H5N1

Vietnam: The outbreak grows

Via Mike Tatarski's excellent Vietnam Weekly: The Outbreak Grows. Excerpt:

Before Friday’s infection updates, the Ministry of Health had logged 120 local COVID-19 cases since this new wave began on April 29. That has now grown to 411 cases of community infection: 120 in Hanoi, 85 in Bac Ninh, 52 in Vinh Phuc and 37 in Bac Giang. Those neighboring provinces make up the bulk of cases, though Da Nang has turned into a hotspot of its own with 48 infections. 

Overall, cases have been found in 26 provinces and cities, while almost 60,000 people nationwide are in some form of quarantine due to exposure to known cases. 

Here in Ho Chi Minh City, the situation is still in good shape, though this week will be different since schools are now closed. 

One concerning aspect of this latest outbreak is its spread into medical facilities: at least 10 hospitals in Hanoi (including a public cancer hospital) and elsewhere are currently locked down. Hospital clusters are what made the Da Nang outbreak last fall so dangerous. In fact, all 35 of Vietnam’s COVID-19 deaths came from that. 

It’s been hard to keep track of exactly where all these cases came from, though we know that many are linked to foreign experts who tested positive after completing quarantine. A karaoke bar in Vinh Phuc has also been linked to a number of cases. 

Nationwide contact tracing is ongoing, and hundreds of direct and indirect contacts have been found for a known patient who went to Da Lat over the Reunification Day holiday - that city was absolutely packed at the time. 

Minister of Health Nguyen Thanh Long has warned of the dangers of this outbreak given the presence of different strains and also multiple initial infection points (the index patient hasn’t been found in some areas). 

In vaccine news, 851,513 Oxford/AstraZeneca doses have been injected, meaning the health ministry has used almost all of the 917,600 doses it has received thus far. There is no word on when more deliveries may arrive. Last Friday, Vietnam reported its first death related to the vaccine, a 35 year-old medical worker in An Giang Province. She died of anaphylaxis.

COVID-19 spreads to rural India, villages ill-equipped to fight it

Via Reuters:COVID-19 spreads to rural India, villages ill-equipped to fight it | Reuters.

Hopes that India's rampaging second wave of COVID-19 is peaking were set back on Thursday as record daily infections and deaths were reported and as the virus spread from cities to villages that were poorly equipped to cope. 

Government modelling had forecast a peak by Wednesday in infections that have overwhelmed the healthcare system, with hospitals running out of beds and medical oxygen. 

A record 412,262 new cases and 3,980 deaths were reported over the past 24 hours, taking total infections past 21 million and the overall death toll to 230,168, Health Ministry data showed. 

"This temporarily halts speculations of a peak," Rijo M John, a professor at the Indian Institute of Management in the southern state of Kerala, said on Twitter. 

While the capital New Delhi and several other cities have been hardest hit so far, limited public healthcare, including a dearth of testing facilities, means the threat is grave in rural areas that are home to nearly 70% of the 1.3 billion population. 

In the town of Susner in Madhya Pradesh state, patients were being treated outdoors under trees, on blankets on the ground. 

Prime Minister Narendra Modi's government welcomed U.S. President Joe Biden's announcement that he would support waiving intellectual property rights for COVID-19 vaccinations. 

Such a waiver would make vaccines more widely available, although it could take months for the World Trade Organization to hammer out any deal. 

VACCINE PRODUCTION STRUGGLES

While India is the world's biggest vaccine maker, it is struggling to produce enough doses. Its two current vaccine producers will take two months or more to boost monthly output to more than 110 million doses from 70 million-80 million. 

Modi stressed on Thursday that Indian states must keep up vaccination rates and that healthcare workers involved in the inoculation campaign must not be diverted to other tasks, the government said in a statement after a meeting between the prime and his top officials. 

 Modi has been widely criticized for not acting sooner to suppress the second wave, after religious festivals and political rallies drew tens of thousands of people in recent weeks and became "super spreader" events. 

