Coronavirus update – Part 14

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!

The Covid-19 numbers

And so the Covid-19 pandemic rolls and rolls on and on – here, there and everywhere.  December has been the month of B.1.1.529, the new Omicron variant.  Experts and politicians have cautioned us about ‘a deeply concerning situation’, ‘a wave of cases is coming’ and ‘prepare for the worst.’

During December, there has been but one huge datum change.  From mid-December, the number of daily UK cases rocketed exponentially from about 60,000 to 120,000 over just a 10-day period.  This was the contagious Omicron effect.  Cases reached a record peak of 189,846 on 31 December.  The total number of UK cases, since the pandemic began, increased to 13 million.  Let nobody say that Covid-19 numbers are declining.  They are most emphatically not.

Yet while UK cases have been zooming upwards, hospitalisations and daily deaths have remained fairly stable at about 8,200 and 100 respectively for most of the month with about 860 patients on ventilators.  Better Covid-19 treatments and more triple-vaccinated people are the major drivers of this statistical stability.  But, of course, hospitalisations and deaths lag behind any upturns in cases by a week or three.  In other words, hospital admissions and deaths are likely to increase from around mid-January.  Even during the last week of December, the numbers began to take off.  There were 12,000 Covid-19 patients in hospital and deaths were up to 200 per day.  Is this a prelude to a crisis?  So far, hospitals are under pressure, but not catastrophically so.

Vaccination numbers have continued to escalate.  Now 76% of the UK population have had at least one vaccine dose – that is, 51.7 million with a first jab and 47.4 million with a second.  Moreover, a total of 33.9 million third booster doses have been administered.

The global figures are unsparingly bad and the picture is worsening.  Total cases have now exceeded 290 million with almost 5.5 million deaths.  The USA still tops the daily infection table with an average of 600,000 cases, followed by France with 200,000, the UK with 190,000, and newcomer Spain with 160,000.  The USA also still dominates the total death table at 825,000 trailed by Brazil (620,000) and India (480,000) with the UK in seventh place at 148,000.

Alpha, Beta, Gamma, Delta …. Omicron.  We are slowly learning the Greek alphabet.  Will it be Pi, Rho or Sigma next?  Who knows?  But, as ever, this wretched Covid-19 virus and its variants have not finished with us yet.  As they say, ‘Everyone who ignores Covid-19 is perpetuating it.’

Implementing Plan B (and C?)

First, a little chronological review.  On 8 December, Boris Johnson, the UK Prime Minister, confirmed that, because of the rapid spread of Omicron, Plan B, first set out in September, would be implemented.  He said that moving to the tougher measures was the ‘proportionate and responsible’ thing to do.  So from 10 December, face coverings became compulsory in most public places, such as shops and public transport, as well as in cinemas, theatres and places of worship, though with exemptions in hospitality settings.  On 12 December, following advice from the four UK Chief Medical Officers, the UK raised the Covid-19 alert level from Level 3 to Level 4.  The latter is defined by the government as ‘a Covid-19 epidemic is in general circulation; transmission is high and direct Covid-19 pressure on healthcare services is widespread and substantial or rising.’  From 13 December, people were again asked to work from home if possible.  From 14 December, double-jabbed people who have been in close contact with Covid-19 patients could take lateral flow tests (LFTs) for seven days rather than self-isolate for 10 days.  Close contact adults, who are unvaccinated, would still have to self-isolate for 10 days.  From 15 December, the NHS Covid Pass on the NHS App became mandatory for entry into nightclubs and other settings where large crowds gather.  In other words, the UK had entered into a very, very serious situation.

No-one believes that Plan B alone will stop Omicron spreading but hopefully it will slow its transmission to allow more time to understand the variant and to expand the vaccine roll-out, including booster jabs, and so reduce likely threats to the NHS.  Instead of the predicted infection peaks occurring in early January, they might now be stretched out over January and into February.

Plan B was outlined under four headings:
1]  Expanding mandatory mask requirements to more venues.
2]  Changing isolation rules to allow contacts of suspect Omicron cases to take daily tests.
3]  Introducing Covid-19 passports for certain venues.
4]  Making it mandatory for NHS staff to get a vaccine.

Plan B needed Parliamentary approval.  On 14 December, having previously debated these four measures, Parliament finally endorsed them with the closest vote concerning so-called Covid passports – some MPs argued this was ‘lockdown by stealth’.  The Plan B regulations are set to expire six weeks from their implementation, with a review after three weeks.  Two questions arise – what is Plan C and when will it come into force?  It could include, for instance, reducing people’s social contacts, which can be effective, but disruptive.  It could also require Covid-19 contacts to isolate, extend Covid-19 passports to hospitality and entertainment venues, require a wider use of lateral flow tests (LFTs) and make facemasks mandatory in secondary schools, all of which would likely be unpopular, but probably effective.

