Hope is not a strategy, but we are increasingly hopeful that we may be near the peak of omicron. We have good reason to believe we are on the way down to COVID-19 becoming a relatively low-level endemic respiratory illness, somewhere between a common cold and the flu. The biggest risk is that another major variant develops, but fortunately, while that’s an unpredictable event, there is reason to believe we may be nearing the end of the major variant train. To better understand that, we have asked several infectious disease specialists why it is that of the 4 other coronaviruses that are in common circulation causing the common cold do not keep mutating into more dangerous variants.
The best theory on this is that viruses tend to mutate until they reach an optimal state for maximizing transmission and then become stable. It is the transmissibility that drives mutation, not virulence, and once the virus reaches a point where it has optimized transmissibility, there is little evolutionary drive for new variants to stick because, at that point, any variation is more likely to decrease transmissibility. With that in mind, now that omicron has evolved to where it is one of the most transmissible viruses out there, near the level of measles, which is the most transmissible common virus, it is more likely than not that any future mutations will be minimal. This includes mutations that could make it more lethal because, in the long run, more lethal viruses actually transmit less because they kill their host and dead hosts do not effectively transmit to others.
Looking at the current epidemiology of omicron, it is responsible for over 98% of cases in the US and the actual percentage is probably even higher because of the large number of cases that are not being reported. This is because the infected person is either not testing or using a test that does not generate a report, such as a home antigen test. In Europe, omicron is felt to represent essentially all cases, and the European CDC estimates that half of all Europeans will contract omicron over the next 6 to 8 weeks. That may be a bit of hyperbole, but looking at New York, where roughly 15-20% of the population is thought to have been infected with omicron since the Thanksgiving holiday at the end of November, it is not beyond belief that the better part of half of Europe will have been infected over the first two months of 2022.
In the UK, where omicron spread widely about 2 to 3 weeks ahead of Europe, since New Year’s Day, cases have dropped about 20% by a seven-day average, with the most recent days showing further drops. Hospitalizations have also peaked, although the decrease is only minimal so far, which would be expected since hospitalizations trail infection. And remember that while hospitalizations have gone up around the world, the rate of the rise has never been as rapid as the total cases, especially in terms of severe cases requiring ICU care, but the combination of cases and healthcare workers denied the ability to work by infection or government vaccine mandates have led to overwhelming of some systems.
In South Asia, Omicron has also driven cases up by a factor of 20 since just before the end of the year, but without the hospitals being overrun as they were during the summer surge. Japan and South Korea are seeing only muted waves so far, but it is unclear as to whether the spikes will be smaller or if this is just early. Singapore and Hong Kong have not seen a large increase numerically, although Hong Kong has seen the first large numbers of community transmission cases in many months, and authorities there are concerned that omicron may have a foothold that will lead to rapid increases in the coming weeks. And finally, in China, there are tens of millions in lockdown, many in complete lockdowns with military and police delivering food rations rather than allowing anyone to leave their residences. The Chinese Communist Party has said that the Olympics will go on as scheduled and these limitations on Chinese citizens are just designed as risk-reduction measures. As things stand right now, and in consideration of the spread that occurred in Japan following the summer games, we would be very uncomfortable with travel to China for the games, not as much for fear of a bad outcome, but more out of concern for how any isolation or quarantine will be managed.
While much of the recent focus in the news and from the government has been on the shortage of tests, remember that much of this shortage was not due to people rushing out to test just because they have symptoms, but the fact that over the holidays, people felt that it was important to test before travel or before seeing at-risk family members. This did drive a shortage, but as more people become less scared of the impact of omicron on themselves or family, and as numbers begin to recede over the next couple of weeks, tests should once again be much easier to come by. Of course, the shortage will likely naturally ease just about the time that the US Government’s massive buy of a half-billion test kits begins to hit the streets.
On treatments, the antivirals paxlovid and molnupiravir are slowly becoming available, but only in very limited supply, and providers are asked to follow guidance to limit prescriptions only to people at the highest risk, with lack of vaccination being an important risk factor that providers have been asked to consider. In the US, a website from the US Department of Health and Human Services purports to direct you to locations that have these treatments available although we strongly doubt that this data set will be kept current. It will at least give you and providers an idea of the facilities that are receiving shipments. The website is COVID-19 Public Therapeutic Locator | HealthData.gov. Internationally, the best source of information will be through local or national ministries of health. If you do look at the website, in addition to paxlovid and molnupiravir, you will also see a listing for Evushield. This is a newly approved long-lasting antibody cocktail is for pre-exposure prophylaxis for the most high-risk patients who are unable to build their own antibody response due to certain required medications or having a severely immunocompromising condition. This is not at all useful for the general population because it would suppress any natural immune development, whether from infection or vaccination, thereby making the recipient indefinitely dependent on the cocktail for immunity.
