13/1/22 Written by the UKMSSNA and subject to change
SARS COV 2 or Covid 19 as we now know it was confirmed by the world health authorisation (WHO) on 31st December 2019 as a cause for concern after a cluster of the virus was found in Wuhan province in China. In January 2020 the genetic code of this virus was established. This paved the pathway for testing for the virus and for vaccinations to be made at world record breaking speed, but still this virus changed the world, leaving health and social systems at breaking point, financial devastation, loss of education and employment and this is before we count all the personal tragedies and devastation this virus has caused. This destruction on a global scale was like nothing the world had encountered before. Nearly two years later after several different variants and the world’s largest vaccination programme has taken place, for some countries we seemed to be coming out of the other end and life has started to resume to some kind of normality when a new variant was discovered on the 23rd November 2021 in South Africa called Omicron and WHO announced this variant would be added to the cause for concern list as have many of the other variants previously.
Other strains of Covid
Alpha :-was found in UK in Sept 2020 initially this variant of SARS CoV-2 was thought to be 70% more transmittable but as time went on it was found to be about 30-40% more transmittable. The vaccines worked well in this strain and were between 74% Oxford Astra Zeneca 93% Pfizer-BioNTech and Moderna 100%
Beta:- was found in South Africa in May 2020 was found to be 50% more transmittable but reduced the ability of some of the vaccines although AstraZeneca faired better than the RNA vaccines with this strain of Covid and was thought to be 82% effective compared to 75% for Pfizer-BioNTech and Moderna.
Gamma:- was identified in Brazil in November 2020 the transmission rate yet again increased and people who were vaccinated contracted Covid but the vaccines appeared to prevent severe disease with this strain suggesting a reduction in neutralising antibodies against this strain.
Delta:- in October 2020 this was identified in India this has up until now become the dominant strain in USA and Europe. It is thought to be 60% more transmittable than Alpha this strain is thought to be able to survive better in the airways which means that less viral load is required to infect a person and once a person is infected the viruses ability to flourish in the airway means the viral load is higher and more virus is expelled in to the air. This variant seemed to affect younger people and although vaccines are effective at reducing severe disease vaccinated individuals still contracted this but had reduced risk of severe illness. (E Mahase BMJ 2021)
Other variants such as Eta, Lota, Kappa, Lambda have been found in a number of countries although little is known about these variants due to them not becoming the dominant variant. It is of interest and may have an impact on our patients that Kappa and Eta may reduce the neutralisation action of some monoclonal antibody treatments. (E Mahase BMJ 2021)
The virus has changed and each variant has meant a change in transmission and caused different impacts to our immune systems defence but now Omicron has arrived so:-
What does this mean?
How will it affect us and our patients?
How is it any different from other strains?
Omicron:-
This variant has a unique genetic profile with mutations from earlier variants but also consists of a lot of changes that have not been seen before. It has over 50 mutations with more than 30 on the spike protein this is the part of the virus that binds to human cells. It is thought that these changes to the virus’s genetic make up could make it more transmittable and more difficult for our immune systems to see and fight off. Although mutations can work both ways making the virus more benign or more infectious. (Callaway &Ledford 2021) The main concerns by scientists are:-
- Whether it can evade the immune response triggered by vaccines or having Covid
- Whether it is more transmittable than other variants
- Whether it causes increased risks of serious illness or risk of death
- How it is transmitted
Our immune system and lymphatic system help protect us against virus pathogens and antigens that enter our body. When we get infected by a virus our bodies produce antibodies (proteins). Antibodies are Y shape proteins that respond to antigens by identifying and neutralising them. Every antibody has a specific section that is sensitive to a specific pathogen. A bit like a lock and a key, you can only use the key that is specific to that lock to open the door. It’s the same with antibodies they will respond to a specific antigen. This is why a new variant such as Omicron is of concern due to the changes in this variant it might mean that the antibodies a person has against Covid either from having Covid or from having a vaccine might not be able to respond as well to the virus as the lock is different therefore the key is not a great fit.
