What is Covid-19?
Coronaviruses are a large family of viruses that are known to cause respiratory illnesses ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS). The recent coronavirus disease, COVID-19 is caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). This is a new coronavirus that our body has no natural immunity to besides being highly infective. Transmissible mainly through respiratory droplets, patients often present with symptoms such as fever, dry cough, and tiredness. Symptomatic people are most contagious, with respiratory droplets being produced when they cough or sneeze whilst possibility of asymptomatic spread remains a question to be answered. To make matters worse, according to the World Health Organization (WHO), 1 infected person can pass this virus to 2.2 people, on average. This partly explains how it has become a horrifying pandemic, especially as there is still no true cure to this problem.
Why do we propose vaccination?
Since there is not a “magic pill” that can cure the virus till date, the idea of vaccination as a possible solution has been taking pace. Vaccines are mainly made of a small amount of weakened (live) or laboratory destroyed (killed) pathogens (bacteria, virus or toxins). Vaccines work by inducing an immunological reaction in our body and building immunity to the specific infection in the future. It does not cause a healthy person to contract the disease as the pathogens are too weak to induce an infection. In other words, there is no risk of healthy people catching a disease from a vaccine. We have seen vaccines being used to manage multiple pandemics such as smallpox and polio as well as other epidemics such as measles, mumps and rubella. When a high percentage of the population is vaccinated, it is difficult for infectious diseases to spread because there are not many people who can be infected. This is the concept of herd immunity. For example, if someone with measles is surrounded by people who are vaccinated against measles, the disease cannot easily be passed on to anyone, and it will quickly disappear again. This will give protection to those who might not be vaccinated such as infants, elderly or immunocompromised groups.
Some parties, however, claimed it is better to contract the disease and let the body establish immunity naturally. This idea, however, is highly unethical and unachievable. For instance, polio can cause paralysis whilst measles can cause encephalitis (inflammation of the brain) and blindness. Both are vaccine preventable diseases in the first place, it is therefore irrational to forego vaccination and expose oneself to the possible risk of debilitating consequences. As we still have not created a vaccine for Covid-19, preventive measures such as social distancing would still be a better option rather than deliberately exposing a whole population to the disease to achieve “natural herd immunity”. To achieve the natural herd community, at least 70% to 90% of its population must contract COVID-19 which literally means 70% – 90% of the population needs to be sick! A study done in Spain meanwhile shows people still have low levels of coronavirus antibodies post COVID 19 infection, about only 5% nationwide, which is farfetched from the proposed 70-90%. Similar findings in Wuhan and Switzerland also indicate that natural herd immunity is unachievable and instead would just lead to a next wave of infection. Besides, most health systems in this world are ill prepared to cope and contain such COVID-19 situation. We have seen many current real lived examples such as India and the US, where the countries are faced with shortage of doctors, hospital beds, and equipment. This will affect the quality of treatment among patients and some might not even be attended to consequently. COVID-19 itself is a fatal disease and only higher death rates will be achieved with this method. High risk groups such as the elderly and immunocompromised groups meanwhile will not be able to mix in the society due to fear of contracting the disease that is certainly life threatening to them.
To debunk some myths against vaccination:
The misinformation surrounding vaccines itself is alarming. Anti-vaxxers often claim vaccines cause autism and sudden infant death syndrome (SIDS) due to a false study reported in 1998 by Andrew Wakefield and 12 of his colleagues. This study raised concerns about a possible link between measles-mumps-rubella (MMR) vaccine and autism. Twelve years after it was first published, “The Lancet” journal retracted the paper after the findings of the study were found to be significantly flawed. As of then, several major studies conducted or funded by US Centers for Disease Control and Prevention (CDC) found no evidence linking vaccines as the major cause of autism or SIDS. Vaccines may cause fever for 1 or 2 days or in rare cases, a mild allergic reaction within minutes of administering the vaccine which can be easily dealt with immediately without causing harm.
