Dr Angelique Coetzee: Don’t Look At Your Positivity Rate Or Your Daily Cases. Look At How Many People Are Admitted In The ICU

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Dr Angelique Coetzee talks about how she first spotted the Omicron variant, how it has replaced Delta in South Africa and whether the Omicron wave will enable herd immunity. This session was moderated by Anuradha Mascarenhas, Senior Editor, The Indian Express

I am a general practitioner and still old-school. So, even with the Beta and Delta wave, we let patients come in, and, I think, that assisted us greatly in understanding how these variants attack the body. We were out of the Delta wave for about eight weeks, and one morning a young man came with some complaints. He tested positive, and subsequently, his family did too. That day, I also saw other patients with more or less the same symptoms, which were very different from Delta. I call it musculoskeletal, mostly because of the sore body, backache, headache, chest pain, scratchy throat and a slightly runny nose, but not really fever and any oxygen needs. In the beginning, when I first saw these patients, I still followed the Delta protocol. In Delta, you have to see your patients back (after a few days), because they tend to turn around by about Day 10; between Day 7 and 10, that’s when they really get bad. But within one week, I realised that out of all the patients that I’d seen, only four came back for a follow-up. The rest said they were much better.

First, you need to look at the definition of the WHO (World Health Organization) regarding mild illness of Covid-19. The definition is clear; signs of upper respiratory tract infection, no shortness of breath, dyspnea, or any abnormal chest X-ray — patients should be able to be treated at home. So, if you look at the definition, less than one per cent are getting severe illness. The majority of patients in primary healthcare are adhering to the definition of mild illness. If you’re unvaccinated, if you have comorbidities, then any viral infection might lead to severe illness and that severe illness would be pneumonia. That’s what we have seen with Omicron. What I can advise you is that do not look at your positivity rate or your daily cases. You need to look at how many people are admitted in the ICU and what are your death rates for patients admitted specifically for Covid-19.

Our data is clear that less than one-third of patients with Omicron were severe in hospitals. With Delta, on July 8, there were 19,900 in hospitals, on July 14, 17,000 in hospitals and on July 10, there were 2,597 in high-care and ICUs. With Omicron on December 17, we had 23,000 cases per day, 528 in high-care and 7,900 in hospitals. Our death rate was much lower; average was about 100. With Delta, we had seen a huge increase in death rates.

In the mild cases, it doesn’t seem to matter whether you have been vaccinated or not. We have seen just as many mild cases in vaccinated people as in the unvaccinated. However, what we did notice was that the severity of the headache or the scratchy throat or the malaise is less intense among the vaccinated. In our ICUs, 88 per cent are unvaccinated.

Not that much as was the case with Delta. Remember the definition of severe illness, which is lung infiltrates, so that’s pneumonia. And those patients with pneumonia will either be in the ICU or in high care. But for the average person out there, Omicron will not affect the lower respiratory tract. In severe disease, it does affect the lower respiratory system, that’s why you are admitted, because of the pneumonia…and that would cause inflammation and cytokine storm, although clinically not so severe as we have seen with Delta, especially among the vaccinated people.

We do see youngsters. From the data on January 7, we see ICU admissions among the 70-plus age group were 270 for the past two weeks, ventilations: 135, and 91 deaths. Among the 60-69 age group, hospitalisations were around 35 per cent. In the 70-plus age group, the hospitalisation was 49 per cent, 50 to 59 was 29 per cent, 40 to 49 was 17 per cent and from 18 to 39 it was 11 per cent. That was the status of hospitalisation for two weeks that was released on January 10.

In South Africa, Omicron has taken over from Delta; we don’t really see Delta cases anymore. Second, regarding protection, you have to understand that this is our fourth wave. There are a lot of people in our country who have been infected before with one of these variants, and have what we call T and beta cells. So, your antibodies will go down, but the moment you encounter a new variant, there will be some memory that will help protect you. For now, definitely Omicron will protect you with T and beta cells.

