 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. We'll be talking about breakthrough infections, but kaagad in the title page palang I'd like you all to remember that vaccines reduce risk for severe breakthrough infections. So I'm sure we are all on the same page that the COVID pandemic has affected every aspect of our lives. Actually, the number of confirmed cases and the number of lives taken by this virus is really, really phenomenal. So what I'll do is I'll just get some very important landmark documents from the United States. From UK, from Israel, from Indonesia, and from the Philippines. Inisip ko how I will talk about breakthrough infections kasi parang andami-dami information. So that's what I'll do. So to review parang the USA is number one, the number of total confirmed cases. And the United Kingdom also has a lot over six million confirmed cases. For both of them, they have been using mostly Pfizer and Moderna vaccines. Israel also Pfizer vaccines with just a little bit over one million confirmed cases as of yesterday. So I wanted to look at what the experience was of Indonesia who used the different set of vaccines, Sinovac primarily, and of course, zooming into our experience in the Philippines. So what are breakthrough infections? So cementimeter na tinanong ni Raymond Kanina. So to clarify para our definitions are just standardized, CDC would say that a vaccine breakthrough infection is defined as the detection of the virus for this particular COVID-19. It's the SARS-CoV-2 RNA or antigen in a respiratory specimen collected from a person at least 40 days after they have completed all recommended doses of an EUA approved COVID-19 vaccine. So ansagot, tamang sagot ng cementimeter question ay two weeks. Now, so going to the experience in the US, I think this particular paper that came out very recently this month actually on breakthrough infections actually happened in Massachusetts outbreak. So it narrated what happened, what led to all of the breakthrough infections. So di ba when they started to be able to rapidly give a lot of vaccines to many of its citizens, the United States actually brought down a little bit the degree of restrictions that they had. So they allowed people to go outside already without masks and have some kind of public events in different parts of the country. So in Massachusetts, there was an outbreak that was documented from July 3 to 17. Very brief lang to two weeks tapas kinalangan na nila i-control kasi they detected them already following multiple large public events in a county in Massachusetts. So that particular county already had a vaccination coverage of 69%, very close to the 70% herd immunity that we are all aspirating for, but nevertheless, they saw 469 COVID-19 cases. And from that pool of COVID-19 cases, 74% were actually fully vaccinated cases. So it really brought a lot of concern for many of the people in the Massachusetts area. And when they looked at, they studied sampling of 133 patients who were able to submit their respiratory secretions for whole genome sequencing, they found out that 90% were already because of the Delta variant. So in paring we already see what are the ingredients for this breakthrough infections. So very early on, the Massachusetts Department of Health was able to quickly detect and follow through the events that seemed to show that there was really a rise, a rapid rise in the number of cases. So parang nag-open sila, nag-invite sila ng mga public events, yung mga race, horses, yan, yan yun nangyari sa Massachusetts. And quickly they were able to stop all of these events in an effort to control the ongoing outbreak. They found out that most of the cases were male, 87%, and the median age was 42. And the distribution of this were because yung mga public events nila invited mostly males and mostly this group of middle-aged people. The vaccines that were received were mostly Pfizer, Moderna, and yan, as indicated here. And 79% reported signs and symptoms, mostly cough, headaches, sore throat, myalgia, and fever. They said that most of this were mild. Only four of all of these cases had to be hospitalized. So mababa-mababa yung hospitalization rate, which was only 1.2%, and no deaths were reported. But because of this, they also tried to compare the city values of, city value is a number we use in infectious disease. When we're trying to see just how infectious or communicable certain samples are. And usually the lower the city values are, the lower, that means it only takes a few cycles for the machine to detect the virus in the sample. So ibig sabi mas madami na siyang virus. So you would see here that it didn't seem to matter kung unvaccinated or vaccinated yung individuals. So the infectiousness looked the same. So what happened? Because of that very important outbreak in the subsequent paper that came out from describing the experience, the CDC now recommends that back nasila sa wearing of the mask. So CDC started to recommend that even if you are fully vaccinated, if you are indoor in public settings, you should wear masks. And that reverberated throughout the country. And yun nga, there are more and more concern about this particular breakthrough infections. And we should really all continue to update ourselves. So maraming, maraming information, mostly in news items. But