Q: Should we mix-and-match Covid vaccines?

A: Possibly, and data is increasing to support this policy.

A "mix-and-match" vaccines policy has increasing science behind it. The scientific term is "heterologous prime boost" (thelancet.com/journals/lance……, from Oxford).

1/4 Another recent study from Spain shows good results: nature.com/articles/d4158….

Many other countries are considering it in real-world practice: reuters.com/world/middle-e…

The concept of "mix-and-match vaccines" is not new, going as far back as 1992: ncbi.nlm.nih.gov/pmc/articles/P…

2/4

🔺SURAT RUJUKAN🔺
Semasa saya bertugas sbg doktor, alat yg paling berkuasa bagi saya ialah Surat Rujukan.

Sejarah pesakit, pemeriksaan fizikal, ujian darah, MRI, ubat-ubatan dll memang penting. Tapi dlm pandangan saya, Surat Rujukan adalah lebih berkuasa.

Kenapa ye?
1/

https://twitter.com/DrKhorSK/status/1351460272100134912

Dua sebab penting:
🔺Saya tak mungkin tahu segala-gala ilmu & sains. Jadi, saya bergantung pada rakan sekerja yg lebih arif dlm bidang-bidang lain.
🔺Saya mungkin silap, jadi saya ingin kurangkan risiko itu.

Maka, Surat Rujukan akan menjaga kebajikan pesakit dgn lebih rapi.

2/

🔺“Doc, I don’t trust the Covid-19 vaccine because it’s too rushed. Normally, vaccines take 7-10 years.”🔺

Here is a thread to reassure you that the Covid-19 vaccine is as safe as possible, with only one year of effective & accelerated research.

1/15 Firstly, 7-10 years is not automatically safe. Most of it is spent waiting, not researching.

Scientists wait for money, for approvals by committees who meet twice a year, or for paperwork.

They also wait for patients to join their trials; this is a major wait.

2/15

A short story:
🔺A Funeral, Durians, SMEs & the Covid-19 Vaccines🔺

Had to organise a funeral (cause of death: lung cancer). Noticed dry ice being used.

Spoke with the undertaker, who told me that each dry ice brick is ~RM20, is -70 Celcius and lasts ~1-2 days.

1/5 Asked him about vaccine storage. He gave two ideas:
1. Ice-cream distributors have cold rooms reaching -20C.
2. Durian exporters to China use a freezing process reaching -80C.

Great ideas from a practical hands-on man!

2/5

BEBENANG: Mengapa 🇲🇾 tak boleh umumkan harga vaksin?

Situasi ini amat kompleks. Kita mesti mempertimbangkan hujah & realiti utk kedua-dua belah situasi ini.
🔺Bab 1: di LUAR kawalan kerajaan (Tweet 3-9)
🔺Bab 2. di DALAM kawalan kerajaan (10-16)
🔺Bab 3: ringkasan (17-18)

1/18 Pertama sekali, sedikit pengumuman:
1. Saya seorang perunding bebas.
2. Saya tak memiliki stok apa-apa sykt di mana-mana.
3. Saya bekerja di Pharma 8 tahun (2Y sbg Medical Manager di 🇸🇬 + 6Y sbg Ethics & Compliance Director di Dubai, Shanghai & Paris, utk EEMEA & China).

2/18

BEBENANG: 6 SEBAB mengapa 🇲🇾 perlukan portfolio vaksin drpd pelbagai syarikat, bukan drpd satu sykt sahaja:

1. Tiada sykt yg mampu bekalkan segala keperluan vaksin 🇲🇾. Kalaupun wujud, mesti setiap negara akan bersaing, & kita masih tak mampu bersaing dgn negara kaya.

1/12 2. Bahaya kalau kita bergantung pada satu sykt saja.

Mungkin ada kluster Covid-19 di kilang mereka. Mungkin ribut taufan melanda kilang mereka.

Mungkin mereka naikkan harga sbb ada kuasa monopoli. Atau mungkin vaksin mereka tak diluluskan NPRA.

2/12

Thread:

Why does 🇲🇾 need a portfolio of vaccines, instead of buying just one?
1. No one company can supply everything we need. If any single company can do that, then every country in the world will race for its supplies. Unfortunately, 🇲🇾 is not rich enough to win.

