On November 18, a 33-year-old patient came to meet Dr Angelique Coetzee, a private medical practitioner at her clinic in Pretoria, South Africa. Coetzee told the BBC, “He said to me that he’s just been extremely tired for the past few days and he’s got these body aches and pains with a bit of a headache.” But instead of a sore throat typical of the Delta variant, he had a ‘scratchy’ throat. There was no cough or loss of taste or smell.
Seven more patients arrived at her clinic with similar systems on the same day. “Something is going on,” suspected the blonde, bespectacled doctor who is the chairperson of the South African Medical Association and an advisor to the South African Health Ministry. The new cases were drastically different from the Delta variant, though their symptoms were very mild. The same symptoms were occurring in other Covid-19 patients. Coetzee decided to test them for the virus—the first doctor to spot the Omicron virus. On November 9, genome analysis of a specimen of SARS-CoV-2 taken from an infected patient in Botswana revealed a novel variant, initially dubbed B.1.1.529, later to be known as Omicron.
At this stage, not much is clinically or epidemiologically known about the variant. However, the mysterious part is that it is not related to any of the currently rampant strains like Delta or Alpha. The WHO is coordinating with many researchers in several countries to better understand how the variant will impact the current pandemic, with new findings expected within days or weeks.
The important questions that come to mind are many.
How fast does Omicron spread? Very.
How dangerous is it? The effects seen so far are mild. But there is not enough data.
Do the current vaccines work against it? Probably not. But research is ongoing and pharma companies are already tweaking existing products to counter the new variant.
With countries shutting borders and the WHO designating Omicron a variant of concern (VOC), should we panic? Probably not. “The Omicron variant is a call for action rather than panic. Mutations are a natural evolutionary outcome in any viral propagation. As and when any virus runs into a huge number of its hosts, it tends to lose amino acids or acquire amino acids change in the amino acid configuration, which may result in either deletion of an entire gene sequence or a changed gene sequence in the virus,” says Dr Satyanarayana Mysore, HOD and Consultant, Pulmonology, Lung Transplant Physician, Manipal Hospitals, Bengaluru, adding, “In the African subcontinent, the virus did go through a chain of transmission through immunocompromised patients, and the healthcare structure probably did not suffice to stop the transmission.”
He further explained for the WHO to label any virus as a VOC, a number of factors have to be met, such as increased transmission, change in the clinical symptoms or disease course, response to medications, change in the diagnostic approach, change with respect to the response to the vaccine, and the immune escape mechanism. The Omicron variant in India may actually lead to increased transmission, which is the only concern. There is no data that it will not respond to monoclonal antibodies and the coming weeks will be able to provide data.
How is Omicron different from Delta and other variants? Dramatically and unexpectedly different. Virologists make the mistake of assuming that future variants of concern would almost certainly descend from the Delta variant, which has been of late causing havoc over the past six months. Omicron has a large number of mutations—over 50 with 32 in the spike protein—allowing the virus to infect the body easily. “By virtue of this, it is expected to be more contagious which needs to be documented with epidemiological studies. However, there is no need to panic as the current evidence from South Africa suggests that the cases are mild and does not require ICU care,” says Prof GC Khilnani, Chairman, PSRI Institute of Pulmonary, Critical Care and Sleep Medicine, Delhi.
Trevor Bedford, a virus researcher, says the new strain’s genomic lineage is not from a recent Covid-19 variant, and its closest evolutionary connection is a SARS-CoV-2 strain detected way back in mid-2020. “This extremely long branch (> one year) indicates an extended period of circulation in a geography with poor genomic surveillance (certainly not South Africa) or continual evolution in a chronically infected individual before spilling back into the population,” Bedford tweeted. In the South African province of Gauteng, Omicron is reasoned to be responsible for taking up the R number (average number of people that one infected person will pass on a virus to) from around 1.5 to nearly 2. It is also being recorded in a growing number of countries outside Africa, such as the UK, Israel, Belgium, Canada, Australia, the Netherlands and Austria.