Several Indian states have imposed various levels of social restrictions to try to stem infections, but the federal government has resisted imposing a national lockdown. 

 The southern state of Kerala announced on Thursday it will impose nine days of curbs on movement from Saturday. 

In the office of a Hindu crematorium in Delhi, the floor and shelves were overflowing with earthen pots, plastic packets and steel containers filled with the ashes of people who have died from COVID-19. 

Practising Hindus collect the ashes of the dead a few days after the funeral for immersion in a river or sea, one of the rituals that they believe lead to salvation of the soul. 

"Our lockers are full. We cannot store any more ashes. We used to get around 40 COVID-19 bodies a day. We are now telling relatives to take the ashes with them on the same day," Pankaj Sharma, a manager at the crematorium, told Reuters.

SARS-CoV-2 elimination, not mitigation, creates best outcomes for health, the economy, and civil liberties

Via The Lancet: SARS-CoV-2 elimination, not mitigation, creates best outcomes for health, the economy, and civil liberties.

The trade-off between different objectives is at the heart of political decision making. Public health, economic growth, democratic solidarity, and civil liberties are important factors when evaluating pandemic responses. There is mounting evidence that these objectives do not need to be in conflict in the COVID-19 response. Countries that consistently aim for elimination—ie, maximum action to control SARS-CoV-2 and stop community transmission as quickly as possible—have generally fared better than countries that opt for mitigation—ie, action increased in a stepwise, targeted way to reduce cases so as not to overwhelm health-care systems. 

We compared COVID-19 deaths, gross domestic product (GDP) growth, and strictness of lockdown measures during the first 12 months of the pandemic for Organisation for Economic Co-operation and Development (OECD) countries that aim for elimination or mitigation (figure). Although all indicators favour elimination, our analysis does not prove a causal connection between varying pandemic response strategies and the different outcome measures. 

COVID-19 deaths per 1 million population in OECD countries that opted for elimination (Australia, Iceland, Japan, New Zealand, and South Korea) have been about 25 times lower than in other OECD countries that favoured mitigation (figure). Mortality is a proxy for a country's broader disease burden. For example, decision makers should also consider the increasing evidence of long-term morbidities after SARS-CoV-2 infection. 

There is also increasing consensus that elimination is preferable to mitigation in relation to a country's economic performance.6 One study quantified the optimal basic reproduction number so that elimination is achieved at minimal economic cost. To this end, consider weekly GDP growth with respect to 2019 for the OECD countries that opted for elimination or mitigation (figure). Elimination is superior to mitigation for GDP growth on average and at almost all time periods. GDP growth returned to pre-pandemic levels in early 2021 in the five countries that opted for elimination, whereas growth is still negative for the other 32 OECD countries. 

Despite its health and economic advantages, an elimination strategy has been criticised for restricting civil liberties. This claim can be challenged by analysing the stringency index developed by researchers at the University of Oxford. This index measures the strictness of lockdown-style policies that primarily restrict people's behaviour by combining eight indicators of containment and closure policies, eight indicators of health system policies, and one indicator of public information campaigns. 

Among OECD countries, liberties were most severely impacted in those that chose mitigation, whereas swift lockdown measures—in line with elimination—were less strict and of shorter duration (figure). Importantly, elimination has been framed as a civic solidarity approach that will restore civil liberties the soonest; this focus on common purpose is frequently neglected in the political debate. 

Evidence suggests that countries that opt for rapid action to eliminate SARS-CoV-2—with the strong support of their inhabitants—also better protect their economies and minimise restrictions on civil liberties compared with those that strive for mitigation. Looking ahead, mass COVID-19 vaccination is key to returning to usual life, but relying solely on COVID-19 vaccines to control the pandemic is risky due to their uneven roll-out and uptake, time-limited immunity, and the emergence of new SARS-CoV-2 variants. 

