health

Don’t Forget The Drugs: An Update

In these pages last March, I reminded readers to be thankful for the vaccines that prevent COVID-19, but to not forget the antiviral drugs that are being developed that might treat the disease. Both vaccines and antivirals are part of the same quiver of weapons we have to fight the pandemic. In that blog post, I mentioned an experimental drug, molnupiravir that was being developed by Merck and Ridgeback Therapeutics. Well, they just posted an encouraging update. It continues to show success at preventing serious disease when given to high-risk people early after infection. Its only side effects were similar to the placebo, meaning it is very safe. In animal studies, the drug also was effective against different CoV-2 variants, including Delta, and against other coronaviruses including SARS and MERS. Molnupiravir is a “prodrug,” which means that it has no activity on its own; rather it is metabolized after ingestion to an active drug that was developed in the early 2000s to treat hepatitis C.

This is a significant step for being able to easily protect high-risk patients at home. The pill that patients take on their own cuts their risk of hospitalization or death by ~50%. The results were so encouraging that the study was halted after consultation with the FDA. Early termination of studies like this is only done when interim data analyses show such good efficacy of a treatment that it would be unethical to continue enrolling subjects, some of whom would receive placebo, thereby being denied an effective therapy.

The drug slows the spread of the virus in infected people by forcing the enzyme that copies the viral genetic material into making so many mistakes the virus cannot reproduce. That, in turn, reduces the patient’s viral load, shortening the infection and damping the type of over-exuberant immune response (cytokine storm) that causes serious problems in many COVID patients. It was not effective when given to already hospitalized, or advanced, patients. It is on track to be approved by the FDA by the end of the year, and would be the first proven and approved oral antiviral drug for treating COVID-19 (neither ivermectin nor hydroxychloroquine have been proven or approved).

The FDA has already cleared another antiviral drug, remdesivir, for treating COVID-19, but it is only used to treat advanced patients who are already hospitalized (interestingly remdesivir was also originally developed to treat hepatitis C and it is also used to treat Ebola). Several lab-produced monoclonal antibody treatments have also been approved by the FDA for treating mild to moderate COVID-19 and they are more successful than molnupiravir at preventing advanced disease. But both remdesivir and the antibody treatments require an intravenous infusion done in a health care setting, making them more complicated and more expensive than just taking a pill at home, which is a decided advantage of molnupiravir. Finally, one of the more effective approved drugs against COVID-19 is the steroid, dexamethasone, but that is only given to very sick patients since its side effects are significant. Therefore, there is much room in the anti-COVID quiver for effective, simple-to-administer drugs such as molnupiravir. Both Pfizer and Roche also have other antiviral drugs that block viral replication in advanced stages of development. Stay tuned.

As of October 5, 2021, the Milken Institute tracker shows that there are 331 “treatments” for COVID-19 in development worldwide. This effort recently got a $3.2 billion boost from the US Antiviral Program for Pandemics, which is a rejuvenated initiative that was started during the MERS outbreak in 2012, but was tabled after MERS fizzled out. Then there is the Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV) program, also sponsored by NIH. These programs focus on developing non-vaccine therapies designed to treat not prevent the disease and they include studies of medicines currently used to treat other diseases (including ivermectin, which has yet to be proven effective) as well as studies of new drugs.

While the news about molnupiravir is encouraging, health experts are concerned that the news also could increase complacency regarding vaccines in the vax-hesitant. It is important to realize that prevention (vaccination) is almost always preferable to treatment (drugs).

Get the vax.

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The Long Haul, Part 1: What Long COVID Is Like

This is the first part of a multi-part blog series on long term morbidity associated with COVID-19 infection (how many parts there will be in the series remains to be determined). When public health scientists assess the impact of a disease on society, they consider both mortality as well as morbidity. In fact, the CDC’s primary assessment of US health is a publication called the Morbidity and Mortality Weekly Report. This blog series was prompted, in part, by repeated assertions by vaccine nay-sayers that since the mortality of COVID is only about 1.5% of those infected (they usually cite a false and much lower mortality rate), the vaccines and mandates are unnecessary. To that naive statement I make three points that the nay-sayers typically ignore:

