There has been only one surprise among the latest COVID-19 events. In the UK, we have continued to see high levels of infection, mainly among gregarious younger people and the unvaccinated, coming in what I predicted would be ripples rather than waves. The rates of serious illness and death are much reduced but still present huge problems for the NHS. I did point to the risk of further waves, if failure to spread effective vaccination round the poor world allowed new variants to challenge the currently dominant delta one, and now we have one such challenger, named omicron.
The surprise was the name. Most of us are still uncertain how we should pronounce this. Its big brother in the Greek alphabet, omega, with which we are more familiar, has a long initial o and I am advised omicron should be pronounced similarly. The virologists jumped to it, the 15th letter of the Greek alphabet, because most of the intervening letters are taken by other similar variants of concern circulating and two, Nu and Xi, were not considered suitable. We have not seen the end of this virus by any means.
The identification of omicron was made in South Africa, a country which like most less wealthy nations has struggled to vaccinate its population. However, cases have already been identified in other countries, including Scotland, without obvious transport from South Africa. This suggests that it has been circulating unnoticed among the predominant delta infections. I take this to be modestly reassuring, hinting that it is unlikely to be worse in toxicity terms than delta (though that is bad enough if you are elderly, vulnerable or unvaccinated).
Less reassuring are the messages from the virologists who point to multiple mutations in the famous spikes that lock the virus into the cells in our respiratory tracts and allow it to replicate. It is certainly more transmissible and these mutations suggest that omicron may be more resistant to vaccines and to some of the antibody-based medicines that are now becoming available for treatment of early cases of infection. On the other hand, we now have a good deal of cellular immunity in the population, and it is expected that we will still be largely protected from severe illness.
We don't know yet whether omicron will displace delta, but it is in South Africa. There is evidence from South Africa that it is more likely to cause symptoms in children than delta. The most likely outcome is continuation of high rates of infection among the unvaccinated and those who are enthusiastic party goers.
It is important to remember that new genetic variants are successful from the virus's point of view if they give it a survival and reproductive advantage, which in the case of respiratory viruses usually means causing mild symptoms such as cough and sneezing without killing its host. We are all familiar with this from personal experience of colds – it's just a wee virus, as doctors say when we don't know the cause of such symptoms. Of course, this is not always true, as experience of HIV and poliomyelitis taught us, and sometimes the initial illness can be severe as indeed it is sometimes with influenza. However, I suspect that the future course of COVID-19 will be rather like that of influenza, caused by a virus that persists, mutates frequently but is controlled largely by annual vaccination against the current or future variants and by good public health measures. This has many implications.
The first implication is that COVID-19 is not an existential threat to civilisation, unlike climate change, but is one of several important competing organisms that humans must adapt to live with. A second is that our adaptation must be behavioural rather than genetic. This may seem an odd thing to say, but in evolutionary terms organisms survive competition largely by genetic adaptation, the fittest surviving. Our survival, however, depends on our collective common sense and ingenuity. Part of this is development of treatments and vaccines, and part is understanding of preventive strategies; both are necessary. Thus, a third implication is that we must develop a habit, as people have in the Far East, of not sharing our respiratory viruses with other people, and this includes hand hygiene and wearing face coverings.
A fourth implication is that we shall require to continue to devote resources to development of new treatments and vaccines. Let us not forget that thousands of us owe our lives to the work in universities that led to these new therapeutic agents.
In 2003/4, I was privileged to sit on a committee that was charged to advise the UK Government on nanoscience – what were the possible threats and advantages of these coming technologies? I am pleased to say that we recognised great possibilities over several decades but described possible theoretical risks that could be guarded against. Our report allayed the fears of some of those, including Prince Charles, who had warned of mortal threats from nanoscience to nature and humanity, but none of us foresaw that, within 15 years of our report, nanoparticle-based vaccines would save millions of lives worldwide.
The technology of the Pfizer and Moderna vaccines, and indeed other different vaccines, combined with the scientific skills of genetic engineering, mean that we can now expect new vaccines and monoclonal antibody treatments to be manufactured remarkably quickly against new organisms and variants. But do not underestimate the ability of viruses and bacteria to outwit us. And this leads me to another implication.
My fifth implication is resilience, and this has multiple aspects from personal and institutional to international. The wearing of face coverings by all of us in appropriate circumstances is important as a signal that we are behaving responsibly and acting to protect others, as well as protecting ourselves. Not to do so is a profoundly selfish and stupid act during a pandemic. At the very least, we should keep well away from these people. The same applies to those who shun vaccination without good medical reason. When levels of infection are high, the prudent among the vulnerable will avoid crowds generally and mix with others in the open air for preference. It is as maddening for NHS staff to have to devote so much time and effort on people who could so simply have prevented their hospitalisation as it is for those whose operations or diagnoses are postponed because beds are blocked by such people.
Institutional resilience, in hospitals, care homes, offices, theatres and shops, for example, will mean continuation of the measures currently underway. Owners and managers will have to balance commercial with preventive health issues, remembering that under health and safety regulations they must take all reasonably practicable measures to protect their workforces and those who enter their premises. To me, this suggests that they must at the least encourage the unvaccinated to change their minds; I personally would go further while infection is rife locally. Social distancing, mask wearing, testing for infection, and improved ventilation indoors should become something that we accept as normal.
National and area-wide resilience means planning for recurrent waves of infection and building the reserve of equipment and workforce required. It would be appropriate to combine this with consideration also of the likely local effects of climate change – floods, storms, and mass movement of people, as I discussed in my
last article.
Many people are asking when we shall get back to normal or regain our freedom. Well, the normal is changing before our eyes. Remember, we adapt to survive, and we now must adapt to both plagues and climate chaos. Freedom is relative and is regulated, both by morality and law; how free are we to infect others? The world's two most dangerous animals, the killers of most human beings, are mosquitoes and… yes, other people. Think of this when planning your Christmas.
On the subject of normal, think how much a 'normal' Christmas had changed over the decades prior to COVID-19. Sometimes the old is preferable to the new. I recommend to readers an old-fashioned Christmas; I'm not keen on welcoming Hogmanay on a ventilator.
Anthony Seaton is Emeritus Professor of Environmental and Occupational Medicine at Aberdeen University and Senior Consultant to the Edinburgh Institute of Occupational Medicine. The views expressed are his own
