COVID: Omicron concerns rise in India as virus rages in other parts of the world

Although the new virus variant’s spread in India is relatively low when compared with the situation in the United Kingdom and the United States, a debate on the country’s preparedness is on in the light of the pandemic experience of the past two years.

A health care worker collects swab samples from a policeman for a COVID-19 test amid concerns over the rising number of Omicron cases, in Jammu on December 24, 2021.

AS the COVID-19 pandemic surges again with a new virus variant, Omicron (B.1.1. 529) in most of Western Europe and the United States of America, concerns have arisen in India regarding preparedness, the need for booster vaccination doses, immune response of the vaccinated, vulnerability of the non-vaccinated as well as immunisation against the virus for children. The variant, first identified in South Africa, is supposed to be highly transmissible, with a “significant growth advantage” over Delta, with a doubling time of one and a half to three days. Omicron was so far deemed to be not as severe as the Delta variant that originated in India and claimed thousands of lives in the second wave in April-May 2021. The variant has infected 1,51,368 persons and claimed 26 lives in 108 countries so far.

The highest number of cases has been reported from the United Kingdom (90,906) followed by Denmark (30,954), Canada (6,978), Norway (5,240), Germany (3,198), the U.S. (3,180), South Africa (1,629), France (1,447), Australia (966) and Estonia (830). According to a technical brief from the World Health Organisation (WHO), contact and household studies in the U.K. have shown a high risk of transmission compared with Delta. The brief, quoted by Indian Health Ministry officials in a press briefing on December 24, cautioned that the overall risk related to Omicron remained very high. In the last four weeks (November 24-December 24), Europe accounted for 54.9 per cent of the number of cases globally, North America 27 per cent, Asia 9.4 per cent, and Africa 5.3 per cent.

WHO’s caution

In Europe and North America, the weekly number of cases has shown a marked increase, threatening to overwhelm health systems. On December 14, talking to reporters from the WHO headquarters, its Director-General Tedros Adhanom Ghebreyesus warned that the variant was spreading at a rate not seen in the case of any other variant so far and that it should not be dismissed as mild. In a veiled reference perhaps to the vaccine push by the pharmaceutical sector and the rush by some countries to manufacture and procure booster doses, he said that “vaccines alone will not get any country out of this crisis”. He expressed concern about booster roll-outs for 18-plus individuals despite a lack of evidence regarding their effectiveness. This would lead to vaccine hoarding and inequity, he said. According to a United Nations brief, Ghebreyesus said he was not against boosters but against the inequity in administering them. There were huge populations in several countries, including those in Africa, which had not received a single dose of any vaccine. The priority, he said, should be to vaccinate people even in countries with better access to vaccines. In about 41 countries, not even 10 per cent of the population had been vaccinated and in 98 countries vaccination had not reached 40 per cent. On December 20, he said there was consistent evidence that Omicron was outpacing Delta. He told the media that more people who were vaccinated or who had recovered were likely to be infected or reinfected.

The concerns over Omicron are legitimate. The virus, which has been classified as a ‘variant of concern’, with features of high transmission, high immune escape and capability of creating huge surges, has been spreading in countries that have populations with high vaccination coverage; for instance, the U.K. where close to 70 per cent of the adult population had received two vaccine shots. The variant had the potential to evade the antibody response among those who were naturally infected by the virus earlier or those who had antibodies after being vaccinated.

Indian situation

The situation in India, which was witness to two surges, one in September 2020 and the other in April-May 2021, has been comparatively better. But there has been a steady increase in the number cases from December 5 onwards when 21 cases were identified as being infected by Omicron. The number rose steadily to 358 on December 24.

Of the 358 Omicron cases reported from 17 States, samples of 183 were analysed. The analysis showed that 87 of those infected in India (91 per cent) were fully vaccinated, three of them had received booster shots, two (2 per cent) were partially vaccinated, and seven (7 per cent) had received no vaccination at all. The vaccination status of 73 people was not known and 16 persons were found ineligible for vaccination. Of the 183 samples analysed, 121 had a foreign travel history, 44 had no travel history, and in the case of 18 persons, no travel history was known. Maharashtra, Delhi and Telangana accounted for more than half the Omicron cases. On December 21, the States were advised to impose containment measures in districts that had a positivity ratio of more than 10 per cent or more than 40 per cent occupancy of intensive care unit beds and oxygen beds.

