Omicron is more transmissible and vaccine-evading than its predecessors

Omicron is more transmissible and vaccine-evading than its predecessors

Some late reporting from labs in South Africa makes aspects of last week’s data look unreliable now. A key question to me is that if Omicron moves very fast, and people end of getting Omicron rather than Delta, it could in theory reduce hospital pressure (assuming they do not get reinfected with delta after), relative to the path where delta grows even more (all assuming that Omicron is much less severe, which is most people’s take on the SA data). As the mild and fast versus severe and slow debate continues.

Preliminary data from Denmark support the hypothesis that the new variant is significantly milder than Delta on average. Further, we have learnt that boosters provide significant protection against Omicron-related infection, though suspect that the UK Health Security Agency (UKHSA)’s estimates of vaccine effectiveness (~30% for two doses of Pfizer and 70–75% for three doses) are too optimistic. It still looks like SARS-CoV-2 has mutated to become more like the flu. Yet we will not be able to rule out the tail risks for another week or so. We await better data from advanced economies about Omicron’s rate of severe disease.

Preliminary data from Denmark support the hypothesis that the new variant is significantly milder than Delta on average. Further, we have learnt that boosters provide significant protection against Omicron-related infection, though suspect that the UK Health Security Agency (UKHSA)’s estimates of vaccine effectiveness (~30% for two doses of Pfizer and 70–75% for three doses) are too optimistic. It still looks like SARS-CoV-2 has mutated to become more like the flu. Yet we will not be able to rule out the tail risks for another week or so. We await better data from advanced economies about Omicron’s rate of severe disease.

Preliminary data from Denmark support the hypothesis that the new variant is significantly milder than Delta on average. Further, we have learnt that boosters provide significant protection against Omicron-related infection, though suspect that the UK Health Security Agency (UKHSA)’s estimates of vaccine effectiveness (~30% for two doses of Pfizer and 70–75% for three doses) are too optimistic. It still looks like SARS-CoV-2 has mutated to become more like the flu. Yet we will not be able to rule out the tail risks for another week or so. We await better data from advanced economies about Omicron’s rate of severe disease.

South Africa:

  • Yesterday, the National Institute of Communicable Diseases (NICD) reported 37,875 new cases in South Africa as a whole. The countrywide test positivity jumped to 28.9% Sunday, from 16.4% Saturday.
  • However, the data release was misleading. The total number included 18,035 true new cases reported in the last 24 hours plus 19,840 nationwide “retrospective” (i.e. backlogged) cases that it had not previously reported, supposedly due to delays in public-sector testing labs.
  • In Gauteng, yesterday’s NICD release counted 16,716 new COVID-19 cases (44% of the nationwide total):

https://twitter.com/nicd_sa/status/1470118484600311813/photo/1

  • It is unclear clear what proportion of the Gauteng daily case count are retrospective cases that should have been counted in previous days. In short, the NICD’s botched data reporting makes it difficult to draw firm conclusions about how close we are to the peak in Gauteng. These retrospective cases also make the test positivity rate an unreliable metric.
  • I think the wave of Omicron cases is within a few days of peak in Gauteng, though I have low confidence.
  • Amid the confusion, some facts are clear. First, Gauteng hospitalization data continue to suggest that Omicron is much milder than Delta on average. All the models predict that daily hospitalizations in Gauteng will peak well below the Delta peak in spring 2021.
  • The true strain on the hospital system is even less, since the average duration of hospital stay is less than half of the length today as it was during Delta, and a much smaller fraction of hospitalizations are converting to ICU admissions and deaths.
  • Like new cases data, South African regional hospital data are of very poor quality, but the trend is directionally clearly visible. All medical sources on the ground are now comparing Omicron to “the common flu.”
  • Finally, death data are encouraging. 21 deaths have been reported in the last 24 hours, down 42% from Saturday.
  • Recent estimates of the case fatality rate (CFR) for the various COVID-19 strains suggest that Omicron’s CFR is ~0.4%, compared to 3-4% for each of the original virus and the Beta and Delta variants:
  • https://twitter.com/pieterstreicher/status/1469743337347371018
  • The caveat is that demographic differences make it hard to extrapolate precise hospitalization and death rates from South Africa to older and more developed countries.
  • Nevertheless, the Gauteng data still suggest that the Omicron variant is just the latest stage of COVID-19’s gradual evolution into a mild illness.
  • We shall get confirmation (or not) soon from Europe, where Omicron has established a foothold and is spreading exponentially.
  • The “mildness” of Omicron could of course prove to be deceptive if this variant of the virus is causing lingering damage (e.g. to organs other than the lungs) that is not immediately obvious in younger people it infects.

