Introduction by Croakey: The COVID-19 pandemic has notched a series of grim milestones, surpassing 35 million cases globally and one million deaths, with US President Donald Trump the latest world leader to be infected and a growing cluster now emerging from the White House.
Trump has stoked controversy at almost every turn of his encounter with the disease, goading Americans not to be afraid of SARS-CoV-2 or allow the pandemic to control their lives and downplaying the seriousness of the disease, days after being evacuated by helicopter to receive medical treatment including an exclusive cocktail of experimental drugs.
Trump persists in scorning mask-wearing and been roundly criticised for taking a joyride during his convalescence to greet supporters outside Walter Reed, knowingly exposing personnel inside the enclosed car with him to COVID. The White House is also reportedly refusing to contact trace cases linked to the growing cluster there.
Trump continues to politicise the US response to the pandemic, attempting to frustrate FDA vaccine review plans in order to rush a COVID immunisation onto market before the November election.
In the latest Croakey COVID-19 Wrap, public health researcher Alison Barrett looks at the race for a SARS-CoV-2 vaccine, the ingredients for a successful control strategy, and why our brains just cannot process the enormity of the pandemic’s vast and mounting toll.
SARS-CoV-2 vaccines in development
Krammer, F, Nature, 23 September 2020
Florian Krammer from the Department of Microbiology, Icahn School of Medicine Mount Sinai in New York, has written a comprehensive review of the current state of vaccine development in response to the COVID-19 pandemic; a process that has moved at a rapid pace.
Vaccine development traditionally takes up to 15 years and is very expensive. Some of the reasons why the vaccine against SARS-CoV-2 is moving so quickly is because preclinical work has already been completed in SARS-CoV-1 and Middle Eastern CoV (MERS CoV) vaccine development; and developers are willing to accept an unusual degree of economic risk because of the speed and widespread impact of COVID-19.
Wrote Krammer:
“It is very important to point out that moving forward at financial risk has been the main factor for accelerated SARS-CoV-2 vaccine development, while no corners have or should be cut in terms of safety evaluation.”
More than 180 vaccine candidates are currently in development; as of October 2, 42 are in clinical trials and nine in Phase III trials, testing the efficacy and safety in large groups of people.
The World Health Organization maintain records of the vaccines in development here.
The nine vaccine candidates WHO have listed in Phase III clinical trials include Sinovac’s CoronaVac, Sinopharm’s inactivated vaccine, CanSino’s AdV5-based vaccine, AstraZeneca’s ChAdOx1 nCoV-19, Moderna’s mRNA-1273, Pfizer’s BNT162b2, Novavax’ NVX-CoV2373, Gamaleya Research Institute’s Sputnik V and Janssen Pharmaceutical Companies’ Ad26.COV2.S.
China and Russia have approved early use of vaccines before completion of Phase III trials: CanSino’s AdV5 vaccine is being used in the Chinese military, and in August, the Russian Government announced Gamaleya Research Institute’s Sputnik V vaccine had been cleared for widespread use, later stating that the approval was subject to positive Phase III results.
In his review, Krammer raised some challenges associated with COVID-19 vaccine development:
- The vaccine candidates currently in development are given intramuscularly, which are effective at enabling antibodies in the lower respiratory tract, but not so proven for the upper respiratory tract. This means they could protect humans from the disease but not the infection, and thus the virus may still transmit between people
- It is unclear at this stage how well elderly individuals will respond to a vaccine. The Phase I and II Sinovac and Pfizer trials indicated higher doses may be required for elderly populations, and this is currently being evaluated in their Phase III trials
- Some of the vaccine candidates have reported side effects (AstraZeneca, Moderna and Pfizer) in their adult cohorts, which raises concerns about reactivity of the vaccine candidates in children
- It’s unknown at this stage how long vaccine immunity will last; booster doses may be required, which may impact global demand and requisite supply
- Duration of time required to vaccinate global population
- Some of the vaccine candidates (in particular, Moderna and Pfizer’s) need to be stored frozen, making global distribution a challenge
- To meet global demand, a minimum of 16 billion doses will be needed, and development and distribution of this dose volume may be a challenge
The global dispersion of vaccine development efforts is a positive, as it should help with distribution issues. It also means that, should not all candidates make it through Phase III trials with positive results, other options will be available.
Krammer concludes by saying:
“Despite all the challenges discussed here, we are in the process of developing vaccines as countermeasure against COVID-19 at record speed and it is certainly possible that vaccines with safety and efficacy proven in Phase III trials might already enter the market in 2020.”
Krammer explained key points from his review in this 138-post Tweetorial:
1) SARS-CoV-2 Vaccines – I promised a Tweetorial and here we go. This is going to be long and nerdy. But I'll make sure it is easy to understand. If you want more details, please just read this: https://t.co/XBnamI2pKk
— Florian Krammer (@florian_krammer) September 28, 2020
Why our minds can’t make sense of COVID-19’s enormous death toll
Richards, SE, National Geographic Science, 29 September 2020
By the end of September, worldwide COVID-19 deaths had exceeded one million, of which 210,000 were from the United States (US), accounting for the world’s highest COVID-19 death toll.
It is likely that the actual global toll is higher than reported, due to inaccurate classification of deaths from COVID-19 and under-reporting. Some countries do not have the capacity to count them all.
It is unclear how the toll will affect people’s mental health and wellbeing, with journalist Sarah Elizabeth Richards exploring in this piece for National Geographic whether the 200,000 death milestone in US will stoke new urgency or merely deepen disengagement.
