15.04.2021

One year on

Good state organisation, not the market, has proven to be the key to success. But globally the vaccination programme has barely got started, warns Mohsen Shahmanesh. This article is based on his April 11 Online Communist Forum talk

Let me begin by giving a brief overview of the new things we have learned over the last few months about Covid. Then I will say a little bit about the vaccines and the issue of the new variants, and I will also focus on the global pandemic and the rollout of vaccinations worldwide.

One thing that is pretty clear now is that the risk of infection outdoors is much lower than indoors. And that is not surprising, because we are talking about airborne micro-particles as the main vehicle of infection from person to person. In the beginning, when we did not know much about the means of transmission, they had us washing our hands like crazy and not touching our nose or eyes, combined with an obsessive insistence on clean surfaces. But now it is quite clear that we are dealing with a predominantly airborne virus that is transmitted via very small air particles. If you are outside, even a small breeze will take them away.

So really the risk is much lower at, say, a football match than it is in a room - and if you ventilate that room the risk is reduced. So if we install ventilation systems in our schools and have the air circulating outwards, these and similar measures that can be easily addressed will drastically reduce cross-infections. You should still keep washing your hands and keep your distance, but maybe be less tense outdoors.

The second thing that has become quite clear is that the risk of acquiring the disease and dying is not just age-related, but relates to a number of other factors, particularly obesity. Someone who is obese is 10 times more likely to become severely ill or die. That is why in all countries where obesity is uncommon mortality rates are lower. But where the opposite is the case - in Britain, Germany, the United States, etc - that is where there are high mortality rates. So obesity is the single most important risk factor other than age. Of course, obesity rises with age, so the two are interlinked. Similarly, obesity and diabetes are also linked, so all three seriously increase the risk of severe and lethal disease. Intensive-care units are full of people who are overweight.

The other issue that has become quite clear now is long Covid, which is actually quite common: 70% of women over the age of 40 who have survived the acute illness, for instance, remain unwell five months or more afterwards. So this is a chronic, often debilitating illness which affects young and old - particularly women. This is interesting, because in general mortality is higher in men than in women, but long Covid is more common in women.

The reason for this is not entirely clear, but Covid quite often presents as a multiple-organ disease, with not just the lungs affected, but malfunctioning kidney, brain and other organs. There are a number of other multiple-organ diseases - what are called auto-immune, such as rheumatoid arthritis, systemic lupus, etc, where it is as though the body ceases to recognise parts of itself and uses the immune system to attack these tissues. Auto-immune diseases are more common in women than in men, so their higher rate of long Covid compared to men may be related to their propensity towards these inflammatory processes. Blood C-reactive protein level, which is a marker of increased inflammatory processes in your body, is higher in women infected with Covid. Long Covid is increasingly being recognised as a significant long-term complication of the infection and we still do not understand its patho-physiology, its natural history or indeed how to treat it. Sadly, because it is a newly recognised condition, many doctors fail to recognise it.

Let me conclude this section by looking at the overall effects of this disease in the UK. So far we have had just under half a million people admitted to hospital and over 130,000 deaths. But the way to consider this question more accurately is to look at the excess deaths. In other words, compare the number of deaths that we had this year with the same period in previous years: that gives you a much more accurate view of the impact of the virus on mortality. In December the United Kingdom was second highest in Europe in terms of excess deaths, but, once the vaccine rollout began, the number of deaths fell and the UK now ranks seventh (although that is still quite high, of course). Before the vaccine rollout the UK had been unable to manage this disease - in fact it was a complete disaster.

Variants

I would now like to discuss the different variants in the Covid-19 virus that have appeared. The Covid virus enters the human cells using a surface protein called the spike protein. The virus produces this protein like a chain or a rope, which then coils on itself, taking a shape that allows it to lock into the receptors on the human cell which the virus can infect. The spike protein acts like a key that locks into the receptors on your cells. Once Covid enters the cell, it uses your reproductive process to reproduce itself and infect other cells in the host or of another person. The better the ‘fit’ of the spike protein to the receptor, the more successful the virus in entering your cell: that is, the more infectious the virus. Therefore, any mutation that improves the locking process gives an advantage to the virus.

