‘Alert but not alarmed’: What GPs need to know about Omicron

Be alert, but not alarmed.
 
That is the overriding message about Omicron, with the Chief Medical Officer, frontline GPs, virologists and infectious disease physicians all following a similar line as scientists work to understand more about the newly identified coronavirus strain.
 
In another demonstration of the swiftly changing landscape of the pandemic, the B.1.1.529 strain of the virus was unknown a few days ago. First identified in southern Africa, it gained global attention within days after being named a variant of concern by the World Health Organization (WHO) last Friday.
 
While its emergence has been widely reported, a lot of detail is still unknown. Here is what has been established so far and what it may mean for general practice.
 
General practice on the frontline
A GP in South Africa played a key role in noticing the spread of the new variant.
 
Dr Angelique Coetzee, who runs a private practice in the South African province of Pretoria, was first alerted by a man in his 30s presenting with fatigue and a mild headache earlier this month.
 
Some of the usual symptoms of COVID-19, including cough, loss of taste and smell, were missing. 
 
‘Symptoms at that stage [were] very much related to normal viral infection. And because we haven’t seen COVID-19 for the past 8–10 weeks, we decided to test,’ Dr Coetzee told Reuters.
 
Dr Coetzee, who is also the current chair of the South African Medical Association and sits on country’s Ministerial Advisory Committee on Vaccines, said the man and subsequently his family tested positive with COVID-19, which turned out be the new variant of the disease.
 
Variant of concern
The B.1.1.529 strain was formally announced on Thursday last week by South Africa’s National Institute of Communicable Diseases.
 
On Friday, the WHO named it Omicron and classified it as a variant of concern, leapfrogging other categories such as variant under monitoring and variant of interest. The WHO cited the variant’s mutations as the main reason for the classification, which ‘may have an impact on how it behaves, for example, on how easily it spreads or the severity of illness it causes’.  
 
Genomic testing found 50 mutations, with more than 30 on the spike protein, which is the target of most vaccines and how the virus enters the body. There are a more mutations in Omicron reported in the receptor-binding domain than for any previous variant.
 
Despite the number of mutations, it has not yet been established beyond doubt whether they will cause the variant to be more transmissible than the current, dominant Delta variant.
 
While Omicron is believed to be behind an upsurge of cases in southern Africa, these could potentially have been the result of a series of more isolated so-called ‘super-spreader’ events rather than its increasing dominance. The prevailing line of thought, however, appears to be that this is likely to more transmissible, with Australia’s Chief Medical Officer Professor Paul Kelly suggesting as much on Monday.
 
‘The information from South Africa is that it has replaced Delta as the major, possibly the only, virus circulating in that country, quite quickly,’ he told media at a press conference held with Federal Health Minister Greg Hunt. ‘So it is transmitting at least as well as Delta. That seems clear.’
 
Since being identified and named, the variant has been detected in an ever-growing number of countries, now including Australia.
 
Two cases were identified in New South Wales this weekend in passengers who had travelled from South Africa. Both were reported as young, fully vaccinated and asymptomatic. Two further cases were reported on Monday, bringing the total for NSW to four, while the Northern Territory also reported that a returned traveller with the variant is currently in quarantine.  
 
There have been a series of travel bans around the world. The Federal Government followed the UK in stopping the arrival of travellers from parts of southern Africa, banning travellers from South Africa, Namibia, Zimbabwe, Botswana, Lesotho, Eswatini, The Seychelles, Malawi and Mozambique.
 
The ban is being strongly contested by South Africa.
 
Virulence
One of the key characteristics of the new strain will be its virulence, and ability to cause severe disease and death. This is still under investigation. While Dr Coetzee described mild symptoms, other reports suggest hospitalisations in South Africa are rising.
 
On Monday, Professor Kelly also discussed the possibility the virus could spread faster but be milder.
 
‘That would be certainly a very interesting change and a positive one,’ he said. ‘But I just really say very clearly we’re not in that position yet to make that statement that that’s definitely how it’s going to end up.’
 
The other crucial question not yet answered is the variants’ impact on vaccination. There is still a large degree of uncertainty about whether the new variant will be able to escape the protection offered by vaccines that have already been approved.
 
Several pharmaceutical companies are looking into whether their vaccines need to be reworked to counter the new variant.
 
The Australian Technical Advisory Group on Immunisation (ATAGI) is also currently reviewing the timespan between the second dose of the COVID-19 vaccine and the administration of a booster, currently required to be at least six months.

What are the implications for general practice?
Dr Penny Burns is a GP who helped to put together the Home-care guidelines for patients with COVID-19, as well as a member of the college’s COVID Working Group.
 
For the moment, she says it is a case of business as usual for general practices around the country.
 
‘We are in a period of not knowing. In terms of what that means to general practices is that we need to be alert but not alarmed, that’s always my fallback,’ she told newsGP. ‘We need to not rush in and do things that won’t be useful when we look back on it.’
 
Dr Burns says keeping a careful watch on any changes in symptoms and their impact on patients will be key for those already working with COVID-19, as demonstrated by Dr Coetzee in South Africa.
 
‘GPs and practices need to continue doing what they’re doing; their careful surveillance for any outbreak, any unusual clusters that might arise, continuing those consistent infection prevention control practices, such as social distancing, grouping of patients, telehealth [and] masks.’
 
Dr Burns also said clear communication within general practices will play an important role, especially given the attention the new variant has already received.
 
‘When this low level of anxiety comes out in the media, it definitely flows through to reception staff, particularly those who are on the frontline,’ she said.
 
‘Keeping staff up to date and confident and giving them the knowledge to impart to patients will help them feel more secure in what they’re doing.’
 
Dr Burns remains hopeful Omicron will be a low-grade variant but is not yet drawing any conclusions.
 
‘We have no idea what’s going to happen in the next few days,’ she said. ‘It’s important to wait and watch and see what happens.’
 
It is a message echoed by Associate Professor Ian Mackay, a virologist at the University of Queensland. 
 
‘My main comment is that we have to have patience as we learn more about this new variant,’ he told newsGP.
 
‘Making early but wrong calls just creates unnecessary anxiety.’
 
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B.1.1.529 COVID-19 Omicron South Africa vaccines variant