 Welcome to the Stop COVID-Dets webinar series brought to you by the University of the Philippines. The Stop COVID-Dets shorts make it easier for you to go to the presentations that you are interested in. I'm Dr. Raymond Sarmiento, Director of the National Telehealth Center. And I'm Dr. Susy Pineda Mercado, Adjunct Faculty of the National Telehealth Center. Together, let's stop COVID-Dets. This is just an update of my previous talk on the Delta variant. And these are my disclosures. Obviously, lots of pharma here. Also an NIH site for COVID, outpatient COVID treatment that's active too. And I'm a minor contributor for the research team. So before I start, let me just summarize my first talk on the Delta variant. In just the highlights, I mentioned that the basic reproduction number of the Delta variants 5 to 8. There's actually some studies showing it's probably up to 9.5. So really the herd immunity is approaching 80 to 90 percent. I also mentioned in my previous talk that all the vaccines are affected in protecting against severe disease that includes hospitalizations and deaths at least 85 percent. And the breakthrough infections, of course, will not be uncommon. And if you get a breakthrough infection, it will tend to be milder. And there will be decreased secondary transmission. There's some data showing there's actually decreased mutation rate. So let's start with the variants of concern. Of course, we have alpha, which is first detected in the United Kingdom. Beta from South Africa, gamma from Brazil. And of course, Delta were going to concentrate on Delta, which was first detected in India. I mentioned before that there was no gamma in Africa, but now obviously there's South Africa, Nigeria, and Sudan with gamma. So in the United States, when I did my talk in July 16, majority are already of Delta variants. But now as you can see, more than 99 percent are Delta overwhelmed. This one is for my previous talk on July 16. And this is showing the epidemic curves of the new cases and deaths for the United States. As you can see, there's a slight increase in the cases at that time and there's stabilization in the deaths. And this is despite the mobility increasing to baseline. And I made a forecast during that time, I made a prediction that it will be similar to the epidemic curves of the United Kingdom where the cases increased, there's a significant increase, but the deaths, the death curve is quite flat. We call this decoupling, decoupling of the cases and deaths. And this is despite the increase in mobility to baseline. There's actually no mask. They actually stopped the mask mandates, at least in the United States. So what happened? Anong nangyari? So obviously I was wrong with my prediction. United Kingdom, of course, it peaked and then of course there's a decrease in cases here. There's some stabilization of hospital admissions for deaths. It's quite flat. This actor is still increasing, but it's quite flat compared to the cases. But the United States, look at this. Increase in cases, increases in hospital admissions and the deaths are still increasing. So what is the explanation for this difference? And it's probably the vaccination rate. As you can see here, there's still a lot of cases, a lot of areas in the United States where the unvaccinated population is more than 10%. And in the United Kingdom, most of the unvaccinated population is less than 5%. So the difference is really about 10%. I thought it would not be a big deal, but obviously the herd immunity probably really approaches 90%. And that's why there's a big difference between United States and United Kingdom. This one is the Delta Bear in Nationwide Transmission. As you can see here, the initial high level transmission happened in the southeastern United States. And this one is showing you the correlation between the 7-day case rate per 100,000 and the percent of state population vaccination. So if, for example, Louisiana, Arkansas, Missouri, and Alabama, they all have low vaccination rate, only about 35%, they have the highest case rate per 100,000. This is Vermont approaching 70% vaccination rate and they have the lowest case rate per 100,000. The only outlier here really is Florida. They have a decent vaccination rate of 50%. Half of the population is vaccinated but they have a very high case rate per 100,000. This one is just from the Kaiser Family Foundation, Kaiser Family Foundation showing the difference in vaccination by race and ethnicity. For African-Americans, 40%. Hispanic-white is 45%. White non-Hispanic is 50%. And for Asians, it's pretty high, 67%. Two-thirds of the Asian population is vaccinated. And I don't have any data for Filipino-Americans but I'm pretty sure it's near the two-thirds, 67%. And for the elderly, I'm pretty sure it's more than 90% of the sub-population is vaccinated. So I'm confident that the Filipino-Americans will be protected at least against severe COVID disease. Now, this one is from the McKinsey's Healthcare System analysis from several sources and one of them was the CDC. This is just showing you the hospitalization and the epidemic curves for the unvaccinated population which is the blue dotted line and the vaccinated population which is the blue solid line. The black solid line, of course, is the entire population will be in between the two. And as you can see for the unvaccinated population, there's a tremendous increase in number of cases even higher than that of the winter surge. And for deaths, it's quite significant but for the vaccinated population, it's quite flat. This lower threshold is the