Breaking the Omicron Wave: Three Actions to Protect Healthcare Workers in Low- and Middle- Income Countries

The Omicron variant, identified in November last year, has rapidly become the dominant variant of COVID-19, with many low- and middle- income countries (LMICs) observing a rapid increase in cases; the Institute for Health Metrics and Evaluation has estimated that Omicron might infect 60 percent of the world’s population by March 2022.  This surge of illness and self-isolation is putting huge pressure on healthcare systems and might result in a sudden drop in health service capacity to deliver essential services. For example, last month as the Omicron wave took hold in South Africa, almost 20 percent of healthcare workers (HCWs) contracted COVID-19, leaving general wards and intensive care units understaffed.  In this blog we argue that protecting healthcare workers, and health systems in general, is now an even higher priority. We propose three strategies that policy makers could implement immediately to achieve this goal.

1. Re-prioritize healthcare workers vaccinations including boosters

LMICs should expand and boost HCWs vaccination as a general strategy—protecting them from Omicron and ensuring essential services can be provided during this wave—, and then focus limited vaccination capacity on the most vulnerable groups.  Prioritising limited vaccination capacity is crucial as many LMICs are struggling to reach initial targets of population coverage, including vaccinating all healthcare workers. In Africa, for example, only 6 percent of people and less than one in ten heathcare workers were fully vaccinated at the end of 2021.

The fast pace of the Omicron wave means that many LMICs have simply run out of time to significantly scale up general population vaccine coverage before the wave hits, so temporarily restoring the original priorities set early in the pandemic is crucial. This strategy goes against several approaches currently being implemented, including focussing on increasing the age range covered (e.g., Zambia, Guinea, Senegal, and Indonesia recently prioritised vaccine delivery for all those 12+ years old).

Countries such as Zambia, with high coverage goals and very wide eligibility, are implicitly aiming to stop transmission in the whole population. However, recent findings—including from the UK Health Security Agency—show that two doses of AstraZeneca do not protect against transmission. High coverage boosting with mRNA vaccines is most likely to bring down Omicron transmission, but these are not commonly available in all LMICs. With the extremely high herd immunity levels needed to stop Omicron, the lack of impact of non-mRNA vaccines on transmission, and the limited time available, all points to re-focusing on vaccinating and boosting the original priority groups, like HCWs and the elderly.

While the reported waning effectiveness of vaccines against Omicron is worrying, this may be less of a concern specifically for HCWs. Effectiveness waning within 10 weeks could significantly effect current vaccination strategies on a national level, but if the peak of this variant is within 10 weeks, which is likely, vaccines and boosters to HCWs is a very viable strategy. In addition, healthcare workers are also much more likely to be able to take up repeat vaccinations and boosters as needed.

2. Don’t stop at vaccination, prioritise holistic care of health workers

It is vital to ensure that healthcare workers, particularly in LMICs, have the right medical products to fight against COVID-19 surges. This includes high quality masks, oral antivirals, and tests. While there are efforts ongoing to increase the availability of COVID-19 testing kits worldwide, including through the Access to COVID-19 Tools Accelerator, supply has continued to lag behind need. Similarly with inject able antivirals: there are very few approved for use against COVID-19, with most therapeutics being expensive and hard to access and administer in  LMICs. New oral antivirals (nirmatrelvir/ritonavir and molnupiravir) recently authorised in the US and Europe, are hugely effective for severe COVID-19 symptoms if provided early, significantly reducing the risk of hospitalisation and death; in under vaccinated communities this could relieve the burden of illness and death on healthcare systems. However, the fact that demand will outstrip supply for the foreseeable future, coupled with the large number of patients in need and the requirement to provide antivirals early in the disease, raises concerns about feasibility, budget impact and cost-effectiveness with universal, untargeted strategies. Targeting HCWs with oral antivirals may well be considered both more feasible and more cost-effective than the general population. Health Technology Assessments of oral antivirals could support policy makers to make informed decisions on their role out and who to target.

In addition to access to appropriate medical products, mental health should also be a priority. Healthcare workers are under huge strain and face difficult working conditions. In the short-term tiredness and stress lead to mistakes being made, and in the long-term many healthcare workers are considering leaving their jobs due to stress. Promoting a healthy work environment, with peer support, open communication with leadership, and resilience training, has all shown positive results and should be included in a holistic strategy to protect HCWs.

3. Make contingency plans for a worst-case surge

LMICs should conduct analysis of health system surge capacity, including identifying weak points and finding ways to increase the surge capacity and flexibility of their health workforce. One option to consider is emergency plans for redeployment within the healthcare system. Experience from South Africa show that because the timing of Omicron waves can vary significantly by region, shortages of HCWs are likely to occur in some areas but not others across specialities/services, so it is important to plan for this and provide rapid training where needed to ensure emergency department, intensive care unit and acute care areas are well staffed. The Philippines successfully implemented a redeployment of staff for previous waves of the pandemic when healthcare workers were redeployed to COVID-19 designated facilities and hotspots, as well as task-shifting of personnel to do contact tracing and testing. Earlier in the pandemic, many countries such as Ecuador, India, Indonesia and Peru also deployed military assistance to support national health systems successfully.

Surge planning could also benefit from reduced isolation periods for HCWs. Mandatory self-isolation for a fixed duration may lead to extreme staffing shortfalls at the same time as hospital admissions are peaking. Research shows the number of infectious days in the community can be reduced to almost zero by requiring at least two consecutive days of negative tests. Argentina, Colombia, and India have recently made this change to isolation rules, with isolation being reduced to just five to seven days.

Conclusion

The speed and nature of the Omicron wave is putting huge pressure on healthcare systems in low- and middle- income countries, especially due to staff shortages related to COVID-19 infections and isolation policies. Prioritizing and protecting health workforces to hold the line against this surge is essential to deliver essential services and care for those with severe COVID-19. Three key strategies to achieve this goal include prioritising HCW vaccinations and offer boosters; ensuring holistic care of HCWs including access to appropriate medical product; and implementing emergency redeployment plans to handle regional and service variation in COVID-19 cases.

Thanks to Vageesh Jain for commenting