History shows that vaccination alone can neither single-handedly nor rapidly control a virus and that a combination of public health measures are needed for containment. The eradication of smallpox required concerted, decades-long efforts, including vaccination; communication and public engagement; and test, trace, and isolate measures. Even at the end of vaccination campaigns, such public health measures must be maintained to some extent or new waves of infections might lead to increased morbidity and mortality. 

With the proliferation of new SARS-CoV-2 variants of concern, many scientists are calling for a coordinated international strategy to eliminate SARS-CoV-2. Moreover, the US Department of State declared in April, 2021, that stopping COVID-19 is the Biden–Harris administration's number one priority and highlighted that “this pandemic won't end at home until it ends worldwide”. 

National action alone is insufficient and a clear global plan to exit the pandemic is necessary. Countries that opt to live with the virus will likely pose a threat to other countries, notably those that have less access to COVID-19 vaccines. The uncertainty of lockdown timing, duration, and severity will stifle economic growth as businesses withhold investments and consumer confidence deteriorates. Global trade and travel will continue to be affected. 

Political indecisiveness and partisan policy decisions reduce trust in government. This does not bode well in those countries that have seen a retraction of democracy. Meanwhile, countries opting for elimination are likely to return to near normal: they can restart their economies, allow travel between green zones, and support other countries in their vaccination campaigns and beyond. 

The consequences of varying government COVID-19 responses will be long-lasting and extend beyond the end of the pandemic. Early economic and political gains made by countries aiming to eliminate SARS-CoV-2 will probably pay off in the long run.

India’s COVID-19 crisis is the world's crisis

Via The Atlantic: India’s COVID-19 Crisis Is the World's Crisis. Excerpt:

India considered itself to be “in the endgame” of the pandemic just a few weeks ago. Now it is the global epicenter. The country recently surpassed the devastating milestone of more than 345,000 new COVID-19 cases in a single day, the biggest total recorded globally since the pandemic began. 

What is taking place in India isn’t so much a wave as it is a wall: Charts showing the country’s infection rate and death toll, which has also reached record numbers in the country, depict curves that have shot up into vertical lines. Public-health experts aren’t optimistic that they will slope down anytime soon.

India’s outbreak is an enormous tragedy for its own people, but it’s also a catastrophe for the rest of the world. Ninety-two developing nations rely on India, home to the Serum Institute, the world’s largest vaccine maker, for the doses to protect their own populations, a supply now constrained by India’s domestic obligations. 

Meanwhile, the coronavirus is mutating. Reports of double- and even triple-mutant strains of the virus, which experts fear could be driving the country’s latest surge, have prompted concerns that what has started in India won’t end there. Despite efforts to restrict the spread of India’s new COVID-19 variant, called B.1.167, it has already been identified in at least 10 countries, including the United States and Britain.

If ever there were a time for intervention, it would be now. But world leaders, who have so far only paid lip service to the need for global cooperation, have mostly been preoccupied by their own internal situations. Although this approach may have served vaccine-rich countries such as the U.S. so far, India could prove its limits. 

How did India, which merely a month ago thought it had seen the worst of the pandemic, get to this point? Michael Kugelman, the deputy director of the Asia program at the Washington, D.C.–based Wilson Center, told me the answer comes down to a “perfect storm” of factors that includes new and existing variants (and a lack of robust genomic sequencing to track them), a continuous stream of widely attended political rallies and religious gatherings (with no social distancing or mask wearing), and a general complacency on the part of the Indian government, which was slow to respond to a crisis in which it had prematurely claimed victory. 

The result has been overwhelmed hospitals, depleted oxygen supplies, morgues that have run out of space, and crematoria that are melting from near-constant use. The country surpassed 2,000 deaths a day last week—and those are just the cases that have been recorded. This time next month, that figure could rise to as high as 4,500 daily deaths, Bhramar Mukherjee, a biostatician and epidemiologist at the University of Michigan who is tracking the situation in India, told me. Others warn that it could get as high as 5,500. Though the projections vary, the conclusions are largely the same. “All the arrows are pointing to real darkness,” Mukherjee said. 

