Will the pandemic ever end? The rise of Omicron and the long road ahead.
Like most people in the World, I am tired of all things COVID! The past two years have been difficult for many people, but particularly those healthcare workers (like me) who have had to “fight on the frontlines” of this nasty disease. Like others, we were hopeful that through mass vaccinations, and perhaps with a little help from evolutionary biology, we could be seeing the end of COVID in 2022. The dreaded public health measures that we have endured for nearly two years (lockdowns, mask mandates, capacity reductions in public areas etc) were all seen as a “bridge” for our society to get to the promise land. Through these measures, we tried to keep infections low so that our healthcare systems (and society) would not be overwhelmed and brought to the brink of collapse, long enough for mass vaccinations (and perhaps mutations on SARS-COV-2 towards causing “milder” illness) to result in enough immunity among the population that either the virus would stop transmitting altogether, or at a minimum, the disease it causes would not result in death and debility. At best, SARS-CoV-2 would just turn into another “seasonal cold” virus, or at worst, something similar to the influenza viruses : colds don’t generally kill people, and flues only kill a relatively few people annually - the rate our society has deemed to be acceptable (just like there is a certain “baseline” level of death from driving, constructing buildings, flying with airplanes etc). After all, “fatalities are a part of life”.
Of course, while the overall goal has been similar, we saw significant differences in execution of such strategies in different countries. Some, like New Zealand and many other Asian countries, adopted a “COVID Zero” strategy designed to essentially eliminate the presence of the virus while vaccines were being developed and administered through large-scale programs. Others, like the UK, Sweden and certain places in Canada (British Columbia, Alberta etc) chose a path of “herd immunity” where by they tried to let the virus run through the community in a “controlled” manner (hoping they could keep the numbers and the ensuing mortality at “manageable” levels). Others still (like Brazil, Iran, Russia) just allowed the viral transmission run wild, allowing many people to get infected. Of course, we now know the results of these strategies.
Yet, almost two years since the pandemic started, reaching the end appears elusive. The emergence of Omicron has particularly added to the uncertainty. Personally, over the past two weeks, as I have watched the data and information about Omicron become available, my sense of weariness and uneasiness has increased. I now feel the same way I felt in March of 2020 when this unknown virus was rapidly turning into a global pandemic, and again in April of this year when our third wave (in British Columbia, Canada) was gaining momentum and our hospitals were rapidly feeling the strains of uncontrolled exponential growth of the Delta variant.
This feeling of uncertainty is compounded by a high degree of (justifiable) frustration (both among healthcare workers, and the broader population). Many are wondering why it feels like we are back to the same situation as in March of 2020, despite the fact that the majority of people have done their part by getting vaccinated and following public health guidelines for two long years. Indeed, we are particularly fortunate in BC that about 80% of the population has been vaccinated with two doses of primarily mRNA shots. Yet, it feels like all that hard work and sacrifice has been for nothing.
While these feelings are perfectly natural and understandable, the fact remains that it is still too early to know for sure where the pandemic is heading. Despite all we know about how the virus spreads (spoiler alert: it is through small particles that can be suspended in the air for very long time and sometimes over very long distances - called Airborne transmission!), what it does, and how we can treat the illness it causes, there are many more unknowns about Omicron and the way it (the virus) and us (the hosts) will battle it out when we face each other. In this post, I try to share some of my thoughts about the current situation we find ourselves in.
COVID has proven us wrong many times
SARS-COV-2 has blown many of our original assumptions and understanding about respiratory viral infections out of the water. It has revealed the degree to which dogma and political expediency influences our approach to pandemic management, and how political considerations routinely get in the way of timely public health interventions. We now know that many of the people who we assumed were “experts” seem to have had an incomplete understanding of the science and were too bogged down by their own egos, ideology and the prevailing dogma to consider alternative explanations of disease transmission and prevention. At the same time, we have seen individuals with diverse scientific backgrounds (but without any formal medical training) emerge as the soundest and most rational voices calling for action. People like Tomas Pueyo, Zeynep Tofekci, Jose-Luis Jimenez and Caroline Colijn (silicon valley pioneers, sociologists, chemistry professors and mathematicians) have been prescient in their predictions and their analytical skills have helped shine a light on the sort of interventions necessary to save lives.
Additionally, since the pandemic started, most of what we thought we knew, or assumed to be true about viruses have been proven wrong. For example, at the outset of the virus, the WHO and many national public health agencies assumed that the mode of transmission was primarily through large droplets. This resulted in much wasted time and energy on disinfecting surfaces and the “6-feet apart” distancing recommendations. Similarly, we assumed that herd immunity was achievable as long as we could get 70% of the population develop immunity to COVID (either through natural infection, or vaccines). However, perhaps because of the ongoing evolution of the virus, or evidence of waning immunity, or both, we now see that we need much higher immunity levels in order to have a chance at breaking the chain of transmission of SARS-CoV-2. In fact, it is legitimate to ask if this goal is even achievable? We see now that Omicron can still infect people and transmit despite prior immunity or vaccination. We have also seen that the idea that viruses mutate into versions of themselves that cause milder illness over time to not necessarily be true with COVID (at least not yet). So far, every variant that has become dominant (the beta and the delta variants) have not only been more transmissible, but also caused at least the same level of illness severity as the original Wuhan strain. Finally, while COVID primarily involves the respiratory system, it is a systemic inflammatory disease that affects multiple organ systems. This is unlike what we see with many other respiratory viruses, and accounts for much of the morbidity and mortality associated with the infection.
Why is Omicron causing so much concern?
