Dr Gagandeep Kang, in an exclusive interview, decodes JN.1 as 'Variant of Interest' and suggests what to do next.
Dr Gagandeep Kang, microbiologist, vaccine expert, and adjunct Professor at CMC Vellore. (Supplied)
The World Health Organization (WHO) has classified JN.1 as a separate “Variant of Interest” (VOI) after the subvariant was detected in three states, even as a spike in Covid-19 cases has created panic in India.
Dr Gagandeep Kang, microbiologist, and adjunct professor at Christian Medical College, Vellore, who is also on several advisory boards including the WHO, spoke about how a majority of JN.1 infections are expected to be asymptomatic despite its ability to spread at a faster rate.
In an exclusive interview with South First, she decoded the WHO’s statement on classification, who should be worried, and what health departments should do to mitigate the Covid-19 situation in India.
Here are excerpts for the conversation:
Q: What does WHO’s classification of JN.1 as a separate “Variant of Interest” mean?
A: First and foremost, a “Variant Of Interest” just means that WHO will be monitoring the spread of the strain. It does not mean that this is a serious illness, nor does it mean that WHO is concerned about this becoming a huge public health problem. It just means that WHO will continue to track reports of this strain from around the world.
The important thing to remember is that there is a difference between a “Variant of Interest” and a “Variant of Concern”. We should worry about a “VOC”, but we should not worry about a “VOI” because it just means that public health authorities will be doing what they are supposed to do, which is to follow any new strain that evolves as it infects people globally.
The advisories are normal public health-related functions, and they are not something to be worried about.
Q: Can this VOI turn into a VOC?
A: Well, in the early days, the variants of concern usually manifested themselves very quickly, with patterns that we were unfamiliar of. We used to see strains where data was unexplained, and people were getting sick very quickly, even if they had been previously infected or had received vaccines some time ago.
An example is what happened with the Delta variant, where the clinical picture was something that was unexpected and was one of extreme severity. Its spread was very rapid. This is not what we are seeing with this threat, so I think it’s important to understand that a VOI is different from a VOC.
Q: JN.1 is now in three states of India? What should we expect?
A: Based on the data we have of other variants, this virus is going to continue to evolve, and this is just the latest evolution of the virus. The fact that we have found cases from three states doesn’t mean there are only so many cases in the country. It means that this strain is spreading in the country and it is very likely to infect people.
Q: How is it behaving clinically? Who should take more precautions?
A: Most infections, even with this strain, are likely to be asymptomatic, and people who are infected might not even know that they have been infected. A very small proportion of people will develop the disease, and among them, only very few will develop severe disease.
All the data we’ve seen for this strain in India and other parts of the world is that the severe outcomes are limited to people who have comorbidities, other illnesses, or are extremely elderly.
It’s very important that if you have comorbidities or are an older individual — especially at this time of frequent gatherings and it being winter — you should be careful and avoid infection as much as possible. So, precautions like using face masks and avoiding crowded areas are advisable for elderly people and those with severe comorbidities.
Q: WHO says this variant has a change in its spike protein and calls it “low risk”. What does this mean?
A: Essentially, if you look at the mutations of SARS-CoV-2, there are mutations across the entire genome, but the mutations that allow for immune escape tend to be concentrated in the spike protein.
This new strain only has one difference from its parent strain, and yet that seems to be enough to allow it to spread rapidly. That’s why tracking the mutations is of interest. The more we learn about these viruses, the better we will be able to think about what mutations have actually lead to wider spread of Covid-19 strains or SARS-CoV-2 variants. Learning more is always an advantage.
On the low risk, it is based on the clinical picture, which is essentially telling us that there is no increased severity of disease. And again, it is something important for us to understand because a virus with certain mutations might cause more severe disease.
So, the more we track all the strains, the more we will understand both about its transmission and severity.
Q: Is there a possibility of a wave-like situation with this variant?
A: A wave requires a baseline level of surveillance, and then you see a temporary increase in the number of cases. Waves go up and down, right? But if you are going to increase testing, can you really say that there is a wave?
When you increase testing, as cases are increasing, you will see an increase in the number of detections. Does that mean that it is a wave? Well, we didn’t test on a stable baseline.
So with the stable baseline absent, it becomes much harder to interpret. But it is important for us to continue measuring the proportion of positives caused by the new and older variants.
Q: How important now is sequence now?
