As we are acutely aware, the Covid virus is widely impacting the lives of China's population. With variants expected to emerge, and in the health interests of our readers, we have again taken the liberty to republish here Ho Ching's recent post on her Facebook page

Some folks have received their notification from MOH that they can go register or book to get their bivalent shots. So should they?
Simple answer is: Yes! Please go get your bivalent shot as soon as you can.
Do so if you are 12 years and older.
And preferably get the Pfizer bivalent shot which is already available in Sg since Monday 12 December more than a week ago.
Why?
This is bcos the highest risk period for folks in Sg is the next 4 months, possibly up to 6 months.

We need to be well prepared for the BF.7 which is currently raging in Beijing, and expected to be sweeping through China in successive waves for the next 3-4 months.

We need also to be prepared in case some other new and potentially more dangerous variants pops up anywhere in the world during the winter surges.

Having an up to date bivalent now, gives us all the best protection over the next 5-6 months. This just in time for the arrival of BF.7 or any other new winter variant/s that could emerge in the next 1-3 months.

**What does it mean to vaccinate “as soon as you can”?**

Just 3 timelines to remember:

• One is if you had a recent covid infection less than 3 months ago. If so, then wait 3 months after a covid infection before taking a covid vaccine shot.

• Two is if you have just taken some other vaccinations like flu or pneumococcal shots. If so, then wait 2 weeks, before taking the bivalent covid shot.

True, in some countries, people are authorized to take flu shots together with their covid shots. However, Sg is more cautious and advises a lag of 2 weeks between the different types of vaccination shots.

• Three is if your last primary series or minimum protection shot was done less than 5 months ago. If so, then wait for the 5-month mark.
Of all these 3 timelines or dates, you are eligible to take a bivalent shot based on or after the latest of these dates.

HoChing12.22

**What else?**

Four groups of people should go sooner than later:
- older adults and seniors, esp the elderly;
- younger people with stable chronic conditions;
- immuno-compromised people
- unvaccinated or partially vaccinated folks.

First are older adults in their 50s, seniors in their 60s and 70s, or older, and esp the elderly in their 80s and older.

The older folks are at increasing risks that shoot up exponentially with age.

Esp for seniors and even more so for the elderly, their last shots are likely to be more than 12 months ago as they were among the first to complete their primary as well as their minimum protection shots in 2021.

Over 90-92% of our seniors in their 60s, 70s, 80s and older, have had their minimum protection shots done. Kudos to the seniors and everyone who helped to achieve this high level of protection for our most vulnerable folks, namely our seniors.

"On a macro basis, Sg is likely to face the highest risk over the next 3-4 months, from new highly highly infectious BF.7 variant now sweeping across China, or some other new winter variants which can emerge from anywhere in the next 1-3 months.

"And so having an up to date Pfizer bivalent shot now will offer the best preemptive protection esp for the next 4-6 months."
The minimum protection shots are either 3 shots of mRNA or 4 shots of inactivated virus vaccines (IIVs).

However, only 60+% are up to date, with their last vaccination done less than 12 months ago.

This means over 30+% took their last shots more 12 months ago – their protection against infection would likely be minimal, though their protection may still be good against severe or fatal outcomes from a covid infection.

These seniors would urgently need to get a bivalent shot to refresh or retrain their immune system to be more ready for the newer variants that are coming.

Even for the older folks, 50 years and up, who have had their vaccine shots less than 12 months ago, but over 5 months ago, esp those in their 70s and 80s and older, it is highly recommended that they go for the bivalent shots soon, rather than wait for the 12-month mark.

This is bcos the bivalent vaccines help broaden the immune system training to be more ready for the new variants that are coming soon, likely before the CNY in January, and also bcos protection against infection would likely wane after 6 months esp among older people.

The 2nd group are those with underlying chronic conditions affecting vital organs like heart, lungs, kidney, liver, or brain; or those with other systemic chronic conditions like hypertension, the risks from covid infection are higher.

Such folks should go sooner than later, as their risk from an infection is higher than their counterparts without such underlying medical conditions.

The 3rd group are the immuno-compromised. Such folks have low immune response, and will likely get very sick if they get infected.

These include genetic cases, transplant patients, as well as cancer patients under active treatment.

Genetic cases can include the very young, while transplant patients likely need to take immune suppressant drugs for their entire life.

