It seems almost certain that the new Omicron COVID variant will soon become dominant in the United States. And though it is not yet clear just how much severe illness that will cause, it is also not at all clear what tools we have left at this point in the pandemic to really slow transmission and lessen the impact of the coming wave. The country is about to enter a new phase of the pandemic, facing the possibility of an absolute tsunami of new cases, armed only with the same preventative measures — and the same reluctant population — that have inadequately suppressed previous, smaller waves. There is no secret set of major new interventions to roll out, and it’s not like the existing ones have been working fantastically well, either — more than a thousand Americans are still dying every day from Delta at an annualized rate of about 400,000.
And here comes Omicron. The variant is now spreading faster in the U.K. than it did in South Africa, where it appears to have originated. It has been estimated that on average, each infected British person is infecting as many as six others. Within households, Omicron appears twice as infectious as Delta. Over the weekend, the U.K. caseload almost doubled in a single day, and within a week, it could look like this:
That growth will likely slow over time as it may already have begun to in South Africa; in fact, there were some early indications over the weekend that the wave there may have already peaked, which would mark an astonishingly fast one, rising much faster than previous ones and, possibly, cresting and declining much faster too. That turn likely reflected data anomalies and delays in reporting rather than a sudden shift in the course of the outbreak, but it is early enough in the Omicron phase of the pandemic that we are learning quite a lot each day. (The variant itself may already be changing.) Most significant, we are already seeing early indications from England — like those from South Africa — that the illnesses caused by the new variant appear overwhelmingly mild so far.
This is all comforting news, at least compared with the alternative. But there are reasons to be cautious about assuming so much so early — both because encouraging early data may reflect a higher number of breakthrough cases, which are expected to be less serious, and because, somewhat counterintuitively, it will take more time for the serious cases to “show up” in faster-growing waves. The Delta wave has illustrated how transmissibility alone can drive much more devastating outcomes at the population level without a variant demonstrating heightened virulence or immune escape: If you multiply the case totals by three, five, or more, a significantly less virulent strain can still produce higher numbers of serious illness and death by essentially accelerating what would have been a more drawn-out trajectory. That should give pause to those who, seeing early signs of relative mildness, have taken to rooting for Omicron to displace Delta and spread country to country, infecting and essentially inoculating the remainder of the vulnerable population, many of whom would never have gotten vaccinated. That may ultimately prove to be the Omicron endgame. But given how many people remain susceptible, both globally and in the United States, a milder strain overwhelming country after country could still mean quite a lot of lives lost along the way.
Around the world, initial responses have suggested that, for policymakers and epidemiologists as for the rest of us, Omicron has felt like a sort of déjà vu — not just because it seems likely to produce a large wave of reinfection but also because it offers an opportunity to do well what had been done poorly at the outset of the pandemic almost two years ago. Travel restrictions were implemented quickly this time and, in many cases, quickly withdrawn again once it became clear how widespread Omicron already was. In the U.K., new mask mandates and other precautions have been implemented much faster in response to this variant than they were in response to the original wild strain. In the U.S., several states have already enlisted the National Guard to reinforce local health-care systems straining under Delta.
At the World Health Organization press conference Wednesday, it almost seemed as if we had traveled back in time, listening to warnings that had been issued in the winter of 2020. “Any complacency will now cost lives,” WHO Director-General Tedros Ghebreyesus said in an eerie echo of WHO Executive Director Mike Ryan’s speech from March 2020. “Be fast; have no regrets,” Ryan said thrn. “If you need to be right before you move, you will never win. Perfection is the enemy of the good. Speed trumps perfection. Everyone is afraid of the consequence of error, but the greatest error is not to move.”
On Wednesday, it was as though Tedros was reading from Ryan’s old script. “If countries wait until their hospitals start to fill up, it’s too late,” he said. “Don’t wait. Act now. We are running out of ways to say this. But we will keep saying it: All of us — every government and every individual — must use all the tools we have right now.”