The reason why understanding this is important is because the number of mutations that occur in the spike protein are fairly limited. All viruses mutate, just as all cells that divide mutate, so mutation is part of the existence of all living organisms. In the case of viruses mutations that lead to improved infectivity gives an advantage to that variant. It is such mutations that are now spreading around the world. There are currently four main ones known.

The first one that was identified was found in Kent. It may have appeared in multiple other sites around the world also, but it was picked up in the UK as we have one of the best surveillance systems in terms of sequencing viruses. One in 10 of all viruses identified are gene-sequenced. So identifying it here does not necessarily mean it originated here. The Kent or B.1.1.7 variant has now been identified in almost all the countries of the world where there has been gene sequencing. Indeed the B.1.1.7 variant is now the dominant variant in Iran (underpinning the fourth wave of Covid in the country), and is also the dominant virus in a number of other countries. The reason for the global spread is that the B.1.1.7 mutation gives the virus 50% more infectivity (the ability to pass from one person to another). This gives it a huge survival advantage. There is also some evidence that the B.1.1.7 may make the disease slightly worse, especially in younger people, causing more symptomatic disease in this age group. Just remember that only a minority of people infected with Covid-19 get symptoms, and only a minority of them get severe symptoms, and a proportion of those die. The younger you are, the more likely for the infection to be asymptomatic, or mild - a little bit of flu-like illness for a few days with a fever, though severe fatal disease is seen in young patients.

But the fact that the Kent variant increases the severity of the disease in younger people is very important. If you look at hospital admissions in the UK, we had more people under the age of 65 admitted in the third wave of the epidemic than in previous waves. Hospital wards and ICUs were filled by younger people, working people, not just pensioners.

The other variants are the South African and Brazil (P1) variants. These two have what is known as the E484K mutation in the spike protein - or EEEK variation, as virologists like to call it among themselves for simplicity’s sake. The EEEK mutation is particularly important because it clearly increases the severity of the disease, and it may also provide some protection for the virus against current vaccines. In Brazil, where the P1 variant was first identified, hospitals are overflowing with severely sick younger Covid-infected patients. From the viewpoint of Covid, this variant is an advantage. It infects more, can cause more severe illness and may resist vaccines. Both the South African and Brazil variants are potentially very dangerous.

In time variants of this type may become the dominant ones globally. As more and more people become vaccinated, it is an advantage to the virus to create an escape mutation - one that protects it against the vaccine-induced immunity. The expanding vaccination programme, where there is a background of high virus replication, will undoubtedly help the virus develop such escape mutations. That is why we need a robust and functioning test-and-trace system (which we still lack in the UK) and social distancing should continue until the level of virus replication is low in society.

Finally, there are a couple of new viruses which have just been reported in California - as far as we know, they are still confined to there. But the other three variants - the British, South African and the P1 from Brazil - are now all worldwide. The Kent (B.1.1.7) variant is more so than the other two, but all have been found in Europe, Africa, the whole of Latin America and parts of Asia.

Incompetence

I want now to discuss the management against Covid in this country. It is an ongoing story, but, of course, it is one of total incompetence.

The first fiasco arose over personal protective equipment. We not only saw incompetence, but massive corruption and nepotism, where money was given to companies that had no experience whatsoever in producing PPE. Next was ‘test and trace’, which really should be ‘test, trace, isolate and support’ (TTIS), because without isolation, and support for this isolation, testing and tracing is virtually useless. But even with test and trace the government has been incompetent, especially with tracing, having spent £37 billion on a test and trace programme - almost entirely given to private firms, even though the national health service could have done this much more cheaply and effectively. The NHS has massive experience in infection control, and had actually prepared itself to perform TTIS, only to see it given away to private firms. The whole system has been ineffective. Yes, ‘test’ has been working, but ‘trace’ less so, while ‘isolate’ has not been managed properly and ‘support’ does not exist in practice.

