UKC

Has been approved! Woohoo!

Happy new year to everyone, this is a great bit of news to welcome 2021

Is it Friday already?! 😃

Fantabulous.

It is.

I wrote this on another thread:

They've also taken a decision as previously speculated on ukc to prioritise getting a first dose of the vaccine to as many people as possible, delaying dose 2 until 12 weeks after the first.

Once things have settled a bit I'm hoping we'll see a full writeup of MHRAs findings about effectiveness etc. The news reports are saying that the data used to claim 90% adequacy with a half dose was inadequate and that the approval is for two full doses, which gave 62% protection in the trial... but that some unpublished data has also showed that two doses gives higher protection if taken further apart.

If one dose gives only, say, 50% protection then I think it's really important that's communicated to everyone who has it.

I'm happy to move on to 2021 already! No need to see any more of 2020! 😀

I don't quite follow what you are saying. 

Is it basically that they are going for spreading it thinner with a lower level of protection?

That seems like a reasonable option for most of the population if the most vulnerable already have the Pfizer one with high level protection, doesn't it?

I guess there is no perfect option, it's all just damage limitation!

They are going to wait 12 weeks between doses rather than 4. That means they can get a single dose to more people quickly. I don't think it's a bad thing to do but obviously it means each individual has to wait longer until they have the full available protection.

They have also specifically approved the two-full-dose version and not the half-,full,-dose version due to a lack of data. It was the latter that gave a high reported effectiveness in the initial press release, the former was only 62% effective.

What I'd like to know is what protection effectiveness % is actually claimed for this vaccine after both 1 and 2 doses, so we can be fully informed (I advocate taking it anyway, but this will affect how much it might allow people to moderate what risks they take. For example if everyone in a care home has had a single dose of AZ and it only gives 50-60% protection at that point, you might still want to restrict visitors, whereas if everyone in another care home has had 2 doses of Pfizer, you might not. Obviously it also makes an important difference for individuals in the community too.)

Remember there's even more subtlety than that. Protection isn't binary. There isn't clear communication on what e.g. "50% protection" means. Early indications are that it means a much lower (even near zero?) chance of getting a bad case and ending up in hospital, but possibly still able to catch and transmit the virus, if I've read the right things well enough. I don't have the information to decide how I feel about it, other than it's obviously very good news either way.

If that's true it would obviously be very good news. What I think we know is that AZ gave the vaccine to about 11000 people and none of them suffered severe disease. We don't know (I don't think) what the age distribution of those people is or how many of them would have been expected to suffer severe covid anyway in that period of time in that location (I think it was mixed across UK and Brazil?) So, this could be really good or it could mean very little. I think we need to see if MHRA says anything about all this like we do about the usual effectiveness measure.

I think the idea that vaccination is a personal saviour is quite dangerous, and a lot of people seem to have that mindset - either for themselves, or their granny. If it's 90% effective and you vaccinate 100 residents in a care home ten of them are still going to die if you let the virus into the home.  The whole point of the vaccine is to provide herd immunity which causes the virus to die out, and until enough people have been vaccinated to do that restrictions are still needed.  I believe vaccinated people will be less likely to heed to restrictions that will still be required for some time and that will affect compliance of those yet to be vaccinated.

A friend is on the trial, she is celiac and deamed high risk for Covid. (I would guess late 50s)

Doesn't know if she had the vaccine or a placebo yet, but hasn't had any covid symptoms.

Not quite true. 10 of them will develop symptoms. The efficacy is not about deaths. It is true that the vaccine isn't a clear pass to immediate normality though. 

Doesn't this mean 10% will get Covid rather than die from it? Then only 1 - 2% of those would die? (maybe more for a care home I guess).

I think the logic of the decision is that a single dose, while not necessarily being enough to prevent infection, is sufficient to prevent serious disease and hospitalisation.  I've heard this a couple of times this morning but I'm not sure what the data are.  I think it's a perfectly reasonable assumption, and I guess there must be a cohort within the trial who only received one shot for whatever reason - whether that cohort is large enough to conclude anything, even if none of them were hospitalised, I've no idea.