Such folks (or their parents/guardians) should discuss with their doctors how best to get their vaccinations done, eg with an additional dose or to vaccinate in between their medical treatment dosages. Or be prepared for other treatment like antivirals or monoclonal antibodies, or prophylactic support like monoclonal antibodies such as the long lasting antibodies which can last up to about a year.

While the vaccine is safe for such folks, the vaccines may not trigger the training of their weakened immune response, and so they may be better off looking for other forms of protection.

There is yet another group of immunocompromised – these are cancer patients undergoing active treatment like chemotherapy.
Such chemotherapy could suppress their immune response.

No point vaccinating when the immune system is too weak to be trained, right?

So any vaccination should be done between cycles when their immune response has bounced back to normal, or after completion of their chemo treatment. Again, the planning for covid vaccines should be done in consultation with and under the supervision of their cancer doctors too.

Again, the vaccines are generally safe for such folks. It is just the need to plan for shots to be done when it is most effective in sparking a defensive response.
Recovered cancer patients, or those in stable condition, can freely and safely take the vaccination, if they are already freely living a normal life without worries about low white blood count from cancer treatments.

If in doubt, immunocompromised folks should discuss with their specialist doctors for an informed opinion specific to their own particular situation and condition.

The 4th group are the unvaccinated or partially vaccinated folks.

The adult population in Sg are well vaccinated for all age groups, with primary shots for over 95% coverage or better for all age groups. Interestingly, the minimum protection coverage is better for older folks than for the younger folks.

Primary shots are 2 shots of mRNA or Novavax, or 3 shots of IIVs like SinoPharm or Sinovac. Minimum protection shots are 3 shots of mRNA or Novavax, or 4 shots of IIVs.

Less than 90% of younger adults have minimum protection coverage, though well over 95% or more have had their primary series. Nonetheless, well over 80% of the younger adults have been up to date, with minimum protection coverage and last shot within the last 12 months.

Depending on age group, the younger adults have between 10-15% without 3rd shots of mRNA or 4th shot of IIV.

With the likely arrival of the BF.7 within weeks into Sg, it is good for these younger folks to complete their minimum protection booster shots if they have not already done so.

And for those who have already done their 3rd shot of mRNA or equivalent, they would need to simply wait for the MOH reminder when they would be eligible for their bivalent shot, to be better prepared for the BF.7 or other newer variants which may pop up over the winter months.

There are also some folks who can’t take their shots bcos of severe allergic reactions like anaphylaxis. For these folks, they could discuss with their doctors whether to switch to a different vaccine like the Novavax vaccine or an IIV.

A tiny minority may have other autoimmune response, and should make a judgment together with their specialist doctors how best to protect themselves.

There are still folks who don’t have any contraindications for vaccination, who are still fearful.

To-date, we have had billions of shots already given, without any news of hospitals being overwhelmed by deaths, or folks turning into automatons.

Instead, what we do have are clear evidence that whenever there are waves affecting cities with no or low vaccination coverage, we would see the hospitals overwhelmed and the mortuaries overflowing.

So it is clear that the risks from Covid are clear and present, while the risks from vaccination are much much less. For most people, it would be no more than 2-3 days of discomfort, which are much more tolerable than those from a covid infection.

**When and how to get bivalent shots?**

In summary, everyone 12 and older are eligible, either 5 months after their last covid shot, or 3 months after a covid infection, or 2 weeks after a different vaccine shot.

"It may be better to go for the Pfizer bivalent, and go for it as soon as we are eligible esp if we are 50 or older, or if we have additional underlying risks, or our last covid shot was more than 12 months old, or even more than 9 months old."
Check for the latest of these conditional dates for yourself - that would be the earliest you can go for your bivalent shot.

Currently, anyone who is 50 and older, can walk into any joint vaccination & testing centre for their bivalent shot.

Those younger than 50 need to book their shots as soon as they receive a notification from MOH.

MOH will begin to notify folks to pace and phase the bivalent shots, starting from the older folks who are at higher risks, and work their way down towards the younger folks who are at lower risks.

Bivalent shots are now also open for the primary series (2 shots mRNA) and for the minimum protection shots (3rd shot after 2 mRNA or 4th shot after 3 IIV).
This means for folks can go straight for bivalent shots, if they haven’t had their vaccinations yet, or they can go for the bivalent for their next shot, if they are halfway through their 1st 3 shots.

