15 June 2021

Coronavirus in Romania: an end in sight?

In the two months since my last update, the situation in Romania has improved significantly. Week after week, cases have declined at a steady pace of 20–30%, down to only 100–200 daily, a level not seen since late May and early June of last year. The number of tests has remained relatively stable, so we can be reasonably certain these case numbers reflect reality. In parallel, the number of patients in ICU is considerably lower as well, confirming this trend: it declined under 900 on May 9th for the first time in six months, and is now already under 300. Authorities have lifted several restrictions on May 15th, starting with the curfew in large cities and mask mandates in open spaces, but masks are still required inside stores, public transportation, and crowded places like bus stations.

As expected, the reported deaths have continued to increase in the first half of April, reaching a record of 237 on April 20th, and then steadily declined at a rate of around 20% each week. On the other hand, the new increases in June, topping 200 daily deaths again on 8th and 9th, is only a reporting artifact. Looking into the detailed daily accounts reveals that many of these deaths occurred in previous months and are just now being added to the official statistic for COVID-related deaths. As an example, on June 8th the official death count was 277, but 256 took place in prior months, going back to June 2020, so the actual death toll for the day was 21. This follows the discovery of inconsistencies between deaths reported by individual hospitals and central government, so I guess this is the solution chosen by authorities to update the number of deceased because of the pandemic. It is a rather odd way of correcting statistics, as it skews both the old reports and the current ones for June and makes it difficult to correlate current mortality with the case numbers.

It is hard to attribute these positive developments to the vaccination program, which is not in particularly good shape. After climbing to a record of almost 120k administered doses on May 15th, the numbers have been in steady decline since, lately dipping under 50k daily doses. More worrying still, the number of daily first doses are down to under 10k for Pfizer and just a couple hundred doses for Moderna and AstraZeneca. On some days, more Johnson & Johnson doses are administered than Pfizer first doses – but at least the people receiving the Johnson & Johnson vaccine can be considered fully vaccinated. It is almost certainly not a problem of capability, but of willingness, as many have feared and anticipated: a general reluctancy against vaccines, fueled by poor education and disinformation through news and social media, and a higher proportion of rural population, which is harder to reach. With infection numbers in steep decline, I am sure many consider the emergency over and found another convenient excuse to shun vaccinations.

In more positive news, the vaccination rates are highest in larger cities, surpassing 40% in the capital Bucharest. We have already started vaccinating the under 18 age group, following the extension of the Pfizer vaccine authorization. There were some early concerns that people were skipping second doses, especially in case of AstraZeneca, because of the reports of rare blood clotting side-effects. The numbers however show a high rate of people are respecting the vaccination schedule: for Pfizer and Moderna, 98.7% of people received their second dose within the official schedule, and 96.1% for AstraZeneca. As a side note, according to some reports, Romania is preparing to discontinue the use of AstraZeneca, following their delivery issues, and donate our existing supply, except for the quantity needed to provide second doses.

I can see an optimist scenario for the near future: despite low overall vaccination rates, people living in cities, including teenagers, will build up immunity through vaccines and prior infections. Since they are more likely to be exposed to the virus because of higher population density and mobility, vaccinating urban population could break the chains of transmission enough that upcoming outbreaks will remain small, contained with lighter measures such as continued mask use. Rural population after all do not usually flock to massive concerts or spend every other evening dining indoors with dozens of strangers.

Of course, a pessimist scenario continues to be possible, in which a large wave will hit again in the autumn – if not sooner – possibly from a mutated strain, newly introduced by people who refused vaccination and traveled abroad for vacations. It could easily spread through young children returning to school, infecting their close families and old relatives. In fact, given how at every turning point until now we have underestimated the pandemic, I would say the pessimistic outcome is more likely.

Daily new confirmed COVID-19 cases mid-June (world)
Daily new confirmed COVID-19 cases mid-June (world)

We can see a similar scenario unfolding in many countries who managed to keep infections low since the start of the pandemic but are recently experiencing local outbreaks caused by the Indian mutation: Taiwan, Vietnam, Singapore, Japan, even China. Others, such as Chile, Mongolia, Uruguay, and the Seychelles, are struggling with new waves despite high vaccination rates, because of a combination of vaccine euphoria and the lower effectiveness of Chinese vaccines.

