Gerry Gajadharsingh writes:
When I see a news clip of a person jumping up and down in euphoria, because they’ve had a COVID 19 vaccine, I can understand their feelings. Paired with the news that the UK government have released their roadmap for ending the lockdown restrictions, hopefully by mid-July, there is certainly a more positive mood in the air.
And yet, perhaps there are several reasons why the government is still urging people to be cautious. Just because you’ve had the first dose of the vaccine, doesn’t necessarily mean you are safe. As I’m sure you are all aware, there are now over 18 million people in the UK who have a first dose of vaccine but very few who have had a second dose. This is because of the government decision to extend the recommended timeframe from 3 to 4 weeks, to 12 weeks after receiving the first dose, the only country in the world to do so.
We have heard a lot over the past weeks about the reluctance of certain countries, notably France and Germany, to offer the AZ vaccine to people over 65. Whilst we might have put this down to a bit of sour grapes given the vast discrepancy in vaccine roll out between the UK and the Euro area, anecdotal evidence is beginning to appear which indicates that a single dose, of not only the AZ vaccine but also the Pfizer vaccine, may not be promoting the antibody response we are being led to believe in >65’s and that meaningful immunity only appears after the second dose. If this is borne out the government’s policy of delaying the second dose for 12 weeks may be questionable and potentially counter-productive.
During the past month we have been able to offer the new Roche Laboratory SARS CoV2 Spike Protein antibody test. The great thing about this latest antibody test is it will pick up people who have had previous COVID-19 infection and produced antibodies, and also people who have had a vaccine and who are producing antibodies. In effect, helping us understand whether the vaccine is working in patients helping them develop immunity (with the proviso that we cannot currently test T cells responses).
As I have previously written that one of the things we lack is a commercial T-cell immune response test. It is thought that a proportion of people who get the virus will not produce antibodies. Perhaps because their innate immune system provokes at least an adequate T cell immune response to deal with the virus which, in a way, is a good thing. This was certainly true last year when at The Health Equation we ran around 200 SARSCoV2 IgG antibody tests before the government, in their wisdom, put it on hold. In May/June 2020, we found around 13% of patients had positive IgG antibodies, however quite a few were adamant that they had had symptoms of COVID-19 but had a negative IgG antibody test, it may be in these patients that either the T-cell response was good enough or perhaps the test was not sensitive enough.
So, what are we finding out with this new spike protein antibody test?
I must thank my close medical colleague Dr Barry Grimaldi FRCP, for sharing some of his anonymized data which I have accumulated with my data. The data set is small at around 100 patients, but we are just starting.
Just for your reference the lab reports negative antibodies at a level <0.8 U/ml and positive antibodies at a level >0.8 U/ml, with the maximum response reported at >2500 U/ml.
We have patients who had symptoms of COVID-19 one year ago, who at that time had negative IgG antibody results, but who now have a positive spike protein antibody result although at a low level. So, it’s likely that this new spike protein antibody test appears to be much more targeted.
We also know that patients who have recently had COVID-19, with obvious symptoms, four weeks later have positive spike protein antibodies at the maximum level that the lab measures >2500 U/ml. One of these patients on repeat of the spike protein antibody test two months after developing symptoms, saw a drop in the level of antibodies from <2500U/ml to 782 U/ml, (but still a very high number of antibodies).
We also know of a patient (>70), who when able to get a second dose of the Pfizer vaccine, saw an increase in their positive spike protein antibodies from an average of 7 U/ml (3 weeks after his 1st dose of the Pfizer vaccine) to >2500 U/ml one week after the 2nd dose of vaccine, so the maximum antibody response clearly only came after the second dose. It seems a bit like the analogy of the first dose priming the immune system and the second dose turbocharging its response. Two other patients also saw a large increase to >2500 U/ml 1 week after their 2nd dose.