there's also a good resource from the CDC MMWR to keep ourselves updated. Okay. Let's go naman to the UK, the United Kingdom experience. This is the paper I thought would help us understand better what's happening with the breakthrough infection. So this are effectiveness against the Delta variants. So this is a description of symptomatic disease. The design of their study was a test-negative design. And the people who did this study were associated with the Public Health England. Siya yung parang equivalent ang Department of Health natin. And you would see in this graph, they tried to map out the vaccine effectiveness for the Alpha and the Delta variant after the first dose and the second dose. And you would see na may malaking difference. So if we just receive the first dose, the protection is only around 30% to at most 50%. But it rises very significantly if we finish the recommended number of dosing. So although it doesn't match breakthrough infections, so don't get this heartened if you get an infection in between the doses because that really happens because our level of protection is not yet full and we stop at the first dose. We really should make every attempt to finish the recommended number of doses. So here after the second dose, you would see that both for Alpha and Delta variants, the vaccines that this group of population received were effective up to 89, 79 to 89%. So the conclusion of this experience from UK is that there's high levels of vaccine effectiveness against symptomatic disease with the Delta variant. If further population receive the Pfizer or the Astra COVID-19 vaccines and that there's reduced effectiveness if we only receive the first dose. So if you know of other people who might stop at the first dose or get disappointed because they got an infection after just the first dose, prod them to go and finish the second dose or the number of recommended doses. Pwede naman tayo sa Israel. Sa Israel, I really try to look for this information about what they experience as breakthrough infections because Israel actually is the number one in terms of coverage for COVID-19 vaccines. And the report here narrates to us the experience of the largest medical center in Israel which is the Shiba Medical Center. At the time they did this study, the vaccination coverage was already 91% for their hospital and this took place over 14 weeks from January to April of this year. So very, very fresh information. So they wanted to see and identify every breakthrough infection including asymptomatic infections among their healthcare workers and it was a matched case control analysis. So what did they see? There were 11, ganong kalaki yung medical center nila na they had 11,453 healthcare workers. They were doing PCR tests whenever the healthcare worker would have been exposed or would have any symptom. And among this, they only saw 39 breakthrough cases or 2.6%. And the characteristics of the healthcare workers who developed this breakthrough infections were mostly nurses, people who were coming in and out of the wards like the maintenance workers, some allied health professionals and physicians. The average age was 42 years old and there was some increase in the incidence among women. The median interval from the second vaccine dose was 39 days and only one person was infected who had immunosuppression. Saan kaya na ko ha yung infection? You would usually ask where did the healthcare worker get the infection? So the Israel group described the breakthrough infection origins mostly from unvaccinated persons around the healthcare workers who were already fully vaccinated. So 57% got it from an unvaccinated household member like children or other household members who were still unvaccinated. And 30% got them from unvaccinated fellow, yung colleagues, fellow healthcare workers for patients. And they were able to track seven healthcare workers who were linked to a patient who had the alpha variant. At the time kasi, the pre-dominant variant in Israel, okay. And again, when they described the severity of the symptoms, 67% were mild and the rest were asymptomatic, so very, very mild, no? Kung meron man, mild mostly. Non-required hospitalization and the most common symptoms were up respiratory congestion, loss of smell or taste and 21% reported fevers or ribers. What happened to them? So it said that after the 14 days, some still had residual symptoms. One-fifth actually reported having the long COVID-19 symptoms so prolonged loss of smell, persistent cough, fatigue, weakness, disnya, or myalgia. One-fourth of those who had the infection actually had to take a leave of more than 10 days longer than the isolation period that we recommend. And there was one worker who was not able to return despite six weeks of leave. So ang conclusion nila was the variants of concern, and as I said, mostly were alpha variant because at that time, 94.5% of the Israeli samples had the alpha variant. So ang conclusion nila was the Pfizer vaccine for them was extremely effective and they actually called, kasi 2.6% in this particular healthcare worker population, the breakthrough infections were rare in incidents. But of course, they sort of give us a challenging situation because many are mild or asymptomatic and may pose a risk for vulnerable populations in a medical health facility. Okay, now