Last week, I was having a cup of tea during a rare break from the clinic, chatting with one of the nurses I work with. We were talking about the rising number of people we were seeing with coronavirus when she said: “It’s a crafty little bugger this virus, isn’t it? Just when you think we are nearly there it mutates and gets away from us.”
I had to agree. The tide did appear to be turning in our favour but then the Delta variant arrived with its mutations, which make it up to 60-percent more infectious than previous variants. Inevitably, countries that were previously experiencing only low levels of infections and mortality are now seeing cases rise.
The Delta variant, first identified in India, arrived on UK shores in April. At the time, the UK government was planning to ease all social distancing restrictions, but the surge in case numbers forced it to delay that for a further four weeks.
The Delta variant poses a threat to us all – not just those countries with larger numbers of unvaccinated people. This is because unlike the Alpha variant, which first emerged in the UK, the first dose of the vaccine does not offer enough protection against it, meaning people are at risk in the interval period between the two doses.
According to a Public Health England study published on May 22, a single dose of either Oxford-AstraZeneca’s or Pfizer-BioNTech’s vaccine only reduces a person’s risk of developing COVID-19 symptoms caused by the Delta variant by 33 percent, compared to 50 percent for the Alpha variant. A second dose of the AstraZeneca vaccine boosts protection against Delta to 60 percent (compared to 66 percent against Alpha), while two doses of Pfizer’s jab are 88 percent effective (compared to 93 percent against Alpha).
The US is also grappling with a rise in cases attributed to the Delta variant, with the Centers for Disease Control and Prevention (CDC) reporting on July 21 that the Delta variant now accounts for 83 percent of new cases of COVID. That makes it more urgent than ever that unvaccinated Americans get their shots as this cohort accounts for the vast majority of new cases, hospitalisations and deaths. And all three of those are increasing again, with new COVID cases on the rise in all 50 states.
It is a situation reflected globally. The World Health Organization’s (WHO) weekly COVID-19 update on Tuesday last week reported cases of the Delta variant in 124 countries, along with 3.4 million new cases of COVID-19 around the world, 12 percent higher than the previous week.
We are only safe when everyone is safe, this means we all need to support the global rollout of effective COVID-19 vaccines.
Nepal and Afghanistan saw a surge in cases attributed to Delta in June, while countries that are better able to contain the virus and suffer relatively low casualties are also seeing a surge in cases.
Meanwhile, there are distressing scenes in Indonesia as the Delta variant spreads across the nation. On Wednesday, July 14, the total number of cases across the country hit more than 54,000 making Indonesia the new epicentre of the pandemic in Asia. The Delta variant has been detected in 94 percent of the tests carried out in Indonesia over the past two weeks, according to the monitoring site, Our World In Data (OWID), and this is against a backdrop of a country that has only fully vaccinated 6 percent of its population against COVID-19.
There have been real concerns that the healthcare system is on the brink of collapse as beds and oxygen are in short supply in many hospitals. There is also concern that many of Indonesia’s healthcare workers are becoming seriously unwell with new COVID-19 infections despite being vaccinated.
Indonesia has predominantly relied upon the China-produced Sinovac vaccine to protect its population against the coronavirus, including its healthcare workers. In clinical trials, Sinovac and Sinopharm’s inactivated virus vaccines have been shown to be 50 to 79-percent effective in preventing symptomatic COVID infection, and more than 95-percent effective in preventing hospitalisation.
While there is no public data on how effective the Sinovac vaccine is against the Delta variant, preliminary studies have suggested its efficacy may be as low as 20 percent. And with health workers who had been fully vaccinated with the Sinovac vaccine succumbing to the virus, Health Minister Budi Gunadi Sadikin said at a press conference on July 9, that all health workers will now receive a “booster” shot with the US-made Moderna vaccine to protect them against the new deadly wave.
Budi said the ministry had discussed the Moderna “booster” plan with the Food and Drug Monitoring Agency (BPOM) and the Indonesia Technical Advisory Group on Immunisation (ITAGI). “We have agreed that the Moderna vaccine will be given as a third dose to provide maximum immunity to existing viral mutations,” he added.