The United Kingdom and Denmark

  • The UK recorded 1,239 new Omicron cases yesterday, nearly twice as many as Saturday.
  • Forecasting the trajectory of the Omicron wave in the UK is complicated by the fact that daily new Delta infections in the country had remained stable at ~35-45,000 per day since around July.
  • Boris Johnson addressed the nation about the coming “emergency,” which he predicted would include a “tidal wave” of Omicron infections. The UK’s Health Security Agency (UKHSA) now thinks that the doubling time of the variant is more like 2 days than 3. And the latest numbers are just over 1,200 daily Omicron infections in the UK.
  • However, the latest London School of Hygiene and Tropical Medicine paper “Modelling the potential consequences of the Omicron SARS-CoV-2 variant in England” projects ~5,000 admissions a day (in England) in the second half of January. This in its “high immune escape”/ “high booster efficacy” scenario.
  • I think this is probably an over-estimate. There will be behavioural change—increased risk aversion over the Christmas period—because talk of a “tidal wave” is bound to alarm a significant section of the public.
  • Johnson announced that all over-18s should plan to get booster shots by December 31. The government will defer some normal medical procedures and appointments to meet the need. I note that 40.2% of over-12s have already had a third dose of vaccine.
  • Over the next few weeks, Omicron will out-compete Delta in the UK, with cases peaking around New Year’s Day.
  • I think further targeted containment measures are still possible in the UK and Europe in the coming weeks, though pressure on hospitals should subside quickly as the Omicron wave will be tall and short-lived.  
  • On Friday, the UKHSA released the first high-quality real-world data on the effectiveness of vaccines against Omicron:

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1040076/Technical_Briefing_31.pdf

  • It found that two doses of AstraZeneca were ineffective in preventing symptomatic infection from Omicron. Two doses of Pfizer were only ~30% effective. Two AstraZeneca or Pfizer doses plus a Pfizer booster were 70–75% effective in preventing symptomatic Omicron infection “in the early period after a booster dose.”
  • Based on Danish data, I think these efficacy estimates are too optimistic.
  • 77% of Danish residents have been fully vaccinated, and 20% boosted. Only 2% of vaccine doses administered there were AstraZeneca’s.
  • Yet, of 2,471 Omicron cases identified in Denmark thus far, 75% were in fully vaccinated individuals and 10% in boosted individuals, suggesting that vaccines and boosters may be even less effective against Omicron than UKHSA estimates suggest:

https://files.ssi.dk/covid19/omikron/statusrapport/rapport-omikronvarianten-12122021-k29d

  • By late this week, will have enough UK and Danish data to estimate vaccine efficacy against severe disease from Omicron. The preliminary Danish data suggest that hospital admissions from Omicron are far below levels observed in previous waves, though we do not know much of this can be attributed to vaccination.
  • Denmark has recorded 27 Omicron-related hospital admissions so far. This implies an Omicron-specific hospitalization rate of ~1.1%, in line with Gauteng data. By contrast, during the country’s Delta wave in late October and early November, hospital admissions had been closer to 2–3% of total cases. Rates of more severe infection were also several times higher.
  • In the UK, no Omicron-related hospitalizations had been observed at the time of the UKHSA report’s publication.
  • Yesterday, a senior member of the UK government stated that “a small number” of individuals are showing up at hospitals with Omicron, but did not specify the exact number.
  • Eventually, if these trends hold, governments are likely to change their definitions of “fully vaccinated” to include recent boosters.

If daily cases are close to peaking in Gauteng, the world can breathe a sigh of relief. But I don’t think we are ready to call the peak. Omicron is more transmissible and vaccine-evading than its predecessors, so the coming peak in cases will be the tallest yet, potentially putting hospital systems globally under extreme strain for a few painful weeks. The downside risk of panicked behavioural overreaction remains, though even in the worst case, the wave will fade away very quickly. We will have better data on rates of severe disease from Omicron in the UK and Denmark later this week.

Outside of South Africa, we are starting to see the early impact of Omicron in the UK and Israel with cases rising, which is contributing to an overall rise in cases. Importantly, though, initial neutralising antibody data from Pfizer showed that a third booster dose restores antibody levels against Omicron to the same level as previously seen and, even more importantly, real-world data from the UK highlighted that efficacy against cases (see Table 1). Notably, while there is no data yet available on the protection against hospitalization, it seems clear based on previous experience that the boosted vaccine protection is likely to remain very high and two doses are likely to provide significant protection as well.

A concern for countries, therefore, is making enough time to boost their adult population as they deal with a Delta/Omicron wave, which could require lockdowns. In the UK, where boosting is more advanced and the school holidays begin in a week’s time (providing a break in transmission in children which represent c. 40% of cases in the UK), JPM do not share some of the concerns of others that further significant restrictions will be necessary. For other countries where hospitalisation is more advanced and the booster programs less advanced they see a continuing need for lockdown measures to be strengthened in the face of Omicron to allow time for boosting of the population.

For the moment the 4th wave in Europe remains a Delta wave, despite concerns about Omicron’s spread (Omicron represents only c. 2.5% of cases this week). Restrictions in Germany and Austria seem to have brought the waves in these countries to a peak, with the continuing deterioration in the situation in France potentially going to require further restrictions being implemented in the next few weeks. This week (December 6 - December 12) infection levels rose in 7 out of 11 countries they are monitoring, with the only fall in countries that have introduced lockdown measures: Austria (by -42%) which is in full lockdown, the Netherlands (by -16%) which is restricting opening times of shops and bars etc, Germany (by -12%) which has a national lockdown for the unvaccinated, and Belgium (by -14%) with local lockdown measures. In the EU5, cases rose in Italy by 15%, France by 15%, Spain by 15% and the UK by 12%. Outside the EU5 cases rose in Denmark by 50%, Switzerland by 5% and Sweden by 1%.

In terms of hospitalisations, Germany saw a rise of 7%, bringing the weekly total to c. 10,800. In France, hospitalizations continue to climb this week by 40% to around 8,179. In the UK hospitalisations rose by 6% this week at 5,850.