going to, siyempre, tatanungin nyo e pano naman yung sa, sa hindi gugagamit ng Pfizer or the other, they call it first world country vaccines. And if you look at the more recent news items from Israel, they've been identifying that breakthrough infections can maybe more severe no? In sicker patients, in older patients, in patients with the comorbidities. So that's something to keep in mind and that's something to make us again, always more vigilant for our vulnerable populations. Ito na talaga. Pupunta na tayo sa Indonesia. So we've been hearing this since around the end of May to early June, how Indonesia was like just swamped with so many cases of COVID-19. And we heard about why hundreds and hundreds of vaccinated healthcare workers actually came down with the breakthrough infections. So actually, if you, or maybe I didn't find them, but I tried to look for them. There was only one case report so far. And of how it was that Sinovac recipients would anyway end up with breakthrough infections. And this letter to the editor published in this particular journal tried to tell us that when they measured the antibody responses of this particular infected healthcare worker, there was a decline in the antibody response at the time that she had the SARS infection, SARS-CoV infection. So in conclusion for that Indonesian paper, the possible factors for breakthrough infections included maybe lack of immune response from different kinds of populations receiving the vaccines and the occurrence of variants of concern in the country. Ayan, pa tan na tayo sa Philippines. So Philippines so far, I really have only healthcare worker data from the Philippine General Hospital. This is our epidemiologic curve of what's been happening lahato healthcare workers through the 18 months that we've been fighting the COVID-19 at the referral center. So meron kami talagang naging surge very recently when the August month came about. And this is the number of healthcare worker breakthrough infections we've had so far. And that amounts to about 71 percent of all the COVID infections we've had with healthcare workers. This one we did last night, we completed this data collection in infographic last night. This is not healthcare worker. These are our current patients in PGH. And in the first set of dots, we were trying to represent persons who were fully vaccinated, sila yung green, partially vaccinated. They are represented here as yellow dots and the unvaccinated as red dots. And you would see na yung green did not proceed to the intubated, critically ill intubated COVID cases. So meron din COVID critical, pero as far as we know as of this morning, they are sort of okay and hanging in there. The ones that really become very, very sick are the unvaccinated or the partially vaccinated individuals who proceed to being critically guarded and intubated. So segue lang ako to saying that our information here in the Philippines is not yet complete enough for large completed studies kasi ginagawa pala nating sila. So we've started to organize ourselves to have this vaccine effectiveness or Philippine VE project. There's a lot of people who will be part of this all over the country and we're going to look at how the vaccines may be the key to end the COVID-19 pandemic. So ang titig nanamin would be a real world vaccine effectiveness data. We will be collecting them in the next 12 months and the project will be trying to estimate effectiveness of the COVID-19 vaccines amidst all of the different vaccines we've been using in the Philippines. We're already on our third month by September to October. So siguro kong imbitahin nyo ako liat makakabigay nako ng more complete data on this and the project design is a prospective cohort of 12 sites. More or less this VE project will look at two arms. There will be antibody testing or immunosurveillance. This is not to say people should go around getting their antibody levels. This is, we recommend this only as part of our research or a clinical study and the other arm would be looking at COVID-19 surveillance exactly sino ba yung symptomatic at sino yung nagkakaroon ng asymptomatic infection. So for PGH we've started to do the antibody test but again under a clinical study setting and looking at the incidence of COVID-19 hospitalization and death among PGH healthcare workers between vaccinated versus unvaccinated individuals. So this is already my last second to the last slide but I hope through all of the slides I've been able to show you through the experiences of the USA, the UK, Israel, Indonesia and a little bit from the healthcare workers in PGH that COVID-19 vaccines are effective but many factors really come into play and that make us more prone to breakthrough infections including host factors like comorbidities or immune responses, situation factors like exposures, use of protection and virus factors like the presence of variants of concern and of course the properties of the vaccines that we use. Okay that's it so kasama ang sambayan ng Pilipino laban sa COVID-19 pandemic. Thank you very much for listening to me. We hope that you learned as much as we did from that excellent presentation. We also hope that you will join us every Friday from 12 noon to 2 p.m. Manila time on Zoom, Facebook or YouTube. So stay safe, stay connected and see you online.