Vaccines are a safe way of showing our body virus pathogens without a person having to contract the virus. The traditional method is to inject a small amount of virus tissue (dead or alive) into the body to allow our immune system to become aware of this pathogen and to build up an immune response to this without putting our body at risk of the virus. This method is used by the Oxford AstraZeneca vaccine. Covid saw the use of a new method of vaccination the mRNA vaccines, such as Pfizer and Moderna. This type of vaccine uses a copy made in a lab of a molecule called messenger RNA. This shows our cells how to make a protein that will trigger an immune response allowing our bodies to create antibodies to protect us against the virus. (centre for disease control and prevention 3/11/21)
T cells do not prevent infection they are a response to a virus entering the body. The amount of killer T cells responding to an antigen such as a virus can determine how ill a person gets. With Covid if the T cells can act before the virus spreads from the respiratory tract then the person will only suffer from mild illness. Because the vaccination causes our body to set off an immune response T cells are activated, and it is thought that the T cell response is longer acting and more difficult for the virus to overcome than the antibody response. Studies have shown that a T cell response is unlikely to be affected by mutations of the virus. T cells target viral proteins that are inside the cell, whereas antibodies detect proteins outside the cell in the case of Covid the proteins that the antibodies from the vaccines or infection target are on the spike protein. As the different variants and mutations of Covid arrive it is the spike protein that has mutated and changed causing the new variant and therefore reducing our antibody response making the vaccines less effective, but due to the immune response that the vaccines cause in our body a it is thought that for all the variants of Covid that are circulating at present that they continue to offer us protection against severe illness. Scientists are looking at ways to increase the T cell response and make vaccines that incorporate the multiple proteins that are found within the cell to increase the effectiveness of the vaccines against different variants. (H Ledford 21)
At the moment it is not known how the vaccines will fare against Omicron. From studies like SIREN
found that people who contracted the virus had 83% protection against reinfection within the first five months although it is thought that if they could still transmit the virus if they became infected in this time they would be likely to have a less severe illness or asymptomatic second time round due to their bodies immune response. This means that they would be less likely to be aware that they were infected and infect people without being aware. It is still unclear as to whether Omicron will have similar reinfection rates, early studies are contradictory with a study from China showing that those who have had a previous Covid strain or are fully vaccinated have a stronger defence and are unlikely to become reinfected (Healtheuropa 2021) whereas early indications from South Africa suggest reinfection rates with this variant are to be alot higher due to its ability to invalidate the immune response. It is likely that with the Delta variant the vaccines protect against severe disease but do not stop people from contracting Covid.
Due to the main resistance the vaccines give us being the antibody defence and research suggesting that this defence starts to deplete after 5-6 months most richer countries are trying to reduce the impact of Omicron by pushing a vaccine booster roll out. The idea of the booster programme is to increase the number of neutralising antibodies and add a wall of defence against the virus. ( Dolgin 2021)
It is unknown how often booster jabs will be needed; some scientists feel that it will be a similar scenario to the Hepatitis B vaccine where after a few vaccines your body maintains a stable level of antibodies to fight off Hepatitis. Others feel that due to the continuing changing nature of Covid and the depletion of antibody response after six months that annually or six-monthly booster jabs will be required to counter act this virus. Pharmaceutical companies have already started to develop a Omicron specific booster but this will take some months to develop by then the next variant could have arrived so it is recommended that the standard booster will boost the immune systems response and give an individual more tools to deal wit the virus. ( Chia 2021)
At the moment it appears that Omicron is much more infectious that other variants since it entered the UK a few weeks ago the infection rates have rocketed with now more than 90,000 new infections a day.(19th December 2021 It remains unclear as to how many people will develop severe illness or die from this variant on 19th December 2021 there had only been 7 deaths in England and 87 people in hospital with this variant but there is a lag of a couple of weeks before it is known how ill someone might get (people in hospital with Omicron now would have been infected about 14-17 days ago) but due to the high numbers it is infecting even a small number of people with serious illness from numbers of infections of 90,000 means that it could cause chaos to an already overwhelmed and over stretched national health service and social services.
