Coronavirus Update of 125: Variants, Vaccine Uptake, Sinovac, Brazil, India, Israel

 In terms of daily new cases in the United   States, we’ve come down considerably and reached a plateau, and that’s because of some heterogeneity.  There’s been some increasing in cases in places like Michigan, New York, New Jersey, Pennsylvania, and   Florida, and there’s been some decreases in California and in Texas. Overall, daily new deaths   in the United States continue to drop. 

Places that we’ve been watching very carefully include Brazil,   where daily new cases are still very high. And daily new deaths in Brazil are at an all-time high.  And the major concern down in Brazil is the infrastructure. Their hospitals are at capacity,   and they’re having a difficult time taking care of the patients that they need to take care of,  but in addition to Brazil, another hot spot that has come up here in the last couple of weeks   is definitely India.

 And as you can see here, the number of cases in India are at an all-time   high. Deaths have started to increase in India,and there’s a concern about what is going on   in that part of the world. And there are a number of reasons for this, according to a   recent Reuters story titled “India’s daily COVID-19 cases rise to record for fifth time this week.”  

The story says, “the government has blamed the resurgence mainly on crowding   and a reluctance to wear masks as businesses across the country have reopened since February only to be partially shut again to control the current surge. Quote: ‘Mass gatherings for   elections and religious events have accelerated COVID, for which all of us are responsible to   some extent,’ Sonia Gandhi, the chief of the main opposition Congress party, said in a statement. 

 In Mumbai, hundreds of poor migrant workers crammed into trains this week to flee, potentially risking   a wider outbreak in smaller towns and villages. The railways department called it a usual rush   this time of year for people to harvest crops back home and celebrate festivals.” What’s ironic is that   India is the largest vaccine maker in the world, and so far it’s administered close to 100 million   doses using primarily the AstraZeneca shot and also another homegrown shot by Bharat Biotech.   

And because India’s pharmaceutical industry is so large and since they export so many medications,   what they are doing now is they are outlawing the exports of some of those medications so that they   can help their own people. One of those medications this week that was no longer being exported   is Remdesivir. And this ban has been in place until “till the situation improves.”   

Interestingly, the WHO in November of 2020 issued a conditional recommendation against the   use of Remdesivir in hospitalized patients, because their randomized, controlled trial did   not show much benefit. However, many countries, including India, are still using Remdesivir   as part of their treatment options for COVID-19. We will definitely need to watch the situation   both in Brazil and in India as things develop here in the next couple of weeks.   And if you’re interested in following how vaccination campaigns are going around the world,   I think this is a great tracker that’s found at Bloomberg.com, and we’ll go ahead and leave the   link for you here in the description below, but as you can see here, 768 million doses have been   administered across the world. 

They also give you an update here of what’s happening in the United   States. Here in the United States, we have 28.5 percent of the population coverage, 183 million   doses given. If we see and look at India, there are close to 101 million doses given, but because   they have well over a billion in population, that’s only 3.7 percent of the population.  In Brazil, we have 29 million doses given at 6.9 percent population coverage, and in some other   areas here in South America, we can see here 12 million with nearly 31.4 percent of the population   coverage in Chile. Many of you have asked about other types of vaccines. We’ve talked here on   MedCram about the Pfizer-BioNTech vaccine, the Moderna vaccine, the AstraZeneca vaccine,   and also the Johnson & Johnson vaccine. 

We’re going to talk a little bit about the Sinovac   vaccine. Sinovac is a private Chinese company that developed their coronavirus vaccine version called   CoronaVac. We’re going to talk about the mechanism of how that works. So basically we have SARS-CoV-2, and, as you know, we have the spike protein, and this is what binds to the ACE2 receptor   on your cells when the virus goes into your body. And inside the virus we have the RNA.   The RNA codes for the information when the virus infects your cells so that the cells   make more viral particles and they can infect more cells in your body. So what Sinovac does   is they made their corona vaccine, or CoronaVac simply by taking coronavirus from multiple   countries and looking at them to see what was the most representative. 

They took eventually   one from China, and since it already had the spike proteins on the virus, all they had to do   was destroy the information to the cells that were telling the cells how to make more viral particles.  And they did that by adding a chemical called beta-propiolactone. And what this chemical does is it   basically goes in and inactivates the messenger RNA so that it can’t be used inside of the cells.   And then they took this inactivated virus and combined it and put it into a vaccine and added   aluminum as an adjuvant. And that word adjuvant simply means it’s something that’s added to the   vaccine to stimulate the recipient’s immune system more to recognize that something foreign is there.   And this is essentially what they have as their vaccine, is what they inject into their recipients,   and we’re going to talk about some of the results from the trials that have gone on   around the world on this vaccine. 

Now remember, since they used a virus from China, it was very   similar to the original virus that came out of Wuhan, China at the beginning of the pandemic,   and so the variants that we’ve seen around the world, like the variant that was first discovered   in South Africa and the variant that was first discovered in the UK and the variant that was   discovered in Brazil first, they’re going to be slightly different than the spike protein   here on this particular coronavirus that was used for CoronaVac. And that’s important to understand,  because as was published here on the BBC News with this article titled “Sinovac: Brazil results   show Chinese vaccine 50.4% effective,” you’ll have to realize that, of course, Brazil is a country with   a very large proportion of their coronavirus infections with the P.1 or the Brazilian variant.   