“Right now, it is most important to take action against the spread of fake news on social media platforms and news channels about Omicron because this spreads misinformation resulting in panic,” says Dr Vikas Maurya, HOD and Director, Pulmonology, Fortis Hospital, Shalimar Bagh, Delhi. According to Dr Rajesh Chawla, Senior Consultant, Pulmonology and Critical Care, Indraprastha Apollo Hospital, Delhi, as of now, we need to continue Covid-appropriate behaviour, focus on achieving the maximum vaccination numbers (as it protects from the severe manifestation of the virus), maintain social distancing and mask up for our safety, .
So why is there panic?
When the WHO announced Omicron was a VOC, there was panic across the globe. Financial markets dived. International borders were closed. Dr Anthony Fauci, America’s foremost virological expert who has served five US Presidents, said that Omicron is almost certainly already circulating in other countries around the world—Australia, Austria, Belgium, Botswana, the Czech Republic, Denmark, Germany, Hong Kong, Israel, Italy, the Netherlands, South Africa, and the UK, although the majority of suspected cases are people arriving from Africa. But the panic may be misplaced.
Doctors in areas experiencing an Omicron surge note that its impact is mild and the virus has mostly affected youth who generally show only moderate symptoms. The early response to Omicron has made meeting the challenge easier for governments and agencies. The massive surge of Delta in India, where it was first reported in October 2020, had claimed many lives by April 2021, until it was designated a VOC only in May. There was a gap of many months between preliminary detection and VOC designation for Alpha, which first made its appearance in the UK.
The world paid a massive price for the delay in registering the spread of the most fatal variant. But South Africa’s genomic surveillance system was so efficient that it caught Omicron on time before it became a global spreader. The tragic irony is that this makes information about the virus scarce. Said Fauci to The Washington Post, “It may turn out not to be nearly as much of a challenge as Delta was, or it might be worse. We don’t know. And that’s why it’s very tough to message that. Because you don’t want to panic people. But you don’t want to blow it off like it doesn’t have a potentially major problem. So you’ve got to prepare for the worst and hope it’s not going to be the worst at all.”
Is India prepared?
In 2017, the country’s national health policy had proposed raising government spending on health to 2.5 percent of GDP by 2025 but this has only marginally increased. It accounted for merely 1.3 percent of GDP in the fiscal year ending 2022. Even the government’s Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, one of the world’s largest public health insurance schemes, has not helped much. So how is India placed vis-a-vis the new strain? “We are better prepared but I cannot be certain. It will really depend on what this new wave is all about. Will the old variant be dominant or a new one? Will it be Omicron? The immunity from the current vaccination will continue to protect from the severity of the infection, hospitalisation and mortality, so in that way, we are prepared, but I am not sure the public health care system has enough manpower and flu clinics,” says Dr Sandeep Budhiraja, Group Medical Director - Max Healthcare and Senior Director - Institute of Internal Medicine, Delhi,
According to him, in the private sector, some of the big hospitals such as theirs are better equipped, especially with oxygen requirements, including LMOs (Liquid Medical Oxygen), O2 generators and concentrators.
Any virus exhibits three types of behaviour (phenotypes) that gauge how dangerous a new variant is. These are transmissibility (the rate of spreading from one person to another), virulence (the seriousness of symptoms) and immune evasion (the degree of protection a person receives from a vaccine or natural infection). Since their generic evolutionary dynamics are complex, it requires both real-time data and clinical laboratory experiments to assess the dangerous properties of a virus. Dr Shalini Joshi, Senior Consultant of Internal Medicine at Fortis Hospitals, Bannerghatta Road, Bengaluru, emphasises, “Two important questions that need to be answered at this crucial time are: is the disease caused by Omicron more serious than the Delta variant? Are the antibodies produced by Covid vaccines going to protect people against this variant? Till these two questions are answered, people should not pull back on their guard, but without panicking.”
Antibodies are produced in the body either by vaccines or as a result of previous infections. When it is under attack by the virus, it produces little molecules called antibodies that attach themselves to the spike protein of the virus, thereby blocking its entry into our cells and making us sick. But when a virus mutates, like it has with Delta and now Omicron, a change in the spike protein occurs, preventing antibodies from attaching to the spikes as effectively as before. The more the spike protein changes, the worse it is for existing antibodies to play their part.