Overall, they see Omicron not significantly changing our view that countries with low booster numbers and high hospitalisations from Delta already (such as France) are likely to need further lockdown measures in the coming weeks. So far the UK doesn't seem to require such measures given our read of the data.

Omicron impact starting to become visible in the UK and Israel, case efficacy at 75.5% after a booster dose

Outside of South Africa, we are starting to see the early impact of Omicron in the UK and Israel along with the initial neutralising antibody data from Pfizer, which showed that a third booster dose restored antibody levels against Omicron to the same level as the levels seen against the wild-type strain. Specifically, the in vitro data showed a reduction after two doses by 25 fold in neutralising antibodies against Omicron compared with the wild-type strain, compared with a c. 6 fold reduction against the Delta variant. A third booster dose, however, restored neutralising antibody levels by 25 fold, highlighting the importance of a booster dose in protecting against Omicron cases, with Omicron thought to be 4x more transmissible than Delta, based on early data.

This data was supported by initial data in the UK, where data on Pfizer primary/Pfizer booster and Astra primary/Pfizer booster protection against Omicron cases (n=581) was published on Friday. The study showed Pfizer primary efficacy against Omicron 15 weeks after the second dose of 34% to 37%, compared with 63.5% for Delta 25+ weeks after the second dose. A third booster Pfizer dose was found to restore efficacy against Omicron to 75.5%, compared with 93.1% against Delta. For the Astra primary series, given the greater period for waning, minimal protection was seen against Omicron but this rose to 71.5% after a Pfizer booster, highlighting the importance of the booster rollout in the UK.

In Israel, a 12% rise in cases was seen this week, to an average of 611 new cases per day, with new severely ill admissions up 26%. A total of 55 Omicron cases have now been confirmed in Israel, compared with 12 confirmed cases last week. While the early rise in Israel could be indicative of a new Omicron-driven 5th wave, a rise in both cases and severely ill admissions could also be due to increased social mixing as a result of Hanukkah (28th November - 6th December) so it remains too early to assess the Omicron impact in Israel.

For South Africa our colleague Alex Comer is monitoring cases and hospitalizations (here). Cases are surging, having almost doubled since last week to a total of 136k weekly cases (19.4k average daily cases), compared with 70.3k total cases last week (10k average daily cases). On Sunday, 38k new cases were reported, the highest daily number of cases seen throughout the pandemic, although previous outbreaks were curbed by earlier restrictions. The current hospitalisation rate in South Africa is 1.8%, although new hospital admissions rose by 137% this week to 2,424 new hospital admissions this week compared with 1,024 admissions in the prior week.

Figure 1: Latest cases in South Africa

Source: worldometer

Figure 2: Weekly hospitalisation rates in South Africa vs. cases

Source: South African Health Ministry

In the coming week, they expect further laboratory data on the reduction in neutralising antibody titres of the Moderna and Astra vaccines against Omicron, which they anticipate could show at least a similar, if not larger, drop against Omicron than the Pfizer data. JPM would continue to stress, however, that antibody levels have not proven to be a strong correlate of protection against hospitalisations so the next key Omicron data point will be on protection against hospitalisation which could take another couple of weeks for robust data, given the lag between cases and hospitalisations.Source: South African Health Ministry

Table 1: Pfizer Vaccine Efficacy against different variants on Cases, Reduction in Neutralising Antibodies and Hospitalisations

Pfizer Efficacy

 

 

   

WT

Primary

 

Alpha

Primary

 

Beta

Primary

 

Delta

Primary

 

Delta 6m

(Primary)

 

Delta

Booster

 

Omicron 6m

(Primary)

 

Omicron

Booster

 

Cases

 

95%

 

93%

 

75%

 

78%

 

63.5%

 

93.1%

 

34-37%

 

75.5%

 

Antibody reduction

 

-

 

2.6

 

4.9

 

5.8

 

ND

 

ND

 

25.0

 

-

 

Hospitalisation

 

99%

 

98%

 

97%

 

96%

 

90%

 

96%+

 

?

 

?

 
                                   

A deeper look at German infections & hospitalisations

Over the week December 6 – December 12 the daily new infection count was down 12% to 351,073 as local lockdowns and a lockdown for the unvaccinated reduced transmission. New case numbers were between 29,633 and 68,832 per day compared with 35,983 and 73,486 per day the week before. Hospitalisations, however, rose by 7% to 10,856. ICU occupancy for COVID-19 also increased by 5% to 4,904, 22.0% of beds, and total ICU occupancy was flat at 86.8% (from 86.6%). Given the national lockdown of the unvaccinated, they would expect cases to continue falling for the next few weeks regardless of the spread of Omicron, although Omicron could lead to cases rising again unless the booster rollout is accelerated.

Figure 3: Germany: Change in Daily New Infections since Feb 26, 20

Source: WHO, Worldometer; J.P. Morgan estimates.

Figure 4: Germany: Change in Daily New Deaths since Feb 26, 2020Source: WHO, Worldometer; J.P. Morgan estimates.

Source: WHO, Worldometer; J.P. Morgan estimates.

Figure 5: Germany: Weekly Hospitalisations since Feb 26, 2020Source: WHO, Worldometer; J.P. Morgan estimates.

