With fewer than one in four people vaccinated globally and barely two percent of Africa’s 1.3 billion people vaccinated, the US and other rich countries are looking to roll out booster shots to the fully vaccinated. The New York Times (US) reports Africa director at the World Health Organization, Dr. Matshidiso Moeti said, “Moves by some countries globally to introduce booster shots threaten the promise of a brighter tomorrow for Africa. As some richer countries hoard vaccines, they make a mockery of vaccine equity.”
 
Power 98.7 (South Africa) quotes WHO’s Tedros: “I called for a temporary moratorium on boosters to help ship supply to those countries that have not even been able to vaccinate their health workers and at-risk communities and are now experiencing major spikes…The divide between the haves and the have-nots will only grow larger if manufacturers and leaders prioritise booster shots over supply to low- and middle-income countries. The virus is evolving, and it is not in the best interest of leaders to just focus on narrow nationalistic goals, when we live in an interconnected world and the virus is mutating quickly.”
 
A Nature (UK) editorial notes, “As Nature went to press, 58 percent of people in high-income countries had received at least one vaccine dose; in low-income countries this number stood at just 1.3 percent.... Choosing an unknown but potentially incremental benefit for a person in a wealthy country over a massive, life-saving one for a person elsewhere in the world is a losing strategy, because new variants will inevitably arise in places where the spread of COVID-19 continues unabated. Instead of offering boosters to large swathes of people, wealthier nations need to be more active in getting the world vaccinated….”
 

If You Are in a Hurry

• Read “Correlation Does Not Equal Causation” at Bhekisisa for a deep dive into how reported deaths and serious adverse events reported after vaccination are investigated.
• Read Nature on a preprint study that found “74 percent of infections with Delta took place during the presymptomatic phase.”
• Read Nature on what’s needed for effective pandemic preparedness.
• Read STAT on the confusion and “bafflement” of some health officials on the US push for booster shots.
• Read a twitter thread by epidemiologist and MD Céline Gounder that lays out the differences between population and individual effect of vaccines.
• Read Quartz on how COVID will likely turn from pandemic to endemic.
• Read physician Jamie Rutland in Public Health Newswire on how to communicate to people who are not yet vaccinated.
• Read a NEJM Perspective on how to counter misinformation.

 

Vaccines Manufactured in Africa Going to Europe

 
The New York Times (US) reports, “South Africa is still waiting to receive the overwhelming majority of the 31 million vaccine doses it ordered from Johnson & Johnson. It has administered only about two million Johnson & Johnson shots. That is a key reason that fewer than 7 percent of South Africans are fully vaccinated—and that the country was devastated by the Delta variant. At the same time, Johnson & Johnson has been exporting millions of doses that were bottled and packaged in South Africa for distribution in Europe….” Researcher Glenda Gray is quoted: “It’s like a country is making food for the world and sees its food being shipped off to high-resource settings while its citizens starve.” Human rights lawyer Fatima Hassan says, “The disproportionate amount of power that Johnson & Johnson has exercised is really concerning. It is harming our efforts to get speedy supplies into the system.”
 
Reuters (UK) reports, “On Wednesday, the WHO Director-General Tedros Adhanom Ghebreyesus said he was ‘stunned’ to hear that J&J vaccines were being exported from South Africa to the EU, because the bloc has very high vaccination rates while even the most vulnerable people in many African countries have not been vaccinated.” Reuters reports the EU says the arrangement is temporary.
 
In a commentary for Observer Research Foundation Amref’s Dr. Githinji writes, “First, a consistent supply of COVID-19 vaccines is critical if countries and communities are to succeed in vaccination. To have inconsistent supply is to impede the vaccination efforts as people wonder when and how they will access their scheduled doses. As Africa works closely with its international partners, Africa must also look inside and ask itself when it will stop relying on its neighbours and friends to take care of its people. Vaccine manufacturing conversations are in high gear and already technology transfer deals have been made…. Secondly, Africa needs to speak to its people. In Kenya, as in many other countries in Africa, major gaps exist in risk communication and community engagement, therefore, the government and policymakers can’t get through to their people. Community structures must be engaged if governments are to succeed in achieving their 60 percent target of their population being vaccinated.”
 

