I’m not going to do one of these every week, but since the situation is still evolving fast, I thought last week’s post about the Omicron variant deserved a follow-up. The reason is that we now have more evidence about the virus than we did just a week ago; South African public health and medical authorities have been providing us with a wealth of epidemiological data, and scientists have been racing to study the new variant. As with last week’s post, this will be a summary of what the experts are saying, followed by my own thoughts. If you want to get the news directly from the experts, check out my list of coronavirus experts on Twitter.
If you haven’t been following the Omicron situation, virologist Muge Cevik has a long and very explanatory thread that’s a good primer to get you up to speed:
But just in the last couple of days, events have progressed, and our data has increased by leaps and bounds.
Point 1: There is going to be a big Omicron wave in the U.S. soon.
Covid has been defined by super-spreader events, and Omicron is no different. An anime convention in NYC has been identified as one important such event. Three apparently unrelated cases have emerged in Washington state. There are reported cases of Omicron transmission between fully vaccinated people. At this point a major U.S. Omicron outbreak is totally unavoidable. It will happen, and it will happen very soon.
Remember, even when a variant spreads fast, it can take months for it to ramp up to a major nationwide outbreak. Trevor Bedford, a top epidemiologist, has a thread in which he argues that we should expect a big Omicron wave in the U.S. and other countries in about eight weeks.
But when it ramps up, this wave could get bigger much faster than Delta. Bedford has another thread citing South African data to show that Omicron is spreading much faster than Delta did — indeed, even with widespread existing immunity and mitigation measures like masks and social distancing in place, Omicron is spreading as fast or faster than the original Covid did in the U.S. before we had any immunity or any distancing measures!
So buckle up, folks, we’re in for a bumpy ride here.
Point 2: Omicron has substantial resistance to existing immunity.
Scientists and public health experts strongly agree that Omicron has significant ability to escape the immunity conferred by both vaccines and by prior infection. Initially, this was based entirely on analysis of the mutations in the new variant — and this was powerful evidence, since scientists understand a whole lot about how this virus works.
Now, though, we’re starting to get epidemiological evidence to back up scientists’ theories. For example, Omicron is spreading rapidly in the UK, which has a very high rate of vaccination.
Epidemiologist Christian Althaus has a thread summarizing the emerging epidemiological evidence that Omicron is resistant to existing immunity. He stresses that there’s a lot of uncertainty here — the new variant could be as little as 31% resistant, or as much as 93%.
And a study found that Omicron is about three times as likely to cause reinfection as Delta.
And here is a thread from biologist Tom Wenseleers explaining why Omicron’s rapid takeover from the Delta variant is almost certainly due to immune escape. If it were coming only from increased infectiousness (as was the case with Delta), Omicron would have to be 3 times as contagious as the most contagious virus we’ve ever found:
So at this point, it’s very clear that Omicron has substantial escape ability, even if we don’t quite know the exact numbers yet.
Point 3: Omicron is less deadly in South Africa so far, but there are several theories as to why.
Omicron is spreading like wildfire in South Africa’s Gauteng province, but so far there hasn’t been a big wave of deaths to match the big wave of cases:
In previous waves, deaths started rising about a month after cases did. This time, it’s been longer than a month and deaths still aren’t rising, so that’s good. One note of caution here is that hospitalizations in Gauteng are increasing fast:
So deaths are pretty sure to rise eventually to some degree. But hopefully the fact that they haven’t risen yet means that the Omicron wave is going to kill fewer of the people it puts in the hospital. And a hopeful sign is that a large percent of the hospitalizations so far are incidental detections in children hospitalized for other reasons (South Africa is testing very vigorously for Omicron).
Some have speculated that this is because Omicron is less deadly than other variants, and this theory is still going around:
In fact, there might be some lab evidence to support this. Some scientists theorize that Omicron shares genes with the common cold, which they think could make it both more transmissible and less deadly.
On the more pessimistic end of the spectrum, Omicron cases in Gauteng might be milder because they’re skewing much younger so far:
This is pessimistic because it could mean that A) Omicron is so infectious that it’s much more able to infect young people than previous variants, and B) when Omicron finally spreads from the young to the old, severity could increase and death rates could soar again.
But experts seem to be converging on a third explanation for Gauteng’s low death rate: Most people in Gauteng simply had some pre-existing immunity, either from vaccination or from prior infection, and that this is making their illnesses more mild. This is supported by early evidence in the U.S., where people who’ve caught Omicron so far have mild cases and were fully vaccinated. There are good scientific reasons for this — even if the virus can evolve to evade antibodies, it’s harder for variants to escape the additional immunity conferred by T-cells:
T-cell immunity is basically a second line of defense that won’t stop you from getting infected, but will stop you from dying or getting a severe case of the disease. Here is a great explainer thread from the Bertoletti Lab, explaining why T-cell immunity is harder for variants to evade:
All of which suggests that Omicron is not entirely resistant to existing immunity; vaccination might not stop you from catching Omicron, but it’ll probably reduce your risk of dying by quite a lot.
