Omicron Is About to Overwhelm Us

The new COVID variant has all the makings of a massive wave.

Photo: Microbiology HKU/BSIP/Universal Images Group via Getty Images
Photo: Microbiology HKU/BSIP/Universal Images Group via Getty Images

For all their limitations, the models right now are flashing bright red. Over the course of the pandemic, again and again, projections based on simplistic extrapolations of current trends have missed the mark when the trajectories turned. Sometimes this has been for the good, with dire warnings looking excessive after waves peaked and declined well before a full penetration of the population; sometimes, unfortunately, the turn has been in the other direction. But right now we don’t need models to tell us that the pandemic is taking a bad turn, and we won’t need to wait to see the projections validated, either. The speed of spread with Omicron is so fast that, when it comes to case growth, at least, the warnings are being validated already.

The relative virulence of the new variant is still clouded by enormous amounts of uncertainty. Only one patient has died with Omicron, thus far, and it is not entirely clear if the coronavirus was even the true cause of death. But in part this lack of severe outcomes reflects just how early in the wave we still are, even in South Africa; the variant was first identified there just three weeks ago, which means many of the early cases are still running their clinical course, and we don’t yet know what the outcomes will be. Hospitalization data comes earlier, and the news has been encouraging there, though experts have warned that what we see as milder outcomes may have less to do with the inherent virulence of the variant and more to do with the fact that more people who’ve caught it are carrying with them protection from vaccination or previous infection. The largest study to date on early South African data — somewhat strangely, it was conducted by an insurance company — found that, overall, those with Omicron were experiencing 29 percent less severe disease than those who got sick in the country’s first pandemic wave. Other, independent assessments have yielded lower — which is to say, more encouraging — estimates: Perhaps Omicron’s severity is lower by two-thirds, perhaps even less.

But a strain that is one-third as deadly and three times as catching lands you pretty quickly in the same spot, death-wise. And a strain that is 70 percent as deadly but five times as catching lands you somewhere a lot worse. That is the logic of some U.K. modeling suggesting that a best case for the country was a level of hospitalization half as high as last winter’s brutal surge, and a worst case for one twice as high. Other estimates are a bit more optimistic. (This model, for instance, predicts that British hospital admissions peak at about half of last winter’s level, with deaths between 30% and 40% of the earlier records.) But keep in mind, that earlier surge — by far the country’s deadliest phase of the pandemic — came before mass vaccination. To approach its death toll despite a very well-protected elderly population would require an explosive couple of months.

And since American vaccination rates are considerably lower than those in the U.K., with booster uptake lower as well, extrapolating the same model to the American population yields an even bleaker set of projections. Even before Omicron, half as many Americans were already dying of COVID-19 as did during our peak winter surge; in fact, that many Americans have been dying every day for three months now. That fact could, counterintuitively, make Omicron’s arrival feel somewhat less brutal, if the new variant effectively displaces Delta, replacing one ongoing wave with one that will almost certainly be bigger but may also be, proportionally, less deadly. But as Trevor Bedford has argued, the variants are also sufficiently distinct that they may not really be in direct competition with one another, meaning that each variant could progress in parallel — two waves at once.

Serological testing suggests that the vaccinated are still relatively well protected against severe outcomes with Omicron, though the protection is notably lower than against Delta. But while protection against infection can be boosted by a third shot, the triple vaccinated are still more likely to get sick than they were with earlier strains, which is one reason that, wherever we look, we see cases absolutely exploding.

In the U.K., Health Minister Sajid Javid estimated yesterday that there were 200,000 cases of Omicron in the country — much higher than the official count of 37,000 Omicron cases (and 59,610 total cases). The country’s previous high was 68,000 official cases; today it hit 78,000 (the equivalent, in the U.S., of more than 300,000). In Denmark, with perhaps the world’s most renowned variant-tracking system, the health ministry warned that the country could soon reach 300,000 new Omicron infections a day — which, given the country’s previous peak of 1,000 and its total population of 5 million, helps illustrate just how limited these models can be. But it also illustrates just how rapid the variant is spreading right now wherever it is — which is 70 countries, at last count, less than a month after discovery.

