# RKS: OMICRON - A TREATISE - All About Waves & Omicron Comparison

 

# RKS: OMICRON - A TREATISE

- ALL ABOUT WAVES & OMICRON COMPARISON

1st March 2022

3RD WAY ONLY SYMPTOMATICALLY MANAGED - Right Or Wrong?

Dear Reader,

Mutation of the dreaded SARS CoV-2 virus commenced the in late 2020s, nearly a year after the first onslaught by the pandemic. The mutants continued to feed fuel to the pandemic and wave after wave of coronavirus attacks was the outcome.

It's now been since over 2 years that the pandemic is yet to be officially announced to an epidemic. But nonetheless, the health professionals, regulators, governments and layman alike are becoming fearless seeing no end to the vaccination routine and masking miseries in sight. It is said by A. M. Willard (Savannah, Georgia: 1977-2018) that -

“Only time will tell, as our memories fade into a past that isn’t meant to be a part of the future. Eventually, we have to find a way to let them go, to move forward and accept what’s to come.”

The 3rd wave is Omicron variant driven and is a larger one but expected to wane quickly and with lower death RATES. The case fatality rates (CFR) have been:

• Alpha: <0.84-0.92%
• Beta: 1.6%
• Delta: 1.3%
• Omicron: 0.9% 

However, there are more patients dead because of infection with the Omicron variant, in spite of its milder causative flu-like illness, than due to previous variants, since a larger populace has been affected in view of its multifold greater transmissibility. Then can one afford laxity in its treatment and elimination? One must wonder.

CORONAVIRUS VARIANTS

The naming and tracking of SARS-CoV-2 and its mutants is done by GISAID (Global Initiative on Sharing Avian Influenza Data, recognized by G-20), Nextstrain (collaboration between US & Switzerland researchers) and Pango (Phylogenetic Assignment of Named Global Outbreak Lineages - software tool developed by UK). At the present time, this expert group convened by World Health Organization (WHO) has recommended using letters of the Greek alphabets for the various variants being unleashed from the original Wuhan coronavirus, i.e., Alpha, Beta, Gamma, Delta which will be easier and more practical to be discussed by non-scientific audiences. 

The United States (U.S. Department of Health and Human Services (HHS) established a SARS-CoV-2 Interagency Group (SIG) to enhance coordination in U.S. among CDC (Centers for Disease Control and Prevention), National Institutes of Health (NIH), Food and Drug Administration (FDA - U.S.), Biomedical Advanced Research and Development Authority (BARDA), and Department of Defense (DoD). Accordingly, the SIG & WHO use three classifications to categorise variants: Variants of Concern (VOC), Variants of Interest (VOI), and Variants being / under Monitoring (VBM / VUM). Out of the 11 variants recognized by the WHO:

1. 2 are currently considered VOC that play havoc - Delta & Omicron
2. 2 are VOI have peaked and peeped out - Lambda & Mu
3. 6 are VBM / VUM or are no longer considered a threat - Alpha, Beta, Gamma, Kappa, Iota & Eta

As per SIG, there is one more category, namely, Variant Of High Concern (VOHC) but there are no SARS-CoV-2 subtype/s currently classified as VOHC. 

(After the Greek alphabet Mu the next letters in line are Nu and Xi. However WHO, for the first time, skipped these and named the latest scourge as 'Omicron' being the next alphabet which sequentially follows. This is because 'Nu' could be mistaken as 'new' and 'Xi' is a common name / surname of many people.)

Incidentally, he letters of the Greek alphabet are: alpha, beta, gamma, delta, epsilon, zeta, eta, theta, iota, kappa, lambda, mu, nu1, xi, omicron, pi1, rho, sigma, tau, upsilon, phi, chi1, psi1, omega.

WHY & HOW VARIANTS EMERGE?

The spike protein facilitates the fuzion between the virus and the human victim cell. Hence, ~90% of the plasma or serum neutralizing antibody activity targets the spike receptor-binding domains and protect against the infecting virus. (Harvey WT et al. Nutrition Reviews Microbiology 2021; 19: 409-424) In order, to circumvent the same, the coronavirus has been undergoing an approximate of 2 mutations per month principally in its spike protein. 

Mutation in the spike proteins changes the shape of spike and the antibodies are then not able to identify and attack the SARS-CoV-2. There are 3 spike proteins which make up one spike and hence each mutant has 3 mutation places in the spike of the coronavirus. The virus and the antibodies are like a lock and key. Once the mutation changes the shape of the spike it will not just fit inside the antibody key and thereby escape being nullified!