This variant only came to light a couple of weeks ago and so there is still lots of research taking place to see how this could impact on individuals. The data may look very different in different countries depending on age of population, ethnicity, the amount of population vaccinated or have been infected by other variants. In South Africa one third of the population is vaccinated and a large number of people have been infected with previous variants of SARS COV 2 (Covid 19). In the UK the variant seemed to be causing only mild illness. This is thought to be due to the population of South Africa being younger and the build up of immunity from previous infection. It is thought that 70% of South Africa population have had a previous strain of Covid. Reports from South Africa suggest a much lower rate of hospital admissions than was seen in the Delta wave of Covid with 1.7% admissions in the Omicron wave to 19% in the Delta wave but cases are 20,000 a day in South Africa compared to 4,400 in the Delta wave. (A Sguazzin 17/12/21 Bloomberg)
Omicron has been seen in more that 89 countries now and cases are doubling every 1.5 days. Data from all of these countries will allow for further understanding of this variant and the likely affect it will have on a population. (WHO 18/12/21) From data that has been collected so far, we know that this variant is more transmittable. It is the dominant variant in Africa and has been seen there to infect people that have already had another strain of Covid or are double vaccinated with Johnson and Johnson, Pfizer-BioTech or Oxford AstraZeneca. In Israel they have been infections seen in people who have received 3 doses of vaccines. (Calliway 2021)
What Covid has meant for MS patients
Multiple Sclerosis does not increase the risk of getting Covid. It could mean that a person may have more complications due to severity of their MS, or from a combination of health problems. (Prosperini et el 2021) Research by Bsteh et al 2021 found that disease modifying therapies that had a immunosuppressive response such as Alemtuzumab, Cladribine, Fingolimod, Ocrelizumab or Rituximab did not increase the severity of Covid in a patient. Therefore, choice of treatment should be based on severity of Multiple Sclerosis and patient neurologist choice rather than the pandemic. Data from America suggests that 29% of people with an auto immune disease including people with Multiple Sclerosis had not been vaccinated because they were concerned about how the vaccine would affect their condition. A further study suggests that 20% of MS patients are vaccine hesitant due to concerns around vaccine safety, effectiveness and the impact on their MS. This was shown in recent paper yet to be published in Neurology, Neuroimmunity and inflammation vaccination reactogenicity in person with Multiple Sclerosis (Briggs et al Jan 2022) suggest that 54% of people with MS who were vaccinated against Covid experienced fever, headaches injection site reactions but this was similar to the general population. Only 2% of people had a relapse with in six weeks post vaccination with Pfizer vaccination and this relapse rate was not statistically different to the group that were unvaccinated (Havla et al J neurology June 2021). Data suggests that having vaccines will not increase MS symptoms or cause a relapse and that the risks from contracting Covid without taking the precaution of the vaccine is much more of a risk to the patient.
Factors that are thought to increase the risk of having more severe Covid are:-
- >70yrs +
- Expanded disability status score (EDSS) 6>
- Pregnancy
- Other long-term health conditions
Certain disease modifying therapies such as those who have had Alemtuzumab or cladribine in the last 6 months or Ocrelizumab in last 12 months and stem cell treatment. All of these treatments alter the way the immune system works and impair a person’s ability to fight off infection.
Patients taking Fingolimod and Ocrelizumab were shown in a study to have build up less antibodies in response to the Oxford AstraZeneca and the Pfizer vaccination compared to people with MS who were not on these disease modifying therapies but they did mount a T cell response to the vaccine. (Prof G Giovannoni and E Tallantyre 2021)
How can we protect our patients?
- Discuss their risk factors
- reassure them
- make then aware of how they can help protect themselves (hand washing, masks social distancing vaccinations)
- what to do if they have concerns, they contracted Covid give them the details of NHS Covid website
- giving them advice of what to do if they contract Covid i.e. isolation
- contact MS centre so that they are aware and so that system can be updated and effects that Covid has on MS patients can be monitored.
The MS Society has all the up to date information about new Covid variants and the impact Covid is thought to have on our patients they work closely with the British association of Neurologists to gather this information.
What we can do to protect ourselves
The risk of the spread of Covid has been found to be reduced by
- Wearing masks 53%
- Hand washing 53%
- Social distancing 25%
(British Medical journal 2021; 375 e 068302)
- Consider getting vaccinated
WHO established Covex at the beginning of the pandemic WHO slogan was No one is safe until everyone is safe fast forward a couple of years and as of 13/12/21 565 of the world population 98.47 million people globally but only 6% of poor countries are vaccinated while richer countries like the UK who have over 75% of the population have had 2 vaccinated as of 11/12/21. (Jaafar Ashtiyeh 2021 )The UK have now started a booster vaccination programme as have other richer countries to try to prevent increase in death rates and to reduce the disruption to their health and social care systems. Going back to WHOs slogan “No one is safe till everyone is safe” Many scientist feel that there response seems futile. Because we live in a world in which global travel means new variants are likely to have spread to a number of countries prior to their detection. Individuals countries responses to protect their own people may therefore impact on the worlds ability to respond to these outbreaks. It may prevent vaccine roll outs in poorer countries because richer countries are buying up the supply of vaccines. This has led to WHO and a number of countries including USA and china and other organisations trying to step up the vaccine programme by backing a campaign to trying to waiver intellectual-property rights to Covid vaccines and drugs to allow manufacturing to take place on a global scale but until this is agreed by pharmaceutical companies and the countries where some of these vaccines were made or until Covex solves the challenges that Covid presents and the world realises that the only way out of this pandemic is to react to it on a global scale. It is likely that more strains of Covid will arise and Covid will remain a threat and part of our everyday life.