The situation has become so dire that the Pune-based Serum Institute, the manufacturer of the AstraZeneca vaccine and a major contributor to the COVAX initiative to provide doses to low- and middle-income countries, said it will not be able to meet its international commitments amid India’s domestic shortage. Once considered the pharmacy of the world, India is now being forced to import doses.

Thailand and Cambodia rush to halt waves of Covid-19 cases

Via The Guardian: Thailand and Cambodia rush to halt waves of Covid cases. Excerpt:

After managing to control the coronavirus for much of 2020, Thailand is battling a fresh outbreak of Covid-19, with officials setting up thousands of beds in field hospitals and warning the public to stay at home. 

A cluster of Covid cases emerged in Bangkok’s nightlife venues last month, just before the Songkran new year holiday, when many Thais travel across the country to celebrate with their families. Following record daily increases last week, tighter measures were introduced from Sunday, including the closure of schools for two weeks. Bars have been shut, restaurants banned from serving alcohol and the opening hours of shopping malls have been reduced in areas such as Bangkok. 

Prof Anucha Apisarnthanarak, chief of the infectious diseases division at Thammasat University, said patients in the current wave, which involves the more transmissible strain first recorded in the UK, were presenting with different symptoms, including rashes and red eyes. Based on conversations with doctors, it appeared that around 40% of patients with symptoms developed pneumonia while in hospital – a much greater proportion than in previous waves. 

Such patients required much more specialist support, placing additional strain on hospitals, he said: “In the next two or three weeks, if the cases are still increasing, we might encounter the situation that Spain or the UK or European countries encountered six month before, because we don’t have enough facilities for care.” 

Almost 14,900 infections have been recorded since 1 April which, though a fraction of the cases recorded elsewhere, is roughly double the country’s caseload for the entire of 2020. 

On Monday, a fourth field hospital was opened in the capital, at the Bangkok Arena sports centre, which will accept asymptomatic cases. Anyone who tests positive is asked to stay in a facility, to avoid spreading the virus further. Converted hotels will also accept patients with no symptoms. 

Natapanu Nopakun, deputy spokesman for the ministry of foreign affairs, said it was hoped that measures introduced by various agencies, as well as the public’s cooperation, would soon have an impact: “In the next two weeks we may have a slightly different or better situation, hopefully,” he said. A further 1,390 new cases were confirmed on Monday, lower than the record 1,767 announced the previous day. 

Neighbouring Cambodia is also rushing to contain a wave of infections that emerged late in February. Last week the prime minister, Hun Sen, said the country was “on the brink of death”, as 2 million people across Phnom Penh and Ta Khmau were placed under lockdown. Thousands of hospital beds have been set up in wedding party halls and schools. 

Cambodia and Thailand were among several south-east Asian countries that kept cases low last year, avoiding the crises that overwhelmed health systems elsewhere. 

Thailand was praised for its early and strict lockdown introduced last April which virtually eradicated the virus, but the government has stopped short of re-imposing the same measures again, due to the steep economic cost. It now faces growing pressure over its vaccine programme, which, as of 17 April, had reached less than 1% of Thailand’s 69.8 million population, according to the tracking website Our World in Data.

Iran orders 10-day shutdown amid fourth wave of coronavirus pandemic

Via Reuters: Iran orders 10-day shutdown amid fourth wave of coronavirus pandemic.

Iran imposed a 10-day lockdown across most of the country on Saturday to curb the spread of a fourth wave of the coronavirus pandemic, state media reported.

The lockdown affects 23 of the country’s 31 provinces, health ministry spokesman Alireza Raisi said. Businesses, schools, theatres and sports facilities have been forced to shut and gatherings are banned during the holy fasting month of Ramadan that begins on Wednesday. 

