The Politics of the Pandemic Vaccine: The Philippine Situation

The human toll of the Covid-19 pandemic is enormous with the reported global deaths now at over 2 million and total cases almost 96 million. The United States leads the world both in number of cases (over 24 million) and deaths (over 400,000). Brazil ranks second followed by India, Mexico, and the United Kingdom. Mainland China where the outbreak originated, reported nearly 89,000 cases to nearly 5,000 deaths. These reported numbers from China are doubtful and can be much higher.

These numbers only cover the human cost. The financial cost is just as enormous. The disease has clearly not run its course thus the interest and rush for Covid-19 vaccines to help stem the tide of virus spread and eventually spur economic growth. There are two approved vaccines (Pfizer and Moderna) already in the market with AstraZeneca not far behind having already obtained emergency use authorizations in the United Kingdom and elsewhere. About a hundred more are inching up in the pipeline towards completion of their clinical trials.

The pre orders amounting to billions of doses are piling up with AstraZeneca vaccine leading the pack followed by Pfizer and Moderna. The top four countries leading the number of cases and deaths from COVID also lead the preorders. While vaccine pre order numbers look promising to meet the needs of the global community now at 8 billion people, the reality is that only a third of the world’s population will get their jabs by the end of 2021 considering that most vaccines require two doses to attain higher vaccine effectiveness.

The Philippine situation is interesting. President Rodrigo Duterte has done a decent job keeping the covid deaths low. Of its 505,000 cases, the vast majority recovered but with nearly 10,000 deaths by mid-January 2021. Duterte acknowledged his shortcomings in the health field being a lawyer but has convened and relied on the Inter-Agency Task Force on Emerging Infectious Diseases (IATF-EID) task force to oversee the COVID-19 pandemic response through the government’s National Action Plan.

The task force has had implementation issues early on that could be traced to bureaucratic layering of agencies. Secretary Francisco Duque as head of the Department of Health leads the task force while retired General Carlito Galvez Jr. is the vaccine czar. The task force could have done a much better job especially for Duque who was also DOH head during the H1N1 pandemic in 2009, but hampered by politics.

The next presidential election is set for 2022, or barely over a year from now. The pandemic, however, has clearly become a political issue. Early on, Vice President Leni Robredo was a constant critic of the government response and would present unsolicited advice on how to deal with the pandemic much to Duterte’s chagrin.

She also tried to rival the government’s emergency response not only during the COVID-19 pandemic but with other calamities that confronted the country in the last two years. Currently, one area of contention is the covid vaccine. Duterte has made it known that he is leaning towards the use of China’s Sinovac. Duterte’s vaccine preference has received pushbacks particularly from the vice president and other opposition figures.

The news that the Presidential Security Group (PSG) charged with protecting the president were vaccinated with smuggled vaccines prompted Robredo, the presumptive opposition presidential candidate, to call for an investigation of the incident. She decried that smuggling should never be tolerated and was concerned that the “dual standard” might further discourage Filipinos from getting the vaccine.

Robredo’s tirades are really getting old and betray her lack of knowledge in public health or just plain politicking. In May 2020, the Philippine Food and Drug Administration (FDA) granted Sinopharm’s request to conduct clinical trials in the country for its vaccine. The actual clinic trial did not materialize due to cost-sharing issues. It appears that the Chinese donated vaccines supplied to the PSG were trial vaccines. The PSG personnel’s alibi that they personally took the trial vaccines out of concern for the president’s safety - their primary duty.

In truth, all high officials of the government including Robredo, should get the first available vaccines. The people need a functioning government that is not hobbled by the COVID-19 disease. Thus, Robredo’s attack on PSG was not taken well. Also, the fact that she highlighted the possibility that the Filipino people might further lose confidence in the virus might just be a self-fulfilling prophecy.

The country’s influenza vaccination program has been ineffective for years. Robredo was not a known advocate for a better annual vaccination program even when she was in Congress. According to the World Health Organization (WHO), the Philippines ranks number 18 in the world in the number of combined influenza/pneumonia associated deaths. These diseases are the third leading causes of death in the Philippines with an annual death rate of over 75,000 with the highest among children 5 years old or younger, and seniors 75 years old and older.

Opposition to the Chinese vaccines are based on the higher cost and perceived questionable vaccine efficiency (VE) but probably more on distrust of China and Duterte’s closeness to the Chinese president. Consequently, it is putting an added pressure to the government’s efforts to have a unified approach.