Folks who have had their first 3 IIV shots are strongly advised to take their 4th or subsequent shot using the bivalent shots too.

**Why bivalent shots?**

Whether the BQ.1 or BQ.1.1 parent-child variants from USA, or the BF.7 from China, these are all great or great-great grand-descendants of the BA.5 which was the wave that swept through the world including Sg, around mid-2022.

The Pfizer bivalent authorized and now available in Sg covers the original covid virus and the BA.5 virus.

Since the BQ.x and the BF.7 are all great or great-great grand descendants of the BA.5, it stands to reason that the Pfizer bivalent could offer perhaps just a bit more fit in working up our immune response to be ready for the latest BF.7 from China that is expected to come into Sg soon, or the earlier BQ.x directly or indirectly from the USA.

The BQ.x is probably already in Sg, and may even be declining given the latest weekly growth ratio that is declining in the last few days after shooting up above 1 recently.

The earlier Moderna bivalent available in Sg covers the original covid virus, and the original Omicron BA.1 virus.
It is still good in stimulating a wide ranging response compared to the original single target vaccine, but it has a slightly higher dosage (50ug vs 30 ug for Pfizer), and is targeting an earlier ancestor of the Omicron family.

Hence, if there is a choice, it may be better to go for the Pfizer bivalent, and go for it as soon as we are eligible esp if we are 50 or older, or if we have additional underlying risks, or our last covid shot was more than 12 months old, or even more than 9 months old.

**Eh? Did we just see a mini BQ wave in Sg?**

Yup, the last XBB wave that started a few months ago in Sg is likely to have died down, or will die down soon.

We know that over the last couple of months, the weekly growth ratio for the XXB grew, as it supplanted the BA.5.

The XBB weekly ratio went over 1, and then started declining rapidly to below 1. That was good!

Then this XBB weekly ratio stopped declining, and was bouncing around 0.75 for a few weeks. Actual new infection numbers continue to go down but at a slower pace than expected.

What is happening?
In the earlier waves, like Delta, or the earlier Omicron waves, we saw weekly growth ratios dropping down to around 0.5 before they stuttered and went up again with waves of new variants supplanting the old.

In the XBB wave, the weekly growth ratio didn’t continue their decline down to 0.5 or weekly halving level. Instead, the ratio began stuttering around 0.75 for quite a number of weeks.

What this means is that there was probably a hidden new wave growing underneath, even as the XBB continues to decline and die down.

This hidden wave is likely to be the BQ.1 and BQ.1.1 from the USA, probably coming into Sg from all directions, given the most countries are now open and relaxed.
As the BQ.x wave grows, it counterbalances the fall in the XBB wave, and so the weekly growth ratio ended up stuttering around 0.75 for a few weeks.
This is as if someone is tapping on the brakes, rather than press the brakes full on continously.

Then the weekly growth ratio started climbing and even broke through to over 1.

Oops! This means a growth in actual new case numbers.

This likely means that the XBB has become extinct already or will be soon, and we were seeing the hidden BQ.1/BQ.1.1 wave pattern itself rising.

Over the last few days, the weekly growth ratio has started dropping down now to the 0.9+ range. This weekly ratio could go down further, accelerating the speed of fall of the BQ.x parent/child pair in Sg assuming the BQ.x has peaked in a mini wave.

If indeed we have already seen a small BQ.x wave towards the tail end of the XBB wave, it is likely due to our population resilience from the successive waves of Delta wave last year, and the multiple Omicron waves this year, including the most recent BA.5 and the XBB waves.

All these on top of a high vaccination coverage that was still very current when we faced the Delta and the earlier Omicron waves, help a lot to build resilience as we face successive waves, and then see off a small BQ wave!

So if these were all there is happening, then we should be fine, and don’t have to worry about getting a bivalent vaccine to keep up to date.

**Why could the next 3-4-6 months bring heightened risks for Sg?**

On a macro basis, Sg is likely to face the highest risk over the next 3-4 months, from new highly highly infectious BF.7 variant now sweeping across China, or some other new winter variants which can emerge from anywhere in the next 1-3 months.

And so having an up to date Pfizer bivalent shot now will offer the best preemptive protection esp for the next 4-6 months.

China saw the emergence of the BF.7 in their Inner Mongolia province over the last few weeks.