Sensibly, neither politicians nor the medical community ruled out the imposition of further restrictions.  And they came.  From Boxing Day, 26 December, the three nations, Scotland, Wales and Northern Ireland, introduced various extra curbs on the hospitality and leisure industries, resumed social distancing rules and put limits on the size of gatherings.  No further measures were announced for England, but Boris Johnson said he would not hesitate to act if necessary.

Where are we now?  Plan B has been implemented.  In reality, it is more like an enhanced scheme, a sort of Plan B+.  What is in Plan C and when will it be revealed?  Will there even be a Plan D?  Throughout December, the citizens of the UK uttered two cries, ‘Save our Christmas’ – accomplished.  And ‘Please, anything other than another full-scale lockdown’ – accomplished, so far.

The Omicron variant

On 25 November 2021, almost 2 years since the first case of Covid-19 was announced, a new variant of concern (VoC), named Omicron, was reported in South Africa.  Though an anticipated event, the arrival of this particular viral configuration was unusual because it is such a highly-mutated coronavirus variant and therefore it posed an unknown threat to the efficacy of Covid-19 vaccines and antibody therapies.  It brought with it two key questions.  How fast will it spread?  How sick will it make people?  While data are still scarce and inchoate, Omicron appears to be more highly transmissible but of milder severity than other variants.

Omicron began to spread rapidly around the world with the first UK case of hospitalisation reported on 11 December.  On 13 December, it was confirmed that the first UK patient had died with Omicron.  Overall, it has created general unease and uncertainty in this viral-weary world.  By mid-December it was becoming clear that the UK was facing a substantial wave of Omicron infections – case numbers were doubling every two to three days.  By the end of December, Omicron had overtaken Delta as the dominant variant in the UK.  According to modelling data from the UK Health Security Agency, an estimated 200,000 people might become infected with Omicron each day.  That proved to be a pretty accurate guesstimate.  Moreover, some scientists reckoned that, without further restrictions, the total number of deaths from Omicron could possibly reach between 25,000 and 75,000 by the end of April.  Others predicted more than 2,000 daily hospitalisations, with a total of 175,000 hospital admissions and 24,700 deaths between 1 December and 30 April.  We must wait to see if these doomsters were correct.

A high degree of uncertainty about Omicron exists.  More real-world, hard figures are awaited.  More transmissible?  Yes.  Less severe?  Probably.  By late December, additional, yet still preliminary, data were emerging from the UK Health Security Agency.  They indicated that people catching Omicron are 50% to 70% less likely to require admission to hospital compared with previous variants.  That was good news.  NHS staff were cautiously delighted.

Though encouraging, consider this.  The fact that Omicron appears more transmissible but less severe, means that it could infect more people though less seriously.  However, some, perhaps many, from that numerically greater infected cohort, could still become severely ill and require hospitalisation.  In other words, Omicron could still lead to increasing numbers in hospitals and therefore still put unsustainable pressure on the NHS.  That was bad news.  NHS staff were cautiously disappointed.

Booster doses

So, the question of the month – how effective will current vaccines be against the Omicron variant?  Preliminary data were not encouraging.  Two doses of the Oxford-AstraZeneca vaccine alone, that is, without a booster, gave less than 10% protection against Omicron, whereas the figure for two jabs of Pfizer-BioNTech alone was less than 40%.  However, when the Pfizer-BioNTech vaccine was given as a booster dose those protection figures rose to 71% and 76% respectively.  These were early days with limited numbers, but, long live boosters!  However, additional research has shown that vaccine efficacy against Omicron starts to wane 10 weeks after the booster dose.

So, what to do?  Obviously, ramp up the booster programme.  And so, starting from Monday 13 December, everyone over the age of 18 in Britain was offered a Covid-19 booster jab by the end of December.  Ts & Cs apply, such as a second vaccine dose must have been administered at least three months before the booster.

Logistically, this is an immense undertaking.  It was estimated that 15 million vaccinations must be administered within three weeks, equivalent to about 1 million doses per day.  On 13 December, the first day of the ramped-up roll-out, the target was hindered because the NHS booster booking website crashed and the demand for lateral flow tests (LFTs) overtook supply.  The latter problem was exacerbated by new advice that fully-vaccinated people should take daily tests for seven days after coming into contact with a Covid-19 patient.  Nevertheless, the scheme soon stabilised.  Healthcare workers were seconded, walk-in clinics were constructed, opening hours were extended and the military were redeployed to speed up the campaign.  There has been jabbing around the clock and, in some places, even on Christmas Day.

