Topic: COVID Update - Situation in Various countries

Speaker: Dr Monica Vasudev, Allergist & Clinical Immunologist, Fellow of American

Academy of Asthma, Allergy and Immunology, Advocate Aurora Health, Wisconsin, USA

5th February, 2022, Saturday; 9.30am-11am

• Omicron sublineage BA.2, also known as the “stealth variant” was first detected in genome sequences from Philippines in November 2021. It is found in 49 countries.
• It shares many of the same mutations as its ancestor strain but with a further 28 mutations not previously seen in the original Omicron variant.
• It does not have the mutation, present in the original variant that made it easier to detect.
• BA.2 is the dominant strain in Denmark; in the US, BA.1 is still 99%
• It may be more transmissible, but there is no evidence that it causes more severe disease.
• Those who are vaccinated and boosted are better protected.
• On Feb. 1, Pfizer BioNTech asked FDA to approve a two-vaccine dose regimen for young children to start with.
• Children 2 to 4 years old who were given two shots were infected at a rate 57% lower than the children in the placebo group. 
• Children 6 months to 2 years old who got shots were infected at a rate 50% lower than the placebo group.
• In a randomized, placebo-controlled trial published in the NEJM, two doses of Novavax vaccine given 21 days apart had an overall efficacy of 89.7%. The primary end point was based on the first occurrence of PCR-confirmed symptomatic Covid-19 with onset at least 7 days after the second vaccination in serologically negative adult participants at baseline.
• The Novavax vaccine has a subunit protein platform and it is formulated with an adjuvant to enhance immune response and stimulate high levels of neutralizing antibodies. The technology is the same as that used in the Flublok influenza vaccine, and is similar to other vaccines that have been around for a long time, like the hepatitis B vaccine.
• On Feb. 3, it was accorded conditional marketing authorization by Medicines and Healthcare in UK and it has also been approved in Australia.
• Dr Pelletier on 28^th January said about the Novavax vaccine, “…traditional option available for both the immunologically naïve and those hesitant to get boosted. It may provide a path forward for some who are pro-vaccine, but who drew the line at novel mRNA products…”
• The US is leading in deaths and falling behind on vaccination
• Unvaccinated people had a greater risk of testing positive for Covid-19 and a greater risk of dying from Covid-19 than people who were fully vaccinated. Case and death rates in fully vaccinated and boosted were much lower than in the unvaccinated people.
• Unvaccinated adults aged 18 years had 13 times the risk of testing positive for Covid-19 and 68 times the risk of dying from Covid-19 in November and 5 times risk of testing positive for Covid-19 in December compared to the fully vaccinated adults who had also taken the booster dose (CDC).
• Outpatient COVID-19 EUA therapies are Paxlovid and Evusheld. 
• In non-hospitalized patients, who have mild to moderate Covid-19 and are at high risk of disease progression, the therapeutic options are Paxlovid (nirmatrelvir with ritonavir), sotrovimab, remdesivir and molnupiravir.
• For those not expected to mount sufficient immune response to Covid-19 vaccine because they are on immunomodulatory therapies or those not able to receive the vaccine, there is Evusheld (tixagevimab/cilgavimab). It has been accorded EUA approval as pre-exposure prophylaxis for >12 years and >40 kg.
• Paxlovid is associated with 88% risk reduction; dose is nirmatrelvir 300mg (2 tab) + ritonavir 100mg twice daily within 5 days of symptoms. It is approved for ≥12 years. Children have to be >40 kg. Dose has to be reduced in patients with renal impairment where nirmatrelvir 300mg (1 tab) + ritonavir 100mg can be given. 
• Sotrovimab: 85% relative risk reduction; dose is 500 mg once IV infusion within 10 days of onset of symptoms. It is approved for ≥12 years and >40 kg. It has been shown to have activity against Omicron.
• Remdesivir has 87% relative risk reduction; needs 3 consecutive doses; 200mg IV on day 1 then 100mg IV on days 2 and 3; it is to be given within 7 days of symptoms. It is approved for ≥12 years and >40 kg. Patients have to be observed for an hour after infusion. 
• Molnupiravir shows 30% relative risk reduction; dose is 800mg PO twice daily for 5 days, started within 5 days of symptoms. There are associated bone/cartilage toxicity concerns. Approved only for ≥18 years of age. It is not recommended for pregnant women due to risk of embryo-fetal toxicity. Less effective than the aforementioned medications.
• Evusheld has 69% relative risk reduction; the dose is tixagevimab150mg and cilgavimab150mg administered as two separate consecutive intramuscular injections.

