Coronavirus update – Part 19 (May 2022)

Dr John Ling continues to provide us with a monthly review of all things Covid. This, his latest offering, was published a few days ago on his personal website, which is well worth a look for many other resources and information. Thank you John!

Covid-19 numbers

Hooray, this is the penultimate update in this series of Coronavirus articles. These days there is decidedly less to report. The pandemic is retreating, at least in the UK, for the moment. The picture does look rosy, certainly less gloomy. Even so, much of the world is still battling the wretched virus. Just because we talk less about it and wash our hands less frequently does not mean that the pandemic is over.

But ponder these UK figures – they do look encouraging. During May, there has been a record drop in the number of reported Covid-19 infections. According to the latest estimates from the Office for National Statistics (ONS), 1.08 million people tested positive for Covid-19 during a week in late May – that is down 15% from the previous week. In other words, Covid-19 had infected only about one in 60 people – in late April, that figure was one in 17.

Hospitalisations have decreased too. Admissions currently continue at about 4,200 with 130 patients on ventilators. During April, the equivalent figures were 14,000 admissions with 320 patients ventilated. Deaths have also plummeted to approximately 60 each day – the equivalent April figure was 330. Nevertheless, the total of Covid-19 related deaths in the UK since the pandemic began now stands at a cheerless 178,000.

Vaccination rates have inevitably also been slowing down after the rush to get jabbed earlier in the year. The UK totals for the whole pandemic now amount to 44.9, 42.0 and 33.0 million for first, second and third doses respectively. The latest weekly numbers were 40,000, 55,000 and 64,000 for first, second and third jabs.

Globally, the picture remains mixed and mobile. The total cases have reached almost 530 million. Total reported deaths have reached 6.2 million (though this figure is disputed by the WHO, see below) and 11,400 million vaccinations have been administered. The USA is still top of the table for total cases at 84 million, followed by India (43 million) and Brazil (31 million). The current ‘hot spots’ with the highest infection rates (as opposed to totals) are the USA, Taiwan, Germany and Australia. And the USA is also the leader in Covid-19 deaths at 1.005 million, trailed by Brazil (666,000) and India (525,000). The UK hovers around tenth place in most global metrics.

These bald statistics tell a story, or rather, part of a story. Such numbers do little to convey the monumental suffering and loss that have been (and will yet be) caused by Covid-19. Personal accounts and pictures help fill out the dimensions of that human cost. History will perhaps better recall what we have lived through. But in the meantime, the refrain is unremitting – this Covid-19 pandemic is not over. Much of the world is still in its grip.

15 million Covid-19 deaths worldwide

Counting the total number of deaths caused by Covid-19 has long been a source of dispute. Of course, it could never be a precise total because of the complexities of poor reporting, gathering data from isolated areas, time lags plus deliberate, as well as unintentional, underreporting. Another major cause of discrepancy has been because people have died either ‘from’, or ‘with’ Covid-19 and it has been impossible to separate the two cohorts. In other words, patients dying in hospitals and elsewhere have often been suffering from fatal comorbidities that have included Covid-19.

Nevertheless, according to a recent report from the World Health Organization (WHO), the pandemic has caused nearly 15 million deaths worldwide. On that basis many countries must have undercounted because only 5.4 million deaths have been officially registered. For instance, in India, the WHO says that 4.7 million Covid-19 deaths have occurred, 10 times the authorised figure and almost a third of the worldwide deaths. Similarly, the WHO maintains that Russia and Indonesia have beaten the USA beyond its much-publicised 1 million mark.

Using its favoured statistical method called ‘excess death counts’ the WHO reckoned that 13% more deaths occurred than would normally be expected over the two-year period from January 2020 to December 2021. Some countries with zero Covid-19 strategies, such as Australia, Norway and Japan, actually saw fewer deaths than would normally be expected. Whether it is 15, or 5.4, or 6.2 million, or whatever, as Samira Asma, the WHO assistant director-general, has said, ‘It’s a staggering number and it’s important for us to honour the lives that are lost, and we have to hold policymakers accountable.’

A fourth jab

Among high-income countries, doses of booster vaccines were always going to be intermittently offered, primarily because Covid-19 antibodies wane over time and therefore patients lose their immunity. Millions in the UK have already had their third shot, now the talk is of number four.