Source: WHO, Worldometer; J.P. Morgan estimates.

Figure 6: Germany: Weekly ICU Occupancy since Feb 26, 2020

Source: WHO, Worldometer; J.P. Morgan estimates.

Development in UK infections & hospitalisationsSource: WHO, Worldometer; J.P. Morgan estimates

Over the week December 6 – December 12 the new infection count increased by 12% to 356,368, of which 2,891 (0.8%) were Omicron cases identified this week (prev. week 243). Testing levels were up 10% and so the rate of positive tests came down to 4.1% (prev. 4.3%). Per day infections were between 45,165 and 57,335 (prev. week between 39,040 and 53,242). The rise in cases continues to be due to an increase in cases in 5-14 year olds (see Figure 12), and also in 40-49 year olds who have yet to be boosted. Cases are falling in 50-59 year olds due to the booster. Importantly the decline in cases in the over 65s is continuing, showing the beneficial effect of the booster doses (see Figure 11). Similar to last week case numbers are starting to outweigh the impact of boosters, with hospitalisations rising this week, by 6% to c. 5,850 (based on the first 3 days of the week) although the rate of hospitalisations still came down to 1.6% (prior week 1.7%). The occupancy of ventilators was down slightly this week at c. 19.9% (last week 20.1%), which equates to c. 893 people.

They also continue to monitor Flu cases and hospitalisations in the UK. Take-up of the flu vaccine was flat w-o-w at 79% of above 65 year olds in the UK currently and flu cases and hospitalisations remain very low. The rate of positivity for flu increased slightly to 0.7% (last week 0.6%) compared to COVID-19 at 4.1%, and significantly below the level seen in 2019/20. Therefore at the moment they don't see flu impacting the decision making around the need for a return of more social distancing measures in the UK.

With Omicron cases increasing significantly from a low base there are concerns that Omicron could require a further tightening of measures to give time for the population to be boosted. However, with 75% protection against infection found in people receiving a booster dose and the school holidays starting in one week’s time (and schoolchildren representing c. 40% of cases) they anticipate cases might not start spiking up through Christmas. In addition JPM believe that vaccine protection against hospitalisation is likely to be largely maintained as well which means that hospitalisations seem likely to remain below 10,000 a week. It is also reassuring at the moment that patients on ventilation are falling. As result while the working-from-home advice could be extended for longer, they don't anticipate major lockdowns being required in the UK at this time.

Figure 7: UK Weekly Infections Aug 2, 2020 – Dec 12, 2021 (actual); Dec 13 - Dec 26 (projected)

Source: WHO, Worldometer; J.P. Morgan estimates.
Figure 8: UK Weekly Hospitalisation Aug 2, 2020 – Dec 12, 2021 (actual); Dec 13 - Dec 26 (projected) at 1.5% of infectionsSource: UK.gov; J.P. Morgan estimates

Source: WHO, Worldometer; J.P. Morgan estimates.

Figure 9: UK Weekly Hospitalisations Aug 2, 2020 – Dec 12, 2021 (actual); Dec 13 - Dec 26 (projected) at 1% of infectionsSource: UK.gov; J.P. Morgan estimates

Source: UK.gov; J.P. Morgan estimates

Figure 10: UK Weekly Deaths Aug 2, 2020 – Dec 12, 2021 (actual); Dec 13 - Dec 26 (projected) at 0.2% of infections (3wks prior)


Source: UK.gov; J.P. Morgan estimates

Figure 11: England Daily Cases for 60+ year olds showing the impact of boosters on cases in recent weeks.


Source: UK.gov

Figure 12: England Daily Cases for 0-19 year olds showing the impact of vaccinations on cases in 15-19 year olds recent weeks.


Source: UK.gov

Development in Vaccinations in the EU5, Israel & the US

Figure 13: Latest booster % over 50s for EU5 and US (% adults)


Source: CDC, UK, French, Germany, Spain, Italy governments. *Note Italy restated booster data by age group this week.

Figure 14: Fully vaccinated % for EU, US and SA (% population)


Source: CDC, UK, Netherlands, Austria, French, Germany, Spain, South Africa and Italy governments.

Figure 15: Latest vaccination % for EU5 and US (% adults)


Source: CDC, UK, French, Germany, Spain, Italy governments. *Note, Italy restated vaccinations data this week.

Figure 16: % Natural Immunity due to prior infection


Source: CDC, UK, French, Germany, Spain, Italy governments.

The UK has fully vaccinated 88.0% of its adult population (prev. week 87.7%), covering 68.7% of the total population. First doses have been administered to 93.4% of the adult population, covering 75.3% of the total population. Looking at vaccination by age, we estimate 49% of 12-15 year olds (prev. week: 45%) and 68% of 16-17 year olds (prev. week: 65%) have now received at least one dose. This compares with 75% of 18-24 year olds (prior week: 75%), 77% of 25-29 year olds (prev. week: 76%) and 95% of those aged 30 and over. Full immunisation has been achieved in 67% of 18-24 year olds (65% in the prior week), 70% of 25-29 year olds (69% in the prior week) and 79% of 30-34 year olds (78% in the prior week) compared with 94% in the 35+ population. The UK has administered 23.1m booster doses (prev. week: 20.3m), with the rate of booster shots rising by 6% to an average of 405k doses per day. As a result, the UK has now administered boosters to 75.4% of over 50s (prev. week: 68%). This should continue to accelerate in the coming weeks with the UK government having accelerated their target to administer boosters to all adults by one month, now targeting for the end of this month (prev. Jan) in order to curb any potential impact from Omicron.

