Omicron: New Variant, New Realities
The omicron COVID variant has swept across the world, driving up case numbers and moving some policy makers to shift back to more restrictive approaches to the nearly two-year-old pandemic. In an effort to address some of the questions raised by the new variant, Hamodia spoke with Dr. Naor Bar-Zeev, Deputy Director at the International Vaccine Access Center, pediatric infectious diseases physician and associate professor of vaccine sciences at Johns Hopkins Global Disease Epidemiology and Control program.
Omicron has been in the public eye for over a month which has given experts more time to observe it. What are your general impressions about the new strain so far?
We have seen that it is highly transmittable and that it evades the immune system’s memory to a greater extent than prior variants. However, there is emerging evidence that it is causing more mild disease.
That is mostly very good news, but it does have to be placed in context. Since it is highly transmissible, there will be a very large number of cases, and even if only a small proportion are severe, that can still be a large number of people. So, even if most people have mild infections, if not properly planned for, an omicron wave could still overwhelm hospital systems.
At the same time, we are in a very different position than two years ago, since a majority of the world has some level of immunity either from past infection, vaccination, or both. So, the idea that omicron will be a terrible wave is not entirely correct and the fear seems to be out of proportion with what is likely to occur. There will be lots more infection, and a rise also in severe cases, but we hope not the levels of hospitalization and deaths seen in early waves.
We hope that while omicron may cause mild illness even to people recovered or vaccinated, it will provide immune boosting at a global scale. But we have to be prepared and not be too dismissive of it.
Based on what we know, how effective are present vaccines against omicron?
There are a few variables to look at and the answer is not the same for each person. A lot has to do with age and health and how long ago they got the vaccine or recovered. Protection against symptomatic disease from omicron of two doses of vaccine is not great and is all but gone by about three months. A third dose provides protection against omicron approaching 60% to 75% depending on the study and there is quite a lot of uncertainty still. Against delta, third-dose effectiveness is about 90%. But two-dose protection against severe disease is retained for delta and is likely also retained for omicron, though definitive data are still pending. These numbers are not so meaningful, because it really depends on one’s underlying risks. People who had COVID-19 and recovered and then received vaccination seem to have the greatest protection.
How essential do you think boosters are; and for whom? Does the emergence of omicron alter this?
The key issue is, what is my risk of severe disease? If I’m healthy and younger and two-dose vaccinated, or recently recovered, or recovered some time ago but got a vaccine dose, my risk of severe omicron disease is low. A booster will improve my protection but the absolute reduction in risk is modest, since it was low to begin with. Since the risk of vaccine adverse events is low, I can choose to gain the benefit of a booster, but if I don’t, my risk is still low, and if I do get omicron, that will certainly boost my immunity.
Older people or those at higher risk should get boosted even if they had two doses or even if they recovered from COVID-19 before, since boosting will increase their protection. From a public health perspective we should focus on ensuring everyone at risk is protected.
I want to be clear that there is no danger in taking boosters, but for younger healthy people at this point, the benefit will be modest. However, people at high risk should certainly get boosted at the earliest opportunity.
That line of thinking, which sounds logical from the layman’s perspective, is not the line the public is hearing from the medical establishment. Why is that so?
The “medical establishment” is a community engaging in open debates about emerging new data. It’s not one monolithic thing. For example, the WHO Strategic Advisory Group of Experts (SAGE) on Immunization, which is a group made up of the world’s top vaccine experts, came out with an opinion piece in The Lancet which argues very much along these lines. Their argument is that it would be most beneficial to focus on risk of severe disease and getting more people globally at least single-dose vaccinated. All along, the WHO has not been advocating strongly for boosters in already well vaccinated populations.
The push by some Ministries of Health to advise boosters for everyone, even low-risk people, aims to reduce transmission. It’s based on modeling data from the Wuhan strain, which was far less contagious. It is unclear whether widespread boosting will reduce community spread of omicron. Masks and distancing can help, but as we know, lockdowns come at major costs to physical and mental health, well-being, education and economic thriving; and for some, economic survival. A reflex return to all this just because the vaccine may not work as well as before would be unwise. Like with a medicine, you treat the patient, not the disease. Same thing in public health, work for the people, not the virus.