According to J.P. Muliyel, Member of the National Technical Advisory Group on COVID, the number of mutations does not translate into viciousness. “Viruses have to mutate to survive. This variant multiplies in the bronchus. Therefore it spreads by cough and therefore it is more infectious. Whether it is going to be doomsday is the question. The fact that it is replacing Delta in the U.K. may be a good thing. The U.K. has an excellent sequencing system, much better than the U.S. In the U.K. too, the number of cases in hospitals has come down and deaths are very less. In India, we should go by the number of cases of hospitalisations and deaths and not by the number of RTPCR positives alone. Most of us, close to 80 per cent, are immune due to natural infection. And combined with vaccination it would be more, close to 90 per cent maybe. We don’t have that problem like the U.S. where people refuse to get vaccinated. But in India if it hasn’t spread so far, it will. It will come as a wave. We should make certain that we have enough oxygen in case there is a problem. There is no evidence that boosters might help. Even people with two or three doses of vaccine in U.K. and the U.S. have got it,” he told Frontline .

Although Omicron is thought to be milder than Delta, there are apprehensions that vulnerable populations might be more susceptible to catching the infection. As enough capacity to handle the situation exists in the country, there are those who believe that booster doses can be given to the vulnerable sections, including those with comorbidities. In India, 85 per cent have had one dose and 61 per cent, two doses. And with 75 per cent of the population having acquired natural immunity after exposure, it is believed that the population in general is well protected. Not everyone is of the opinion that the fully vaccinated need booster doses. Says immunologist Satyajit Rath: “The Omicron strain is clearly quite transmissible and is capable of spreading, with fair efficiency, even among vaccinated people. I think it is quite unclear as yet if it causes serious illness with the same likelihood that the delta strain does. I should note that even the delta strain is not as ‘dangerous’ to individuals as it has been to communities. I also think that the data are beginning to suggest that, while vaccinated people can indeed be infected with the Omicron strain, their likelihood of getting serious illness even so seems to be quite low.”

Genome sequencing

In the U.S., more than 70 per cent of COVID cases were caused by Omicron. And this was possible to identify due to greater genome sequencing. In India, the proportion of COVID cases sent for genome sequencing is not even known. In Delhi, positive samples from returnees at airports were sent for genome sequencing. On December 20, the Delhi government announced that all positive cases would be sent for genome sequencing from now on.

Says Satyajit Rath: “I do not think we are doing new SARS-CoV-2 sample genome sequencing on a large enough scale as yet, even now. And I do not think that this is only an Omicron-related problem. It is a much more general issue. We need to be tracking SARS-CoV-2 virus variants and strains quite closely and carefully so long as the virus is circulating widely, and we are not yet doing that well. Panic is never ‘justified’, or, more to the point, useful as a response. We have substantial numbers of people who have not yet gotten even one dose of a COVID vaccine, leave alone being fully vaccinated. A fast-moving SARS-CoV-2 strain can create very large numbers of seriously ill people in need of hospital care, and can overwhelm our facilities and resources, at least in some locations. This is why it would help greatly to be able to track the growth, if any, of the Omicron strain with good evidence in real time, so that specific locations and the communities and local authorities there can get a little warning and prepare for a fast-growing outbreak.”

Chandrakant Lahariya, physician-epidemiologist and public policy and health systems specialist, told Frontline that while the numbers and proportion being genome sequenced were relevant, the more important question was whether the samples were representative. “The approach on sample collection needs to be aligned with the purpose of genomic sequencing. The objective of genomic sequencing is not just to know variants in every single case, but mainly to track the variants circulating as well as to examine the trend over a period of time. Therefore, sequencing all samples from a small geographical area is less useful than sequencing reasonable numbers, not all samples, from more geographical settings. I don’t think there is anything like an ideal number or proportion. I also think sequencing more than 10 per cent or 20 per cent of confirmed COVID-19 cases in a large city is inefficient use of resources, as some of those samples would be linked to each other and it will skew the findings. At the State or national level, we can sequence up to 2 to 3 per cent of the total confirmed cases. What is more important is that if we have additional sequencing capacity, then it should be used smartly to ensure that samples from specific subgroups such as pregnant women, travellers, hospitalised patients with different levels of illness, the elderly, the fully and partially vaccinated and children are included in genomic surveillance. It is helpful to be aware that the U.S., the U.K., Denmark and Sweden are reporting a large proportion of Omicron cases. However, we need to be mindful that at this stage of the pandemic, every setting is different and the epidemic pattern would be completely different.”

