Professor Michael Edelstein
Professor of Epidemiology Michael Edelstein: An Update on COVID-19 and What Lies Ahead
Professor Michael Edelstein - Professor of Epidemiology Michael Edelstein An Update on COVID-19 and What Lies Ahead
- Good afternoon, good evening everybody, wherever you are. Welcome back, if you were with us this morning. I would like to welcome a special guest, a new guest, a professor of epidemiology, Michael Edelstein, who will give us an update on Covid 19 vaccination at what lies ahead. We will also have a chance to hear more about his work in Eswatini with IsraelAID. So very, very, very warm welcome Michael. And I’d like to thank you, Carly, for joining us again. Carly will be in conversation with Michael. A quick bio, Michael Edelstein is public health doctor with international experience specialised in infectious disease and vaccine epidemiology. His expertise and interests include vaccine epidemiology and policy, health inequalities, outbreak management, data quality and the use and role of digital tools to improve public health. At Bar-Ilan University, his focus is on reducing health inequalities in both infectious and non-communicable diseases in Israel and beyond. Professor Edelstein is also deputy editor of the journal, Epidemiology and Infection, and president of the infectious disease section of the European Public Health Association.
He’s also a member of England’s national Covid 19 surveillance team. As an honorary associate professor of public health at London School of Hygiene & Tropical Medicine, his research focused on barriers enablers to reduce health inequalities in vaccine programmes. Prior to Covid 19, he has responded to major public health emergencies in Africa, Ebola and Southeast Asia, typhoon in Philippines, earthquake in Nepal and various European outbreaks. He has published over 50 peer reviewed publications. Very impressive Michael, we are so looking forward to hearing from you and to hearing what you have to say. So I’m now going to hand over to a wonderful Carly and to you. Thank you.
Thank you.
Thank you, thank you, Wendy. So Michael, although we are actually in the same country, we’re separated by a few hundred miles. So thank you for joining us on your family holiday, the one week in the year where Israelis hope to be able to escape work for a few days. And with Israel’s world breaking vaccination campaign, you’re actually allowed to travel. So we really appreciate you taking time out from your family holiday. And as this is the second or third call we’ve joined together today, I know you’re not getting very much of a holiday. So I wanted to start by a bit of a kind of Covid 101. Just tell our audience, you know, exactly what Covid is, why it’s so contagious and why it’s gripping the entire world in this unprecedented way?
Sure, so, well, first of all, thank you for the introduction and you know, let me start by giving a very brief introduction of where we are and why we’re here. So Covid 19 is a pandemic that started late in 2019, and the virus is called SARS-CoV-2 and it’s the virus that causes Covid 19. It’s part of a family of viruses of which there are four known types that affect human populations. Now, this is not the first pandemic that human populations face, but it’s certainly the largest and most impactful of recent, of recent memory. And I think what makes it, it’s in many ways it’s not unique because, you know, it’s an airborne virus that transmits from person to person. There are a few things that make it unique and has led to the situation we’re in. The first one is that if you think about what viruses need to do to survive in human population and to thrive, this is exactly what Covid 19 is doing. It’s quite infectious in the sense that every case of Covid 19 will generate three to, around three additional cases. And you think about it in a, you know, if you plot this very quickly, you get to very, very large numbers. Which is what you see, you know, one case generates three cases and each of these generates three, et cetera, et cetera. So within a few generations, and each generation is about a week to two weeks, you get to, you know, tens of millions, hundreds of millions of cases. And what it does is that it actually, in the vast majority of cases only causes a mild illness or no illness at all. And from an evolutionary perspective for a virus, this is the best way to ensure that it keeps propagating.
And if you think about a virus like Ebola, for example, where most people who get infected get incredibly unwell, so unwell that’s, you know, they really cannot leave their bed and they die within a few days. But this is not the case with Covid 19. Most people are only mildly ill and they carry on, you know, with the daily activities. They go on public transport, they go to work and that gives them plenty of opportunities to, for others to get infected. And this is really what’s caused this, you know, this really smart way of propagating and in infecting people just enough, and causing just enough severe disease to, for the pandemic to keep going. And of course, with, you know, the situation that we have now in the early 21st century, which is unprecedented in terms of the volume and the speed of travel and trade. You know, people go from one country and to another, they go to, you know, from Israel to Europe, from South Africa to the US for a day. It takes, you know, 10, 12 hours, it’s very quick. That’s, you know, that’s a brilliant and fantastic playground for viruses to spread. Because you can be in Johannesburg or in Tel Aviv one day, you got infected, you don’t know it yet.
You will travel in less than 24 hours you’re in New York or London or Paris, and you develop symptoms and by then you’ve infected other people. So it’s a combination of characteristics of the virus together with the globalised world that we live in today that has enabled the virus to spread very rapidly to a very large number of people. And despite, you know, best efforts of most governments in the world, initially without vaccines, with social distancing to try and and control the spread. And that’s worked to some extent, but it’s not enough to really control the virus. Despite that the virus has continued to spread and we now have vaccines. And I’m really happy and proud to say that looking at what’s happening in Israel now, and you know, yesterday I was in a restaurant with my family and after showing my vaccine certificate, I was able to, you know to have dinner with my kids outside in a way, you know, almost as if nothing’s ever happened. And this is because of vaccination and because of the vaccine. And I think this is going to be our way out of the pandemic together with other measures. But, and Israel shows that it’s possible but it will take, it will take some time.
