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AstraZeneca second dose: Should I get the same vaccine or choose Pfizer or Moderna?

Hundreds of thousands of Canadians got a shot of AstraZeneca’s COVID-19 vaccine for their first dose. They now have a choice for their second dose: AstraZeneca again, or Pfizer or Moderna mRNA vaccine?

Pharmacist Barbara Violo arranges all the empty vials of the AstraZeneca COVID-19 vaccine that she has provided to customers at an independent pharmacy in Toronto. THE CANADIAN PRESS/Nathan Denette

People in Canada whose first dose of COVID-19 vaccine was AstraZeneca have a choice to make: They can either choose one of the mRNA vaccines (Pfizer or Moderna) or another dose of AstraZeneca for their second shot.

The saga of AstraZeneca’s COVID-19 vaccine has been complicated. Clinical trials and real-world data from the United Kingdom have demonstrated its superb efficacy against severe illness and hospitalizations due to COVID-19.

In March, as much of non-Atlantic Canada experienced a surge of COVID-19 cases driven by the alpha (B.1.1.7) variant, reports from the European Union confirmed an association between AstraZeneca vaccine and rare but potentially fatal blood clots termed “vaccine induced thrombotic thrombocytopenia,” or VITT.

Jagmeet Singh getting an injection
NDP Leader Jagmeet Singh gets a shot of AstraZeneca vaccine from Dr. Nili Kaplan-Myrth at a family medical practice in Ottawa on April 21. THE CANADIAN PRESS/Adrian Wyld

On March 31, given an unfavourable risk-benefit balance in younger people from the association with VITT, the National Advisory Committee on Immunization (NACI) recommended suspending the use of AstraZeneca in all people under age 55 in Canada. On April 23, as critically ill patients strained many hospital systems, NACI relaxed its guidance on AstraZeneca vaccine to allow its use in people over age 30 to speed up first dose uptake across Canada.

Finally, on May 11, Alberta and Ontario announced they would discontinue the use of AstraZeneca for first doses, citing uncertain supply of AstraZeneca vaccine and the evolving risk of VITT in Canada (1 in 55,000). Other provinces and territories quickly followed suit.

On June 1, NACI released additional guidance suggesting that people who received a first dose of AstraZeneca could receive either a second dose of AstraZeneca or a second dose of an mRNA vaccine. Provinces quickly amended their guidelines to allow recipients of AstraZeneca vaccine to choose their second dose of vaccine for themselves.

So the question of the moment is: What do I choose for my second dose if I’ve received a first dose of AstraZeneca?

Evidence for mixing and matching vaccines

Justin Trudeau getting a shot while Sophie Gregoire Trudeau holds his hand.
Prime Minister Justin Trudeau and his wife Sophie Gregoire Trudeau received AstraZeneca shots at an Ottawa pharmacy on April 23. THE CANADIAN PRESS/Adrian Wyld

Let’s begin with the evidence we have so far around mixing and matching vaccines, specifically AstraZeneca and Pfizer/BioNtech (Pfizer). On May 12, initial data on reactogenicity (the ability to produce common side-effects) data from the COM-CoV study in the United Kingdom was released. It included 830 people ages 50 and older, who were randomized into four study arms that received different combinations of AstraZeneca and Pfizer vaccines at four-week dosing intervals.

Participants who received different vaccines for their first and second doses, regardless of sequence of vaccination, had more side-effects (non-serious ones that resolved on their own) than those who received the same vaccine twice. No safety concerns were noted.

Experts theorized that the greater number of side-effects might predict a more robust immune response, but immunogenicity (the ability of the vaccine to provoke an antibody response) data is still pending and expected later this month.

Results from the Spanish CombiVacS study were reported on May 18. The study randomized 663 people who received AstraZeneca as their first dose to either receive Pfizer as a second dose booster eight weeks later, or into a control group with no second dose at all.

Those who received AstraZeneca followed by Pfizer developed twice as many antibodies as historically seen in people who received two doses of AstraZeneca alone. No safety concerns were identified.

