I've been busy working on tracking Covid variants with Brooks Miner (www.covidvarianttracking.com & @CovidVariants on Twitter) so haven't written a Covid update in a while. Here's the first of two back-to-back posts focussed on vaccines and evolution. I would strongly advise you to get any vaccine you have access to, with strong caveats for the Bharat Biotech Covaxin vaccine in India (zero data, shady govt. practices), and weaker ones for the Chinese & Russian vaccines I discussed a few weeks ago (some data available, seems okay if it is reliable):
1) What you probably already know: the UK variant and the South Africa variant spread substantially faster than background strains - somewhere between 30% & 70%. A Brazil variant with some of the same mutations probably spreads at a similar speed. The UK variant has increased rapidly in Denmark, Ireland, Portugal, and now Switzerland - the picture has been pretty bad in these countries in recent weeks. Check our maps at the link above and you see cases of it have been detected in most parts of the world. Though many are from travellers, it's too late for many/most countries to avoid outbreaks. But where it is still at low frequency, there is probably a 2-4 month window before this variant (or one of the others) forms the majority of cases. The South African variant is also being detected much more widely now, with many more cases from African countries (which generally have poorer genetic surveillance systems in place) and clear signs of community transmission in the US. The Brazilian variant P1 seems to be wreaking havoc there but has not really spread outside it yet - as far as we know.
2) What you can do: distance yourself even more strictly for now, and get better masks. Buy yourself N95/KN95/FFP2 masks without valves and wear them. If you don't have access to these, wear multiple layers of masks. Before we got our FFP2s, we were wearing cloth masks on top of surgical masks for some additional protection.
3) These variants and similar ones will likely cause an increase in case loads in many countries that are lagging on vaccinations (most of them). This is NOT inevitable! The UK & Ireland were the countries worst hit by these faster-spreading strains - and they have seen cases decline rapidly since they put in place additional protection measures. It's still possible to control this, and we must do everything we can to. The vaccinations give us an additional edge in this race, but the same old measures - masks, distancing, quarantines - are sufficient if done well.
4) We have data on 2 new effective vaccines (Novavax, Johnson & Johnson) but there are good reasons for concern in the medium to long term. These new vaccines have been tested recently and we can evaluate their performance against the new variants. Both are very effective against most Covid strains but Novavax is slightly less so against the UK variant B117 (~85% efficacy vs. 95% for older variants). Both also considerably less effective against the South African variant B1351: approximately 60% instead of 90% for Novavax, 60% vs.70% for Johnson & Johnson (the values may be more similar for serious infections). We've had good reason for some weeks to think that antibody responses against the South African & Brazil variants are less effective, and this shows that those reductions matter in the real world. It also probably means that all the other vaccines will also offer less protection against at least these two variants, as well as others that are not yet on our radar. Yet again, there's been misleading public health messaging around this, I'm afraid.
5) 60% effectiveness is very good and you should definitely get vaccinated! And the protection against serious infections seems even better (if you fall ill, it appears to be milder). If the virus could not evolve any more, a 60% reduction in infection rates everywhere would end the pandemic. But they will continue to evolve (see next post about this). If 60% reflects vaccine effectiveness now, additional evolution should reduce that number as more mutations arise in these variants. At least some of those mutations will make the virus even better at getting around our antibodies. Vaccine makers are creating new forms of the vaccine that will specifically target the mutations in the new variants. The mRNA vaccines from moderna and Pfizer/BioNTech are particularly good for this - they can be retooled in weeks. But it's a moving target and our vaccine manufacturing and distribution capacity (not to mention our political and administrative capabilities) lag well behind the viral spread.
6) [Warning: speculation] If antibodies from the vaccines are less effective against these variants, it also seems likely that antibodies from an earlier Covid infection will be less effective. Immunity is about more than antibodies and reinfections are rare now. But I would expect that getting infected a second time will be more likely with the new variants.