So we’re going to get to talk about the vaccination nation as it’s been, been named shortly. But before we do that, I want to talk about variants because, you know, not only are we seeing the Covid that I caught in March of last year, and I will tell you that a mild version of the virus can still, can put you in bed for eight weeks. So I was well, but I, and Covid did not do any good with me ‘cause I didn’t spread it to anyone else. But you know, what we are seeing is I’ve spent the last few months in South Africa, and there’s obviously a lot of talk about the challenges of the South African variant. You know, even just yesterday I was reading about an Israel variant that they were pleased to see responds well to vaccines. You know, every country seems to be developing its own variant. And just before we started, you know, Bill Gates’ weekly Gates notes arrived in my inbox and the subject line was, you know, five things you need to know about the variants. So what does the variants mean for the vaccines and, you know, is variants something we should expect and we’ll continue to see with Covid, or is this for real concern?
That’s a very good question. So I think the first thing to understand is that all viruses mutate all of the time. It’s not something that is unique to the SARS-CoV-2 virus. And again, you know, with any vaccine preventable disease that you can think about, whether it’s measles or polio, or flu, all these viruses mutate and it’s just a chance happening that happens on a regular basis. And I think there’s two things that we’re seeing here. The first one is because, you know, because there is undue, oh no, not undue, but sort of very, very, a very high level of scrutiny and of attention on Covid 19. Every variant or every mutation is reported like as if it was, you know, a disaster. Now that’s not the case. And most, the vast majority of variants like the Israeli one that you mentioned, Carly, are actually of no public health impact. And I’m actually, I think there’s too much attention on variants and attention on these sort of actually contributes to increasing the fear that, that Covid 19 instils in people. Having said that, some variants can be significant in terms of, and it’s, they’re particularly concerning if the mutation that occurs in the virus has an impact on either how transmissible it is, how severe it is in terms of disease. And probably the most worrying would be whether, especially now that we have vaccines, whether it means that it will have the ability to escape immunity conferred by the vaccine.
Now we have seen a few variants, really three that have been significant in terms of disease severity and transmission. You know, the UK variant, the South African variant, the Brazilian variant have all been more contagious, meaning that for the same number of people infected initially, it will lead to more people being infected. Meaning that even if they’re not more serious, which is the case, so each case is not more likely to be severe. There are more cases and therefore even if the proportion of severe cases is the same, in absolute numbers there are more severe cases and therefore hospitals get overwhelmed more quickly, et cetera, et cetera. In terms of vaccination so far, the vaccines that are licenced seem to cover the existing variants, including the South African variant at least in terms of the most severe forms of the disease. So you know, there are sort of vaccine variant combinations that are less effective in terms of vaccine effectiveness. So for example, the AstraZeneca vaccine may be less effective against mild form of the South African variant, but it keeps protecting against severe forms of disease and it doesn’t really seem to have, the variants don’t seem to have a huge impact so far in terms of effectiveness against hospitalisation and mortality.
So I think so far we’ve been relatively lucky, but you have to remember that mutations by a large extent are chance events, and the more transmission you have, the more common mutations will be. And it is not impossible although so far it hasn’t happened, that a strain emerges that sort of affects the efficacy of the vaccine. And if that strain becomes a dominant strain and it starts circulating widely, then you have a problem. And I think that’s why it’s really important for vaccine manufacturers to anticipate this and begin a process by which they can respond very quickly to the emergence of a new strain, by modifying their products in order to respond to the vaccine. In a sense, this is exactly what happens with influenza vaccination, where every year the formulation changes to respond, to match the circulating strain of flu. And this is exactly what vaccine manufacturers are doing. Modernas doing it, Pfizer’s doing it, AstraZenecas doing it. And particularly with the mRNA technology used by Pfizer and Moderna, it’s actually all, you know, in relatively speaking, relatively quick and easy to tweak the formulation to adapt to these strains.
So you brought up the AstraZeneca vaccine, which as a Brit, which was developed in partnership with Oxford, I feel kind of bizarrely patriotic about but I also feel that they’re getting a rough ride. And you know, with AstraZeneca it seems to have been one drama after another from, you know, you could argue political issues in Europe, political issues in South Africa, and then perhaps their own PR errors in releasing studies before they were ready. And now they’ve got the blood clot situation. And if you look at the UK advice versus the Canadian advice or the German advice, you know, it’s all very different. So how would you assess the potential blood clot risks and the AstraZeneca vaccine, and if you were offered it, would you take it?
Okay, so I agree with you. I think AstraZeneca didn’t do themselves a lot of favours by, you know, releasing data and then backtracking and correcting the data. And then there was the study in South Africa that you mentioned, that was, I think, hugely misinterpreted, we’ve had some discussions about this in the past. Now to talk specifically about the risk of blood clots. So I think it’s, the first thing to say is, you know, these are vaccines that are under a huge amount of surveillance including safety surveillance. And it’s really, really important that this is in place. And I think detecting a signal, which is actually a very small signal if you know about vaccine safety, demonstrates that you know, that the safety system is working. And that’s, I think that’s hugely reassuring. Now, in terms of the risk of blood clots, you have to, we’re talking about a few dozens cases. So first of all, these are a very specific type of blood clots in, it seems that it’s effects a subgroup of people, mainly females, possibly with some blood clotting and disorder in the background. And it’s a rare event considering that, you know, tens of millions of people have been vaccinated. So I think the, so far the advice by the European Medical Agency is that the risk, if there’s any risk, though, sorry, the benefit of vaccination so far outweighs the any potential risk.
Having said that, that risk is being investigated. And I think it’s really important to be open and transparent about it. If there is a risk and if there is it will become I think, clear in the next few days. It’s likely to be A, very low and B, restricted to particular groups of people. So I think in the current situation, I would agree with the assessment that the benefit, you know, you’re talking about a relatively remote likelihood of, you know, one in several million of a side effect that is potentially serious, but very, very rare. Versus particularly if you’re in countries where there’s ongoing transmission, a very, a very real risk of infection. And as you said, Carly, the consequences even in mild cases and I’ve been in mild case as well, and I’m still a year after, haven’t got my breathing fully back. You know, a risk there is very real and yes, in most people it doesn’t kill but it’s really, it can have severe impact on quality of life. So I think in the current situation, we’re not really in a position to pick and choose vaccines. And yes, I would absolutely receive the AstraZeneca vaccine tomorrow.
