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Monday, Mar 29, 2021 - 18:14 SGT
Posted By: Gilbert


Let's see how many places this gets recognized...

That's both doses received, which may make a good opportunity to return some coverage to the coronavirus situation. The first jab wasn't remarkable, while the second resulted in some soreness to the relevant arm together with a light fever, which was not uncommon amongst my colleagues.

Excess Mortality, Explained?

(Source: medrxiv.org, "The World Mortality Dataset: Tracking excess mortality across countries during the COVID-19 pandemic", Karlinsky & Kobak, 2021)

Before beginning, a quick follow-up on February's concerns over local excess mortality figures - it seems that the method of computing (or correcting for) excess mortality might indeed have resulted in the WSJ infographic's implications, given that it utilized the average from the preceding five years, whereas a gradually-increasing base might indeed have been more appropriate for Singapore. While the slowing in growth of the local resident population might also be considered (+18k last year despite the pandemic, compared to about +30k in each of the preceding few years, which may also depend on cut-off dates), this estimate seems probably a closer approximation of the actual situation than an average, and corroborated by the nice round just-reported provisional death figure of 22,000.

Pfizer/Moderna vs. Sinovac: Struggles & Signals

It might have been observed by careful readers that the vaccination card had Pfizer, Moderna and Sinovac listed as default options, which had some scratching their heads given that Sinovac had not yet been approved for use here, with more data being requested for review by the HSA, and Phase 3 trial data apparently unavailable, unlike say with Pfizer and Moderna (both approved). Moreover, a Reuters editorial had pointedly noted late last month that "Singapore is the only wealthy country considering the use of Sinovac's vaccine", with some musing as to why the stock had been accepted before approval; to this, the Minister for Health had an easy answer - we have already paid for it, so we take delivery lor.

It is perhaps unavoidable that countries' choice of cure will be scrutinized as a clue to their leanings as the world draws up battle lines for the oncoming Cold War II, however, and for all of our Prime Minister's (logical) insistence that vaccines have no nationality and that Singapore would use vaccines from any source so long as they work, it could be telling that Russia's Sputnik V for one doesn't seem to have been considered, despite The Lancet backing its trial results of over 90% efficacy - though to be fair, the Ruskies themselves don't seem too keen. Oh, the MOH and our Foreign Minister have insisted that "Singapore cannot be bought, bullied or intimidated into approving any vaccine", to which r/singapore and EDMW were basically united in giving out virtual pats on the back to said minister to the effect of "yeah it's okay, we understand, man", while remarking that this was exactly what someone being coerced would say (blink twice if there's anything wrong!)

While some things cannot be openly stated, inferences might be drawn from all that's going on: Sinovac has already been supplied to all ten ASEAN states (and many mostly-developing countries besides), with Vietnam apparently the only ones daring to state reluctance outright, and the various nations' response to this vaccine diplomacy outreach will doubtless be carefully watched. Hungary, for one, is looking to Russia and China after the failing European Union's monumental miscalculations (to be covered in the next section), with some Latin American countries such as Peru desperate enough that politicians getting jabbed was viewed as jumping the queue.

Discuss similarities between patterns in the above map, and the First, Second and Third World blocs in Cold War I
(Source: forums.hardwarezone.com.sg)

Let's not kid ourselves here - while vaccines may well not have nationalities, the choice of which vaccines to use certainly has consequences; the U.S., for example, has openly admitted to pressuring Brazil to reject the Russian offering, China is refusing to approve Pfizer & Moderna, Pakistan and the Philippines amongst others are making a point of ordering from China, Taiwan is basically sponsoring vaccines from anywhere but China, and a Hong Kong clinic has reportedly been punished for pushing Pfizer ahead of their own. The latest development is the American-led Quad promising a billion jabs for Southeast Asia alone to overtly counter China, and while this largesse is breathtaking, more seasoned analysts are reading the obvious rationalization - that this is in anticipation of Southeast Asia being the main front of the New Cold War.