  1. The Spanish flu had a similarly low mortality rate as COVID-19, but in just 24 weeks during its second wave, it killed more people around the world than were killed in the 10 years of WWI and WWII combined. Hence, just looking at the percent of infected people who die does not tell the whole story if you do not also mention the total number of people infected. One percent of a billion people is a very large number, for example.
  2. By focusing only on the low mortality rate, the vax nay-sayers are engaging in a logical fallacy called “confirmation bias.” That is, they totally ignore the statistics that do not support what they want to believe. What they ignore here is the cost incurred by disease survivors, or the morbidity. Morbidity rates usually swamp mortality rates and, as we shall see in this blog series, long COVID can cause a disproportionate cost to individuals and society in terms of damaged health, lost productivity, increased burden on health systems (which also affects care of critical non-COVID patients) and insurance payors, lost earnings, interrupted careers, and even delayed deaths that are not attributed to COVID, such as suicide, which I discuss below.
  3. Last December, just before the vaccines first rolled out, I reported that COVID-19 deaths had become, by far, the number one killer in the US, which contradicts the “negligible death rate” narrative of the nay-sayers. At that time COVID deaths far outpaced deaths due to cancer and heart disease, the previous top two causes of death in the US. That high COVID death rate dropped because of the vaccines. These facts put the lie to anti-vaxer’s claims that we do not need vaccines or public health mandates because the death rate from COVID is low. The COVID death rate had become very high, but is now much lower precisely because of the vaccines and mandates.

In this post, Part 1 in the series, I relate what long COVID is like to some long haulers. In future posts, I will focus on the costs of long-term COVID, and on the specific devastating health effects long-haul COVID can have on the neurological system, on the kidneys, lungs, and on new-onset Type 1 diabetes. And I will discuss what we have learned about the causes of long COVID and how to treat or manage it.

What is it like for long haulers? I began this blog in April 2020, and one of the first posts I made was about the experience of an emergency room doctor who was on the front lines of the early pandemic working in an ER in NYC, which was very hard hit by the pandemic. She caught the disease and spent a couple of weeks in the ICU recovering from it. But, something was not right with her after she was discharged from medical care, and she was re-admitted to an in-patient psychiatric unit to treat her mind. After a few weeks, she was released to convalesce at her sister’s home. But, she was still not right in her mind and eventually shot herself in the head. Her suicide was not counted as a COVID death. There have been other post-COVID suicides since then.

There are the recent post-COVID suicides of Texas Roadhouse CEO Kent Taylor and "Dawson's Creek" writer Heidi Ferrer and several others, which reveal a heightened risk of suicide as a sequelae of long COVID.

Sometime early in the pandemic, a healthy, young journalist who had recently graduated from journalism school also caught the disease. She eloquently wrote about the ordeal, which began in full four weeks after she had been diagnosed and two weeks after she no longer tested positive for the virus. She wrote how her body shook for five days before checking into a North Carolina hospital not knowing what was wrong. She wrote that two nights before going to the ER, and after being “cured” from COVID-19, she was jolted awake by what felt like a “brain zap.” She staggered into the hallway which she described feeling like it was on a funhouse tilt. She said she felt like she was in a Salvador Dali painting, “distorted and oozing.” When she tried to speak to her husband, the words came out drowsy and slow. I personally found the description of her feelings interesting since a friend of mine who had experimented with drugs in her earlier life once told me about tripping on LSD and feeling like her “face was melting like in a Dali painting.” For the young journalist, long COVID was somewhat similar to the experience of my friend on LSD.

Like 10-30% of the ~200 million, globally (a large number), who have survived COVID-19, the journalist did not get better after she was declared to be COVID-free,  and in fact she said that what came next was much worse than the disease. After a month of non-stop post-COVID malaise, she found herself in the emergency room complaining that she had a “shaky, electric feeling” in her stomach, and that she could not think or sleep. Eight months later the waves of illness had not let up. She was one of the early cases of long COVID, which we now know occurs in 10-30% of COVID survivors (although one study from Italy claimed that >50% of COVID survivors experienced symptoms at least four months after their infection).

The journalist wrote in July 2021, “Since December (2020), I've seen 15 specialists, received eight scans, visited three ERs and--even with insurance--spent $12,000 seeking a return to normal life. Since February, I moved across the country (from North Carolina) to receive treatment from a post-COVID recovery clinic at (the) Keck School of Medicine at the University of Southern California. The clinic refers its patients to specialists depending on their symptoms and provides a social worker. I receive weekly treatment from a physical therapist, occupational therapist and neurologist there.”

