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Responding to the new COVID-19 sub-variants, now and in future

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By: CHANDRAKANT LAHARIYA

It is four years since the novel coronavirus (2019-nCoV, later renamed as Severe Acute Respiratory Syndrome Coronavirus-2 or SARS-CoV2) was first reported on December 31, 2019 from China. In the months which followed, it caused severe COVID-19 waves in nearly every country, across the world. Alongside, at end December or early new year, there would be news of a new variant or sub-variant, or of a surge in cases in some countries. At the end of 2021, it was an Omicron variant (BA.1.1.529), and by the end 2022, the COVID-19 case surge in China made news. Now, a new subvariant of the Omicron variant of SARS-CoV-2, the JN.1, is making news.

Virus behaviour

The JN.1 sub-variant of Omicron has been reported from multiple countries and designated as a variant of interest (VoI) by the World Health Organization. This has raised some concerns and caused some worries. But is it really cause for concern? The short answer is a no. The reason is that the reporting of a new variant or sub-variant is on expected lines. In fact, in May 2023, while declaring the end of the COVID-19 pandemic, WHO had highlighted the need for continuous tracking of the virus and its variants. The rationale was simple. The pandemic is over, but SARS-CoV-2 was and is circulating in all countries and all settings and will continue to do so for long, and possibly forever. That is how most viruses behave. Therefore, there is always the possibility of some seasonal changes in the number of cases, at unpredictable intervals. A linked feature is that the genetic material of the circulating viruses — especially of the respiratory virus — keeps changing over a period. These changes in genetic structure (genome) result in the designation of new variants and sub-variants.

Since the reporting of the novel virus in 2019, more than 1,000 subvariants and recombinant sub-lineages have been reported. Against this backdrop, the emergence of JN.1 is not surprising. However, every change in genome does not matter, and the international agencies and subject experts are on task to assess the risk. However, if mutations or genetic changes result in an alternation in the characteristics of the virus (such as higher transmission, more severe disease or immune escape from vaccine induced or natural immunity), it merits greater attention. The variants are then termed as VoI or variants of concern (VoC). At present, there is no VoC in circulation in any part of the world. On March 16, 2023, WHO’s Technical Advisory Group on SARS-CoV-2 Virus Evolution had downgraded the Omicron as the ‘previous’ variants of concern. However, national and global agencies are tracking the virus and JN.1 has been designated as VoI.

JN.1 has been designated a VoI, which means it has some genetic changes and indicative characteristics in circulating viruses which need to be monitored by the health agencies and government. Such a designation is a call to step up genomic sequencing scientific work and use data to track the virus. JN.1 is not a new virus but a sub-variant of BA.2.86, which itself is a subvariant of the Omicron variant of SARS-CoV-2. Till now, there is no evidence that JN.1 causes more severe disease or causes immune escape and is, thus, not a reason for worry. In short, designating a variant as VoI does not automatically mean there is a reason to worry. Till now, there is no evidence that JN.1 is responsible for severe disease or immune escape. In fact, the waste-water surveillance in some Indian cities had indicated that the new sub-variant has circulated to a majority of the population without major change in reported or clinical cases in the way of a ‘silent wave’.

The vaccine response

Does it mean we need to get additional shots of COVID-19 vaccines? Current scientific evidence supports that vaccines and natural infection continue to provide protection from any sub-variant, though there is some possibility of a decline in protection, as time has lapsed since the last vaccination. Immunologically, the natural infections which have happened in addition to vaccine shots, have provided hybrid immunity to people in India and many countries. Therefore, there is no immediate reason to worry. There is no scientific evidence to support having a fourth shot of COVID-19 vaccines, for any age group.

We also need to interpret the rise in COVID-19 cases more carefully. The spike in COVID-19 cases in India could be more artificial than real. It is likely that ramped up COVID-19 testing is picking more cases. Then, some deaths are being attributed to COVID-19. However, there is no evidence that those deaths are causally linked to SARS-CoV-2. These appear to be in the individuals who were already sick and had COVID-19, as an incidental finding. The average five or six deaths in a day in India also need to be considered in perspective.

To put this in context, every day in India, an estimated 27,000 people die due to a range of reasons that include old age. In contrast, respiratory diseases and tuberculosis kill 50 to 60 times more people every day than COVID-19 now. We need to shift attention to preventable deaths due to many other reasons.

Act responsibly

Yet, four years should help us to learn. The government’s COVID-19 response and actions should be more nuanced and informed by all evidence and real time data. Citizens need to act responsibly and not share unverified social media messages or forwards. Science communication from the government needs to be more interactive, and public communication messaging should be more routine and easy to understand. There is a possibility scenario where reported COVID-19 cases may increase slightly in the days ahead, or in the months ahead — as it happened in April 2023 when daily cases had spiked. However, for most circulating respiratory viruses including SARS-CoV-2, mere transmission or an increase in cases is not an immediate concern. Right now, SARS-CoV-2 infections do not appear to change clinical outcomes in any age groups.

How should we respond to current or any future uptick due to SARS-CoV-2? The short answer is in the same way that we respond to any seasonal rise in cases of flu, respiratory illnesses or dengue virus. By the government increasing standard public health preventive measures such as Severe Acute Respiratory Infections (SARI) and Influenza-like Illness (ILI) surveillance, waste water surveillance and improving provision of required services at health facilities. The clinical management should focus on a syndromic approach to respiratory illnesses. At the individual and community levels, there is no need to disturb the routine or change your travel or vacation plans. People with cough and cold or flu-like illness must follow good respiratory etiquette such as wearing masks in public places, covering their nose and mouth when coughing or sneezing and frequent handwashing, irrespective of whether it is a type of SARS-CoV-2, seasonal flu or any other respiratory illness. It is proven that the risk to children is the lowest among any age group and thus, school closure should never be considered an option in response to a COVID-19 case surge.

It is time we handle SARS-CoV-2 or COVID-19 just like any other respiratory illness. It is more of an individual health concern than a public health concern. COVID-19 is not a novel virus any more and is here to stay. But it is not a reason to worry.

Dr. Chandrakant Lahariya is a medical doctor with over 15 years of work experience with the World Health Organization (WHO) in the India Country office, the regional office for Africa, Brazzaville; and the WHO headquarters in Geneva. The views expressed are personal

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