Health care’s modern-day version of the Greek chorus is growing louder and more persistent. My colleagues and I have long been among them.
In news conferences, journal articles, and podcasts, this chorus is pleading with the public to pay attention to its message: SARs-CoV-2 is not done with us. Omicron can kill; it can infect the vaccinated.
We have found, like everyone else, that Omicron runs on its rules; with Delta, two vaccine shots were able to lower the positivity rate. With Omicron, two shots have not been enough.
The WHO used the word “surprise” in its November announcement that Omicron was a variant of “concern.”
So did Trevor Bedford, a computational biologist and infectious disease scientist at the Fred Hutchinson Cancer Center in Seattle, who said that Omicron “took me and everyone by surprise.”1 Speaking on KevinMD’s podcast, he told his host that with the degree of immunity in the global population, he was expecting subsequent evolving strains to have minor, subtle genetic mutations, akin to how flu varies from year to year. What was a surprise was the giant leap in evolution that occurred with Omicron, which contains 36 mutations in the spike protein and approximately 50 mutations in total. Because of these mutations, the original two-shot mRNA COVID vaccines becomes only 40% effective against symptomatic disease after several months (thankfully a booster shot increases this to ~80%).2 But the decreased vaccine protection without a booster, along with relaxation of mitigation measures, brought us to where we are now.
In Chicago, we knew the Omicron variant would move quickly, considering how it moved through South Africa and the United Kingdom. What we didn’t anticipate was that in one week’s time, our hospital would need to add another 100 dedicated COVID ICU beds. Nor did we anticipate the extent that Omicron would affect staffing levels in the same amount of time.
At our hospital, we have eliminated elective surgeries that require a hospital stay, which includes surgeries for cancer. One of my colleagues, Ryan Merkow, MD, a surgical oncologist, remarked recently he had to cancel half of his scheduled surgeries because of a lack of hospital space.3
Dispelling Myths
What is concerning about this current wave is how many unvaccinated are hospitalized. Because Omicron is so infectious and because of lower vaccination rates in younger adults and children, we have a younger group of adults and children admitted with COVID, who had been uninfected by previous surges.
A major myth that makes health care workers so frustrated is the tale that Omicron is milder. Unvaccinated people infected with this variant are seriously ill and are dying. Despite its “mild” label, once a patient is hospitalized, Omicron can be just as severe as its predecessors.4 For many, getting vaccinated is the difference between staying at home with some symptoms and being in the ICU.
As of January 10, according to the CDC, although 88% of people over the age of 65 are vaccinated, only 37.5% have gotten boosters which are key to restoring protection against Omicron. And among children, only 54% between 12- and 17-years-old are fully vaccinated, and a mere 17% of children aged 5 to 11 have gotten both of their shots.
Remember the conversations regarding natural immunity? Omicron has muffled that conversation. Those who have been infected with SARS-Co-V2 before can still get infected and very ill with Omicron. So now is the time to get vaccinated.
Transmissibility
We knew SARS-CoV-2 could spread 1 of 2 ways: large virus-carrying droplets that enter through the nose, mouth, and eyes, as well as miniscule airborne droplets of virus that float in the air and travel further than 6 feet. However, prior to Omicron, transmission of these smaller droplets via the air was not as frequent. But with Omicron, while it still travels by larger respiratory droplets, it appears to have more airborne spread.
In late December, The Lancet Regional Health published results of research conducted one month earlier at a designated quarantine hotel in Hong Kong.5 The index case was housed in the room across a hallway from the second case, who developed their case 8 days into quarantine. Testing showed the Omicron variant in both cases. Environmental testing of the walls and ceiling suggested airborne spread of the virus in places unreachable by large respiratory droplets.
Now with Omicron, people need to wear high-filtering masks that fit tight against the face, such as a N95, KN-95, or KF-94 if possible. And when removing the mask to eat and drink, one should be in well-ventilated areas, away from others.
People should avoid getting Omicron, regardless of vaccination status. This variant is so infectious that, compared to the Delta variant, people are twice as likely to infect others that live with them. And infecting others leads to a chain of transmission that can close schools, take over hospital beds, and disable or kill the most vulnerable in our communities.
Public and private behavior, and public policy
In July, months before that WHO announced Omicron’s existence, Rella and colleagues reported in Scientific Reports on the outcome of a new model designed to show how a vaccine-resistant strain could rapidly transmit through a highly vaccinated population if transmission mitigation interventions are dropped too soon.6
The authors wrote that the success of a vaccine-resistant strain making inroads into a population depends on the obvious – it finds populations with a low rate of vaccination. What is not so obvious, the authors wrote, is that a vaccine-resistant virus does its worst when transmission is not well controlled in a highly vaccinated population. What can prevent a surge like this are social behaviors and public policy that decrease the chain of transmission of SARS-CoV-2, such as vaccination, masking, and testing.
It is people’s behavior, and ineffective public policy, that are so frustrating to us. The WHO’s secretary general warned against relying solely on vaccines in December. “Vaccines alone will not get any country out of this crisis.”
Omicron takes a new mindset. What we were doing before is not protecting now. Unchecked spread is overwhelming our health care systems and putting the vulnerable in our population at risk. The ramification of this unchecked spread reaches everywhere – into the economy, our educational system, and our nation’s mental health.
When the pandemic started, the policies to control its spread rested on local government and public agencies; we all would have been better served had there been a unified, national response to an infectious threat that does not obey municipal or state boundaries.
The universal sentiment among health care workers is frustration with local and state governments that are either dictating policy that can harm the public we are trying to protect.
As of September, at least 23 state legislatures have passed laws changing a governor’s executive power reach. Many have taken it away. Others are fighting in the courts over mask mandates.
As for when the pandemic will subside, that appears to be up to the public and public policy makers. They will determine how long this will last and how many will die or be disabled before its end.