Is the South African COVID variant immune to vaccines?
Dr Khan investigates concerns that the variant of the coronavirus which was first detected in South Africa might be able to evade one or all of the current vaccines, and explains the approach he takes to his fasting diabetic patients during the holy month of Ramadan.
The COVID-19 vaccine created by Pfizer and BioNTech has been a feat of medical science.
The first mRNA vaccine of its kind to receive approval from regulatory bodies, it has been one of the shining lights in what has been an otherwise dark year. This vaccine is being used in countries throughout the world and has been shown to be effective at reducing illness and death from the coronavirus. Studies have shown it to be up to 95 percent effective in preventing serious illness in those who contract the virus.
However, there is now a question about its ability to protect people from the new variant of this coronavirus that was first detected in South Africa.
The South African variant of the coronavirus contains a number of mutations, but the one that is worrying scientists the most is the E484K mutation.
This mutation affects the spike protein that lies on the outer surface of the virus. The spike protein is instrumental in allowing the virus to bind to and gain entry to human host cells, thereby infecting them.
The immune response triggered by the Pfizer vaccine is trained to recognise this spike protein as “foreign” and help it destroy the virus and any cells infected by it.
However, E484K is called an “escape mutation” because it changes parts of the spike protein so much that the immune system can longer recognise it as easily. There is also a concern that the E484K mutation may affect the longevity of the immune response and the strength of the neutralising antibodies, meaning the virus could reinfect those who have had previous infections with the original variant of the coronavirus.
Until recently, scientists have relied on laboratory studies to tell them how effective the vaccines may be against any of the variants. But with large-scale vaccination programmes being rolled out across the world, it is now possible to obtain reliable information from this “real world” data.
As a world leader in the vaccination roll-out and by using mainly the Pfizer vaccine, Israel has been able to follow up those vaccinated to ascertain how effective the vaccine is against variants. The results have been published in a pre-print, non-peer-reviewed study.
The study compared adults who had received either one or two doses of the Pfizer vaccine to a control group who remained unvaccinated. The study showed the Pfizer vaccine was effective against the original strain of the virus in the vaccinated group, but that the prevalence of the South African variant in the vaccinated group was eight times higher than the unvaccinated group. This would suggest that the vaccinated group were able to mount a good immune response to the original variant but not the South African variant. It would also suggest the South African variant is not the dominant variant otherwise we would have expected to have seen it far more frequently in the unvaccinated group.
What all this seems to show is that it is likely that the South African variant is able to evade some of the immune response triggered by the vaccine.
The authors of the study voiced caution about the conclusions, as the sample population size was relatively small, and said that the South African variant was found in low numbers overall, meaning it was not widespread.
Despite this caution, the study emphasises the importance of tracking new variants through regular genome sequencing in people being tested for COVID-19 and isolating those who test positive.
The way to reduce the number of new variants cropping up that may find ways to evade our vaccine response is to reduce the spread of the virus and therefore its ability to replicate. Vaccines are one way to do this, but until there are enough to inoculate the world’s entire population, we will have to rely on social-distancing measures.
Many scientists now agree that the current batch of vaccines will have to be “tweaked” to make them more effective against emerging variants and that booster shots are likely to be required in the future.
Progress Report: How effective is the Chinese Sinovac COVID-19 Vaccine?
With limited data made public by the Chinese authorities, it has been difficult for the international community to formally assess the efficacy of the Chinese-manufactured Sinovac vaccine, CoronaVac. The vaccine has been fully authorised for use in China and millions of doses have been shipped to other Asian countries as well as large parts of South America and Africa.
CoronaVac works in a different way to the vaccines that are being used across most of Europe and North America.
While the Pfizer and Moderna vaccines use mRNA technology and the Oxford-AstraZeneca and Johnson & Johnson vaccines use viral vectors, the CoronaVac uses the more traditional method of injecting inactivated particles of virus. These inactivated – or killed – particles of the coronavirus cannot cause the person being vaccinated to become ill, but do trigger an immune response to the virus.
The question is, how effective is this immune response at preventing serious illness from COVID-19?
The complete phase-three studies of CoronaVac from Brazil, Indonesia and Turkey have yielded results that seem to be at odds with each other. Turkey reported an efficacy of 83.5 percent. However, Brazil, which is suffering huge loss of human life due to the coronavirus, has reported an efficacy as low as 50.7 percent, though better results were achieved when the two doses were spaced out further apart than the original two weeks (62.3 percent). By comparison, the Pfizer vaccine boasts an efficacy of 95 percent.
With efficacy rates being so variable, experts have expressed concerns over the use of the Chinese CoronaVac vaccine. On April 11, at a Chengdu conference on COVID-19 vaccines, George Gao, the head of the Chinese Center for Disease Control and Prevention, said: “We will solve the problem that current vaccines don’t have very high protection rates. It’s now under consideration whether we should use different vaccines from different technical lines for immunisation.” He also suggested changing dosing intervals as well as the possibility of using vaccines from other manufacturers. “Everyone should consider the benefits mRNA vaccine technology can bring for humanity,” said Gao. “We must follow it carefully and not ignore it just because we already have several types of vaccines already.”