1/11 2. It’s dangerous to depend on one company only. E.g. a shortage of raw ingredients might disrupt their supply chain, a hurricane might damage their factories, or the company may raise prices as they have monopoly and leverage. Or the vaccine isn’t approved by NPRA.

2/11

Q: Is NPRA too slow to approve the vaccine?
A: Yes & No.

True Answer: This is not a practical question. Even if NPRA approves it today, the first vaccine batch will only arrive in Feb 2021. So, we have time to plan & work.

In this thread, I'll explore vaccine approvals. 1/n NPRA has a Priority Review (PR) process. This takes up to 120 working days and provides Full Registration for the vaccine.

Emergency Use Authorisation (EUA) in US, UK & Singapore is NOT Full Registration. It's a short-term limited use only, e.g. 6 months. It must be renewed. 2/n

#Budget2021 is NOT cutting health budgets, but is irregular (Part 2):

The Govt is using a different accounting treatment for health spending (e.g. buying medicines, dialysis etc) by decreasing OPEX & increasing DEVEX. Why?

1/n

https://twitter.com/DrKhorSK/status/1324973002459471873

1. In our fiscal rules = OPEX can be financed by revenue; DEVEX by revenue or borrowing.

2. Revenue (tax, Petronas etc) is likely to decrease in 2021.

3. So it’s logical to shift health spending from OPEX to DEVEX, so we can borrow money to pay for health.

2/n

#Budget2021 is NOT cutting health budgets. But it looks that way because the accounting treatment has changed.

1. Line Item 20000 is Services & Supply (see pic, in red). All are zeroes.

No Govt is so cruel/foolish to cut health spending to zero overnight. So where is the money? 2. The money is being reallocated from Operating Expenditure to Development Expenditure.

See pic of Services & Supplies, with 840% INCREASE in DEVEX & a 12% DECREASE in OPEX.

Two questions:
a. Why move from OPEX to DEVEX?
b. What is the breakdown in DEVEX, by category?

This week, I'll share interesting vaccine facts after 🇲🇾 joined COVAX. Today, it’s about global vaccine supplies.

The single biggest purchaser of vaccines in the world is not China or India.

It’s @UNICEF, buying >2 billion doses a year. @stefanswartpet is Head of Health there. In 2017, UNICEF purchased:
=~2.5 billion doses
=~25 vaccines
=for ~100 low and middle-income countries
=covering ~45% of all children <5 years old.

This massive purchasing power allows them to reduce unit prices (and is the same principle behind COVAX).

This week, I'll share some fun vaccine facts because 🇲🇾 joined COVAX.

Fact 2: there are ~10,000 diseases but only ~1500 treatments & ~30 vaccines.

How many diseases have been 100% eradicated by vaccines? Only one: smallpox, declared in 1980. (1/6) ~10,000 diseases? It's a rough number because “disease” could mean different things.

One resource is the International Classification of Disease 10th edition (ICD-10), managed by @WHO. It has ~70K codes!

Some are hilarious, like this pic. These are not diseases, of course.

The COVAX Facility aims to provide fair & equal access to the Covid vaccine for 7.8 billion people.

To commemorate 🇲🇾's entry into COVAX, I'll spend this week on some fun vaccine facts.

Fact 1: Edward Jenner discovered the concept of vaccination in 1796, ~220 years ago. (1/6) For many years, he heard stories that dairymaids don’t get smallpox if they’ve had cowpox previously. Dairymaids spend a lot of time with cows to make milk or cheeses in a dairy.

This pic is cowpox. (2/6)

RM10,014 per pax. That is Remdesivir’s list price for 🇲🇾.

2. It’s not even truly 100% effective. Trials only show “relatively modest clinical effect”.

3. @malaysianhc & @DNDi urged on 19 May that 🇲🇾 must lobby for access to Covid global public goods, like meds & vaccines.

https://twitter.com/nytimes/status/1277626387898216449

4. As 🇲🇾’s national Covid situation stabilises, it’s time to work globally to ensure that 🇲🇾 has equitable access to meds & vaccines when they are proven truly effective.

5. Decisions on Covid med prices must never be influenced by Wall Street or commercial considerations.

Difference between:
*Asymptomatic*✅Covid❌symptoms for entire disease. (~40-45% of all Covid cases). Therefore, 🇲🇾 might have ~14K total cases (not ~8K) because no symptoms = no test.

