Dr. J. RADHAKRISHNAN, 1A. porter Principal Secretary to Government, nee: Health and Famiy Welfare Deparment Phone : 91-44-2567 1875 ‘Government of Tami Nadu = Fax: 91-44-2567 1253 E-Mail: hfwsec@gmail.com No.3 / Pe dated 28.11.2021 Dear Colleagues, Subject: Reports of Identification of Omicron - B.1.1.529 a variant of concern in certain countries - Background, surveillance and preparedness measures to be undertaken- reg- Referenc Letter received from the Union Health Secretary dt 25.11.2021 and shared with all by the Secretary, Health Govt of Tamil Nadu on the same day. 2.Technical Brief dated 27.11.2021 on Enhancing Readiness for Omicron(B.1.1.529) in the WHO South East Asia region I would like to invite your kind attention to the subject and references cited above and would like to draw your attention to the need to tighten the COVID 19 disease control measures including tracking travellers returning or transiting from the ‘at risk’ countries updated from time to time by the Government of India and arriving in our State. Considering the emergence of the new variant of concern an update and the steps to be taken is shared with you as a ready reference. Background *On 25 Th November 2021 the Union Health Secretary wrote to the State Health Secretary about the reports of emergence of this new variant and directed the states to be alert. On the same day all Collectors were given suitable follow up instructions to all the Collectors and Corporation of Chennai and airport authorities. This was followed by field level inspections and instructions by the Minister, Health in the presence of the Secretary, Public Health, Airport Director among others in Chennai airport.* On 26 November 2021, WHO designated the variant B.1.1.529 a variant of concern, as Omicron on the basis of advice from WHO's Technical Advisory Group on Virus Evolution ‘+ This variant has a large number of mutations, some of which are concerning = Omicron may be associated with higher transmissibility and immune escape Potential. However, there are still considerable uncertainties. +The variant Omicron was first reported to WHO from South Africa on 24 November 2021. In recent weeks, infections hav creased steeply in South Africa, coinciding with the detection of Omicron. The first known confirmed Omicron infection was from a specimen collected on 9 November 2021. The number of cases of this variant appears to be increasing in almost all Provinces in South Africa. * The variant Omicron was also detected in Botswana in samples collected on 11 November 2021. As of 27 November 2021, travel-related cases have also been detected in Belgium, Hong Kong, Israel and some European countries. * This variant has a large number of mutations, some of which are concerning. Preliminary evidence suggests there may be an increased risk of reinfex with this variant, as compared to other variants of concern (VOCs). * Current SARS-CoV-2 PCR diagnostics continue to detect this variant. Several labs hav icated that for one widely used PCR test, one of the three target genes is not detected (called S gene dropout or S gene target failure) and this test can therefore be used as marker for this variant, pending sequencing confirmati *It has been reported that internationally, there are a number of studies underway to evaluate this variant. it is anticipated that the Ministry of Helath and Family Welfare, Government of India, WHO and experts from National Centre of Disease Control, ICMR and public health experts and virologists will keep communicating new findings to the public as needed. Risk Assessment ‘Given its immune escape potential and possible transmissibility advantage compared to Delta, likelihood of potential introduction and subsequenttransmission of Omicron in the South-East Asia region including India is high. In case another major surge of COVID-19 take place in the Region driven by the Omicron, consequences will be severe. «Overall risk related to the novel variant Omicron for WHO South-East Asia Region is assessed high. Priority actions being taken by the State based on the various communications + Enhance surveillance and sequencing efforts to better understand circulating SARS-CoV-2 variants. ‘Perform field investigations and laboratory assessments to improve understanding of the potential impacts of the Omicron. * As S gene target failure (SGTF) is indicated for Omicron, the SGTF can used as the marker for this variant, which may lead to efficient detection of the Omicron «Continue to accelerate the vaccination coverage, especially among priority populations initially targeted for COVID-19 vaccination who remain unvaccinated or not yet fully vaccinated. «Based and after instructions / guidance by the Government of India Timely adjustment of international travel measures in precautionary manner guided by risk assessment is advisable. As and when further instructions are received it would be shared with you all immediately. «The use of masks, physical distancing, hand hygiene, and improving ventilation of indoor spaces remain key to reducing transmission of SARS CoV-2 even with the Omicron. * Contact tracing of COVID-19 cases with an epidemiological link to the affected areas is strongly advised. * While it is too preliminary to assess the transmissibility and impact in case it is detected in our state, in the anticipation of COVID-19 case-load and associated pressure on the health system, we need to ensure mitigation plans are in place to maintain essential health services and necessary health care resources are in place to respond to potential surges.