A study recently looked at the adherence to isolation of those who had tested positive and found that it was worse for working people - particularly males working in key industries. The reason why it was so bad is that there was little or no support for isolation. If you tell someone to isolate, either you have to compensate them for lost earnings, so they can survive, or they will simply not listen to you - and that is exactly what has happened.

The study found that only 20% of people would actually go to a test centre if they were symptomatic. That means 80% of people would not bother to be tested, because they knew if they did they would be told to isolate. In another study, only 50% of people who were asked to name the symptoms of Covid could actually list them. So we have an education problem too.

The vaccination programme has been very successful, however. The reason for this though is not anything to do with the government: it is because it was given over to the NHS. We have a highly organised NHS system that has experience of mass vaccinations. Everyone is registered with GPs, there is a doctor each patient is linked to, so the system already has the necessary organisation to deliver vaccinations. It is no surprise that the moment the government gave the vaccination programme to the NHS it was rolled out phenomenally effectively. As a result some people have sadly forgotten the PPE fiasco, the non-functioning test and trace and all the incompetence and thievery that went with it.

Vaccines

There are currently over 300 vaccine types being tested. Among these six vaccines have gone through ‘phase 3’ trials and their results have been published, so we know how effective they are and what their side effects are - publication allows the data to be scrutinised by other scientists.

Most Covid vaccines have used vaccine development techniques that have been used in other previous successful vaccines. Two of them - Pfizer and Moderna - use a novel technique where the messenger RNA that is coded to produce the spike protein is injected into the recipient. The injected messenger RNA then activates the recipient body’s cell machinery to produce the large quantities of spike protein (which in itself is harmless) and this then provokes an immune response to create antibodies and cell-mediated immunity against the Covid virus.

All of the vaccines currently being used, no matter what you hear in the media, are equally effective: there is nothing to choose between them. The different figures of efficacy that are given are not comparable, because the end points used in the different studies are different. In real life, all of these vaccines are between 70% and 80% effective.

The other published vaccines are the Astro-Zeneca (Oxford), the Russian Sputnik V and ‘Johnson and Johnson’ - vaccines which all carry the spike protein into the body attached to an adenovirus (the spike protein has to be delivered to the body using a vehicle). In these three vaccines the vehicle - the ‘platform’, as we call it - is an adenovirus, a virus that can cause a cold-like disease. In the case of Astra-Zeneca, it is a ‘monkey adenovirus’, with Sputnik V it is two different human adenoviruses, and with Johnson and Johnson it is also a human adenovirus, but packaged in a different way, so patients only need a single injection. Thus, these three vaccines are all related to one another, and employ a familiar technology which has been used successfully in other vaccines.

The final vaccine which has been licensed is the Novavax, in which the platform is a protein. This too is a methodology used in many commonly used vaccines.

All of the above are between 70% and 80% effective, and almost 100% in preventing severe disease or death. However, while in the prevention of severe disease or death they are very effective, their effectiveness against mild disease varies from one to the other.

There are other vaccines that are being used around the world, from India and China. One Indian vaccine (Covishield) uses a similar technology to the Astra-Zeneca and is produced under licence. The other vaccines use an inactivated whole virus - that is, a virus that cannot replicate within the human body. The Chinese vaccine, Sinopharm, has been widely used in the Middle East. Sinovac (also Chinese) has been used extensively in China as well as outside. Though most of these have had phase-3 trials, for some reason the results have not been published. It is not clear to me why, particularly in relation to the Chinese ones, which have now been given to 20-30 million people worldwide. But they are being used in large numbers and, as far as we know, they have no more side effects than the others whose results have been published. Since there have been no published results for them, however, and therefore no possibility of scrutiny of the data, as a doctor I could not recommend them.

What about the side effects of these vaccines? The first reports were deaths from anaphylactic (allergic) shock immediately after receiving the Pfizer vaccine in a number of people. All of them had a history of allergies and the Pfizer vaccine is no longer given to people who have such a history.