Iran’s coronavirus cases have surpassed 2 million with a new daily average of over 20,000 infections over the past week, according to the health ministry. It has reported more than 64,000 fatalities. 

“Unfortunately, today we have entered a fourth wave,” President Hassan Rouhani said in televised remarks. He blamed the surge foremost on the variant that first emerged in the UK which spread to Iran earlier this year from neighbouring Iraq. 

Other factors included widespread travel, weddings, and celebrations during the Iranian New Year holidays that began on March 20, he said. 

The UK variant is now predominant in the country, and 257 cities and towns are in red alert, Raisi said. 

Iran has been the epicentre of the pandemic in the Middle East. In February, it closed several crossing points with Iraq in an effort to stem the spread of the UK variant. 

The country’s vaccination drive has also been slow going. Tehran says it has received more than 400,000 of 2 million Sputnik V vaccines on order from Russia, and that it is awaiting delivery of 4.2 million AstraZeneca shots. It has also received 250,000 doses of China’s Sinopharm vaccine and part of an order of 500,000 doses of India’s COVAXIN. 

With a population of 83 million, Iran had hoped to secure over 2 million vaccines by March 20 to vaccinate mainly healthcare workers. It is developing at least four local vaccine candidates, one in cooperation with Cuba, which are expected to reach production in a few months.

COVID-19: March highlights

An OCHA report: COVID-19: March Highlights. Excerpt:

Top 5 highlights to know: 

• In March, more than 5.1 million new cases and 120,000 deaths were recorded in countries in the Global Humanitarian Overview – a 70% increase in cases and a 32% increase in deaths from February. Attribution is difficult, but the surge in cases and deaths could be explained by a combination of the spread of new variants, the lack of widespread access to vaccines, and the relaxation of and dwindling compliance with public health and social measures. 

• Ten countries with an inter-agency Humanitarian Response Plan (HRP) are experiencing a consistent rise in cases and deaths. Yemen experienced an 85% increase in reported cases and 39% increase in deaths over the previous month. Seven of the countries reported their highest case numbers and five countries their highest number of deaths since the start of the pandemic. Five countries have verified at least one Variant of Concern (VOC) and all ten countries border countries with verified VOCs. 

• Vaccines are being delivered to HRP countries, but in relatively small quantities. In March, COVAX delivered over 9.2 million doses to 11 countries bringing the total number of COVAX deliveries in HRP countries to 11 million. This is approximately 15 per cent of the 73 million doses that COVAX aims to deliver in the first round to HRP countries, which it aims to conclude by end of May. A further 3.6 million doses are estimated to have been donated by other countries to HRP countries or procured directly by national authorities in March. 

• Lower administration of vaccines remains a challenge in HRP countries. Based on available data, of the 21 million doses delivered in HRP countries only 3.5 million have been administered. As of 31 March, for every 165 people globally receiving a dose of COVID-19 vaccine only one person resided in a country with a Humanitarian Response Plan. 

• Since the start of the pandemic, the International Financial Institutions have provided $68.7 billion to 46 countries in the GHO. Countries with a humanitarian response plan have received the least funding, with half receiving less than $23 per person.

Haiti has no Covid-19 vaccine doses as violence looms larger than pandemic

Via The Guardian: Haiti has no Covid vaccine doses as violence looms larger than pandemic.

Haiti does not have a single vaccine to offer its more than 11 million people over a year after the pandemic began, raising concerns among health experts that the wellbeing of Haitians is being pushed aside as violence and political instability across the country deepen. 

So far, Haiti is slated to receive only 756,000 doses of the AstraZeneca vaccine through a United Nations program aimed at ensuring the neediest countries get Covid-19 shots. The free doses were scheduled to arrive in May at the latest, but delays are expected because Haiti missed a deadline and the key Indian manufacturer is now prioritizing an increase in domestic demand. 

