number of replicating viruses. Viruses are incredible replicating machines, the number in existence, which has to be a very rough estimate, is thought to be about the number 10, followed by 31 zeros.

So, thinking globally, the pandemic is far from over. There are still 650,000 cases and 11,000 daily deaths across the world and some nations are doing very badly. Brazil is suffering with the P1 variant which sadly seems to be affecting the young far more than the first wave. The graph below shows the problems currently faced by so many nations. To remind us that we are a global community, the P1 variant has now been detected around the world, and there is now evidence of community spread in New York. Brazil may have incubated the future.

Meanwhile, the EU is in the grip of the more transmissible B117 (Kent) variant, which is 64% more likely to cause death and lead to a very unhappy locked-down Easter across Europe. This has not been helped by the limited uptake of AZO vaccine consequent of vaccines scares, the emergence of rare side effects, production hold ups and bad publicity. The resultant vaccine hesitancy will lead to some deaths which could haver been avoided. In the USA too, there are concerns that an uptick in cases may lead to another wave of hospitalisations.

All over the world we need to get cases down to levels low enough to allow testing, tracing and isolation to work.

Beyond Europe, the COVAX programme is getting off to a slow start with as usual, the lions share of vaccines having gone to a very small number of nations – sad reality is that the vaccine rollout is following the money rather than the virus and this could well stretch out the pandemic.

Vaccination and Variants

As well as affecting younger age groups, the P1 variant is less susceptible to immunity acquired from vaccinations and natural infection, though it is hoped the current vaccines will offer some protection against moderate or severe illness. Much of the lab work to assess vaccine effectiveness on the new variants looks at how antibodies from vaccines or natural infection responses neutralise the new strains. However T cells can recognise other parts of the viral structure in addition to the spike and continue to be effective, so I wonder it will be our wonderful T-Cells to the rescue again.

Meanwhile in Africa, new variants have emerged in a continent with relatively little capacity for genome testing. While convergent evolution is taking place – similar mutations appearing spontaneously across the world – the African one is unusual in that is it related to the A lineage (family) from China as opposed to the B lineage that dominates most of the globe. Like others, it contains the E484K change, but also has a novel mutation called R346, the impact of which is being evaluated. New mutants can go under the radar in Africa, perhaps due to younger populations and more asymptomatic spread leading them becoming established almost before they are noticed.

COVID19 Treatments

While vaccination campaigns and their hiccups are grabbing the headlines, there is other news. Sadly, Ivermectin, an anti-worm medication with theoretic activity against Sars-Cov2 seems of little use in treating the real illness; following hydroxychloroquine down the tube into the useless bucket. Indeed treatment of established illness has been a big disappointment apart from high dose steroids used at the right time, and one monoclonal, toclumizab, helpful for those critically ill.

Might that change? GSK have announced results of a phase 3 trial of a monoclonal antibody manufactured from the B Cells of a SARS 1 patient called VIR-7831 which show an 85% reduction in hospital admission of high risk COVID patients. The trial has been stopped due to evidence of “profound efficacy”. There have been false dawns before with monoclonal antibodies, and with vaccines so comparatively cheap the place of expensive treatments will remain unclear. They might be useful for those with compromised immune systems such as patients undergoing cancer treatment or immunosuppressive treatment. Because the antibody binds to a stable part of Sars1 virus which has remained present in Sars-Cov2, it means it should work on the new variants too.

For me, making sure we have enough Vitamin D remains important both to prevent the infection and the improve the effectiveness of the vaccine while, (just like with MS), we await definitive trials. We are left with prevention by vaccination as the best therapy for the pandemic.

Politics and the pandemic

The EU has not done well recently. Nor for that matter has the UK, the west, or China. The wave of B117 infections spreading across the continent from Kent have exposed cracks in EU’s collective pandemic management which the UK seem delighted to inflame with our headline grabbing vaccine nationalism. This sadly seems in tune with our new Trumpian flag waving culture encouraged by tub thumping nostalgics who it seems cannot appear in public without a flag behind them.

The EU have been administratively clunky, the UK selfish and greedy and the international co-operation the pandemic needs seems sadly wanting. Despite pleas from the WHO, we continue to vaccinate lower and lower risk groups while health care workers and the vulnerable around the world wait.

