Omicron COVID-19 update
If you are on an anti-CD20 therapy waiting weeks or months for B-cell reconstitution is going to put you at high risk of getting COVID-19 from Omicron.
In response to many emails and direct messages on Twitter a quick Omicron COVID-19 update.
Researchers at Imperial College have reported that there is no difference in COVID-19 severity between the Omicron and Delta SARS-CoV-2 variants (Ferguson et al. Report 49. 16-Dec-2021). The risk of reinfection, however, is 5.4 times higher with Omicron. Previous infection or a two-dose vaccine regimen offer no more than 20% protection against symptomatic cases of Omicron. However, a booster with an mRNA vaccine increases this to 55-80%. So get boosted ASAP.
I suspect the reason we haven’t seen a surge of COVID-19 hospital admissions and deaths in South Africa where Omincron likely emerged is that this virus was spreading in a population with a lot of herd immunity. Despite relatively low vaccination rates in South Africa, the high wild-type infection rate explains the high background rate of antibodies against SARS-CoV-2 in the general population (see figure below). Another factor are demographics; Soth Africa has a very young population and many of the vulnerable elderly may have already succumbed to the virus. So contrary to what I have said before the evidence is not looking good, i.e. Omicron is as bad as Delta and the other earlier variants.
Omicron is now out-competing other strains and is likely to become the dominant strain globally. It now dominates in England, accounting for ~54% of cases. As you can see the new infections reported yesterday in the UK was a record. The doubling time for new infections is now less than 2 days therefore things are going to get worse before things get better. Don’t forget the incubation time for getting COVID-19 after being infected is 5-7 days, therefore, the new infections that will occur in the next week are already incubating and primed to happen.
It is worrying that Omnicron is evading most of the therapeutic monoclonals, except for sotrovimab (Xevudy, GSK), which was approved by the MHRA earlier this month. Yes, Ronapreve and the other monoclonals are ineffective against Omincron (Gruell et al. MedRxiv 14-Dec-2021). I am told the NHS will be switching from Ronapreve to sotrovimab (Xevudy, GSK) from this Monday (20-December-2021).
Oral Molnupiravir (Lagevrio) is likely to still work, albeit with moderate efficacy. Molnupiravir (Lagevrio) is being dispensed by general practitioners and is a community-based treatment for vulnerable or high-risk patients who don’t require hospitalisation. If you have MS and are on an anti-CD20 or S1P modulator and have just been treated with alemtuzumab you need to make sure your GP knows you are vulnerable and are on the Government’s shielding list. In fact, people with MS should be on this list already.
In addition to being on the shielding list if you get symptoms suggestive of COVID-19, you need to get yourself tested for the virus. When you test positive for COVID in the community a cross-check will happen on the government shielding list, and your name will automatically be flagged for possible molnupiravir treatment. I am told you will then need to go through the triage process which will involve an HCP telephoning you and checking you are vulnerable before prescribing Molnupiravir (Lagevrio).
The good news is that nirmatrelvir (Paxlovid), a new oral small molecule antiviral, is likely to be very effective against Omicron, but as it has not been approved by the MHRA yet it is not going to make a difference to the treatment of the current wave of infections.
So what am I advising my patients in relation to the current wave of infections?
I think I need to be pragmatic and go back to my original advice "get vaccinated/boosted ASAP as some immunity is better than no immunity even if it is only T-cell immunity". For example, if you are on an anti-CD20 therapy waiting weeks or months for B-cell reconstitution is going to put you at high risk of getting COVID-19 from Omicron. Yes, the antivirals are a backup, but making sure you maximise your own immunity to the virus, in your current state, has to be a priority. In addition to this remain vigilant and socially distanced. Wear masks, wash your hands, make sure closed spaces you have to share with others are well ventilated and don’t forget your prehabilitation and if you can afford it purchase a pulse oximeter or make sure you have access to one in the event you get COVID-19. This advice is particularly important if you live alone. You can’t rely on symptoms to know if you are deteriorating you have to know what is happening to oxygen levels in your blood.
If you haven’t been vaccinated or are against being vaccinated please reconsider. I agree with Karl Lauterbach, the new German minister of health when he stated that by March or April of next year you will either have been vaccinated and avoided the infection, gotten the infection and recovered or gotten the infection and have died. The message can’t be more simple and stark.
The above advice is from a privileged UK perspective and won’t apply to all countries in the world. Please let me know how you are coping and how the above advice differs from what you have been given.
I would urge you to read my previous newsletters on prehabilitation and pulse oximetry.
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General Disclaimer: Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust. The advice is intended as general advice and should not be interpreted as being personal clinical advice. If you have problems please tell your own healthcare professional who will be able to help you.
Hello Professor Giovannoni, regarding your comment about being on the shielding list, should people on Ocrelizimab be on the shielding list?
I ask because I have never been asked to shield. I contacted my GP surgery when the government announced that more people were being added to the list and letters were being sent, and was told they don't add people to the list. I then contacted my MS nurse and was told that I should avoid going to the shops and follow social distancing and hand washing, but no need to sheild. My neurologist also listed obesity on my record so was surprised that I wasn't on the list, I am 49 too, so perhaps considered less of a risk.
I had my 3rd vaccine on the 1st October, which I only got as I challenged the advice I was given not to delay my infusion for the covid vaccine , my next infusion was due that month too. The Royal London then booked me in for my last infusion on the 7th December. I understand that I should now have a 4th vaccine (booster) 3 months after my last which would be the 1st January, but that would be 3 weeks after my infusion. I'm not sure on the time delay between infusion and the booster. Do I need to leave a bigger window or is it advisable to get this done as soon as possible around the 1st?
Having read a previous article of yours I have bought an oximeter, so thank you for that.
Kind regards
Rachel
I just recovered from covid. Inevitable. Everyone in London I know has it right now! Luckily it wasnt as bad as I thought it would be considering no vaccine response and I think I got away pretty unscathed. Apart from my neck glands are bloody sore still, 2 weeks on.. Now I’m wondering, I guess I’ll have some antibodies. How long will these last for? I read on gov website something like 90 days? Booster due in Feb due to timing with next Ocrevus infusion (to be delayed..) . Am I likely to get reinfected like, before 90 days? Is that possible?!