Looking across the EU4 on the primary vaccination series, Spain has fully vaccinated 90.4% of its adult population, France is on 90%, Italy is on 81.8%, and Germany is on 79.6%. Spain has partially vaccinated 92.2% of its adult population, France is on 92.0%, Italy is on 87.7% and Germany is on 83.3%. Germany reported a 23% decline in first doses to an average of 77k doses per day with second doses flat this week at 66k doses. We expect uptake of both first doses and second doses to rise in the coming weeks following the introduction of mandatory vaccination (or confirmation of recovery from COVID-19) for all healthcare workers at hospitals, doctors' offices and nursing homes, which will be enforced by mid-March. France's second-doses rate rose by 16% with first doses up 1% given concern over the potential for restrictions. Italy's first doses rose by 7% (with second doses declining by 4%), continuing to benefit from the extension of vaccine mandates for a wider group of public-sector workers (from healthcare workers only to all school staff, police and the military) and restrictions on unvaccinated were implemented.

On the rollout of booster jabs, France continues to lead the way with 48.8% of over 50s having received a booster dose, compared with 34.7% in the prior week, with daily boosters rising by 32% to an average of 644k doses per day. Germany has seen an acceleration in booster uptake this week with 47.6% of over 50s having now received a booster (32.8% in the prior week), with booster doses rising by 15% this week to an average of 872k doses. Italy has boosted 33.6% of over 50s (25.3% in the prior week) while Spain has boosted 31.8% of over 50s (29% in the previous week).

The US has fully vaccinated 72.0% of adults (prev. week: 71.4%). First doses have been administered to 84.2% of its adult population (prev. week: 83.3%). Booster doses have been administered to 39.9% of over 50s, with booster doses down 33% this week to an average of 744k doses per day.

Figure 17: EU 5, Israel & US Cumulative 1st doses administered


Source: UK, France, Germany, Spain, Italy and Israel governments; CDC. Note, country-level data frequently restated for Germany, Italy and Israel.

Figure 18: EU 5, Israel & US Cumulative fully vaccinated


Source: UK, French, German Spain, Italy and Israel governments; CDC. Note, country-level data frequently restated for Germany, Italy and Israel.

Figure 19: EU 5, Israel & US % of Population received 1 dose


Source: UK, French, German Spain, Italy and Israel governments; CDC. Note, country-level data frequently restated for Germany, Italy and Israel.

Figure 20: EU 5, Israel & US % of Population fully vaccinated


Source: UK, French, German Spain, Italy and Israel governments; CDC. Note, country-level data frequently restated for Germany, Italy and Israel.

Figure 21: EU 5, Israel & US Cumulative Booster doses administered


Source: UK, French, German Spain, Italy and Israel governments; CDC. Note, country-level data frequently restated for Germany, Italy and Israel.

Figure 22: EU 5, Israel & US Cumulative Boosters % of Population


Source: UK, French, German Spain, Italy and Israel governments; CDC. Note, country-level data frequently restated for Germany, Italy and Israel.

Examining the impact of the Vaccine in the UK, US and Israel

Israel, which has fully vaccinated c. 90% of its adult population and has administered booster shots to c. 69% of its adult population, saw a 12% rise in cases this week to an average of 611 new cases per day, the fourth week of a rise in cases, with new severely ill admissions up 26% to 5.7 new admissions per day equating to a new severely ill rate of 0.9%. A total of 55 Omicron cases have now been confirmed in Israel, compared with 12 confirmed cases last week. The positivity rate in Israel averaged 0.69% this week, compared to 0.62% last week and 7% at the end of August, in the early stages of the booster campaign, so cases still seem to be under control in Israel but focus remains on the impact of Omicron on breakthrough cases and hospitalisations in Israel.

US cases declined by 1% this week to an average of 123.5k cases a day, although hospitalisations continued to rise by 9% to an average of 7,949 new admissions per day, a hospitalisation rate of 6.4%. States in the North East seem to be the most impacted by a Delta-driven surge in hospitalisations with >50% rises in hospitalisations reported vs. two weeks ago (prior to Thanksgiving) in Connecticut, New Jersey, Washington D.C., Vermont and Rhode Island. New York has implemented a vaccine mandate for all private workers and has re-implemented mask wearing to contain the ongoing spread of Delta as well as the recent surge in Omicron, although cases in the US still continue to be dominated by Delta. The CDC has reported 43 Omicron cases in the US to date with 34 in fully vaccinated individuals (14 of which had also received a booster), with 25 cases in people aged 18 to 39. Symptoms were largely mild to moderate with one person requiring hospitalisation for two days.

In the UK, cases rose by 12% this week to an average of 50,190 cases per day with testing levels up 10% and hospital admissions rose by 6% to 854 new admissions per day. Early data on booster vaccinations in adults aged 50 and older indicate that after a booster dose of the Pfizer/BioNTech vaccine, vaccine effectiveness against Delta symptomatic disease rises to 93.1% among those who received the AstraZeneca vaccine as their primary course and 94.0% among those who received the Pfizer/BioNTech vaccine as their primary series. Against Omicron, initial data from the UK on symptomatic disease indicates a vaccine efficacy of 71.5% with the Astra primary series and a Pfizer booster, with an efficacy of 75.5% with the Pfizer primary series and Pfizer booster. Protection from the Pfizer primary series is estimated to be 34-37% at 15 weeks, compared with 63.5% for Delta.