How will the U.S. respond to such rapid case growth? Just a few days ago, I was skeptical we would do much at all, but over the last few days the policy landscape appears to have changed. Norway is in “partial lockdown”; in the Netherlands, officials are closing schools; in France, they are closing the border to visitors from the U.K. In South Africa and the U.K., hospitals are reconsidering vaccine requirements and quarantine policy for staff, calculating that it may be impossible to keep facilities running if every positive test means the loss of a nurse or a doctor for a week or ten days. In the U.S., Amtrak has already withdrawn its vaccine requirement for the same reason, worrying about staff shortages, and Cornell and Princeton have both shut down in the face of rapid case growth. Higher education is one place where mass testing has been actually implemented in this country; another is the sports world, and there, too, leagues have already been plunged into COVID disarray.

It is not clear what the near future will look like. Beyond the question of virulence, the new variant’s speed throws all of our inadequate prep and policy into similar disarray. Even in a best-case scenario, the country is almost certainly going to be overwhelmed, very soon, by new cases. Perhaps they will be overwhelmingly mild. The economist Tyler Cowen recently described this scenario — the optimistic one, keep in mind — as “pure chaos,” because we do not have pandemic policy in place designed to respond to case numbers well beyond the highest we’ve seen so far in the pandemic. (Most organizations and institutions still require isolation after a positive test, for instance, which is a different kind of policy when test positivity rates are below 4 percent, as they are in New York City, rather than 34.9 percent, as they are in South Africa right now.)

Even those pushing back against Omicron fatalism — like Gavin Yamey, William Hanage, and Tom Moultrie, today, in Time — have only the same familiar public-health prescriptions to offer: more vaccination and more boosters; more testing and more rapid testing; more mask-wearing, and handwashing, and social distancing. These are all helpful tools, but they have not allowed us to successfully fend off earlier waves of much less transmissible variants, and they are unlikely to allow us to really blunt this one, either, even putting aside growing pandemic fatigue and public resistance to 2020-style interventions. “Even in the best-case scenario in which Omicron causes a mild illness, the repercussions could be huge,” the authors of the Time essay acknowledge.

Imagine, for example, that the entire world caught a cold at the same time. There would be a rise in deaths among older, vulnerable people — such as those in nursing homes — and the mass absences from work would have major societal consequences. Even if only a small percentage of people get ill or die, a small percentage of a very large number would still be a large number. And in many nations, including the U.S., there is no slack in the health system to deal with another surge in COVID-19 hospitalizations. Hospitals are already at capacity dealing not just with COVID-19 (cases and deaths from Delta are rising in the U.S.) but with catching up on a backlog of surgeries and other treatments delayed or deferred by the pandemic.

When I used the phrase “flatten the curve” yesterday in an interview with Megyn Kelly, she laughed at me.

One dim light shining through the bleak gray of uncertainty and fatalism is the news from therapeutics. As I wrote a few weeks ago, before Omicron, the clinical trial of Pfizer’s Paxlovid drug was the most encouraging development in many months. Yesterday, they announced updated data from the trial: 89 percent reduction in severe illness and 100 percent reduction in observed deaths. That’s incredible — a pandemic game-changer, as I wrote then, though it is supposed to be taken within five days of symptom onset (a tight window when PCR tests still often yield results only after two or three days).

But the FDA has not yet approved Paxlovid. Instead, a preliminary assessment by an advisory group recommended for emergency-use authorization another new therapeutic, molnupiravir from Merck, which is barely a third as effective (a reported 30 percent reduction in severe disease) and has what’s called a positive Ames test, which means by one crude measure it represents a cancer risk.* Merck has, it seems, done its due diligence to demonstrate that risk is at or very close to zero. But Pfizer has Merck beat on all points. Except FDA support, of course.

Why does the much-worse drug have FDA support now, when the much-better one doesn’t? The simple answer is agency protocol: Merck got its application in first. It’s yet another instance of the agency struggling to perform in a crisis situation with anything like the urgency the situation seems to require. But even upending FDA protocol more aggressively than it has been to this point probably wouldn’t help all that much with Omicron: Although manufacturing of Paxlovid has already begun, and 10 million doses have already been purchased by the federal government, immediate approval is not likely to yield widespread supply over the next month or two, when this wave is likely to be most punishing. With immediate approval, the company could provide only 180,000 doses, it has said; by the end of February, only 300,000. Those treatments could help, of course, but unless the new variant takes a surprising turn soon, even the game-changing drug we have in hand now can’t be deployed in time to really change this game. Omicron is simply moving too fast for that.

This article has been updated to reflect the fact that the FDA has not given approval to the Merck drug molnupiravir; a panel convened by the agency simply recommended it for an emergency-use authorization.

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Omicron Is About to Overwhelm Us