Like the BQ.1 and BQ.1.1 parent-child pair of Omicron variant from the USA, the BF.7 is also a great or great-great grandchild variant of the BA.5 that hit Sg around mid-2022.

This highly infectious BF.7 is estimated to have highly highly infectious R0 of between 10 and 18+.

This means each BF.7 case infects another 10-18+ others.

The average R0 of all the previous covid variants are about 5-6, with the Delta and the earlier Omicron more like the 5-8, even 9 level.

So when we expected the original Omicron to infect everyone sooner or later, these later Omicron BA.5 great or great-great grand descendant variants and combination variants are even more infectious.

The speed at which the BF.7 seems to be sweeping through Beijing currently seems a lot faster than other covid waves elsewhere. Perhaps it is a function of the high R0, or perhaps it is due to the relatively covid naïve status of the China population compared to populations in the rest of the world.
As the wave in Beijing dies down, the wave in Shanghai will rise next.

And so as the BF.7 ricochets from town to town, city to city, province to province, in China, it could take 3-4 months of very huge numbers of infection to sweep through China before dying down.

Net net, we should expect multiple waves to sweep through China over the next 3-4 months.

At the same time, this infectious BF.7 must leak through to the rest of the world.

In this huge wave hitting what is largely a covid naive population, that is not so well vaccinated, or with last shots done mostly over 12-18 months ago, we can also expect higher risks of new variants emerging in China.

Meanwhile, USA is going through a triple epidemic of flu, covid and RSV – that could also raise the risk of new winter variants. Ditto with various other places in the throes of a winter surge.

The Delta variant showed that it is possible to have both a more infectious variant that is also more dangerous as well.
For instance, Delta infections caused 30% more stillbirths than the earlier Covid variants, with R0 at least double that of the original Covid virus. So Delta was both more infectious and more deadly.

The infectivity mutations can happen independently of the deadliness or virulence mutations, with deadlier outcomes from a more infectious variant or a more evasive variant.

With the huge waves from BF.7 in China and going out of China, on top of the BQ.1/BQ.1.1 in USA/Europe, as well as potentially the XBB waves elsewhere, we have millions of infected people actually as bioreactors to stir, mix and perhaps create more variants or even combination variants like the XBB.
There is a risk that a new more infectious AND more virulent variant could appear.

Any new emerging variants are all likely to be great great great grand descendants of the BA.5 variant.
Hence, the next 3-4 months could be critical to have updated vaccination protection.

**Why does it matter to have a bivalent as soon as possible?**

First and foremost, the BF.7 is likely to enter Sg at a time when we are enjoying our festivities and activities around Christmas, New Year and CNY in quick succession.

So having a recent and up to date Pfizer bivalent vaccine (or Moderna bivalent for that matter), will be a strong preemptive protection ahead of both the BF.7 and any other new variants that could come along.

True, our more recent BA.5 and the XBB and possibly BQ.x waves would have added to our immune resilience against the BQ.7, unlike the highly covid naïve population in China.

But with the very high infectivity of the BF.7, it is much better to be ready with a more recent bivalent vaccine shot, that is less than 5 months old.
Hence, all in all, it is better for everyone to go for the Pfizer bivalent as soon as we are eligible rather than wait.

Earlier, as the Pfizer bivalent was still not available, we would have recommended going for the Modern bivalent – no fish, prawn also good, right?
By doing the bivalent as soon as possible, we can also better weather any new variants popping into our midst, esp with the various festivities and activities of Christmas, New Year, and CNY over the next several weeks.

With good overall up to date bivalent coverage, we could also likely reduce the numbers and peaks of infection wave, even for the highly infectious BF.7. This in turn will reduce the risk of our more vulnerable folks catching an infection. It is our collective way of protecting vulnerable among us who are unable to get vaccinated or for whom vaccination does not stimulate enough protective immune response.

By flattening the speed and peak of the wave, as well as the overall numbers, we are also likely to avert any pressures on our healthcare system and personnel, and so enable all patients to get their medical care in a timely manner.

Net net, it makes sense for both the individual and the community for all over us to get updated sooner than later, given the threat of the BF.7 and other possible new VOCs that may pop up during this winter.

Keep well, everyone, and let’s give ourselves one more shot for ourselves, our families and the vulnerable among us.

Ho Ching was CEO of Temasek Holdings for 17 years and is the spouse of Prime Minister Lee Hsien Loong. She posts frequently on her Facebook page here.

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