The latest 3 week data on COVID-19 hospitalisations by vaccination status as at December 9, 2021, highlight that 78% of hospitalisations in the UK (n=8,156) are in over 40s. Among hospitalisations in fully vaccinated individuals, over 40s comprise 92% of total hospitalisations, clear evidence of waning of protection from the vaccines against hospitalisation, with hospitalisations in the younger age groups (12-39) largely in unvaccinated individuals. Across the same period, cases in over 40s have accounted for only 38% of total cases although over 40s accounted for 68% of cases in fully vaccinated individuals, continuing to highlight the need for vaccination, beyond boosters, in younger age groups to curb the current case trajectory, with boosters, particularly in older adults, necessary to curb hospitalisations. Putting this into perspective, the hospitalisation rate for unvaccinated over 40s was 6.4% based on the latest data, with a rate of 1.3% in vaccinated individuals, which should be curbed further as boosters continue to be rolled out. Across all adults, the hospitalisation rate in unvaccinated individuals was 2.9% vs. 1% in fully vaccinated individuals.

Figure 23: Israel Vaccinations compared to Daily Infections


Source: Israel government, worldometer, J.P. Morgan estimates.

Figure 24: Israel Vaccinations compared to Daily Severely Ill Pts


Source: Israel government, worldometer, J.P. Morgan estimates.

Figure 25: US Vaccinations compared to Daily Infections


Source: CDC, worldometer, J.P. Morgan estimates

Figure 26: US Vaccinations compared to hospitalisations


Source: CDC, J.P. Morgan estimates

Figure 27: UK Vaccinations compared to Daily Infections


Source: UK government, worldometer, J.P. Morgan estimates.

Figure 28: UK Vaccinations compared to Daily Hospital Admissions


Source: UK government, J.P. Morgan estimates

Development in New Infections in the EU5

  • Looking at the new infection data on a weekly basis over the last week (December 6 – December 12) the EU5 new infections rose by 5% to 1,255,891, a new high week of the pandemic so far. Cases rose in only 4 out of 5 countries with Germany seeing a fall by 12% to 351,073 due to the national lockdown for the unvaccinated. Cases rose in Italy by 15% to 116,444, in France by 15% to 341,428, in Spain by 15% to 90,578, and the UK by 12% to 356,368.

Figure 29: Weekly New Infections Development since Feb 23, 2020 for the EU5 Countries


Source: WHO, Worldometer; J.P. Morgan estimates.

Development in Deaths

  • For the week ending December 12, the total death count in EU5 increased by 21% week on week to 4,389, with deaths increasing in 4 out of 5 countries. Deaths rose in France by 40% to 896, Germany by 24% to 2,727, Spain by 8% to 225 and by 20% in Italy to 628. In the UK deaths were flat at 834.

Figure 30: Weekly New Deaths Development since February 2020 for the EU5 Countries


Source: WHO, Worldometer; J.P. Morgan estimates.

Table 2: Death Rate of Cases during different waves

Death Rate

 

Italy

 

France

 

Spain

 

Germany

 

UK

 

EU 5

 

23 Feb to 28 Jun

 

14.4%

 

19.0%

 

10.6%

 

4.7%

 

15.0%

 

12.6%

 
                           

5 Jul to 30 Aug

 

2.1%

 

0.7%

 

0.3%

 

0.7%

 

2.2%

 

0.7%

 

1 Sept – 27 Sept

 

0.9%

 

0.4%

 

0.8%

 

0.4%

 

0.5%

 

0.6%

 

28 Sept – 25 Oct

 

0.7%

 

0.5%

 

0.9%

 

0.4%

 

0.7%

 

0.7%

 

26 Oct – 27 Dec

 

2.3%

 

2.0%

 

1.9%

 

1.7%

 

1.8%

 

2.0%

 

28 Dec- 28 Mar

 

2.4%

 

1.7%

 

1.8%

 

4.1%

 

2.7%

 

2.1%

 

29 Mar – 5 Jun

 

2.6%

 

1.1%

 

1.2%

 

1.4%

 

0.7%

 

1.3%

 

6 Jun – 12 Dec

 

0.9%

 

0.4%

 

0.5%

 

0.6%

 

0.3%

 

0.4%

 
                           

Source: WHO, Worldometer, J.P. Morgan

Development in Hospitalisations

  • Daily Hospital Admissions: Hospital admissions in France were up 28% at 8,179 for the week ending November 21. In Germany hospital admissions were up 7% to 10,856 which is the worst week of the pandemic so far and in the UK, hospital admissions were up 6% at c. 5,850.
  • UK hospitalisations by Age: The data was updated on December 9, 2021 for the period up from Nov 3, 2021 to Nov 30, 2021. During November the proportion of people hospitalized above the age of 75 fell, as we hoped as a result of the administration of boosters. Increases in hospitalisations in the 55-64 year olds shows that boosters are needed in this age range. The proportion of hospitalisations from the age group 18-54 also rose which fits with the government decision to boost all adults even before concerns about Omicron were raised. We would expect the hospitalization rates to trend down with boosting through our December.

