As the current surge of the SARS CoV-2 Omicron variant takes grip on communities around the globe, our collective dream of a ‘return to normalcy’ in 2022 appears to be far from reality. But I find myself asking the question –  was this dream ever going to be a reality? 

I am used to writing research articles based on scientific premise, data and evidence  – however, what I provide here is truly my own opinion based on scientific evidence to date on what we can expect to see in India as we brace for the third wave of the COVID-19 pandemic. At the outset, I can say that I will be very happy to be incorrect.

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First, it is critical to understand the difference between relative risk and absolute risk. When the Omicron variant was first described, experts from around the world presented anecdotal evidence from South Africa that “Omicron was not as severe as Delta”. 

But it is important that we recognize the implications of that simple statement. While it offered hope for the world, it also perpetuated challenges. Let us assume that Omicron is in fact less severe than Delta – lets even say it is only 1/5th  as pathogenic as Delta.

This would imply that for every five people who get Omicron, only one will get as sick as a person infected with Delta. But if Omicron is 10 times more infectious than Delta, that affects the total number of people who will be infected with Omicron compared to Delta. 

Applying this to a population-level, if we take a population of 100 people and say one percent of those with Delta will need to be hospitalized, that would translate to needing just one hospital bed. However, in the case of Omicron which if 10 times more infectious, ten people will get infected and two would need to be hospitalized. 

I still distinctly remember the horrific images and stories of people searching for hospital beds and never-ending funeral pyres – if we do not take adequate precautions, India could see much worse with Omicron.

Reuters

Even with the widespread use of mRNA vaccines and boosters, the US is witnessing the highest number of inpatients hospitalizations since the start of the pandemic when there were few mitigation strategies available. 

It is also likely that similar to what we are seeing in the US, in India we will see significantly more infections and severe infections in children – this is the population that is yet to be vaccinated in India. Given the lack of vaccination among children in India and the highly infectious nature of Omicron, the absolute number of children infected will also be significantly higher resulting in higher numbers of hospitalizations among children. 

The infectivity of Omicron also takes a toll on health care facilities. Hospitals in the US are unable to function at full capacity because the health care staff needed to man these beds have themselves been infected with SARS-CoV-2. 

It is likely that India will experience a similar situation and so, it is imperative that we begin planning on reinforcing our health care workforce with residents, final year medical students, and workers from allied health sciences. It is also critical that those with underlying medical conditions such as diabetes, hypertension or other immunosuppressive disorders (e.g., HIV or oncology/transplant patients on immunosuppressive therapy) are extra cautious and adhere to their treatment regimens at this time for two reasons – one, these underlying conditions worsen COVID-19 outcomes and two, it is likely that the hospitals will be overrun with COVID-19 limiting their ability to accommodate other conditions as we are now seeing in certain parts of the US.

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The only way India will be able to get out of this without great loss of life, is if Indians unite to curb its spread. This is something that will only work if we work together as a nation. The primary objective of combatting the surge will be to curb its spread. 

The pillars of prevention remain the same –  vaccines, masks, social distancing and hand-washing. There is recent evidence to suggest that booster doses of vaccines within recent months have the ability to neutralize the virus in tissue cultures. 

The government of India is opening up “booster” doses – it is imperative that every citizen receives their routine vaccine course and a booster. Masks act as a barrier to prevent spread and not as a fashion statement – so, it is critical that we embrace masks that are efficacious (e.g., N95/KN95/surgical masks in that particular order) and bid farewell to the fashionable cloth masks.

If you are someone who cannot give up fashion, ensure you double mask with a surgical or a N95 mask under your fashion statement. And in India, where there is such a high burden of tuberculosis and air pollution, these masks are even more critical – I was in Delhi recently and was musing to myself why I never wore a mask before to combat the pollution. Social distancing is a luxury and in most households in India is an oxymoron – so, I am not someone who is going to tell you to stop going out. 

I would instead suggest you reduce your social interactions and shopping trips – recent data from the UK shows that shopping more ≥1 time per week was the strongest correlate of SARS-CoV-2 infection in the UK. 

So, as per the principles of harm reduction, if you usually go to the grocery store 3 times/week, reduce it to once per week. And last but not the least, hand washing is critical – not just for SARS CoV-2 but for a whole plethora of infections all of which have reduced since the start of the pandemic.

Reuters

While there have been some advances in therapeutics, the mutations of the Spike region have affected several of these therapies. For example, most of the monoclonal antibody therapies have lost their neutralization activity against Omicron. 

New data suggests that remdesivir infusions in early infection could prevent hospitalization and steroid therapy in those with reduced lung function can prevent mortality. Newer data also suggests that convalescent plasma rich with high level of antibodies to the Omicron variant could be efficacious in preventing disease progression but this relies heavily on the identification of people with high-titer antibodies to Omicron and harvesting their plasma. 

But then this also implies that people with Omicron need to be diagnosed early which brings me to my last point – testing.

We have several types of tests but none of them are definitive, but all have a critical role to play. They are much more likely to produce false negative results depending on the timing of the test post-exposure and region swabbed (nose vs. nasopharynx vs. throat) as opposed to false positive results. 

Yes, we should improve access to testing and self-testing but simultaneously, we as citizens, should take the collective decision that if we are symptomatic or exposed, we do the right thing and isolate at least for 5 to 7 days even if our tests say we are negative.

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Maybe the Omicron variant does produce less severe disease but isn’t the goal of health to be free from disease and not just “severe disease”. The next six to eight weeks will be critical to India and the fate of the nation does not rest with the government but with the people – what are you going to do?

The Author, Dr. Sunil Suhas Solomon, MBBS PhD MPH is an Associate Professor in the Division of Infectious Diseases at the Johns Hopkins University School of Medicine. He completed his medical training at the Sri Ramachandra Medical University in Chennai, India, and received a Master’s in Public Health and a doctorate in Epidemiology (PhD) from Johns Hopkins University, USA. His research is primarily focused on the epidemiology, clinical management, and access to care for HIV and viral hepatitis among vulnerable Indian populations such as people who inject drugs (PWID) and men who have sex with men (MSM).