The Omicron Surge
Francis Collins, outgoing director of the NIH, stated recently that we need to be prepared to see 1 MILLION new cases per day with Omicron.
For context, the prior all-time high for rolling average daily cases was 251,232 in January 2021. We have already passed the peak of cases from the Delta surge over the summer as well, and based on a doubling-time of Omicron cases of 2–3 days, we will surpass this January 2021 peak within the week.
With the rapid spread and high transmissibility of Omicron, we are seeing comparisons made to measles, the most highly contagious human-to-human transmitted infection — an airborne respiratory virus — we need to acknowledge that #COVIDisAirborne and we need better masks. #N95sNow
To understand the comparison, Omicron has early estimates of an R0 consistently around 6–8, meaning one person will potentially infect 6 to 8 people and that then leads to rapid exponential spread. Measles is the most infectious virus with an R0 of 12–18.
Here’s a great article in Nature has a great article worth reading and probably the best summary of where we at with SARS-CoV-2 evolution and Omicron.
While I am not prepared to say Omicron is causing significantly less severe disease than prior variants in unvaccinated people, the data is clear that people who are vaccinated, especially with 3rd doses, have less severe disease and a lower chance of hospitalization and death.
The hard part has been getting accurate regional numbers of 3rd doses, and the linked article has the best statewide aggregates that I’ve found so far. The percent vaccinated with 3rd doses will likely make the biggest difference in terms of how a state or region is impacted, given that we see dramatically increased neutralizing efficacy with 3rd doses as opposed to one or two doses.
Along with vaccinations, we will have some oral treatment options that may help reduce hospitalizations and while our currently available monoclonal antibodies are no longer effective, there will be another option that may be beneficial for reducing severe disease.
Then factor in that new cases will increasingly be unreported as at home rapid tests ramp up and are utilized to catch positive cases — exactly why these will be such important tools in our pandemic management toolbox.
This is a good thing, though means that our denominator — or the total number of positive cases — is going to be a wildly inaccurate underestimate. With an artificially low denominator, that will lead to overestimates such as of hospitalizations and severe disease as a percentage of total positive cases. Which means effectively a decoupling of the case numbers and hospitalizations and deaths; therefore, paying attention to case numbers won’t necessarily be useful. The number to pay attention to now, and what I am most concerned about, is the number of hospitalizations.
While individual risk is lower if vaccinated, and especially if triple vaccinated, remember that children under 5 still cannot be vaccinated and are increasingly getting infected and getting sick with Omicron. As parent of two kids under five, that obviously is one of my concerns.
But I’m even more concerned about the healthcare system collapse and nationwide crisis levels. According to a survey done by Morning Consult and cited in an excellent article in The Atlantic by Ed Yong titled “Why Health Care Workers Are Quitting In Droves,” the healthcare workforce has contracted by half a million workers since the pandemic started — an estimated 30% total, with 18% quitting and 12% being fired. That’s just the beginning. We are tired and are being targeted. More want to leave. According to the same survey cited in the article in The Atlantic, 31% of the remaining workforce have thought about quitting and 66 percent of acute and critical-care nurses have thought about quitting nursing entirely.
What do I mean when I say “targeted?” I mean by patients and their families, and increased rates of violence. I mean by disinformation and the “infodemic.” I mean by a prior President and his adherents. I mean by our own institutions — see the recent CDC and AHA guidance.
Here’s the recent American Heart Association updated guidance — including that healthcare workers don’t need PPE because even if they might get COVID they are considered “low risk.”
Never mind that this means devaluing our own lives, the idea that we are “low risk” is certainly not true for all, and also means potentially becoming a vector of infection and spreading diseased to our families and our communities.
I have written previously that “there is no emergency in a pandemic.” While we can disagree about the word choices here, the message nonetheless holds true. None of my team will be running codes without proper PPE. I don’t care what the AHA says.
Then came CDC guidelines on work restrictions for healthcare workers in terms of quarantine for high risk exposures and isolation of COVID positive.
Note that we are either in or will be entering “crisis” in many regions if not most and how we become more and more expendable.
You can read the entire CDC statement here.
Why crisis mode? While the number of cases alone may not matter or be reliable anymore, if the decrease in average severity l does not lead to a very significant decrease in the rate of hospitalizations per case as compared to Delta, we will become overwhelmed rapidly.
We were stretched beyond hospital capacity in many regions at the peak of hospitalizations during the Delta surge, which crossed 100k twice at a nationwide level.
We have already exceeded the peak of cases during the Delta surge, so unless this is so significantly less severe than Delta overall in that the exceedingly high number of cases still amount to significantly fewer hospitalizations than at the peak of the Delta surge, then the healthcare system will be overwhelmed nationwide. Obviously there are significant regional confounding variables, and areas with low overall vaccination rates — again, pay attention to the rate who have received 3rd doses — will likely get hit much harder than those with much higher rates.
While we will certainly see regional differences, given that spread is rapid and exponential everywhere, as we are starting to see, then we won’t just have “spot fires” around the country as with prior surges, but the entire country will have regions on fire simultaneously. We have not seen a nationwide surge yet, and this will limit our ability to move resources around to respond to different regions when they need help. Everyone could need help at the same or near the same time, and that will put an even greater strain on a system that has already collapsed.
What do I mean when I say that the system has already collapsed? When hospitals are all full and patients aren’t able to even get into emergency departments, as we are already seeing in some places in the country, when rural hospitals are closing and those that remain open are unable to transfer critically ill patients to larger centers for days at a time and potentially many states away, and when people are dying both from COVID, and even more concerning, from other preventable diseases because staffing and resources are so limited or when the healthcare workers are now being asked to come back to work when COVID positive and even still with symptoms because the entire system is so short staffed and the only way to pretend like the system hadn’t already collapsed is to exploit the workforce even more then you know that the system has actually already collapsed, that we gave up on #FlatteningTheCurve and are already above our threshold for healthcare resources.
I’ve been predicting for a while that non-COVID deaths will likely match if not exceed COVID deaths due to the system collapsing and being beyond the resource threshold. This is why. This is what I am more concerned about, and what keeps me up at night.
Stay safe, y’all. Get vaccinated including a 3rd dose. Wear a better mask. Avoid high risk situations as much as possible and within your own personal relative risk assessment. And mostly, I hope you don’t need to utilize any healthcare resources in the next few weeks to months.