Hooray for boosters!  They are probably here to stay.  Maybe we will need extra jabbing every few months or every year.  So, is a fourth vaccine on the cards?  Israel has already started testing such a scheme targeted at the vulnerable over-60s and healthcare workers.  We already have the essential vaccine technologies, so why not improve them and use them?

Above all, the Omicron saga has shown that two jabs are not enough – a third booster dose is needed to improve immunity.  The full-page newspaper advertisements scream ‘GET BOOSTED NOW.’  It has become the UK’s pandemic war cry.

New vaccine and new treatment news

Vaccine makers are already busy – yes, even this very day.  Not only are they actively manufacturing their already-approved products, but many are planning ahead and tweaking their vaccines, especially against Omicron.  Some of these updated versions should be ready by early 2022, say, around March.  In addition, new vaccines and treatments are in the news, in trials and in cold storage.  It is estimated that researchers are currently developing more than 300 novel products.  Of these, nearly 200 are being tested in Phase 1 and Phase 2 laboratory and animal studies while 40 are in large international Phase 3 human clinical trials and a few are actively seeking regulatory approval.  Here is a selection of the most ready so far – the news is not all good.

On 4 November, the Medicines and Healthcare products Regulatory Agency (MHRA) authorised the UK to become the first country to approve the use of molnupiravir, an oral antiviral drug, marketed as Lagevrio.  Interim data from clinical trials showed it could halve the risk of hospitalisation for Covid-19 patients.  On 19 November, the European Medicines Agency (EMA) informed EU member states that they too could use molnupiravir to treat Covid-19 cases.

Strangely, this US product had not yet been approved for use in the US.  On 30 November, an advisory committee of the US Food and Drug Administration (FDA) voted to recommend its approval, but by only 13 to 10.  Why the delay and lack of accord?  Simple.  Full trial data submitted to the FDA showed molnupiravir to be less effective than originally thought.  That luminous 50% reduction in the risk of hospitalisation was now reported to be a lacklustre 30%.  Moreover, there are now concerns about research suggesting that molnupiravir can cause mutations in human DNA.  Last October, Britain bought almost 500,000 courses and in December procured another 1.75 million.  Were these good buys?

In early December, the global healthcare giant, GlaxoSmithKline (GSK) together with Medicago, a Canadian biopharma company, announced preliminary results from a Phase 3 trial of their plant-based Covid-19 vaccine.  It is the first vaccine of its kind to reach the stage ready to seek approval from regulatory agencies.  In the trial, with over 24,000 adult participants and against various Covid-19 variants including Delta, efficacy was recorded as 75.3%.  The vaccine was well-tolerated with no serious adverse effects in the vaccine group.

What is the basis of this somewhat usual, and as yet unnamed, vaccine?  Medicago uses Nicotiana benthamiana plants as bioreactors to produce non-infectious, so-called Virus-Like Particles (VLPs).  VLPs are designed to mimic the physical structure of the Covid-19 viruses so they can trick the body’s immune system into recognising them as hostile.  But VLPs lack the core genetic material so they are unable to replicate.  Hence, any viral attack is halted.  Fascinating!

The Big Three vaccines approved for use in Britain are owned by Oxford-AstraZeneca, Pfizer-BioNTech and Moderna.  What has happened to the Novavax vaccine (officially known as NVX-CoV2373 or Nuvaxovid), that fourth vaccine with such big promise?  Indeed, the UK government was so impressed by its interim trial results of February 2021, which reported a 95.6% efficacy against the original virus, that it ordered 60 million doses.  However, subsequent studies reported reduced efficacies of 90.4% in a Phase 3 trial and 51.0% in a Phase 2 trial against Beta.  Further difficulties and delays with manufacturers, scientists and regulators, especially the FDA, seem to have scuppered Novavax’s early promise.

Have these delays disqualified Novavax from joining the Big Three?  In late November, Novavax submitted its final trial data to the UK Medicines and Healthcare products Regulatory Agency (MHRA) and the European Medicines Agency (EMA).  Approval by the latter was granted on 20 December – the European Union (EU) has already signed a deal to buy up to 200 million doses.  Novavax remains hopeful that, by the end of 2021, it will be able to manufacture 150 million doses a month and that the pending authorisation problems will be solved.  In the meantime, Novavax has reported commencement of human trials of its new Omicron-specific vaccine in early 2022.

And where is that one-shot Janssen vaccine manufactured by Johnson & Johnson?  It was approved for use in the UK in May 2021 with doses due to be delivered by the end of this year.  The UK ordered 20 million doses, but, somewhat oddly, these are now destined to be donated to developing countries, via the COVAX initiative, as soon as they come off the production line in 2022.  Is this a case of ‘vaccine dumping’?  The Janssen vaccine has been associated with rare but serious blood clots and some deaths and subsequently downgraded for use in the USA.