Most people are showing a positive spike protein antibody response after around 4 weeks after their 1st dose of vaccine (either vaccine), although the actual level of antibodies that we have seen have been very low, averaging around 9 U/ml in patients >69 yoa. There are, however, some patients in that age category who are not showing any positive antibodies at all at least 3 to 4 weeks after receiving the first dose (of either Pfizer or Oxford)
It’s interesting that the elderly usually don’t seem to suffer many side-effects from having the first dose of the vaccine (either vaccine). The younger age group patients seem to suffer more side-effects – there aren’t many of those around at the moment and the ones that are obviously have underlying health conditions – so perhaps that also influences things or they are health care workers. The healthcare workers that we have seen (23 to 36 yoa), have average antibody levels of 132 U/ml.
It’s interesting looking at the recent papers from Israel and the UK and their suggested 75% efficacy after the 1st dose (Pfizer). This clearly seems to be true for healthcare workers, which is what those research papers are based on, but does not seem to apply to the elderly population generally.
It might well be that if your immune system senses the vaccine and reacts to it, you develop more initial side-effects. As we begin to test more of these younger age patients, it will be interesting to see whether they appear to develop a much higher level of antibodies after the first dose than in the older age group patients (this seems to be true at the moment). As we all get older, we know that the immune system doesn’t work terribly well, and it may well be that the vaccine struggles to stimulate an adequate immune response on the 1st dose.
Albeit, only based on a small sample as yet, we are routinely seeing patients who, one month after receiving their first dose (of either vaccine), are not showing any spike protein antibody response at all.
One of the possible links to some of these patients, based on my initial data, is that their underlying medical conditions suggest that they are immunocompromised, primarily because of the drugs they take for their particular medical conditions. To me, this makes sense as they are taking drugs to dampen down the immune response, usually in relation to a variety of diagnosed autoimmune conditions. Perhaps the first dose of vaccine is simply not strong enough to allow their individual immune systems to build a response.
It is these patients I am worried about, and I need to declare an interest here, as my 80 yoa mother is one of them.
I do wonder whether the UK government is aware of this very vulnerable cohort of patients and their seemingly limited response to the first dose of the vaccine? If they are, it seems that the only obvious solution is to bring forward their second dose of the vaccine urgently as it is their stated aim is to protect the most elderly and vulnerable patients.
I have been slightly surprised when some patients inform me that they’re not interested in knowing their immune response post vaccine.
If I had had Covid, I would want to know if I have positive antibodies and their level. You are not allowed to have a vaccine if you have developed Covid in the previous 28 days, because of the high likelihood of side-effects. Other countries are beginning to recognise that patients who have had Covid have probably at least as good immunity, if not better, than people who are receiving the vaccine. There is some evidence to suggest that giving a vaccine to someone who has high levels of antibodies may not be a clever thing as they may well suffer from more serious side-effects. There are at least 4 million people in the UK who have had COVID 19 confirmed by PCR, many of those will have some immunity. All of the patients I have tested so far have a higher level of antibody response subsequent to COVID-19 infection, both in young patients and elderly, compared to almost all patients four weeks after the first dose of the vaccine.
If I’d had a first dose of the vaccine, I would want to know my antibody response 4 weeks down the line, to gauge my own risk profile and the things I would want to do and not want to do as lockdown gradually begins to lift. I would also want to know my antibody response one or two weeks after receiving the second dose to see how well the whole process has actually worked.
Based on the government’s own figures, published in their recent report COVID 19 Response, Spring 2021, they expect 13% of the population who have received the vaccine to not have an adequate immune response, that is a lot of people. What I can’t quite find out is – are these figures based on simply the first dose of vaccine or an estimation after both doses of vaccine. Let’s hope it’s just an estimate based on the first dose of vaccine.
Maybe the government knows all of this and that’s why the roadmap to release lockdown, seems longer than many people might wish and that might be the right solution. Perhaps another solution is to change the strategy and concentrate on giving the most vulnerable categories 1 to 4, the second dose of the vaccine ASAP.
