Boosting booster jabs against Omicron

For the first time in four months, Nepal recorded over 1,000 daily new Covid cases on Sunday. Of the 12,632 people tested nationwide, 9% were positive – proving that Omicron has replaced Delta as the dominant strain.

Reacting to the sharp rise in infections, Nepal’s Covid-19 Crisis Management Committee (CCMC) has imposed a ban on gatherings of more than 25 people in public spaces, and made it compulsory to show vaccine certificates before entering them. Schools that had just opened following winter vacation, will also be shut for another three weeks.

“It will be foolhardy of us not to expect a surge now. But if the vaccination drive slows, we will pay for it dearly,” warns Buddha Basnyat, a physician at Patan Academy of Medical Sciences.

But Nepal’s vaccination drive has hit a speed bump because of a shortage of syringes. Although there is a stockpile of 12 million doses in refrigerated stores across the country, and 6 million more doses on the pipeline, there are a limited number of needles to administer them.

Nepal was one of the first countries in the region to start Covid vaccinations in March 2021, and has managed to fully inoculate only 36.8% of its 30 million population. Only half the population has received the first dose. 

The needle shortage is holding back first jabs, second doses and booster shots for the vulnerable groups including health workers, the elderly and immuno-compromised individuals.

“Two doses of vaccines against Omicron is not as effective but a booster is. So we have to provide the third dose not so much to prevent mortality, but to stop Omicron from spreading rapidly and overwhelming our healthcare system,” says epidemiologist Lhamo Yangchen Sherpa.

She adds: “Yes, there is a moral dilemma to boosters. Given that a majority of Nepalis haven’t yet been fully vaccinated we have to consider the latest development as the doses are approaching their expiry date.” 

Nepal is planning to provide boosters only when 40% of the population has been fully inoculated. But studies have shown that the immunity afforded by vaccines wanes over time with a significant decline in the level of antibodies. And while most of the vaccines are not as effective against Omicron, they still largely prevent severity.

Says Minister of Health and Population Birodh Khatiwada: “We are trying to sort out some final details and will make an announcement on boosters soon.”

Studies have now confirmed that Omicron produces less damaging infections with impacts largely limited to the upper respiratory tract and does not multiply readily in lung tissue, leading many to believe that the new variant is much milder and hence likely to replace Delta.

“We must provide boosters for the most vulnerable groups, I have seen many patients at my hospital who are fully inoculated but struggling with complications,” says virologist Sher Bahadur Pun at Kathmandu’s Teku Hospital. “Just because they have already received two doses we can’t leave them to die.” 

He adds: "In the meantime, we also have to identify groups who can’t access shots and those who are still hesitant to inoculate, and work out strategies that address them best to speed up the vaccination drive.”

Most infected people are also experiencing much milder symptoms of Omicron, either because they have been vaccinated or have natural immunity due to previous infections that they were not aware of. Even so, the sheer transmissibility of the new strain will likely overwhelm Nepal’s understaffed and underfinanced healthcare mechanism.

In neighbouring India, the daily caseload is now nearing 150,000 a day, and it is doubling every 1.5 days in Bihar state across the border. During the Delta surge, Nepal’s cases peaked two weeks after it did in India, but with Omicron it may not even take that long. 

“We are prepared for hospitalisations if cases are milder and not as serious but we don’t know how the virus will behave. We are also better prepared than the last surge with oxygen, ICUs and other facilities,” says Sangita Kaushal Mishra at the Ministry of Health Health Coordination Division.

That may be the case, but across Nepal many rural hospitals are still understaffed and do not have trained personnel to operate ventilators and run ICU wards. Similarly, not all newly installed oxygen plants are functional yet.

Then there is virtually no contact tracing, leading experts to believe that figures for Omicron are underreported, and only individuals with symptoms are being tested. 

“Given how contagious Omicron is, increased testing can go a long way in controlling the surge, so can institutional isolation of active cases,” says Bikash Gauchan of the Gandaki Province Infectious and Communicable Disease Hospital in Pokhara.

Children all over the country are still largely unvaccinated, and should be prioritised during the time that schools are closed. There has been a worrying rise in paediatric hospitalisation in the US and Europe among unvaccinated children. And while people below 18 years have been largely spared so far, they are nonetheless an active medium for the virus to spread rapidly to more at-risk groups.

The community spread of Omicron in Nepal is blamed on large gatherings of major political parties during their conventions in the past month. Such irresponsibility from top leaders has also led general populations to flout safety measures. Maoist Centre Chair Pushpa Kamal Dahal, his family and many of his close aides have tested positive, and leaders of other political parties, including ministers are in isolation.

The once-in-12-year Makar Mela is expected to draw 6 million visitors in a month to Panauti starting next week, and can be a hyper-spreader event. So can the lead-up to the local elections slated for April. 

“The fact that Omicron is much milder can make people more careless, so we must once again reinforce the importance of masks, ventilation and distancing,” says Pun.

Besides this, the second line of defence is to vaccinate as many people as soon as possible, and start giving boosters to the rest. 

Adds Buddha Basnyat: “We were lucky with Omicron that it is mild but we should use it as an opportunity to vaccinate both the unvaccinated and boost the vulnerable groups simultaneously on war footing to prevent stronger variants from arising.”