“I've had more than 50 symptoms ranging from cognitive impairment, insomnia, vertigo, extreme light and sound sensitivity, and fatigue, to convulsion-like shaking, slurred speech, hair loss, muscle weakness, anxiety.” She said that she was too “foggy” to read or even to watch TV news, which was her occupation. She was unable to write for six months, and had not had a symptom-free day since November 6, 2020, the day she tested positive for Covid-19. Most of these symptoms occurred simultaneously.

She writes on, “Before my illness, I never had any thoughts about suicide. This changed after I got sick. I'm no longer in this dark place, but the months it held me hostage I inched closer to the edge than I ever wished to be. As my brain fog intensified, I developed such a palpable anxiety, it brought with it new compulsive behaviors like "trichotillomania," or hair pulling. The days blended into one dream-state. I had only what I can describe as brain zaps. I'd wash my hair, forget, then wash it again. The further I slipped away from reality, the deeper my depression became.”

“I found myself researching death-with-dignity laws. I learned that Northern European countries have some of the most lenient.” She entertained suicide for the first time in her life. Other post-COVID patients have also described having thoughts of suicide and some have acted on that.

The experience of this journalist and a few million others like her quickly became noticed anecdotally by the medical establishment and the patients were referred to as “long haulers.” Their constellation of symptoms became known as “long COVID,” or more formally Post-Acute Sequelae of COVID-19 (PASC). As long COVID became increasingly recognized, the medical establishment realized that it was something entirely new and that they had little clue on how to deal with it other than try to manage the myriad symptoms, now numbering at more than 200. We now know that long haulers can suffer months of “brain fog,” persistent headaches, chronic fatigue-like symptoms, breathing problems, lung failure (sometimes requiring transplants), new-onset diabetes, depression and/or anxiety, dizziness, muscle and joint pain, and more. These occur in 10-30% of old and young infected people, and even in those who had mild COVID-19.

Medical science is slowly catching up, but progress is slow, not for lack of effort, but simply because medical research takes time. The very recent FAIR Health study of COVID-19 patients, the largest to date, analyzed health records of nearly two million people who have been infected with the virus in the US and found that hundreds of thousands have sought care for new health conditions after their acute illness subsided. New research points to neuropsychiatric changes in Covid-19 survivors potentially due to brain inflammation or to a disruption of blood flow to the brain. Then there are other theories, partly borne out by an Oxford study, that the virus affects serotonin and dopamine neurotransmitters, affecting brain function and physiology. A recent case published in the Journal of Psychiatry Neuroscience and Therapeutics reported that "autoimmune-mediated psychosis" caused a 30-year-old without previous health or psychological conditions to become delusional after recovering from COVID. In response to this increasing concern over long COVID, NIH launched a large nationwide study of long COVID and recently  awarded $470 million to New York University Langone Health. This NIH REsearching COVID to Enhance Recovery (RECOVER) Initiative aims to learn why some people have prolonged symptoms or develop new or returning symptoms after they recover from the acute phase of infection.

In future posts in this blog series, I will cover in more detail what we have learned to date about long COVID. Since the data keep coming in, I cannot predict when this series will end.

So, stay tuned and please ask questions.

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HIV And Coronaviruses: A Bad Combo

Africa is the continent least vaccinated for COVID-19 and it also has been where several CoV-2 variants have arisen: Beta in South Africa, most recently C.1.2 (not yet given a Greek letter designation) also from South Africa, and Eta in Nigeria. A possible reason for the appearance of these variants is because Africa is also home to the most immunocompromised people. HIV is common in Africa and tuberculosis is rampant on the continent.

One HIV-positive woman in South Africa was reported to carry active CoV-2 infection for 216 days, during which time it mutated 30 times according to Tulio de Oliveira, who runs gene-sequencing centers at two South African universities. This is concerning since South Africa has the world’s largest HIV epidemic. It is estimated to have 8.2 million people infected with HIV. While most of these take antiretroviral drugs, which keep the virus at bay, many do not. And neighboring countries, Botswana, Zimbabwe, and Eswatini also have very high HIV infection rates. The burden of HIV, TB and other chronic diseases is higher in these countries than in other countries around the world due to extreme poverty and poor health care for millions of Africans. When these people also become infected with CoV-2, they grow and shed the virus longer than someone with a good immune system and good health care. That means that the virus has longer to mutate in an infected, immunocompromised person.