7) I want to underscore that we can get ahead of this and avert much loss of life from these variants in developed countries at least. Remember that an infected 80-year-old is 100 times more likely to die than a 40-year-old, and about 1000 times more likely to die than a 20-year-old. If countries prioritise the most vulnerable populations (basically the elderly) for vaccination, then they should avoid most deaths even if the variants continue to spread. This would be a massive success and is actually quite likely. Israel has given nearly 60% of its population at least one dose! The UAE is at about 30%. The UK about 12%. The US is at 8% despite its very public failures on many counts. The EU is lagging badly at 2.5% and has been hit by a string of bad news, with many expected vaccine deliveries being delayed. All these numbers are way lower than they would have been if governments had reacted competently, but they still represent real and important progress. I expect to see rapid declines in deaths in the next few weeks starting with Israel and the UAE, but also the US and the UK, partly driven by vaccination and partly because the deaths caused by the Christmas travel will fade out soon. We might see flare-ups again because of these variants, but I would expect deaths in most of these places to remain low even if infections rise again because the elderly will be vaccinated.
8) The medium-term outlook (~few months) is more scary in the developing world, which is at the back of the queue for vaccines. Most African countries have not started vaccination because they could not pay as much as developed countries. They are not expected to make major progress on vaccination till 2022, and some might take till 2023 to complete. There has probably been large-scale underreporting of cases and deaths from many of these countries, and the rise of fast-spreading variants could quickly drive new outbreaks even in countries that have controlled their spread (and many developing countries have done so, which should shame the developed ones).
9) The long-term outlook is complicated because a pandemic that is still out-of-control in some parts of the world threatens even those parts that have been vaccinated. Every outbreak offers more opportunities for evolution, which you cannot stop. The best way to avoid this mess was to not give the virus trillions of opportunities to mutate and therefore 'find' some of the rare mutations that help it. In other words, stopping the pandemic early on. That ship has sailed. The next best is to reduce community transmission now so that in addition to vaccination, we deny the virus opportunities to accumulate new mutations that will help it spread in the face of antibody defences. It will be impossible to sustain this effort for another 2 years while we get every developing country vaccinated. In that time, additional mutations will quite likely arise that will lead to variants with a stronger ability to evade our antibodies re-entering developed countries (see next post).
10) It therefore continues to be overwhelmingly valuable even for developed countries to invest in production facilities for vaccines. And in optimising the entire supply chain. The reason why some places got 6 doses instead of 5 from their Pfizer vials is that they were using special syringes that wasted less liquid - how many lives can we save by producing more 'low dead space syringes'? We are not in the endgame yet and the benefits of these investments outweigh the costs by several orders of magnitude. One estimate is that moderna & Pfizer will earn about $10 billion from the vaccine; the economic losses due to Covid are so far in the region of $5 trillion. Just give them all more money to make more and faster. I'm astounded that the EU delayed vaccines by - among other things - negotiating strongly for lower prices and for manufacturers to be held liable for problems.
1) What you probably already know: the UK variant and the South Africa variant spread substantially faster than background strains - somewhere between 30% & 70%. A Brazil variant with some of the same mutations probably spreads at a similar speed. The UK variant has increased rapidly in Denmark, Ireland, Portugal, and now Switzerland - the picture has been pretty bad in these countries in recent weeks. Check our maps at the link above and you see cases of it have been detected in most parts of the world. Though many are from travellers, it's too late for many/most countries to avoid outbreaks. But where it is still at low frequency, there is probably a 2-4 month window before this variant (or one of the others) forms the majority of cases. The South African variant is also being detected much more widely now, with many more cases from African countries (which generally have poorer genetic surveillance systems in place) and clear signs of community transmission in the US. The Brazilian variant P1 seems to be wreaking havoc there but has not really spread outside it yet - as far as we know.
2) What you can do: distance yourself even more strictly for now, and get better masks. Buy yourself N95/KN95/FFP2 masks without valves and wear them. If you don't have access to these, wear multiple layers of masks. Before we got our FFP2s, we were wearing cloth masks on top of surgical masks for some additional protection.
3) These variants and similar ones will likely cause an increase in case loads in many countries that are lagging on vaccinations (most of them). This is NOT inevitable! The UK & Ireland were the countries worst hit by these faster-spreading strains - and they have seen cases decline rapidly since they put in place additional protection measures. It's still possible to control this, and we must do everything we can to. The vaccinations give us an additional edge in this race, but the same old measures - masks, distancing, quarantines - are sufficient if done well.
4) We have data on 2 new effective vaccines (Novavax, Johnson & Johnson) but there are good reasons for concern in the medium to long term. These new vaccines have been tested recently and we can evaluate their performance against the new variants. Both are very effective against most Covid strains but Novavax is slightly less so against the UK variant B117 (~85% efficacy vs. 95% for older variants). Both also considerably less effective against the South African variant B1351: approximately 60% instead of 90% for Novavax, 60% vs.70% for Johnson & Johnson (the values may be more similar for serious infections). We've had good reason for some weeks to think that antibody responses against the South African & Brazil variants are less effective, and this shows that those reductions matter in the real world. It also probably means that all the other vaccines will also offer less protection against at least these two variants, as well as others that are not yet on our radar. Yet again, there's been misleading public health messaging around this, I'm afraid.