What makes the Omicron variant more infectious than its predecessors is the occurrence of about 50 mutations - not seen in combination before, including 30 mutations in the gene for the spike protein that the coronavirus uses to attach to human cells. (Corum J & Zimmer C. Tracking Omicron and Other Coronavirus Variants. https://www.nytimes.com/interactive/2021/health/coronavirus-variant-tracker.html. Accessed on 20th February 2022)

ABOUT SARS-CoV-2 VARIANTS

As English Naturalist Charles Darwin (1809-1882) says of the laws of the nature - 'the survival of the fittest' is also applicable to viruses. The variants took over from the original Wuhan virus; however, the Alpha SARS-CoV-2 faded away when the Delta subtype emerged and even the attention to Beta variant waned what with Delta coronavirus reaching the finishing line! The Mu variant made a splash but disappeared without a whimper.

One of the current strain dominant coronavirus variant is Delta since it is at least 2 times more infectious than other previous variants. One person infected with original Wuhan virus spreads the infection to 2.5 people whilst the Delta strain spreads from one victim to 5-8 those close-in-contacts. 

Omicron may have less severe symptoms than Delta SARS-CoV-2 subtype, but it is more transmissible - 1 affected individual the spread could be to 15-30 close bystanders! Hence, the prediction is that this variant is here to stay for long and eventually become the dominant strain.

OMICRON

BIRTH

• November 14, 2020: A new variant of COVID-19, B.1.1.529 was detected in Botswana (South Africa).
• November 24, 2021: SARS-CoV-2 variant B.1.1.529, was reported to WHO.
• November 26, 2021: WHO named the B.1.1.529 as Omicron and classified it as VOC.
• November 30, 2021: The U.S. also designated Omicron as a VOC.
• December 1, 2021: The first confirmed U.S. case of Omicron was identified.
• December 2, 2021: Two first-time detected Omicron cases in Indian state of Karnataka - 30th country in world to report this coronavirus variant.
• January 20, 2022: Omicron subtype of SARS-CoV-2 has been identified in 171 countries and across all 6 WHO regions.

It needs to be mentioned herewith that the 'Deltacron' variant is a myth - actually there could be patients who have been infected simultaneously with Delta as well as Omicron subtypes of SARS-CoV-2 as per Professor Ravindra Gupta, Clinical Microbiology, Cambridge Institute of Therapeutic Immunity & Infectious Disease (CITIID, UK).

CLASS

Omicron coronavirus is technically SARS-CoV-2 variant: B.1.1.529. It is a VOC since it fulfils all the defining criteria:

• Increase in transmissibility or detrimental change in COVID-19 epidemiology; OR

1. Transmission advantage Omicron has over Delta variant of SARS-CoV-2 is 105%.
2. Previously 1 in 12 people tested for new respiratory symptoms tested positive for COVID-19 but, now, 50% are detected as suffering from coronavirus post the emergence of Omicron variant.
3. The recent rise in incidence in those 75+ years of age is also very worrying.
4. More than half the hospitalized children, relatively unscathed during the previous two waves, are admitted to ICU and at least 40% require ventilatory support!

• Increase in virulence or change in clinical disease presentation; OR

1. Omicron patients have a 53% reduced risk of hospitalization and also a 74% reduced risk of Intensive Care Unit (ICU) requirement because it multiplies 10 times less efficiently than Delta variant inside the lungs. Yet, there are 4 times more hospitalization rate during 3rd wave for children than due to previous SARS-CoV-2 variants' driven coronavirus waves.
2. Omicron subtype is 2-4 times more contagious than Delta variant since it multiplies 70-times faster in the upper airways than Delta, supporting the transmission advantage.  

• Decrease in effectiveness of public health and social measures or available diagnostics, vaccines, therapeutics.

1. PUBLIC HEALTH: Although N-95 (China equivalent is KN-95) masks were already in vogue, Omicron has been responsible for attention being given to the N-99 variety since these are thicker & offer 99% protection against the virus. Alternatively, double-masking with 3-ply surgical masks could be acceptable if not indoors or in a crowded place or airplane, or if an N-95 / N-99 mask is discomforting - as in asthma patients. The protective differences by various masks (CDC, Spring 2021) has been reported by ACGIH's (American Conference of Governmental Industrial Hygienists) Pandemic Response Task Force (formed in 2020 at behest of CDC). 
   
   
   
2. SOCIAL MEASURES: Omicron variant was found to survive on plastic for 193.5 hours (vs 56, 59.3, 114, 156.6 & 191.3 hours for Wuhan virus, Gamma, Delta, Beta & Alpha variants respectively) and on skin for 21.1 hours (vs 8.6, 19.6, 19.1, 11 & 16.8 hours for Wuhan virus, Gamma, Delta, Beta & Alpha variants respectively). The silver lining is that a 15 second exposure to 35% alcohol is equally effective at inactivating the virus, regardless of the strain.
3. DIAGNOSTICS: Omicron sub-lineage BA.1 has a genetic change called a deletion in the “S” or spike gene which allows it to escape detecting by RT-PCR (Reverse Transcription-Polymerase Chain Reaction) testing.
4. VACCINES: Two doses of a COVID vaccine provide just 0-10% protection against infection with Omicron 5-6 months after the second jab. UK data suggests two doses of AstraZeneca or Pfizer offer around 35% protection against hospitalisation by six months after the second dose. Although booster dose restores protection to 60-75% two to four weeks after a Pfizer or Moderna vaccine, the same wanes to 30-40% after 15 weeks! 
5. THERAPEUTICS: Favipiravir, molnupiravir and remdesivir have similar efficacy against both Delta and Omicron variants of SARS-CoV-2 much to the relief for the treating medical professionals believing in their value.