But what would that mean? What are those tools? At its press conference, the WHO applauded the removal of travel restrictions and declined to reverse its guidance on booster shots, advising nations to prioritize first and second doses. A number of WHO scientists emphasized the value of a “wait-and-see approach” despite the urgency expressed by Tedros, Ryan, and others. “What we really need now is a coordinated research effort and not jumping to conclusions,” said WHO chief scientist Soumya Swaminathan. “I think it’s premature to conclude that this reduction in neutralizing activity would result in a significant reduction in vaccine effectiveness.” Just a few days later, there are signs vaccine effectiveness against transmission has fallen dramatically with Omicron — perhaps to as low as 30 percent for those who have been fully vaccinated with the Pfizer vaccine and perhaps all the way to zero for those fully vaccinated with AstraZeneca. Zero is a number you do not want to see in contexts like these, though those estimates only refer to transmission, not severe illness, and it appears efficacy could be largely restored by boosters.
At the global level, of course, there is a whole lot more that can and should be done on vaccination, which is what the WHO panel focused on most: “The primary attention here has to be on assuring that everybody who has not yet had a primary series of vaccination has access to that vaccine,” said Kate O’Brien, the WHO’s director of immunization, vaccines, and biologicals. But in much of the world, fulfilling that goal isn’t a matter of getting from 95 percent coverage to 100 percent; across Africa as a whole, less than 10 percent of people are fully vaccinated. And while those low figures reflect some vaccine skepticism and reluctance as well as issues of supply, it remains not just outrageous but puzzling that so little effort has been made to really vaccinate the world given how much that route is in every country’s naked dollars-and-cents self-interest.
In June, the International Monetary Fund estimated that an effort to fully vaccinate the world would cost just $50 billion dollars. Though such investments should not be left to individuals, Elon Musk made six times as much as that just during the pandemic, and Jeff Bezos, Larry Ellison, Larry Page, and Sergey Brin each made enough since early 2020 to fully fund such a program. Last week, the U.S. House passed a $778 billion defense budget including $25 billion more than had been requested of it — meaning the Pentagon just got a gratuity from Congress that could have covered half the cost of a global vaccination program. What is perhaps most astonishing about the IMF estimate is not the tiny cost but the enormous collective benefit: Measured purely in economic terms, the IMF found such a program would bring almost a 200-fold return on investment — $9 trillion — in just four years. An economy the size of America’s would receive many times more benefit from global vaccination than it would cost even if the U.S. were fully funding the effort without any help from other wealthy countries, which would also reap the benefits. And that’s not to mention the humanitarian payoff or the diplomatic benefit to be gained. Yet nothing like that comprehensive a project has been undertaken by the U.S. or anyone else. Perhaps the course of the pandemic over the next few months will inspire that kind of effort, but presumably it would have to be aimed at preventing waves from future variants, should they arrive, given that any dream of standing up such a program now, in time to combat Omicron, doesn’t appear credible. Over the past week, almost every country in southern Africa has seen its COVID case numbers at least double; in many places, cases have quintupled.
Things look a bit different in the U.S. given the widespread availability of vaccines, but while there may be some gains left to be made with further vaccination, vaccine resistance means those benefits are likely to be relatively small and would probably have little meaningful impact in blunting a big Omicron wave. New vaccinations have ticked up again as news of the new variant has spread, but given the trajectory of waning immunity, more people may be losing protection from vaccination each day than are being vaccinated for the first time — which means that, on the margins, the country as a whole is becoming more vulnerable, not less so. Vaccine mandates could help, of course, but the potential speed of Omicron’s spread sets a very intimidating timetable, and getting from 60 percent coverage, where the U.S. is, to 88 percent coverage, where Portugal is, means vaccinating more than 80 million people who have declined it thus far. A focus on seniors, where most of the country’s mortality risk is concentrated, might be more strategic because elevating protection of that population by 10 or 15 percent — enough to bring the U.S. to parity with many of its peer countries — would require vaccinating only an additional 5 or 10 million people. But even that would be a monumental task given how short the Omicron timeline appears to be.
When it comes to dealing immediately with Omicron, the strongest tool in the American toolbox is almost certain to be booster shots, restoring full protection to those who have already demonstrated their willingness and comfort with vaccination. According to the CDC, whose data can’t be entirely trusted at this point, only 26 percent of the eligible population has gotten boosted — and only 51 percent of seniors have, meaning nearly half the country’s most vulnerable people are much more at risk than they need to be. There has already been quite a lot of Omicron-inspired public-health messaging about the need for a third shot, but probably the single most effective initiative to be undertaken right now would be a mass booster-delivery program targeting nursing homes and eldercare facilities over the next few weeks.