So we have some results, and some of them are subdivided. For instance, when we look at the data   that’s come out of Brazil, they initially had reported for mild and severe cases   an efficacy of 78 percent. However, when they added to that the very mild cases, they found that in   those cases, the overall efficacy was 50.4 percent, and that may be as we’ve discussed a result of   the fact that Brazil has a lot of variants and specifically the Brazilian variant, which may   not be as similar as it could be to the original virus that was discovered in China. Now, there have   been some other trials, for instance, in Turkey that showed that the efficacy there was 91.25%  in terms of cases. And in Indonesia, recently it was shown at 65.3 percent.   This data is also very interesting when you consider what’s going on in Chile. Now, if you   notice here in Chile, there’s 12 million doses that have been given and that’s enough for 31.4   percent of the population. Very similar or even higher than that here in the United States, and   yet if you look and see what’s going on in Chile you’ll see that cases are actually increasing and   have been at an all-time high, despite that level of vaccination. And according to this article, more   than 93 percent of those in Chile who have gotten both shots received the Sinovac vaccine. Other   vaccines that are also approved in Chile include the Pfizer-BioNTech vaccine, the Oxford-AstraZeneca   vaccine, and also just recently added to that list was the CanSino single-dose vaccine. So as we look   at the numbers, I think the three countries to watch carefully would be Brazil, India, and   Chile, in terms of how things turn with respect to the policies of vaccinations and precautions. We’ve   talked about in those countries there will be a strain on the healthcare system and many patients   who will be waiting while they have been infected with COVID-19 before they can get to the hospital.  For that, I recommend watching our 10 tips video on COVID-19, and for those who are taking care   of patients on ventilators, our free ventilator course on how to manage patients on the ventilator.

  So let’s turn to Israel where they have done a tremendous job at vaccinating quite a bit of their   population. If we look at Israel, we can see here that 10 million doses have been given and enough   for 56.5 percent of the population coverage, and that is probably the highest in the world, if not   very close to it. A very small percentage of the infections going on in Israel right now   are related to the South African variant. Most of the surge that was seen prior to this last   round with vaccination was due to the UK variant, and this study, which was reported on in The Times   of Israel shows that there is some interesting data that is contrary to some of the Pfizer data,   in terms of the South African variant being able to break through the Pfizer. And this is the   pre-print that will be published. “Here, we perform the case-control study that examined whether  [vaccinees with the Pfizer-BioNTech vaccine] with documented SARS-CoV-2 infection were more likely to   become infected with B.1.1.7 [or the UK variant] or  B.1.351 [or South African variant] compared with   unvaccinated individuals.

 Vaccinees infected at least a week after the second dose were   disproportionately infected with the B.1.351 (with an odds ratio of 8:1). Those infected between   two weeks after the first dose and one week after the second dose were disproportionately infected   by the B.1.1.7 [or the UK variant]… suggesting that reduced vaccine effectiveness against   both VOCs (variants of concern) under different dosage/timing conditions. Nevertheless, the B.1.351 [or the   South African variant] incidence in Israel to-date remains low and vaccine effectiveness remains high   against the B.1.1.7 among those fully vaccinated.” So of course to keep in mind that the way that this   study was designed is not to look at the efficacy of the Pfizer-BioNTech vaccine. On the contrary,   this was looking at positive results to see which types of variants had come through and made up   those positive values. And so again, it’s important to understand that this study really can’t study   and look at the true efficacy of a vaccine, which clearly no vaccine is 100 percent effective. 

  And as we’ve seen in other variants, escape from the vaccine typically is seen in the more milder   infections and not in hospitalizations. And in this study we really didn’t get a chance to   see where these South African variants were seen. Were they seen in asymptomatic patients, or were   they seen in hospitalized patients? And we don’t know the answer to that based on these results.   And here you can see with their news release, “Pfizer and BioNTech confirm high efficacy and   no serious safety concerns through up to six months following second dose in updated topline   analysis of landmark COVID-19 vaccine study.” And you can see here that they said that the “vaccine   was 100% effective in preventing COVID-19 cases in South Africa, where the B.1.351 lineage is prevalent.”   Despite all of that, there is an article here in The Times of Israel stating that   “Serious COVID cases in Israel fall below 300 for the first time since early December”   and “only 0.5% of tests come back positive, the lowest rate in almost a year.” So in addition to   those other three countries that we talked about, Israel is also a notable case to look   at very carefully, because perhaps more than any other country on the planet, they have rolled out   the vaccine faster and with the highest amounts of vaccination than just about any other country.  

 Over the next few weeks, what we will be needing to watch very carefully is what happens in Brazil   with currently 29 million doses given and only 6.9 of the population covered with the vaccine.   And this may be why the deaths have soared in Brazil to the point where they are essentially   number two in the world, right behind the United States in terms of total deaths at 332,000. That   puts them at 159 deaths per 100,000 population, and according to the article, it looks as though the   President is now turning his focus to a nationwide vaccination drive, something that many critics say  has been lacking up until this point. If you look at intensive care occupancy in Brazil, you’ll see   here that they are overflowing. We, in January and February of this year, in Southern California were   also in a situation very similar to this. It puts a lot of strain on health care personnel,   and it’s very disheartening. 

This is not the only place in the world where this is happening.  If you are listening to this and you’re in those parts of the world, I highly recommend that you   look at our MedCram update 59, which talks about supplements that I was taking during the pandemic.   Also look at our 10 tips for COVID-19. And for those of you who are healthcare providers, go   to MedCram.com for more information about how to manage ventilators in patients with   COVID-19. This is a very critical point in the pandemic.