On this, Singapore has not unexpectedly been attempting to keep as low a profile as possible, with the arrival of the Sinovac vaccine getting a muted reception compared to Pfizer/Moderna, suggesting that the early delivery might well have been slightly one-sided, all the more since it doesn't seem all that widely used at home, to begin with. Sinovac's low claimed efficacy has only complicated matters, since this is an entirely valid factor for individuals picking their vaccine, and while Sinovac does appear to have some support, this seems in the minority amongst locals, with some considering to forego vaccination altogether if it came down to Sinovac or bust.

The problem of how to deal with the Sinovac issue had been raised in January, recall, and the authorities might just have squared the circle here, with their solution of mandating a single vaccine brand to be used at each vaccination centre; this seems to imply that one can indirectly control the vaccine they will be administered, by visiting the appropriate location. Well, we will see if this is enough to satisfy the powers that be, and if not, there's always out-of-favour party members and the younger low-risk group to offer up; watch for impressionable freshie national servicemen to be "highly encouraged" to volunteer...

Additionally, there are possibly more immediate and concrete implications as to personal vaccine choice: while vaccine passports have been touted (to be implemented on blockchain, so sez our Foreign Minister), beginning with closest neighbours Malaysia for us, it remains to be seen how recognized individual vaccines will be; the European Union's vaccine passports have been proposed to only admit EMA-approved jabs - not Sinovac, at last check - with China easing restrictions for only those taking their own products. Creating travel bubbles is hard enough as it is, given how New Zealand were warning that Australia opening one with Singapore could hinder Australia's own plans with New Zealand, but at least discussions on mutual recognition appear ongoing in this particular case.

AstraZeneca: Safety or Shade?

Onwards to Europe, their vaccination response has been underwhelming when put against say the U.S., with much of America's success in churning out vaccines far faster than what the mainstream news insisted was possible, attributed to the previous administration's initiative and support for Operation Warp Speed, together with a united front on endorsements by Presidents past and present.

Of course, a large part of America's (and to an extent, Britain's) success in this regard has been due to their export bans on vaccines. Selfish, perhaps, but in America's case, it is possibly notable that the supposed-saintly and multilateral new admin has done nothing to reverse this ban - amongst many quiet continuations of their predecessor's (actually well-conceived) policies - which only serves to remind the importance of securing one's own supply chains and manufacturing sector is, in the new geopolitical reality. We have witnessed the unsightly scramble for masks, ventilators and other supplies in the early stages of the pandemic, and from how some European countries are themselves now blocking exports - at least before discovering 29 million doses under the sofa - it might be fairly construed that for all the honeyed words, when the chips are down, it's every country for themselves.

Another view is that Europe are at the back of the queue because they tried to push their luck too far on negotiations with the Big Pharma producers, and simply wound up outbid on priority by the U.S., U.K. and certain other wealthy nations (ahem, ahem). Now, there may be a lingering impression that the lack of indemnity for side-effects is due to Big Pharma kindly supplying vaccines at cost, but the ugly fact is that this is the exception rather than the rule; Pfizer's groundbreaking vaccine, for instance, is on track to become one of the most lucrative drugs ever, buffing an expected revenue of US$100 billion combined from 2020 and 2021, and they're definitely counting the pennies - developed nations will pay at least what America's paying, to begin with, and poorer ones are being made to pony up sovereign assets as guarantee against future legal suits.

Europe in a shambles
(Source: theguardian.com)

But back to what's happened with the AstraZeneca (AZ) vaccine in Europe. It all began a couple of weeks back, with Denmark and Norway pausing its use after isolated cases of blood clots, swiftly followed by other European nations over the next days, for a total of at least 24 countries by March 16, extending as far abroad as Thailand. The climbdown then began, with the EMA insisting that there was no indication that the AZ vaccine had caused the clotting, only to be contradicted by a Norwegian chief physician confirming otherwise in their national paper. Nonetheless, use of the AZ vaccine would soon be resumed in Germany and elsewhere despite some of their own researchers claiming a link, possibly due to getting swamped by a second wave - though their populace was already wary to begin with.

