Population Immunity and Covid-19 Severity with Omicron Variant in South Africa

N Engl J Med. 2022 Apr 7;386(14):1314-1326. doi: 10.1056/NEJMoa2119658. Epub 2022 Feb 23.


Background: The B.1.1.529 (omicron) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first identified on November 25, 2021, in Gauteng province, South Africa. Data regarding the seroprevalence of SARS-CoV-2 IgG in Gauteng before the fourth wave of coronavirus disease 2019 (Covid-19), in which the omicron variant was dominant, are needed.

Methods: We conducted a seroepidemiologic survey from October 22 to December 9, 2021, in Gauteng to determine the seroprevalence of SARS-CoV-2 IgG. Households included in a previous seroepidemiologic survey (conducted from November 2020 to January 2021) were contacted; to account for changes in the survey population, there was a 10% increase in the households contacted, with the use of the same sampling framework. Dried-blood-spot samples were tested for IgG against SARS-CoV-2 spike protein and nucleocapsid protein with the use of quantitative assays. We also evaluated Covid-19 epidemiologic trends in Gauteng, including cases, hospitalizations, recorded deaths, and excess deaths from the start of the pandemic through January 12, 2022.

Results: Samples were obtained from 7010 participants, of whom 1319 (18.8%) had received a Covid-19 vaccine. The seroprevalence of SARS-CoV-2 IgG ranged from 56.2% (95% confidence interval [CI], 52.6 to 59.7) among children younger than 12 years of age to 79.7% (95% CI, 77.6 to 81.5) among adults older than 50 years of age. Vaccinated participants were more likely to be seropositive for SARS-CoV-2 than unvaccinated participants (93.1% vs. 68.4%). Epidemiologic data showed that the incidence of SARS-CoV-2 infection increased and subsequently declined more rapidly during the fourth wave than it had during the three previous waves. The incidence of infection was decoupled from the incidences of hospitalization, recorded death, and excess death during the fourth wave, as compared with the proportions seen during previous waves.

Conclusions: Widespread underlying SARS-CoV-2 seropositivity was observed in Gauteng before the omicron-dominant wave of Covid-19. Epidemiologic data showed a decoupling of hospitalizations and deaths from infections while omicron was circulating. (Funded by the Bill and Melinda Gates Foundation.).

MeSH terms

  • Adolescent
  • Adult
  • Antibodies, Viral / blood
  • Antibodies, Viral / immunology
  • COVID-19 Vaccines
  • COVID-19* / blood
  • COVID-19* / epidemiology
  • COVID-19* / immunology
  • COVID-19* / virology
  • Child
  • Humans
  • Immunoglobulin G / blood
  • Immunoglobulin G / immunology
  • Middle Aged
  • Public Health Surveillance
  • SARS-CoV-2* / genetics
  • SARS-CoV-2* / immunology
  • SARS-CoV-2* / pathogenicity
  • Seroepidemiologic Studies
  • South Africa / epidemiology
  • Spike Glycoprotein, Coronavirus / immunology
  • Young Adult


  • Antibodies, Viral
  • COVID-19 Vaccines
  • Immunoglobulin G
  • Spike Glycoprotein, Coronavirus
  • spike protein, SARS-CoV-2

Supplementary concepts

  • SARS-CoV-2 variants