Over the last two weeks, one of the most common questions that we have received has been, “OK, I was just diagnosed with COVID…my symptoms are pretty mild…what do I do?” If you do not have any significant risk factors, which we will list in a moment, the best approach for most people is to treat it as you would any other virus, including the flu: isolate yourself from others, increase fluid intake, make sure you eat, take Tylenol 3 to 4 grams per day divided over 3-4 doses alternating with a Non-steroidal such as Motrin or Aleve in the standard labeled amounts for fever, aches, and pains, maybe add zinc and vitamin C, and monitor your oxygen saturation with a pulse oximeter to make sure it stays above 93%. If you have a bad cough or congestion, add a cold medicine with a decongestant and expectorant. Most people are seeing omicron symptoms reach their maximum on days 3 or 4, then clear over another 3 to 4 days. However, If you do have a risk factor, or have not been vaccinated, work with your care provider to get either paxlovid or Sotrovimab monoclonal antibody cocktail. One of these is generally available in most areas, but often only with a long wait or at a very high cost. Availability varies by day. The key risk factors that should be considered are age ≥65 years, immunosuppression, type 2 diabetes, and chronic kidney, cardiac, pulmonary, neurologic, or liver disease. In a large study, all persons with severe COVID-19 outcomes after primary vaccination had at least one of these risk factors.
The second most common question that I get is, “Should I get a booster.” The answer to that for most people is simple: Yes. There are those that disagree with us, saying that the primary series, especially for the mRNA vaccines, adequately protects against severe outcomes, so getting the booster adds risk while only protecting against the more minor outcome of a mild to a moderate bout of COVID-19. We’ve seen enough patients who were pretty sick with “moderate” COVID-19 and we would not wish that on anyone. The booster now has a good track record of little or no added risk over the primary series and it does diminish the risk of even moderate COVID. Breakthroughs still happen, but breakthrough infections that happen at least two weeks after a booster are generally very mild. Of note, many people opposed to boosters cite “The Ontario Study” that looked at a large number of cases and found that case rates actually increased after the booster. A major factor here is that people tended to drop their guard shortly after receiving their booster, leading to cases developing before the booster had the 10-14 days needed to take full effect. This was amplified by the fact that booster uptake really started after omicron began to take off in early December and by the time that people got their booster in response, it was too late for it to be effective as they went to their usual holiday gatherings. The other major finding from that same study was that the resulting cases from people who were boosted at least 14 days prior to the development of symptoms were almost universally mild.
The one group that we are not quite as enthusiastic about receiving boosters are 12-18 year old’s for whom boosters were recently authorized. If you have a child in this group and they have any risk factor OR they are routinely around someone, such as a grandparent, who has a risk factor, OR their school requires it, then we have little concern with getting the booster. For others, holding off is not an unreasonable option. The risk of myocarditis is present, but that only occurs in about 3 out of a million kids (mainly males) and even then, it is rarely severe or has any sequelae. Just for reference, myocarditis is also reported after the use of penicillin-related antibiotics in kids, at about the same rate, and no one thinks twice about that. The argument for not taking the booster is that these non-at-risk children have such a low risk of severe disease that the additional risk lowering of the booster is clinically very minimal.
With the number of breakthrough infections we are seeing around the world, the last question we commonly get is, “I was vaccinated, but then I got COVID anyway, do I still need a booster, and if so, when?” The official answer is that you should get the booster as soon as you clear isolation. Our feeling, though, is that so far, we don’t know how long immunity from the booster is going to last. The immune booster effect of getting COVID as a breakthrough is well established, and although the duration of that immunity is in question, at least 90 days is accepted. Our current thinking is to “use up” that infection-induced immunity before recharging your immune system 90 days down the road. Right now, we don’t know the real immunity duration, nor do we know how active the epidemic is going to be in 90 days. I think there is a reasonable chance that we may be mostly through with COVID by then and you may be able to put off that booster, how long for that is another question for another day. But save that booster for when you can make better use of it for extending your duration of strong immunity.