The Covid-19 vaccine produced by the French biotechnology company Valneva (officially known as VLA2001) looked set to be another effective weapon in the armamentarium.  Functionally, unlike most other Covid-19 vaccines, it targets not just the spike protein of the virus but rather the whole virus.

In February 2021, the UK government increased its order of 60 million Valneva jabs by securing an extra 40 million doses of this ‘promising vaccine candidate’ for delivery in 2021 and 2022.  However, in September, before the Phase 3 trial’s data had been reviewed, the UK Health Secretary, Sajid Javid, announced that the Valneva vaccine would not be approved by the UK Medicines and Healthcare products Regulatory Agency (MHRA).  At the same time, the UK announced it was cancelling its 100 million dose contract with Valneva, a deal worth £1.2bn.  What, why?  Apparently, Javid had ‘misspoke’ and meant to say that the vaccine had ‘not yet’ been approved.

A month later, in October, Valneva reported efficacy data similar to those for the Oxford-AstraZeneca vaccine suggesting that UK authorisation could be imminent.  The decision from the MRHA is expected by the end of 2021 with initial approval probably for use in 18 to 55-year-olds.  Meanwhile, on 10 November, an agreement for supplying up to 60 million doses was reached with the European Commission (EC) for delivery starting in 2022.  With considerable foresight the EC president, Ursula von der Leyen, stated that, ‘The contract allows for the vaccine to be adapted to new variants.’  Or was that transaction simply an advertisement designed to instil confidence in other potential buyers?  Politics and medicine can be strange bedfellows.

And there is Sotrovimab.  Who names these medicines?  At the beginning of December, sotrovimab, commercially known as Xevudy, was approved by the UK Medicines and Healthcare products Regulatory Agency (MHRA).  It is another monoclonal antibody (like AstraZeneca’s Evusheld).  Developed by GlaxoSmithKline (GSK) and Vir Biotechnology, based in San Francisco, sotrovimab works by binding to the spike protein on the Covid-19 virus. This in turn prevents the virus from attaching to and entering human cells, so that it cannot replicate in the body.

In clinical trials, a single dose of Xevudy was found to reduce the risk of hospitalisation and death by 79% in high-risk adults with symptomatic Covid-19 infections.  It was found to be most effective when taken during the early stages of infection and so the MHRA recommends its use as soon as possible and within five days of symptom onset.  Sotrovimab is administered by intravenous infusion over 30 minutes.  It is approved for individuals aged 12 and above who weigh more than 40kg.

Dr June Raine, MHRA Chief Executive, commenting on Xevudy’s approval said, ‘This is yet another therapeutic that has been shown to be effective at protecting those most vulnerable to Covid-19, and signals another significant step forward in our fight against this devastating disease.’

On 22 December, Paxlovid, the take-at-home, twice-a-day, oral antiviral drug from Pfizer, became the first such pill to be authorised by the US Food and Drug Administration (FDA) to treat Covid-19.  In trials it achieved a nearly 90% reduction in hospitalisations and deaths among those patients most likely to get severe Covid-19.  In October, the UK government purchased 250,000 courses of Paxlovid and in December signed a contract for 2.5 million additional courses.  The drug finally received approval from the UK’s Medicines and Healthcare products Regulatory Agency (MHRA) on 31 December.

Vaccine mandates, or mandatory or compulsory vaccinations

Fact 1: vaccination is the principal tool that every country, every jurisdiction, is currently using to fight the Covid-19 pandemic.  Fact 2: already Covid-19 vaccinations have undeniably saved millions from death and serious illness.  Fact 3: some people struggle with vaccination hesitancy or vaccination refusal.  Fact 4: mandatory or compulsory vaccination is a thorny issue.  But it is not a new issue.  Way back in 1853, the UK’s Vaccination Act made jabs against smallpox compulsory for infants under 3 months old.  Parents who failed to comply were liable to a fine.  It was in the name of public health that governmental authority was challenging traditional civil liberties.  Yet this strategy of a vaccine mandate caught on and as a result the often-deadly disease of smallpox was essentially eradicated worldwide.

The UK and most other countries in the developed world have made vaccination their primary medical response to control and escape the Covid-19 pandemic.  Two simple statistics tell the story.  In mid-September, according to England’s Deputy Chief Medical Officer, Jonathan Van-Tam, ‘Our latest estimates are that since we began deploying these vaccines, they’ve probably averted in the region of 24 million cases of COVID in the UK and 112,000 deaths.’  However, this issue of compulsory vaccination remains contentious and complex.

