Chemistry Manufacturing and Controls Development, Industry Reflections on Manufacture, and Supply of Pandemic Therapies and Vaccines

This publication provides some industry reflections on experiences from the Chemistry, Manufacturing, and Controls (CMC) development and manufacture and supply of vaccines and therapies in response to the COVID-19 pandemic. It integrates these experiences with the outcomes from the collaborative work between industry and regulators in recent years on innovative science- and risk-based CMC strategies to the development of new, high-quality products for unmet medical needs. The challenges for rapid development are discussed and various approaches to facilitate accelerated development and global supply are collated for consideration. Relevant regulatory aspects are reviewed, including the role of Emergency Use/Conditional Marketing Authorizations, the dialogue between sponsors and agencies to facilitate early decision-making and alignment, and the value of improving reliance/collaborative assessment and increased collaboration between regulatory authorities to reduce differences in global regulatory requirements. Five areas are highlighted for particular consideration in the implementation of strategies for the quality-related aspects of accelerated development and supply: (1) the substantial need to advance reliance or collaborative assessment; (2) the need for early decision making and streamlined engagement between industry and regulatory authorities on CMC matters; (3) the need to further facilitate 'post-approval' changes; (4) fully exploiting prior and platform knowledge; and (5) review and potential revision of legal frameworks. The recommendations in this publication are intended to contribute to the discussion on approaches that can result in earlier and greater access to high-quality pandemic vaccines and therapies for patients worldwide but could also be useful in general for innovative medicines addressing unmet medical needs.

Genetic variations among SARS-CoV-2 strains isolated in China

The rapid spread of COVID-19, which has led to a global pandemic, has placed public health systems under severe pressure. Identifying variations in SARS-CoV-2 strains from different regions is a key factor for understanding the pathogenic mechanisms, aid in diagnosis, prevention and therapy of this disease. The present study is an analytical descriptive study aimed to determine genetic variations among SARS-CoV-2 strains isolated in China. Sixty six complete genome sequences of the virus were retrieved from NCBI, the sequence of original Wuhan strain accession number NC 045512 was used as the reference sequence. Each genome sequence was blasted against the original Wuhan strain; the analysis was done using NCBI Nucleo-blast. The collected sequences showed 10 different variants. One hundred and thirty four mutations were identified among the variants of SARS-CoV-2 in this study; most of them 52.2% (70/134) were missense point mutation, majority of the mutations 65.7% (88/134) occurred in the open reading frame a/b (ORFab), few mutations occurred in the structural viral genome, each of spike (S) gene and nucleocapsid (N) gene showed 4 mutations; 2 silent point mutations and 2 missense point mutations occurred in each gene whereas membrane (M) gene showed silent point mutation and no mutation observed in the envelope E gene. The remarkable observation in this study showed by Yunnan variant accession number MT226610 which exhibited high incidence of mutations, it displayed 28 different point mutations; only 3(10.7%) of them were silent mutations while the rest were missense mutations. Our analysis showed several mutations including spike S gene and membrane M gene which may be responsible for a change in the structures of target proteins.

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SARS-CoV-2 genome showed genetic mutations that affect the viral protein structures and functions.

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Mutation in the open reading frames do not affect the viral genome directly but may contribute with high pathogenicity and mortality rate.

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High mutated variant of with 28 different point mutations (Yunnan variant Accession # MT226610) was detected in the SARS-CoV-2 variant, leading to difficulty in developing of the vaccines.

Necessity of brain imaging in COVID-19 infected patients presenting with acute neurological deficits

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Overlap with respiratory and neurological symptoms in the COVID-19 population.

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Obtain early head imaging in COVID-19 patients with a poor neurological exam.

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COVID-19 patients can develop CVAs and may benefit from neurosurgical interventions.

Background

Patients undergoing cardiopulmonary stabilization in the intensive care unit for novel coronavirus (COVID-19) are often sedated, placing timely assessment of a neurological decline at risk.

Case description

Here, we present two cases of COVID-19 infected young patients transferred to our facility in a cardio-pulmonary crisis, with a poor neurological exam. While there was significant delay in obtaining brain imaging in the first patient, the second patient had timely recognition of her ischemic infarct, underwent emergent surgery, and is now doing well.

Conclusions

These cases highlight the importance of early head imaging in COVID-19 patients with a poor neurological exam. While lungs remain the primary target of COVID-19, these cases alert the medical community to suspect involvement of the central nervous system, since there may be life-saving surgical interventions available.

In-hospital airway management of COVID-19 patients

Those involved in the airway management of COVID-19 patients are particularly at risk. Here, we describe a practical, stepwise protocol for safe in-hospital airway management in patients with suspected or confirmed COVID-19 infection.

Otolaryngology Resident Practices and Perceptions in the Initial Phase of the U.S. COVID-19 Pandemic

OBJECTIVE

The coronavirus 2019 (COVID-19) pandemic has had widespread implications on clinical practice at U.S. hospitals. These changes are particularly relevant to otolaryngology-head and neck surgery (OHNS) residents because reports suggest an increased risk of contracting COVID-19 for otolaryngologists. The objectives of this study were to evaluate OHNS residency program practice changes and characterize resident perceptions during the initial phase of the pandemic.

STUDY DESIGN

A cross-sectional survey of U.S. OHNS residents at 81 programs was conducted between March 23, 2020, and March 29, 2020.

RESULTS

Eighty-two residents from 51 institutions (63% of invited programs) responded. At the time of survey, 98% of programs had enacted policy changes to minimize COVID-19 spread. These included filtered respirator use for aerosol-generating procedures even in COVID-19-negative patients (85%), decreased resident staffing of surgeries (70%), and reduced frequency of tracheotomy care (61%). The majority of residents (66%) perceived that residents were at higher risk of contracting COVID-19 compared to attendings. Residents were most concerned about protective equipment shortage (93%) and transmitting COVID-19 to patients (90%). The majority of residents (73%) were satisfied with their department's COVID-19 response. Resident satisfaction correlated with comfort level in discussing concerns with attendings (r = 0.72, P < .00001) and inversely correlated with perceptions of increased risk compared to attendings (r = -0.52, P < .00001).

CONCLUSION

U.S. OHNS residency programs implemented policy changes quickly in response to the COVID-19 pandemic. Sources of resident anxieties demonstrate the importance of open communication and an integrated team approach to facilitate optimal patient and provider care during this unprecedented crisis.

LEVEL OF EVIDENCE

4. Laryngoscope, 130:2550-2557, 2020.