According to a recent UK trial, a fourth dose will increase protection against Covid-19, especially among the over-70s age group. Already from April, the UK has started a fourth dose roll-out for the over-75s and the vulnerable. The extent of that new strategy will depend upon whether new variants emerge and whether hospitals are under excessive pressure.

This recent UK trial, conducted at the University of Southampton, involved 133 participants with a median age of 70. They were vaccinated with either a dose of Pfizer-BioNTech or a half dose of Moderna vaccines about seven months after having had their third dose. The results showed that two weeks after their fourth dose, these vaccines were ‘well-tolerated’ and ‘boosted immunity’. In fact, the peak antibody responses were as good as, or even better than, their third doses.

The study has been reported as, ‘Safety, immunogenicity, and reactogenicity of BNT162b2 and mRNA-1273 COVID-19 vaccines given as fourth-dose boosters following two doses of ChAdOx1 nCoV-19 or BNT162b2 and a third dose of BNT162b2 (COV-BOOST): a multicentre, blinded, phase 2, randomised trial’ by Alasdair Munro et al., and published in Lancet Infectious Diseases on 9 May 2022.

The researchers concluded that, ‘The strengths of this study include it being the first to report on mixed-schedule fourth-dose data from a randomised trial and on populations who had received vaccines other than BNT162b2 [Pfizer-BioNTech] as their first, second, or third dose. This study provides important data to help guide policymakers in decisions on how to use fourth doses of COVID-19 vaccines.’

However, this was only a small study. More research over a longer period is needed. And not all scientists are enthusiastic about the prospect of an extra jab. The recent Omicron surge means that many people will already have high antibody levels and are unlikely to benefit from a fourth dose. Yet some countries, such as Israel and Germany, have already started offering all their adults a fourth dose.

The question is, will a fourth dose benefit the wider population? In late May, the UK government declared its hand. A mass booster campaign this autumn will offer about 20 million UK adults the extra jab aimed at curbing a winter wave of Covid-19. All over-65s will be eligible. And over-75s, who are currently being offered a spring booster, will get the chance to roll up their sleeves for a fifth dose. The NHS has been asked to prepare the necessary roll-out plans.

Covid-19 surges

As data pile up from two years of the pandemic, our knowledge of that wily Covid-19 virus is growing. It is now six months, from November 2021, since the Omicron variant was first identified in South Africa. It has since surged around the world. Currently, the focus is on its sub-lineages, BA.4 and BA.5, still highly transmissible and less susceptible to neutralisation by antibodies derived from either previous vaccines or infections. These variants are presently surging in South Africa, with hospitalisations for severe cases still low but rising.

What is next? More variants, more sub-lineages, more surges? Some scientists see a predictable pattern of new variant waves. Tulio de Oliveira, a professor of bioinformatics at Stellenbosch University in South Africa, has said, ‘These are the first signs that the virus is evolving differently’ compared with the first two years of the pandemic, when variants seemed to appear out of nowhere.

BA.4 and BA.5 currently account for between 60% and 75% of Covid-19 cases in South Africa. In addition, they have spread to more than a dozen countries, mainly in Europe. From about 1,500 South African cases in March to 5,000 in April, these variants are reckoned to be spreading faster than the BA.2 sub-lineage. Increased transmissibility looks like a viral advantage. But why? Are they inherently better at spreading? Or are they better at dodging antibodies? Or both? This, in the eyes of some experts, looks like the prelude to a new and sizeable infection on the horizon.

Indeed, as immunity to Omicron and its new variants increases around the world, there is the possibility that another variant, perhaps of the apparently outmoded Delta, which has not yet disappeared, could make a comeback. It seems as though such surges are appearing roughly every six months. This is not good news. What is good news, is that the vaccinated combat new and old variants better than the unvaccinated. But maybe this wily virus simply does not follow predictable patterns of mutation and emergence. Put another way, a Covid-19 surge can be expected anytime soon, or otherwise.

Spreading the IP

Covid-19 vaccines are complex entities and expensive to manufacture. Their makers have invested heavily in their production and expect a reasonable return on their financial outlays as well as protection of their skilled know-how, called intellectual property (IP). This raises two problems – how can low-income countries afford the vaccines and, without access to the necessary hush-hush technology, how can they attempt to localise and master cheaper production? Some biotech companies have sold vaccines to poor countries at cost. But they have been reticent to give away or share their trade secrets, especially their IP patents. Yet vaccination rates in wealthy countries are now as high as 90%, but in poorer countries they are as low as 10% or even less. In other words, has production in wealthy countries passed its peak? Will profits now dwindle?

