Coronavirus update – Part 20 (June 2022)

Dr John Ling continues to provide us with a monthly review of all things Covid – although this will be his last update. 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!

My Coronavirus swansong

Hip, hip, hooray, this is the very last of my Coronavirus updates. They started in October 2020 as a one-off piece concentrating on the bioethical issues of vaccines made with the help of tissue components derived from aborted human foetuses. They were never meant to stretch to Part 2 let alone Part 20.

So why stop at Part 20? It is certainly not because Covid-19 has gone away. Even in the UK, there has been a recent resurgence of cases. Nor is it particularly because of a lack of Covid-19 news, but this has, perhaps inevitably, become somewhat samey – a new surge here, a sub-variant there, new vaccines here, something weird there. By now, we are all familiar with these sorts of themes. And moreover, by now, I think I have said all I want to say about the wretched virus. I want to move onto new projects.

During this 20-month sojourn, I have sought to report on and interpret the fundamental topics – vaccine safety, Covid-19 symptoms, serious human trials, novel strategies, likely causes, promising treatments, potential cures, and so on. Nor have I shied away from censuring anti-vax rhetoric, conspiracy theories and diverse doubters. Overall, I have taken a mostly cautious, risk-averse, scientific approach. Some have disagreed with my stance, but thankfully, more people have expressed their appreciation. I am grateful for all who have bothered to read these articles and contact me. It has been a fascinating and educational road trip. Thank you! Until the next pandemic!

Covid-19 numbers

Welcome to the UK’s Coronavirus statistical switchback. Most of June had been a month of consistent decline in Covid-19 cases, hospitalisations and deaths. A very encouraging trend. But then, in late June, the unexpected reverse occurred. This contrary virus and its adverse symptoms were back with seeming vengeance.

By the end of June, the latest figures from the Office for National Statistics estimated that 2.3 million UK people were infected. That is about one in every 30 people – an increase of 32% on the previous week, after rises of 23% and 43% during the preceding two weeks. What has been happening? The rise is thought to be predominantly due to two fast-spreading sub-variants of Omicron, known as BA.4 and BA.5. These two now account for more than half of new Covid-19 cases in the UK. We are firmly in the grip of a third wave of Omicron.

This upward trend may have been partially caused by increased socialising over schools’ half terms and the Queen’s platinum jubilee weekend celebrations. By contrast, the recent transport strikes and their associated increases in WFH (working from home) may yet bring about a statistical fall.

The weekly death toll in the UK during mid-June was 334 bringing the total pandemic figure to 180,800. Will it ever reach that quarter of a million mark? Hospital admissions have also been creeping up to almost 6,400 from 4,200 in May. The big vaccine roll-out continues with 150 million jabs given to 53 million people – that means about 93% of those aged 12 and over have received at least a first dose. Some 50 million people have had second jabs and 39 million have had booster doses. An extra autumn booster jab roll-out for the over-75s and the vulnerable is about to get underway.

Globally, the figures are mixed, but mostly gloomy. According to the Johns Hopkins Coronavirus Resource Center the worldwide totals are now 550 million cases with 6.3 million deaths. At the end of June, the USA was top of the league table with 87 million cases and 1.02 million deaths. The UK was in eleventh place with 22.8 million cases and 180,800 deaths.

There seems little point in rehearsing more details. Instead, remember that unremitting refrain – this Covid-19 pandemic is not over. Much of the world is still in its grip.

What has Covid-19 taught us?

We have now lived through more than 2 years of the Covid-19 pandemic with some 6.5 million, but perhaps as many as 15 million, deaths and about 550 million cases. In addition, we have witnessed this tiny microorganism destabilise healthcare systems, unbalance economies and confound government leaders worldwide.

The pandemic has indisputably changed our world. This has been a long and uncertain journey. Yet we now seem to have arrived at a crossroads. The pandemic is subsiding in many places. Restrictions are being lifted. Testing has dwindled. The return to something like pre-pandemic life and work is evident. In other words, we have begun to move from living under Covid-19 to living with Covid-19. Where do we go from here? It is a baffling question. Some months ago we thought that if we tolerated a few lockdowns and some personal restrictions, the pandemic would blow over. But that has clearly not been the case. The pandemic marches on and we have yet to experience Covid-19 closure.