This information was correct at the time of writing, but the situation changes on a daily basis
Reference list
Briggs and colleagues. Neuroimmunol Neuroinflamm 2021; epublished November 9, 2021 https://nn.neurology.org/content/9/1/e1104
Bsteh Gabriel 2021, COVID-19 severity and mortality in multiple sclerosis are not associated with immunotherapy: Insights from a nation-wide Austrian registry
Roles Conceptualization, Data curation, Formal analysis, Writing – original draft
* E-mail: gabriel.bsteh@meduniwien.ac.at
Affiliation Department of Neurology, Medical University of Vienna, Vienna, Austria
https://orcid.org/0000-0002-0825-0851
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Roles Data curation, Methodology, Writing – review & editing
Affiliation Department of Neurology, Medical University of Vienna, Vienna, Austria
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Calliway.Ewen 2021 Heavily mutated Omicron variant puts scientists on alert
Researchers are racing to determine whether a fast-spreading coronavirus variant poses a threat to COVID vaccines’ effectiveness. www.nature.com/articles/d41586-021-03552-w
Callaway & Heidi Ledford (Dec2021) How bad is Omicron? What scientists know so far COVID researchers are working at breakneck speed to learn about the variant’s transmissibility, severity and ability to evade vaccines. Nature dec 2021 https://www.nature.com/articles/d41586-021-03614-z
Chia, W. N. et al. Dynamics of SARS-CoV-2 neutralising antibody responses and duration of immunity: a longitudinal study. Lancet Microbe 2, e240–e249 (2021)
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The technology could revolutionize efforts to immunize against HIV, malaria, influenza and more.
https://www.nature.com/articles/d41586-021-00019-w#author-0
Dolgin Elie 2021 Omicron is supercharging the COVID vaccine booster debate
The data are growing that booster jabs enhance protection — but their durability, impact and ability to quash the new variant are unknown. Omicron is supercharging the COVID vaccine booster debate (nature.com)
G.Giovannoni & E Tallantyre 2021 New insights into impact of multiple sclerosis treatments on Covid-19 vaccine effectiveness
Treatments used to help people with multiple sclerosis (MS) manage their condition can reduce the effectiveness of Covid-19 vaccines, according to research from Cardiff University and Queen Mary University of London https://www.qmul.ac.uk/media/news/2021/smd/new-insights-into-impact-of-multiple-sclerosis-treatments-on-covid-19-vaccine-effectiveness--.html
Mahase Elisabeth Covid-19: How many variants are there, and what do we know about them?
BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n1971 (Published 19 August 2021) Cite this as: BMJ 2021;374:n1971
Mahase Elisabeth Covid-19: “Mix and match” primary vaccines are safe and effective, study finds BMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n3030 (Published 07 December 2021)Cite this as: BMJ 2021;375:n3030
https://coronavirus.data.gov.uk/
Ledford Heidi 2021 How ‘killer’ T cells could boost COVID immunity in face of new variants
In the race against emerging coronavirus variants, researchers are looking beyond antibodies for clues to lasting protection from COVID-19.
https://www.nature.com/articles/d41586-021-00367-7
Noh, J.Y., Jeong, H.W., Kim, J.H. et al. T cell-oriented strategies for controlling the COVID-19 pandemic. Nat Rev Immunol 21, 687–688 (2021). https://doi.org/10.1038/s41577-021-00625-9
https://ourworldindata.org/covid-vaccinations
Prosperini (2021) Omicron: what does it mean for MS?
https://msology.ca/omicron-what-does-it-mean-for-ms
Jaafar Ashtiyeh 2021 Omicron: the global response is making it worse
The pandemic will not end while vaccine equity keeps getting pushed to the margins.