In wealthier countries in the West, a rich debate is ongoing about whether to add another shot (booster) to already vaccinated people. One of the biggest arguments against this is that those booster vaccines are needed much more in poorer, and woefully under-vaccinated countries, such as those in Africa. The concern is that our boosters come at the expense of basic immunization of these impoverished countries, which facilitates the generation of troublesome viral variants. On the other hand, if CoV-2 is running rampant because the health care infrastructure in these countries is not up to delivering those vaccines, maybe it would be better making sure that richer countries are as protected as possible.

These are the proverbial two horns of a dilemma. Which horn would you choose?


Vaccines And Myocarditis In Young People

Rare cases of inflammation of the heart muscle, or myocarditis, have been found in 1,200 younger people (16-24) after receiving an mRNA vaccine, and this has been used by anti-vaxers to further the hysteria around the vaccine. But, if you talk to a pediatric cardiologist you will learn that we should be much more worried about the disease than the vaccine. There simply is no comparison.

The post-vaccine myocarditis is very mild, has caused no deaths, is easily treated with anti-inflammatory drugs, and quickly goes away without lasting problems. On the other hand, COVID-19 can linger for months, and, as of June 9, has caused ~3000 deaths in young people. Because of this, the American Heart Association and American Academy of Pediatrics continue to strongly recommend vaccination for young people.

Myocarditis in young people is not a new thing, and is usually associated with a viral or bacterial infection. One vaccine against small pox has also been weakly linked to myocarditis. People from puberty through their early 30s are at higher risk for myocarditis, according to the Myocarditis Foundation. Males are affected twice as often as females. Most of these cases are very mild and many times people with myocarditis do not even know they have the problem. The incidence of myocarditis in young people peaks this time of year when the coxsackie virus, which can infect the heart, is more common. This means that an undetermined fraction of post-vaccine myocarditis is likely due to concomitant infection with coxsakie virus and not due to the vaccine.

Bottom line: Post-vaccine myocarditis is much ado about next to nothing. This should not cause one to hesitate getting the vaccine, unless the person has another underlying cardiac problem. The mildness of this rare side effect contrasts with the thousands of young people who have contracted serious COVID-19 and have even succumbed to the infection. While severe morbidity and mortality from COVID-19 is rarer in children and adolescents than in older adults, the number of cases in young people has been steadily rising on a weekly basis according to the CDC. This trend will likely accelerate as the more infectious, and possibly more lethal Delta variant becomes dominant in the US. Since most older adults have been vaccinated, that leaves younger people as available targets for the new virus surge. There is no rational reason for 99.9% of people to not be vaccinated.

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Almost All US COVID-19 Deaths Occur In Un-Vaccinated People

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As the anti-CoV-2 vaccines roll out in the US, COVID-19 infections and hospitalizations have plummeted. Deaths, too, have plummeted from a peak of 3,400 a day in mid-January to fewer than 300 today. About 63% of vaccine-eligible Americans (those 12 and older) have received at least one vaccine dose, and 53% are fully vaccinated. All this demonstrates the efficacy of the vaccines.

Also showing how effective the vaccines are, almost all new infections, hospitalizations, and deaths now occur in unvaccinated people. An Associated Press analysis of CDC data since May reveals that fewer than 1,200 vaccinated people, out of a total of 853,000, were hospitalized for COVID-19. Furthermore, in May there were 18,000 COVID-19 deaths in the US, of which only 150 were fully vaccinated. The vaccines are so successful that the CDC director was quoted as saying, “…nearly every death…due to COVID-19 is, at this point, is entirely preventable.” Let me repeat that, COVID-19 deaths are almost 100% preventable now because of the vaccines. Let that sink in, anti-vaxers.

These observations are especially relevant in the face of the Delta, or double mutant virus variant that has taken over India, the UK, Israel, and is rapidly spreading in the US. As I reported earlier, this double mutant variant first appeared in India and carried the same mutations as two earlier variants first identified in the UK and in South Africa. Individually, these mutations made the variants either more virulent, or able to spread faster than the parent virus. Together, they create a more dangerous, faster spreading virus. The good news was that the current vaccines are pretty effective against the Delta variant.