True, reported cases and deaths have been declining in many countries, but more than 3 million cases are regularly reported each week. Even that, because of less surveillance and testing, is a numerical underestimate. Global deaths hover around 10,000 each week. Covid-19 is killing hundreds of people every day. This is a miserable and unsustainable situation for both the rich and the poor of this world.

Though we wish otherwise, the virus persists. But there are now other pressing issues to occupy our brains and news media – Brexit, national strikes, monkey pox and polio, a global recession, rising inflation, the cost of living crisis, abortion in the USA, war in Ukraine. Small wonder that Covid-19 is so easily supressed or disregarded.

Yet the pandemic is not over – maybe it never will be. So, what has the wretched virus taught us? Or, more significantly, what have we learned from it? Here are four weighty lessons.

First, have we been too parochially minded? Covid-19 is not equality driven – its unequal toll has left tens of millions in poverty and its greatest effects have been exerted on already-disadvantaged groups. The world has not suffered evenly, so while we in the UK, and the West in general, may think that Covid-19 is largely over and wish to forget it, many other countries are still in the thick of it – think China, North Korea and most African countries. And do not forget that every devastating pandemic is followed by a devastating aftermath.

Second, have we been too smug? We in the rich world have been offered, and mostly accepted, effective vaccines and other treatments, such as anti-viral medicines. They can reduce the risk of severe symptoms, hospitalisation and death. Yet these have not been universally available and effective global protection strategies have not been implemented. The World Health Organization (WHO) once had the aim of vaccinating 70% of the world’s population by June 2022. That policy had clearly hit the buffers. Whereas, some 60% of people have now been double jabbed, in at least 40 countries less than 20% have. Good intentions are praiseworthy, but robust policies and workable systems are needed to deliver them.

Third, are we sufficiently variant-aware? The possible / probable emergence of new and dangerous variants is a continuing threat, even for those fully vaccinated. Think of the Omicron BA.4 and BA.5 sub-variants first reported in South Africa and now potently dominant here in the UK and elsewhere. Mutations creating new Covid-19 variants with high transmission rates, more severe outcomes and the ability to bypass the antibody protections from vaccines and previous infections could rock our world again. New and better targeted vaccines will help. But immunity forever wanes. Will our world need to be boostered forever?

Fourth, are we now planning for the next pandemic? Think monkey pox and polio, though their reach is probably limited. Nevertheless, surveillance and preparedness are key. These will require tough science (what is long Covid, etc.?) and resilient healthcare plans (who should get booster vaccinations, etc.?). It will all cost money, but hopefully well-spent money, not like the eye-watering financial wastes in the wake of the current Covid-19 pandemic – the UK bill presently stands at £321bn with an additional £55bn due soon. Learning from the mistakes and failures over Covid-19, we should be personally, nationally and internationally better prepared to face the next biological onslaught.

The official UK Inquiry into the Covid-19 crisis should be revealing as well as educational. However, its publication is unlikely to be before 2024. Too late? Not really. We already know largely what to do for a better future. Wash hands, avoid crowds, isolate if positive – you know the drill whenever it will be needed. We have already learned great lessons, but our general ignorance is still prodigious.

Omicron sub-variants BA.4 and BA.5

BA.4 and BA.5 were first designated as Variants of Concern in the UK during mid-May 2022. They appeared to be more infectious than the previously dominant Omicron BA.2 variant. The UK Health Security Agency (UKHSA) now reports that BA.5 is growing 35% faster than BA.2 whereas BA.4 is growing only 19% faster. In other words, BA.5 is likely to become the prevailing variant in the UK.