In early May, members of the World Trade Organization (WTO) proposed a waiver on the IP rights for Covid-19 vaccines in the hope of speeding up roll-outs worldwide. The plan, approved by the so-called Quadrilateral Security Dialogue (QSD), colloquially known as the Quad, an informal strategic forum including Australia, Japan, India and the United States, will still have to be approved by the full council of the WTO. If that hurdle is cleared, it will allow developing countries to make Pfizer-BioNTech, Moderna and other pharmaceutical companies’ vaccines without paying the hefty licencing fees. It is hoped that final approval will come in June.

Not all are in favour. Some in the pharmaceutical industry have lobbied against the Quad proposal. Others maintain that waiving IP rights will not solve vaccine inequity in the short-term. Maybe that is true, but the launching of such huge potential global agreements has to start somewhere, somehow. But last month this looked an unpromising prospect as three of the world’s largest Covid-19 vaccine producers refused to share their IP. Despite billion dollar profits from Covid-19 vaccines, shareholders at the AGMs of Pfizer-BioNTech, Johnson & Johnson and Moderna voted down such plans.

Covid-19 in the USA

In mid-May, the White House announced that the USA Covid-19 death toll had passed one million. This is generally considered to be the highest official total of any country anywhere in the world. President Joe Biden said the country was marking ‘a tragic milestone’ and each death was ‘an irreplaceable loss’. He ordered flags across the US to be flown at half-mast to demonstrate the nation’s grief.

It has been a momentous, even disastrous, two years for the USA and Covid-19. The first confirmed case was reported on 20 January 2020, when a man flew home to Seattle from Wuhan in China. Now, besides its seven-figure death toll, the USA has also recorded more than 80 million Covid-19 cases out of a 330 million population.

And more is predicted to come. While the Covid-19 pandemic is showing signs of slowing in many countries, others are experiencing surges. Among the developed countries, the US is suffering badly. During May, health officials in some cities have been calling for a return to mask-wearing and social distancing. For instance, Covid-19 cases have recently surged across most counties of New York State putting them on ‘high’ alert. Why? Did the Land of the Free abandon such precautions too readily? Moreover, why are only 67% of American adults fully vaccinated, compared with 73% in the UK, 77% in Germany and 82% in Canada?

The fear is that the USA might be about to experience a sixth wave. The White House is forecasting a US wave of up to 100 million infections in the autumn. By late May, cases were up by 26% and hospital admissions by 19%. Yet each day only about 3,000 Americans were being hospitalised and 275 deaths were being announced – figures that are much lower than during the fifth wave. So, is a sixth wave really on the cards? Is the US ready to fight it? Certainly, the US Congress is reluctant to fund the colossal sums required for purchasing supplies of the next generation of Covid-19 vaccines and testing kits to meet such a new wave.

Americans like to do things differently. The Covid-19 pandemic in the US has been highly politicised and subject to numerous zany conspiracy theories so that mask-wearing, social distancing and vaccination uptake have been largely neglected. Most Americans are averse to any governmental mandates and would be prone to more lockdown angst. And so the population remains apparently unconcerned about the current rise in cases. Recent polling showed that only about 30% of US adults are concerned about catching Covid-19, the lowest proportion recorded since July 2021. They may be in for a shock later this year.

Covid-19 in the Americas

According to the World Health Organization (WHO), Covid-19 case and death rates have been rising in May across the Americas. During one week in mid-May, more than 918,000 cases were recorded – that is a 27% increase on the previous week – together with over 3,500 deaths. The Pan American Health Organization (PAHO) has reported that 18 nations saw upsurges in hospitalisations, while admissions to intensive care rose in 13 countries.

On 18 May, Dr Carissa Etienne, the PAHO Director, declared that, ‘The rise in cases should serve as a wake-up call. When people get sick, hospitals get overwhelmed, health systems are challenged, and the number of deaths rise.’