Whether this was a way to put pressure on the Chinese government to consider the use of non-Chinese vaccines or think about developing the country’s own mRNA vaccine is unknown. Gao later said that his comments had been misinterpreted and he was talking about all COVID-19 vaccines, not just Chinese-made ones.
Whatever the outcome of his comments, it remains imperative that we use vaccines with the most efficacy. Populations around the world are relying on the vaccines to help end national lockdowns, open up economies and allow a return to some semblance of normal life.
If the vaccines that are being rolled out on such a huge scale prove to be less effective than what is needed to allow that to happen, we may face another surge in cases, hospitalisations and even deaths.
In the Doctor’s Surgery: Managing patients’ health during Ramadan
The holy month of Ramadan is upon us. A month of fasting, prayers and reflection and one you may not associate with tricky medical conversations. Although I am a family doctor, I have a special interest in diabetes. I run designated diabetic clinics and, in the area of northern England that I work in, I see a diverse population, many of whom are fasting for Ramadan.
The Islamic faith allows those whose health may be adversely affected to be exempt from fasting. These people are able to make up the blessings gained from fasting in other ways. But to many of my patients, religious beliefs often come before their health.
When I first started my specialist diabetic clinics, I would try with very little success to convince my patients that fasting could increase their risk of developing life-threatening hypoglycaemia (low blood sugars) and that our local Islamic scholars had provided us with written material saying they could abstain from fasting should they need to do so. Some people took the advice and chose not to fast, but there were some for whom the month of Ramadan was too holy and an opportunity for blessings that simply could not be missed.
“I have faith in God,” one gentleman said to me. “He will stop me from getting sick.”
That was difficult to argue with; his belief was strong and not much I could say would change that.
I tried, nonetheless. “But God has said that you don’t have to fast,” I said.
“We look forward to Ramadan each year, and I always fast. Nothing has happened to me so far, and I believe that is because of my prayers,” he answered gently, giving me a look that I knew meant there was no point in pushing the matter further.
After trying my best to convince others that they, too, ought to prioritise their health, I realised I was having no success and that both I and, worse, my patients would leave the consultation unhappy and feeling misunderstood. Eventually, it dawned on me that this was their diabetes and these were their religious beliefs and it was up to me to meet them on their terms.
I discussed the subject with Mama Khan (my mum). She is a devout Muslim and, like my patients, looks forward to Ramadan each year. She, too, is diabetic (although her diabetes is well controlled with oral medication) and insists on fasting.
“Dawa and dua,” she said to me, which translates as “prayer and medicine”. “The two are not mutually exclusive, they work very well together.”
It makes sense. The consultation between a doctor and patient is not a wrestling match, but more of a finely tuned dance where each takes it in turn to lead. During Ramadan, I had to let the patient lead.
I could very easily take a doctor-centred approach and tell them what they should and shouldn’t be doing but, as I have discovered, this rarely works. Besides, Ramadan is only four weeks out of an entire year and, if these patients feel listened to, understood and, most importantly, valued, they are much more likely to comply with the medication and lifestyle advice I give them during the rest of the year.
So now when a patient tells me it is important to them to fast, I tell them I understand that and work with them to adjust their medication in order to minimise their risks of hypoglycaemia and now both the patient and I end the consultation much happier.
And now, some good news: Mix-and-match vaccines may be on the way
With concerns over the efficacy and side effects of some of the COVID-19 vaccines, as well as supply and manufacturing issues, it will come as good news to many that a United Kingdom study into whether COVID-19 vaccines can be mixed with different types of jabs used for first and second doses is being expanded.
The Com-Cov study – as it is named – is being carried out by the University of Oxford and is inviting any adult over the age of 50 who has already had the first dose of either the Pfizer or AstraZeneca vaccine to be included in the trial. Under the trial, they will receive their second dose, which could be the same vaccine again or a shot of Moderna or Novavax instead. The study was set up earlier this year with just over 800 participants, but has now been extended to include 1,050 volunteers.
The volunteers will have regular blood tests to see how well their particular vaccine combination is triggering an immune response. They will also be monitored for any potential side effects, though most scientists agree that mixing vaccine doses is likely to be safe and effective. Results from the first part of the trial could be made available as early as next month.
Reader’s question: Can I have the COVID-19 vaccine if I am fasting?
This question comes up all the time whenever a vaccine drive coincides with the holy month of Ramadan, but this year is exceptional in that it coincides with one of the biggest vaccination programmes the world has ever seen.
Most Islamic scholars agree that having the vaccine does not constitute breaking your fast as it has no nutritional content, animal or foetal products. The holy Quran is often cited as saying: “To save one life is to save the whole of humanity.”
Taking up the COVID-19 vaccine could save your life, so it is important to have it if you are called, even if you are fasting. There are some that are concerned about side effects for those who are fasting, but these are mild if they occur at all and Muslims are allowed to break the fast to take medication if they are feeling unwell, including as a result of having a vaccine.
Essentially, it will come down to individual choice and belief. But, if large swathes of the population choose to delay their vaccines during the month of Ramadan, then this could see numbers of people infected with coronavirus increasing.
The advice of this Muslim doctor is to take the vaccine if you are offered it, whether you are fasting or not.