Omicron: Monoclonal Antibody treatment will be a game changer, experts claim

“Monoclonal antibody should be given to high-risk patients, which attacks the spike protein and arrests the virus when it does not attach to the host cells. It might be a game changer for this new mutation. Even if there is some kind of immune evading mechanism in this mutant with the previous vaccination, it still gives you some kind of protection in the body,” claimed Dr Viny Kantroo while commenting on the efficient solution for the newly discovered Omicron variant of Covid-19.

In a discussion with Medically Speaking, a panel of top health experts explained the South African variant, the possible treatments known so far and travel restrictions. The panel included: Dr Viny Kantroo, Senior Consultant, Critical care, Indraprastha Apollo Hospital; Dr Dodul Mondal, Senior Consultant, Radiation Oncologist, Indraprastha Apollo Hospital; Dr Praveen Gupta, Principal Director, Neurology, Fortis Hospital; Dr Vivek Nangia, HOD, Pulmonology, Max Healthcare.

Here are the excerpts from the exclusive interview:

 

What exactly is this new variant and what does the government mean by “horrible mutation”?

Dr Viny Kantroo: The fact that we had Covid in the backburner was something people were not trying to understand and forgot about the Covid Appropriate Behaviour because respiratory viruses mutate every year, example given influenza virus. The new Covid variant found in South Africa is said to have 30 mutations in the spike protein, which makes it more aggressive to connect to the tissues and leads to disease that are more infectious, furthermore leading to another pandemic wave.

Variant of Concern does not necessarily mean that it will lead to the 3^rd or 4^th wave in India, but since it has so many mutations, the government is fearful that it may lead to increase in the number of cases and may evade the immunity created by vaccination.

 

What does it mean for those who are vaccinated?

Dr Vivek Nangia: This virus has over 50 mutations out of which 30 are on the spike protein, something that is targeted by the vaccines. Right now we only know that the vaccines can protect us from catching Covid and serious illness. So we should go and take our vaccination and not take them lightly. If these mutations will result in more severe disease or not, we do not know yet, but we do know that the infectibility and transmissibility is higher. If it took about 6 weeks for the Delta variant to grow from 0% to 50% positivity rate, this virus takes just 2 weeks and hence the chances of spreading are very high. Only for the few cases detected, several others will go undetected.

 

What are these various variants and how is the new variant different from Delta?

Dr Praveen Gupta: Once the virus undergoes mutation, it changes the way it engages with the host. If the virus progresses in the body faster, it can cause more aggressive disease also. Which means once the virus mutates, it invades the immunity that has been acquired and that happens with influenza every year. People roam around in the country as if Covid has gone now and we are celebrating it. The variant now reaches people faster than the older ones. Which means that without Covid Appropriate Behaviour, it could start a wave and trigger it very fast. Therefore the easiest path is to go back to Covid SOP’s which will prevent the spread. Although the report from South Africa says that vaccines will be able to provide some immunity, but due to some mutations in the glycoprotein, it will be able to evade the immunity created by vaccines also to and extent. Therefore, vaccines may not be able to provide adequate protection.

Thirdly, we saw that antibodies and Pfizer vaccine was not as effective on the Delta variant as it was on the previous variants. As more and more variants come in, the impact of the current medications and the vaccines may not remain as robust as it was with the previous variants and that is the main reason to call it as the variant of concern as it has the potential to start another wave in our country and across the world also.

 

Dr Guleria says that we do not need booster shots, but we also know that the efficacy and antibodies wane with time. What is your view on booster shots concerning the new variants?

Dr Dodul Mondal: The age of the current pandemic is nearly 2 years now and everything is under research and we are not very sure to confidently comment on any need of doses. We have to wait till the time scientific data is available. But as of now, we know that in many vital infections, booster dose really works.

 

We can say that the scientific evidence is awaited but we know that the efficacy wanes and with this new mutation, there is a higher concern. What would you say about the booster doses?

Dr Viny Kantroo: There is no one to one answer to your question, but even our second dose is pending and has been given only to 30 to 35 per cent of the population. Therefore, thinking of a booster dose with the first generation vaccine is a bit premature as we are seeing the need to upgrade them to the second generation. We are seeing a lot of mutations inside the virus every 3 to 6 months and hence second generation vaccines would be a greater option than booster doses.

 

Isn’t second generation vaccine a much longer process? Can’t the doses that lie unused in the hospitals be utilized for giving booster to those who ask for it?