Is this of concern? Researchers at Beth Israel Deaconess Medical Center of Harvard Medical School think so. They have recently reported that BA.4 and BA.5 appear to escape antibody responses among people who had previously had Covid-19 infections and among those who have been fully vaccinated and boosted with the Pfizer-BioNTech vaccine. The levels of neutralizing antibodies produced were several times lower, by a factor of 21, against the BA.4 and BA.5 sub-variants compared with the original coronavirus.

The relevant paper is entitled ‘Neutralization Escape by SARS-CoV-2 Omicron Subvariants BA.2.12.1, BA.4, and BA.5’ by Nicole Hachmann et al.,and was published in the New England Journal of Medicine (22 June, 2022).

The researchers concluded, ‘These data show that the BA.2.12.1 [the dominant variant of BA.2 in the US], BA.4, and BA.5 sub-variants substantially escape neutralizing antibodies induced by both vaccination and infection. Moreover, neutralizing antibody titers [concentrations] against the BA.4 or BA.5 sub-variant and (to a lesser extent) against the BA.2.12.1 sub-variant were lower than titers against the BA.1 and BA.2 sub-variants, which suggests that the SARS-CoV-2 omicron variant has continued to evolve with increasing neutralization escape. These findings provide immunologic context for the current surges caused by the BA.2.12.1, BA.4, and BA.5 sub-variants in populations with high frequencies of vaccination and BA.1 or BA.2 infection.’

In other words, if BA.4, and especially BA.5, become dominant within a population, will the antibodies elicited by both vaccinations and previous infections be sufficient to destroy them? Or will these sub-variants slip through the defensive wall and wreak havoc?

Autumn jabs

When will we get the next jab? The UK’s spring booster programme for vulnerable people and over-75s is still running. The autumn booster programme will start in September and is likely to include the over-65s as well as vulnerable people. Government advisers are weighing up whether to extend this to the over-50s. Younger people are unlikely to be eligible. The advance campaign is already underway. The two mRNA vaccines selected to be used are from Moderna and Pfizer-BioNTech. GP practices will soon be invited to sign up for this autumn booster roll-out now that NHS England has confirmed it will offer a fixed payment per jab with a supplement for housebound patients.

By September, Moderna’s new vaccine should be available for UK residents. This is a bivalent jab that consists of the original Moderna vaccine plus a newly-formulated component designed to boost protection against the BA.4 and BA.5 variants. The current contract with Moderna ensures that the UK will automatically receive the newest version of the vaccine. Other companies are gearing up too. Pfizer-BioNTech has recently announced enhanced results for its tweaked vaccine, though it may not be ready by September. A new bivalent vaccine jointly developed by the French and British drug firms, Sanofi and GSK, has also been shown to generate substantial immune responses against some Coronavirus variants. Other manufacturers are working on joint influenza-Covid-19 vaccines, but they are unlikely to be obtainable before late next year.

The push to boost immunity across rich income, developed populations, before the winter sets in, has become a large-scale crusade. Countries, such as Germany and Israel, have started their autumn booster roll-outs. Others, like the USA, are on the cusp of announcing their intentions.

Covid-19 reinfections

Covid-19 is not a one-off disease. Everyone currently has a different level of immunity depending on their infections, vaccinations, both or neither. Some people have had two jabs, others four. Different mixes of different manufacturer’s vaccines have also been deployed. A report from the Office for National Statistics (ONS) in May suggested that Covid-19 infections provide a stronger and more durable protection against further infection compared with vaccinations.

This is important because most people have by now had their Covid-19 antibody levels raised naturally and/or artificially. So reinfection, or what has been termed ‘Covid rebound’ has become a key issue. The ONS report showed that people who had been infected with Omicron (or the BA sub-variants) had a 77% reduced risk of reinfection. Those infected by Delta had 57% protection, the Alpha figure was 41% and that of the early Wuhan strain was 40%. Strange to say, having a disease apparently offers advantages.

Loss of smell

Anosmia, or loss of smell, was once an early diagnostic feature of Covid-19 infections. As the virus has evolved this effect has become less important. 
An interesting study entitled, ‘Decreasing Incidence of Chemosensory Changes by COVID-19 Variant’ and conducted by Daniel Coelho and colleagues at the Virginia Commonwealth University has been published in Otolaryngology – Head Neck Surgery (3 May 2022).

