Omicron looks pretty scary

Omicron looks pretty scary

What we know and what we can do about it

The United States is at what appears to be the beginning of a significant winter Covid-19 wave, with cases and hospitalizations both clearly on the rise over the past couple of weeks. Significantly, we see cases rising not only in the Northeast and Midwest where the weather is getting truly wintry but also in the South where conservative political leaders spent much of the fall taking victory laps after the region’s massive Delta wave burned out.

Part of the context for this is seasonality, part is the holiday travel and gatherings that inevitably spread pathogens, and of course, part is the new Omicron variant, which based on what we can see in South Africa appears to have considerable ability to re-infect people with acquired immunity from previous infections. We also know that vaccinated people experience waning unless they get a booster shot, and a large share of the American public remains unvaccinated.

All told, I think this adds up to a pretty scary picture.

Deaths fell this fall after the peak of the southern Delta wave, but they never fell all the way back down to their pre-Delta level. They are now rising again from their current level of two 9/11s per week.

For a whole bunch of reasons (primarily because people can and should get vaccinated), I am not a proponent of trying to return to mandatory social distancing measures. But that doesn’t mean we should minimize the scale of suffering or loss of life. A lot of people have been dying through the low ebb. More people than that died during the Delta peak. And it seems likely to me that even more people will be dying this January and February when Omicron wreaks havoc on an under-vaccinated country. The Biden administration is over-indexing on signaling Covid-19 caution with things like having the vice president wear a mask during an outdoor photo op. But that doesn’t mean there’s nothing we can or should be doing to save lives.

As a person with a platform, the best thing I can say is that you should get vaccinated and boosted, you should get your kids vaccinated, and you should encourage others in your lives to do the same.

Vaccines offer meaningful protection at such low cost that it’s clearly worth it even for people in low-risk categories. Something we all knew and took for granted before Covid-19 is that getting sick sucks and is worth trying to avoid, even if you’re not worried about hospitalization and death. And there are externalities in play, so the sensible thing is to lean in the direction of protecting yourself and thereby protecting the community.

A policy no-brainer — repeal travel bans

The other no-brainer is that the Biden administration should admit the horse is out of the barn and remove the Omicron-related travel restrictions it imposed on South Africa and its neighbors when the variant was first discovered.

I think we learned over the course of the pandemic that the expert consensus against travel restrictions was misguided. But the handling of Omicron has confirmed exactly the ideas that gave rise to that consensus in the first place:

South Africa is worse off than it would have been if it did not have good genomic surveillance in place and didn’t warn the world about Omicron.

The travel restrictions imposed were on South Africans (and citizens of other nations in southern Africa) rather than travelers from South Africa as if viruses care about citizenship and pandemic prevention can be treated as an immigration policy.

Containment of Omicron has already failed and the new variant is clearly spreading inside the United States. Even if it wasn’t, it’s clearly spreading in a bunch of European countries that aren’t under travel restriction.

That’s the risk with travel restrictions — you create perverse incentives for countries to cover up public health problems while doing nothing to safeguard your population.

The administration wasn’t necessarily wrong to give this a shot, but it didn’t work. They ought to reverse course and try to do something nice for South Africa to thank them for their excellent surveillance work. Fauci says the administration is reviewing this, but honestly, what’s to review at this point? Omicron is clearly spreading globally.

(Wu Xiaoling/Xinhua via Getty Images)

The good Covid-19 intervention: vaccine mandates

I’ve gone back and forth inside my own head in terms of how enthusiastic I am about vaccine mandates.

But here’s what I am sure of — to the extent that you want to deploy coercive public health measures to combat Covid-19, the thing you should be doing is mandating vaccination. Vaccination is a much more effective intervention than mask-wearing or half-assed quarantines. And even though not everyone believes that vaccines are safe, objectively, they are in fact safe.

Here are some things that I believe, and that most Democratic Party elected officials say they believe:

The Pfizer and Moderna vaccines are safe.

The Pfizer and Moderna vaccines are effective.

There is some collective obligation to reduce the burden of Covid-19 on our community.

If you believe all of those things, then mandating the vaccines makes a lot of sense. The really nutty voices on the right are spending time denying (1) and (2). The moderates are holding the line at (3), and I think that’s a somewhat reasonable debate to have — most people are pretty selfish, and conservative politics appeals to people’s sense of selfishness. Personally, though, I don’t think an ethic of selfishness is admirable or appealing.