Anyway, there's every intention that everyone will receive a booster shot, and, in practical terms, there's quite a big window in which it can be administered.  The idea here is to flex the timing of the booster to maximise the number of people who are kept out of hospital by getting at least the first dose.  

https://www.astrazeneca.com/media-centre/press-releases/2020/azd1222hlr.htm...

That's really interesting. I did hear some fears that for a double shot vaccine, the Pfizer one, they were worried many people were too useless to go back and get the second one implying that it wouldn't work. I assumed that the two weeks was kind of a critical timing. But from what you say that's not the case.

There's also the issue with paranoia. I know one person who is more worried about the vaccine than Covid. Don't know what percentage of the population is like that but I'm guessing that if I know someone it's probably fairly widespread. These fears tend to get spread on social media pretty rapidly these days.

Yes you're right, but the IFR for oldies is more than 2%:-

0.4% for o55s

1.4% for o65s

4.6% for o75s

15% for 085s

I don't think many people would accept a 10+% fatality risk for Granny in the care home - I don't personally know any u80s in care homes.

The amount of anti-vaxxers on FB is ridiculous. Much of it is the 'I don't want it until it's proven to be safe, look at thalidomide' variety.  Some of it driven by the 'in a trial 4 people got Bells Palsy' bullsh*t, some of it driven by the 'it's been rushed through and can't have been tested properly because it takes years to approve drugs' theories. The anti-vaxxer / conspiracy theorist venn diagram is virtually a single circle......

I wanted some good news today. 

My dad died on 18th December and my 20 year old moggie has just been given a diagnosis of cancer.

The vaccine and a gradual return to longer days will cheer me up a bit. 

2020 has been hard. Roll on 21.

Oh, I'm very sorry to hear this. I hope you have lots of happy memories to treasure.

Agreed! Here's hoping it will be a jollier year all round!

Good to be optimistic at times though personally I was thinking 2021 could be the bad year what with the new mutant strain, Brexit and another year of useless, corrupt Torries in power. Still good to see the end of Trump and a vaccine starting to get rolled out.

They will need to be very clear as to what the risk still is during the process. I anticipate this communication being clearer in Scotland than in England! 

Yes this, that's the really important bit.

This isn't true. The other vaccines offer near 100% protection against serious covid.

A 41 year old US politician just died of covid, he had a heart attack. We still don't fully understand it's impact on the heart and blood clotting.

I struggle to understand these fears from unknown issues with the vaccine and then a total ignorance about the unknown risks from covid.

Roy Lilley on vaccination today

"Start today...

I’m back… early. I’d planned to drop into your inbox in the New Year. But, I couldn’t wait. The whole NHS-Covid situation is turning into everything we’d hope to avoid. Every-which-way the NHS turns, it’s hitting a wall. You’ve seen what’s on the telly… the graphs all looking like ski-slopes. Hospitals as full with Covid patients, as last time, except more. Winter exacerbating the problem. Electives paused. Ambulances busier than Deliveroo. Wards choc-a-bloc. The new strain of Covid, ripping through communities and that includes NHS staff. Thousands of whom are off-sick or self isolating. The perfect storm.

Will the NHS fall over?

Years and years ago, when Florence and I used to come to work on our bikes, I did the community leaders’ course at the Easingwold Civil Defence College. It’s still there. Now, it teaches resilience. Same things but without the threat of nuclear conflagration and with a slightly different name. It’s gruelling. The drills, exercises and scenarios become very real. The mounting problems leave you gasping for breath. Take away learning? Prioritise, make clear-decisions clear to everyone, if you are wrong… fix-it-quick and the lasting message; ‘You can’t look after people, unless you look after the people looking after the people…’ Covid is no different; look after the people looking after the people. The NHS.

