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Omicron Update

01 Jan

While on call for my clinic over Christmas, the Omicron variant’s extreme contagiousness became quite clear. I received call after call from vaccinated people who tested positive. This is what I’d been expecting as I’ve followed the story of omicron since learning of its existence on Thanksgiving. It is much more contagious than previous variants and our vaccines aren’t nearly as effective at preventing it from infecting us. At the same time, I’ve been heartened to see lower hospitalization rates than during previous waves in countries experiencing omicron surges. This seems to be from two factors. First, while vaccinations and previous COVID infections are not as effective at preventing omicron infections, they are decreasing the severity of infections. Even if our antibodies aren’t as effective at binding to Omicron’s spike protein, T cells induced by the vaccines are effectively neutralizing the virus. The second reason for lower hospitalization rates than during previous waves is that omicron appears to be less innately virulent. Multiple studies have shown it binds less effectively to lung cells, decreasing its ability to cause the devastating COVID pneumonia that has caused so much disability and death. 


But even if omicron isn’t causing as severe of disease, its extreme contagiousness is still straining health care systems and other essential institutions. A small percentage of a very big number is still big. That is to say, even if a small percentage of people with omicron need to be hospitalized, with so many folks infected, hospitalizations could still rise to concerning levels. Beyond that, a huge number of people getting sick all at once and out of work threatens the functioning of key institutions such as health care, schools, grocery stores, and public transportation. This is part of the reason the CDC shorted the period in which someone should isolate after being infected. You should isolate from others for 5 days, then for the following 5 days always wear a mask when around others. The rationale is that most of the virus shedding occurs during the first 5 days and any further, smaller amount of shedding the following 5 days can be minimized by wearing a mask. 


Right now I am most concerned about the two groups of people who don’t have immune protection against omicron. The first are those who haven’t been vaccinated or previously infected. The second are immunosuppressed people like organ transplant recipients who didn’t develop a protective immune response to vaccines. These groups could fill hospitals since right now we lack for available meds to reduce hospitalization. For much of the pandemic, monoclonal antibodies have been very effective treatments to prevent high risk people from being hospitalized or dying. But available monoclonal antibodies don’t work against omicron. The monoclonal antibody that does work against omicron is in very short supply. The Pfizer pill Paxlovid that reduces hospitalization and death by 89% is also currently so scarce as to be effectively unavailable. (The Merck med which lowers risk of hospitalization by only 30% is also scarce and difficult to access).


After we get through this omicron wave, there’s a case to be made that it will put us in a better place with COVID. Omicron appears to be crowding out delta to become the dominant variant. A less virulent variant of COVID will in the long term result in less disability and death. In addition, Omicron’s extreme contagiousness means many more people will have been infected, providing them with immunity for at least some period of time. 


Since there’s a good chance you or somebody in your household will be infected with COVID sometime soon, what is my advice? I’d first place yourself on a risk spectrum. On the one end, are people who are young, vaccinated, aren’t immunosuppressed, lack high risk health conditions, and won’t be spending time with people who are high risk of getting sick with Omicron. Such people are at low risk of directly hurting themselves or others by getting infected with COVID. The biggest harm from their getting infected right now is helping to overwhelm urgent care and primary care clinics should they seek care for COVID. They might also contribute to a chain of infection that could ultimately infect a high risk person. Finally, there is the risk that they might develop the poorly understood condition called “long COVID”, in which people feel and function poorly for some period of time after infection. With all that in mind, however, I’d say this group of folks can most safely open us their lives. At the other end of the spectrum are unvaccinated people, immunosuppressed people, and those who will regularly be around immunosuppressed people. These are the folks at highest risk of being or contributing to hospitalization and death. I recommend this cohort of people markedly decrease their physical interactions with others for roughly the next month. If around others, I recommend they be outside at a distance and if indoors, wear a high quality mask such as a KN95. By being careful over the next month, they’ll give time for case numbers to come down and the Pfizer med and the effective monoclonal antibody to become available. 


So what should you do if you get infected? If you’re at the low end of the risk spectrum, monitor you pulse oximetry. If it stays below 94%, make an apt with your primary care physician’s office or an urgent care clinic. If your oxygen level level is above 94% and you’re not having any severe symptoms such as marked shortness of breath, don’t seek medical care. Doctors won’t have any tools that will alter your clinic course since you will most likely recover without any medical treatment. Your seeking care will needlessly overwhelm already overwhelmed primary care and urgent care clinics. Allow them to focus their limited resources on higher risk people. Use over the counter treatments for cough and congestion such as a Flonase, a saline rinse, and Mucinex. Use Tylenol, Advil, or Aleve as needed for headaches, body aches, and fever.


If you are at the high end of the risk spectrum and get infected, immediately seek care your primary care clinic or an urgent care center. Make sure to to have your pulse oximeter readings ready. Your doctor may prescribe a med called Fluvoxamine as well as an inhaled steroid such as Budesonide.  Both have modest evidence for decreasing the risk of hospitalization and shortening duration of symptoms. (Note that some people develop nausea in response to Fluvoxamine and inhaled steroids can be expensive.) If you are very high risk, your doctor might try to obtain some of the very scare supply of Paxlovid or the effective monoclonal antibody called Sotrovimab. Be aware that your doctor has limited control over accessibility of these meds. 


This is a difficult time for us all. So let’s show each other some grace and patience in the early days of the new year. We will get through this.
 
1 Comment

Posted by on January 1, 2022 in Uncategorized

 

One response to “Omicron Update

  1. Nancy Marroquin

    January 2, 2022 at 1:09 am

    Wry informative Thanks!

     

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