A: The requirement is to do sequencing. Because if you want to understand which variant you have, you have to sequence it. PCR or the rapid tests that we use quite widely now don’t reveal the strain. So, to identify the strain, lineage, and sub-lineage, we should sequence.
It’s not necessary to sequence every strain, but a small proportion of strains should be sequenced so that we have an understanding of what is going on.
The government’s advisory for monitoring influenza-like illness and testing all people in ICUs with respiratory disease is exactly what we should be doing because this will allow us to understand what proportion of these clinical conditions is being caused by variants and subvariants.
Q: Have symptoms of Covid-19 changed for JN.1?
A: As far as I’m aware, there are no changes in clinical symptoms. Remember that most infections will be asymptomatic. People who have been previously infected or vaccinated are much more likely to have asymptomatic infections.
But in general, younger, healthier people, with all of the variants that have come through, have tended to have more asymptomatic infections and milder infections.
People who develop severe, long-lasting illness are generally a subset of a healthy population or have other conditions as well.
Q: Does that mean that despite being asymptomatic, one can still spread the infection?
A: Yes, the problem with asymptomatic infection is that you don’t know that you are infected and you might very well spread it to others. But as I mentioned, the risks of severe disease are low.
Q: But with repeated infections, people are worried about long Covid. What is your take on this?
A: What we don’t understand about Covid today is long Covid. It seems like each time you get infected, it is logical that there is a chance that you might develop long-lasting symptoms.
However, what proportion of people might be affected, and whether there is a difference between various strains are yet to be understood.
So there are several reasons for us to continue to monitor Covid and keep studying it deeply.
Q: Is there a specific vaccine for the JN.1 variant, or do the vaccines already received provide sufficient protection? Additionally, is there a necessity for a booster dose?
A: The Food and Drug Administration in the US has approved three vaccines that are actually updated vaccines for 2023-24. These vaccines are based on XBB 1.5, and they are made by Moderna, Pfizer, and Novavax. Pfizer and Moderna’s vaccines are recommended for children, and Novavax can be given as a booster to adults as well. Now, these vaccines are different from the vaccines that we’ve had before.
Earlier, when new boosters were made, the recommendations were to go for bivalent boosters, meaning using the old strain as well as new strains of the virus. But now the recommendation this year is to have a monovalent, only the updated strain, based on laboratory studies. It seems these vaccines are based on a more recent version of Omicron, and it does seem like there will be some neutralising antibodies that will protect against JN.1.
The question is, these are lab studies. We will know of the protection these vaccines provide only after they are used for a longer period. These vaccines are not currently available in India.
Q: So for now, it is whatever we’ve taken is enough?
A: I think the important thing to remember is with any vaccine you have taken and with infection, you have developed a certain level where your immune system recognises at least older versions of the virus. So given that situation, I think we should expect that there is some level of protection.
Q: Should we use the old vaccines as boosters?
A: We don’t have data to show whether it will be useful or not. It would be great if we could do an effectiveness study. But those studies are hard to conduct and extremely expensive. So in the absence of data, it’s hard to make a recommendation on a booster with older strains.
Q: Many people have booked their tickets to Kerala and other places for the upcoming holidays. Should they be concerned about infections? Should there be a ban on travel?
A: No. travel bans won’t help. See, at the time we imposed travel bans, the world was a very different place from what we have today. We know that this is a strain that is spreading but it is not causing severe disease. So, what are we trying to control with a travel ban? If the hospitals are not filling up, there won’t be any increased demands on the healthcare system. What sense does a travel ban make?
I think the authorities are doing exactly what they should be doing. They’re monitoring the situation. They’re looking at influenza-like illness cases, they’re looking at severe acute respiratory infections, they will be sequencing. I don’t think there is a need for them to do more.
It is important to remember that even though SARS-CoV-2 is fresh in our memories, we have lots of other infectious diseases that we live with everyday. Follow Covid-appropriate behaviour wherever you are and those with comorbidities need to be extra careful.
Q: Mutations are a never-ending process. So, is there any possibility of us getting rid of this for good, or will we have to live with it?
A: It’s very difficult to get rid of a virus that can cause asymptomatic infections. It requires an incredible amount of effort, and especially if you have a virus that can move between humans and animals — which we know SARS-CoV-2 can — then it becomes nearly impossible to wipe the virus out.
So, I don’t think we should be thinking about eradication. We need to develop a rational approach to use our resources to handle this infectious disease, while remembering that other infectious diseases still exist.
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