Next Pandemic we should have Challenge Trials

Covid-19 is long enough away now that we should look at what happened and decide what we want to to next time there is a pandemic. One thing we could do is challenge trials of vaccines. This would have sped up vaccine deployment hugely and saved time and huge amounts of money.

Reading books like Vaxxers there were several vaccines ready for early testing in the first weeks of 2020. But it still took until December for the vaccine to be approved. This is because if you have tens of thousands of people in your vaccine trial but tiny amounts of the disease out there it takes a long time for enough people in the vaccinated and unvaccinated sides of the trial to get infected to be able to judge that the vaccine works. 

If instead after the initial testing on a small number of people just to make sure no reactions are common a challenge trial took place. Where after vaccination both arms of a larger phase 3 trial are deliberately infected with the virus you gather enough people in the vaccinated and unvaccinated groups to judge the effectiveness in a matter of weeks not months. 

These sorts of challenge trials are much more common now but it is the sort of thing that agreeing about now will make it much easier and more trustworthy when the challenge trial based vaccine experiments happen. 

Back of the envelope with these sorts of trials a vaccine could have been tested by the time lockdowns started to happen. Even if this was just for medical professionals initially. and rolled out to older people shortly afterward this could have avoided a huge number of issues

Opening Up with Adults Unvaccinated.

 I argued here Vaccinate the old fast that the old had such higher Covid fatality rates that it was worth trying to vaccinate as many of them as fast as possible as possible.

But what happens to adults 18-50 if they are unvaccinated. The risk of being hospitalised is about 3% across this age group. 

There are about 1.5 million Irish people in this age group. 3% of this is about 50,000 people who would be hospitalised if we all got it. Though herd immunity might drop this a bit.

The Irish Hospital system went pear shaped in January at '1,846 people with Covid-19 in hospital' which means 50k even if spread out a bit would be really bad for fatality rate of hospitalised cases. Even just for non covid cases if the hospitals are overrun you won't get the other treatment you might need. And we shouldn't traumatise medical workers with the awful conditions that many sick people at once would cause.

All this means I don't think we can have really high rates of covid even in healthy 18-50 years olds without causing so much lack of care that death rates would rise sharply. And we have to make sure we keep the rates low until vaccination rates are much higher in this age group.

Needle Phobia and Covid Vaccinations

Between 10-20% of adults are really scared of needles. Anti Vax people are really hard to persuade. But anti needle people might be easier. And a fair number of people claiming to be vaccine skeptics might just be shy to admit a fear of needles is a big factor.

"Avoidance of influenza vaccination because of needle fear occurred in 16% of adult patients"  Soon we will have enough vaccines for all adults but if 10-20% of them do not get vaccinated due to Trypanophobia thats a lot of unnecessary deaths and it makes reaching community immunity levels impossible.

Trypanophobia is classed as a phobia with a known process of medical treatment. The steps to get over it seem to be three types
1. Cognitive behavioural therapy, hypnotherapy and other psychological techniques 

2. Nice relaxing location. comfy seats etc for where the injections happen.

3. Topical cream to reduce pain on the injection site.

These are described here, here and here.

Tech people think there should be an app for everything. But in this case it might work. A Cognitive Behavioural Therapy (CBT) app that gradually helped people get over their fear of needles might really help increase uptake of the vaccine. There are loads of CBT apps out there. If you know a good one that deals with needle phobia please comment.

There will be vaccinations for covid that do not need needles in the medium term. But for the moment getting people over their fear is needed. 

The needle phobia apps I can find I can find are aimed at kids to explain to injections to them. Rather than steps to get adults over a fear of needles.

The vaccinations created and tested in under a year are amazing. And we are going to get a lot more of them soon. Helping people get over the common fear of needles is an important step if we want to get as many people vaccinated as possible.

Vaccinate the old fast

The CDC give Infection Fatality Ratios for people of different ages as

0-19 years: 0.00003
20-49 years: 0.0002
50-69 years: 0.005
70+ years: 0.054

This mens 5.4% of all over 70s who are infected with Covid they believe will die.

The number of people in these age groups in Ireland is

425k over 70s

55-69 year olds =720k 

18-54 is 1,350,000

0-18 about 1,200,000 people

The ages do not quite line up but they are close enough.

If all over 70s in Ireland got infected with covid 23,000 would die. Assuming the infections were spaced out enough that the medical system stayed working.

All 55-69 about 3,600 would die

All adults 1350000 * 0.0002= 270 deaths 

Children=36

This ignores long term issues that Covid could cause. But hospitalisation numbers track Deaths pretty clearly. And long term issues seem to track hospitalisations.

The numbers are pretty stark though and indicate to me we should rapidly vaccinate older (and vulnerable) people as quickly as practical.

What jobs have most risk of Covid?

This data is Norway but I will assume the US and other countries would be similar. The full paper is Occupational risk of COVID-19 

"The difference between the first and second wave may be due to changes in the test criteria. In the first wave, there was a shortage of test equipment, and patients, risk groups and healthcare personnel were prioritised for testing. In the second wave, close contacts and people with mild symptoms could also be tested. " so I'll use the figures from the second wave for the risk.