5) 60% effectiveness is very good and you should definitely get vaccinated! And the protection against serious infections seems even better (if you fall ill, it appears to be milder). If the virus could not evolve any more, a 60% reduction in infection rates everywhere would end the pandemic. But they will continue to evolve (see next post about this). If 60% reflects vaccine effectiveness now, additional evolution should reduce that number as more mutations arise in these variants. At least some of those mutations will make the virus even better at getting around our antibodies. Vaccine makers are creating new forms of the vaccine that will specifically target the mutations in the new variants. The mRNA vaccines from moderna and Pfizer/BioNTech are particularly good for this - they can be retooled in weeks. But it's a moving target and our vaccine manufacturing and distribution capacity (not to mention our political and administrative capabilities) lag well behind the viral spread.
6) [Warning: speculation] If antibodies from the vaccines are less effective against these variants, it also seems likely that antibodies from an earlier Covid infection will be less effective. Immunity is about more than antibodies and reinfections are rare now. But I would expect that getting infected a second time will be more likely with the new variants.
7) I want to underscore that we can get ahead of this and avert much loss of life from these variants in developed countries at least. Remember that an infected 80-year-old is 100 times more likely to die than a 40-year-old, and about 1000 times more likely to die than a 20-year-old. If countries prioritise the most vulnerable populations (basically the elderly) for vaccination, then they should avoid most deaths even if the variants continue to spread. This would be a massive success and is actually quite likely. Israel has given nearly 60% of its population at least one dose! The UAE is at about 30%. The UK about 12%. The US is at 8% despite its very public failures on many counts. The EU is lagging badly at 2.5% and has been hit by a string of bad news, with many expected vaccine deliveries being delayed. All these numbers are way lower than they would have been if governments had reacted competently, but they still represent real and important progress. I expect to see rapid declines in deaths in the next few weeks starting with Israel and the UAE, but also the US and the UK, partly driven by vaccination and partly because the deaths caused by the Christmas travel will fade out soon. We might see flare-ups again because of these variants, but I would expect deaths in most of these places to remain low even if infections rise again because the elderly will be vaccinated.
8) The medium-term outlook (~few months) is more scary in the developing world, which is at the back of the queue for vaccines. Most African countries have not started vaccination because they could not pay as much as developed countries. They are not expected to make major progress on vaccination till 2022, and some might take till 2023 to complete. There has probably been large-scale underreporting of cases and deaths from many of these countries, and the rise of fast-spreading variants could quickly drive new outbreaks even in countries that have controlled their spread (and many developing countries have done so, which should shame the developed ones).
9) The long-term outlook is complicated because a pandemic that is still out-of-control in some parts of the world threatens even those parts that have been vaccinated. Every outbreak offers more opportunities for evolution, which you cannot stop. The best way to avoid this mess was to not give the virus trillions of opportunities to mutate and therefore 'find' some of the rare mutations that help it. In other words, stopping the pandemic early on. That ship has sailed. The next best is to reduce community transmission now so that in addition to vaccination, we deny the virus opportunities to accumulate new mutations that will help it spread in the face of antibody defences. It will be impossible to sustain this effort for another 2 years while we get every developing country vaccinated. In that time, additional mutations will quite likely arise that will lead to variants with a stronger ability to evade our antibodies re-entering developed countries (see next post).
10) It therefore continues to be overwhelmingly valuable even for developed countries to invest in production facilities for vaccines. And in optimising the entire supply chain. The reason why some places got 6 doses instead of 5 from their Pfizer vials is that they were using special syringes that wasted less liquid - how many lives can we save by producing more 'low dead space syringes'? We are not in the endgame yet and the benefits of these investments outweigh the costs by several orders of magnitude. One estimate is that moderna & Pfizer will earn about $10 billion from the vaccine; the economic losses due to Covid are so far in the region of $5 trillion. Just give them all more money to make more and faster. I'm astounded that the EU delayed vaccines by - among other things - negotiating strongly for lower prices and for manufacturers to be held liable for problems.