Studies have shown the Moderna vaccine is more than 94-percent effective at preventing COVID-19 in people who have received both doses. A Canadian study pending peer review has found that a single dose of Moderna is 72-percent effective at preventing symptomatic infections caused by the Delta variant after two weeks. This would mean a relatively improved level of protection for Indonesia’s healthcare workers even after just one booster shot of the Moderna vaccine.
Thailand is also seeing a rise in COVID-19 cases where, according to the chief of the Department of Medical Sciences, Dr Supakit Sirilak, Delta has overtaken Alpha as the dominant variant, accounting for 63 percent of new cases. Thailand’s government has now announced a lockdown in Bangkok and other high-risk regions. The country, which heavily depends on the tourist industry, had only recently opened up to visitors but is now re-introducing restrictions to help curb the spread of infections.
Elsewhere, Pakistan is also seeing a rise in cases after a fall in numbers over the spring, with Karachi recording the highest numbers of Delta cases. Just 2 percent of Pakistan’s population is fully vaccinated. COVAX, the WHO vaccine-sharing scheme, is planning to send an additional three million Moderna vaccines to Pakistan to help fight this new surge in cases.
But the morale of healthcare workers in some of the worst-affected areas is reported to be low, with some in Malaysia saying they are working 36-hour shifts in order to cover for colleagues who are either sick or self-isolating. Exhausted doctors are so fed up with the lack of proper pay and working conditions in the country that they have been walking out of hospitals across the country, including in the capital Kuala Lumpur.
The Delta variant has shown us how things can change in this pandemic and how the emergence of a variant in one country can quickly become a global problem. Ensuring equity of effective vaccines is key. When a person is fully vaccinated, they are far more likely to mount an immune response against the virus should they come into contact with it, which will kill it before it has time to mutate again. It has been said time and time again, but in my opinion, it cannot be overstated: we are only safe when everyone is safe, this means we all need to support the global rollout of effective COVID-19 vaccines.
Progress report: Can some vaccines cause heart problems?
It is important to remember that no medicine or vaccine is 100-percent effective or free of side effects. When vaccines go through trial processes – and the approved COVID-19 vaccines have gone through rigorous trials, the results of which have undergone the deepest scrutiny from experts – any side effects from trial participants are listed. Approval is only given when the benefits of having a vaccine significantly outweigh any risks, and this is true of the Pfizer and Moderna vaccines and, in the spirit of full disclosure, I will state that I have myself been vaccinated with the Pfizer vaccine.
The European Medicines Agency (EMA) released a statement on July 9, recommending listing myocarditis and pericarditis as new “very rare” side effects in the product information for the Pfizer and Moderna mRNA vaccines, together with a warning to raise awareness among healthcare professionals and people taking these vaccines. The two conditions cause inflammation of the lining of the heart or parts of the heart muscle. Symptoms include shortness of breath, chest pain and an irregular heartbeat.
These symptoms can last for anything from several hours to months and, on very rare occasions, they can lead to permanent damage to the heart muscle and even death. While the exact way in which these vaccines may cause these conditions is not yet understood, the fact that the symptoms in the small numbers of people affected came on three to five days after the second dose of the vaccine suggests it may well be an overstimulation of the immune system that can then go on to inflame the lining of the heart.
The EMA analysis of cases found that among 177 million doses of the Pfizer vaccine given, 145 cases of myocarditis and 138 cases of pericarditis were reported. Out of 20 million doses of the Moderna vaccine given, 19 cases of myocarditis and 19 cases of pericarditis were reported.
In total, five people have died. The review found that they were all either elderly or had other health conditions.
The US Food and Drug Administration (FDA) issued a similar statement at the end of June listing the heart conditions as very rare side effects of the Moderna and Pfizer vaccines while the UK’s Medicines and Health Products Regulatory Agency (MHRA) has made a similar move. There has been no link to these conditions found for vaccines such as Oxford-AstraZeneca or Janssen, which use a genetically modified virus.
While the risk of either myocarditis and pericarditis is still very small, especially when compared with the risk of developing serious heart conditions if you get an acute infection of COVID-19, it is important for clinicians and those vaccinated to be aware of it so they can recognise it if it occurs. It is also worth remembering that the majority of patients with myocarditis and/or pericarditis can be treated effectively using common drugs. The benefits of having the vaccines still outweigh the risks and I would still recommend going for your vaccine when your turn comes.