While people try to compute staggering death tolls and case counts, there are many more pressing concerns for both individuals and communities: income, education, elections, and changes to our basic way of life, whether that’s shopping, socialising, or work.
“More tragedy doesn’t always elicit more empathy; it can counterintuitively bring apathy,” Richards wrote.
People can become less compassionate due to “psychic numbing,” and an inability to “scale up” our compassion, according to Paul Slovic from the University of Oregon.
Slovic has found that people’s concern for those in need doesn’t increase proportionate to the volume of the needy, but instead tends to fragment.
“Our feelings are very strong for one person in danger, but they don’t scale up very well,” he said. “If there are two people, you don’t feel twice as bad. Your attention gets divided, and you don’t have as strong an emotional connection.”
As the pandemic stretches into its tenth month, with no clear end in sight, a kind of tolerance is developing, where increasing numbers may no longer prompt the same emotional response.
Other factors allowing people to detach from mounting COVID-19 tolls and other pandemic news include being at a remove from anyone directly affected, and an inability to properly grieve and memorialise deaths due to social distancing.
“People are hitting the wall because we’re talking about these deaths in every other way except loss,” said David Kessler, author of Finding Meaning: The Sixth Stage of Grief.
Slovic, Kessler and UCSF Professor of Psychiatry Mardi Horowitz have the following recommendations for dealing with news of the pandemic:
- Find ways to acknowledge feelings of hopelessness and fear and accept them as normal feelings
- Avoid compassion fatigue by thinking of individuals with names and faces, not as a number. If we honour the people who have died, that provides more meaning to the death tolls
- Recognise the instinct to disengage as an important motivator for change: redirect these feelings into practical measures like encouraging others to wear a mask or practice physical distancing
“Numbness should not let us off the hook,” Kessler said.
Lessons from easing COVID-19 restrictions: an analysis of countries and regions in Asia Pacific and Europe
Han, E et al, The Lancet, 24 September 2020
Movement restrictions and lockdowns have helped reduce the spread of the novel coronavirus; but, at huge socioeconomic cost.
According to the World Bank, a global recession is imminent, the likes of which we have not seen since World War Two.
Given this economic cost and the emotional toll of lockdown, governments and public health experts are looking for more nuanced ways to manage ongoing waves of COVID-19, recognising that strict population controls cannot be maintained long-term.
This is particularly salient as European countries including the UK, France and Spain experience an resurgence in cases and are looking to reimplement restrictions.
An analysis published in The Lancet on September 24 outlines some key criteria that countries should meet before easing COVID-19 restrictions, assessing this framework in relation to the exit strategies and experiences of nine countries that have emerged on the other side of a first outbreak wave: Hong Kong, Japan, New Zealand (NZ), Singapore, South Korea, Germany, Norway, Spain and the UK.
The key criteria for easing restrictions, and examples, contained in the paper:
Knowledge of infection status – Before reopening, countries should have efficient surveillance systems in place to monitor and identify the infection rate. This includes calculating the national reproduction number and being able to determine locations where the virus is still spreading. In Hong Kong, they have been estimating the real-time reproduction number since February, minimising inaccuracies from delays in reporting.
Community engagement – Policies about physical distancing, mask wearing and reopening schools should be implemented and communities empowered to adhere to them by providing effective education and communication. Governments in South Korea and NZ have provided great examples of empathetic and transparent communication throughout the pandemic, winning widespread public support for their COVID-19 policies.
Systems to protect and support vulnerable populations should also be in place. All nine countries included in the analysis provided some level of financial support to help minimise the financial impact of the pandemic; however, as COVID-19 has been found to disproportionately affect vulnerable populations, more could and should be done.
Public health capacity – Before reopening, countries should have the capacity to test all suspected cases, trace their contacts and isolate confirmed cases effectively, with support being provided for people during isolation.
The authors found that differences in the implementation of public health measures such as testing and contact tracing were particularly evident between Asian and European countries. Hong Kong, South Korea and Singapore were quick to implement widespread testing, tracing and isolating regimes from the beginning of the pandemic, whereas delays in implementing these measures occurred in most European countries, except Germany.
Health-system capacity – Ability to ensure adequate treatment facilities, medical equipment, and health care workers is vital for health systems to cope with a potential resurgence in cases after restrictions have been eased. Shortages of personal protective equipment (PPE) were not as prevalent in Asia as in Europe, again with the exception of Germany. As a result of limited PPE supplies in Spain, ten percent of their total COVID-19 cases were in medical staff.
Measures for border control – Effective management of inbound travellers is pivotal in reducing the risk of COVID-19 as borders reopen. This may include policies already in place in many countries, such as 14-day mandatory quarantine, and denial of entry or rigorous testing if from a high-risk country.
In summary, key lessons learnt for countries considering easing restrictions include:
- having strong epidemiological data and health systems;
- efficient testing, tracing and isolating regimes;
- border control policies; and,
- effective, clear and transparent communication
The authors concluded:
As New Zealand’s experience shows, easing restrictions is something that should be managed with great care and continued vigilance, and, at the time of writing, Spain, Germany, and the UK have offered a reminder of the enormous potential for resurgence if comprehensive safeguards are not in place.”
Alison Barrett is a Masters by Research candidate and research assistant at University of South Australia, with interests in public health, rural health and health inequities. Follow on Twitter: @AlisonSBarrett. Croakey thanks her for providing this column as a probono service to our readers.
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