However, there are two concerning things about the Delta variant that raise alarms. First, in Israel, about half of adults infected with the variant were fully vaccinated with the Pfizer vaccine. 90% of new infections in that country are now caused by the Delta variant and children under 16 account for about half of those new infections. So-called “break-through infections” can occur in fully vaccinated people, but have been, so far, rare. This makes the high level of break-through infections in Israel worrisome. Breakthrough infections in previously vaccinated people are especially worrisome--how is the virus avoiding vaccine immunity? These kind of infections are what most concerns this writer, since a virus that can replicate in a fully infected person suggests we could have a new variant that resists vaccine immunity. We do not yet know why break-through infections appear with greater frequency in that country. However, when vaccinated people are infected, they almost always avoid severe symptoms. Hopefully, this will continue to be the case in Israel. We will see.

The second concerning thing is something I have earlier warned anti-vaxers about—the emergence of further variants that could be even more virulent or able to avoid vaccine immunity. India has just reported a new Delta variant, referred to as “Delta Plus.” It also has been detected in 11 countries including the UK, Japan, and the US. Little is known about this variant, but it has been declared a “variant of concern” and is being closely watched. Again, we will see.

Delta Plus arose in people who have not been vaccinated. As I have strongly argued in these pages, each anti-vaxer represents a potential incubator for a new variant for which current vaccines are ineffective and/or is much more lethal. And as I also pleaded in a previous blog post, “get over yourselves; it is not all about you!” Get the shots.


Anti-vaxers, Get Over Yourselves--The Vaccine Is Not All About You

As predicted, viral variants are now causing most of the new cases of COVID-19 disease around the world. The Delta variant, formerly known as the “double mutant,” which first arose in India and as earlier discussed in these pages, is extremely transmissible and seems to cause more severe illness. It arose in India because the country was way under-vaccinated and, therefore, a prime incubator for producing more lethal viral variants. As the virus replicates in a person’s cells, then spreads to another person, it accumulates small mutations that, by chance, can make a significant difference in its virulence. The virus replicated over and over and over in unvaccinated India and a more potent strain evolved. It is a matter of time before an even more potent virus emerges that resists the current vaccines, thanks to people who refuse to be vaccinated. That refusal potentially affects all of us, not just the vaccine recipient.

It is one thing to not be vaccinated because of vaccine supply and delivery problems. India, and countries in Africa and South America fall into this category. It is another thing to willfully refuse to be vaccinated when the vax is readily available. The latter is just wrong and inexcusable. There is no rational reason to not be vaccinated!

Anti-vaxers cite a litany of false claims about how the vaccine might be dangerous for them (the evidence refutes that). They say it is experimental (it has been well proven and uses technologies that are decades old!), or that it is not FDA approved (it is!), or that it is ‘gene therapy’ (it is NOT!), or that people have died or become sterile from it (flat wrong!). Anti-vaxers also complain that we do not know the long term effects of the vax (name ONE vax that had long term effects!). After millions have been infected with the virus or have been vaccinated, the evidence clearly shows that the worst thing that can happen to someone is to be infected with the virus, and that the safest thing is to get the shot. Follow the science, not your emotions.

Note that the objections to the vaccine are all self-focused. No thought is given to the reality that if an unvaccinated person is infected and does not practice caution, he will be responsible for spreading the virus to his family, friends and strangers. And, he might very well be the source of the next, more deadly variant. As I wrote earlier, a great example of how vaccines protect others is the Japanese experience with flu vaccines. After Japan mandated that school kids be vaccinated against the flu, elderly flu deaths plummeted. The vaccine clearly did not just benefit the kids, it benefited others with whom they had contact. The same holds true with the coronavirus vaccine.

Unvaccinated people in India led to the emergence of the Delta virus variant that has overwhelmed health care systems in India. Even younger, healthier people are getting sick. Delta is now spreading in unvaccinated people in at least 62 countries, including the US where it now accounts for 20 percent of new cases, up from just 2 percent a couple of weeks ago. You do not have to be a scientist to see where that trend is leading.

Delta also is now the dominant strain in the UK accounting for three quarters of new cases there. It has forced a four-week pause in the UK’s reopening plans. The variant could also affect reopening in the US as well, thanks to the anti-vaxers.

The good news is that people who are fully vaccinated are well-protected against the Delta and other variants—so far. Again, it is just a matter of time that a vaccine-resistant variant emerges. Again, there is no rational reason to not be vaccinated, but there are billions of reasons to get vaccinated. It is not all about you, but also about your fellow humans on the planet. Get the shot!

