Susan Levenstein, MD, on the Omicron Variant

To encourage wider dissemination, we're happy to offer right here an author-abridged and -authorized model of a current variety of the Stethoscope on Rome weblog by Susan Levenstein, MD. A very long time resident of and training internist in Rome, she has been interviewed in lots of international locations each within the US and in Europe. She right here dissects the newest information, as of 4 days in the past, on the Covid-19 omicron variant.

Dr. Levenstein, skilled within the US and an avid pupil of its medical system, is a reader of HCR.  Her personal blog superbly enhances and extends what we do right here. Readers would do nicely to subscribe to each, in addition to to contemplate dipping into her just lately revealed, and most illuminating ,autobiography, Dottoressa. This account of a life and profession spanning two cultures is a masterful overview not simply of a serious element of European drugs — one of many EU's most profitable programs — however of the comparative facets of nationwide well being programs throughout two continents.

[Jump to succinct run-down on holiday tips — what to do and not to do: skip to the end.]

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An Replace and Some Recommendation on Protected Celebration from Dr. Levenstein

Vaccines

Proof that the Omicron variant escapes vaccine safety is mounting. Take the 7 younger, wholesome German guests to South Africa who all fell ailing with Omicron regardless of being triple vaccinated, excellent demonstration that neutralizing antibodies from boosters don't essentially translate into real-life safety. 

Our greatest knowledge come from a UK study. Vaccine effectiveness in opposition to symptomatic Omicron, 15 or extra weeks after dose 2, was nil for AstraZeneca, 35% for Pfizer. A Pfizer booster raised it to 71% following AstraZeneca, to 76% following Pfizer. Two-dose Pfizer was significantly simpler in opposition to Omicron within the quick run, 88% at 2-9 weeks after dose two. Since larger doses of medicines typically last longer, merely hiking up Pfizer’s 30 mg to Moderna’s 100 mg and even Moderna’s 50 mg booster may make that prime effectiveness longer-lasting. That’s purely my very own, presumably loopy, thought. 

One other study, from a South African insurance coverage firm, discovered double vaccination with Pfizer 70% protective in opposition to Omicron hospitalization, however simply 60% at ages 70-79. Towards any COVID-19, effectiveness was solely 33%. Too few South Africans have obtained boosters for this research to gauge their impact.

Are new vaccines or new variations of outdated vaccines vital? As of December fifteenth Anthony Fauci was nonetheless saying no, as a result of “Our booster vaccine regimens work against Omicron.” I say sure: even 76% safety just isn't adequate. 

Transmissibility

Omicron is certainly a superspreader. In South Africa essentially the most helpful measure (Rt) for COVID-19 copy rose from 0.8 late within the Delta wave to nicely over 2 now. However most South Africans have some immunity from prior publicity (seropositivity charge 60-70%), so the speed of unfold could possibly be even sooner elsewhere. Certainly, confirmed Omicron instances double within the UK each 3 days, for an estimated Rt  of three.7, which means each case infects about 4 others. If something, it’s worse within the US: 0.7% of infections 2 weeks in the past, 12.6% one week in the past, 73% now.

A laboratory study from Hong Kong provides early hints of why Omicron behaves because it does. Researchers uncovered surgical specimens of bronchial and lung tissue to the Wuhan, Delta, and Omicron strains, then watched for 48 hours. Omicron multiplied sooner than the others in bronchial cells however extra slowly within the lung, maybe explaining each sky-high transmissibility and low virulence. 

Severity

In Denmark the brand new variant is quickly taking over. However as of December twelfth they’d had solely 27 hospitalizations out of 2471 instances, in contrast with a Delta-wave hospitalization charge of around 10%. Danish scientists are involved nonetheless: 

• The brand new variant has unfold so far largely in younger individuals, who hardly ever get very sick
• COVID-19 sufferers typically deteriorate every week or extra after symptom onset, so it’s early to guage 
• Denmark is essentially the most extremely vaccinated nation in Europe, however most have had solely two doses of vaccine, and boosting all people can be a logistical nightmare
• The variant spreads like wildfire, so even with much less extreme illness, the hospitals could possibly be overwhelmed 

At the moment that wildfire is burning its method by means of the US, the place solely 72% of adults have had even two doses of vaccine (versus 96% in Denmark) and the place 15% of all adults – together with 5% of these over 65 – have nonetheless not had a single shot.