But I really do not think it’s reasonable to require masks on planes but not vaccination. Or to have very strict quarantine rules in schools but not require vaccination. If you want to go Republican and just say it’s everyone for themselves, that’s bad, but it’s at least logical. If you want to take collective action, it should focus on vaccination.

The Biden administration tried to do the right thing here and ran into two problems. One is that the politics simply haven’t worked out as well for them as they hoped. The other is that Trump appointees in the courts may toss the whole thing out. I don’t have any solutions to offer for the problem of the judiciary. Politically, though, I think the White House erred by not pairing its mandate efforts with a promise to lift other restrictions. How do you get an already-vaccinated person enthusiastic about the prospect of coercing other people to vaccinate? With the promise that this means more freedom for the already-vaccinated in the form of reduced restrictions in other areas.

Unfortunately, though, the politics of this have gotten even dicier because the vaccines are markedly less effective against Omicron.

Omicron has weakened our vaccines

Hannah Kuchler, Donato Paolo Mancini, and Oliver Barnes at the Financial Times did a write-up of data from the UK Health Security Agency that I think really clarifies the vaccine situation.

I’m going to steal their chart because it’s good. The key points are that vaccination works against both Delta and Omicron, but it works significantly less well against Omicron. Boosters work against both variants, but again less well against Omicron. A boosted person has similar protection against Omicron as a non-boosted person has against Delta.

So I’m boosted, you should boost, we all should boost. At the same time, this is telling us we should expect a lot of symptomatic infections even among boosted people.

Pfizer, optimistically, is telling us that its vaccine still offers a 70% reduction in the risk of severe (i.e., you end up in the hospital) Covid-19. And unless something really weird is happening, that should also mean at least a 70% reduction in the risk of death. But while 70% is pretty good, South African health journalist Mia Malan notes it is far less than the 93% protection provided against Delta. Most people naturally tend toward absolutism, so they’ll hear about a large reduction in relative risk and figure “okay, I’m safe.” Then they’ll hear anecdotes about severe breakthroughs and ask, “is it all a lie and nothing works?”

We live in a big country (and a bigger world), so even though a 70% reduction in severe disease is significant, we’re still going to see a lot of vaccinated people end up in the hospital — including some relatively young people with no clear comorbidities.

It’s important not to freak out too much, but it’s also important not to overpromise, and I have read a bit too much hopium about the alleged mildness of Omicron cases.

Omicron is generating lots of mild breakthrough infections

Relying again on the FT’s excellent team, Omicron is generating a gigantic spike of cases in South Africa. The good news, as many have noted, is that these cases are on average milder than the cases South Africa experienced during the Delta wave. But how good is this news really? A very large share of the Omicron cases is in people who already recovered from Covid-19 in a way that should complicate the mildness narrative.

Natalie Dean did a good thread making this point, complete with a graphic that I thought was a little complicated, so we made a different graphic that errs in the direction of oversimplification.

Consider three possible outcomes from an encounter with an infected person — you get a serious illness, you get a mild illness, or because you’re immune, you don’t get sick at all. Now consider two different variants, A and B, with B causing both more serious cases and more mild cases because fewer people are immune. Deploying the magic of arbitrary fake numbers, we see that the ratio of mild to severe cases is much higher with Variant B even though Variant B is much more dangerous.

In other words, the relative mildness of the cases is good news in the sense that it shows Omicron’s immune evasion is partial rather than total. But it’s wrong to infer good news for the rather large number of Americans who have no immunity at all or for vaccinated-but-not-boosted seniors with waning immunity. Meanwhile, South Africa has a much younger age structure than the United States, so despite low vaccination rates, there are low underlying levels of vulnerability there compared to the U.S. It’s difficult to tell for sure because the quality of our vaccination data is so bad, but my guess is that “unvaccinated elderly people” is a larger share of the U.S. population than of the South African population just because elderly people comprise a much larger share of our population.

Antivirals won’t save us

The best news on the horizon is that unless Pfizer is lying through their teeth, their forthcoming anti-viral Pavloxid is highly effective at keeping Covid-19 patients out of the hospital, and that holds true for Omicron. It is a little frustrating to me that we don’t see a clearer plan from the FDA to step on the gas in terms of getting this pill out there.

But even with speedy approval, we have some big problems:

Pavloxid needs to be given early after a Covid-19 diagnosis in order to prevent severe outcomes; it’s not a treatment to help people with severe Covid-19 recover.