“Haiti has only recently completed some of the essential documentation that are prerequisites for processing of a shipping order,” said Gavi, the Vaccine Alliance, a Geneva-based public-private partnership that is co-managing the UN-backed Covax effort. 

The country also didn’t apply for a pilot program in which it would have received some of its allotted doses early, according to the Pan American Health Organization. However, a spokeswoman commended its other pandemic efforts, including reinforcing hospital preparedness. 

Meanwhile, a human rights research center cited in a new US state department report found Haiti’s government misappropriated more than $1m worth of coronavirus aid. The report also accused government officials of spending $34m in the “greatest opacity”, bypassing an agency charged with approving state contracts. 

Lauré Adrien, general director of Haiti’s health ministry, blamed the vaccine delay on scrutiny of the AstraZeneca shots and concerns that the country lacks the necessary infrastructure to ensure proper vaccine storage, adding that his agency prefers a single-dose vaccine. AstraZeneca requires two doses. 

“It’s no secret that we don’t have excellent conservation facilities,” he said. “We wanted to be sure that we had all the parameters under control before we received vaccine stocks.” 

Adrien also noted all the money his agency received has been properly spent, but said he could not speak for other agencies. A presidential spokesman did not return calls for comment.

Ebola virus transmission initiated by relapse of systemic Ebola virus disease

Via NEJM: Ebola Virus Transmission Initiated by Relapse of Systemic Ebola Virus Disease. The summary:

During the 2018–2020 Ebola virus disease (EVD) outbreak in North Kivu province in the Democratic Republic of Congo, EVD was diagnosed in a patient who had received the recombinant vesicular stomatitis virus–based vaccine expressing a ZEBOV glycoprotein (rVSV-ZEBOV) (Merck). His treatment included an Ebola virus (EBOV)–specific monoclonal antibody (mAb114), and he recovered within 14 days. 

However, 6 months later, he presented again with severe EVD-like illness and EBOV viremia, and he died. We initiated epidemiologic and genomic investigations that showed that the patient had had a relapse of acute EVD that led to a transmission chain resulting in 91 cases across six health zones over 4 months. 

See also this Reuters report on the case.

COVID-19 vaccines in high-risk ethnic groups

Via The Lancet: COVID-19 vaccines in high-risk ethnic groups.

Black, Asian, and minority ethnic communities worldwide have a disproportionate risk of severe COVID-19. In the UK, as of May 19, 2020, 36% of critically ill patients with COVID-19 requiring intensive care were from Black, Asian, or minority ethnic groups.1 According to Public Health England, the mortality risk from COVID-19, after accounting for sex, age, deprivation score, and geographical region, is double in Bangladeshi people and up to 50% higher in Black and south Asian people compared with White British people. This finding contrasts with age-adjusted all-cause mortality from previous years, which was lower in Asian and Black people than in White British people. These data imply that COVID-19 has more serious effects in Black and Asian people. 

The ethnic groups most affected by COVID-19 are under-represented in the COVID-19 vaccine trial data published so far. Despite efforts to encourage participation from Black, Asian, and minority ethnic groups, of the 552 participants in the phase 2/3 Oxford–AstraZeneca trial (based in Southampton and Oxford, UK), only one participant was Black and 19 were Asian. Large-scale trials also have a smaller proportion of minority groups compared with the populations sampled (appendix).

Black, Asian, and minority ethnic individuals are under-represented in research. However, the ongoing pandemic necessitates that access to trials and vaccinations shifts from being equal to being equitable. Study recruitment and participation designs should improve diversity in ethnic groups to maximise the validity of results to the populations concerned. Age and sex are routinely considered in recruitment design—the same should now apply to ethnicity. 

In the context of a pandemic that has higher infection and mortality risks in certain ethnic groups, it is important that these specific groups are adequately represented in vaccine trials to evaluate both immunogenicity and efficacy.