*Pre-symptomatic*✅Covid, but❌symptoms yet. Median time to symptoms: 4-5 days from exposure.

https://twitter.com/WHO/status/1270740973195341827

Ref 1: acpjournals.org/doi/10.7326/M2…

Ref 2: cdc.gov/coronavirus/20…

Drunk-drivers must be punished. But banning alcohol to stop deaths is like using a nuclear bomb to kill an ant.

In 2018, 0.85% of road traffic deaths were drunk-drivers. 61% of deaths were motorcyclists; should we ban 🏍️?

Solutions must be proportional to the problem. Harsher punishments may not fix the problem either; no point in having death penalty if it's too slow or not used often enough. Regular, predictable & swift enforcement is always better than harsh punishments that are never enforced.
(P/s I'm nearly teetotal).

APA ITU SEBUAH NEGARA?🇲🇾
1. Sains Politik: mesti ada kedaulatan dalaman (pilihanraya) & luaran (diiktiraf oleh negara lain).
2. Geopolitik: sempadan yg kukuh.
3. Instrumen: kerajaan mandiri, matawang & undang2 dikongsi.
4. Psikologi: identiti yg dikongsi

1/5 PERBEZAAN ANTARA NEGARA & “STATE” (Kenegaraan):
1. Negara = spt di atas.
2. “State” (mis. Persekutuan Malaysia) = unit pentadbiran yang diiktiraf (Kerajaan & YDP Agong Malaysia) untuk satu kawasan geografi (Malaysia).

PBB mempunyai “Member State”, bukan “Member Country”.

2/5

WHAT IS A COUNTRY? 🇲🇾
1. Political Science: must have Internal (elections) & External Sovereignty (recognised by other countries).
2. Geopolitics: secure borders.
3. Instruments: own government, currency, laws, etc.
4. Psychology: shared national identity or founding myth.

1/5 DIFFERENCE BETWEEN COUNTRY & STATE?
1. Country = see above.
2. State (e.g. Federation of Malaysia) = the legally recognised administrative unit (Government & King of Malaysia) of a geographic area (Malaysia).

The United Nations has Member States, not Member Countries.

2/5

Greetings, 🇲🇾ns. Please retweet:

“LOVING OUR PARENTS DURING COVID ❤”
Covid is dangerous if you're >60 yrs old. Many ways to love our parents, e.g.:
1. Avoid leaving home, but care for their mental health & exercise,
2. Avoid events & travel
3. Deliver groceries to them. There's no “one advice for all older adults”, as they are many in 🇲🇾! If they already have diseases, then we must care more closely.

Use your judgment to balance their unique needs & wants with reasonable Covid precautions. Don’t panic while loving them, coz they'll know! ❤

Salam, Rakyat prihatin 🇲🇾. Sila retweet bebenang:

"JOM JAGA WARGA EMAS! ❤"
Covid bahaya utk usia >60thn. Bynk cara utk sayangi ibubapa kita spt:
1. Elakkan keluar rumah jika tak perlu, tapi jaga mental health & senaman
2. Elakkan majlis & cuti
3. Beli barang runcit utk mereka. Susah nak bagi satu nasihat utk *semua* warga emas 🇲🇾, sbb ramai! Kalau ada penyakit dll, mestilah jaga lebih rapi.

Gunalah budi bicara utk mengimbangi keperluan & kehendak unik ibubapa kita DAN berjaga2 semasa Covid. Jgnlah panik bila menyayangi mereka, sbb mereka akan tahu! ❤

Salam Rakyat 🇲🇾 yg prihatin: sila retweet:

UJIAN UNTUK COVID:
Gelaja: demam, batuk, sesak nafas.
Takde? Selamat & tak perlu ujian.
Ade? Jumpa doktor.

Ujian tak diperlukan = pembaziran. 🇲🇾 perlu berjaga2 dgn kit ujian yg terhad, supaya masih ada lagi bila betul2 diperlukan. RAKYAT: kami faham anda gelisah, & kami ingin meyakinkan anda. Mencuci tangan & "social distancing" lebih baik drpd ujian Covid negatif, sbb anda masih boleh dijangkit esok (& takkan nak belanjakan RM500/ujian setiap kali jumpa doktor!).