These researchers surveyed a database of 616,318 people in the United States who had had Covid-19. They found that compared with people infected with the original virus, those who had contracted the Alpha variant were 50% less likely to lose their sense of smell. Moreover, such chemosensory disruption was 44% for the Delta and only 17% for the Omicron variants.

As the authors concluded, ‘These data strongly support the clinical observation that patients infected with more recent variants are at a significantly lower risk of developing associated chemosensory loss.’

There is bad and good news. Smell problems can be long lasting – perhaps for years. As Valentina Parma, a research psychologist has stated, ‘For these people, help can’t come soon enough. Simple activities such as tasting food or smelling flowers are now “really emotionally distressing”.’

The positive news is that our understating of the interaction of Covid-19 and anosmia is improving, but still inchoate. Accumulating evidence suggests there may be some genetic mutations, specifically in two genes called UGT2A1 and UGT2A2, in anosmatic people. Or are structural changes somehow caused by Covid-19 in the brain’s olfactory centre the cause?

Nevertheless, treatments are elusive. Small clinical trials are currently testing a range of potential remedies, including steroids to reduced inflammation, and blood platelet-rich plasma that contains many therapeutic biochemical compounds. For the moment only ‘smell training’ is on offer, but maybe additional and improved therapies will soon become available. The estimated tens of millions of patients with lingering smell difficulties will certainly hope so.

Vaccinations for children

Children are not adults. True. This is an important distinction when it comes to drug testing and drug administration. Moreover, the volunteers in clinical trials have long been predominantly men, often students of a certain age. In other words, women and children have typically been side-lined. If a new medicine is designed to treat whole populations then it should be rigorously tested on the representative whole. Age and sex are important.

So, early on in the development and production of Covid-19 vaccines, it was clear that the distinction of child and adult medicines must be recognised. And for children the demarcation has arbitrarily been regarded as from 5 to 15 years old. In the UK, the NHS recommends two ‘adult’ doses for that age group, with a 12-week intervening gap. Similar strategies have been authorised elsewhere, for example, in the USA.

And so attention has now turned to the under-5s. And, of course, in the medically-informed USA, this has been a hot topic of concern. The upshot has been that during mid-June, the White House announced a highly-anticipated Covid-19 vaccine roll-out plan for children aged between 6 months and 5 years – the first nation in the world to permit such a medical practice. This means that an extra 18 million people in the US will now be eligible for Covid-19 vaccinations.

The US Food and Drug Administration (FDA) has authorised the use of both the Pfizer-BioNTech and Moderna vaccines for these young children. The Pfizer-BioNTech’s vaccine for children aged six months to four years old is a tenth of the adult dose and requires three shots. Moderna’s vaccine for children aged six months to five years old is a quarter of the adult dose and requires two shots.

Vaccine hesitancy is a potent American trait. Only 67% of US adults, 60% of children aged 12 to 17 and 29% of 5 to 11 year olds have been fully vaccinated. So, unsurprisingly, only 18% of parents plan to have their under-5s vaccinated right away, while 38% want to wait and see how the vaccine roll-out progresses. Meanwhile, 27% say they will definitely not proceed. So how successful will this childhood vaccination campaign be? At the moment, it looks uncertain.

The greatest loss from Covid-19

Who, or what, should have the last word in this series of Coronavirus updates? Let it be the children, the next generation, who must live with the fallout of this current Covid-19 pandemic.

The pandemic has brought about many devastating losses – of human life, global economies, healthcare practices, and so on. But perhaps the greatest and longest-lasting impact will be on education, namely children’s schooling.

The United Nations (UN) estimates that more or less all – all of the 1.6 billion schoolchildren in the world – have suffered an average loss of 4.5 months of formal education, mainly because of school closures during the pandemic. Most may well catch up, but for too many, especially among disadvantaged and vulnerable children, that loss will be the most damaging legacy of Covid-19 because it will never be salvaged. That is indeed a sad end.