A little over a month ago, Pfizer delivered very optimistic news about the clinical trial of a new therapeutic COVID drug, Paxlovid, which appeared to reduce severe illness and death among those infected with COVID-19 by 89 percent. But the drug is not yet approved by the FDA, and the real rollout is likely to take longer still. As for the “non-pharmaceutical interventions” that have dominated our pandemic imaginations the past two years, it would probably take a much worse experience than we had with Delta — which killed several hundred thousand Americans in just a couple of months — to put crisis measures like large-scale lockdowns back on the table given how few were imposed during even the deadliest phase of the pandemic last winter (and fewer still for Delta). It seems safe to say nothing of that kind will be imposed preemptively for Omicron, though the ferocious velocity of transmission means hospital systems may find themselves overwhelmed again (perhaps prompting hospitals to risk reconsidering their staff quarantine policies, as South African scientist Shabir Madhi has suggested).
As shambolic and ineffectual as the initial pandemic response was, not just in the United States but across the West, it appears in retrospect to be a scale of intervention we are unlikely to ever repeat or even approach through the remainder of the pandemic, no matter how bad it gets. Even amid a grim wave, lesser measures — work from home, school closures, social distancing — are likely to be imposed more weakly and tentatively if at all. Mask-wearing can and will be encouraged, but even the celebrated studies of mask efficacy have found relatively modest effects. And caseloads of the scale we have today, before Omicron, are already well beyond our capacity for contact tracing. These various tools can still play a useful mitigating role, but for many Americans, pandemic burnout has set the standard for such measures so high that even staggering daily case counts and death totals may not meet it.
Mass rapid testing — which has become a sort of crusade for many engaged Americans, especially since White House press secretary Jen Psaki bungled a question about providing self-tests more widely — may be quite helpful at the individual level, but various efforts by the Biden administration still haven’t made the tests much more easily accessible. And as The Atlantic’s Benjamin Mazer recently pointed out, even in countries that have made rapid antigen tests more or less universally and cheaply available, it’s not like the pandemic has disappeared (in fact, Germany, often held up as a model, has endured one of the world’s worst late-fall surges).
For months, those longing for an end to the pandemic have suggested we shift away from counting cases and look instead to hospitalizations and deaths. This weekend, the New York Times published an op-ed by physicians Monica Gandhi and Leslie Bienen making the case that Omicron calls for the turning of that page. But until this point in America, no decoupling between the two has taken place that would make such a conceptual shift meaningful because, at the national level, the ratio of cases to severe outcomes has held remarkably steady since before widespread vaccination. In particular communities with high vaccination rates, there has been more divergence, which suggests there may be wisdom in shifting toward a more local understanding of the state of play. But at least through the Delta surge, whether you were tracing the national pandemic through cases or hospitalizations didn’t matter — the two figures told the same story.
Perhaps Omicron will bring that national decoupling, producing higher rates of growth in case totals than in hospitalizations and deaths. But as epidemiologist Deepti Gurdasani pointed out, if a strain is doubling every three days — even if it produces half as many severe cases — the benefits of that relative mildness are comparatively limited, buying only three additional days before reaching the same number of serious cases. In England, where 70 percent of the country is “fully” vaccinated and 30 percent have been boosted, scientists are warning of the possibility of 75,000 additional deaths this winter — more than half as many Brits as died in two years of the pandemic. They have a history of making alarmist predictions over there with many of those scariest projections ultimately failing to materialize. But even in a best-case scenario with Omicron producing comparatively mild illness, if the new variant doesn’t dissipate quickly, it is unlikely to spell a painless transition in the United States or anywhere else. Such an astonishing rate of spread is a good bet to ultimately produce a spike in those serious outcomes as well. We may want to do something to stop that, but can we? Over the last few months, we’ve heard quite a lot about pandemic exhaustion. Resignation may be a better word. As Omicron looms, we’re mostly hoping for the best.
More on omicron
- What to Know About the New COVID Booster Shots
- The Dismantling of Hong Kong
- What We Know About All the Omicron Subvariants, Including BA.2.12.1