Where to start?  Back in October 2020, Coronavirus – Part 1, which can be accessed at: http://www.johnling.co.uk/Covid1.html, discussed something of the basic ethics of vaccination.  Four major points arose.  First, some are troubled by the vaccines themselves, including their development from cellular material historically derived from aborted human foetuses.  Others cite their alleged hasty production and abridged testing of the vaccines.  Second, there is the ethical force of the Golden Rule, expounding an obligation to our neighbours – vaccination benefits both us and them.  Third, the unvaccinated can expect prohibitions, such as exclusion from public spaces, entertainment venues and community services.  Fourth, the notion and role of conscientious objection is moot.

The discussion context here is a binary model – there are two camps, two factions.  First, there are the healthcare workers and second, there are the general public.  In the grand scheme of the pandemic, they are the care givers and the care receivers.

And so first to the frontline of healthcare workers – NHS staff and care home staff.  These are the people most frequently in contact with the most vulnerable – the elderly, the chronically ill, the disabled, and, of course, Covid-19 patients.  On 9 November, the UK government announced that all ‘health and social care workers, including volunteers who have face-to-face contact with service users, will need to provide evidence they have been fully vaccinated against Covid-19 in order to be deployed.’  There was a 12-week grace period between the regulations being made and coming into force to allow those who have not yet been vaccinated to have the required doses.  Enforcement would begin from 1 April 2022.  In other words, the UK Health Secretary, Sajid Javid, mandated that care home workers who are not prepared to get the Covid vaccine should get another job.

It has been estimated that 73,000 NHS staff would leave front-line roles in addition to another 38,000 employees from care homes.  According to Javid, there are around 100,000 unvaccinated NHS staff.  There is obvious concern about the cumulative effect of staff departures and insufficient recruitment arising from this vaccine mandate.  A survey conducted during the autumn of 2021 showed that over 90% of NHS trust leaders were worried by the projected outcomes, whereas 58% of them supported mandatory Covid-19 vaccinations for staff.  Of course, temporary and permanent workforce absentees, including both those infected and contacted, plus leavers, including both those voluntarily and obligated, will increase the workload of existing staff, while infected employees will be potential spreaders also adding to the overall burden on the NHS.

Arguably, the first and foremost reason to get vaccinated is to protect oneself.  However, the healthcare profession uniquely functions face-to-face with others, and often physically closer than that.  Does this occupational uniqueness bring extra obligations?  Yes, because patients are not secondary, nor is this a case of ‘my body, my choice.’  Consider those two ethical giants, Scripture and the Hippocratic Oath.  The former expresses the primary public duty in the so-called Golden Rule of Matthew 7:12, ‘In everything, do to others what you would have them do to you’ and again in Matthew 22:39, ‘Love your neighbour as yourself.’  The Hippocratic Oath expresses the primary medical duty even more succinctly as ‘first, do no harm.’  These two enduring ethical statements re-emerge, for example, in the first rule of the General Medical Council’s (GMC), updated November 2020, publication, ‘The duties of a doctor’, which states, ‘Make the care of your patient your first concern.’  Furthermore, the GMC instructs doctors to be ‘immunised against common serious communicable diseases.’  Herein, already exists a robust ethic for medical professionals, so why should further insisting it is underwritten by a legal mandatory requirement be anything other than a minor step?  Surely it is a minimal intrusion into personal freedom, yet justifiable on the grounds of protecting the health and welfare of both staff and patients.

However, the professionals are not all approving.  For example, the UK’s Royal College of Physicians and the Royal Pharmaceutical Society have spoken out against mandatory Covid-19 vaccinations for healthcare staff.  The Royal College of Nursing has ‘significant concerns’ about it.  And the Nuffield Council on Bioethics has called for more evidence of the need for mandatory vaccination before resorting to coercion.

Now, what about compulsory vaccination and that second branch of the binary model, the general public?  At a televised press conference on 8 December, the UK’s Prime Minister, Boris Johnson, stated that ‘I didn’t want us to have a society and a culture where we force people to get vaccinated.’  However, he went on to say, ‘I do think we need to have a national conversation about ways in which we deal with this pandemic.’  And he declared that ‘the country can’t keep going indefinitely with non-pharmaceutical interventions’ [NPIs, such as imposed lockdowns] just because ‘a proportion of the population’ remain unvaccinated – the latter currently extends to some six million Britons, who are eligible, but have yet to receive even a first dose.  Yes, this issue is certainly contentious and complex.