*The Health department and the districts should regularly communicate evidence-based information on the Omicron and potential implication for the Public in timely and transparent manner, including what Is known, what is unknown and what is being done by responsible authorities. Risk assessment for our State * There is still substantial uncertainty related to Omicron, with regard to its transmissibility, immune escape potential (from infection- and vaccine- induced immunity), severity of disease, and response to available countermeasures (e.g. diagnostics, vaccines, therapeutics). ‘At present, there is no evidence of importation and transmission of the Omicron in our State. * Given travel has been ongoing between the affected countries and countries, it is possible that despite increasing and tightening the surveillance, the Omicron might still slip in or get. introduced. *Given its immune escape potential and possible transmissibility advantage compared to Delta (as indicated by rapid surge in South Africa), likelihood of Potential introduction and subsequent transmission of Omicron in other countries is rated as high. + In case another major surge of COVID-19 take place driven by the Omicron in the Region, consequences will be tough and hence we have to take all measures to prevent its entry into our State as like Delta this may pose overwhelming demands on health care systems, and may lead to increased morbidity and mortality. The impact on vulnerable populations would be enormous. + Overall risk related to the novel variant Omicron for WHO South-East Asia Region is thus considered igh. This assessment Is based on considerable uncertainty and will be updated by WHO and the national agencies as more information becomes available. Potential scenarios The following four scenarios can be considered to guide for planning and enhancing readiness for the potential introduction and subsequent spread of the Omicron in the countries.* The novel variant Omicron is not yet detected and considered not yet Present in the State. © The novel variant Omicron is considered not yet present in the community, but at some stage may be detected among the incoming travellers. * The novel variant Omicron at some point gets detected in community, but as sporadic cases or within a few manageable sizes of clusters * In rare cases, if despite the preventive and control strategy and measures the novel variant Omicron becomes wide spread in communities. Only after watching the international situation and developing stories and trends in the coming weeks this can be assessed. Actions to be taken Based on the risk assessment and potential scenarios, the in continuation of the points already emphasised in the earlier paragraphs despite appearing Fepetitive, the following actions which have been recommended by the Technical brief of WHO and also certain points already included in the earlier letter from the Government of India already communicated to you are again reiterated below to highlight the points and areas of actions so as to enhance Feadiness for tackling and eventuality against the emergence of the novel variant Omicron in any part of the State. Enhanced Surveillance * Monitor and implement the guidelines for travellers from abroad and those from at risk countries as per the protocols issued from time to time. * Enhance surveillance and sequencing efforts to better understand circulating ‘SARS-CoV-2 variants. *Genomic surveillance is of crucial importance for early detection and monitoring the epidemiological trends of emerging variants, and will provide information to guide response. The State Public Health lab is fully equipped to handle this. * This should include not only regular testing of representative samples but also strengthening targeted sampling from persons coming from high-risk areas.* For the surveillance in communities, use indicator-based and event-based surveillance to timely detect potential signals of emerging variants: + In future, in case of any reports of rapidly spreading outbreaks in healthcare facilities or communities immediately raise the concern that these events could be due to a variant that spreads more easily from person to person. * Similar reports of breakthrough or re infections from populations expected to have a h level of immunity (due to prior infections or igh vaccination Coverage) may indicate the presence of a variant able to evade the immune response. * Specimens collected during such investigations and in case of outbreaks or clusters and following travel history from at risk countries, it should warrant Prioritisation for sequencing for which instructions have already been given to the State Public Health Laboratory at Teynampet where samples should be sent. * The epidemiological studies and sequencing of specimens can be targeted to those with particular individual-level characteristics (e.g. clinical characteristics; immunocompromised patients and selective sequencing of vaccine breakthrough), as well as usual clusters and super-spreader events. * Ensure early warning system is in place, composed of a set of indicators such as indicator of rapid growth (e.g. growth rate, effective reproduction number), case incidence, and test positivity proportion. It is also crucial to use indicators related to disease severity and pressure on health care systems (e.g. bed occupancy of general ward and intensive care unit). Already the State task force and the