Mr Gerry Gajadharsingh DO
with contribution from Dr Barry Grimaldi FRCP
26.2.21
The UK government has just published an important report
COVID 19 Response, Spring 2021.
Below are some excerpts from the UK government report.
It gives the background behind some of their decisions regarding the vaccine rollout and the roadmap for releasing the lockdown. It’s an interesting read and I’ve attached the whole document at the end of this article.
The 4 most vulnerable cohorts as identified by the joint committee on vaccination and immunisation (JCVI) are
- Elderly care home residents
- Those aged 70 and over
- Those with conditions that would leave them clinically extremely vulnerable to serious illness and death as a consequence of COVID-19
- Frontline health and social care staff
These first 4 cohorts are responsible for 88% of COVID-19 deaths and their prioritisation for vaccine is justifiable.11% of deaths are in Cohort 5 to 9, ages 50-69 and clinically vulnerable ages 16 to 64 with underlying health conditions.
That means the only 1 % of deaths come from outside of any of these 9 groups of patients.
The total in the priority groups 1 to 9 comprises of 32 million people, the rest of the adult population comprises of 21 million people.
Even when vaccinated, there is still a chance people can contract the virus and pass it on. No vaccine is 100% effective and, like all viruses, COVID-19 can mutate. As a result, as lockdown is lifted, there will sadly be more cases, hospitalisations and deaths.
At the end of 2020, a new and more transmissible variant of COVID-19 (B.1.1.7) The so-called UK Variant began to spread very quickly across the UK.
Since the beginning of January 2021 to 16th February 2021, the figures for England are:
COVID 19 cases have fallen around 80%
Hospitalised patients have fallen around 49%
Deaths have fallen 60%.
Most clinicians I know agree, this was primarily because of lockdown not because of the vaccine.
The UK has ordered enough doses to vaccinate all of the eligible adult population – a total of 457 million doses, comprising eight different vaccines.
3 vaccines have been approved Oxford/AstraZeneca, Pfizer/BioNTech and Moderna although Moderna is not yet onstream.
When these vaccines were developed it was stipulated that patients needed two doses of the vaccine at the recommended 3 to 4 weeks apart.
It is well known that the UK government have, controversially gone down a different route (compared to any other country in the world so far) and targeted many millions of people to just have one dose while delaying the second dose for up to 12 weeks.
There is no doubt that the 18 million also people who have been vaccinated in the UK so far has been a major achievement, but at the cost of delaying the second dose to millions of the most vulnerable people in cohort 1 to 4. The aim of the UK government is for these cohorts to have the second dose by mid-May, this is still three months away.
Vaccine Efficacy
First, the vaccine is preventing people from catching COVID-19. Studies in healthcare workers (the majority will not be elderly or immunocompromised or with major underlying health problems) show that one dose of Pfizer/BioNTech vaccine reduces the risk of catching infection by more than 70%. A second dose reduces the risk by a further 15%, meaning protection of up to 85% after two doses.
Secondly, the vaccine is preventing symptomatic cases of COVID-19 in the older people who were first eligible for vaccination. The data suggests that one dose of Pfizer vaccine reduces symptomatic cases by between 50% and 70% in those aged 70 years and over. This effect occurs about three weeks after the first dose of vaccine, and the second dose improves this protection to between 80% and 90%.
So, the question is who are the 30-50% of elderly people not developing good enough immunity to stop symptoms?
Data for the AstraZeneca vaccine is not yet reliable enough for the government to give sensible conclusions.
The vaccines have transformed our efforts to tackle COVID-19 and will prevent many deaths. However, they will not guarantee protection to everyone.
For these reasons, a significant proportion of the population could still be infected, either because they have not been vaccinated or because the vaccine is not effective for them.
They estimate that 13% of the population even if they have a vaccine will not be protected.
It is not currently known for how long people who receive a COVID-19 vaccine will be protected. This is because, as is the case with many vaccines, the protection they confer may weaken over time. It is also possible that new variants of the virus may emerge against which current vaccines are less effective