The South African insurer’s study discovered a 29% lower hospitalization charge than in early 2020. And a authorities presentation (screenshots above) stories strikingly decrease mortality and ICU admission charges amongst hospitalized sufferers than in earlier waves. Perhaps medical doctors are hospitalizing people who find themselves much less sick, however that appears unbelievable. Extra related is that South Africans’ widespread earlier publicity to SARS-CoV-2 and their relative youth (median age 28, versus 39 within the US) predict milder illness regardless of the viral pressure. 

But extra hints: 4 of these 7 young Germans in South Africa had solely cold-like signs, however 3 turned wanting breath regardless of their age, triple-vaccination, and regular oxygen saturations. And 85 Omicron-related hospitalizations, largely in double-vaccinated people, have been reported within the UK, with 7 deaths.

Predicting the longer term

A current Bloomberg headline — “England might face 75,000 deaths this winter” — is terrifying. However when you have a look at the associated study itself you see much less dire outcomes. The researchers constructed fashions based mostly on completely different ranges of vaccine efficacy and immune escape, with the 75,000-death determine assuming excessive immune escape and boosted vaccine efficacy of fifty%-60%. However with our best estimate of boosted effectiveness over 70%, the variety of hospitalizations and deaths can be decrease. Much more crucially, the fashions assume that Omicron is simply as virulent as Delta. Since appreciable proof signifies the opposite, these dire predictions ought to be additional adjusted downward. The authors cautiously name their report not a preprint however a piece in progress, to be up to date as extra knowledge change into accessible. 

Nevertheless… Tedros Adhanom Ghebreyesus, the non-alarmist Director-Normal of the WHO, emphasizes, as I do, that even when Omicron does trigger milder illness it's so contagious that it might nonetheless overwhelm well being care programs if enormous numbers of individuals get sick directly. A large surge of even delicate instances might wreak havoc on economies, healthcare programs, and other people’s lives, with swab-positives and their contacts staying house in isolation or quarantine. A large pandemic of lengthy COVID would seemingly ensue, since it could possibly comply with mild disease – presumably (questionably) even asymptomatic infection. In the long term Omicron ought to be the variant from heaven, infecting extra individuals than Delta whereas inflicting fewer deaths, nevertheless it might certain be hell within the subsequent few months.  

What to do? It appears apparent that we have to vaccinate the unvaccinated like loopy, increase the vaccinated like loopy, work like loopy on Omicron-specific vaccines, and intensify masking, air flow, and distancing. I personally assist much more drastic measures: institute Inexperienced Passes in all places (coming quickly within the UK), shut down eating places and different public-facing companies for a number of weeks (taking place already within the Netherlands), promote working from house, quarantine individuals coming into international locations, or US states, from high-risk areas, and think about transient lockdowns. Time will inform.

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Some tricks to make your self safer.

• preserve the visitor checklist down, so seats will be spaced out on the desk
• be certain everyone seems to be vaccinated (with boosters in the event that they’re 5 months out)
• all people ought to do speedy exams that morning
• anybody with the slightest symptom ought to keep house
• celebration open air if climate permits
• all people wash their palms once they are available
• depart a window a minimum of partly open
• think about carrying masks when not truly consuming or ingesting
• think about investing in a conveyable HEPA air air purifier: examples within the US and Italy
• hugs and kisses: attempt to withstand the temptation
• separate unvaccinated youngsters from older adults
• no Christmas carols! (singing is the easiest way to unfold droplets)
• be additional cautious if anybody is over 65, chronically ailing, immunosuppressed, or pregnant 
• be additional cautious if there’s excessive group transmission
• coming in by prepare, bus, or airplane? Put on KN-95 masks when travelling, seize bites rapidly, open a window when you can…
• and, ideally, self-isolate for 3-5 days earlier than the occasion