We’re all frustrated and discouraged. By now we all expected life would be back to some kind of “normalcy,” and instead here we are faced with soaring COVID-19 cases, due almost exclusively to the omicron variant.

Dr. Kenneth Krell

Dr. Kenneth Krell

And cases are indeed soaring, now having exceeded the number of cases from a year ago, the previous peak. Per the New York Times, nationally cases are up 185% in the last 14 days, with hospitalizations up 84%, though deaths are up less, 42%. In Idaho, cases are up 188% and in Bonneville County 327%. We don’t know the real numbers for Idaho, which reported 1,335 new cases on Jan. 11, since the state has 14,800 outstanding lab results, which don’t count rapid antigen tests done by individuals and not reported. Cases in Bonneville County now exceed those from a year ago at our previous peak of cases, but statewide hospitalizations are less than half the previous peak, and intensive care unit admissions are a smaller percentage of total hospitalized than previously. Hospitalizations, however, lag behind cases by a couple of weeks.

And while pediatric cases are soaring, with adverse implications for schools, and while the number of pediatric and adult admissions with COVID, rather than because of COVID has increased significantly, the number of pediatric deaths from COVID has increased only from one to two per hundred thousand (which still ought to be cause for concern).

And now Walensky at Centers for Disease Control and Prevention is suggesting that like South Africa the U.S. may see a “precipitous decline” in omicron cases, and yet Janet Woodcock at the Food and Drug Administration and Fauci testified this week that “most people are going to get COVID.” What’s going on here?

First, omicron is horribly infective, probably four times as infective as delta, and thus cases spread almost exponentially, but as seen in South Africa and other countries hit early, cases peak early, since such a large portion of the population is vulnerable at the same time. Omicron infectivity is COVID on steroids, with bronchial levels 70 times that of delta 24 hours after infection.

Secondly, it’s becoming clearer, as shown by the disconnect between total cases and hospitalizations that omicron behaves differently than previous variants, especially delta. Why?

Multiple animal studies from over a dozen labs across the globe with the omicron variant demonstrate that while omicron adheres avidly to upper airway epithelia, the amount of lung damage, weight loss and death was substantially lower in hamsters and mice infected with omicron compared to earlier variants, according to a report by a large consortium of Japanese and American scientists released in late December. “This was surprising because every other variant has robustly infected these hamsters,” stated Dr. Michael Diamond from Washington University, co-author of the study.

They found that the level of omicron in the noses of the hamsters was the same as animals infected with earlier variants, but levels in the lungs with omicron were only one-tenth or less than with earlier variants, and omicron grew more slowly in the lungs than did delta and other variants.

So, what does this mean we might expect in the near and mid-term future?

First, omicron can, and does, cause serious disease and death, particularly in those unvaccinated and the immunosuppressed, and the burden for post-COVID syndrome (long haulers) could be substantial and is yet unknown.

Our two-dose vaccinations are not as much protection as desired, but a booster dose provides significant additional protection. A recent report (in pre-print) from the FDA demonstrated that when using a neutralization assay, titers against omicron were low or undetectable after two immunizations, and in most convalescent sera from individuals with previous variant infection. But a booster vaccination significantly increased titers against omicron to levels comparable to those seen against earlier variants. Thus boosters protect against omicron, but not two-dose vaccination, a particularly sobering fact in that only 65.2% of Idahoans over age 65 and 40.7% over age 18 have received a booster dose. We don’t even have data for those under age 18. Boosters also elicit strong protection against omicron in patients with cancer.

Neutralization antibodies aren’t the whole story on immune protection, and the data on T cell response for omicron after two immunizations is varied, with some studies suggesting protection and others suggesting decreased killer T cell responsiveness to COVID, so those boosters take on new importance with omicron.

And, of course, the most vulnerable are those unvaccinated, and as with earlier variants most hospitalizations — the vast majority — occurring in unvaccinated individuals. Total cases with omicron are five times as high in the unvaccinated, and deaths are 13 times as high, verifying the protection of vaccines and boosters. So, both primary vaccination and boosters are critically important in stemming this tide.

Previous COVID infection with earlier variants offers little protection from omicron. A study from China demonstrated that due to mutations in the spike protein by omicron, neutralization of omicron decreased by 8.4 fold in convalescent sera of those previously infected, compared to 1.2 to 4.5 fold decrease for earlier variants.

Will omicron infection protect against subsequent infection with earlier or subsequent variants? We can hope so, but the data is early and preliminary. Encouragingly, data from South Africa found following omicron infection neutralization of the delta virus increased 4.4-fold. So, we can keep some hope and optimism that following this surge of omicron we may see some protection against delta, which is more deadly, and future variants, although we don’t know the real effectiveness of protection or how long protection might last.

In the meantime, the best we can do is the same advice as before — get vaccinated, get boosted, distance and wear a mask (and the KF94 and KN95’s are comfortable and offer excellent protection). Unfortunately, the shortage of quick antigen tests inhibits our ability to detect early cases, but isolation for five days if symptomatic and vigilance in masking after infection makes sense.

Most importantly, heed those precautions to protect our beleaguered health care workers. With the spike in hospitalizations and the number of health care workers out with COVID infections, hospitals, emergency rooms and clinics are severely stressed. Health care workers are tired and discouraged and need our help.

Krell is an intensivist at EIRMC.

Recommended for you