People ages 45 and over line up at a walk-in COVID-19 vaccination clinic to receive the AstraZeneca vaccine in Montréal on April 21. THE CANADIAN PRESS/Paul Chiasson

A recent study from Germany released June 1 as a non peer-reviewed preprint adds additional information around mixing and matching AstraZeneca and Pfizer vaccines. This preliminary data included 26 individuals, ages 25 to 46, who were administered AstraZeneca as their first dose of vaccine, followed by a second dose of Pfizer given eight weeks later.

Neutralizing activity was 3.9 times greater against the alpha (B.1.1.7) variant and similar against the delta (B.1.617.2) variant compared to neutralizing activity seen in people who received two doses of Pfizer vaccine. No safety concerns were noted.

Lastly, a small Canadian study from Dalhousie University took two volunteers aged 66 and administered a first dose of AstraZeneca vaccine followed by a second dose of Pfizer vaccine 33 days later in both. The antibody responses were reported as being strong, with no safety concerns.

VITT risk with a second dose of AstraZeneca

The risk of VITT with a second dose of AstraZeneca for those who have received a first dose of AstraZeneca is very low. The best data currently available is surveillance data from the United Kingdom. As of May 27, 17 cases of VITT had been reported after 10.7 million second doses of AstraZeneca vaccine, for a risk of about 1 in 600,000.

John Tory getting an injection, giving a thumbs-up
Toronto Mayor John Tory receives a dose of the AstraZeneca COVID-19 vaccine from pharmacist Niloo Saiy at a Toronto pharmacy on April 10. THE CANADIAN PRESS/Cole Burston

Vaccine supply and availability

First doses of AstraZeneca vaccine were paused in Canada partly due to concerns with supply. However, a shipment of about 655,000 doses of AstraZeneca vaccine arrived in Canada in mid-May from COVAX, the global vaccine sharing initiative. It has been distributed now to provinces for use as second doses for persons who received a first dose of AstraZeneca.

The current and anticipated availability of both mRNA vaccines in Canada is excellent, with ongoing anticipated shipments throughout all of June and July. This means there will be no need to wait for one’s preferred option in most cases.

So what’s the best choice?

I was fortunate to receive two doses of COVID-19 vaccine in early 2021, so I don’t have to make a decision for myself. However, I’ve had many people ask me for advice on this subject on behalf of loved ones, friends and themselves.

While the data isn’t definitive, evidence is mounting to support a mixing and matching approach with AstraZeneca followed by Pfizer being at least as good (if not better) than giving two doses of the same vaccine. There is no inherent risk of mixing vaccines, and no safety concerns have been noted thus far.

Additionally, by taking an mRNA vaccine, one avoids the risk of VITT altogether. Even though this risk is very low, VITT is serious and potentially fatal.

For those reasons, my opinion is that if it’s accessible, a second dose of mRNA vaccine (either Pfizer or Moderna) is preferred for most people in Canada who have received a first dose of AstraZeneca.

The mRNA vaccines are anticipated to be widely available throughout June and July, when most Canadians will be lining up for second doses, so availability will not be a concern for either option.

The case for AstraZeneca

A sign for AstraZeneca at a vaccination clinic
Some may prefer the proven approach of receiving two doses of AstraZeneca vaccine. THE CANADIAN PRESS/Paul Chiasson

There are many reasons why one might choose AstraZeneca over an mRNA vaccine for their second dose. There is no clinical efficacy data for mixing and matching vaccines, such as clinical trials or real-world studies. For this reason, some may prefer a “proven” approach of receiving two doses of AstraZeneca. Some people who did not experience any adverse effects with their first dose of AstraZeneca may opt for a second dose of the same to try to avoid side-effects.

The COM-CoV study from the United Kingdom will report data on immunogenicity (antibody response) later this month. It may or may not be supportive of a mixing and matching approach. Some may prefer to wait for this data before deciding. Others may just be happy to take whatever vaccine is available and offered to them first.

Regardless of one’s decision, the critical point is for everyone to get a second dose as soon as they are eligible, whether it be AstraZeneca or an mRNA vaccine. The available evidence gives confidence that both options are safe and efficacious, so there’s no “wrong” choice here. Being fully vaccinated provides optimal protection against current and emerging strains, including the delta variant.

We are very fortunate in Canada to have the privilege to choose between two excellent options for our second doses. We have a responsibility to ensure that any unused vaccine supply is not wasted, and we must do much more to support global vaccine equity to help put an end the COVID-19 pandemic worldwide.

