There have been plenty of new developments on the Covid front this past week. Some of them surprised me, they came so fast and furious, and I’m in healthcare.
Some did not.
I’ve been forcibly reminded of how Covid pushed its way to the front of my medical practice 3 years ago, like a single-minded, 900-pound puppy. First, I’d get an occasional question about a new disease folks had heard about. Next, people started calling who were actual close contacts of someone with the coronavirus. Then, I’d start getting abnormal test results — positive Covid tests — from our urgent care offices or the ER, on patients needing to follow up.
At the height of the worst surge of the pandemic, every 2nd or 3rd appointment was for Covid in a patient or a close family member.
Hello, darkness, my old friend.
J&J is no longer equal in status to the mRNA vaccines
From the CDC’s website: “In most situations, Pfizer-BioNTech or Moderna COVID-19 vaccines are preferred over the J&J/Janssen COVID-19 vaccine for primary and booster vaccination due to the risk of serious adverse events.”
The J&J vaccine is still recommended, but for narrower indications: if a person had a severe adverse reaction to a previous Pfizer or Moderna vaccination (rare but not impossible), or if the J&J is the only Covid vaccine available for some reason.
The potential J&J side effects — TTS that has been associated with 9 deaths, and Guillain-Barré syndrome — are still uncommon (about 3 per million and 16 per million, respectively). But the Pfizer and Moderna vaccines do not increase the risk for either condition.
If folks have the option and haven’t gotten their first Covid vaccination, the CDC recommends starting with either the Pfizer or the Moderna. And for those who’ve already gotten a J&J vaccination, they also recommend doing the 2-month follow-up booster with one of the mRNA vaccines.
Pfizer booster wait period now just 5 months
Until this past week Wednesday, the waiting time between a 2nd Pfizer shot and getting a Pfizer booster was 6 months, but the CDC and FDA have dropped that to 5 months.
Several other countries have a booster eligibility just 3 months after the second vaccination, including the UK, South Korea, Israel, Greece, and Germany; from its own internal research, Israel is recommending a 4th vaccination/2nd booster for its population. Based on the historical record, there’s a good chance the United States will eventually follow.
The CDC clarified its shorter 5-day isolation/quarantine guidelines
The initial press release was a pleasant surprise for many — reducing a 10-day stay-at-home timeline to 5 days — but caused confusion given the large number of possible different scenarios (I stopped counting after 10).
The CDC issued a more comprehensive explanation midweek. It’s clear, specific, and I strongly recommend bookmarking the page. Unfortunately, with the tremendous increase in Covid Omicron cases, there’s a good chance you’ll need to refer to it.
The simplest take-home: if you’ve been exposed, or develop cold/flu-like symptoms, or test positive, mask for 10 days like the life of your beloved depends on it, go home, and talk with a medical professional about when it’s safe for others to be around you. Depending on your situation, it could be immediately, 5 days from now, 10 days from now, or longer.
Antigen testing über PCR (sometimes)
The deep nasal swab PCR test is the gold-standard, but it can stay persistently abnormal for weeks, even months after a person is no longer infectious.
The rapid antigen test, like the Abbott BinaxNOW or Quidel’s QuickVue, is slightly less sensitive than the PCR (less likely to show if someone has Covid early on). But it correlates well with when a person is putting out live virus that can be cultured, and goes negative (normal) quicker than the PCR. Both the Navy and the CDC mention antigen testing specifically in the context of ending isolation or quarantine.
Finding a rapid antigen test is another matter. If you’d use testing to guide decision-making for visiting others and you find antigen tests online or at a pharmacy, you should consider getting them on the spot. I’ve checked, and retailers who’d carried the tests were sold out within 24 hours.
Thinking Omicron’s not a big deal ‘cuz “I’ll jess get monoclonal antibody or that new Pfizer pill?” Yeah, about that…
There are 3 monoclonal antibody infusions that you could have gotten for Covid Delta, if you had elevated risk of disease progression (nearly any chronic condition including hypertension and obesity would count).
But Omicron is resistant to 2 out of the 3, and the third, Sotrovimab, is in incredibly short supply: at this time, 2,658 doses have been allotted to the entire state of California, and is being prioritized for those at the highest risk of disease progression (i.e., major pre-existing medical conditions and/or advanced age).
The new Pfizer antiviral pills (Paxlovid) look promising for outpatient treatment, with an effectiveness approaching 90% for preventing progression to severe Covid. But only 6,180 courses of treatment have been allotted to California, with a total for the entire nation of 65,000 courses for now. More will become available, but the current supply is being prioritized for those at high risk of disease progression.
Cool tools aren’t helpful if you can’t get them. I wouldn’t rely on them as a justification to be lackadaisical about Omicron.
KF94 and KN95 masks
Actual N95s are still difficult to get if you’re not a healthcare worker, but Chinese KN95s and Korean KF94s have very similar filtering qualities, are definitely an upgrade over cloth or standard surgical masks, and most importantly are actually available online.
To date, there have still been no cases at our offices of healthcare providers wearing N95-level masks contracting Covid from seeing patients. The main risk of contracting Covid comes from off-work exposures, when unmasked at public gatherings or family meals. With the tremendously increased infectiousness of the Omicron variant, KF94s are the standard for me and my family if we have to go out in public.
Omicron IS milder than Delta, and we can’t not use boosters
There are solid indicators that Omicron is, in fact, milder than Delta. The roughly 3-week lag between case counts rising at the start of a surge and delayed uptick in death numbers has shown an astronomical rise in numbers of infected (215% in the past 2 weeks), with a much smaller increase in the number of dead (16% over the same time frame).
Make no mistake: Omicron is still putting people in the hospital. But to borrow a phrase from Tolkien, it’s not slaying them in heaps — if they’ve been fully vaccinated and boosted.
The current boosters — not yet specific for Omicron — decrease the risk of mildly symptomatic infections. But the reduction is more modest than the protection against severe disease: about 70-75% instead of near 90%, and antibody levels drop in a matter of weeks. Which may be why you know people who’ve gotten boosters yet still came down with (mild) Covid.
That said, here’s why boosters were a good call, and will continue to be a good call for future variants that are highly contagious:
We can judge the wisdom of choices by looking back afterward, but we can only live life going forward.
Even with mRNA technology’s ability to distribute an updated vaccine within 100 days — a never-before-seen, unbelievably short turnaround time — if a future variant turned out to be as contagious as Omicron, the lives of millions would be at stake if the variant could overtake a nation in 40 days, like Omicron has. We are still 2 months out from getting an Omicron-specific vaccine. Imagine if public policy had been against using original vaccines for boosters, and Omicron had turned out to be super deadly (translation: heaps).
There’s some debate about ongoing boosters using existing vaccines against Omicron, knowing what we know now. It’s a great situation to be in, being able to calmly have a debate because a variant turned out to be not-awful by sheer luck. But we won’t know the deadliness numbers until several weeks into a surge, and by then, it’d be too late to save heaps of lives by starting a booster campaign. If boosters work even halfway to reduce infections in the vaccinated, there’s no way around recommending them for a surging variant.
Why get boosters when the variant is mild(er) and you can still get (mildly) sick after being boosted? That’s kind of a Monday Morning Quarterback question, being asked with the benefit of hindsight. Health policymakers at the front end of a surge don’t have that luxury, and can’t not recommend preventive boosters without gambling with the lives of millions.