Dr Angelique Coetzee: Don’t look at your positivity rate or your daily cases. Look at how many people are admitted in the ICU
🔴 Dr Angelique Coetzee talks about how she first spotted the Omicron variant, how it has replaced Delta in South Africa and whether the Omicron wave will enable herd immunity. This session was moderated by Anuradha Mascarenhas, Senior Editor, The Indian Express
Dr Angelique Coetzee, Chairperson, South African Medical Association (Illustration: Suvajit Dey) Anuradha Mascarenhas: With this new variant, the majority of the symptoms are mild. So, what really caught your attention? What made you sense that something is different and how did you treat it?
I am a general practitioner and still old-school. So, even with the Beta and Delta wave, we let patients come in, and, I think, that assisted us greatly in understanding how these variants attack the body. We were out of the Delta wave for about eight weeks, and one morning a young man came with some complaints. He tested positive, and subsequently, his family did too. That day, I also saw other patients with more or less the same symptoms, which were very different from Delta. I call it musculoskeletal, mostly because of the sore body, backache, headache, chest pain, scratchy throat and a slightly runny nose, but not really fever and any oxygen needs. In the beginning, when I first saw these patients, I still followed the Delta protocol. In Delta, you have to see your patients back (after a few days), because they tend to turn around by about Day 10; between Day 7 and 10, that’s when they really get bad. But within one week, I realised that out of all the patients that I’d seen, only four came back for a follow-up. The rest said they were much better.
Amitabh Sinha: One of the things that we have been hearing about the Omicron variant is that it is mild. But at the same time, scientists have also consistently been saying that the evidence is not conclusive yet. At what stage do you think the evidence would be conclusive to say that this particular variant is a milder variant, that it would not cause any serious disease?
First, you need to look at the definition of the WHO (World Health Organization) regarding mild illness of Covid-19. The definition is clear; signs of upper respiratory tract infection, no shortness of breath, dyspnea, or any abnormal chest X-ray — patients should be able to be treated at home. So, if you look at the definition, less than one per cent are getting severe illness. The majority of patients in primary healthcare are adhering to the definition of mild illness. If you’re unvaccinated, if you have comorbidities, then any viral infection might lead to severe illness and that severe illness would be pneumonia. That’s what we have seen with Omicron. What I can advise you is that do not look at your positivity rate or your daily cases. You need to look at how many people are admitted in the ICU and what are your death rates for patients admitted specifically for Covid-19.
Amitabh Sinha: Can you tell us a little more about what exactly happened in South Africa in that case? How many people actually ended up in the hospitals, in the ICUs? How many deaths occurred during this Omicron wave to suggest that it was nothing like what the Delta wave was?
Our data is clear that less than one-third of patients with Omicron were severe in hospitals. With Delta, on July 8, there were 19,900 in hospitals, on July 14, 17,000 in hospitals and on July 10, there were 2,597 in high-care and ICUs. With Omicron on December 17, we had 23,000 cases per day, 528 in high-care and 7,900 in hospitals. Our death rate was much lower; average was about 100. With Delta, we had seen a huge increase in death rates.
It’s extremely important for people to understand that vaccines are not going to protect you against mild disease but your symptoms will be less intense. And that’s what we’ve seen
Kaunain Sheriff M: WHO says that this variant is causing very high breakthrough infections. Are you seeing severe breakthrough infections in South Africa?
In the mild cases, it doesn’t seem to matter whether you have been vaccinated or not. We have seen just as many mild cases in vaccinated people as in the unvaccinated. However, what we did notice was that the severity of the headache or the scratchy throat or the malaise is less intense among the vaccinated. In our ICUs, 88 per cent are unvaccinated.
Kaunain Sheriff M: In the case of severe infections, we are seeing that Omicron is affecting the upper respiratory tract and the airways and not really the lungs. Are you seeing these two things, which are blood clots as well as cytokine storm, in severe patients with Omicron?
Not that much as was the case with Delta. Remember the definition of severe illness, which is lung infiltrates, so that’s pneumonia. And those patients with pneumonia will either be in the ICU or in high care. But for the average person out there, Omicron will not affect the lower respiratory tract. In severe disease, it does affect the lower respiratory system, that’s why you are admitted, because of the pneumonia…and that would cause inflammation and cytokine storm, although clinically not so severe as we have seen with Delta, especially among the vaccinated people.
Anuradha Mascarenhas: Are the majority of patients only above 60 years of age, those with comorbidities? Do you see youngsters at all in the ICUs?