As I mentioned a few paragraphs ago, it is hard for many to understand why the emergence of Omicron is resulting in such high levels of concerns among the leading public health figures and healthcare providers. People I know are legitimately wondering why people like me are so apprehensive about what is coming our way, and can’t quite wrap their head around why being vaccinated with two doses of a vaccine is no longer considered sufficient to prevent getting infected.
It is true that on an individual level, the risk of getting severely ill or dying is significantly lower for those with at least two vaccine shots than those who are unvaccinated. This means that if you were to get COVID, you are less likely to need to be admitted to the hospital or die from COVID (although it is still unclear what sort of longterm effects you may have from even a “mild” infection). However, we now know that immunity from both infections and vaccines wanes over time, which means that while two shots of Moderna or Pfizer may save you from getting really sick, they will not prevent you from getting infected in the first place and once infected, passing it on to others around you. Moreover, with waning immunity, the chances of developing more severe illness (while much lower that NOT being vaccinated at all) is higher than before. This is why getting a “booster” has become such a pressing priority.
However, the larger issue with Omicron is on a societal level. We now know that Omicron is much more transmissible than any variant we have seen to date, with unprecedented doubling rate of 2-3 days. While the jury is still out on whether or not Omicron causes “milder” illness, the fact is that with the rapid dissemination of the virus, the number of people who will get really sick in a very short time is simply outstanding! A smaller fraction of a much larger number will still end up being a very large number.
To illustrate that, let’s look at British Columbia. Like every where else on planet earth now, there are only two types of people in BC: those who are completely susceptible to getting COVID (i.e those who are not vaccinated AND have not previously contracted COVID), and those who have some level of immunity against the SARS-CoV-2 virus (either because they have received 1, 2 or 3 doses of a vaccine, AND/OR have had COVID some time in the past two years). Let’s look at some numbers: BC has a population of about 5.2 million inhabitants. Of these, about 224,000 are children under the age of 5 (who are not yet eligible for any vaccines against COVID), and for the sake of simplicity I will exclude them from my “back of the envelope” analysis. That leaves just under 5 million individuals, of whom about 82% are doubly vaccinated. This means about a million people are still unvaccinated in the province. Even if we assume that all of the 228,000 individuals who have contracted COVID to date refused to also get a vaccine, that still leaves around 770,000 people who are completely susceptible to getting infected! In Canada, about 7% of COVID patients are hospitalized. If over the next 3-6 months, Omicron infects all the people who have no immunity to the virus, we would be looking at about 53,000 hospitalizations!!! Even a fraction of this number can easily overwhelm our chronically underfunded healthcare system (not to mention our exhausted healthcare workforce). This math does not even take into account the fact that some of the other 82% of doubly vaccinated individuals will also get breakthrough infections and require admission to hospitals!
Does this mean the pandemic will never end?
To be honest, I really have no idea! On the one hand, an optimist could argue that Omicron may well be the beginning of the end of the pandemic! If it truly results in milder disease, its rapid transmission rate would mean that sooner or later, everyone will be exposed to it. Just like we have a pandemic of the common cold every year, every individual will get COVID at some point. Many of those who do not have any protection from prior infections or vaccines will get really sick and/or die, but the majority (as with the previous variants, probably about 80%) will get a relatively “mild” infection - though many may have long-term effects. Those who have some immunity will by-and-large survive, though long COVID may still be a possibility for them too. If Omicron outcompetes other variants to become the dominant version of SARS-CoV-2 (as it is set to become very soon), it will continue to circulate in the population and re-infect individuals, but over time and with repeat infections, it may well turn into another “common cold” virus!
On the other hand, a pessimist (like me!) could reasonably deduce from the data that our road ahead remains long and uncertain. If Omicron continues to transmit freely, in spite of prior immunity, it will continue to have an opportunity to mutate and change. Is there any guarantee that future mutations will be less deadly or have lower immune escape potential? Our experience to date does not show that…yet! So far, SARS-CoV-2 has defied many of our expectations about how respiratory viruses should behave. Moreover, if immunity to natural infection or from vaccines wanes the way it appears to, then we may well be doomed to a life of COVID booster shots every 6 months if we want to avoid getting really sick, or booster shots designed with new variant mutations! This won’t be that different from the annual influenza shots that we should all get, but again SARS-CoV-2 continues to be more deadly than influenza on average, so the stakes are higher.
What can we do now?
Regardless of what scenario ends up being the case, we know that our priority NOW should be to do what we tried to do when all this started in March 2020: slow down transmissions so that we can reduce mortality rates and hospitalizations, while we give everyone boosters on a global scale. This means avoiding unnecessary indoor gatherings (yes, that Christmas party you were so hoping to go to should wait for another time!), having proper ventilation when we have to be indoors (HEPA filters, opening windows etc) and spending time outdoors as much as possible. It also means wearing a good fitting mask that provides high levels of filtration (i.e NOT a flimsy cloth mask with your company’s logo on it!), and getting vaccinated as much as possible and as soon as possible. It also means staying home when sick, and taking your symptoms seriously. As I have said over and over again to my friends on social media, “it’s not just a cold, it’s COVID unless proven otherwise”. This means getting tested when not feeling well (be it through PCR or Rapid Antigen Tests) and repeating it if symptoms are not resolving or getting worse.
Yes, it may feel like we are back to square one, but we are also vastly more prepared to prevent illness and treat it better. In spite of my pessimistic predisposition, I continue to hope that we will eventually come out the other end of this pandemic. It will just take much longer than we all like or initially thought it would.