Living with Covid in 2022

It has been two years since the coronavirus turned the world (and Nepal) upside down.  Masks have become the norm, physical distancing is a must, vaccines are mandated, and parts of the world are going back to lockdowns. The virus has infected 277,523,045 people and killed over 5.3 million, a figure that does not count ‘excess fatalities’. 

Just as everyone was waiting for business to go back to normal in 2022, countries have been hit with a highly contagious new variant. There are now serious worries about the efficacy of vaccines against Omicron and who and when to boost. 

Lab tests have shown that the AstraZeneca and VeroCell vaccines most used in Nepal may not be so effective against Omicron, and only m-RNA vaccines like Pfizer and Moderna may be effective as boosters to stop infections. However, researchers have said all vaccines, including AstraZeneca and the Chinese jabs, significantly protect against serious illness. 

Nepali Times spoke with national and international health experts to verify these initial findings and how it is likely to impact Nepal’s response to the new strain.

“The coronavirus is here to stay and it will remain with us for decades to come. To do this it will find ways to continue to infect people in communities even if they are vaccinated,” Andrew Pollard,  who helped develop the AstraZeneca vaccine told Nepali Times from Oxford.

He added: “The important role of the vaccines is to prevent severe disease and the evidence so far, even with Omicron, does appear to indicate that vaccines are still holding up in preventing most of the severe outcomes.”

“All vaccines prevent severe Covid”, Nepali Times

Infectious diseases specialist at HAMS hospital in Kathmandu Anup Subedee agrees: “It is true that mRNA vaccines are more effective against the new variant but all the shots still significantly reduce severity and mortality. So our priority must be to vaccinate as many people as soon as possible and to boost the immune-compromised and frontliners.”

Researchers recommend using mRNA vaccines as booster for the vulnerable populations. Last week, Nepal received nearly 2 million doses of Moderna shots from Germany via the COVAX facility, which is sufficient to provide booster doses for the elderly. Health Minister Birodh Khatiwada announced on Wednesday that Nepal would start boosters from mid-January. 

A recent study by The Imperial College London estimated that the risk of reinfection with the Omicron variant is 5.4 times greater than that of the Delta variant. What this means is that the protection against reinfection by Omicron afforded by past infection may be as low as 19%. Early studies also suggest that Omicron is four-fold more infectious than the Alpha strain and two-fold more infectious than Delta.

“There is some evidence that shows that a natural immunity from past infection and or vaccine-induced immunity from prior vaccination may not be sufficient to prevent Omicron infection. But it is too early to make a concrete statement,” regional health expert Sushil Koirala told Nepali Times via email from Bangkok. 

Preliminary findings suggest that Omicron may be milder than previous variants, but its increased transmissibility could still result in high rates of severe disease and death particularly among vulnerable and unvaccinated groups, overwhelming ICU capacity. 

“The real question is not how many people Omicron is likely to kill but given its higher transmissibility, how Nepal’s limited health infrastructure will deal with a surge,” says Dibesh Karmacharya of the Centre for Molecular Dynamics Nepal. “We have to also see how Omicron affects vulnerable populations in Nepal that have already been vaccinated.”

The general consensus is to launch mass immunisation and administer booster shots for the vulnerable population simultaneously. Early evidence based on lab studies shows a booster jab with any vaccine increases protection against Omicron and reduces hospitalisations and deaths.

“Boosters do seem to increase antibodies and some early evidence from the UK shows that boosters increase protection against these mild infections,” says Pollard. “Boosters may be important for some of the frailest in our communities to keep them safe if their protection has waned. Some countries have started booster programs focusing on these risk groups first.”

“Nepal has all the conditions for an Omicron surge”, Nepali Times

The Ministry of Health has announced booster shots from mid-January 2022 provided that the World Health Organisation (WHO) permits it. The WHO has been prioritising first and second doses over boosters, especially where there is a short supply of vaccines, and recommended boosters only after 40% of the population is fully vaccinated.

“WHO might have its guidelines but we must also stick to our national priorities, we must provide boosters for frontliners so that Omicron does not shut down our health care system,” adds Subedee. “We must not miss immune-compromised and the elderly, it is more important for now to provide boosters for 80+ people than administer a single dose to 12-18 year olds.”

Nepal’s vaccine stockpile is now so big and vaccine uptake so slow that there is a danger of vials having to be destroyed because of the lack of refrigerated storage,  and there are millions more vaccines in the pipeline. Nigeria this week destroyed 1 million vials saying the international community provided those doses close to expiry dates.

“We now need to get jabs into arms as soon as possible, we must continue inoculating those who haven’t yet been vaccinated while simultaneously also administering boosters, given the decreasing antibody levels and the rise of new variants,” says Buddha Basnyat, a physician at the Patan Academy of Medical Sciences.

So far, Nepal has confirmed three imported Omicron cases, the first in mid-November, meaning a small cluster transmission is already at play. Superspreader political events and large gatherings have increased the risk of further transmission. 

Given relatively lower vaccination coverage, lack of booster doses, unknown efficacy of Chinese jabs used and insufficient safety measures, Nepal is a breeding ground for a highly contagious variant to spread. But what will happen in Nepal will largely depend on how the Omicron outbreak plays out in India. 

Says Basnyat: “We have to prepare for a new surge, we have been caught too many times with our pants down."

The way to do that, Koirala says, is to increase surveillance on the Indian border, and accelerate the vaccination drive. “It is of utmost importance that Nepal start preparing critical care and for possible lockdowns for a large-scale Omicron outbreak. We can’t afford to wait.”

As we welcome 2022, the New Year’s resolution should be normalising the pandemic by increasing the global vaccine equity. Says Dibesh Karmacharya: “Some countries now have the fourth dose but unless we achieve vaccine equity and herd immunity, Omicron will just be one among a long line of variants.”