Yes, I think we did a bit of a war as to who’s still got the bigger antibodies a year after Covid. So we both know that mild is a loose form of the word in Covid situation. So we’ve got a lot of listeners from the UK and from Canada on the phone. And as all you know, both countries have decided to stagger the second dose, you know, the Pfizer advice was 21 days and AstraZeneca was 12 weeks. Both countries are pushing that timeline quite considerably. Now, we have seen some new data come out of the UK in the last week to 10 days, which shows that it seems, you know, that was a risk worth taking. But how do you analyse the pushing of the second dose?
Yeah, so the first thing to say is you know, this is, having worked in the UK for many years and having been on, you know, the advisory body that advises the government. These decisions are not taken lightly and they’re taken based on evidence rather than opinion. And if you go back to the trial data from Pfizer, it’s very clear that a single dose of vaccine is highly efficacious. You looking at about 50% efficacy at 35 days going up to more than 80%. And you have to remember that before the vaccines were available, the World Health Organisation recommend that any vaccine with efficacy over 30% would be considered good enough be, you know, to be rolled out. And here we’re looking at 80% with a single dose. So I think the calculation that was made by the British government and I imagine by the Canadian government is, is looking at protection not at the individual level but at the population level. And the calculation is very simple. You’re looking at what is going to prevent or to reduce transmission of disease in a population. This going to give 80% protection to more people or 90% protection to half of the people that you could protect with 80%. And the math is pretty clear that’s going with one dose to more people is a better calculation than a 90% to less people. Now there’s one caveat to that, this is you’re looking at situations where there’s not enough doses for everyone.
If you have the ability to give the, you know, the recommended schedule to everyone, which, you know, in Israel we’ve been fortunate to have, by all means go for it. But here we’re looking about, we’re talking about imperfect situations where there isn’t enough doses. And what you have to do is you have to make the most of what you have. And the most of what you have in this situation is one dose to more people. And I think today, two days ago, there was an American study that came out showing that at least with the Pfizer vaccine, not only the vaccine protects against disease in individual, but actually we’re seeing decreases in transmission by up to 90%. And that really, that indirect effect of not just protecting individuals from being sick, but actually by getting vaccinated also protecting others strengthens this approach. And, you know, you will begin to see an impact in the UK, which is, you know, doing not quite as well as Israel but not that far behind.
Yeah, you’re very fortunate to have advised the two countries who could be considered to be doing the best. Perhaps you’re the common denominator. But let’s talk about.
I wish.
Let’s talk about Israel. So, you know, there’s lots to be said about how Israel dealt with Covid before the vaccine and we could spend a whole hour on that. But instead I want to talk about the actual rollout. You know, there’s been a lot of beautiful stories on the internet about Albert Bourla’s family and that, you know, Israel and the importance of the Holocaust was one of the reasons why Israel, you know, was able to do a deal. I’ve also read what sounds to me like the more likely story about the use of the data and the healthcare records in Israel. You know, we also know that Israel is in election season and anyone following the Israeli news in the last day or two will have seen that, you know, it’s time for Israel to approve more Pfizer vaccine orders, and there appears to be a hold up. So, you know, how is Israel’s vaccination campaign doing? Is it as successful as it seems to the world and what does its future vaccination campaign look like?
So I think the, I’m not going to go into the causes of why Israel managed to get hold of so much vaccine because as you say, we could talk about that for an hour. And there’s a lot of theories. Certainly, you know, the data deal is public knowledge and I think it’s absolutely a contribution, you know, absolutely a contributing factor, there’s no doubt about it. This is not unusual in any ways, by the way, you know, the UK also makes deals like this, you know, preferential treatment for good data. It’s pretty, you know, it happens because the manufacturers need this data to monitor their products. But you know, it’s a complex story. Yes, Israel’s doing is doing very well and it’s certainly, you know, ahead of any country in the world at the moment, particularly if you look at the older age groups where over, you know, over 90% in the over 60s, which is, you know, absolutely phenomenal and the younger age groups are catching up. I think there’s a lot of underlying reasons for that. Obviously vaccine availability is a prerequisite, but it’s not, you know, it’s necessary, but it’s not sufficient. I think what we’ve seen is, well first of all, you know, Israel’s got a relatively small population compared with the US or the UK and it’s also a very densely populated.
So in terms of logistics and getting the vaccine to people, it’s much easier than, you know, in a territory like Canada where you have to go to far-flung arctic region to vaccinate some of the populations. The other thing is, you know, Israel has, and I can say that coming from the UK, Israel has a really a data system of very, very high standards. It’s, you know, it’s real time, it’s interoperable. You can get vaccinated in one place and then three hours later you get the results on, you get the confirmation on, in your app, on your phone. You know, for most countries including the UK, that’s kind of a science fiction at the moment. So it really has enabled to track in almost real time who’s vaccinated, who’s not vaccinated, who’s due for a second dose, not just at the individual level but also at the community level. And that means that you can track which, you know, which town, which village is under vaccinated. And if you know, you know, whether they’re a Jewish village or an Arab village or a Druze village, or a religious or not religious village. You can tailor your communication strategy to specifically target these population that are under vaccinated. And what we’ve seen in Israel is some very, some sort of hyper contextual communication campaigns with, you know, free food being offered at the same time of vaccine and the food matching the preferred type of food of this particular part of the country, these kind of approaches. And it’s, you know, it’s worked to a large extent. And you’re seeing the younger age groups, you know, they’re coming and being vaccinated. And I think we’re now at 56% of the entire population including children, including people who were not eligible because they were vaccinated.