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Why It Is Necessary To Vaccinate Kids

Vaccine makers are applying to the FDA for approval to give the COVID-19 vaccines to children. Some people have questioned the need for this since kids seldom get sick, let alone die from COVID-19. But, there is a very good reason to vaccinate them, which is to protect them, as well as the rest of us from the emerging new viral variants that are more infectious and more potent and that I discussed earlier.

Vaccines do two things; 1) they protect the vaccinated from the disease, and 2) they prevent the further spread of the pathogen and disease. A good example of the latter point is Japan and flu vaccines. A number of years ago, Japan mandated that all school kids be vaccinated against the flu. A major result was a sharp drop in flu deaths in the elderly. Kids are walking incubators for respiratory viruses and carry them home for their families to enjoy. Thus, Japan's flu vaccination program meant that fewer kids were catching the flu and carrying it home to infect their parents and grandparents. Hence, flu mortality dropped.

That is why we need to vaccinate kids against CoV-2 even though they seldom get seriously ill from it. Related to that point is the fact that the more CoV-2 spreads, the greater the chance that the virus will mutate into variants that are increasingly infectious, more deadly, and that can evade the immune response to the current vaccines. If that happened, we would be starting all over again. Hundreds of thousands, if not millions around the world would die, countless more would suffer long term consequences from COVID-19, and the disease could very well become more serious in young people. We already are seeing increases in infections and hospitalizations in younger, healthier people from the viral variants that already have arisen in the UK, South Africa, Brazil, and India.

We need to vaccinate kids in order to slow as much as possible transmission of this virus in order to minimize the development of potentially more deadly variants.


What Caused India’s Devastating Second Wave?

Understanding what contributed to a second, more intense COVID-19 surge in India can inform the rest of the world on how to avoid a similar surge for this and future pathogens. This outbreak threatens to extend the pandemic itself and drive world-wide infections to new highs, creating an enormous a breeding ground for new and potentially more dangerous viral variants. If variants emerge that are not touched by the current vaccines, the world will be at square one with the pandemic. What a depressing thought.

It appears that the second wave arose due to a combination of three things: 1) India’s relaxing quarantine measures back in January, 2) the emergence of more rapidly spreading viral variants, including one that first appeared in India, and 3) a very poor rollout of vaccines to protect India’s population from spread of the virus. These are further discussed below.

  1. Relaxed safety measures. India’s second surge came after loosening restrictions, which let public complacency set in, which, in turn, was exacerbated by government officials like Prime Minister Modi and Health Minister Harsh Vardhan declaring that the pandemic was defeated. Life returned to normal. Masks went away, as did social-distancing. Weddings and parties resumed, which usually are large events in India. A new season of state-level elections ushered in big political rallies and street parades. A massive religious festival known as the Kumbh Mela took place, bringing an estimated 5 million Hindu pilgrims to the banks of the river Ganges in April. By mid-March, cases started gradually climbing again—then suddenly accelerated, becoming a vertical line rather than an upward sloping curve. The government was slow to respond. It was not until late April that Modi finally acknowledged the urgency of the situation. Local containment measures are beginning to be enacted, including shutting down the capitol of Dehli, and a few Indian states. However, Modi remains reluctant to enact country-wide restrictions like he did during the first wave. Without a more aggressive vaccine campaign, that could be a bad decision.

The more the virus spreads throughout India, and even into its neighboring countries of Nepal, Pakistan, and Bangladesh, the greater the risk that it will generate more infectious and dangerous viral variants that will not be affected by the current vaccines. If that happens, well vaccinated countries will have to start over. That is not a pleasant prospect, and is further discussed below.

  1. More infectious viral variants. India’s more deadly second wave of the CoV-2 virus can also be attributed to more infectious and more persistent viral variants. In this second wave, India, like many other countries, has been inundated with viral variants first identified in the UK and South Africa that were recently discussed in these pages. The UK variant has a mutation in its spike protein that makes it more infectious than its parent virus. The South African variant has a different mutation in its spike protein that makes the virus more resistant to some vaccines.

India’s second surge also has introduced the world to a unique viral variant dubbed the "double mutant," which was first identified in October. It is now the dominant strain in the state of Maharashtra, home to India’s financial center, Mumbai.

