COVID-19 Prospects in the New Year

What's going on with vaccines, treatments, and variants?

By Michael Jorrin, "Doc Gumshoe", January 28, 2021

Believe me, I’ve been looking forward to putting Doc Gumshoe to work on topics other than COVID-19, which is far from being the only disease that affects our health and requires careful attention.   But as the global case numbers have topped 85 million, and global deaths are approaching 2 million, COVID-19 demands to be first in line.   And there certainly are new developments that emerge, just about daily.   

Here’s the status in the US as of this morning:

New cases (as of 28 January):  148,733
New deaths:   3,962

Total cases: 25,604,635
Total deaths: 429,322

How is the vaccination drive going?

For a start, we have now definitely entered the era of vaccines.   Several are now available, and more will be coming into use.   But there are lots and lots of questions about vaccines, for example, how should they be given, who should (or should not) be vaccinated, what are the contraindications.   And, are some of the old vaccines helpful?

And there is that new variant, which seems first to have emerged in the UK, but has turned up in a number of other locations.   Is it more transmissible?   Will the vaccines protect us from this new form of the coronavirus?   And, the big question – will it result in a more severe form of the disease?

Beyond those issues, there will continue to be the question of how best to treat patients who have been infected and developed some of the many symptoms associated with COVID-19.

What’s the status of the vaccination drive?

In the United States, the plan was to have about 20 million persons vaccinated – or, at least, having received their first dose of a vaccine – by January 1st, 2021.   We came nowhere near attaining that goal.   Instead, we just got over the 4 million mark by that date.   This was more a matter of logistics than of a major flaw in the planning.   There were several agencies involved in the rollout, and they were all to some degree responsible for the delays.

Dr Martin Makary (author of Unaccountable, which I have discussed in some detail) recently pointed out that, for a start, the National Academy of Medicine’s guidance was somewhat abstract, and did not commit to a clear prioritization order, but described the groups that were to receive vaccines earlier only in the most general terms – e.g., “essential workers,” but without defining what an essential worker is.  The Centers for Disease Control had plenty of time to develop principles on which prioritizations were to be developed.   The CDC’s Advisory Committee on Immunization Practices (ACIP) had nine months to formulate guidance, but it was less than a week before Christmas that they voted on their recommendations on vaccine prioritization.   That was two weeks after the FDA authorized the Pfizer vaccine.   By that time, significant quantities of vaccine had been shipped to a number of states, but these states were unsure of what to do with it.   By Tuesday, January 5, about 17 million doses of the vaccine had been shipped to the states, but only 4.8 million had been used.   Clearly, the gears of bureaucracy badly need lubrication (progress has continued since, six weeks into the vaccination campaign the CDC now says 24 million doses have been administered, at a pace now of roughly a million doses a day).

Even with somewhat more specific guidelines, the prioritization guidelines have some pretty obvious flaws.   Yes, health-care workers in direct contact with patients should be prioritized, but these priorities should not be completely equivalent.   The 35-year-old surgeon who works in a scrupulously sanitary operating room is at much, much less risk than the 65-year-old nurse who sees patients presenting in the emergency department.   And, obviously, not only health-care workers, but the population in general should be prioritized according to their over-all risk characteristics.   A considerable number of low-risk individuals have been vaccinated because of their connections, such as family members of physicians and hospital board members.   Meanwhile, many persons at high risk wait their turn.

At the same time, the dosing issue is somewhat muddled.   The clinical trial data suggested that the Pfizer/BioNTech vaccine should be given in two doses, four weeks apart, while the Moderna vaccine’s two doses should be given three weeks apart.   However, Moncef Slaoui, who was until recently the chief advisor to Operation Warp Speed, and formerly head of AstraZeneca’s vaccine development department, suggested giving adults between the ages of 18 and 55 two half doses of the Moderna vaccine so as to speed the rollout of vaccines and boost herd immunity. 

And the Brits are proposing a dosing schedule that has some scientists a bit worried.   They are planning to stretch out the interval between the first and second doses of the COVID-19 vaccines that have been approved in the UK to as long as three months, instead of the three to four week intervals that have been tested in clinical trials.   Also, they have stated that the first and second doses could be from different manufacturers, if a second dose of the matching vaccine is unavailable.   

The plans to alter the dosing schedules that were used in the clinical trials and shown to be efficacious are based on general knowledge of how vaccines work, not on data about these specific vaccines.   That is, an initial dose confers a degree of immunity, mostly based on the generation of antibodies   As the antibodies diminish, lasting immunity ramps up, carried by T-cells and memory B-cells.   How long this takes varies with individual vaccines.   

Paul Bieniasz, PhD, a virologist at Rockefeller University, has suggested that the UK’s delaying the second vaccine dose could be fostering vaccine-resistant forms of the virus.   “My concern, as a virologist, is that if you wanted to make a vaccine-resistant strain, what you would do is to build a cohort of partially immunized individuals in the teeth of a highly prevalent viral infection.   You are essentially maximizing the opportunity for the virus to learn about the human immune system. Learn about antibodies. Learn how to evade them.