On boosters

There is a view based on some studies that mRNA vaccines would be more effective as boosters though Satyajit Rath does not agree with that. He says that view is based on preliminary evidence. “Immunologically, there is no reason to think that ‘boosting’ will fail with almost any combination of vaccines. More to the point, we have gotten ourselves, both in the country and in the world more broadly, into this situation where we are thinking of trade-offs between completing the basic COVID vaccination and beginning to give ‘boosters’, when we should have shown sufficient urgency to manufacture and supply more to be able to do both. However, a more nuanced approach might perhaps be to begin giving ‘booster’ doses to professions that are highly at risk, such as the health care sector. However, even this cannot easily be done without some evidence about such boosters for regulatory clarity.”

Says Chandrakant Lahariya: “In the long run, booster dose might be required for select population subgroups; it is not the case that everyone needs a booster dose, immediately. Secondly, the primary objective of COVID-19 vaccination drive in India is to prevent severe disease, hospitalisation and deaths, which two primary doses continue to provide for up to 9 to 12 months and even longer. Having said that, considering our understanding of immune protection against SARS CoV2 and that Omicron is still evolving, therefore, it is important that every country, India included, develop a detailed booster dose strategy, outlining the priority groups, interval need between primary schedule and the booster and the selection of right vaccines for boosting on the basis of scientific evidence and epidemiological data, among others. Making a plan or strategy for COVID-19 booster is a step independent of rolling out of the booster shots. India should prepare and plan for booster doses, identify evidence gaps, conduct research to fill those gaps; that is how booster dose policy will emerge. It is true that mRNA-based vaccines as a booster provide the best immune response. However, we also need to be mindful that those vaccines are not available immediately for purchase and not in the quantity which India would need. Then, there is no urgency for a booster vaccine in India. Therefore, India should use time at hand to conduct research on alternative booster doses. It is possible that in the months ahead, the second generation mRNA-based vaccines, some of which are under development in India, will become available and licensed. India should also conduct scientific studies on use of ZyCoV-D; Covovax and Corbevax as heterologous booster options. India is in a different stage of the pandemic and it needs not to follow the booster dose policy of the other countries. The benefit of two primary shots is proven and far more than any known benefit of boosters. Therefore, the first focus has to be on ensuring that every eligible individual gets COVID-19 vaccines. The decision on boosters has to be based on local evidence. Once a decision on administering booster doses in India is made, the cost of booster doses should be borne by the government and free for all eligible citizens.”

Vaccination for under 18

Opinion on whether to give vaccines to children is also divided. As most schools have reopened, concerns have been expressed about infections spreading among children. Says Satyajit Rath: “I have been arguing that we should have been doing, at speed, the necessary regulatory investigation required for approvals for COVID vaccines in all age groups. I continue to think that, Omicron or not.” Chandrakant Lahariya does not believe that children need to be vaccinated as of now.

He says: “The objective of COVID-19 vaccines is to reduce severe disease, hospitalisation and deaths, which are very low in children. That is why all healthy children do not need COVID-19 vaccines. The COVID-19 vaccination of children should be far more targeted, prioritising high risk 12-17 years in which the benefit of vaccination is far greater. It is also important to note that Omicron has not changed anything as far as risk to the children or need for their vaccination is concerned. We also need to remember that the risk of poor outcomes in children (moderate to severe disease and hospitalisation) has not altered with Omicron. We know that even the variants before Omicron, Alpha, Beta, Gamma and Delta, had a similar pattern of age-specific disease outcome and mortality. The age-specific vulnerability of the population has not changed with newer variants and there is no reason to believe that Omicron is going to affect children disproportionately. Some of the countries that have started vaccination of children are doing so with an objective to reduce the risk of infection and transmission. Those countries are using mRNA-based vaccines for children, which have a far more proven role in reducing the risk of transmission. Similar evidence on reducing disease transmission is not available for COVID-19 vaccines approved for use in children in India. Every which way we look, the benefit of COVID-19 vaccination of healthy children in India is limited. There is a far greater benefit of vaccinating adults.

Children in India have already suffered a lot due to school closure. The schools remained closed for far too long because of unscientific claims that children will be at higher risk of infection in subsequent waves. As Omicron cases may spike in India, there is a risk of some demand to close schools. The governments need to pay attention to the UNICEF and UNESCO guidance that in pandemic-related restrictions, the schools should be the last to close. In a possible scenario of rise in Omicron cases, the Indian States need to keep schools open, unless there is strong reason and scientific evidence to close schools.”