Vinod Balasubramaniam, a virologist from Monash University in Malaysia, was quoted as saying that the Omicron mutations are prevalent in regions previously linked to increased transference and immune evasion. All the 32 mutations together will change the shape of the structure, inhibiting vaccine-induced immune response. Omicron’s 32 mutations include E484A, K417N and N440K, which have been noticed to aid virus to escape detection from antibodies. Another mutation, N501Y, increases the virus ability to enter human cells, thereby boosting transmission. Doctors speculate whether this could be a reason for the faster transmission of Omicron.
How well will current vaccines work against Omicron?
Experts are divided over this question. “So far there’s no empirical information that it evades vaccines. The current vaccines have been effective at defending against severe disease, hospitalisation and death, even for mutated variants of Covid. They are among the best in the history of vaccines. We have no reason to think that our vaccines will not be able to stand up to Omicron. Some modifications in the formulation may be required, but the idea will be basically the same,” says Dr Tobi Saidel, Epidemiologist and Director at the Partnership for Epidemic Analysis, adding, “Caution dictates that we assume the worst i.e that Omicron causes more severe disease and evades vaccine. So the prudent
response, until we know more, is to limit travel and require people infected with this variant to quarantine so as to limit the spread.”
Budhiraja shares that some within the community believe that this new variant may be vaccine-resistant and potentially more infectious, but the immunity from the current vaccination will continue to protect from the severity of the infection, hospitalisation and mortality. Some may have minor symptoms like cold, runny nose, or headache and the chances of admission into intensive care may be minimal.
However, Dr Leong Hoe Nam of Singapore’s Mount Elizabeth Novena Hospital says booster shots are key in fighting the new Covid variant. Do Indians need a booster dose? “A booster makes the risk a tiny bit lower, and it doesn’t hurt to get it, but the main focus should still be on making sure that everyone (globally) is vaccinated. Because an unvaccinated person is fertile ground for the virus to mutate—which is how we end up with variants like Omicron. I don’t think people should panic about getting boosters, but if one is offered to you, by all means you should take it, ” says Saidel.
Even after Omicron, or because Omicron rose, the possibility of strange new variants emerging in any location of the globe is a distinct possibility. The world’s major manufacturers of Covid-19 vaccines, including Moderna, Pfizer and Johnson & Johnson, are working to adapt their shots to Omicron—Pfizer claims it can have a new Omicron vaccine rolled out in 100 days. Virologist Alex Sigal who heads a team of Covid-19 researchers at the Africa Health Research Institute in Pretoria calls Omicron “the most mutated virus we’d ever seen.”Within 36 hours of discovering the new variant, the team sent out a red signal to the world. Sigal hopes that by next week, they will know whether Omicron is stopping the power of existing vaccines. He is growing Omicron at the Institute’s high-security bio-hazard lab to test the mutant against the blood of fully immunised people and that of recovered patients.
What is WHO up to?
It seems that the WHO, which designated Omicron a VOA, is overreacting. Whether its mild symptoms being seen can become serious for the elderly or people with comorbidities is unknown. But the world’s premier health body has been beset with controversies, accused of being controlled by China. Its Director-General (DG) Dr Tedros Adhanom Ghebreyesus publicly praised the Chinese government’s Covid-19 response as ‘setting a new standard for outbreak control’. After a meeting with Chinese President Xi Jinping in Beijing in January 2020, he lauded the top leadership for “openness to sharing information internationally” even as Xi was arresting and jailing citizens in Wuhan for ‘spreading rumours’. WHO depends on voluntary budgetary donations to operate.
While assessed contributions from its global partners have grown by only 3 percent since 2014, China’s contributions have grown by 52 percent over the same period to around $86 million. China actively supported Ghebreyesus in the WHO’s DG election in 2017. The naming of Omicron shows that the Chinese influence has not abated with Ghebreyesus at the helm. After the furore in Beijing over former US President Donald Trump calling the coronavirus “Chinese virus”, the WHO announced on May 31 a new naming system for variants and mutations. Each variant gets a name from the Greek alphabet to de-stigmatise the new variants. Ghebreyesus’s logic is that any government would be willing to report a new variant if the name is not linked to the country.