Indeed, upholding a bold ethical stance and formulating a practical response can be a knotty conundrum.  And the UK is not alone.  What is happening worldwide?  France has already taken the leap.  Back in July 2021, when a new law on mandatory vaccinations was announced, the vaccination rates among healthcare workers was 60%, but by October it had reached over 99%.  Then, at the beginning of December 2021, Austria and Greece announced that their citizens must be fully vaccinated against Covid-19 by early 2022.  Austria is requiring all adults to be vaccinated by February 2022.  Greece is targeting the over 60s and has already started collecting monthly fines from those who refuse.  Meanwhile, in the USA, where the pandemic has already killed over 800,000 citizens, mandatory regulations are escalating.  For instance, on 5 November, the Biden administration, under the auspices of the Occupational Safety and Health Administration (OSHA), issued a ruling that companies with 100 or more workers must require their employees to be vaccinated or undergo weekly testing.  The decree was immediately challenged, then suspended and then, on 18 December, reinstated by the courts.  This vaccine-or-test order will effect 84 million US workers.  In the meantime, driven by recent surges of the Omicron variant, more and more countries around the world are faced with implementing or, at least, discussing plans for mandatory vaccinations.

So, what to do?  There are three possible strategies.  Strategy 1 is, to do nothing and hope the pandemic will somehow naturally come to an end – an unlikely scenario.  It consists of neither carrot nor stick, and is hardly worthy of the title ‘strategy’.  Yet it has its supporters, especially among those who consider that herd immunity will get us out of this dilemma.  However, for that to work a population must consist of about 70% of carriers of Covid-19 antibodies.  To achieve that high figure will require not only naturally-infected individuals but also a cohort who have already submitted to the ‘derided’ vaccines.

Strategy 2 is, to use the current ongoing, gentle, nuanced persuasion campaign, with a specific focus on the disinclined, plus a greater provision of easy-access vaccination facilities in order to achieve a largely, triple-jabbed populace.  A public majority would deem this as the most sensible approach – indeed, it is currently being enacted – but is there sufficient time and means to realise it?

First, who are these disinclined, those who are impeding Strategy 2?  They consist of two rather nebulous groups.  There are the indolent, whose lives are typically characterised by a measure of disorder and sloth.  Yet given time and encouragement and some badgering, most will eventually get round to organising that trip to the vaccination centre.  And there are the vaccine hesitant.  They tend to be genuinely unsure about certain aspects of the whole Covid-19 affair.  They come in assorted flavours.  For instance, there are the ethically hesitant, such as those who fear the vaccines have been specifically derived from human abortion materials.  They have largely misunderstood the basics of vaccination.  And there are the legally hesitant, those objectors who would cite Article 7 of the EU Charter of Fundamental Rights, or some similar statement, ‘Everyone has the right to respect for his or her private and family life, home and communications.’  For them a government diktat is a step too far in curtailing their liberties.  However, time usually erodes their objections.  After all, such citizens of the so-called Free World, frequently baulk at governmental edicts.  For instance, in the UK, when the wearing of motorbike helmets was made compulsory in 1973, and car seatbelts a decade later, there were howls of protest.  Nowadays, these measures are regarded as for the individual and public good.  And there are the scientifically hesitant.  They fear that the vaccines have been too hastily made and insufficiently tested.  Again, they are unaware of the decades of completed research that underlies the current vaccines.

It is these vaccine-hesitant folk who are currently attracting the ire of the general public.  One simple statistic tells the story.  Up to 93% of Covid-19 patients, who are hospitalised in the UK and occupying intensive care beds, are unvaccinated.  In other words, they are denying hospital access to numerous victims of strokes, heart attacks, elective surgery and so on.

Caution, caution!  Making moral judgements against the unvaccinated is not without menace – restraint and benevolence are called for.  For example, are the unvaccinated any worse than those who drink or smoke excessively, those with a high BMI or those who engage in dangerous sports?  They too are mostly making deliberate choices that can lead to illness, hospitalisation and death.  Such people are also costing the NHS dear.  After all, their lifestyles can also place them in competition with the unvaccinated for those scarce, intensive care unit beds.  But are we less angry with them?  And are the advocates of ‘no vax, no bed’ on a slippery slope to denying medical treatment for all Covid-19 patients?  And are supporters of ‘no jab, no job’ happy to deny employment opportunities for many?  Yes, this issue is certainly contentious and complex.

Second, quite part from the disinclined, the indolent and the hesitant, there are the anti-vaxxers, the conspiracy theorists, various ideologues, Uncle Tom Cobley and all, who tend to be militantly opposed to all things vaccination.  They tend to dislike legislative authorities and their rulebooks, so they regard the government’s Covid-19 responses as government overreach.  Theirs is a continuing campaign of misinformation, fake news and false claims conducted mostly via social media.  Such widespread dissemination of falsehoods about the safety, efficacy, components, adverse effects and purpose of vaccines and vaccination programmes will have negatively affected vaccine uptake among some.