Recently we started hearing about people who suffered from a particular kind of stroke following vaccination. In England there have now been 79 cases so far, of which 19 have died. Among them are a certain number who had a very rare form of stroke - and in addition to a stroke they also had a low platelet count. This is a rare condition, seen as a complication of the oral contraceptive pill and in some people receiving the drug, heparin, which was prescribed to thin their blood. What happens is that something causes the platelets to stick together, and that triggers a process that causes a clot in a blood vessel. Thus alongside a clot that blocks a blood vessel, the blood platelets are depleted as well. The result is thrombocytopenia (low blood platelets) at the same time as a blood clot - a very unusual combination.

The normal reaction from a health worker when faced with someone who has a major blood clot would be to give them an anticoagulant. But in the case of this rare form of stroke, where the platelets that are so vital in the clotting system are destroyed, giving the patient an anticoagulant would worsen the condition. My guess is that some of the reported deaths were probably caused because, before we knew of this unusual condition, the stroke patient may have been given an anticoagulant. By ‘thinning’ the blood that is already ‘thin’, you may exacerbate the condition. Now that we know of this rare event, hopefully the management of these patients will be different. Although these incidents have been extremely rare, and the numbers fairly small - roughly one in 600,000 - the clinical picture suggests that this is a ‘signal’: ie, a complication of the vaccine, albeit very rare. A similar side effect has now been reported with the Johnson and Johnson jab, which is from the same family of vaccines.

Let us put these problems in perspective. If you do not go out for a drive for an hour, you will cancel out the miniscule risk of this vaccine. That should give you some notion of how small the risk of the Astro-Zeneca vaccine is. Look at it another way: one in a million of us who receive an annual flu vaccine will become paralysed. But none of us bat an eyelid when we go for our annual flu vaccine. So you have to decide what the risk is. If you are between 18 and 49 in the UK there is a 0.05% risk of dying from Covid - 50 people out of every 100,000. That is a 1:2,000 chance of dying. Let us, for the sake of argument, ignore the issue of long Covid - you have to balance this risk with 1:600,000 of getting a stroke and a smaller chance of dying. The maths are clear. If you are under 49 you are 300 times more likely to die of Covid than get a stroke after an Astro-Zeneca vaccine. The maths are simple. In the older population, however, it is a no-brainer, because in people over 60, 9% will die of Covid. So the advantage of taking the vaccine overwhelmingly outweighs any risk. There should be no hesitation in anyone over 65 to have the vaccine. Those under 50 may want to think about the alternatives, but what is that alternative?

We have now had a signal from Johnson and Johnson that maybe this is a feature of the virus itself, because the same syndrome I have just described with a clot and low platelet count also occurs with Covid-19 disease. It may be something to do with the spike protein actually initiating this reaction in a small number of people. If that is the case, we may also see the same reaction with the other vaccines, but it has not yet been reported across the world.

Rollout

This is a global disease, which means you are never truly safe until everybody everywhere has been vaccinated. So this vaccine nationalism that we are witnessing is effectively, as we say in Farsi, ‘spitting upwards into the sky’: ie, the spit comes back and lands on your face.

To date 130 countries have had either very few or no vaccinations. By contrast, 10 countries have given two-thirds of all vaccinations. According to a very recent Duke University study, 4.5 billion doses have been given in rich countries - as opposed to just 650 million in poorer countries. In the entire continent of Africa, on April 10, roughly 200,000 vaccinations were carried out on that day - half of what were given in the UK alone in a single day. What are the reasons for this disparity?

The first concerns patents. The World Health Organisation proposed (and was supported by a number of countries) that patents be suspended for the duration of the pandemic. This is exactly what happened with HIV drugs. It took a bit of persuasion, but, once that was agreed, it was very successful and the drugs were rolled out across the world - there are literally millions of people across the world with HIV who were given antiviral drugs. The drug companies actually did not lose out. Yes, they considerably reduced the margin of profit on each transaction, but by selling the drug for use by millions of people they still made a huge profit. This time around, however, both the UK and US have opposed patent suspension. There is a huge production capacity - eg, in India - to manufacture huge numbers of vaccines.