Country Updates

• South Africa: People are too relaxed. There is a common feeling that we are out of the pandemic. Schools will now be fully reopened. There has been a slight increase in cases in the last week linked to Sports Day in schools. Families are again coming with infection. But infection is mild, not alarming. Now there is no quarantine for people exposed to the infection. New cases range from 3000-4500 in the last week. In the last 24 hours, there were 2700 cases and 221 deaths. The number of people tested so far is 32 million – 3.1 million were positive. The recovery rate is 95.5%. Total deaths till now are 95,000. Hospital admissions came down to 4800 in both public and private hospitals. ICU admissions are also down - there are 404 cases, 180 on ventilator, the positivity rate is 8.2%.

• Taiwan: The country is doing well to contain the pandemic. Recently, there was a low-grade community spread of Omicron. The country has a very good hand hygiene practice and people wear masks even outdoor. We have encouraged touch and disinfect policy to prevent fomite transmission. In addition to face masks to block droplet and airborne transmission, the fomite transmission is also blocked. The booster coverage is around 80%.
• Australia: The Omicron wave has reached the peak, but deaths are still a concern with 30-40 deaths in each state per day; 85% deaths are in 60-70 years age group or older predominantly from nursing homes as many of the elderly are yet to get their booster dose; there is a crisis in the form of staff shortage; over 94% have received both vaccine doses; around 30% have taken the third dose. Vaccination for 5-11-year age group has started. Duration of quarantine has been reduced to 7 days. Positive persons but asymptomatic are asked to come back to work with masks.
• India: The curve is flattening with around 1.2 lakh daily cases; 169 crore vaccine doses given; 99% have received the first dose, while 85% have received both doses. vaccination drive is going very strong in 15-18-year age group. Booster dose among high-risk persons is picking up. Regarding treatment, even omicron is responding to monoclonal antibodies especially when given in early stages. Remdesivir continues to be in the treatment protocol. Molnupiravir, though authorised by drug regulator, is not included in government treatment protocol because of high side effects. Steroids, anticoagulants continue to be given. ICU admissions have come down to less than one percent. Despite increase in the number of cases, the mortality remained same or only marginally high. ICMR studies show that vaccinated persons have mild infection. Covid appropriate behavior is stressed upon and crowd management has been given importance. Quarantine requirement for international travel has been relaxed. The budget has provision for teleconsultation for mental health problems. 
• Bangladesh: More than 50% people have received both doses and more than 60% have taken the first dose. Hospitalization is less. Only schools are closed. But people are not following SOPs. They are also not being strictly enforced.
• Philippines: In the last 24 hours, there were 8000 new cases, a declining trend was seen from mid -January to the first week of February. 151,000 active cases comprising 4.2%, the total number of cases is 3.3 million, total deaths are 54, 214 deaths. The vaccination for 5-11-year-olds (14 million population), which was to start from Feb. 4, has been postponed for later this month. There is a decrease in cases in the national capital regions, but there is a surge in cases in the provinces.
• Pakistan: The Omicron cases have plateaued for the last three days; it had reached 8000 cases per day but now there are 6000-6500 cases per day with 30-40 deaths; 8.4 crore fully vaccinated 10.8 crores are partially vaccinated, 2.7lakh booster dose. Mortality in children is high around 14%, which is worrisome. The positivity rate is decreasing. SOPs are not followed.

Participants

Member National Medical Associations

Dr Marthanda Pillai, India Member World Medical Council, Advisor CMAAO

Dr Angelique Coetzee, South Africa

Dr Akhtar Hussain, South Africa

Dr Salma Kundi, Pakistan

Dr Qaiser Sajjad, Pakistan 

Dr Benito Atienza, Philippines

Dr Muh-Yong Yen, Taiwan

Invitees

Dr Russell D’Souza, Australia UNESCO Chair in Bioethics

Dr Errol Alden, USA

Dr Monica Vasudev, USA

Dr S Sharma, Editor IJCP Group

 

Moderator

 

Mr Saurabh Aggarwal