The UK, notably poor at managing the spread since the beginning, has also postponed relaxation measures while the new Indian variant is spreading uncontrollably, causing a new rise in cases. Studies have shown that vaccines are less effective against this Indian mutation: one vaccine dose offers little protection, while the full regimen is only 60% effective in case of AstraZeneca and 88% in case of Pfizer. UK’s reliance on AstraZeneca and their decision to delay the second dose for up to three months has come back to haunt them, as expected. Although Boris Johnson’s poor leadership is continuing to contribute, in this case because he delayed tightening travel restrictions to and from India.

Speaking of India, the country where this most recent variant of concern emerged, it has struggled with a massive wave of infections and deaths. This is another case of poor management, as the ruling party has bombastically declared the pandemic over in February, encouraged massive political rallies and allowed festivals with large numbers of participants. Their vaccination program was also poorly organized: despite having local production, the central government failed to order and purchase doses for its citizens, leaving this task up to regional governments, who started bidding against each other, driving prices up. And in midst of all this, the Modi government was apparently more concerned with censoring criticism on social media than taking concrete measures. I can easily imagine the situation would be similar in the European Union if the Commission had not negotiated joint EU-wide contracts – or in the US if Donald Trump would have won a second term.

I found the media – and Twitter – coverage of India’s COVID spike puzzling to put it mildly – disingenuous would be more accurate. They reported fervently on the (absolute) number of cases and deaths, and how these are likely to be severely undercounted. But relative to the country’s population these numbers are simply nowhere near many other countries around the globe, including the US and UK – as a reference, the US has recently passed 600.000 deaths caused by COVID, or 1810 per million people (according to some estimates, the death toll has actually exceeded 900.000), while India reported around 380.000 deaths, equivalent to 270 per million. Moreover, whenever it reported on the US and UK peaks in cases, the media was quick to stress per population numbers, and how other countries were doing worse. Brazil (almost 2300 confirmed deaths per million!) and much of South America is in a far deeper and more prolonged crisis because of this virus, and few journalists continue reporting on it. I suspect English-speaking bias is tainting and distorting reporting: most American journalists are only English speakers, so news in other languages barely register with them, and they probably feel an unconscious need to minimize problems in their own countries, even though this perpetuates issues because the public fails to grasp their severity.

Inside India’s Catastrophic Second Wave

I also failed to understand the hysteria around sending vaccines to India: first of all India is itself a large vaccine manufacturer – and exporter until this crisis; vaccines do not work instantly to protect people from disease; and given the country’s population the rest of the world does not have nowhere near the supply needed to vaccinate India, even if by some absurd miracle we could deliver doses there immediately.

After the fury of commentary and opinions around rare side effects of AstraZeneca vaccines in March, a similar story developed around the Johnson & Johnson vaccine in April, with the same intense arguments for and against stopping vaccinations pending a thorough review. Both vaccines use a similar technique, an adenovirus vector, so there is reason to believe these blood clotting events have a common cause – and that the Russian Sputnik V vaccine could cause similar issues. According to some reports, a German researcher proposed a way to prevent this condition, but this would have to be incorporated into the manufacturing process as far as I understand. Recently there have been reports of possible Pfizer side effects in young people, rare heart inflammations predominately in men.

The online conversation has largely shifted towards calling for more vaccines for the developing world, casually ignoring the massive manufacturing and logistic challenges. I find this narrative a bit hypocritical as well: we spent the past year hearing how African and South Asian nations were doing fine on their own, managing the spread better with more basic tools than the West, but now that the West has vaccines in palace, everyone else is loudly demanding a share. I am all for helping the rest of the world, but priorities feel very misplaced: why are Japan and the US rushing vaccines to Taiwan, with its meager hundreds of cases, instead of Brazil and the rest of Latin America? The Biden administration is busy promising new deliveries every other week, with the most recent pledge of 500 million doses coming at the G7 summit – back in the real world, the US has shipped very few doses, and the pledged 500 million are to be supplied over the course of an entire year, 200 million in 2021 and the rest in 2022. Meanwhile, millions of doses of Johnson & Johnson are sitting unused in various US states, nearing their expiration date, and 60 million doses were scrapped because of possible contamination in an Emergent BioSolutions facility (because of this, the Johnson & Johnson doses distributed in the US were manufactured in the Netherlands). Compare this to the EU and China, which to date have exported around 300 million doses each…

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