The Debate Over Booster Shots

 
Based on data from three new CDC studies that showed waning immunity and protection against the Delta variant, the Biden administration announced that booster shots would be made available to fully vaccinated people eight months after their second dose, pending approval by the US CDC and FDA. Beyond the concerns about global vaccine equity, some scientists expressed doubt that the boosters are needed. STAT (US) reports the decision “is being met with bafflement, concern, and even anger from a number of immunologists, vaccinologists, and people steeped in the normal way such decisions are made…. Anna Durbin, a vaccines researcher at Johns Hopkins University, said the vaccines continue to be highly effective in preventing hospitalizations, severe infections, and deaths among most vaccinees. That they may not work as well over time in preventing mild illnesses among those vaccinated isn’t necessarily a sign the vaccines are failing, said Durbin, who insisted that people are going to need to accept that fact. ‘We cannot keep [boosting] and say: ‘We’re going to prevent colds in everybody,’ she said.”
 
POLITICO (US) reports on the CDC data: “The evidence, compiled by federal scientists over the past several months, showed a decline in the initial round of protection against COVID-19 infection that's coincided with a resurgence in cases driven by the more contagious Delta variant. The data looked at vaccine effectiveness in individuals across age groups, with varying medical conditions and who received the shot at different times. It was presented to White House COVID-19 task force officials at a meeting Sunday.” The CDC data is here.
 
Late on Thursday, Bloomberg (US) reported, “The Advisory Committee for Immunization Practices, originally scheduled to meet and possibly make a recommendation about the need for boosters on Aug. 24, is now set to convene the following week…. The plan is surrounded by controversy as the medical community remains divided about whether the data support a need for boosters and the World Health Organization has called for richer countries to hold off on distributing third doses until less-vaccinated countries catch up. The Biden administration still needs the CDC’s recommendation and approval from the Food and Drug Administration to proceed with the plan.”
 
The Washington Post (US) reports, “Critics say the CDC’s failure to share real-time data led to overly rosy assessments of vaccine effectiveness—and complacency on the part of many Americans,” noting “the growing frustration with the CDC’s slow and siloed approach to sharing data, which prevented officials across the government from getting real-time information about how the delta variant was bearing down on the United States and behaving with greater ferocity than earlier variants—an information gap they say stymied the response.”
 
DW (Germany) reports, “WHO scientist Soumya Swaminathan said on Wednesday in Geneva: ‘We believe clearly that the data does not indicate that boosters are needed’ for everyone. She cautioned the world could be facing ‘even more dire situations’ down the road if it left billions of people in the developing world unvaccinated, as this would only fuel the emergence of new variants.”
 

Vaccine Efficacy Wanes in Face of Delta

 
Medscape (US) reports, “Having two doses of a COVID-19 vaccine remains the most effective way of ensuring protection against the Delta variant first identified in India, preliminary research has found. A preprint study by scientists at the University of Oxford found that both the Pfizer/BioNTech vaccine and the AstraZeneca/Oxford vaccine offered good protection against the Delta variant but that effectiveness was reduced compared with the Alpha variant that was first identified in the UK…. Another key finding was that Delta infections after two vaccine doses had similar peak levels of virus to those in unvaccinated people.”
 
Nature (UK) reports the UK study “results raise questions about whether it could be more effective to have doses of different vaccines, rather than multiple doses of the same one, especially if a third, booster dose is to be considered. Georg Behrens, an immunologist at Hanover Medical School in Germany, says that mixing vaccines could increase their effectiveness. The immune system reacts differently to different types of vaccine—and this could be exploited to trigger a better overall response.”
 

Delta Spread by People Who Feel Fine

 
Nature (UK) reports on a preprint study: “People infected with the Delta variant of SARS-CoV-2 are more likely to spread the virus before developing symptoms than are people infected with earlier versions, suggests a detailed analysis of an outbreak in Guangdong, China…[researchers] found that, on average, people began having symptoms 5.8 days after infection with Delta—1.8 days after they first tested positive for viral RNA. That left almost two days for individuals to shed viral RNA before they showed any sign of COVID-19. An earlier study and an unpublished analysis by Cowling and others estimate that before Delta emerged, individuals infected with SARS-CoV-2 took an average of 6.3 days to develop symptoms and 5.5 days to test positive for viral RNA, leaving a narrower window of 0.8 days for oblivious viral shedding…. 74 percent of infections with Delta took place during the presymptomatic phase—a higher proportion than for previous variants.”
 