Maria Van Kerkhove, the WHO’s coronavirus lead scientist, told an interviewer without irony that once the alphabet’s 24 letters run out, the agency will devise a new method. This time, with Omicron, the WHO decided to skip Nu and Xi while naming Omicron. The previous variant to get a Greek name was Mu in late August. Omicron was given the 15th letter of the Greek alphabet. “Two letters were skipped—Nu and Xi—because Nu is too easily confounded with ‘new’ and Xi was not used because it is a common surname and WHO best practices for naming new diseases (developed in conjunction with FAO and OIE back in 2015) suggest avoiding ‘causing offence to any cultural, social, national, regional, professional or ethnic groups’,” the WHO said in a statement. Incidentally, Xi is both the ruler of China and the foremost patron of Ghebreyesus. Badiucao, a fierce critic of the Chinese Communist Party, blasted the WHO for skipping “Xi” (pronounced “ksi”). He tweeted saying that all variants should be considered the “Xi Virus,” after the Chinese Communist Party leader, because of his cover-up of the spread of the virus in late 2019 which led to the global pandemic. “Shame on @WHO,” he vented.
Why is the pandemic not being contained?
Researchers have found that there were more than 30 mutations in the new virus spike protein. These mutations are more than double the number of dangerous Delta variant spike protein mutations. “That is why medical experts believe that this variant can spread rapidly, attach to body cells and become dangerous. Concerns have been raised that this could lead to another Covid wave as a result,” says Dr E Ravinder Reddy, Senior Pulmonologist, Kamineni Hospitals, Hyderabad, adding that the handling of the virus, from the first Covid-19 to Omicron, has revealed a malicious disparity between the rich and the poor. “The huge gap in inoculation between rich and poor countries is shameful and leads us to this point. Vaccine equity campaigners have been crying hoarse to give lifesaving shots to the countries that cannot afford it. Omicron is a price the world pays for the poor policy decision of some of the advanced countries. Botswana, for instance, where the new strain was first identified, has fully vaccinated only 20 percent of people. If you discriminate in vaccine distribution, hoard vaccines and don’t waive intellectual property rights, there will be more such dangerous variants,” says a Delhi-based independent scientist who did not want to be named.
A challenge facing inoculating a population is poor government coordination and delivery apathy. Getting vaccines to the developing world and vaccinating the people is far behind the deadline. Unused stock of around 60 lakh Covid-19 vaccines is lying with private hospitals in India, of which around 10 percent are set to expire by December. India resumed vaccine export in October. Some countries, including South Africa, have enough doses, but are facing distribution challenges, said Scott Gottlieb, who was FDA commissioner under the Trump administration and sits on Pfizer’s board. “South Africa has told J&J and Pfizer—the two countries that are distributing vaccine there—to throttle shipments or stop shipments because they have an excess of vaccines,” Gottlieb said on CBS News’ ‘Face the Nation’. The UK is blocking a proposed patent waiver for coronavirus vaccines while most countries have been urging world leaders to waive intellectual property on coronavirus vaccines, tests, and treatments so that they can produce their own jabs.
The matter is being considered by the World Trade Organization. Srinivas Murthy, an infectious disease expert, told the media, “Allowing new variants to emerge and spread, 13 months into the vaccine era, is a policy choice by the rich world.” But EU countries immediately imposed restrictions on travel from southern Africa. Ironically, a news report says that the Omicron variant was in Europe before South Africa flagged it. Dutch health authorities on November 30 declared that they found the new variant in cases that go as far back as 11 days, according to CBS News. Belgium and Germany have also said that tests show the variant was in their countries before South African health officials pointed it out, says the report. “Rich nations are very quick to ban travel but very slow to share vaccines and know-how,” said Madhu Pai, Canada Research Chair in Epidemiology and Global Health at McGill University. But countries are coming together to evolve a framework to tackle the crisis.