Updates on Covid-19 Vaccination
This brings us to the idea that if a vaccine is successfully created for COVID-19, it can be a vaccine-preventable disease. The first COVID-19 case appeared in December 2019, so you might be wondering what is taking so long to develop a vaccine for this then? Well, before a vaccine can be used worldwide, it must go through many steps beforehand. The first step is to search for safe and replicable vaccine designs using different approaches followed by animal testing in laboratories. Once appraised, these vaccines will enter clinical trials where they are evaluated for safety, efficacy and side effects across a variety of populations. This clinical trial is divided into 3 phases in which the number of populations being tested gets larger as they progress to the next phase. Finally, the manufacturing of approved vaccines is produced and distributed for public use. All these steps can take up to 20 years in total. However, with this pandemic, researchers are doing their best to employ numerous strategies to develop a possible vaccine as quickly as possible without compromising its safety. Many of them are working on different vaccine designs in different labs and running multiple clinical trials simultaneously to speed things up. Constant communication between labs and manufacturers are also being done to initiate the production of approved vaccines immediately without any delay. Even with these efforts, realistically a possible vaccine will not be available for at least another 12 to 18 months.
Currently, there are more than a hundred projects being carried out in developing Covid-19 vaccines all over the world with the assistance of WHO, who has created a research and development blueprint for researchers to collaborate and work together. One of them is BBIBP-CorV, developed by the Chinese researchers with funding from Sinopharm has shown promising results. It appeared to be safe in animals and was able to trigger an immune response with only local irritation at the injection site being a downside. It also has good genetic stability and efficient productivity making it relatively easy for production. This possible vaccine has completed phase 2 whilst phase 3 with more than 1000 participants is under way.
Meanwhile, a vaccine developed by Oxford University and AstraZeneca pharmaceutical company, AZD1222 vaccine, with a 1-billion-dollar funding from the US government, was said to be the furthest along of several candidates worldwide. They have entered phase 3 trials with the vaccine now being tested on 5,000 volunteers in Rio de Janeiro, São Paulo and an undisclosed site in northeastern Brazil. It can generate a strong immune response from just one dose. It is not a replicating virus so it will not cause an ongoing infection in the vaccinated individual. If all goes well, as early as autumn or towards the end of the year the vaccine could be used on a wider scale.
Another possible vaccine is mRNA-1273 which is developed by Moderna Inc, a US biotechnology company, in collaboration with the National Institutes of Health (NIH). It can protect the lungs against viral replication without any toxic effects after just one dose when being tested on mice. The expected start date of phase 3 trials with more than 30,000 participants was pushed back as the company is making changes to its trial plan. They are still committed to get the trials running somewhen in July. Moderna expects to be able to deliver about 500 million vaccine doses each year and possibly up to 1 billion doses annually starting next year. Other countries are also contributing in developing a possible COVID-19 vaccine like Australia, Singapore, Germany, Italy and Belgium.
World without Vaccination?
Having said that, a vaccine has never been successfully made for any coronaviruses so far. So, what if a vaccine is not successfully developed? Then, the tedious process of identifying, screening, contact tracing, quarantine or, if needed, hospital admission will be a routine until a better solution has been found through ongoing randomised control trials of various preventive measures, antivirals and vaccines. The idea of adopting “natural herd immunity” would just put more lives at stake, which would not make it a good policy to adopt. Vaccination still appears to be a promising long-term solution as it can provide passive immunity for us without us contracting the disease and experts remain confident a breakthrough will be made as coronavirus does not mutate rapidly as HIV or malaria. The more realistic expectation for the world as of now will be practicing “The New Norm” to limit the spread of the disease and the use of antiviral medications to treat the complications of the disease. We should start adopting these new norms such as social distancing and follow the advice from the Ministry of Health, which is to avoid the 3Cs: crowded places, confined spaces and close conversation whilst practicing the 3Ws namely wash our hands, wear a mask and warn ourselves constantly in daily life.
References
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Written by: Palvinder Singh A/L Param Jit Singh*, Aisyah Farah Binti Abd Rahman*, Gan Xhi Yan*, Muhd Ilham Fuad Bin Awang Mohammad*, Sofea Syazlin Binti Azhar*, Yeap Lee En*, Liyana Binti Mat Rosly*
Supervised by: Prof. Dr. Claire Choo Wan Yuen**, Prof. Dr. Victor Hoe Chee Wai Bin Abdullah***
*Group 4B Community Posting, Final Year Medical Student, University of Malaya
** Prof. Dr. Claire Choo Wan Yuen is a lecturer in the Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya
*** Prof. Dr. Victor Hoe Chee Wai Bin Abdullah is a Public Health Medicine Specialist in the Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya