What approach should we take to treat omicrons?

Omicron has a reputation for being ‘mild’. Is it true?

Dr V Ramasubramaniam: We are fortunate that the current third wave, which is mainly caused by strains of Omicron’s lineage, appears mild. In other words, the disease is much more spreadable but the disease severity is much lower than the delta variant. The incubation period is very short, the transmission efficiency is high, very high and rapid, and the disease is mild. All I would say is that unlike Delta, which caused mild infections in young people, we now find that young people also have high-grade fevers. But fortunately for most people, it gets better in three to four days. Even though the omicron has significant mutations, and it spreads very rapidly, the disease severity is less than that of the delta.

Dr. Subramaniam Swaminathan: Delta was an indelible disaster not only for us, but for the whole world. We have many symptomatic diseases now. We are seeing quite a few elderly people, especially those with co-morbidities, now coming in with serious illness; My ICU is full now. And I have some patients that we would classify as severe COVID-19 cases.

And do not forget that the mortality rate is not insignificant. Based on the oxygen requirement, we call this variant mild. But having said that, I see an increase in the number of people who are completely pathetic because of Omicron because it causes fatigue and body aches. I see many elderly people with mental fog. They have a loss of energy, some of them bend over and fall, some have a drop in blood pressure. Neither of these would qualify as a serious illness, but symptoms can be alarming in older people.

So, when treating COVID-19, possibly since the major strain is now omicron, do we take a conservative approach or a more aggressive route?

Dr. Ramasubramaniam: This is a difficult question in the sense that there are people who can become ill – for example, elderly people with co-morbidities may be very ill. But if you look at the percentage of people who get sick, it’s very small compared to the number of people who get sick and have symptoms, which is much higher than what we saw with Delta. So, people who are elderly, have co-morbidities, or those who have not been vaccinated can fall ill. But this percentage is very less.

Since [symptoms in] Most people settle in three to four days, we have at least five days before we react to it. I don’t think we should rush and give anything on the first or second day of transition. So my advice is to wait three to four days. If by the fourth day, the patient is feeling much better, which is the case with most people, they should be fine. But if things aren’t going well for four or five days, the patient isn’t feeling better, then maybe we need to take action.

Dr. Subramaniam: I agree with this. Tossing the gun and running for medicine to every patient is probably wrong advice. I think we have to be very generous with things like paracetamol. Rest, drink plenty of fluids. [symptoms in] Most patients are going to settle very well.

Can vaccination prevent death, serious illness and hospitalization? Are any more children infected?

Dr. Subramaniam: The vaccine campaign has been one of the major victories that we have had in mitigating the impact of COVID-19. It is definitely making a difference. The question is, how long does immunity last and how effective is it, especially in the most vulnerable groups? Clearly, the unaffiliated remains a significant vulnerable group. However, we are seeing that in patients 70 years of age and older, especially those with multiple co-morbidities, if they were given a second dose of the vaccine more than six months ago, this seems to be sufficient. Not protecting them at all. Those who had received a second dose of the vaccine within the past six months, regardless of their age, did not seem to have it. So, I think there is some value in the booster dose. And I really wish we had started giving the third dose already.

And yes, we have a lot of kids and teens coming down with fever. But thankfully, most kids don’t have any problems. It is enough just to observe the symptoms and provide symptomatic treatment. My colleagues are telling me that children are having seizures due to fever. It is too early for us to say whether there is any real connection to COVID-19 or it is just an incident. But this is something we need to look at very carefully.

Dr. Ramasubramaniam: With regards to helping with vaccinations, it is spot on. But we have seen that as the antibodies decrease, the risk of taking Omicron is higher. Now studies have shown that if people were given a booster dose or a third dose, they would be less likely to develop symptomatic delta virus infection. If your immunity was about 80-90% after two doses and had subsided after six months or so and you were given a booster for delta virus infection, the protective efficacy would have increased again to 80% or 90% . In other words, the booster increases your level of protection against symptomatic disease by 80-90%. But with Omicron, protection from the third dose was really only about 50-60%. Therefore, the booster dose for Omicron was not as effective in preventing symptomatic disease as it was with the delta version. It is clearly documented.

But if you look at the severity, which guarantees hospitalization or complications and death, even for Omicron, the third dose did really well. The need for boosters in preventing serious infections, be it Omron or Delta, is very well established. But one thing I would like to add is that even though we are looking at giving three doses to most people, I think the priority is to make sure that two doses are given to the entire population.

How do you deal with the constantly changing target positions for treating COVID-19?

Dr. Subramaniam: The process of collecting data is not necessarily linear or streamlined. If we look at medicine as it is, we have developed our own way of looking at data and understanding the science of it better than we did 50 years ago.

When you have a new problem, and a new molecule, and new drugs, if a study with enough numbers is done very well, it can be quite useful in deciding the way forward. But we need to do the study in different settings and populations, and then decide how it works. During an emerging pandemic, what is true in one wave may or may not apply in another, especially when it comes to antivirals. Right there we are going.

Thirdly, it also depends on what kind of population we are looking at. For example, a lot of studies, on the basis of which we have got approvals for different drugs, were done on people who were not vaccinated. But now, almost everyone who visits has been vaccinated.

When we talk about COVID care, it has two parts – antiviral and treatment of hypoxia. And the good news is that for the second part of the treatment, which is the treatment of severe COVID-19, which is basically lung injury, the treatment data is pretty clear. Antiviral use is a dynamic goal and it changes depending on where you are and what you are studying.

Dr. Ramasubramaniam: Medicine is constantly evolving. But we have to understand that there are two issues. One medical and the other advocacy. If you look at the medical evidence, it has to be based purely on science, purely on randomized control studies. But these kinds of trials and studies take time, you can’t wait for advocacy to come along. The advocacy will include political issues, logistical issues, such as the question of lockdown.

In the early stages of the pandemic, all kinds of drugs were recommended for all kinds of conditions. which has been organized. So, we have certainly gotten much better in our approach to dealing with this crisis. But we need to understand that this situation is constantly evolving. Previously, no one had been vaccinated; Now we have a vaccinated population. So, will the same drugs work? It depends on the dynamics and behavior of the population; on each person’s susceptibility to infection, whether unvaccinated/vaccinated; On the immune response to earlier infections. And most importantly, it will depend on the variants and how they behave. So, the bottom line is, it’s still constantly evolving, and we need to learn along the way.

Is it possible to ensure that certain recommended protocols are implemented across the country?

Dr. Subramaniam: This is a very complex area. While COVID-19 has made headlines over it, it is happening everywhere. So, while the government has very detailed guidelines on the treatment of many diseases, not many doctors are aware of them. Obviously there is a problem in education and dissemination and this needs to be addressed. These protocols should be strictly followed in educational institutions. Only then will we be able to fix the private sector.

Dr. Ramasubramaniam: With regard to COVID-19, there is also a problem with the evidence as it is constantly evolving and what was true two months ago may no longer be valid. In the Indian situation, another complication is the scope of care that is delivered to the patient, unlike in the US or UK, where the standard of care is a very small band and the best and worst fall within the band. In India, the best hospital is probably equal to or better than some of the hospitals in the west, but the worst hospitals are really bad. Therefore, it is very difficult to come up with guidelines to cover this entire spectrum of population and healthcare delivery.

Subramaniam Swaminathan, Director, Infectious Diseases and Infection Control, Gleneagles Global Hospitals, Chennai; V. Ramasubramaniam is Senior Infectious Disease Consultant, Apollo Hospitals, Chennai