Please, go and get fully vaccinated both for yourself and for your community!

Dr. Alexander Wong has previously received an honorarium for leading a scientific discussion for healthcare professionals on AstraZeneca COVID-19 vaccine.

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A popular vacation destination is about to get much more expensive

The entry fee to this destination known for its fauna has been unchanged since 1998.

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When visiting certain islands and other remote parts of the world, travelers need to be prepared to pay more than just the plane ticket and accommodation costs.

Particularly for smaller places grappling with overtourism, local governments will often introduce "tourist taxes" to go toward things like reversing ecological degradation and keeping popular attractions clean and safe.

Related: A popular European city is introducing the highest 'tourist tax' yet

Located 900 kilometers off the coast of Ecuador and often associated with the many species of giant turtles who call it home, the Galápagos Islands are not easy to get to (visitors from the U.S. often pass through Quito and then get on a charter flight to the islands) but are often a dream destination for those interested in seeing rare animal species in an unspoiled environment.

The Galápagos Islands are home to many animal species that exist nowhere else in the world.

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This is how much you'll have to pay to visit the Galápagos Islands

While local authorities have been charging a $100 USD entry fee for all visitors to the islands since 1998, Ecuador's Ministry of Tourism announced that this number would rise to $200 for adults starting from August 1, 2024. 

More Travel:

According to the local tourism board, the increase has been prompted by the fact that record numbers of visitors since the pandemic have started taking a toll on the local environment. The islands are home to just 30,000 people but have been seeing nearly 300,000 visitors each year.

"It is our collective responsibility to protect and preserve this unparalleled ecosystem for future generations," Ecuador's Minister of Tourism Niels Olsen said in a statement. "The adjustment in the entry fee, the first in 26 years, is a necessary measure to ensure that tourism in the Galápagos remains sustainable and mutually beneficial to both the environment and our local communities."

These are the other countries which are raising (or adding) their tourist taxes

While the $200 applies to most international adult arrivals, there are some exceptions that can make one eligible for a lower rate. Adult citizens of the countries that make up the South American treaty bloc Mercosur will pay a $100 fee while children from any country will also get a discounted rate that is currently set at $50. Children under the age of two will continue to get free access.

In recent years, multiple countries and destinations have either raised or introduced new taxes for visitors. Thailand recently started charging all international visitors between 150 and 300 baht (up to $9 USD) that are put toward a sustainability budget while the Italian city of Venice is running a test in which it charges those coming into the city during the most popular summer weekends five euros.

Places such as Bali, the Maldives and New Zealand have been charging international arrivals a fee for years while Iceland's Prime Minister Katrín Jakobsdóttir hinted at plans to introduce something similar at the United Nations Climate Ambition Summit in 2023.

"Tourism has really grown exponentially in Iceland in the last decade and that obviously is not just creating effects on the climate," Jakobsdóttir told a Bloomberg reporter. "Most of our guests visit our unspoiled nature and obviously that creates a pressure."

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Merck’s six-year deal strategy could deliver a blockbuster if hypertension drug is OK’d this month

With an FDA decision expected next week for its blood pressure drug sotatercept, Merck is hoping that its bundle of acquisitions in recent years will lead…

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With an FDA decision expected next week for its blood pressure drug sotatercept, Merck is hoping that its bundle of acquisitions in recent years will lead to multiple approvals and late-stage clinical wins.

The regulator is set to decide whether to approve the pulmonary arterial hypertension drug known as sotatercept by March 26. If approved, the drug could generate $1.9 billion in sales in 2025, according to Leerink Partners analyst Daina Graybosch.

The subcutaneous treatment came to Merck by way of its $11.5 billion acquisition of Acceleron in 2021.

Sunil Patel

“We viewed [Acceleron] as a great Merck-type company to own, especially with their legacy of R&D,” Sunil Patel, Merck’s head of corporate development and business development & licensing, said in an interview.

For the past few years, the pharma giant has been amassing help from external biotechs to broaden its pipeline and prepare for the looming patent deadline for Keytruda, the cancer immunotherapy that had $25 billion in sales last year. It’s Merck’s most notable treatment to come from external innovation; Organon made the drug, known then as pembrolizumab, and was bought by Schering-Plough, which merged with Merck in 2009.

