IATA Medical Contact Group - update COVID-19

An earlier update than planned, mainly because of the concerns that some of you have expressed about monkeypox. 

Firstly regarding COVID-19:

• A rise in hospitalisations is reported in a number of countries including Canada, USA, Australia, France, and Italy.

• Indonesia now sees a sudden dramatic increases in cases;   infections have risen 55.6% over the last two weeks, but the absolute number of cases per million still remains very low.  Indonesia will drop requirements for people to mask outdoors and for vaccinated travellers to show negative pre-departure tests.

• In the USA, COVID-19 infections have increased by around 60% led by increases in the Midwest and Northeast. Inversely, deaths have declined around 50% over the last two weeks, however this number will likely rise in the coming months, given the lag in deaths behind overall disease burden.

• South Africa cases have risen 43% over the last two weeks, and then started to decline over the last 7 days. Deaths have increased dramatically by 360% over the same time period. 

• Brazil’s deaths have reduced by about 10% over the last two weeks, and in April Brazil reported 1,104 Covid deaths, the lowest number since March 2020. However, cases have increased over the last two weeks.

• Japan’s cases increased by ~24%, and deaths by around 10%, over the last two weeks. However, Japan announced it would start "test tourism" in the form of limited package tours in May as a way of gathering information prior to a full re-opening of the country.

Today an article confirming a greater degree of immune escape of BA.4/5 and BA.2.12.1 (against sera from boosted health-care workers) than previous BA.1/2 subvariants and the Delta variant.   Qu et al from Ohio State University:  https://www.biorxiv.org/content/10.1101/2022.05.16.492158v1 BA.5 is becoming the dominant variant in Portugal currently. 

SARS-CoV-2 RNA Can Persist in Stool Months After Respiratory Tract Clears Virus. https://jamanetwork.com/journals/jama/fullarticle/2792688 - this is an article discussing possible reasons and consequences for this finding.  

Also, a quick summary in JAMA about the breath testing device that gained EUA approval from the FDA - https://jamanetwork.com/journals/jama/fullarticle/2792268 - including that follow-up data on Omicron supported the previous findings regarding efficacy.  

An article from Cornell Univ. where a comprehensive set of public health measures including testing, symptom screening and indoor mask wearing failed to prevent an Omicron surge. Meredith et al: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2792382

Belgian study Braeye et al: https://www.medrxiv.org/content/10.1101/2022.05.09.22274623v1 - essentials:
Against Omicron, an initial VEi (vaccine efficacy against infection) of 37% (95%CI 34-40) waned to 18% (95%CI 17-20) 100-150 days after primary-vaccination. Booster-vaccination increased VEi to 52% (95%CI 51-53) and it then waned to 25% (95%CI 24-27) 100-150 days after vaccination.

Initial VEh (vaccine efficacy against hospitalisation) for booster-vaccination decreased from 93% (95%CI 93-94) against Delta to 87% (95%CI 85-89) against Omicron. VEh for Omicron waned to 66% (95%CI 63-70) 100-150 days after booster-vaccination.

Hybrid immunity conferred by prior infection and booster-vaccination outperformed booster-vaccination only even if the infection was over one year ago, 67% (95%CI 66-68).

Similarly, booster vaccination reduced breakthrough infections as well as severity of illness in a HK study, Zhou et al:  https://www.biorxiv.org/content/10.1101/2022.05.09.491254v1

And a South African retrospective study with good evidence for the reduced severity of illness with Omicron – Jassat et al: https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(22)00114-0/fulltext

(For example:  10.7 in-hospital fatality ratio for Omicron vs 26.4% during Delta;  33% of those admitted had severe disease during Omicron wave vs 63% during Delta).

The Antidepressant fluvoxamine was declined EUA by FDA as a COVID treatment.  The submission was based on results of the Phase III TOGETHER trial, with the FDA stating that the data was insufficient to conclude that fluvoxamine may be effective, citing “uncertainties” regarding the trial.  (Source: Airfinity).

Information regarding Monkeypox:

Recently 110 cases (39 confirmed) of monkeypox have been detected in 11 countries in Europe (UK, Spain and Portugal), North America (US, Canada) and Australia.  These cases appear to be the West African “clade” (strain), which has a reported case fatality rate of around 1%; the Central African clade has a higher reported CFR of over 10% (the difference may relate partly to the strength of healthcare systems).

The monkeypox virus is related to the virus which caused smallpox, declared eradicated in 1980. The symptoms of monkeypox are similar to but milder than smallpox.  Infected people develop flu-like symptoms — fever, body aches, chills, headache — but also swollen lymph nodes. With one to three days of the onset of fever, a distinctive rash appears, often starting on the face, with vesicles (blisters). The monkeypox rash has some unusual features, including that vesicles can form on the palms of the hands.  It has a reasonably long incubation period of 2-3 weeks, and is not believed to be very infectious until symptomatic.  This means that isolation, contact tracing and post-exposure vaccination can be very effective for monkeypox.  It also means that isolation periods for contacts need to be long.

Typically the illness resolves within 2-4 weeks without treatment.  Severity of illness does relate to health status and age: it tends to be more severe in children, and cause complications during pregnancy. Smallpox vaccines have been shown to be highly effective in preventing monkeypox but are not widely available.  There is also an antiviral approved for use in Europe but it also is not widely available. 

In countries where monkeypox is endemic, the virus is believed to mainly spread to people from infected animals when people kill or prepare bushmeat for consumption.  Once the virus jumps to people, however, human-to-human transmission can occur via respiratory droplets — virus-laced saliva that can infect the mucosal membranes of the eyes, nose, and throat — or by contact with monkeypox lesions or bodily fluids, with the virus entering through small cuts in the skin. It can also be transmitted by contact with clothing or linens contaminated with material from monkeypox lesions. There is some evidence the virus may be able to remain airborne for many hours.  However it is less contagious than COVID-19 - the R0 of monkeypox is around 2 (whereas for Omicron SARS-CoV-2 it is over 10). 

Although many of the current case clusters include men aged 20–50, a number of whom are gay, bisexual and have sex with men (GBMSM), the virus is not known to be sexually transmitted, and it appears likely that the virus was coincidentally introduced into a GBMSM community, and has continued circulating there just through the usual close contact mechanisms.

Cases outside of Africa have previously been rare, though there was a large outbreak in the United States in 2003 that involved 47 cases in six states. That outbreak, the first reported from outside Africa, was traced back to importation of small mammals from Ghana.  In recent years exported monkeypox cases appear to have become more common: the U.S. detected two in 2021, both in travellers returned from Nigeria; UK has seen multiple importations in the past few years and Israel and Singapore have also detected cases.  Knowledge of monkeypox is still based on only a few thousand cases therefore caution should be applied to any conclusions.  However this infection remains rare and is far less infectious than COVID-19. 

Other outbreak information: 

A fatal H5N6 avian influenza case reported in Guangxi, China - a 49-year-old male who had visited a live poultry market. He developed symptoms on April 16, was admitted on April 18, and died April 24 (“Outbreak News Today”). 

Wild polio has been identified in Mozambique now, joining Malawi - after there had been none in Africa for some years (source: Airfinity). 

In addition to the locations mentioned on the last update, there is a significant dengue fever outbreak in Singapore.

Best wishes,
David Powell
IATA Medical Advisor