I have to day its a bit rich for Bo-Jo to create worry about the European wave crashing “washing back over our shores” when we clearly exported our winter wave to the EU in the first place. His private comments on the benefits of greed and capitalism say more that any press release about how he will now attempt to claim political credit from the scientists who deserve, but don’t seek the bulk of praise, and cover up some pretty hopeless pandemic management over the last year. The UK’s test and trace system remains nothing less than a scandal.

It would have made more sense for the whole continent (indeed world) to vaccinate health care and key workers twice with the mRNA vaccines as recommended by the manufacturers, and the wider at risk population with the vector vaccine at an interval of three months. So, in terms of virology, a EU wide strategy which included the UK would have been a far better option for all. If the EU have egg on their faces, so do we.

Here in the UK we might fall over our own sword of vaccine nationalism, the vacuity of which is demonstrated by the potential supply problems after India followed our example in deciding to vaccinate their own people before exporting home made vaccines. Global co-operation continues to creak and appeals for equity while not quite falling on deaf ears, have been down the queue of priorities as COVAX creaks into action.

Meanwhile, in China, the WHO team investigating the origin of the pandemic have pretty much discounted the leak-from-a-lab story, though that will hardly satisfy sceptics. They fail to grasp that Sars-Cov2, (like SARS 1 and MERS), is far more likely to be added the long list of other zoonotic illnesses which are due to our destructive interactions with the natural world.

Vaccine problems and solutions

Last week I posted about the clotting issues with the AZ vaccine, and it seems the risk is now best displayed by the following graphic from the Winton Centre of Risk Management below. It explains the UK recommendations against its use in those under 30. The overall risk of clots seems to have settled to about 1:100,000 as more cases have been reported. One hope is that vigilance in diagnosing clotting problems early will mean these lives can be saved too.

Similar problems with the new Johnson and Johnson vaccine means that the problem might well be in the vector – the adenovirus used to carry the active vaccine component. They have withdrawn their vaccine while they await analysis of the clotting problems associated with the vaccine, in particular once again the clots to veins carrying blood away from the brain. It might be that there is a similarity between bits of the virus used by these vaccines and bits of our own platelets which causes auto-immunity. This would mean the problem could potentially be engineered out of future vaccines and the problem disappear.

The whole affair shows that the regulation system seems to be working well – detecting a problem and reacting to it, but I do worry that AZO and now J+J vaccine restrictions around the world means that more people will die or suffer due of COVID infection than will be saved from problems with clotting. These vector vaccines are cheap, easily distributed and stored and remain the solution for middle and low income countries.

The US National Institute of Health rarely issues public rebukes, but did so in the case of Astra-Zeneca after a press release of their Phase 3 results in the American arm of their trial pre-empted the NIH’s analysis of their data. They wondered if the AZ data might be not absolutely up to date and therefore appear more positive that it should be – that is, before more people in both arms of the trial get infections.

This spat was followed by Astra Zeneca publishing the up to date info which gladly is fine: the vaccine has 76 percent efficacy at reducing symptomatic COVID19 overall, and 85 percent efficacy in people 65 years and older. So the vaccine works well. In the naughty corners are both AZ and the NIH, the first for prematurely going public with data which should have sat with the NIH, and the NIH for going public with its rebuke, something it didn’t do with other premature press releases and will hardly encourage enthusiasm for the troubled AZ vaccine.

Mass Screening – the scandal in a picture

I posted in detail on this last week, but the graphic below shows that the UK has gone testing mad – not something being done elsewhere according to Our World in Data. This will have a huge opportunity cost in terms of wasted resources. Small pilot trials would help determine the right way of going about this, but the Liverpool mass screening experiment in November was an expensive flop, yet has been ignored. Lateral flow testing has their uses, to determine community immunity for one thing – currently running at about 50% in the UK, and may be useful for specific situations, but the screening of schoolchildren and the population at large continues to seem little more that attempts to use up warehouses of tests bought with some pretty irresponsible contracting, particularly with Innova.

NHS reform again – incredibly, its goodbye to the Internal Market!

Slipping under the radar somewhat is another re-organisation of the NHS. Incredibly and without much fuss, the internal market, conceived and developed by generations of fawning Conservative politicians is being junked. This reverses just about every aspect of the much hated Health and Social Care Act 2012, which facilitated a big shift of contracts to the private sector and encouraged fragmentation of the NHS. We are now heading for more integrated health regional health systems with more co-operation in mind as advocated by NHS bosses for some time as being essential.