So go get that booster shot if you haven’t already. There’s very strong evidence that boosters are highly effective, including against earlier variants that showed some immune escape ability.
I have two thoughts this week. The first is about the end of the Covid pandemic. Mass vaccination back in early 2021 gave us the hope that the end of this global nightmare was finally in sight, and people are certainly tired of things like masking, social distancing, and (especially) school closures. Delta, with its increased infectiousness, pushed the date of the end of the pandemic further out. But Omicron, with its immune escape properties, is raising the question of whether this will ever be over in any meaningful sense. Even if we make variant boosters against each new variant that comes out, that would still be an eternal battle if the virus keeps evolving to escape each booster. Are we going to have to spend the rest of our lives wearing masks and sending our kids to school over Zoom?
No. First of all, if we keep weathering new variants, eventually we’ll just have so many different kinds of antibodies and T-cells built up that new escape variants will be less and less deadly, and Covid will become like the flu — a yearly danger, but not something that alters the face of our society. This will happen even faster if Covid actually does evolve to become less deadly, as some predict. The four endemic coronaviruses that cause common colds probably are each the remnant of a long-ago Covid-type pandemic; in a few decades we may simply have five.
But a few decades is a long long time — the remainder of many of our lives. In the meantime, we can speed Covid on its way out the door by developing pan-sarbecovirus vaccines. Eric Topol, whom I interviewed the other day, has been one of the leading proponents of this approach, and it’s a good one. We just need to fund and coordinate it. The Biden administration should be pursuing a pan-sarbecovirus vaccine with as much vigor and determination as the Trump administration pursued Operation Warp Speed to develop the initial vaccine. The failure to do this so far is a failure of leadership, and more people need to be making noise about this. We need that supervaccine, and we need it ASAP.
In the meantime, since new therapeutic drugs are still not being manufactured in sufficient quantities, our best tool against the virus remains vaccine boosters. And here it’s becoming ever clearer that U.S. public health authorities have dropped the ball, and badly. A big reason that America lagged the rest of the developed world in booster shots was that our public health authorities, including the CDC, failed to encourage third doses.
Even as Israel quashed the Delta wave with a swift and effective booster campaign, some American public health officials were actively downplaying boosters in order to appear more concerned about ensuring vaccine supplies for the developed world. Paul Romer, an economist who has followed this issue closely and argued vigorously for a big expansion in vaccine manufacturing, minces few words here:
A general recognition of this failure is starting to sink in.
In other words, this looks to have been an elite virtue signaling campaign that ended up costing a significant number of lives. And with Omicron on the way, it’s now clear that our national failure on boosters is going to cost more lives than the complacent public health people predicted. Public health people are now starting to question the anti-booster approach, but this is too late for many, and of course no one will be held accountable. And a few extremely irresponsible voices in public health are still sending out an anti-booster message, even in the face of Omicron!
This failure should cause us as a nation to rethink a couple of things. First, it should serve as yet one more reminder — as if we needed another! — that our CDC and FDA are deeply damaged institutions that need to be thoroughly rebuilt. But also, the symbolic and ideological nature of the anti-booster campaign should illustrate how our nation’s political unrest has compromised our effectiveness in preserving the safety of our people. The right-wing antivax movement — a politically motivated campaign of symbolic defiance — has caused the tragic deaths of hundreds of thousands. But the anti-booster movement shows that progressive politics is not blameless here either. We need to focus on going back to being a nation that puts pragmatism and safety before symbolism and signaling, as we were back in the days when we vaccinated everyone against polio.
One of the things you didn't hit upon is how wrong we apparently got vaccine spacing. There was an interesting thread yesterday by your boy Topol talking about this.
It's possible that the reason the booster is so important is not because it's a 3rd dose, but because its spaced out from the first dose.
There is such a dichotomy between the awesomeness of our private companies and their ability to leverage science and technology to provide such awesome tools to fight this virus and our government agencies complete inability to adapt to novel situations. Imagine if the CDC and the FDA (more importantly) were able to shed the bureaucratic nonsense the keeps us from using data from foreign countries to make decisions, or to approve challenge trials.
On a political note: I wonder how much patience the public has for a new round of precautions. Seems pretty clear to me that we are about to have a 4th??? wave over the next two months.
Even if hospitalizations are high because of the sheer number of cases, if the severity and individual risk of hospitalization/death is low, you are going to see the public become even more apathetic.
Politically, another wave is going to hurt Democrats if it is accompanied with more school disruptions.
Finally: why are you always up so late dude. Damn. I wake up here in Argentina, and you are still going strong on Twitter.
Paul Offit and the crew on the TWiV podcast aren't convinced about boosters. Quite the battle going on in the public health and virology space. Just about as a bad as the mask and test battles early on. Unfortunate.