Yet, for the vast millions of citizens, this Strategy 2 generally progresses quite nicely without any inducements – most people accept a Covid-19 vaccine when offered.  But occasionally the roll-out can be helped along with real-life sticks and carrots.  Some jurisdictions use sticks.  For instance, in Singapore, those who choose not to be vaccinated must, from 8 December, pay for treatment costs if they contract Covid-19.  A stay in intensive care is reckoned to cost about £14,000.  That stick may well increase the vaccine take-up rates.  Other jurisdictions use both sticks and carrots.  For example, when New York City insisted that its public employees must get jabbed, the stick was loss of employment, whereas the carrot was an extra $500 in their pay packets.  What about carrots alone?  Certainly in the USA, gifts of tickets to entertainment events, free food and even lotteries with cars as prizes have driven up jab rates.

And when all of the above Strategy 2 arguments and urgings prove to be insufficiently effective, what?  Strategy 3 is, to legally impose mandatory vaccination – by and large, it would likely succeed, but at a price.

While the majority of people favour Strategy 2, that is, a policy of multiple and widespread vaccinations, they are less enamoured about a programme of compulsory vaccination.  After all, the implementation of such an obligatory scheme would not be simple.  For instance, how are the unwilling to be vaccinated?  Should they be restrained and jabbed by force?  Should they be repeatedly fined until they are bankrupt?  What about those, who, with some ethical vigour, oppose vaccinations in general and Covid-19 vaccines in particular?  Is the legal status and role of conscience objection moot?  Should no-one ever have their conscience rubbed raw?  Should no-one ever be coerced to participate in an action against their ethical principles?  Healthcare workers are already excused some procedures on personal medical grounds, but what about on ethical grounds?  Non-involvement in procedures, such as abortion, are allowed since a colleague can usually be readily deputed, but a colleague cannot stand in to receive a proxy Covid-19 vaccination.  What about those employees who are threatened with the loss of their jobs because they refuse to be jabbed with what some conscientiously regard as experimental vaccines, which are still only permitted under so-called Emergency Use Authorisation (EUA) and which inevitably lack long-term safety data?

Life is often beset with difficult choices.  Formulating personal and community values and then framing appropriate responses are best achieved by discussion and argument.  Questioning is crucial.  For example, why are NHS workers continually constrained to treat the unvaccinated?  Why are tens of thousands of NHS workers refusing to be vaccinated?  Why not insist that unvaccinated patients are treated by unvaccinated staff in isolation hospitals?  Why not mandate all unvaccinated front-line healthcare workers to accept frequent Covid-19 testing?  After all, would not a recent negative test result provide better patient protection than a vaccine passport that merely indicates details of past vaccinations?  Yes, this issue is certainly contentious and complex.

But there comes a time when a decision has to be made, albeit even with partial information.  For the Covid-19 pandemic that time, at the borders of 2021 and 2022, is imminent.  Omicron has forced our hand.

For front-line medical healthcare and care home workers especially, unless they are medically exempt, they should be subject to mandatory Covid-19 vaccinations to protect not only their own lives but also those of the patients they treat.  Caution, caution!  The statement of such a single-minded approach to healthcare can be easily misunderstood and quickly turned to be perceived as both coercive and cruel.  Granted this approach is radical and all-inclusive.  But cruel?  Never.

And for the general public?  A more rigorously-implemented Strategy 2 vaccination programme, perhaps with additional restrictions, even lockdowns, will counter much of this anti-vaccination narrative and see us through.  In other words, as yet, keep Strategy 3 in reserve.  In the meantime, follow the mantra, ‘GET BOOSTED NOW.’  And when that fourth jab becomes available, get that too!

Vaccinating the world

‘No-one is safe until everyone is safe.’  Who coined this now famous sentence?  Certainly it was used at a media briefing on 18 August 2020 by Dr Tedros Ghebreyesus, the Director-General of the World Health Organization (WHO).  And it has since become the watchword of several global organisations like the WHO, UNHCR and COVAX.  Who first said it?  Never mind, because it is ethically, politically, socially and medically true.

At that same meeting, Ghebreyesus called for international collaboration with regards to research, medicines and supply of necessary items, including vaccines.  He said, ‘We need to prevent vaccine nationalism.  This is the only way to ensure equitable access and fair allocation of future vaccines.’

Think about this.  The western and developed world has stockpiled more Covid-19 jabs than it can use.  Demand has dipped below supply.  Excess stocks can go out of date.  Poor logistical and health infrastructures remain key challenges.  While vaccine inequity persists it will prolong the pandemic.  If billions of people are left unvaccinated, the virus is more likely to mutate and return and render stockpiled vaccines ineffective.

According to a recent report from the House of Lords, as of mid-December, only 6% of people in low-income countries have received at least one vaccine dose compared with 75% in high-income countries.  Similarly, the WHO has calculated that by mid-2021 more than 5.7 billion vaccines doses had been administered globally, but only 2% had gone to Africans.  Just 1 in 4 front-line healthcare workers on the African continent had been fully vaccinated.  Is there a moral imperative to ensure that Africa receives sufficient vaccines for its 1.2 billion people?  Africa is but one example – other poorly vaccinated areas exist.