Perhaps, after the countless billions spent on encouraging competition, the penny has dropped that in a health care sector, co-operation works better just about every level. The potentially darker side is the increased power vested in the Health Secretary which is a concern with “Handsfree” Hancock’s pathological disposition to cronyism and overall enthusiasm for all things private and electronic as opposed to public and hands on; sufficient supply of staff, beds and things like PPE stores have not been his strong point. Im being diplomatic.

I won’t be waiting for politicians could put their hands up and say sorry everyone for spending all those billions, wasting all that capacity, time and energy on such a destructive process, which was accompanied by the loss of beds and staff which has cost us so dear in the pandemic.

Recovery

Recovery from an illness is not always as straightforward as it may seem. So too with an illness of society which in many ways the pandemic is. Much damage has been done. The £8.1 billion stumped up in the UK for increased activity in the NHS is a start, but will not be enough given the phenomenal increase in those waiting for operations and is compromised too by the lingering damage from the virus itself. 122,000 NHS staff are suffering from Long COVID which adds to the problems of 30,000 staff currently off sick. 120,000 teachers too are affected, and both groups are being asked to increase their workload significantly. Easier said than done.

The Post COVID decade

A study from the British Academy, commissioned by the UK government, (well done them) has reported some of the improvements we need to make as a society in the decade after COVID19. For current politicians, it wont make comfortable reading as once again, co-operation gets a good deal of coverage, competition none. It seven main recommendations are:

• better local government,
• better information sharing to facilitate decision making based on understanding,
• elimination of the digital divide to improve education,
• better towns and cities with a re-imagination of living spaces,
• big changes in the way we educate our children,
• expansion of community led infrastructure, especially in deprived areas,
• integration across charity, business and voluntary sectors to enhance a sense of collective purpose.

They were not briefed to look as the fundamental changes in our lives which will be needed to halt, or try to live with climate change, this report offers ways in which things may improve. Sadly, it seems the government are doing pretty much the opposite to what they recommend.

We are planning to spend billions on old fashioned big roads which generate astonishing amounts of CO2, as do vanity rail projects and airports, while neglecting local living spaces and electrification of transport. Local government is facing an existential crisis which increases in Council tax will not solve. We have a Police Bill which is draconian in its power. The sight of armoured Police forcing filling up local emergency units with protestors has chilling echoes from around our troubled world. Our commitment to climate change seems paper thin when it comes to policy.

Internationally we have cut aid to the developing nations while still raking in interest from loans from some of the poorest countries on earth. We are rolling out vaccines to the wider population while poorer nations fill their ITU’s with the vulnerable, and, as I said earlier, we have a Prime Minister who feels that greed is good and that that old conservative thinking of austerity, simultaneous generation of poorly distributed wealth and poverty have not gone away. There have been fortunes made by some during the pandemic and the new thinking needed for the future has yet to emerge. I would like to see a Universal Basic Income emerge from the ashes of the furlough scheme, yet we have profligate spending on those old nutmegs of carbon heavy infrastructure and weapons.

Nature bites back

Away from this blog, I head back to the garden to see what is going on. Though mid-April, the beds lie empty other than the last of the leeks, emerging frost hardy broad beans and winter onions. Too cold and dry to sow or plant right now, due to weird weather once again. To further remind me of our total and immediate dependence on nature, the French wine harvest has been decimated by more climate change driven freak weather. This time it’s late frosts. Ironically, the paraffin fires lit to try to keep the frosts from biting off the vine lead buds have led to choking fumes affecting the health of local urban populations.

Growing any food brings you into a direct relationship with the difficulties faced by farmers trying to feed the world. Global agricultural productivity has been set back 7 years by the effects of climate change so far, though far more in tropical regions worst affected. Nature is indifferent to concepts such as justice. My veggie plot will, according to forecasts, have almost completely missed out on April’s traditional showers and this is following a dry March. I wonder if like last year, the drought will be followed by a deluge. that would be better than continued drought. Everything is becoming more delicate and any threat to global food supplies will create problems of a different magnitude to COVID19.

COVID19 is the latest consequence of our disconnect from the reality of the natural world. Its immediate, short and long term consequences will be with us for a long time yet. Perhaps as we celebrate time with family and friends, the ability to go to the shops and eat out when we want to, we can have a much wanted breather from the feeling of crisis. But it is not like the end of a war, or the cure of an illness. Less of a full stop and more of a semi-colon. If we continue our conflict with nature, we will continue to lose.