It is two months since Omicron (B1.1.529) was first reported as a variant of SARS-CoV-2. Since then, Omicron has been identified in 171 countries; it has become the dominant variant in many countries, and the world is experiencing the highest daily new COVID-19 infections since the start of the novel coronavirus pandemic. Alongside, there has been a better understanding about the new variant and its spread. Omicron is three to four times more transmissible than the Delta variant. Epidemiological data points to a ‘decoupling’ of Omicron infections from the hospitalisation and deaths. A majority of cases — in nearly all settings — continue to remain asymptomatic. Omicron causes mostly mild disease — at least in those fully vaccinated. And a surge due to Omicron peaks in two to three weeks with an equally steep decline.
A ‘medicalised response’
Yet, two years into the pandemic, many countries — especially high income countries — are still struggling in their response to the Omicron surge. Part of the reasons, arguably, is a ‘medicalised’ health system response and insufficient adherence to COVID appropriate behaviour by citizens. As an example, while two doses of vaccine continue to provide protection from the severe disease, hospitalisation and deaths, administering a booster dose to keep antibody levels high is a ‘medicalisation’ of a public health intervention. Similarly, COVID-19 testing is being promoted to carry out routine activities of daily life, while there is limited public health benefit of such testing in halting transmission. These are examples of medicalisation of the pandemic, and the list is really long. In this backdrop, it is not a complete surprise that spread continues unabated in some of these countries.
In contrast, in South Africa — which first reported the Omicron variant — the fourth wave begun by this variant is already over. It clearly has some lessons for other settings. In the recent wave, in spite of the high number of cases, South Africa imposed minimal restrictions, which were lifted quickly. In response to this wave, the country revised the isolation, quarantine and the contact tracing strategies, based on new epidemiological understanding. There were no reports of excessive use of blood tests, CT scans or unnecessary medications or hospital admissions. Though schools were closed for a very short period, the Government was equally quick in reopening schools. Following the Omicron surge, South Africa decided to introduce COVID-19 vaccine booster dose; however, a reason was that one of the vaccines being used in the country is a single dose vaccine (Johnson & Johnson), with lower efficacy. Essentially, for that vaccine, a booster means a total two doses.
As countries prepare to respond to the Omicron surge, there are two overarching messages. First, do not merely continue with the old strategies of ‘test, trace, isolate or treat’ but review and update all public health policies to factor in new epidemiological and scientific evidence. Second, prepare for COVID-19 endemicity in your country setting.
Ongoing third wave in India
India is in the middle of its third wave driven by the Omicron variant. Considering the many similarities with South Africa (than European countries) — such as median age, population density, health system infrastructure and natural infection rate — India is more likely to follow an Omicron wave trajectory that is similar to South Africa’s. As the third wave is likely to affect Indian States in phased manner (major cities, followed by urban settings and then rural areas), States can benefit by putting the learnings so far into practice. First, considering the infection and hospitalisation ‘decoupling’ in this wave, the old indicators, i.e., new daily COVID-19 cases and test positivity rates are not the best parameters for decision-making. The new indicators to track the pandemic should focus on daily symptomatic cases, hospital bed occupancy, intensive care unit admissions and a few more refined stratifiers of pattern and outcome of infection in high risk groups (unvaccinated, co-morbid or elderly) and non-high-risk groups, amongst others.
Second, the Government should focus upon developing science and evidence-based case identification and treatment plans which are strictly adhered to, by both public and private health-care providers. Some of the policies on testing, isolation and hospital discharge have already been revised, recently. However, there is need for further revision in admission policies and clear articulation of the contact-tracing approach. Adherence to the latest official testing, admission policies and treatment guidelines should be ensured through effective monitoring and better enforcement of health-care regulations.
Third, every effort should be made to continue economic activities. There is very limited relevance of any type of COVID-19 curbs with the only exception being large public gatherings, in which physical distancing is not feasible. The essentials such as elections, etc. can still be planned in a calibrated manner, with stringent adherence to COVID appropriate behaviour.
Fourth, the ‘Infodemic’ continues to be a major challenge in this pandemic. It is never too late to mount a credible, timely and transparent science communication from trustworthy sources. This approach should continue till the COVID-19 pandemic becomes endemic.
The number of new infections in the ongoing Omicron wave might have been very similar to previous waves driven by the Alpha, the Beta or the Delta variants; however, there is sufficient epidemiological evidence to conclude that Omicron does not cause severe disease, at least in fully vaccinated individuals. It also means that while responding to the ongoing surge, it is time to get future ready and prepare for COVID-19 endemicity.
The most important step would be to use the data on COVID-19 infection, hospitalisation, deaths as well as clinical and vaccine-related aspects, which should be analysed proactively. That would help in answering pending policy questions and decide and plan evidence-informed strategies.
The new scientific and epidemiological understanding should be used to ensure that social and economic activities return to normalcy. To facilitate the process, there has to be a renewed focus on improving ventilation of especially indoor spaces and effective public health communication for calibrated COVID appropriate behaviour, commensurate with the local COVID-19 transmission. The governments should consider incentives to increase adherence to COVID appropriate behaviour and explore public subsidies for masks including provisions for free mask distribution.
There is a need to ensure that non-COVID-19 essential health services are not disrupted, in any subsequent surge of COVID-19. Testing is done in a targeted manner for high-risk populations; genomic sequencing is optimally used along with setting up of waste water and sewage surveillance for tracking SARS-CoV-2 transmission in communities. Alongside, countries that are having a surge of Omicron should not be in a rush to introduce booster doses for healthy adults or to vaccinate healthy adolescents or children.
About schooling
There is sufficient evidence that children are at lowest risk of poor outcomes of COVID-19. However, arguably, they have been impacted the worst by the pandemic because of disruption in in-person schooling. Therefore, the focus of every country and society has to be on how to keep schools open. Schools in Indian States should be open urgently. In any future COVID-19 surge, schools should be last to close and the first to open.
One of the biggest learnings from two years of the pandemic is that all countries need to strengthen primary health-care systems, which could become the fulcrum of the COVID-19 response in the post-pandemic period. The pandemic response strategy should be revised to ensure that the majority of infections are detected and COVID-19 cases attended at primary health-care facilities which are closer to the people. In fact, the proportion of all COVID-19 cases detected and managed at peripheral facilities could be a performance indicator of the health-care system. The pandemic should be used as an opportunity to train and retrain (in clinical skills and various aspects of COVID-19 case management) and empower general physicians, family physicians and primary-care providers in every setting. The post and long-COVID conditions as well as mental health and school health need to be given renewed policy attention.
No royalty status please
It is more than two years since SARS-CoV-2 was first detected and reported. It was a novel virus then, but not any more. The world knows a lot more about this coronavirus than many other viruses which cause illnesses in humans and were detected years ago. It is time we stop giving ‘royalty’ status to SARS-CoV-2. The world has enough scientific and epidemiological understanding which should be used to respond to the current surge and prepare for the post-pandemic period. The low-income and middle-income countries need to show leadership in bringing the world out of the pandemic. It is very much doable.
Dr. Chandrakant Lahariya is a physician with advanced training in epidemiology and public health and based in New Delhi. Dr. Angelique Coetzee is a physician in general practice and the Chair of the South African Medical Association, based in Pretoria, South Africa