What to do?  COVAX is the major player in the global effort to provide fair and equitable access to Covid-19 vaccines for every country in the world.  It is backed by the UN and co-led by the Gavi Vaccine Alliance, the World Health Organization and the Coalition for Epidemic Preparedness Innovations.  It allocates vaccine doses proportionally among its 140-plus beneficiary states according to population size.  COVAX faces a mountainous task.

What has the UK contributed?  At the June 2021 meeting of G7 leaders in Carbis Bay, Cornwall, the UK promised to donate 100 million vaccine doses by June 2022.  Of these, 80% would be distributed through COVAX.  Back in October 2021, the UK promised to give away all of its ordered 20 million Janssen vaccine doses to COVAX by 2022.  After all, the UK had decided to use mRNA vaccines, such as the Pfizer-BioNTech and Moderna, for most of its teenage and booster vaccination programs rather than the adenovirus-based Janssen vaccine.  The UK is also not using the Oxford-AstraZeneca jab in its current booster program, nor for those aged under-40 who have been advised to have mRNA vaccines for their two main doses.  As of 6 December 2021, according to a House of Lords research briefing, 26.2 million doses of the Oxford-AstraZeneca vaccine had been delivered to COVAX, with a further 20 million expected by the end of 2021 and around another 20 million in 2022.  This brings the UK’s grand total of donated plus promised doses to a laudable 86 million.  But do these dealings hint at a quiet ditching of our unwanted vaccines rather than a wholehearted donating?

Elsewhere, COVAX has, for example, set aside 4.73 million doses of AstraZeneca’s vaccine for shipment to North Korea, one of the very few countries that has not yet started vaccinating.  The reclusive state had earlier rejected the offer of nearly 2 million doses.  This allocation is part of COVAX’s grand plan to distribute another 43 million doses of the Oxford-AstraZeneca and Moderna vaccines by the end of December 2021, bringing to fruition its aim to ship up to 1 billion doses in total during 2021.

Of course vaccine donation is not the only way to help vaccinate the world.  Exempting Covid-19 vaccines from intellectual property (IP) rights would allow greater production worldwide and so improve access and equity.  Simple cash is also useful to fund not just vaccine manufacturing facilities but also to initiate test and trace schemes and other public health measures.  These and other arrangements are currently being addressed and answered in mostly minor ways.  After all, what is the UK’s promised contribution of 100,000,000 vaccine doses in a world of 8 billion or 8,000,000,000 people?  It’s 1.25%.  And that percentage will be lower when the required multiple doses are taken into account.

This Covid-19 pandemic has undeniably created a global rich versus global poor conflict.  It is the duty of the rich to sort it out.  As they say, ‘No-one is safe until everyone is safe.’  We are certainly not safe yet.

Covid-19 in animals

Human beings are self-evidently prime targets for several of the variants of the Covid-19 virus.  But animals are sometimes infected too.  For example, the famous Lincoln Children’s Zoo in Nebraska has long enjoyed the antics of three of its snow leopards – Everest, Makalu and Ranney.  In mid-November, the Zoo announced that these celebrated cats had died of complications from Covid-19.  Other animals, including hippos and hyenas, have also been infected at other zoos around the world.  In addition, wild animals, such as the white-tailed deer in USA, are susceptible to Covid-19.  Could such captive and wildlife animals become reservoirs of Covid-19 infections, or even locations for viral mutations, that could be transmitted to people and other animal populations?

And what about pet animals?  What are the threats to pet owners?  It seems that humans can infect cats and cats can infect other cats.  But, so far, there is little evidence for Covid-19 transmission from either pet cats or dogs to humans.  Nevertheless, the very origins of the Covid-19 pandemic in Wuhan, China, may have involved the initial virus jumping from animals to humans, possibly from bats or pangolins or some other intermediary.  Meanwhile, the US Centers for Disease and Control Prevention (CDC) warns that the virus could spread from people to animals during close contact.

Will there be jabs for cats and all those newly-acquired ‘pandemic’ dogs?  Could they become cuddly, silent super-spreaders?  Already, Zoetis, a global animal health company, a spin-off from Pfizer, has developed a vaccine based on coronavirus spike proteins which could be adapted for a wide range of animal species.  Zoetis has recently donated 11,000 doses of this experimental Covid-19 vaccine to nearly 80 zoos across the USA for use in animals ranging from great apes to mink.  However, Covid-19 vaccines for domestic pets are not generally available, or needed.  Yet.  So your Felix and Rover are currently spared the needle.