What Are Vaccines Supposed to Do?

 
The debate over boosters and vaccine efficacy has led to a number of conversations and media coverage about just what the COVID vaccines are meant to do. In an excellent twitter thread epidemiologist and MD Céline Gounder examines this issues, writing, “The question is not whether you see infections, hospitalizations, & deaths among vaccinated persons. The question is whether there is a LOWER RISK of severe disease, hospitalization, & death among vaccinated versus unvaccinated persons…. We need to think in terms of RELATIVE RISK REDUCTION We also need to shift from thinking in terms of individual immunity to POPULATION or COMMUNITY IMMUNITY. We need to think about vaccination as a POPULATION-LEVEL intervention.”
 

ICUs Stretched in Many US States

 
The New York Times (US) reports, “Data from the Department of Health and Human Services shows that the number of hospitals with very full ICUs doubled in recent weeks. Now, one in five ICUs have reached or exceeded 95 percent of beds occupied, a level experts say makes it difficult or impossible for health professionals to maintain standards of care for the very sick.”
 
AP (US) reports, “Many overwhelmed hospitals, with no beds to offer, are putting critically ill COVID-19 patients on planes, helicopters and ambulances and sending them hundreds of miles to far-flung states for treatment. The surge in the delta variant of the virus, combined with low vaccination rates, has pushed hospitals to the brink in many states and resulted in a desperate scramble to find beds for patients.”
 

Antibody Levels Predict Vaccine Protection

 
Nature (UK) reports “Antibody levels in blood can predict the level of protection provided by Moderna’s COVID-19 vaccine. After receiving the vaccine, people with relatively low levels of antibodies were more likely to develop symptomatic infections than were those who mounted a stronger antibody response, according to a new analysis of such ‘breakthrough’ infections during the trial of the vaccine’s efficacy.” The author of the preprint study “hopes the analysis will help researchers and regulators to identify a ‘correlate of protection’ for COVID-19 vaccines, allowing them to predict the efficacy of new vaccines on the basis of the immune responses of a relatively small number of people, instead of using large-scale trials.”
 

Children and COVID

 
NPR (US) reports, “the delta variant proved to be much less discriminating [than earlier versions of the virus], and has led to more child hospitalizations. Now, health care workers on the front lines say there is another frightening prospect looming: a surge in children diagnosed with a combination of COVID-19 and respiratory syncytial virus…. Pediatric hospitals in Texas—and around the country—are reporting unseasonably early outbreaks of RSV, a respiratory virus that mostly manifests as a mild illness with cold-like symptoms in adults but that can cause pneumonia and bronchiolitis in very young children…. At the moment there is little data available on the impact of contracting both viruses and whether the two together can make a person sicker. But health officials worry it could put young patients—who are not eligible for the vaccine—at greater risk.”
 
The New York Times (US) reports, “Babies and toddlers are less likely to bring the coronavirus into their homes than teenagers are, but once they are infected, they are more likely to spread the virus to others in their households, according to a large new study by a Canadian public health agency. The findings can be explained, at least in part, by behavioral factors, experts said, including the fact that very young children require lots of hands-on care and cannot be isolated when they are sick.”
 

Is COVID Going to Be Endemic?

 
As the Delta variant pushes infection rates higher and vaccination rates remain too low for herd immunity, some experts are positing that the COVID pandemic will not end, but the virus will become endemic.  Quartz (US) published an explainer to help understand the difference. “To understand the import of Covid’s eventual shift from pandemic to endemic, it’s necessary to define both terms. This is a bit trickier than one might think…. It’s safe to say that a pandemic involves a disease that’s contracted by a lot of people in geographically diverse locations…. (CDC) says that endemic ‘refers to the constant presence and/or usual prevalence of a disease or infectious agent in a population within a geographic area.’…We don’t know yet when COVID-19 will cross over into endemic territory, in the US or anywhere else. But when it does, it should present a much less significant threat to our health and our daily lives. Vaccines and immunity from previous infections will give most people protection against severe cases of the virus, and measures like regular testing and outbreak tracing can hopefully keep a lid on any resurgences.”
 