The WHO agree. This is their guidance on vaccinations; ‘… use available doses for target groups… … In Phase 1, countries are advised… define their health workers, including in the private sector, who are at higher risk of COVID-19 … than the general population… ’ They add; ‘In the latter part of Phase 1, countries are advised to define their older people by age-based risk… to be decided at the country level… and those with underlying health conditions…’

You will note our vaccination policy seems to be the other way around. This is what HMG guidance says; ‘There is clear evidence that those living in residential care homes for older adults…. have had a high risk of exposure to infection and are at higher clinical risk… given the increased risk of outbreaks, morbidity and mortality in these closed settings, these adults are considered to be at very high risk. The committee’s [JCVI] advice is that this group should be the highest priority for vaccination…’

This puts us bang in the middle of an ethical dilemma and at odds with WHO… but only if you forget the training; '... look after the people looking after the people.' Care-home-vulnerable people will still need care, vaccinated or not and if all the care workers are sick, they have a bigger problem. If the supply chain can manage the target of a million vaccinations a week, don't forget it needs two jabs, effectively doubling the completion time.

There are calls to double vaccinations to two million a week. First question, can we speed this up? Probably, by strengthening the delivery chain. But it takes time and time we don't have. There is a companion strategy; giving as many people as we can the first, single-dose, makes an immediate impact on the virus' spread. Prof David Salisbury, who was in charge of immunisation at the DH until 2013, told the BBC Today programme; ‘… you give one dose you get 91% [protection]… give two doses and you get 95%… only gaining 4% … with current circumstances, I would strongly urge you to use as many first doses as you possibly can for risk groups and only after you have done all of that come back with second doses…’

Second question, a million a week? Vaccination hubs are tasked to do 975 vaccinations a week. That’s because Pfizer’s stuff gets delivered and thawed in those quantities. Get yer calculator out… in a month, that’s a tad under 4,000. A million? We’ll need; over a thousand hubs working flat-out, ,battalions of vaccinators, an army of ancillary support, a computer system that actually works, a rock solid supply chain..... and a vaccine that is easier to handle than Pfizer’s Kryptonite. The Oxford A-Z vaccine can't come too soon.

Do we have all that? Dunno… we have a minister...

If the NHS falls over it won’t be for the lack of beds, or for people working their socks off. It will be the lack of people. If care collapses, it will be because the people delivering care are too sick to care. Let’s stop and think… something else from the Easingwold play-book;‘… don’t get swept up in events, control them.’ Prioritise health and care staff, with a single dose vaccination. Start today. See you next year...

Want to contact Roy Lilley? Please use this e-address roy.lilley@nhsmanagers.net  "

I'd agree NHS frontline staff should be high up the list.  I wouldn't bother quoting the WHO, as it hasn't exactly been at the forefront all along, it's just been doing what most of its funders want it to.  TBH, I'd seriously consider withdrawing from it; it's basically been useless throughout and is as such a waste of money.

I’ve just heard Sarah Gilbert say they have data from people who didn’t get the booster until 26 weeks but are confident at least to 12 weeks.

Protection is apparently good after 3 weeks from the first shot but lasts much longer following a booster.  What we need right now is the immediate protection, not the 1-5 years’ potential of the booster.

Someone help me, why does  the gov website show so few cases?

https://www.gov.uk/government/publications/notifiable-diseases-weekly-repor...

I totally agree frontline staff (healthcare, police etc) first. Coupled with care staff both in the community and care homes.

Next teachers. Its not just about education and then mental health of kids, they are also an essential care providers.

Next care home residents, and those of working age who have been officially shielding.

Followed by the over 80s, over 70s and then over 60s.

Controversially perhaps, but at this point id possibly consider making the vaccine available to the general population as a private prescription for those who are prepared to pay to jump the queue.

Id then jump drop down to the 18-25 as it was shown in September that these are superspreaders (often in shared houses and more social mixing).

Probably then the 50+ and work down through the age groups.

It's care home residents to free up ICU beds. That's the issue here. Most of the US is reaching their ICU capacity or it's at least getting concerning how many beds are left. Just by vaccinating care home resudents we reduce the ICU pressure massively.

On the radio this morning, it was said that the effectiveness/response was better if there was a longer interval between Jags, as you might say. So presumably better than the 70+% quoted previously.

It would be pretty unusual for a care home resident to be in ITU in the UK. The chance of survival to any kind of good functional outcome is extremely low. Something must be going pretty wrong if the ITUs are clogged up with people from care homes receiving medically futile treatment? (unless the definition of intensive care is different in the US?).

The UK issue is just the numbers of hospital admissions from care homes and the elderly.

Here they will throw the kitchen suck at guys with dementia and three kinds of cancer. My wife is an oncologist and is amazed how far they take treatment.