What we have seen is that whether you have been vaccinated or not, you still get the mild disease. I think, it’s extremely important that people understand this, that the vaccines are not going to protect you against mild disease but your symptoms will be less intense. And that’s what we’ve seen. In that case, vaccines are still good for the world. However, going forward, I don’t think you’re going to get your population to go every six months for a booster. I think at some stage people are going to say no, I’ve had enough of this.

In South Africa, unfortunately, one-third of our healthcare workers are not vaccinated for various reasons. We didn’t see a huge strain on our hospitals. Maybe we have a different system than other countries because we are very much primary healthcare-orientated, with people going and seeing the doctors physically, and that also helps to explain the disease to patients. So, it’s all about empowering the people out there. But there is mental fatigue everywhere. Even I get fed up, I actually had a fight with two patients who were admitted, because they didn’t get vaccinated. Luckily, our hospitals are not overwhelmed so it was easy to get a bed for them. But this could have been prevented.

The use of masks should not be negotiable; it should be compulsory. It’s interesting that one of the first things some of the first-world countries did was to close the borders with other countries, including South Africa, while they let people walk around without masks, spreading the virus. A mask should be part of your daily make-up.

Let’s tackle the mutation. First, it’s a possibility. Hopefully, that will never happen. But if it would, that would be a disaster, because then you will have a faster-spreading viral infection with a lot of severity.

I presume that there will be a few cases with long Covid with Omicron for those people who have been on the ventilator and discharged. But, so far, we haven’t really had any experience with that.

Yes, we did see that right in the beginning. That’s always in any wave; children first. So for now, at this stage, even looking at the data, there are not really anyone (children) in the hospital. We don’t see children getting that sick anymore.

You need to watch and see what the virus is going through or the viruses are going to do, especially around mutations going forward. But again, no guarantees. But it comes back to T cells. It depends on your immune system. And we unfortunately know that the older you get, the poorer your immune system is or the younger you are, the better your immune system is. Herd immunity was something that we thought we would get via vaccination. But looking at vaccinations, especially in Africa, we are never going to get herd immunity through vaccination. So, the only other way that you’re going to get herd immunity most probably would be by getting infected, unfortunately. And then there’s the law — the fittest survive. If you need to choose between which variant you want your people to get herd immunity by, you will choose Omicron and not Delta. We hope that a lot of people get immunity through Omicron, at least lasting for another year. So, only time will tell but the scary thing would be if Delta and Omicron mutate. Another scary thing, which, I think, we also need to start making people aware of, is the use of antibiotics. The irresponsible use of antibiotics during these viral infections might lead, going forward, to a bacterial pandemic and that would kill us.

That’s a possibility. There’s a flip side of the coin; it might be less as well, that’s also a possibility. Always remember, it’s not in the virus’s best interest to kill us off because then the virus is going to die as well. So, it will try to survive. So, it will try to evade our immune systems as much as possible. That’s where the wearing of the masks is so important so that you don’t spread it.

I don’t know why our trajectory is different from what you see. Based on the data we have, I think, we peaked around December 17 or 18. If I look at the peaks, we didn’t have the same peak. It was less than it was with Delta, but very far spreading, and just as quickly, it went down. I think, that’s the nature of the virus.

We have done away with our restrictions on movement (of people), closing of restaurants, sale of alcohol, but mask-wearing is still compulsory, there’s still a cap on big gatherings — indoors 1,000, outdoors more. Indoor gatherings of 1,000 people are allowed because of political pressure from the churches. But we haven’t really seen an uptake in the number of infections, even from indoor gatherings of churches.

An unvaccinated person with untreated HIV or TB (tuberculosis), or any other immunocompromised disease, would lead to variants mutating because that host body can’t detect the virus and that would be an excellent platform for the virus to mutate. We need to get our immune-compromised people with TB, HIV, or those who are on dialysis for kidney disease, treated. Going forward, that is extremely important, otherwise you will see mutations. Incidentally, data points out that Omicron actually started in the Netherlands. So, that’s very interesting.

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