If you’re looking at those who are eligible for vaccination, it’s more like 80% or possibly more. So, but having said that, it’s now really stagnating. And it’s important to understand that as the campaign progresses, the reasons for not getting vaccinated change. And those you know, the last 20% are going to be the hardest because these are people who, you know, really realistically by now, anyone who wants to be vaccinated will have been vaccinated. So you need to think about the remaining people who are not vaccinated and why they’re not vaccinated, and what you can do to motivate them. And there are different, and this is where you get, you know, into a more grey zone in terms of ethics. And there are discussions ongoing, for example, should employers be allowed to refuse people coming back to work if they’re not vaccinated? You know, what restrictions exist for people who are not vaccinated? At the moment if you’re not vaccinated, you can’t go to a restaurant, you can’t go to a concert, you know, is that enough? And that, that is enough to motivate some, but not all. And how far can you go in order to get the, you know, the last 20%? This is a, an ongoing question. It’s an ethics question as well as a communications question and it’s an ongoing one. When you unpack the last 20%, you also see that who’s not vaccinated is not homogenous across the country. And there are specific groups that are remain less vaccinated than others, and that is also understanding who these people are and tailoring the strategies to these particular communities is also something that needs to be done.
So one of the things that I think the public really struggles with is, you know, we’ve now got many vaccines on the market. You know, each one has different positives, you know, each one has different rollout times, refrigeration temperatures, you know. Can you get two vaccines combined together, especially in countries where there is a shortage? So has there been any studies done on, you know, your first dose being AstraZeneca and your second dose being Pfizer, and how these two work together, and also how long immunity lasts after the vaccine?
I need a crystal ball to answer these questions, I’m afraid. But let me give you some elements of answers. So in the first question there isn’t, there are ongoing what we call combination studies and head-to-head studies that’ll look at combination and the efficacy of such combinations. As far as I know, there aren’t definitive results that are available. But from first principles, there’s no reason to believe that that combining vaccines won’t work. And this is something that is done quite commonly with other vaccines, you know, with rabies vaccination, with diphtheria, tetanus, pertussis vaccination. You know, from the basics of immunology, there’s no reason to believe that it won’t work, it may work better or worse in certain combination. And certainly some countries, including the UK, have actually issued guidance around that to say that even though there isn’t evidence, the best option at the moment because of that lack of evidence is to not combine vaccines and go with the you know, with the course of the same vaccine. However, there will be circumstances where it’s not possible to do that because you know, someone’s been vaccinated with a particular vaccine, and then at the time where they’re eligible for the second dose, another vaccine is available. In those circumstances, according to the UK guidance, it’s preferable to get the vaccine that you can get rather than delay to get a second dose of the same vaccine if you don’t know when that’s going to come.
So if I can ask you to consult your crystal ball again, there has been new data in the last few days on the effect of the vaccine campaign on immunosuppressed people, or people who are undergoing cancer treatment or even certain types of blood cancers for ongoing treatment. What have you seen on that and how would you advise current patients?
Yeah, so I think there’s emerging data around that and you know, it’s again, looking at other, you know, from the knowledge we have from other vaccines. People who are immunosuppressed and depending on what part of the immune system is suppressed, and that depends on, you know, the type of treatment or the type of illness they suffer from. It is very common for these patients not to respond to vaccination as well as people with a sort of intact immune system. And there are studies that are emerging looking specifically at Covid 19 and immunosuppression. Now these studies show that people, particularly with certain types of cancers, don’t produce as much antibodies as people who are you, you know, healthy controls. Now antibody levels are not necessarily, it don’t necessarily give you the full picture in terms of immunity, and you can have low antibodies or no antibodies and be immune. So I think it’s work in progress and there will be more studies, but nevertheless, I think at the moment in, you know, in the absence of evidence that these individuals are fully protected and with, you know, kind of interim evidence suggesting that maybe their response is not quite as good.
You know, these people should certainly, you know, in circumstances where the, you know, the second dose is delayed, for example, you know, there should be perhaps exceptions and these people should look at getting the full schedule according to recommendations. And I think some countries are already creating these exception groups. So I think it’s early days to say, but from the little evidence that exists around Covid and the wider body of evidence around other vaccine, it is likely that these people will need a kind of, a slightly different vaccine regiment with, you know, maybe an additional dose or less base doses, et cetera, et cetera. But it’s a bit early to give a definite answer.
So I would like now to turn to the developing world who hasn’t had the same access to vaccines. And you know, as we’ve discussed and as has been written in many an article, you know, the world isn’t safe until everybody has access to a vaccine. You’ve touched on the greater risk of variants, you know, and the need to vaccinate as many people as possible, even if it’s one dose as best we can. Now, you know, there’s a lot of vaccine nationalism going on, whether it’s countries, you know, stockpiling or preventing exports, you know, COVAX was supposed to start supplying much of Africa. The decision by the Indian government to prevent exports of AstraZeneca or the version it’s making, you know, is causing a huge problem. And we can talk about that firsthand in Eswatini where you are working. So we’ll talk about Eswatini at depth in a minute, but first of all, let’s talk about vaccine access. You know, how do you see Africa, for example, starting to come out of this?