“We shouldn’t need another wake-up call,” Ghebreyesus pleaded with WHO member nations for a legally binding treaty. The US and Russia too are dragging their feet. However, health ministers of 32 nations, including Germany, the UK, South Korea and Turkey, signed an article in the BMJ medical journal in favour of a legally binding agreement.
An independent panel, headed by former New Zealand Prime Minister Helen Clark and former Liberia President Ellen Johnson Sirleaf, investigating Covid-19 response said the international system is unfit to avoid another disease from spiralling into a Covid-19-like pandemic. A yearly fund of at least $10 billion for pandemic preparedness and a pool of $100 billion to be made available in the case of a specific threat have been proposed. In spite of the Chinese stain, the words of Dr Ghebreyesus last week rang true, “Omicron’s very emergence is another reminder that while many of us think that we are done with Covid-19, it’s not done with us.” In a few weeks’ time, with more data coming in and governments and private health institutions on overdrive to combat the new threat, the true picture of Omicron’s profile and possible impact on a pandemic-ravaged humanity will surface. New vaccines will neutralise it until the next variant surfaces. The truth is that more than learning to develop new preventives, the virus has shown that the world has to learn to live together. In that concord is humanity’s hope.
What is Omicron?
The variant known as B.1.1.529 or Omicron has a high amount of spike mutations that have never been seen before. It popped up in many European countries just days after it was identified in South Africa. Omicron, listed by the WHO as a ‘variant of concern’, has infected people in more than 20 countries to date. Its nomenclature has an interesting story. The WHO names variants after letters of the Greek alphabet. When Omicron was identified, the WHO had already used the first 12 letters to name the previous strains of the virus. It decided to skip the next two letters, “Nu” and “Xi” because “Nu” can be confused with “new” and “Xi” is a common last name and happens to be the name of the President of the People’s Republic of China. Omicron is the 15th letter in the Greek alphabet.
The Third Wave Threat Looms?
“Omicron could trigger the third wave in India if allowed to enter. We have already witnessed the disastrous effect of the previous variant. In the smaller towns, Covid has been long forgotten. Nobody wears masks. Social distancing is laughed at. In larger cities such as Delhi, Mumbai, Bengaluru, etc, people wear masks out of force or fear of penalisation. Look at the crowded markets, full-to-the-brim restaurants and over-the-top weddings taking place across India. If this continues, Omicron will create havoc.” Dr Manoj Kumar Consultant - General Physician, Internal Medicine, Manipal Hospital, Vijayawada, Andhra Pradesh
“I am... concerned that several Member States are introducing blunt, blanket measures that are not evidence-based or effective on their own, and which will only worsen inequities.”
Dr Tedros Adhanom Ghebreyesus, Director General, WHO
“As most vaccines (work by) forming antibodies against the spike protein, so many mutations (in Omicron) at the spike protein region may lead to a decreased efficacy of Covid-19 vaccines.”
Dr Randeep Guleria, Director, All India Institute of Medical Sciences
“We just really need to, as I’ve said so often, prepare for the worst. And it may not be that we’re going to have to go the route people are saying.”
Dr Anthony Fauci, Chief Medical Advisor, White House, USA
What India Needs to Do Now
✥ Stocking up on oxygen and steroids. Not to mention, simple drugs such as paracetamol that hospitals ran out of last time.
✥ Making sure there are enough hospital beds
✥ Bolstering vaccination drive and administering booster shots
✥ Social distancing
✥ Masking up
✥ Restricting travel
Dr Jagadish Hiremath Chairman, Aasra Hospital, Bengaluru, and Dr rajesh chawla, Senior Consultant, Pulmonology and Critical Care, Indraprastha Apollo Hospital, Delhi
The first image of the Omicron variant, compared to the Delta variant, made by the Bambino Gesu Hospital in Rome
Any virus exhibits three types of behaviour (phenotypes) that gauge how dangerous a new variant is. These are transmissibility (the rate of spreading from one person to another), virulence (the seriousness of symptoms) and immune evasion (the degree of protection a person receives from a vaccine or natural infection).