But saying that she's had elderly people with survivable cancer who now have terminal cancer because they couldn't risk them coming in. 

But it's still high risk groups who are putting pressure on hospitals. My wife gets her vaccine today but we've been vaccinating high risk groups for a few weeks. It means families can see relatives again too.

That's great news! Makes the roll out faster and better effectiveness!

My wife was saying today she worked with a British trained Dr in an ICU in NH and he was always saying how many of their patients they had in their ICU wouldn't even get through the door in the UK. They'd just make them comfortable. Here it seems a totally different mindset and a massive waste of resources.

Before you know it, we'll be ice-climbing on the Ben again!

:-}

Sorry for slow reply. The link you provided was just the original press release, which was what contributed to my question in the first place. However this subsequent Lancet paper has more information;

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32661-1/...

In the vaccinated group there were no hospitalisations or severe cases. In the control group there were 10 hospitalisations, 2 severe cases, 1 death.

Yeah, I made it 30-odd thousand participants from that press release.

I think this should be the headline figure. Not the whatever% efficacy (which is not effectiveness! Can't say that enough either).

It's the "100% didn't end up in hospital" that we should be putting in the headlines.

Tbh I don't agree. If there were only 2 severe cases in the control group then I don't think you can read very much in to it. I think it was probably only communicated at all because AZ knew their headline efficacy figure would read poorly next to those of Pfizer and Moderna that had just been released at the time.  It certainly can't be a bad thing though.

Hopefully it won't fall to our spineless government to make this point, the professionals administering the vaccine can pick that up, more universally trusted, hopefully well informed about efficacy by the time they start delivering it.

Jk

I would assume that ventilating an elderly dementia patient for a week before discharging them in a completely dependent state to a nursing home earns the hospital a fair amount of money.

Great plan. "assume" is definitely the right course of action here. Not "research", "look up", "ask about" or even "a quick google". Definitely go with assume.

Edit: took about 20 seconds to find this:
https://improvement.nhs.uk/resources/national-tariff/#h2-202021-national-ta...

Edit edit: been pointed out you're talking about the US. Probably harder to get to the bottom of it.

I think he was talking about the US? I figured that was where roadrunner lives.

Hadn't clocked that. Makes more sense but point still more or less stands. The link, less so.

Well, roadrunner described significant differences between medicine in the UK and US above. The US medical system is more interventional and can tend towards overmedication and overtreatment. An issue with privatised healthcare systems is that they can overtreat. I have first hand experience of this. The more interventions are done, the more money the hospital gets. Why are elderly care home residents with dementia on ITU in the US? It's very unlikely to provide them with any benefit, and even if they do survive they won't ever recover properly. I'm not saying they're doing it to earn money, but the influence of money on the medical system gives this outcome.

There may also be effects around religion - a mate of mine moved from Bristol to Dublin, hes a Paeds interventional cardiologist and gets to see more and more complex cases than in the UK, and also parents are more likely to push for treatment for severe cases rather than palliation. A large part of this appears to be related to views on sanctity of life, rather than money.

I think it's a legal thing too, unless they are on a DNR they can't really withhold life saving care like they can in the UK. Especially if a family wants them to be kept alive. 

https://newsroom.uw.edu/story/icu-ventilators-overused-advanced-dementia-pa...

There's starting to be a change about how soon they talk about death with patients and their families. A patient can go on hospice once they have 6 months to live (I think it is), yet the average time on hospice care is something like days in the US. However, with lung cancer they have now shown if you transfer a patient to palliative care earlier they actually live longer and have more chance of dying at their home.

https://www.cancernetwork.com/view/timing-palliative-care-linked-better-lun...

Yeah my wife was at a birth where the kid faced certain death (poor brain development). Yet the parents went through with the birth, had a priest there to baptise him so he could die after being baptized. Poor kid lasted a few days unable to eat and in pain. But some of that is connected to poor maternal health support through the pregnancy, so some very high risk births get very far down the line before things are picked up. It's why US maternal mortality rates are so high. With adequate insurance and health coverage the mothers go for more regular check ups. They can get this all for free but often won't for fear of immigration issues or medical debts.