Yeah, so I think you’re absolutely right and you know, I talked in the beginning about living in a globalised world. And you know, this is, and we’ve seen this with Ebola, we’ve seen this with many, many global outbreaks. No country exists in isolation and particularly, you know, countries are interdependent in terms of travel, in terms of trade. And unless you’re willing to completely isolate yourself from the rest of the world, and some countries have done that you know, New Zealand’s done that, Australia’s done that. There’s only so long you can go on like this. So, you know, if you want to revert to the ability to, do you know, travel and trade with other countries, you need global and equitable access. And this by and large hasn’t happened. And I think this is one of the failures. COVAX as far as I’m concerned, you know, is a great initiative in principles so far, I don’t think it’s delivered what was anticipated. And we’re seeing exactly as you say, you know, vaccine, I dunno if we, well partly vaccine nationalism but the individual countries and sovereign states putting their population first. Which, you know, it’s their responsibility and it’s not completely un-understandable. Having said that, there are many countries and I include Israel in that, that is stockpiling vaccines beyond what the countries need, just in case. And I think in Europe now, there is more than one, you know, more than two doses per person. I think there’s enough to vaccinate the population five times or something like that, whereas other countries are really struggling to get access to any doses.
And this is, you know, a failure of the international system to regulate this. And clearly a country like India can actually block the COVAX process by saying we’re not exporting. So I think there’s a lot of lessons to be learned but there’s also an urgent need to redress the situation. With regards to Africa specifically, actually Africa’s in a, not in such a terrible place despite a lack of access to vaccination. And you know, early on, I remember, you know, when the pandemic started in China and then spread to Italy, you know, all of us epidemiologists were saying, you know, this is going to be an absolute disaster when it hits Africa. You know, a combination of lack of surveillance, you know, the inability to monitor the situation, poor, you know, poor healthcare infrastructure, potentially, you know, immunologically weak population because of you know, malnutrition and other things. And by and large, this has not at all materialised. Many, many African countries have actually had relatively mild, you know, mild, a mild pandemic compared with Europe, for example, or the United States. And there are many reasons for that, you know. Initially the, you know, the sort of knee-jerk reaction was, oh, you know, you’re not detecting the cases because your surveillance systems are not good enough. That has not really proved to be the case because when we look at mortality, which really is most countries are able to monitor relatively well, there hasn’t been a lot of, you know, a high mortality reported in most African countries.
So they’ve been spared partly because, you know, this is a disease that by and large, in terms of severe cases mainly affects elderly population. And at least initially in Europe for example, the very high mortality was because of spread in care homes and nursing homes. Now, Africa has about 3% of its population is over the age of 65 versus, you know, 25% in Europe. And there are, you know, very few care homes in Africa. So partly, you know, partly the makeup of the population, partly under detection and partly perhaps other reasons that we don’t fully understand. Whether it’s, you know, environmental issues, genetic issues. It seems to have been hit less, less than other parts of the world. Having said that, I think there are reasons to push and to advocate for vaccination in Africa. One of them is long Covid and this is something that we don’t fully understand. This is something that is not easy to detect and something that affects, you know, even mild cases and young individuals. And the last thing you want is you is to create cohorts of, you know, young individuals that will contribute to the future success of Africa, and having a high proportion of them being affected by a chronic complications of Covid 19. So I think so far, you know, it hasn’t been the disaster that was predicted, but it’s certainly not a reason to say that, you know, Africans don’t need vaccination because this is absolutely not the case.
So as I referenced at the beginning of the call, this is not our first time together on the phone, and that’s because you are part of an organisation called IsraAID Which is a, an international non-governmental humanitarian aid organisation that’s based in Israel that was founded in 2001, and has so far helped over 50 countries around the world, normally responds to a crisis, be it a typhoon, a hurricane, Ebola. And the Kirsh Foundation is working in partnership with IsraAID to help Eswatini look at their vaccination rollout. Now you’ve just touched on how Africa has got off, you know, relatively lightly. I would say, you know, Eswatini is showing us a bit of an exception to that. You know, they lost their prime minister, four members of senior members of the government and ambassador. And you know, proportionately have got the highest death count in Africa. Now they also have a very immunocompromised population with very high rates of HIV. But Eswatini has really been ravaged, and I don’t need to tell you considering you were there last week. So maybe you can tell our audience a little bit more about the work there and how you are using your expertise to help them.
Yeah, sure, yeah. So first of all, you’re absolutely right. I mean, you know, Africa’s a big place and it has I think 53 or 54 countries with, you know, huge variety in terms of socioeconomic levels and conditions. So it’s a bit of a generalisation and there are exceptions. And unfortunately Southern Africa, particularly Eswatini and South Africa to some extent have been exceptions to what I’ve said. So in terms of Eswatini, absolutely it’s a real pleasure to work with IsraAID and being supported by the Kirsh Foundation in this role to support the rollout of the vaccine there. And what we’re doing there is essentially supporting the government of Eswatini, and trying to share some of the lessons we learned in Israel and apply them to Eswatini. And I’m very happy to share a few of my initial thoughts about my visit there. And I’m hoping to go again in a few weeks and in the meantime, providing remote supports. First of all, you know, I’ve worked in Africa a fair bit and what struck me in Eswatini is that, well, first of all it’s a very small country with a very small population of, you know, around 1.1 million people.
And unlike you know, a larger countries in Africa like, you know, DRC or Nigeria, or other parts of West Africa. Most of the population has relatively good access to healthcare. You don’t really have a high proportion of the population that is very, very remote. And by that I mean, you know, no one needs to walk 14 hours to reach a health centre. And that is a huge advantage when it comes to delivering a vaccine programme. What it also has is, you know, a functional healthcare system and you know, I was fortunate to visit quite a few health centres both rural and urban. And these centres have, you know, they have computer terminals with electronic medical systems, they have nurses, they’re staffed, they’re experienced in delivering routine immunisation. And they have partners in countries as well from, you know, the private sector, from donor organisation who are long-term partners and know the country well. And I think this creates a situation where essentially you have a lot of the pieces of the puzzle that are available in country, and what you really need is to put them together and to, you know, to reconstitute the puzzle and be able to deliver a successful vaccine campaign. Now this has started to some extent, and the country has started to receive doses, I think so far it has about 35,000 doses of AstraZeneca vaccine. And very interestingly, what we’re seeing, initially there were, you know, concerns about vaccine hesitancy and people wouldn’t turn up.