In the doctor’s surgery: ‘How can I have COVID? YOU gave me both doses of the vaccine’
This week I had a challenging consultation with a patient. A middle-aged man presented with a sore throat, headache and fever. He thought he had tonsillitis and was keen to get a prescription for antibiotics, but when I examined him I could find no evidence of an acute bacterial infection. Instead, I suggested he take a COVID-19 PCR test. The Delta variant is prevalent in the UK and is known to produce symptoms outside of the typical cough, fever and loss of sense of smell.
“I can’t have coronavirus, doc,” The man said. “I’ve had both doses of the vaccines. In fact, it was YOU who gave them to me.”
I had no recollection of giving this man his vaccines, though it was entirely possible. I do regular shifts in our vaccination centre, where each patient is allocated three minutes per appointment and comes in wearing a mask, making them difficult to recognise. There is no time for pleasantries – it really is a case of jab, go, next patient.
“There is a small chance you can still get the virus,” I explained, through my personal protective equipment (PPE). “It is probably best to get tested in case we need you to self-isolate.”
“I just need some antibiotics, doc,” he pleaded. “I will be fine if you just give me a prescription.”
I explained why antibiotics were inappropriate and told him again that he should book in for a coronavirus test. He left slightly unhappy but agreed to book the test.
The following day I received a notification telling me he had tested positive. I rang him up to see how he was.
“I am really surprised, doc,” he said to me. “I genuinely thought I couldn’t get the virus after having had the vaccine.” He then confessed that he had somewhat let his guard down after having the vaccine, socialising in large groups and not wearing a face covering.
Thinking that vaccinations give you 100-percent immunity to the virus is a common misconception. It is important to remember: The job of the vaccine is to protect from serious illness from COVID-19. Vaccines do not make you entirely immune to the virus and there is a small chance that you can still get the virus and pass it on to others. It is quite possible this man would have had far more severe symptoms had he not been inoculated, and he was lucky to have mild symptoms only.
I reminded him that even though he has been vaccinated it is important he takes care, especially in large crowds and indoor spaces and encouraged him to wear a mask, wash his hands regularly and try to meet people outside or in well-ventilated indoor spaces after he recovers from his illness. He promised me he would.
And now, some good news – a new blood test for Long COVID may be on the way
Long COVID is a term that strikes fear into the hearts of many people. Having treated many patients with it myself, I have seen first-hand how debilitating it can be.
Thankfully, there is increasing evidence that the vaccines not only reduce the risk of getting Long COVID but may also reduce symptoms in those who already have it if they are given the vaccine as a treatment.
Long COVID is the name given to an array of symptoms affecting people who have suffered an acute COVID-19 infection. These symptoms can last for weeks, months or – it may turn out – years. They can affect between 10 and 30 percent of people infected by the virus, including those who had mild symptoms only. Symptoms include, but are not limited to, fatigue, shortness of breath, joint pain, chest pain, coughing, loss of sense of smell, confusion or “brain fog”, headaches, and muscle pains.
Until recently, Long COVID could only be diagnosed clinically – through observation by a healthcare professional of someone who has previously had COVID-19. There was no diagnostic test that could confirm the diagnosis. However, scientists at Imperial College London now say they have identified an auto-antibody in those with Long COVID which is not present in those who have made a full recovery from COVID-19, and which can be tested for via a simple blood test.
Auto-antibodies, unlike antibodies that target disease-causing organisms or infected cells, tend to mistakenly target healthy tissue and organs causing the symptoms of long-COVID. The researchers at Imperial hope their work will be the first step towards a point-of-care diagnostic blood test for Long COVID. If the blood test proves to be an effective tool for diagnosis it may be ready for use in doctors surgeries within months, which is certainly good news for those who have symptoms of the illness and would like an official diagnosis.
Reader’s question – I’ve never had COVID symptoms; can I still get Long COVID?
The short answer to this is “yes”. We know that Long COVID can affect even those who had mild or no symptoms of the coronavirus so it is entirely possible that you have had the virus without knowing it and this means you can still go on to develop Long COVID. It is important your doctor rules out other causes for your symptoms first before you attribute them to Long COVID, however. There are some treatment options and it is worth speaking to your doctor to see if you can be referred to a specialist Long COVID centre.