The Atlantic (US) reports, “the pandemic will end. One way or another, it will end. The current spikes in cases and deaths are the result of a novel coronavirus meeting naive immune systems. When enough people have gained some immunity through either vaccination or infection—preferably vaccination—the coronavirus will transition to what epidemiologists call ‘endemic.’ It won’t be eliminated, but it won’t upend our lives anymore…. The timing and severity of reinfections and breakthrough infections once COVID-19 becomes endemic depend on how quickly the protective effects of immunity against the virus wanes. And that, in turn, depends on a combination of two factors: first, how quickly our immune systems get rusty against SARS-CoV-2, and second, how quickly this coronavirus evolves to disguise itself.”
 

No Deaths and Few Side Effect from Vaccines in South Africa

 
Bhekisisa (South Africa) reports, “Nobody has died as a result of COVID vaccines in South Africa, according to the country’s medicines regulator, the South African Health Products Regulatory Authority (Sahpra), which monitors side-effects…. Fifty-three deaths of people who had been vaccinated against COVID had been reported to Sahpra between May 17 and July 31…The regulators’ investigators found no link between the deaths and COVID vaccinations….” The in-depth story, headlined “Correlation does not equal Causation” looks at reported side effects of COVID vaccines (they were low) in the country and explains how deaths and serious adverse events reported after vaccination are investigated.
 

Pandemic Forecasting

 
Reuters (UK) reports, “The US Centers for Disease Control and Prevention said on Wednesday it is creating a new disease forecasting center to improve the ability to use data to predict and gauge emerging health threats. The Center for Forecasting and Outbreak Analytics will help in sharing information in real time to activate governmental, private sector, and public actions in anticipation of threats both domestically and abroad….”
 
Nature (UK) reports, “Governments and private funders have poured millions of dollars into building [pandemic preparedness plans]. Researchers have painstakingly tested and evaluated these plans to identify and fill gaps. Still, COVID-19 has demonstrated that the world was even less prepared than most had imagined. And what makes some scientists nervous is that current discussions on how to defend against the next pandemic are stuck on the same strategies as before.
 

COVID Origins

 
Bloomberg (US) reports, “The origin story of COVID-19 remains a mystery mired in contentious geopolitical debate. But a research paper that languished in publishing limbo for a year and a half contains meticulously collected data and photographic evidence supporting scientists’ initial hypothesis—that the outbreak stemmed from infected wild animals—which prevailed until speculation that SARS-CoV-2 escaped from a nearby lab gained traction.”
 

Helping People Choose Vaccination

 
Physician Cedric “Jamie” Rutland writes in Public Health Newswire (US), “Public health advocates can…find ways to empower others so that they can talk to hesitant friends, families and colleagues in their own safe spaces. Communications should be clear, in layman’s terms and include relatable examples of other trusted vaccines, such as those for polio and measles…. By tailoring our approaches to be specific to the audiences we wish to reach, meeting populations where they are, and using the latest technology and tools to help contextualize the importance of vaccinations and other treatments as they emerge, we can help encourage those that remain hesitant to feel empowered to make the right choice.”
 

Applying the Epidemiologic Model to Counter Misinformation

 
In a NEJM Perspective the authors argue, “We believe the intertwining spreads of the virus and of misinformation and disinformation require an approach to counteracting deceptions and misconceptions that parallels epidemiologic models by focusing on three elements: real-time surveillance, accurate diagnosis, and rapid response…. Our model will be more effective for people intrigued by misinformation but not yet under its thrall than for committed acolytes sequestered in echo chambers. But the model’s strength, like that of epidemiology, is in recognizing that effective prevention and response requires mutually reinforcing interventions at all levels of society, including enhancing social-media algorithmic transparency, bolstering community-level norms, and establishing incentives for healthier media diets.”