WHO office stationed at Chennai is regularly giving us the analysis on these issues for us to take advance actions. Laboratory *Sampling selection criteria should include cases from any unusual transmission events (e.g., increased transmission despite interventions in place), unexpected disease presentation/severity, vacci breakthrough, severely ill patients and international travellers,It is critical that all SARS-CoV-2 testing is linked to public health actions to ensure appropriate ical care and support and to carry out contact tracing to break chains of transmission Retrospective sampling * In addition to prospective sampling, a retrospective review of available genomic sequences at country level should be done, with sample collection dates from mid-October 2021 till date. © Specimens with S gene target failure in the recent past, preferably from mid- October 2021, till date can be sequenced to identify variant strain- if not done already. Vaccination ‘According to the Technical brief of the WHO for the region, the presence of multiple mutations of the spike protein in the receptor-binding domain indicates that the Omicron have a high likelihood of immune escape from antibody-mediated protection. However, immune escape potential from cell- mediated immunity is more difficult to predict. Overall, there is still considerable uncertainties in the magnitude of immune escape potential of the Omicron. Further research studies are needed to better understand the escape potential against vaccine- and infection-induced immunity. Research efforts are ongoing, and the data are expected to be available within two to three weeks. Despite uncertainties, available vac legitimate to consider that currently es may offer some level of protection against in and death. , efforts should be intensi ¢Meanw ied to accelerate the va ity popul: lly targeted for COVID-19 vaccination who remain unvaccinated or not yet fully ation coverage, especially among pri ns, vaccinated. Increasing COVID-19 vaccination coverage in all el ible age groups, | but particularly in the old adults, health care workers and others with high risks of severe diseases should be prioritised by public healthPul health and social measures (PHSM) +The use of masks, physical distancing, hand hygiene, and improving ventilation of indoor spaces remain key to reducing transmission of SARS CoV-2, even in the context of emerging variants. *However, higher level of adherence may be required to control transmission with more transmissible variant. Health care system readiness + The rapid pace of replacement of the Delta variant by Omicron in South Africa raises concerns that this variant is significantly more transmissible than Delta. In addition, the high observed growth rate could be due to immune escape. As part of preparedness activities and in the anticipation of COVID- 19 case-load and associated pressure on the health system, districts are advised to ensure mitigation plans are in place to maintain essential health services, and necessary resources are in place to respond to potential surges. In anticipation of the next surge already the Medical infrastructure had been upgraded. This needs to be sustained. Risk communication and community engagement © The authority should regularly communicate information related to Omicron and potential implication for the public in timely and transparent manner to further foster trust and increase acceptance on response measures. © One of the most important and effective interventions in a public health response to any event is to proactively communicate with the population what is known, what is unknown and what is being done by responsible authorities to get more information. * COVID-19 information overload and misinformation and unverified and unsubstantiated social media forwards should be rebutted and overall Information should be managed at all stages of the response by providing the right information at the right time to the right people through trusted channels (e.g. with evidence based factual information and information provided by the public health and clinical experts, family doctors and other Influential members of society). There should be a monitoring system in cecaplace to capture emerging trends to enable delivery of a targeted communication package. In conclusion, I would like to inform that in the light of various reports of the emerging new Variant of concern and the anxiety among people and the need to be updated about the available information, this background and the situation analysis has been shared with a view to not only sensitise the districts on the emerging scenario but also ensure that we are adequately Prepared and are ready to tackle such public health challenges which has become common while tackling COVID-19 and its variants which keep evolving from time to time. However, at this stage, I would also like to caution that we should also be alert and sensitise the public about the fact that the other Delta variant Is still active and the standard five pronged strategy of Test, Trace, Treat, Vaccination of eligible persons and follow up of COVID appropriate behaviour and strict implementation and enforcement of the standard operating procedures for permitted activities continue to be even more relevant now than ever. With regards, aH. Dr J Radhakrishnan To, 1, All District Collectors, 2. Commossioner, Greater Chennai Corporation, 3. Director Public Health and Preventive Medicine, 4, Airport Directors 5. Heads of Departments