The AZ vaccine has certainly endured an inordinate amount of criticism, much of it somehow from the U.K.'s erstwhile closest ally, with the American NIH and NIAID's very-public questioning running the gamut from cherry-picking to providing incomplete data (also a concern of a number of European doctors and scientists, mind). More than a few underlying reasons have been suspected, including "post-Brexit animosity" and supply failures from the continentals, but there have also unavoidably been whispers about more prosaic motivations: it's not as if other vaccines don't have their own concerns and reported adverse events, after all, and AZ is the only major Western vaccine being sold at cost, for now at least. Surely, a hundred billion bucks might have influenced a lot of the skewed press going around?

Mutations and the Long Game

From what's known thus far, even were the rare clotting indeed caused by the AZ vaccine, the benefits of using it likely still outweigh the costs; as a Science Translational Medicine commentary closes with, "You would want to see a higher number in a better world, but 60% is a damn sight better than not getting vaccinated at all" (there's more to be said about this [reasonable] line of thought, possibly in the next blog post)

For completeness, the main argument against vaccination - or at least, compulsory vaccination for lower-risk groups (i.e. healthy persons below about fifty, perhaps supported by the local experience with foreign workers) - is that the odds of mortality are very significantly lower for youngsters, with over-60s literally a thousand times more likely to perish than teenagers... which is maybe not a bad thing, for the kids at least? To this, the usual counter has been that getting hospitalized remains no joke, what with the potential lingering long-term effects of getting the virus (i.e. "long covid"). Sounds plausible enough, even if studies on long covid are obviously somewhat preliminary for now, and it might perhaps be confirmed whether it's expressing the symptoms that causes the long-term damage, or simply catching the virus - because if the latter, it's not very clear if the vaccines actually mitigate it.

It's turning out to be a running battle anyhow, with multiple supposedly more-contagious substrains already verified and spreading, with certain vaccines unfortunately turning out to have reduced efficacy against them - as possibly reflected by the sudden rise in cases in Chile:

You going to say "no", comrade?
(Source: straitstimes.com)

The most direct implication of these variants would be that annual - or even more frequent - vaccinations might become necessary (ka-ching?), which is before getting into a supposedly PCR-undetectable variant from France, and possible immune escape from current prophylactic vaccines not actually stopping virus spread, possibly creating more such super-strains - though it's not clear what the alternative is here, other than simply letting it burn through the population. Someone up there should really take the difficulty level down a notch or two...

Arcturus, the DIY Spirit

Leaving the main players aside, it's not been the best of goings for Singapore's joint venture with a U.S. biopharm firm (who appear to be getting a great deal from the EDB, in having their loan forgiven in case of failure); latest reports suggest a product by next year at best. Well, one has to start out somewhere in a new business, I suppose, and even giants such as Merck have had to abandon their vaccine development.

From another angle, however, whipping up a potential vaccine candidate's apparently not that complicated - there's RaDVaC, an open-source vaccine design and protocol platform, and a fellow has kindly documented a walkthrough on how to manufacture your own batches: search for some COVID virus peptides (short protein sequences), have them synthesized by a commercial provider, and do your own pipetting and mixing. Cost: about US$2 per dose. Too good to be true? Eh, it's possible in principle, but one suspects that Big Pharma won't be too pleased about this developmental model.

It's rather less trouble to expand the use of existing vaccines, which is what the local authorities are doing in waiting for trial results on kids to come in. That, and relatively simple tweaks like leaving more space in front of face masks (promoted here last May), as the Temasek Foundation has done - which has naturally led to gripes that the masks now resemble underwear for the well-endowed. Small price to pay to be able to breathe freely, in my opinion. Moreover, Temasek have reportedly also dipped into Bitcoin since 2018, along with some other sensible initiatives to be discussed soon, so perhaps they're not as hopeless as the average netizen would have them to be.

Here's to another vessel getting raised
[N.B. At US$400 million an hour, that must be a lot of prayers]

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