In fact, Omicron variant of SARS-CoV-2 satisfies all the criteria to be classified as a VOC by the WHO. Its treatment and management just cannot be taken lightly. 

MANIFESTATIONS 

More than 50% complaints due to Omicron variant related coronavirus disease are runny nose, headache, fatigue, sneezing and sore throat.

Less than one-third of patients will have fever, and loss of smell has fallen from the top 10 symptoms in October 2021 to 17th place during the 3rd wave.

DIAGNOSIS

For RT-PCR testing it is necessary to have knowledge of the fact that in the case of Omicron, the maximum amount of virus appears after day three of onset of symptoms, till day six. After that, there is a drop. Hence, even if the RT-PCR is negative but symptoms are typically COVID-19 related it is advisable to isolate for 7 days. The most common window to test positive is between 24 hours prior to developing major symptoms.

It is important to remember that the now gaining popularity and acceptance Rapid Antigen Test (RAT) is only 50% sensitive as compared to the gold standard RT-PCR test.

Two lineages within Omicron have been reported, such as: BA.1 and BA.2, that are quite differentiated genetically. The sub-lineage BA.2, unlike the BA.1, is called “stealth Omicron” because it lacks the deletion and this allows it to be picked up by PCR tests - this variant is fortunately the major Omicron lineage in India.

PROGNOSIS

Omicron variant can re-infect those already having suffered from COVID-19 diseases since it can evade the immunity that was thereby acquired - the protective power in such cases is a mere 19%. Even those doubly vaccinated individuals can be targeted by Omicron variant but hospitalization is 16 times more in those unvaccinated!

A negative repeat RT-PCR testing done twice (at 24-hours interval) is ideally necessary on day 10 in asymptomatic patient, or before discharge or freeing from quarantine. However, 10-30% of cases test positive after 6 days and 5% will remain positive even after 10 days.

Interestingly, the first wave peaked in 108 days, the 2nd wave in 63 days and this 3rd wave has started declining in 36 days. This professes that Omicron will be a short-lived tsunami.

TREATMENT PRINCIPLES

"Nothing about this has been mild for us at all," says Dr Taison D Bell (Assistant Professor of Medicine in the divisions of Infectious Diseases and International Health and Pulmonary and Critical Care - UVA, U.S.) as he walks across the ICU in the University of Virginia (UVA). "We're still working just as hard to try to keep people alive with omicron as we were with delta."

“We have increasing information that Omicron is less severe than Delta, but it is still a dangerous virus,” says the WHO’s (Health Emergencies Program) Dr Maria DeJoseph Van Kerkhove, American infectious diseases epidemiologist

In treating the Omicron variant infected patients, what matters is not only symptom relief but also preventing hospitalization and its implied possibility of mortality. 

TAKE HOME MESSAGE

Kill the virus before it kills you should be the motto! Best way to evade hospitalization and escape death. God has given us a weaker version but it does not mean we oppose the Omicron variant meekly and defensively.

'Nip it in the bud' as the saying goes [used first and recorded in a Beaumont and Fletcher play of 1606-1607 called: The Woman Hater (comedy)] should be the motto and the aim of the treating professionals, and aspirations of misguided and misinformed victim patients during the Omicron surge and their well-wishing family and well-wishers. 

If virus is the culprit kill it with an antiviral and not rely solely on an antibacterial or an antiprotozoal agent.

It makes an important knowledge-additive to grasp the following basics.

Co-amoxiclav = Amoxicillin + Clavulanic Acid combination

In spite of such stark realities, why do healthcare professionals yet disfavor a specific antiviral seems baffling. Yet these very same Drs start such agents when symptoms appear or begin deteriorating and / or hospitalization stares in the face. 

Seemingly it means that when the dreaded cytokine storm kickstarts there is a happy realization to quell the same with a steroid and killing the causative SARS-CoV-2. Brave warriors are the caregivers who await the enemy's lethal attack before attacking rather than killing the invader already on the doorstep!

More about the true antiviral’s value vs an antibacterial advocating logic in COVID-19 management – be it due to Delta or Omicron variant, in the next upcoming blog.

DR R K SANGHAVI

Prophesied Enabler
Experience & Expertise: Clinician & Healthcare Industry Adviser