Figure 31: Daily Admissions to Hospital since Feb 23, 2020 for EU4

Source: UK.gov; ecdc.europa.eusalute.it

Figure 32: Daily Hospital Admissions/New Cases since Mar 22 for EU4


Source: UK.gov; ecdc.europa.eusalute.it

Figure 33: England Monthly Hospital Admissions by Age Oct 20 – Nov 21 (Data up to Nov 02)


Source: NHS England

Figure 34: UK Hospital Admission as % of cases in the week & % of cases 1 wk prior


Source: UK gov

  • Hospital Occupancy: Occupancy rose in France by 23%, in Italy by 18% but was flat in the UK.

Figure 35: Hospital occupancy since Feb 23, 2020 for EU3 (# of beds)


Source: UK.gov; ecdc.europa.eusalute.it

Figure 36: Hospital occupancy since Feb 23, 20 for EU3 (% of beds)


Source: UK.gov; ecdc.europa.eusalute.it

  • ICU Occupancy: In Germany ICU occupancy increased by 5% to 22.0% or 4,904 beds on average occupied. This takes the overall occupancy in Germany to 86.8%. Occupancy in the UK was down this week at 19.9% (prev. 20.1%). ICU occupancy in France increased to 32.2% (prev. 25.6%) of beds occupied and an average of 1,934 beds occupied. In Paris occupancy also rose to 43% (last week 37%). In Italy occupancy increased by 14%, with the percentage of beds occupied at 10.6% (prev 9.3%).

Figure 37: ICU Occupancy since Feb 23, 2020 for EU3*


* UK data is Ventilator Bed OccupancySource: UK.gov; govu.frsalute.it

Figure 38: % ICU Beds Occupied by COVID-19 since Mar 22 for EU3*


* UK data is Ventilator Bed OccupancySource: UK.gov; govu.frsalute.it

Development in New Infections in other EU Countries

  • Among the smaller European countries, the new infections decreased in Austria by 42% due to the full lockdown, in the Netherlands the partial lockdown lead to 16% fall in infections and in Belgium infections fell by 14%. Infections increased again in Denmark by 50%, Switzerland by 5% and Sweden by 1%.

Figure 39: Other EU Countries: Weekly New Infections Development since Jul 5, 2021


Source: WHO, Worldometer; J.P. Morgan estimates.

Figure 40: Other EU Countries: Weekly % Change in New Cases


Source: WHO, Worldometer; J.P. Morgan estimates.

Detailed Country Analysis

  • Italy: Over the week December 6 – December 12 the daily new infection count rose for the eighth week in a row by 15% to 116,444, with testing levels down 9% this week with total tests at 3,657,401 and so the rate of people testing positive rose to 3.5% (from 2.7%). The daily new infection count ranged from 9,489 to 21,039 per day (prev. 7,968 to 17,025 per day). The level of deaths increased by 20% to 628 (prev. 525). The average number of people in hospital with COVID-19 during the week increased by 18% to 7,099 (prev. 6,033). ICU average occupancy increased to 10.6% for the week (last week 9.3%). Although cases and hospitalisations continue to rise, Italy still seems some way off from needing to control the 4th wave with a lockdown.

Figure 41: Italy: Change in Daily New Infections since Feb 26, 2020


Source: WHO, Worldometer; J.P. Morgan estimates

Figure 42: Italy: Change in Daily New Deaths since Feb 26, 2020

Source: WHO, Worldometer; J.P. Morgan estimates.

Figure 43: Italy: % of COVID-19 tests positive (weekly)

Source: salute.gov.it.

Figure 44: Italy: Wkly % Change in Tests & % Change in New Cases


Source: salute.gov.it.; J.P. Morgan analysis.

  • France: Over the week December 6 – December 12 new infections increased for the ninth week in a row by 15% to 341,428, the second worst week of the entire pandemic from a case perspective (with the daily increases between 11,308 and 61,340 compared to between 8,279 and 51,624 per day for the previous week). The rate of testing positive was up to 6.0% (prev. 5.5%) which means that the French outbreak is still exponential based on WHO terms (i.e., a positive test rate of 5% or above). Deaths were up 40% at 896 for the week. Hospitalisations rose by 28% to 8,179 for the week. ICU occupancy increased by 26%, with COVID-19 patients now occupying on average 2,443 beds 32.2% of France's ICU capacity on average for the week (last week 25.6%) - on Dec 12, 2,602. In Paris ICU occupancy increased to 43% (prev. 37%). Another increase of 500 in the ICU occupancy and France will reach the upper end of the threshold the government used for reopening. With another increase of 500 this week it looks increasing likely that France could introduce a partial lockdown in the next two weeks, with the closing of nightclubs not enough to deal with the current situation.

Figure 45: France: Change in Daily New Infections and Hospital Admissions since Feb 26, 2020


Source: WHO, Worldometer; J.P. Morgan estimates.

Figure 46: France: Change in Daily New Deaths since Feb 26, 2020


Source: WHO, Worldometer; J.P. Morgan estimates.

Figure 47: France: % of COVID-19 tests positive (weekly)


Source: WHO, Worldometer; J.P. Morgan estimates.