“Double mutant” is actually a misnomer for this variant since it has 13 mutations throughout its genome. However, it acquired that sobriquet because it has joined the UK and South African spike protein mutations in the same virus. It is a double whammy.

While scientists are still learning about the double mutant variant, India is seeing people who were previously infected become re-infected with this new variant. Also, younger and healthier people are being hospitalized in greater numbers. These observations are concerning. Similar observations of re-infection have also been seen in Brazil with yet another viral variant that was first identified there (more about Brazil in a future post). The ability of viral variants to re-infect people can be an important driver of future pandemic waves even in countries where the population is well vaccinated, but where isolation measures have been lifted or ignored.

For the country overall, the double mutant virus made up 70.4% of the samples collected during the week ending March 25, and that is compared with 16.1% just three weeks earlier, according to Covid CG, a tracking tool from the Broad Institute of MIT and Harvard. The tool mines data from the GISAID Initiative, a global database for coronavirus genomes. These data also show that the double mutant virus has already hopped to at least 21 countries including the US. In Australia viral genome sequencing showed that the double mutant made up 40% of the samples collected over the week ending April 15, compared with 16.7% a month earlier. It accounted for 66.7% of samples from New Zealand for the week that ended April 8, up from 20% a month ago. It also has been detected in California, according to Dr. Benjamin Pinsky, director of the Clinical Virology Laboratory at Stanford University. Clearly, where the double mutant virus appears, it quickly achieves dominance.

  1. Poor vaccine distribution. As of 4/30, India had only administered 15 million vaccinations, a tiny proportion of its population of 1.4 billion people. The country is the primary producer of the AstraZeneca vaccine that has run into supply chain problems causing delays in vaccine delivery. In February, Biden signed the Defense Production Act to boost U.S. COVID-19 vaccine production but that decision cut off US exports of raw materials that India needs in order to maintain its vaccine production capabilities. Thus, vaccine makers around the world, including the Serum Institute of India (SII), the largest vaccine manufacturer in the world, face a shortage of materials to make COVID-19 vaccines. The ban has garnered much criticism as resource hoarding that threatens global vaccine production. On April 16, SII appealed directly to Biden to lift the embargo of raw material exports so that vaccine production could continue. Several days later, the White House announced it would partially lift the ban for materials the Indian company needed to manufacture the AstraZeneca vaccine, specifically.

The US also inexplicably has a large stockpile of millions of doses of the AstraZeneca vaccine, that were made here, even though it is not approved for use in the US. If we are not using it, why not release the stores to the world? The Biden administration also has faced criticism for hoarding these doses that could help India and other countries around the world that also are experiencing a new surge in infections. On Friday, April 30th, the U.S. Chamber of Commerce called on Biden release the AstraZeneca vaccines to India and other hard-hit countries.

There is some irony in all of this since India is a huge manufacturer of vaccines and pharmaceuticals for the world, and likes to bill itself as the “pharmacy of the world.” India produces 60 percent of the world’s vaccines, but cannot supply its own country, partly because of reduced production due to the supply chain problems, but also because it failed to order sufficient vaccine doses. India almost completely halted vaccine exports last month in order to divert supplies to its domestic population, which is affecting supply in the rest of the world. Rather than rely on its own manufacturers for vaccines, India approved Russia’s Sputnik vaccine, and has fast-tracked the approval process for other vaccines manufactured in foreign countries. That means that while the industrialized world was being vaccinated with vaccines produced in India, the country was still looking at approving foreign-made vaccines for use in its country.

Bottom line. The combination of relaxed safety protocols, the appearance of deadlier viral variants, and poor distribution of vaccines to its people has left the country as the world’s epicenter for the pandemic. As the virus races through its huge population, all of this provides an enormous breeding ground for new variants to arise, which is worrisome even for countries that have had successful vaccine rollouts and have begun to see reduced viral spread. Let us hope this is not a perfect storm for restarting the pandemic with vaccine-resistant variants.

And India is not the only problem. In Africa, vaccination is also off to a slow start. Just 6m doses have been administered in sub-Saharan Africa, fewer than in New Jersey. Just 1% of African adults have received a first jab, versus a global average of 13%. Prepare for Africa to become the next hot-spot and breeding ground for troublesome variants, if Brazil and South America do not beat them to the punch.

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