And there’s been a lot of work in the background in the last few weeks that IsraAID has supported in terms of training healthcare workers, communication campaigns, setting up data systems. And in a few weeks the country’s really put a huge effort and it’s not perfect by any stretch of the imagination, but it’s actually, you know, the different elements are in place. And there was a real fear that no one would come because of fear of, you know, misinformation about the vaccine and particularly around the AstraZeneca vaccine because of the situation in South Africa that Carly, you referred to. But what happened is actually the system was completely overwhelmed today and they had to turn people away. So, and you know, this is very rapidly and I was on a call with, and you were as well with the ministry of health earlier on. And I think they’re really, they’re taking the situation very seriously and they’re really trying as hard as they can and harnessing the support from various partners, including IsraAID to deliver the vaccine. And they’ve actually already delivered several thousand doses, including to healthcare workers. And I think considering, you know, the level, the socioeconomic level of the country, this is a big achievement for a country of that size in Africa. And I’m optimistic, I think there’s a lot of hurdles still to be overcome, including coordination between the different partners, including data management, including logistics. But I think, you know, IsraAID has made a commitment to support these different aspects and there are also other partners. And I’m confident that Eswatini will be a success story in Africa, in terms of Covid vaccination.
So Wendy is helping hosting me-
Assuming we’re going to get enough, they can get enough doses.
Yeah, Wendy is helpfully telling me to tell you all that Eswatini was formally called Swaziland. I’m now so well trained to call it Eswatini, but.
It was, they’re absolutely right.
It was formally Swaziland for people who are trying to place it on a map. Now, we’ve touched on Africa and perhaps why it didn’t spread in the same way. But a year in, is there anything to suggest that there are certain populations that are more at risk to catching Covid or more at risk to having worse effects? You know, there was a lot of theories early on that maybe the TB vaccine or sunlight or, you know, certain populations were more at risk. Has anything scientific been proven around that?
So, I mean, I think there’s you know, there’s all kinds of theories that have emerged. I think in terms of who’s at risk, there are groups that are very clearly at risk. The first very clear risk factor is age. I think that’s been, you know, that’s very clear in all population. The second one is, there are certain conditions that predispose you to, not necessarily to increased risk of infection but increase risk of severe disease. Particularly things like, you know, obesity, certain chronic conditions like diabetes and other chronic conditions. I think severe, you know, severe immunosuppression is a risk factor for severe disease. Mild immunosuppression, less clear. And for example, you know, HIV positive individuals who are on treatment with a normal CD4 count don’t seem to be at much higher risk. The other piece of evidence that came out of the UK is that certain ethnic groups are more at risk even after adjusting for other factors. And it’s not entirely understood why that is and how applicable this is to other, you know, to other countries. So there are very clear risk factors. There’s a lot of other theories that have been proposed, but most of them have not hold, that have not held to scientific scrutiny.
So now to turn to the younger population, you know, we are seeing increased illness and more concerning forms of Covid in increasingly younger populations. You know, Canada is really experiencing a steep rise in the number of deaths of young people or serious illness. We also saw that Pfizer came out today and showed that they feel their vaccine is safe for 12 year olds and over. And then Israel is also now vaccinating pregnant women as it feels that with some of the variants, they are at greater risk. In terms of the younger population, both what’s happening in Canada and also in vaccinations. You know, would you be looking at vaccinating children? And then if you were advising a pregnant woman, where would you stand?
So let me come back to the previous question about at risk because one group that I forgot that is important is pregnant women. Pregnant women are at higher risk of, compared with women of the same age who are not pregnant, they’re more likely to get infected and they’re more likely to have severe outcomes including death, than the non-pregnant counterparts. And safety hasn’t really been an issue in this group. There’s been study, fairly large studies with, you know, over 10,000 pregnant women in the US that have shown no particular concerns in terms of safety. So pregnant women are advised to be vaccinated from the second trimester onwards. And I would, you know, this is something that I would strongly urge pregnant women to do because of the risk of disease. And unfortunately in Israel, we’ve had a few cases of women, pregnant women who’ve been infected and unfortunately passed away. And the babies, you know, the unborn baby passed away as well and these were not unvaccinated women. So that’s an important, you reminded me of that, Carly, so thanks for that. In terms of younger individuals, well if you think about as, if you think like a virus, what you try to do is you try to infect as many people as possible because that’s how you perpetuate yourself as a species, if you can call virus a species. So once the older individuals are vaccinated and they’re no longer an option for you, what happens is you will see a shift of, you’ll see a shift of the epidemiology towards younger age groups.
And that’s why with and it’s not, again, it’s not unique to Covid. You see a change in the age groups that are predominantly affected just because those in the other age groups are no longer, you know, no longer susceptible to infection. So you’re seeing an increased number of cases in young people, and it’s not necessarily that the virus is causing a higher proportion of people to have severe outcomes. But just in the absolute numbers, because there are more people infected, you see a larger number of young people in hospital and a larger number of young people dying. And we saw exactly the same in Israel, it’s a natural consequence of vaccination or of ongoing infection. So it’s an interesting debate as to whether children should be vaccinated. In my opinion, they should be vaccinated for several reasons, although, you know, children in at the individual level are at a lower risk of developing severe outcomes. When they become the sole susceptible population, you will see infection within children between children, and even though children to children transmission occurs less than say from adults, you will still, you know, because it’s the, it’ll be the last remaining population, you will see this population being more infected and in absolute numbers they will, you know, you will see the number of severe cases rising. So if you’ve got a vaccine that is safe and effective in this population, you know, I don’t see a good reason not to vaccinate them. Now, if you have a limited supply of vaccine, maybe they shouldn’t be prioritised.