Now, Merck is once again hoping a drug that it bet billions of dollars on will lead a spate of approvals out of its promising late-stage pipeline. The company has put at least $50 billion toward business development since 2018. Aside from Covid-19 treatment Lagevrio, which was authorized in late 2021 and developed with Ridgeback Biotherapeutics, Merck’s dealmaking over the past few years has not produced another blockbuster medicine.

In three months, Merck could have another approval in patritumab deruxtecan, an antibody-drug conjugate it’s developing with Daiichi Sankyo, in certain forms of non-small cell lung cancer. The FDA set a decision date of June 26. As part of the $4 billion upfront deal, Merck is co-developing and co-commercializing three antibody-drug conjugates with the ADC powerhouse.

Merck also expects a late-stage race with Roche in the inflammatory market, stemming from its $10.8 billion acquisition of Prometheus Biosciences last year. It began a Phase III of Prometheus’ lead drug, now called tulisokibart or MK-7240, in ulcerative colitis last fall. Meanwhile, the company also bagged a Phase I/II cancer drug via its more relatively modest $680 million acquisition of Harpoon Therapeutics earlier this year.

The acquisitions are likely to keep coming. Merck CEO Rob Davis said earlier this year the pharma is willing to spend as much as $15 billion on M&A.

It’s made more than 20 biotech acquisitions in the past 10 years, and that has led to at least 17 compounds that have been approved or are in mid- and late-stage development, Patel said.

“This current management team is deeply rooted in the legacy of this company. They understand the importance of building a long-term sustainable future, and they’re just not afraid to make the bold scientific bets,” he said.

Last year, Merck adjusted the way it calculates R&D spending to factor in M&A and licensing costs, and doing so catapulted the company to the top of Endpoints News 2023 pharma R&D expenditure list.

But not all deals have been smooth. Merck discontinued a Covid-19 treatment candidate from its 2020 acquisition of OncoImmune. And a chronic cough drug that it gained through its 2016 acquisition of Afferent Pharmaceuticals has twice been rejected by the FDA. The drug has been approved in Europe, Switzerland and Japan.

All told, Merck inks about 80 to 100 business development transactions per year, Patel said. That includes licensing pacts and early-stage collaborations, like a $1 billion biobuck-loaded deal for new biologics with Pearl Bio that it announced last week.

“Once we get through the science, we act decisively and very rapidly to bring the right type of BD structure,” said Patel, who’s been at Merck Research Laboratories for 25 years.

Dean Li

About 80 employees search and evaluate potential transactions, which are then presented to a committee led by Dean Li, president of Merck Research Laboratories. Li joined Merck in 2017 from the University of Utah Health, where he co-founded biotechs such as Recursion and Hydra Biosciences.

“It’s seamless between Merck Research Labs and the BD unit. We’re just one simple group that operates with the one pipeline mentality,” Patel said.

About 60% of the Acceleron team remains at Merck.

“That’s a testament to how we can integrate these teams and how we embrace the science that we’re acquiring,” he said.

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Key Events This Week: Central Banks Galore Including A Historic Rate Hike By The BOJ

Key Events This Week: Central Banks Galore Including A Historic Rate Hike By The BOJ

According to DB’s Jim Reid, "this could be a landmark…

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Key Events This Week: Central Banks Galore Including A Historic Rate Hike By The BOJ

According to DB's Jim Reid, "this could be a landmark week in markets as the last global holdout on negative rates looks set to be removed as the BoJ likely hikes rates from -0.1% tomorrow." That will likely overshadow the FOMC that concludes on Wednesday that will have its own signalling intrigue given recent strong inflation. We also have the RBA meeting tomorrow and the SNB and BoE meetings on Thursday to close out a big week for global central bankers with many EM countries also deciding on policy. We’ll preview the main meetings in more depth below but outside of this we have the global flash PMIs on Thursday as well as inflation reports in Japan (Thursday) and the UK (Wednesday). US housing data also permeates through the week as you'll see in the full global day-by-day week ahead at the end as usual.

Let’s go into detail now, starting with the BoJ tomorrow. We’ve had negative base rates now for 8 years which if is the longest run ever seen for any country in the history of mankind. In fact it is doubtful that pre-historic man was as generous as to charge negative interest rates on lending money prior to this! It also might be one of the longest global runs without any interest rate hikes given the 17 year run that could end tomorrow. So, as Reid puts it, a landmark event.