Dr Vivek Nangia: Science has showed that there are studies where the immunity, may it be through vaccines or natural, is likely to wane in a period of 6 to 8 months. Therefore, booster or a second dose of vaccine is definitely necessary. Only a small segment of the population has been vaccinated till now and 76% is still to be vaccinated. If we already start talking about the booster dose, things will become a little tricky. Considering the influenza situation, every year there is a new strain and a new vaccine based on the prevailing strain. Covid might as well require new vaccine each year, and we are not sure if the current vaccine can cover Omicron completely. These questions will be answered in due course of time.

 

What will be your advise to the policy makers as WHO says travel restriction is not the most stop robust reaction?

Dr Praveen Gupta: Omicron is a variant of concern at this time and when this concern will convert into a real problem, we do not know as of now. In a period of two to three weeks, we will experience a wave, and while the wave is reaching its peak, we could consider revaccination especially for people at rest. But if revaccination with the same vaccine will be of any help is still a doubt.

There are concerns at two levels as of now, individual and social and this virus varies between the two. But since this disease is a community disease, we need to find out best measures to prevent it at a community level and reiterate the Covid appropriate behaviour that is the cheapest most effective way to combat every variant. Giving some help or incentive to people practicing covid appropriate behaviour and reprimanding those who flout this behaviour and not taking vaccines is possibly a better way for us.

 

We have seen that people have a lackadaisical attitude due to decreasing number of cases. Is Omicron a cause of concern for people and they must follow the same protocol that they did while the second wave was at its peak?

Dr Dodul Mondal: This is the best way to prevent any illness that spreads through respiratory tract. People living in metropolitans do follow these protocols, but once you are out of the metro cities, they are completely different. I visited smaller cities recently and saw that the markets and shops are open and no one is wearing masks. People think there are no Covid cases. Hence reiteration of the SOP’s is needed by all means. I do not think policies cannot help until and unless people are concerned and educated because forcing them cannot help in the long run.

 

What will be your suggestion to those who are thinking of international travel?

Dr Viny Kantroo: If there are variants of concern in some parts of the world like South Africa, you should be avoiding travel in those parts and people coming in from those countries should be given rigorous scanning at the airport and should be tested for Covid-19. It is better to take preventive measures than to let this virus go on to a level where we cannot curb it.

 

Can this variant cause reinfection?

Dr Vivek Nangia: This virus can easily cause reinfection and that is what it is known to cause as of now. Secondly, we know that it can be diagnosed easily with the existing RTPCR kits. There are three strands to look at for every PCR kit and if two of them test positive, it can be diagnosed as Omicron. Thirdly, we know it is easily transmissible and the doubling time is pretty rapid. As far as the immune escape is concerned, we still do not know if the medication, antibody cocktail or the vaccine will be effective.

 

What do we know about the efficacy of Covaxin and Covishield as of now?

Dr Praveen Gupta: Our vaccine basically works on the spike glycoprotein and as we have already discussed, there are over 30 mutations on the spike glycoprotein of Omicron, which is where the question of the vaccine efficacy arises from because if the target has undergone mutation, vaccine may not work at all or as well. We have seen that a large number of vaccinated people have got infected, but thankfully the infections are mild and hospitalizations are less. Therefore we say that we may need second generation vaccine which are able to surmount the variants and are effective against them. That is where the concern lies because of a variant with high transmissibility, increased infectivity and some vaccine resistance. If it spreads, it may not be possible to check it because instead of 6 weeks, it may spread in two weeks. We have a situation similar to March and February where people were meeting and celebrating and the festivals are around the corner. The concern is there but very low.

 

Why is there an alarm regarding this variant in India?

Dr Dodul Mondal: Now since the international travels are open for almost every country, definitely, there is a reason to be concerned. Therefore, there has to be rigid policy to prevent infection from other countries, which we noticed in previous waves. Secondly, there is no replacement of the fact that SOP’s are the cheapest most effective way to curb any infection.

 

What do we know on the treatment front?

Dr Viny Kantroo: The symptoms are quite similar to the previous variant as there has been no report of any different one so far. The treatment is going to be similar because the infection was very mild previously and the hospitalizations were very low and we hope the same happens this time as well. I believe monoclonal antibody should be given to high-risk patients which attacks the spike protein and arrests the virus when it does not attach to the host cells. It might be a game changer for this new mutation. Even if there is some kind of immune evading mechanism in this mutant with the previous vaccination, it still gives you some kind of protection in the body. If people have any hesitancy regarding the second dose, they should get vaccination because it will prevent you from getting hospitalized or getting on any kind of oxygen support despite n number