That means that to use it effectively, we need to test people quickly and then get them medicine quickly.

That both raises lots of longstanding questions about America’s testing capacity and means that faced with a huge Omicron wave, we’re going to need a ton of Pavloxid.

Pfizer says they can deliver 180,000 courses by the end of 2021 and 10 million courses for the United States over the course of 2022. We’re currently looking at 120,000 new cases per day and rising, so this is not even close to enough doses to actually provide treatment for everyone who could need it. The global portrait is even bleaker, because that 10 million course is one-eighth of Pfizer’s global capacity for a country that only contains 4% of the world population.

I do not have any great ideas for how to scale up production more rapidly. But I would sure love to see world leaders doing everything in their power to investigate what the answer is. We’ve spent trillions on pandemic relief, and if we can get more treatments to more people by spending billions, we should.

Variant-specific vaccines

Everybody wants to reassure people that the existing vaccines are still useful against Omicron and that everyone who can take them, should take them. That said, they are clearly less effective than they were against Delta. And they were less effective against Delta than they were against the original strain.

With the flu, we have an established process for creating variant-specific shots for each new flu season and approving them very rapidly. We could set up a process like that for variant-specific boosters, but so far we have not. And that, in turn, has made it unclear to pharmaceutical companies whether developing variant-specific boosters is likely to be lucrative. There’s a good case to be made that we should not be so heavily reliant on the profit motive when it comes to pharmaceutical development. But the fact is that we are dependent. Right now, Pfizer and Moderna are selling every dose of mRNA they can make, so it’s not obvious that there is a super-strong business case for developing new vaccines. If we want to see that happen, we need to put money into it and we need regulatory clarity.

I’m just going to quote an email that Harvard’s Michael Mina sent to Holden Karnofsky, because it’s very smart and also because maybe people will trust a Harvard epidemiologist rather than a “contrarian” on Substack.

Enjoy:

We should do the least necessary checks of the new variant vaccines. Put them into 20 people and make sure they elicit the desired immune responses. Do NOT do any sort of efficacy study and these vaccines should be fast tracked like flu shots.

Unfortunately FDA has essentially no ability to balance the cost of slowness and the cost of inaction with the benefit of action. The FDA viewpoint is that inaction and whatever cost comes from that is not on them. They are used to a system where it’s better to do nothing than act with any uncertainty. But that’s Bc the FDA is not designed for emergencies. It just isn’t. It is horribly inefficient and unable to effectively make calculations around public health vs medicine.

To this day we still do not have a regulatory framework for products that have as a base use one of public health. Vaccines elicit ideas of public health but ultimately are evaluated and regulated as medicine. As far as safety this is important. But as far as efficacy and the regulatory approaches and data required, it’s entirely around individual benefit. Which at this point I hope everyone recognizes that’s the wrong angle in a pandemic.

For example, we knew that a single dose vaccine would yield 90% or more protection from severe disease for at least a few months, yet we withheld first doses in order to give people second doses and importantly we have those second doses in a suboptimal manner just Bc that’s the hard data we had. But the soft data (the data from decades of immunology research across the world) allowed us to know that spacing the vaccines months apart would have been better both for individuals and for public health. We didn’t do that.

At this point, we can’t get optimized vaccines off the ground in time to head off an Omicron wave. But we will still be vaccinating (and boosting) people next summer, by which time Omicron will still be kicking around everywhere, so it still helps. More to the point, we’re in a world where different variants are going to be popping up for a while, so we need to be ready to optimize.

The long road to endemicity

Covid doves are correct when they say this virus is going to be with us forever in an endemic state, and we really do need to shift to sustainable policies and not keep doing things like locking down Cornell’s campus or denying younger children an education.

But I disagree with their blasé attitude toward the prospect of several more years of greatly elevated death rates and the ongoing unraveling of our healthcare workforce. At some point in the future, everyone will either have such sufficiently robust immunity to SARS-Cov-2 that it only makes them mildly sick, or else they’ll be a little kid who almost never develops a severe case. That’s how a novel pandemic becomes a common cold. But this process would take years and years and potentially several rounds of breakthrough reinfection.

It matters a lot how many people die between now and whenever that is, and policies to bring that number down — by scaling up production of anti-virals and vaccines and by optimizing our vaccines to work better — are really, really important.