North America, principally the USA and Canada, accounted for more than half of the new infections. Central America saw the largest rise in cases when infections soared by 80%. In South America, Brazil recorded more than 120,000 cases – a 9% rise. Argentina reported almost 34,000 cases – a staggering 92% increase on the previous week. Other countries in the sub-region also experienced surges of cases, while Venezuela, Paraguay and Brazil all recorded increases in deaths. The Caribbean experienced a 9% increase of cases and a 49% increase in deaths during May.

Much of this bad news can be attributed to many national and local authorities abandoning mask-wearing and social distancing requirements. In addition, only 14 of the 51 PAHO countries and territories have reached the WHO’s target of vaccinating 70% of their citizens. The general public have an obligation to adopt protective measures, including vaccinations. Governments have an obligation to protect their people, especially their most vulnerable. But they must also invest in healthcare systems, maintain surveillance programmes, including testing, and respond to adverse trends. As Dr Etienne has stated, ‘The truth is this virus is not going away anytime soon.’

Covid-19 in North Korea

The Democratic People’s Republic of North Korea (DPRK), the so-called hermit kingdom, is a spooky place at the best of times. Transparency is certainly not one of its key attributes. No cases of Covid-19 have been announced since it closed its borders two years ago. Moreover, its response to the Covid-19 pandemic has been suitably scary – it has organised no public vaccination programme, despite the virus emerging from its next-door neighbour China and despite offers of vaccines from China and Russia via the COVAX vaccine-sharing scheme. Instead it has recommended the use of analgesics, antibiotics and traditional Korean medicines, such as drinking willow leaf tea and gargling with salt water.

In mid-May, the country’s official news agency, KCNA, reported ‘deaths and a large number of people with fever.’ Covid-19, mislabelled as ‘fever’, has apparently reached almost 2.5 million with as many as 200,000 cases each day. It was only a few days earlier that the State had announced its first Covid-19 death. A few days later, Kim Jong-un, the North Korean supreme leader, ordered a nationwide lockdown, calling the outbreak the ‘gravest national emergency’ that demanded ‘maximum emergency measures’. At the same time, he also berated government officials for the ‘immaturity in the State capacity for coping with the crisis.’ He is indeed the archetypal despot looking for scapegoats. Experts believe that North Korea is standing on the brink of a Covid-19 catastrophe.

Certainly, North Korea is not in good shape to resist and treat the pandemic. Its 26 million citizens can access few, if any, vaccines and antiviral drugs, and they suffer from a dilapidated medical system, scarce intensive care facilities, widespread malnourishment and a rundown economy – the very marks of a vulnerable population doomed to low Covid-19 immunity. Even testing for Covid-19 has been rudimentary. According to the World Health Organization (WHO), only 64,200 tests have been carried out since the start of the pandemic compared with 172 million in adjacent South Korea. The North Korean situation looks grim, even beyond grim.

Long Covid singalong

Long Covid is the Cinderella of the pandemic. Lots suffer from it, but there are few successful, evidence-based interventions available. Since breathlessness is a common symptom of long Covid and opera singers are experts in breathing exercises, the two have joined forces in a trial undertaken by the Imperial College Healthcare NHS Trust and English National Opera (ENO).

The report of the trial, entitled, ‘An online breathing and wellbeing programme (ENO Breathe) for people with persistent symptoms following COVID-19: a parallel-group, single-blind, randomised controlled trial’ by Keir Philip et al., was published on open access in the Lancet on 27 April 2022.

A total of 158 long Covid patients were randomly assigned either to participate in the English National Opera (ENO) Breathe programme, or to continue with their usual care. Participants in the former cohort underwent a 6-week online breathing and wellbeing programme, developed by the ENO for people with long Covid that focused on breathing retraining by using singing techniques. After six weeks, the volunteers were assessed by a cluster of subjective and objective tests.

Overall the programme’s singing and music was enjoyable and beneficial. The ENO Breathe volunteers reported three health-related quality-of-life (HRQoL) enhancements. They were, ‘(1) improvements in symptoms; (2) feeling that the programme was complementary to standard care; and (3) the particular suitability of singing and music to address their needs.’

However, don’t rush to sign up. Potential participants do need to be referred from their NHS post-Covid assessment clinic. In the meantime, if you are suffering from long Covid, and specifically breathlessness, why not turn on the radio and sing along? Apparently, it does not need to be Mozart or even Bernstein – the Beatles will do. Sounds good to me!