influenza rate, hospitalization and death rate. Upper threshold is the peak rate. And as you can see, hopefully during the winter season, it will not reach this threshold for the peak influenza rate. This is actually our goal for COVID-19 just to be at least similar to the influenza. We don't have any immunity against influenza at least we're controlling it with regular vaccination. However, the problem is we underestimated the number of unvaccinated individuals. This one is from Chile which use Sinovac. As you can see, there's increase in cases but in terms of number of deaths, it's actually quite relatively flat. There's still decoupling here and this is despite increase in the baseline mobility. This is from the Philippines. This is from my previous talk showing there's a decrease in cases and the deaths are stable. Obviously, there's increase in mobility. At the time, the Delta variant still starting and obviously, I made a comment that it's unstoppable. The Delta variant is unstoppable and there's a tremendous increase in number of cases in the Philippines. Although the increase in deaths is not proportional so it looks like there's some decoupling between the case and the deaths and this might be secondary to the high vaccination rate of the elderly in the national capital region. The problem is if it spreads outside of the national capital region because the vaccination rate for the elderly outside of NCR is much lower and there's also increase in mobility in the Philippines so that's a concern. This is of course from India. India did not have any decoupling. You get no decoupling with cases and deaths. About half a million reported deaths, the estimated excess deaths according to a Harvard study is about five million so obviously the cases decrease because of the decrease in mobility but it's increasing again. I don't know if a significant proportion of the population is still not infected. They will have it a next wave. Now what is the reasoning behind the increased transmissibility of Delta and this is from a study from Singapore showing that the viral load of the Delta variant is much higher compared to the other variants. This is the viral load. It depends on the city value. The lower the city value, the higher the viral load. The higher the city value, the lower viral load. So for example, it's four to five. That will be the threshold. So lower than that will be considered undetectable. And this one is also from Singapore showing a study comparing breakthrough infections from vaccinated individuals in infection and vaccinated individuals. As you can see in the first five days the viral load is high and comparable but there's a rapid drop in the viral load in breakthrough infections in vaccinated individuals. This might explain the increased protections again, severe disease. This one is from a preprint by Shamir and this one is showing that although the viral load is comparable between unvaccinated and vaccinated healthcare workers the probability of cultural positivity is lower in patients who are vaccinated with breakthrough infections compared to unvaccinated. So there's actually decreased infectiousness compared to unvaccinated individuals. This one is just for multiple sources just showing that there's decreasing protections against infections including asymptomatic infections especially in Israel versus the Delta variant compared to the Delta variant. But if you look at the hospitalization or death rate or severe COVID disease there's actually not much of a decrease. Still 100% in Qatar, 91% in Israel 96% in England and Canada. So there's lower protection against infection including asymptomatic infections but still great protection efficacy against severe disease including hospitalizations index. This one is from the Mayo Clinic Health System showing there might be some difference between Moderna and Pfizer in terms of infections including asymptomatic infections but if you look at hospitalization rate there's really no significant difference between the two. This one is from the MMWR study showing that the vaccine effectiveness is decreased comparing the pre-Delta variant predominance and Delta variant predominance from 91 going to 66%. It also shows that there's probably some waning in immunity 85% 14-19 days after full vaccination decreasing to 73% with more than 150 days after full vaccination. So there might be some waning in immunity however in this study based on the COVID net cohort although there's an increase in infections these are the surges not infections or hospitalizations for the vaccinated population it's quite flat. The hospitalization rate for the vaccinated individuals with breakthrough infection is quite flat. Okay, there's not much difference and this is the last slide this is from LA County reporting in the MMWR showing the infection and hospitalization rates from May to July and this is when the Delta variant became predominant and as you can see there's an increase in infection rates some is slight increase for vaccinated and partially vaccinated individuals but for hospitalization rates although there's increase for unvaccinated it's quite flat for fully vaccinated and even partially vaccinated individuals so even partially vaccinated individuals have great protection against severe disease. That should be it. That's all I have. Thank you. We hope that you learn this much as we did from that excellent presentation. We also hope that you will join us every Friday from 12 noon to 2 pm Manila time on Zoom, Facebook or YouTube. So stay safe, stay connected and see you online.