It is worth remembering that virtually all the major new drugs and vaccines over the last 5-10 years have been funded by states, by governments - in other words, by the people. Effectively these are research projects funded collectively and, if they are successful, the drug companies take them up and are given the patent. But there is absolutely no reason why governments themselves should not produce such drugs. Effectively you are handing over a blueprint to a drug company to make millions, when you have taken all the risks and done all the research and all the funding. This is true for all the Covid vaccines, with the partial exception of the Pfizer. The development of the Johnson and Johnson, the Astro Zeneca, the Moderna to some extent and the Novavax have all been state-funded. So that is the second thing to bear in mind.

The third thing is that the major western countries have pre-purchased some drugs by up to five times their own need. So there are excess, surplus vaccines, which could be distributed across the world. Why has this not happened? In the US, for example, the contracts with the drug companies included a clause that prohibits the export of excess drugs to any other country. The Biden administration has had to build a new factory to make vaccines it can donate to other countries. In the case of the UK, we do not know what has been agreed, because the contracts are secret. As for Israel, it has given away its surplus, while refusing to vaccinate its own Palestinian population that is under occupation.

What about the prices of the vaccines? Mostly they are kept secret, but, where we do know them, there has been a huge variation across the world. Astra-Zeneca has said (and we have to take their word for it) that they are giving it out at cost price. But none of the others have disclosed information on this, while Pfizer is clearly making as much money as it can before the patent may be taken away, selling it at a hell of a price. Most such prices are not disclosed, but we are talking about a variability of two or threefold.

Vaccines have also been used as a political tool. If you look across Europe, one of the countries that has the highest rate of vaccination - even higher than the UK - is Serbia, which had the vaccines provided for free by Russia. As a result, in contrast to all the incompetence in western Europe, almost all of the people in Serbia have been vaccinated. As for China, it has used its vaccine as a tool of diplomacy, giving it to Pakistan, Peru, the Emirates and Saudi Arabia, which have all achieved very high rates of vaccination, using Sinopharm (the vaccine about which little is known, though presumably it works to some extent).

When the pandemic started, the UN, the WHO and a few other organisations came together to create the Covax Initiative in order to provide and distribute vaccines across the world - after all, a global pandemic requires a global response. But it is very much underfunded, and has nowhere near the £27 billion it needs to buy the drugs, and it is also in competition with governments trying to buy the same drugs. By March 277 million doses had been given worldwide, while billions are needed.

But receiving the vaccine is only the first step. Vaccines need to be rolled out. Here there is huge variability in competence. For example, Iran has been allocated 3.6 million doses by Covax (with a population of 80 million it would need to vaccinate 56 million persons - 70% of its population - to get herd immunity). It has so far received 700,000 from Covax, and an unknown number from Russia, but so far only 200,000 have been vaccinated: ie, 0.15% of the Iranian population. Compare that to Turkey, where 12% of the population have been vaccinated - and Turkey is not even part of the Covax programme.

Looking at Africa, Nigeria - one of the richest countries in the continent - is on the Covax list and has already been given four million doses, but only 0.5% of the population have been vaccinated. So it is not just a question of receiving the vaccine: there also has to be the organisation in place to distribute and deliver it. Only 10% of Nigeria’s vaccines have been used. Ghana has received 600,000 doses and vaccinated 2.2% of the population: that is, more than four times that of Nigeria. Zimbabwe has not received any vaccine from Covax, yet it has vaccinated 3% of its population - better than Ghana. Even when everything else appears to have has collapsed, Zimbabwe still seems to have an effective health structure. South Africa, one of the major centres of the Covid crisis in Africa, has only just begun vaccinating.

To conclude, let me point out that the pandemic has not only caused massive deaths and disease across the world: it has also increased the misery of people who were already very miserable. Migration into the US from Latin America has shot up - people trying to escape not only poverty and wars, but also Covid-19. And the problems of migration itself - isolation, people not able to get into overcrowded camps or waiting to get from one place or another - all these are increasing the risk of spreading this disease.

We are facing a global catastrophe and have barely begun to address it.