But when other groups have been vaccinated and there’s willingness and ability to vaccinate them, then why not protect them? And again, it’s about individual protection for the children themselves, but also about protection for to others. And now we know that vaccines also decrease the risk of transmission. So you have to remember, some people cannot be vaccinated because of, you know, severe allergies or other conditions that prevent them from being vaccinated. And they will benefit from indirectly being the, indirectly benefit from children being vaccinated. The other thing is, at least in Israel, and I know that is similar in other countries, you know, Covid infection in children may not be, may not always be severe, but it’s heavily disruptive. Every time there’s a case, there needs to be an investigation, classes need to be closed, you know, people, the pupils need, other pupils need to go into quarantine, everyone needs to be tested, et cetera, et cetera. Which is, you know, expensive, disruptive, and has a negative impact on children education and development, et cetera. So again, if we have an option that is safe and effective to prevent these kind of situations, why not use it?
And going back to pregnant women, you know, do you feel all of the vaccines offer the same benefit or is there one that is preferable?
So I haven’t, I have to say that I haven’t looked at vaccine specific data in pregnant women specifically. As far as I know, there isn’t really any, first of all, I don’t think there’s any safety concerns. In terms of efficacy, I don’t know, there may well be variations. I’m not sure whether that’s the case or not. But again, I think in most situations there isn’t, you know, the option to choose really isn’t there. And if you can get some protection, then you should really take the vaccine that is offered. I haven’t seen the data for all the vaccines so I can’t really say that vaccine X is better than vaccine Y in this particular group.
So you touched on the high risk categories. If you’re someone living with someone who is high risk, and we touched on transmission, how important is it for that person to get vaccinated as well, even if the person at risk has already been vaccinated?
So first of all, everyone, you know, everyone who’s eligible should be vaccinated because it’s offered. I think it’s, you know, no vaccine is 100% effective. And we know that the vast majority of transmission occurs in households so from person to person in the same household. So if you have someone who’s vaccinated, in the best case scenario, he’ll be 90, you know, his protection will be around 95%. If he’s someone who’s immunosuppressed, it may be less. And you know, you referred to that study earlier on. So the next best thing you can do is for the carers and household members to also be vaccinated. Because if they, if that vulnerable person gets infected despite being vaccinated, it will almost certainly be from one of their household members. So by vaccinating the household members, you drastically reduce the risk of infection in that person. So yeah, absolutely, they should be vaccinated if they’re eligible.
Now there’s quite a lot of excitement around the J&KJ vaccine, as I touched on in, you know, South Africa obviously really felt the need to go down that route. You know, some people are, “waiting for J&J” because it’s one shot. Other than the fact it’s one shot, and obviously you lose statistically a certain number of people who forget or don’t bother to go back for their second shot. Is J&J actually superior in any way?
So the data I’ve seen from J, I mean, yeah, I mean it’s one shot and that’s very important. I think that the benefit of one dose is clearer in situations where it’s hard to get people back, or it’s hard to monitor who’s due for a second dose. If you look at the Israeli data, there’s actually very few people who don’t come back for the second dose. So it may be beneficial in some settings, absolutely. What I’ve seen is the J&J data compared with the AstraZeneca data, and from what I’ve seen is very, very similar. It’s not superior, it’s not inferior either. It’s just as good. Now the does it, yeah, just one.
Sorry, go on.
One thing we don’t know and I guess we don’t know for other vaccines either, is the duration of protection and whether a single dose vaccine will protect for less time than a two dose vaccine because you don’t have a boost. That’s a question that’s remains to be answered.
I mean, presumably J&J may consider a boost in the same way that, you know, AstraZeneca is already talking about a booster, as is Moderna, Pfizer, you know, especially around the variants. But we’ve obviously got a different use of technology between the various vaccines, you know. Pfizer and Moderna are both using, I would say this new technology, although we know it’s been being developed for the last decade, but mRNA. And then AstraZeneca and J&J are more traditional. If, I know we’re slightly pushing up against our hour but I will wrap up very quickly. But can you just break down the differences and you’ve touched on that there’s no safety concerns for any of them, but perhaps you can just comment on that as you’re going.
So, I mean very, in very brief terms, the technology is different because the mRNA vaccine essentially makes use of the human body machinery to engineer the antibodies to the virus, whereas the traditional vector-based platforms have the actual antigen embedded into the virus. In terms of vaccine efficacy, the platform per se doesn’t, you know, it doesn’t mean that one is better than the other. I think there’s been concerns particularly around the mR, you know, there’s misunderstandings about the mRNA vaccine that somehow, because it’s a, you know, an RNA vaccine, it can modify, it can modify people’s genome and DNA. That’s absolutely not the case. There’s no real biological mechanism through which that could happen. I think there is one advantage to the mRNA vaccines, and that’s in terms of the flexibility and the ability to tweak the vaccine to respond, to adapt to new variants. I think it’s a little bit quicker and easier than with more traditional vector-based vaccines, but they’re both work working on that. So it wouldn’t, it really wouldn’t be, at least from my perspective, you know, the technology behind it is not a determining factor as to what vaccines to receive.
And for my final question, and you and I have actually talked about this as I snuck in a free consultation. If you’ve had Covid, should you be getting vaccinated and should you be getting one dose, two? Does it matter which one, how long after you’ve been sick? What’s your opinion on that?