We do see youngsters. From the data on January 7, we see ICU admissions among the 70-plus age group were 270 for the past two weeks, ventilations: 135, and 91 deaths. Among the 60-69 age group, hospitalisations were around 35 per cent. In the 70-plus age group, the hospitalisation was 49 per cent, 50 to 59 was 29 per cent, 40 to 49 was 17 per cent and from 18 to 39 it was 11 per cent. That was the status of hospitalisation for two weeks that was released on January 10.
It would be scary if Delta and Omicron mutate. Also scary is, the irresponsible use of antibiotics during these viral infections might lead to a bacterial pandemic and that would kill us
Kaunain Sheriff M: There are lab studies, not peer reviewed, that say that Omicron is providing some protection against Delta. There is also now epidemiological data from the UK which shows that Omicron is taking over Delta. What is your take?
In South Africa, Omicron has taken over from Delta; we don’t really see Delta cases anymore. Second, regarding protection, you have to understand that this is our fourth wave. There are a lot of people in our country who have been infected before with one of these variants, and have what we call T and beta cells. So, your antibodies will go down, but the moment you encounter a new variant, there will be some memory that will help protect you. For now, definitely Omicron will protect you with T and beta cells.
Kaunain Sheriff M: Is it the end stage of Delta now, globally?
In South Africa, we are not seeing Delta. So, in South Africa, I think, that’s the end stage of Delta, but it depends on what the variant is going to do going forward.
Kaunain Sheriff M: Most of our vaccines were tested on the Wuhan strain. Our boosters were also mostly tested on that strain. How effective are the boosters for Omicron?
What we have seen is that whether you have been vaccinated or not, you still get the mild disease. I think, it’s extremely important that people understand this, that the vaccines are not going to protect you against mild disease but your symptoms will be less intense. And that’s what we’ve seen. In that case, vaccines are still good for the world. However, going forward, I don’t think you’re going to get your population to go every six months for a booster. I think at some stage people are going to say no, I’ve had enough of this.
Kaunain Sheriff M: There’s a lot of fatigue in this Omicron infection. A lot of frontline workers are getting infected. How is it affecting the healthcare system in South Africa?
In South Africa, unfortunately, one-third of our healthcare workers are not vaccinated for various reasons. We didn’t see a huge strain on our hospitals. Maybe we have a different system than other countries because we are very much primary healthcare-orientated, with people going and seeing the doctors physically, and that also helps to explain the disease to patients. So, it’s all about empowering the people out there. But there is mental fatigue everywhere. Even I get fed up, I actually had a fight with two patients who were admitted, because they didn’t get vaccinated. Luckily, our hospitals are not overwhelmed so it was easy to get a bed for them. But this could have been prevented.
Partha Biswas: Are we looking at a masked world for a very long time?
The use of masks should not be negotiable; it should be compulsory. It’s interesting that one of the first things some of the first-world countries did was to close the borders with other countries, including South Africa, while they let people walk around without masks, spreading the virus. A mask should be part of your daily make-up.
Anonna Dutt: After the Delta wave, a lot of people were going back to the hospitals with breathlessness, fatigue, and a variety of symptoms, even some cases of mucormycosis. Are there any long-Covid symptoms that you’ve started seeing right now? Do you see Delta and Omicron probably mutating together in the future and coming up with a more virulent version?
Let’s tackle the mutation. First, it’s a possibility. Hopefully, that will never happen. But if it would, that would be a disaster, because then you will have a faster-spreading viral infection with a lot of severity.
I presume that there will be a few cases with long Covid with Omicron for those people who have been on the ventilator and discharged. But, so far, we haven’t really had any experience with that.
The use of masks should be compulsory…One of the first things some first-world countries did was to close the borders while they let (unmasked) people walk around, spreading the virus
Anonna Dutt: Did you see an increase in infection in children compared to Delta?
Yes, we did see that right in the beginning. That’s always in any wave; children first. So for now, at this stage, even looking at the data, there are not really anyone (children) in the hospital. We don’t see children getting that sick anymore.
Amitabh Sinha: Two questions; first, some scientists have suggested that Omicron could be a blessing in disguise because everyone will get it and we would reach some sort of herd immunity. Now, here in India, during the second wave, over 70 per cent people were already estimated to have been infected. If 70, 80 or 90 per cent didn’t get us herd immunity, what is the guarantee that Omicron would bring herd immunity? The other question is that Omicron is spreading this fast mainly because it is able to escape immune response. So, even if we attain herd immunity, what is the use of this herd immunity if a future variant once again develops this capability to evade immune responses?
