Omicron Is Forcing Us to Rethink Mild COVID
When Delta swept across the United States last year, the extremely transmissible and deadlier variant threw us into pandemic limbo. The virus remained a danger mostly to unvaccinated people, but they largely wanted to move on. Vaccinated people also largely wanted to move on. The virus did not want to move on. So we got stuck in a deadly rut, and more Americans died of COVID-19 in 2021 than in 2020. Now Omicron is sweeping across state after state—even highly vaccinated ones—and new cases are shooting up and up. The virus is still deadliest to the unvaccinated, but the sheer number of mostly mild infections in the vaccinated is shocking us out of that post-Delta stasis. To deal with this extremely transmissible but now milder variant, we are in the middle of a COVID reset.
Already, the CDC has shortened the isolation period for vaccinated people. Breakthrough infections are becoming routine. And Anthony Fauci is pointing to hospitalizations, rather than cases, as a measure of Omicron’s true impact because many infections are now mild breakthroughs.
By infecting so many people so quickly, Omicron is also speeding us toward an endemic future where everyone left has some immunity, so the coronavirus is eventually less deadly. But in the short term, Omicron as an accelerant is dangerous. The fastest path to endemicity is not the best path. The U.S. still has too many unvaccinated and undervaccinated people, and cases that might have been spread out over months are now being compressed into weeks. Even if a smaller percentage of patients ends up in the hospital than before, that small percentage multiplied by a simply huge number of cases will overwhelm hospitals that are already stretched too thin. The coming weeks will be a bad time to have COVID, or appendicitis, or a broken leg.
Compressing all those mild cases into weeks has its own toll: Too many health-care workers are falling sick at the same time, exacerbating hospitals’ ongoing staffing shortages. Schools, airlines, subways, and businesses are finding their workers out sick with Omicron too. There may be no preemptive shutdowns, but there will be unpredictable cancellations. “It’s going to be a messy few weeks. I don’t think there’s any way around it,” says Joseph Allen, a professor of public health at Harvard.
The fact that we’ll eventually end up with endemic COVID has not changed. And the fact that people cannot expect to avoid the virus forever in an endemic scenario has not changed. Omicron is now forcing us to look squarely at the reality that people can get and spread COVID even when vaccinated. The problem is, we’re doing it in crisis mode.
With so many people getting COVID, our mindset toward the virus is changing. Breakthrough infections are the new normal. For a while, in certain highly vaccinated bubbles at least, people who got breakthrough infections racked their brains about what they did “wrong.” But now—excuse the hyperbole—everyone has COVID. And if you don’t, you probably know someone who does. Even the most careful people are getting sick. “I think the silver lining, to the extent there is any silver lining, is that the shame [of getting COVID] is quickly melting away. And thank goodness,” Lindsey Leininger, a public-health-policy expert at Dartmouth College, told me. Breakthrough infections will be the norm when COVID eventually becomes endemic too.
Vaccinated people also see, correctly, that their individual risk of a bad COVID case is much, much lower than it was in March 2020. (Omicron also appears to inherently be a little less virulent than Delta, but because Delta was more virulent than the original coronavirus, Omicron is in the same ballpark as the original.) The transition to endemicity was always going to be in part a psychological one, in which people slowly let go of the idea that COVID must or can be avoided forever. Omicron has simply made that clear very quickly.
Even if COVID can’t be avoided forever, there are good reasons to try to avoid getting or passing it on over the next several weeks. Better treatments for Omicron are on the horizon, Syra Madad, an infectious-disease epidemiologist at Harvard, told me. Pfizer’s very effective pill has just been authorized by the FDA, but supplies are short. Only one monoclonal antibody, sotrovimab, currently works against Omicron, and supplies are also short. “It’s a terrible time to unfortunately be hospitalized and not have these types of therapies available,” Madad said. In a few months, the outlook will get better for individual people at serious risk from COVID.
For society at large, too, a huge number of cases right now is a risk to our hospitals and our essential services. Consider everything that someone who is vulnerable to COVID needs, Leininger said. “We need water in her faucet, and we need food in her fridge. And we need the visiting nurse to be able to fly in because our hospitals are under siege,” she told me. That means water plants and grocery stores and airlines need employees to stay healthy and continue working.
This is where things get messier. Our Omicron strategy is also constrained, at this point, by the willingness of a wearier public. With so much virus out there, we are once again needing to flatten the curve. But back in March 2020, we understood social distancing to “flatten the curve” as a temporary measure to get us through the next weeks or months. “Well, now it’s been two years. Do we have to do this for five years? It’s just not sustainable,” says Julie Downs, who studies risk perception at Carnegie Mellon University. If the most drastic COVID restrictions—stay-at-home orders and preemptive closures—are off the table, then we cannot avoid a staggering number of Omicron cases.
The CDC cutting isolation periods from 10 to five days for sick people is an attempt to balance these realities. The agency managed to roll out the new recommendations in the most confusing way possible—by first not requiring a test for people with no symptoms and downplaying the utility of tests before adding an optional test. But the CDC is fundamentally dealing with a hard set of trade-offs: We don’t have enough rapid tests for every sick person right now, and isolating people for too long or too short of a time both have consequences. Keep teachers and students in isolation for too long and schools can’t stay open; make them go back too soon, they spread the virus, and schools also can’t stay open.
Omicron is forcing us to reconsider how we deal with mild cases of COVID, which will never completely go away. It is doing so, unfortunately, in a chaotic and dangerous moment. For the next variant and for next winter, we need to plan in advance. The challenges ahead are already clear. Hospitals, which are stressed even in bad flu seasons, will have to deal with combined COVID and flu every winter. The coronavirus will also keep evolving, and new variants that keep eroding our immunity will emerge. In a series of three papers last week, a group of former Biden advisers laid out a long-term strategy to monitor all respiratory infections—including COVID, flu, and respiratory syncytial virus—and keep their collective burden below that of a bad flu season through more robust testing, surveillance, mitigation, and vaccine and therapy development. We’ve spent the past year lurching in reaction to new variants, but what the U.S. needs now is a big-picture goal for COVID, even if the coronavirus surprises us again.