How many people have these jobs? The US bureau of Labour Statistics has good numbers on occupations here 

I took all these jobs and got the numbers of US workers with them and their chance of getting ill. It works out that about 10% of workers account for 30% of cases (in workers). That is still about 16 million people. But it does give a possible next group for vaccines after medical workers. I put the combined risk and numbers employed data into a spreadsheet here 

 

Short Supply of Flu Vaccines

 

On February 21, 2020 i blogged here about how 'Ireland should make the Flu Vaccine Free for All'. I thought this because the risk of Covid was high enough to make it really worthwhile this year.  It seems that there is now not enough flu vaccine to meet demand in Ireland this year. 

I wrote to various politicians. Including current Health Minister Stephen Donnelly.

	22 Feb 2020, 17:58
to Stephen.Donnelly

Dear Mr Donnelly 

Congratulations on your reelection as a TD. 

I would like you to consider it be Fianna Fáil policy for the government to offer free flu vaccines to everyone in Ireland this autumn. 

Firstly, Research from Canada says offering such free flu vaccination is cost effective[1]. Secondly, Ireland has particular issues with hospital overcrowding during flu season which makes reducing these cases very valuable to us. Thirdly, possible covid19 spread means any spare capacity we can get in our health system is particularly valuable this year[2].

Orders for doses of flu vaccines have to be made relatively soon. I understand the process of forming a government at the moment makes making such an increased ordering decision for use this Autumn more difficult.

Thank you for your attention.

   Best regards,

[1] Systematic review of the cost-effectiveness of influenza immunization programs by Eon Edward Kwokho Ting https://tspace.library.utoronto.ca/bitstream/1807/70706/1/Ting_Eon_201511_MSc_thesis.pdf

[2] http://liveatthewitchtrials.blogspot.com/2020/02/ireland-should-make-flu-vaccine-free.html

And his office replied

Dear David,

 

We thank you for your correspondence, and considerate thinking.

I have raised your concerns and proposals with Stephen Donnelly.

 

Kind regards,

 

 Office of Stephen Donnelly T.D.

There could be many reasons that there is not enough flu vaccine this year. But I think this exchange shows that 'No one thought or suggested before March that we would need more flu vaccines' is not a reason.

Temperature Measuring Bracelet

If it is a good idea to check peoples temperatures a lot there are probably three distances you want to check them at

1. Personal level

2. Places lots of people go through like employee bathrooms

3. Public places like airports.

Each of these has different requirements.

For Personal thermometers the idea is you have a temperature sensor showing you do not currently have a fever. And if you do that is rapidly detected to reduce the number of people you infect. 

Personal thermometers they need to be really cheap. Not need much power. And be socially fashionable to show off.

Liquid crystal thermometer fits most of these requirements. These were suggested by Tara Whelan

Can they be made durable enough and fashionable enough to get people to wear them?

Earlier posts: Why temperature checking would help . 

Edit: the physiology of the arm means these won't work as bracelets.

Automatic Temperature Scanning

I blogged last night about how automatic temperature reading of people several times a day might reduce the number of infectious people out in public

Temperature Scanners Everywhere  Is that post if you want to see the reasoning. 

How about we put a remote thermometer and displays on bathroom mirrors?

What would happen if you 

1. Attached Infrared thermometers (slightly reassembled) to the mirror

2. Put a switch on it that turned it on when someone stood in front of the mirror

3. Output the reading to a display on the mirror

There are several instructable here on how to make the handheld type of forehead thermometer at a distance https://www.instructables.com/id/Arduino-Laser-Infrared-Thermometer/ this is much the same mechanism but in a different container.

All these parts combined and mass produced would probably cost around 10 Euro. Private and Employee bathrooms might be best for privacy reasons. There is no network connection or face recognition involved here just a very simple temperature reading.

Temperature Scanners Everywhere

'Why did Singapore’s containment strategy work, in such a high-density location?  Their program is mostly symptom/temperature checking-based'

It does seem like having symptoms really ups how infectious you are
"while we are learning that there are people who can shed COVID-19 virus 24-48 hours prior to symptom onset, at present, this does not appear to be a major driver of transmission. " WHO

'Some spread might be possible before people show symptoms; there have been reports of this occurring with this new coronavirus, but this is not thought to be the main way the virus spreads. ' CDC

Singapore is doing twice a day checks for some people
'All employers should require their employees to check their temperature at least twice daily, check for respiratory symptoms, and for those unwell to visit a doctor immediately.' During SARS they did something similar 'Singapore became the so-called country of thermometers: temperature monitoring was made mandatory in schools and temperature screening was instituted at entry to public buildings.'

In China 'In every business I enter (whether that’s a restaurant, supermarket, or retailer), someone takes my temperature and asks me to write down my phone number. Taikooli, the large outdoor mall by where I live, has blocked off most entrances to corral people into temperature check zones'

Airport screening does not work as it only catches you if you are sick at just the right moment so the checks have to be regular.

 What is the most efficient way to get peoples temperatures checked twice a day? Non-Contact Infrared Thermometer are cheap ($10). Paying people to hold them is expensive. Grabbing a thermometer others have grabbed sounds unhygienic. And trusting people to measure themselves expects a lot from them. But a thermometer held on a stand that checked people, that's cheap. Some logging would probably be necessary but lets work out the basic concept first.

Would twice daily temperature checks reduce R0? The idea is to reduce the period of time someone with symptoms is not isolated.
If so is there a way to set up a machine to check your temperature so they do not have to be manual?