DB's Chief Japan economist expects the central bank to revise its policy and abandon both NIRP and the multi-tiered current account structure and set rates on all excess reserves at 0.1%. He also sees both the yield curve control (YCC) and the inflation-overshooting commitment ending, replaced by a benchmark for the pace of the bank’s JGB purchasing activity. The house view forecast of 50bps of hikes through 2025 is more hawkish than the market but risks are still tilted to the upside. On Friday, the Japan Trade Union Confederation (Rengo) announced the first tally of the results of this year's shunto spring wage negotiation. The wage increase rate, including the seniority-based wage hike, is 5.28%, which was significantly higher than expected. This year will probably see the highest wage settlements since 1991 which given Japan’s recent history is an incredible turnaround. This wage data news has firmed up expectations for tomorrow.

With regards to the FOMC which concludes on Wednesday, DB economists expect only minor revisions to the meeting statement that saw an overhaul last meeting. With regards to the SEP, the growth and unemployment forecasts are unlikely to change but the 2024 inflation forecasts potentially could; elsewhere, expect the Fed to revise up their 2024 core PCE inflation forecast by a tenth to 2.5%, although they see meaningful risks that it gets revised up even higher to 2.6%. In our economists' view, a 2.5% core PCE reading would allow just enough wiggle room to keep the 2024 fed funds rate at 4.6% (75bps of cuts). However, if core PCE inflation were revised up to 2.6%, it would likely entail the Fed moving their base case back to 50bps of cuts, as this would essentially reflect the same forecasts as the September 2023 SEP.

Beyond 2024, DB expect officials to build in less policy easing due to a higher r-star. If two of the eight officials currently at 2.5% move up by 25bps, then the long-run median forecast would edge up to 2.6%. This could be justified by a one-tenth upgrade to the long-run growth forecast. After all this information is released the presser from Powell will of course be heavily scrutinised, especially on how Powell sees recent inflation data. Powell should also provide an update on discussions around QT but it is unlikely they are ready yet to release updated guidance.

One additional global highlight this week might be a big fall in UK inflation on Wednesday, suggesting that headline CPI will slow to 3.4% (vs 4% in January) and core to 4.5% (5.1%). Elsewhere there is plenty of ECB speaker appearances including President Lagarde on Wednesday. They are all highlighted in the day-by-day guide at the end.

Courtesy of DB, here is a day-by-day calendar of events

Monday March 18

  • Data: US March New York Fed services business activity, NAHB housing market index, China February retail sales, industrial production, property investment, Eurozone January trade balance, Canada February raw materials, industrial product price index, existing home sales

Tuesday March 19

  • Data: US January total net TIC flows, February housing starts, building permits, Japan January capacity utilization, Germany and Eurozone March Zew survey, Eurozone Q4 labour costs, Canada February CPI
  • Central banks: BoJ decision, ECB's Guindos speaks, RBA decision
  • Auctions: US 20-yr Bond ($13bn, reopening)

Wednesday March 20

  • Data: UK February CPI, PPI, RPI, January house price index, China 1-yr and 5-yr loan prime rates, Japan February trade balance, Italy January industrial production, Germany February PPI, Eurozone March consumer confidence, January construction output
  • Central banks: Fed's decision, ECB's Lagarde, Lane, De Cos, Schnabel, Nagel and Holzmann speak, BoC summary of deliberations
  • Earnings: Tencent, Micron

Thursday March 21

  • Data: US, UK, Japan, Germany, France and Eurozone March PMIs, US March Philadelphia Fed business outlook, February leading index, existing home sales, Q4 current account balance, initial jobless claims, UK February public finances, Japan February national CPI, Italy January current account balance, France March manufacturing confidence, February retail sales, ECB January current account, EU27 February new car registrations
  • Central banks: BoE decision, SNB decision
  • Earnings: Nike, FedEx, Lululemon, BMW, Enel
  • Auctions: US 10-yr TIPS ($16bn, reopening)
  • Other: European Union summit, through March 22

Friday March 22

  • Data: UK March GfK consumer confidence, February retail sales, Germany March Ifo survey, January import price index, Canada January retail sales

* * *

Finally, looking at just the US, Goldman notes that the key economic data releases this week are the Philadelphia Fed manufacturing index and existing home sales reports on Thursday. The March FOMC meeting is on Wednesday. The post-meeting statement will be released at 2:00 PM ET, followed by Chair Powell’s press conference at 2:30 PM. There are several speaking engagements from Fed officials this week, including Chair Powell, Vice Chair for Supervision Barr, and President Bostic.