My worry is that, at a moment when people are already lacking trust, if you push them and mandate things that are not really based on good evidence, they’ll reject vaccination in instances where it’s really important. COVID-19 vaccines are phenomenal, a real brachah in the form of good science. But I fear that by pushing people to vaccinate children who are not really at risk, people will start to question not only COVID vaccines, but measles and polio and other vaccines they never had any question about. That would be a terrible result.
It’s an important time for the medical establishment to be humble, put the pros and cons on the table without whitewashing, and give people the freedom to make wise choices. Trust the people and they will trust you too.
Do you feel that policy makers in states and cities that are taking more stringent approaches to this wave are misguided as well?
It’s a good idea to prepare health systems since the volume of infection from omicron will drive more hospitalizations and it’s wise to take some steps to mitigate transmission so those health systems do not get overrun. But it must be remembered that between 60 and 80% have some type of immunity so the idea that we could get a drastic wave like we saw after Purim 2020 or even last winter is not likely.
Of course we do want to reduce the number of people who could get hospitalized or die, R”l, and there is common sense in reducing large gatherings and guidance on masking. There are a lot of unknowns and reliance on recovery or vaccine immunity to protect us is less sure. But we can also acknowledge that we are in a very different place now than in 2020 and that normal life has to go on.
Border closures, for example, are unlikely to be successful because, by the time omicron was discovered in South Africa, it had already been circulating for six to eight weeks and had already spread around the world.
When public guidance changes, there is sometimes public criticism. But it’s important for public health officials to acknowledge changing realities, and to explain how those changes impact on policy. Treat people as intelligent and aware. If our arguments and justifications are solid, people will largely accept them. If they are arbitrary, outdated, or needlessly stringent, people will reject them. When we are uncertain, we should say so. When we are worried, we should explicate why. Where there is reasonable choice or debate, it should be voiced and heard.
How effective do you think natural immunity from other variants should be against omicron?
A lot depends on when you had COVID-19. After three months, immunity against infection wanes, but it is likely that protection against severe disease is retained. Available data for omicron show that it is optimal for recovered persons to have at least one dose of vaccine. Omicron is mild and highly transmissible and exposure to it boosts protection against more severe variants.
With more time to see vaccine risk, has your estimation of risk changed since vaccines were first released?
We’ve confirmed with great confidence how low the risks are. As more people get vaccinated, the rates of incidents of myocarditis or some of the other potential side effects have remained extremely rare, to the point where the benefits of vaccination still vastly outweigh the risks.
There is reporting on more cases among children. To what extent is this just more positivity or does it seem that there are more serious pediatric COVID cases than in the past?
There has been a relative increase, but it’s important to remember that children are the residual part of the population that has the least immunity.
I do not think we have seen clear data indicating that omicron is causing more severe illness in children. We also have not seen reports of multi-system inflammatory syndrome, which was a concern, but this may yet take some time.
Something seen lately, certainly in Orthodox communities, are widespread flu cases. Is there an explanation as to why there seems to be so much more than in previous years? Does the pandemic play a role?
Multiple strains of influenza co-circulate and vary in dominance from year to year, and some are more severe than others. Over the last two years, due to the pandemic, there has been very little flu transmission as a result of the measures people took to slow the spread of COVID. But that means that our immunity against flu has waned a little bit since we didn’t get last year’s boosting from natural exposure.
It’s an extra push to get a flu shot this year. Influenza is usually not dangerous, but if you are in a high-risk group it is dangerous, and if you have never had it before, it can be very unpleasant even if you are young and healthy.
Any closing thoughts?
People should use their common sense. Omicron is mostly good news in that it is milder and will give us much more immunity, so there is no cause for panic. At the same time, it can still pose serious risks to people who are medically vulnerable, and they should get boosted. Those people should take more precautions and we should respect that and take more precautions around them. Your past recovery or vaccination likely cannot be relied on for transmission prevention, though it may help somewhat, but use masks with high-risk interactions, and be mindful of crowded events, etc.
Think of others, as we always should.
We’ve done a lot of hishtadlus against this virus and that was called for at the time. Now is a good time to approach it with more bitachon in the Ribbono shel Olam.
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