Some personalities have entered the fray. Vice President Leni Robredo questioned why the Chinese vaccine preference when there are other cheaper vaccines in the market with higher vaccine efficiencies like AstraZeneca. Many local government units and private companies have signed tripartite agreements with AstraZeneca guaranteeing over a million doses. But is AstraZeneca’s AZD1222 vaccine better than the Chinese vaccines?

A city mayor justified ordering the AstraZeneca vaccine because it is cheaper, high VE at 90%, and good reputation of the UK Oxford AstraZeneca vaccine maker. Okay, let us break it down. Price, no doubt is cheaper but not a good measure for selecting vaccines. Second, high vaccine efficiency. AstraZeneca is claiming that its vaccine has 70% effectiveness. This number is misleading because the phase 3 trial data is questionable.

The company averaged the results from the first group (90% VE for 2,741 participants) given a single dose, and the second with 62% VE (8,895 participants) and were given two doses one month apart. The 90% VE was given to participants 55 years old and YOUNGER and did not include older people who are at higher risk if they get the covid virus. The Brazilian aspect of the trial only involved healthcare workers. AstraZeneca also changed the protocols midway of the clinical trial (varying doses) which is unethical. It appears that the company manipulated the data by pooling from separate trials and excluded some, to make it appear more effective.

Remember also that the vaccine clinical trial was halted last year because of a severe neurological outcome (transverse myelitis) from a participant. The trial participants in U.K. and Brazil were 80% white, 50% female, and half of the people in the Brazilian trial were left out from the data that included seniors. AstraZeneca also dropped a subgroup of children under 5 years old from the study group. The FDA approved clinical trial in the Philippines was withdrawn by AstraZeneca claiming they had enough data.

AstraZeneca was previously involved in criminal litigation in the United States and paid $520 million dollars to resolve the allegations that AstraZeneca illegally marketed their Seroquel drug for other unapproved uses. The allegations in the suit included illegal acts including violating the Anti-Kickback Statute for offering and paying doctors to serve as authors for ghostwritten articles supporting efficacy of their drug. Is that a good reputation?

Retired Supreme Court justice Antonio Carpio questioned Duterte’s tying the Visiting Forces Agreement (VFA) with the United States to covid vaccine acquisition. He failed to see the nexus and tied Duterte’s preference for closer partnership with China and lack of action regarding China’s invasion of the West Philippine Sea as motives. Here’s a fact: The United States has cornered over a billion doses of guaranteed future productions of covid vaccines for its 300 million plus citizens when it advanced billions of dollars to several vaccine companies. Shouldn’t they share some of it to the Philippines through USAID, even if it means a condition for keeping the VFA?

The Chinese vaccines (Sinopharma) have been used in Wuhan and generally in some cities in China (Sinovac). Both vaccines are attenuated much like the annual influenza vaccines, thus safer. The city of Wuhan is now alive and economically thriving. The Sinovac vaccine was administered by Indonesia, Brazil, and some Middle Eastern and African countries. To compare to AstraZeneca’s, let’s look at the Brazil clinical trial data for Sinovac collected by Brazilian researchers from Butantan Institute. Brazil’s data is relevant to the Philippines because of its tropical, humid weather.

Sinovac’s overall VE is 50.4%, just above the WHO VE threshold. But, several important findings make it a better choice for the Philippine situation. According to the data, Sinovac is 78% effective for “mild-severe” covid cases, and 100% effective for “moderate to serious cases.” Turkey researchers reported Sinovac to be 91.25% effective while Indonesia who already mass vaccinated with Sinovac, said it is 65.3% effective.

Vaccine data is critical and should be used when evaluating vaccine effectiveness for its intended use and target populations. Meaning, review the demographics (age groups) of the covid cases and see which of the vaccines will work better. Older people produce 50-75% lower antibodies which protect against the vaccine antigens than younger people do. That is why they need higher doses of regular influenza vaccines.

The world clearly has banked on any or all of these vaccines to deliver them from this pandemic. But the vaccines are not a sure thing to eliminate this public health problem. They also yield mixed results from country-to-country. The Pfizer and Moderna vaccines are using a modern approach using the messenger Ribonucleic Acid (mRNA). While animal research using mRNA has been ongoing for the last 10 years, this is the first time the covid vaccine technology is used on humans. Hence, it is still a work in progress with side effects, immunity duration, and whether the process in the body will not provoke the immune system to create untoward reactions, still wholly unknown. It could be the technology for the future but for now, mRNA is still on trial that is why the Pfizer and Moderna vaccines are not licensed yet and only approved for emergency use.