Monday, March 18

  • There are no major economic data releases scheduled.

Tuesday, March 19

  • 08:30 AM Housing starts, February (GS +9.4%, consensus +7.4%, last -14.8%); Building permits, February (consensus +2.0%, last -0.3%)

Wednesday, March 20

  • 02:00 PM FOMC statement, March 19 – March 20 meeting: As discussed in our FOMC preview, we continue to expect the committee to target a first cut in June, but we now expect 3 cuts in 2024 in June, September, and December (vs. 4 previously) given the slightly higher inflation path. We continue to expect 4 cuts in 2025 and now expect 1 final cut in 2026 to an unchanged terminal rate forecast of 3.25-3.5%. The main risk to our expectation is that FOMC participants might be more concerned about the recent inflation data and less convinced that inflation will resume its earlier soft trend. In that case, they might bump up their 2024 core PCE inflation forecast to 2.5% and show a 2-cut median.

Thursday, March 21

  • 08:30 AM Current account balance, Q4 (consensus -$209.5bn, last -$200.3bn)
  • 08:30 AM Philadelphia Fed manufacturing index, March (GS 3.2, consensus -1.3, last 5.2): We estimate that the Philadelphia Fed manufacturing index fell 2pt to 3.2 in March. While the measure is elevated relative to other surveys, we expect a boost from the rebound in foreign manufacturing activity and the pickup in US production and freight activity.
  • 08:30 AM Initial jobless claims, week ended March 16 (GS 210k, consensus 215k, last 209k): Continuing jobless claims, week ended March 9 (consensus 1,815k, last 1,811k)
  • 09:45 AM S&P Global US manufacturing PMI, March preliminary (consensus 51.8, last 52.2): S&P Global US services PMI, March preliminary (consensus 52.0, last 52.3)
  • 10:00 AM Existing home sales, February (GS +1.2%, consensus -1.6%, last +3.1%)
  • 02:00 PM Federal Reserve Vice Chair for Supervision Barr speaks: Federal Reserve Vice Chair Michael for Supervision Barr will participate in a fireside chat in Ann Arbor, MI with students and faculty. A moderated Q&A is expected. On February 14, Barr said the Fed is “confident we are on a path to 2% inflation,” but the recent report showing prices rose faster than anticipated in January “is a reminder that the path back to 2% inflation may be a bumpy one.” Barr also noted that “we need to see continued good data before we can begin the process of reducing the federal funds rate.”

Friday, March 22

  • 09:00 AM Fed Reserve Chair Powell speaks: The Federal Reserve Board will host a Fed Listens event in Washington D.C. on “Transitioning to the Post-Pandemic Economy.” Chair Powell will deliver opening remarks. Vice Chair Phillip Jefferson and Fed Governor Michelle Bowman will moderate conversations with leaders from various organizations. On March 6, Chair Powell noted in his congressional testimony that if the economy evolves broadly as expected, it will likely be appropriate to begin dialing back policy restraint at some point this year.
  • 12:00 PM Federal Reserve Vice Chair for Supervision Barr speaks: Federal Reserve Vice Chair for Supervision Michael Barr will participate in a virtual event on “International Economic and Monetary Design.” A moderated Q&A is expected.
  • 04:00 PM Atlanta Fed President Bostic (FOMC voter) speaks: Atlanta Fed President Raphael Bostic will participate in a moderated conversation at the 2024 Household Finance Conference in Atlanta. On March 4, Bostic said, “I need to see more progress to feel fully confident that inflation is on a sure path to averaging 2% over time.” Bostic also noted, “I expect the first interest rate cut, which I have penciled in for the third quarter, will be followed by a pause in the following meeting.”

Source: DB, Goldman, BofA

Tyler Durden Mon, 03/18/2024 - 09:59

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