Collation of data

One standard complaint among public health experts has been that although there was a lot of data in sheer quantifiable terms, not much was known in terms of breakthrough infections, antibody levels or even genome sequencing in the public domain. Says Chandrakant Lahariya: “It is beyond doubt that the quantity of COVID-19-related data collected by the Indian government on various aspects, including testing, hospitalisation, clinical outcomes, and vaccination, is quite comprehensive. However, as this data are not available in the public domain, it is not possible to comment about the quality of data. It has not been shared with researchers and experts, even after explicit requests and open letters sent to the government. Second, no one outside the government really knows whether this humongous data are being analysed sufficiently even by the government, for informed decision-making. Third, the potential of COVID-19 data, for policy decision-making related to COVID-19 response is immense. For example, if data on vaccination status, COVID-19 testing, hospitalisation and genomic sequencing are analysed together, we can get answers to operational questions such as which vaccinated groups is developing severe disease and how over time the protection after vaccination declines, and in which age groups; what are the rates of reinfection or breakthrough infections, amongst many other groups. In short, the Indian government seems to be sitting on really valuable COVID-19 data which, if analysed comprehensively, can guide and provide direction to India’s pandemic response, which is at a crucial juncture. This is an area in which the government urgently needs to act. Analyse data at its own level; make primary data available in public domain, and invite and engage independent experts to analyse, interpret and make sense of COVID-19 data. Data has no value if not sufficiently analysed and used for action.”

Omicron lessons

Says Satyajit Rath: “The Omicron lesson remains the same; we need to stop treating the pandemic as a short-term problem that will go away quickly. We need to invest substantially and stably in the development of health care resources, in both hospitals and in communities. We need awareness and active participation from the people and communities in the cultural normalisation of physical distancing, testing and vaccination. We need large-scale manufacturing and wide distribution of high-efficiency near-N95-level reusable masks for everyone. We need much more widespread availability of easy and cheap COVID-19 testing, linked to variant identification. We need coherent policies for large-scale production of oral antiviral drugs such as Molnupiravir and the Nirmatrelvir-Ritonavir combination, as well as of a portfolio of COVID vaccines, connected to much higher pace and effectiveness in our COVID vaccination campaign. We need ongoing vaccine studies to enable us to develop and implement sensible and targeted supplementary vaccine doses to specific categories without adverse effects on the basic vaccination campaign. We need ongoing monitoring to link variant tracking studies to new-generation vaccine development programmes. None of these are new lessons; all that the Omicron strain has done is underline them yet further.”

Not a big threat

Chandrakant Lahariya, feels that Omicron is a threat but not a big one. He says: “The most important point to remember is that Omicron is not a new virus but a variant of a virus—SARS-CoV-2—which we have been living with for the past two years. What does it mean in epidemiological and operational terms? It means that when SARS-CoV-2 first emerged, everyone across the world was equally susceptible to the virus. The threat was indeed big. Two years on, with a large proportion of the world population either getting natural infection during the successive waves or receiving COVID-19 vaccines, the majority has some degree of protection. Therefore, even with threefold higher transmissibility in comparison to the Delta variant and a possible immune escape, the threat posed by Omicron is far lower. Therefore, if Omicron is of some concern, but not a big one. Now, the risk posed by Omicron to any country is going to be differential, specially determined by the exposure of that country to the virus, in the last 21 months and by the level of vaccination. With Omicron, the unvaccinated population has greater risk than the vaccinated. The countries with poor vaccine coverage, low adherence to COVID-appropriate behaviour have higher risk than others. As far as the severity of disease caused by Omicron is concerned, most reports so far indicate that it causes mild disease. When it comes to public health response, specially in India, considering that Omicron is more transmissible but causes mild disease (based on current data), there has to be more focus on strengthening smaller primary health facilities to ensure easy access to early diagnosis and consultation with physician than entirely focussing on the hospital beds and ICUs. Secondly, every effort should be made to keep economic and social activity going with preventive measures and keep restrictions to the minimum. The restriction planned by any State or district, if any, should be very localised, planned in granularity, should factor in vaccination status of population and only for a shorter period of time.”

No health expert has until now advised a lockdown. But many of them have pressed for data on breakthrough infections, which are not yet available. Such data, several public health experts believe, are crucial to understanding the trajectory of the virus. Says Satyajit Rath: “While the data are of good quality, we are still falling short on the scale of systematic data collection, and even more, systematic data collation and analysis, on all these aspects.”

Health Ministry officials told the media on December 24 that such data (on breakthrough infections) was still being put together. While containment, surveillance, testing and contact tracing were advised as strategies, social distancing was no longer a top priority. Ministry officials declined to comment on a query about a recent High Court order advising the government to call off the Uttar Pradesh Assembly elections. At the moment, there is an expectation that the fatalities due to Omicron would be less and, therefore, life can go on as usual but no one is sure which way the variant will turn.