Figure 48: France: Weekly % Change in Tests & % Change in New Cases


Source: WHO, Worldometer; J.P. Morgan estimates

  • Spain: Over the week November 29 – December 5 the infection count was up by 43% based on the first 5 days of the week, suggesting weekly infections are around 91k for the week. Deaths in the first 5 days of the last week were up 8% week on week at around 225 deaths. Although cases have risen again this week, Spain’s 4th wave remains manageable at this stage.

Figure 49: Spain: Change in Daily New Infections since Feb 26, 2020


Source: WHO, Worldometer; J.P. Morgan estimates.

Figure 50: Spain: Change in Daily New Deaths since Feb 26, 2020


Source: WHO, Worldometer; J.P. Morgan estimates.

Figure 51: Spain: Weekly % Change in New Cases


* 5-day data used for the December 12 datapointSource: WHO, Worldometer; J.P. Morgan estimates.

Figure 52: Spain: Weekly % Change in New Deaths


* 5-day data used for the December 12 datapointSource: WHO, Worldometer; J.P. Morgan estimates.

The UK:

Figure 53: UK: Change in Daily New Infections since Feb 26, 2020


Source: WHO, Worldometer; J.P. Morgan estimates.

Figure 54: UK: Change in Daily New Deaths since Feb 26, 2020


Source: WHO, Worldometer; J.P. Morgan estimates.

Figure 55: UK: % of COVID-19 tests positive (weekly)


Source: UK government J.P. Morgan estimates.

Figure 56: UK: Weekly % Change in Tests & % Change in New Cases


Source: UK government J.P. Morgan analysis

Figure 57: England % of cases by Age since Nov 2020


Source: UK government

Figure 58: England % of cases hospitalized by age since Nov 2020


Source: UK government

Figure 59: UK: Weekly deaths (as of 26 Nov) – 5yr avg. vs. 20/21


Source: ons.gov.uk

Figure 60: UK: Deaths by age (as of 26 Nov) – avg. 2015-19 vs. ‘20/21


The effort to explain where and how Omicron was quietly evolving has given rise to competing theories. The most popular view among virologists is that it spent months mutating in an immunosuppressed person with a chronic infection. Other ideas include evolution accelerated by the use of anti-Covid drugs, and crossover into an animal species that later jumped back into humans:

A South African research team, discovered an untreated HIV patient late last year who was infected with Covid-19 for more than six months and gave rise to a string of mutations that affected the spike protein, the part of the virus where most of Omicron’s adaptations are located. A UK study observed a similar process in a Covid patient with blood cancer:

https://www.medrxiv.org/content/10.1101/2021.06.03.21258228v1.full

The immune response of an untreated HIV patient would be too weak to clear the virus but strong enough to drive the process of evolution; this process would allow coronavirus to mutate without being “picked up” as many of these patients are asymptomatic and therefore do not get tested. This evolutionary pathway is likely to be rare but it’s a plausible reason for the emergence of Omicron. More than half of the world’s 37.7m HIV sufferers are in east and southern Africa. In South Africa alone, around 1.9m individuals have HIV that is undetected, untreated or poorly controlled, according to UNAIDs, the UN programme on HIV/Aids:

Another theory about how Omicron emerged in southern Africa has been advanced by William Haseltine, a virologist who has speculated that mutations could have been caused by Merck’s Covid-19 antiviral pill. He noted that South Africa was among the locations chosen for clinical trials of the drug molnupiravir, which began in October 2020:

https://www.ft.com/content/e1a059dc-ab09-47c0-b7b9-2b79dd1c911b

With the emergence of the omicron variant of SARS-CoV-2, emphasis on third-dose vaccinations has intensified in many countries. In Israel, the first country to offer third-dose booster shots to all adults, the discussion has now shifted to the possibility of offering a fourth dose. In the US, the CDC are now urging all adults (aged 18 years and older) to have booster shots, with the UK set to follow suit in early 2022. Even before omicron emerged, questions abounded over whether a mix-and-match strategy for third-dose vaccines would generate a better immune response than a third dose of the same vaccine given initially.

In the COV-BOOST trial, published this week in the Lancet, seven different COVID-19 vaccines were given as a third dose to nearly 3000 adults who had received two doses of either the ChAdOx1 nCov-19 (Oxford-AstraZeneca) or BNT162b2 (Pfizer-BioNTech) vaccines 2-3 months earlier. The bottom line of the trial was that the third-dose vaccines, whether with the same or a different vaccine—boosted neutralising antibody and T-cell responses to both wild-type and variant viruses (with somewhat blunted responses to delta), regardless of age. The exception was the inactivated VLA2001 (Valneva) vaccine when given after two doses of BNT162b2:

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02717-3/fulltext?

A third dose of CoronaVac, the world’s most widely offered COVID-19 vaccine, also effectively boosted immune responses, according to a trial from China. CoronaVac was also shown to be immunogenic in patients with immune-mediated rheumatic diseases in a study from Brazil, with the generation of robust neutralising antibody responses seen after a single dose in those with prior SARS-Cov2 infection:

https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(21)00681-2/fulltext?

https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(21)00327-1/fulltext?

These studies leave little doubt about the ability of third-dose vaccines to ramp up anti-COVID-19 immunity. Yet, the super-charging of booster programmes has reinvigorated debate over vaccine equity, with a concern that the expansion of booster vaccines in high-income countries will further exacerbate the global vaccine imbalance.

 

Justin Stebbing
Managing Director

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