You need to watch and see what the virus is going through or the viruses are going to do, especially around mutations going forward. But again, no guarantees. But it comes back to T cells. It depends on your immune system. And we unfortunately know that the older you get, the poorer your immune system is or the younger you are, the better your immune system is. Herd immunity was something that we thought we would get via vaccination. But looking at vaccinations, especially in Africa, we are never going to get herd immunity through vaccination. So, the only other way that you’re going to get herd immunity most probably would be by getting infected, unfortunately. And then there’s the law — the fittest survive. If you need to choose between which variant you want your people to get herd immunity by, you will choose Omicron and not Delta. We hope that a lot of people get immunity through Omicron, at least lasting for another year. So, only time will tell but the scary thing would be if Delta and Omicron mutate. Another scary thing, which, I think, we also need to start making people aware of, is the use of antibiotics. The irresponsible use of antibiotics during these viral infections might lead, going forward, to a bacterial pandemic and that would kill us.
Amitabh Sinha: You do not discount the possibility that in the future, we might have something which might be more transmissible than Omicron or maybe even more dangerous than Delta?
That’s a possibility. There’s a flip side of the coin; it might be less as well, that’s also a possibility. Always remember, it’s not in the virus’s best interest to kill us off because then the virus is going to die as well. So, it will try to survive. So, it will try to evade our immune systems as much as possible. That’s where the wearing of the masks is so important so that you don’t spread it.
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Kaushik Das Gupta: Right now in South Africa, the cases seem to be declining. Could you tell us a little bit about the trajectory of this outbreak in South Africa?
Amitabh Sinha: Also, why is the South African trajectory different from what we are seeing right now?
I don’t know why our trajectory is different from what you see. Based on the data we have, I think, we peaked around December 17 or 18. If I look at the peaks, we didn’t have the same peak. It was less than it was with Delta, but very far spreading, and just as quickly, it went down. I think, that’s the nature of the virus.
Kaushik Das Gupta: For how long did you have the restrictions after the Omicron outbreak?
We have done away with our restrictions on movement (of people), closing of restaurants, sale of alcohol, but mask-wearing is still compulsory, there’s still a cap on big gatherings — indoors 1,000, outdoors more. Indoor gatherings of 1,000 people are allowed because of political pressure from the churches. But we haven’t really seen an uptake in the number of infections, even from indoor gatherings of churches.
Sandeep Dwivedi: The Indian cricket team is in South Africa and they’ve been in a bio-bubble. How safe are these bio-bubbles and should we be continuing with these kinds of tournaments in a sanitised environment? The second question is that a medical panel allowed Novak Djokovic the exemption despite him not being vaccinated. What are your views on that?
Common sense will say that the rule should be the same; it doesn’t matter whether you sweep the floors in a hospital, or whether you are the president of a country. And the rules should be clearly spelled out. If you look at people coming to matches, if you are not vaccinated but you do expect people to come and pay for your performance and they must be vaccinated, then you have to go and really think about this again, and what your priorities are. Globally, there should be a unified rule. Regarding cricket in South Africa, you can be in a bio-bubble as much as you want, but if you go out to a gathering, you don’t know whether those people are vaccinated. Then you would make a mockery of your bubble. The question is, where are the leaks? We are the leaks, we are the soft points. But for now in South Africa, cricket is an open event.
Monojit Majumdar: How do you like to explain the protests, which have been sometimes violent, that have been seen in cities in Europe and the US against Covid-19 curbs, masks?
What it tells me is that either the government or the medical fraternity is not speaking to the people. It comes back to not empowering the people with correct facts. Your people are not stupid; they will sit down, they will listen to what you’re saying, and they will make up their own minds. So, when you try to bring out a message there, you have to be honest. You have to say ‘I don’t know’ if you don’t know, you have to take them on the journey with you and empower them.
Anuradha Mascarenhas: Scientists tracking the virus said that there is a potential link with HIV. We know South Africa has several cases of HIV. Do you think at a time when there is greater global action, this fight against HIV has been neglected in some way, because of the pandemic?
An unvaccinated person with untreated HIV or TB (tuberculosis), or any other immunocompromised disease, would lead to variants mutating because that host body can’t detect the virus and that would be an excellent platform for the virus to mutate. We need to get our immune-compromised people with TB, HIV, or those who are on dialysis for kidney disease, treated. Going forward, that is extremely important, otherwise you will see mutations. Incidentally, data points out that Omicron actually started in the Netherlands. So, that’s very interesting.
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