Sure, so I’m very proud to say that’s my team in Israel is one of the possibly the first, or one of the first teams in the world who’ve looked at that. And what we’ve seen is that a single dose of vaccine after infection, after national infection confers very strong immunity regardless of how long ago you’ve been infected. And many countries, including France, including Israel now is recommending a single dose of vaccination for those who have been infected in the past. It seems that the second dose in these individuals doesn’t really make a difference, at least in the short term. It may be that it confers longer, longer term immunity we don’t know yet. But in terms of antibody response at least, which is only part of the story, it doesn’t make any difference. So it seems that a single dose is sufficient in these individuals. And in terms of when to receive it? Well, there isn’t really a clear guidelines and in our study we had people infected a month ago up to people infected 10 months ago, and the response was very similar. There is one kind of rule and again not specific to Covid 19, but applicable to most vaccine, which is, you know, if you’re infected and you’re unwell, you should wait until you’re recovered and you’re feeling better. Or you know, and that’s at least a month after infection.
So Michael, I know we could have gone for a full second hour. I’m very conscious that you’re on holiday with your family and it’s already 10:00 PM. But maybe in a couple of weeks after your next trip to Eswatini, we can convince you to come back. So I’m going to hand back over to Wendy and I’m looking forward to seeing you on no doubt in Eswatini call tomorrow while you’re on holiday.
Pleasure.
Well, thank you very, very, very much, Michael. I just have one question myself that I’d like to ask you. What about if you have been vaccinated and you’re surrounded by people who are not vaccinated, and don’t want to be vaccinated or nervous of it? What are the chances of transmission? What should one have social distancing, should one be eating outside, not indoors? You know, how, what?
Yeah, so it’s a good question. First of all, you should tell your friends off for not wanting to be vaccinated. But no, seriously, well, the you know the.
The young ones mind. It’s not my .
The young ones, I know.
It’s the younger generation. They’ve, you know, they’ve spun this myth about not being vaccinated. Go on, sorry.
So the vaccine, you know, the vaccine gives the 90, you know, 95% protection. And that means that it would, compared to those who are not vaccinated, your risk of being infected is reduced by 95%. And that’s not 100%. So there’s always a risk. And this is why in, as the vaccination campaign progresses, there is this period where, you know, vaccination needs to take place alongside other measures. And until there’s enough, enough people in the community or population being vaccinated, and these measures, you know, masks and social distancing need to stay in place. Now there’s a point at which once you reach a high enough proportion of people being vaccinated, the likelihood of you being in a situation where you’re going to be in a, in close enough contact with someone who’s not vaccinated to enable transmission becomes quite low. And the risk of that really is, is sort of, you know, is not high enough to warrant continuing these measures. Now, but it’s, you know, finding that balance is difficult. And now you know, in Israel we’re about 85% vaccinated among those eligible, and only now are we starting to talk about taking masks off outside, not inside.
So you really need to reach very high levels of vaccination to be able to make do with or, you know, to remove these other social distancing measures. Now if you’re talking about very specific situations where, you know, you’re inviting a friend and you know that they’re not vaccinated and you know that you’re going to be in close contact, I don’t think it’s unreasonable to say, “Well, you know, "I would prefer, I would prefer that you wore a mask, "or I would prefer that we kept a social distance.” I think that’s really, that’s more a case by case judgments you know, depending on your own medical history and risk and how comfortable you feel, depending on whether it’s indoors or outdoors. But I think it’s not entirely reasonable because as you know, Carly said, and I can attest to, as someone who’s recovered from Covid, you know, being infected is not fun. And I think it’s completely legitimate to, you know, want to reduce that risk to as low as possible and actually to expect others, you know, because vaccination is not just about you, it’s also about others. And deciding not to be vaccinated is a decision that affects those who don’t get vaccinated, but also affects others because they’re putting others at risk. So I think, you know, expecting others to be vaccinated and if they’re not, expecting them to behave in a certain way to protect you is not unreasonable.
Right, okay. Well, I was much more worried about infecting them because I’m surrounded by a lot of young pregnant women who are afraid to be vaccinated. So now I, especially after listening to you today, I feel much more anxious about actually being in their presence. And I’m just wondering what precautions I should take, you know.
Okay. So I’m, if I’ve generated anxiety, I’m a bit worried
No, no.
That the message hasn’t gone down. But no, so the first thing to say is if you’re vaccinated, you’re reducing your, you’re not only protecting yourself, but you’re reducing your risk of transmitting to others by about 90%. So the chance, the likelihood of a vaccinated person infecting someone else, particularly when circulation decreases is pretty low, it’s pretty low. But again, you know, if you want to be, if you want to be extra cautious, you should say, you know, you can, let’s keep a distance. Let me, you know, let’s both wear a mask just in case, even though the risk is very low, but really you should get vaccinated.
Okay, thank you. Well, that was truly, truly excellent to break, you know, to have the ability to break down such complex issues so that we can all understand it, is a real skill. So really, thank you very, very much for that.
Pleasure.
Yeah, thank you for that fact filled hour. You know what, during Covid, having the facts and knowing what to do is so important so that we can really keep ourselves, you know, informed. So I, as you know, as Carly said, I’d like to say hopefully that you have really earned yourself a repeat appearance. And I’d also just like to add that you and IsraelAID’s efforts are really truly lifesaving, to quote my dad. And through your efforts, you are changing the lives of every person in a country. I mean, that’s unique. So on behalf of my family and the people of Eswatini, my homeland, Swaziland, which is a very close to our hearts, and I know there other Swazis on this call. I just received an email from John Tyberbusky yesterday. Other Swazis who I’ve not seen in 40 or 50 years. I just want to say to you a very, very big thank you. Thank you for the work that you do and thank you for this very interesting and informative hour. And to our wonderful Carly, thank you for arranging it and for today.
Pleasure, thank you very much.
Thank you, thank you everybody for joining us. Goodnight and goodbye. Thank you.
Bye.