It’s a paradigm shift
CLINICAL MATTERS
As new daily cases of COVID-19 in the US breach the one million-mark, government leaders and healthcare officials in many countries are being forced to confront the inevitable question: Since the Omicron variant is out of control, what is an acceptable way to live with the virus?
The extreme contagiousness of Omicron, along with its shorter incubation time and unprecedented immune evasion, has completely obliterated previous public health defenses. For variants prior to Omicron, the potential for preventing infection through rapid testing and contact tracing, though difficult, was still feasible. There was an approximately three-day gap between exposure and start of infectiousness. Pre-Omicron variants and lineages typically manifested with symptoms on the fifth day following exposure, with patients becoming contagious one to two days prior to the appearance of symptoms.
With Omicron, the incubation period is shorter, with symptoms usually appearing on the third day following exposure. This suggests that people can become contagious in as little as one to two days after exposure. This makes it very difficult to find and isolate infected people in a reasonable amount of time. People with Omicron are not only spreading the virus prior to the appearance of symptoms. Their own close contacts may already be spreading the virus just as the initial contacts are become symptomatic and are contact traced. By the time testing is completed, spread to the second and third generation contacts is already under way.
With the seeming inadequacy of conventional measures to prevent widespread infection, resources need to be allotted to mitigate the impact of infection in those at highest risk. Testing needs to be rationalized for those patients who will benefit the most from medical interventions. Isolating contagious individuals who are low risk for severe outcomes becomes a priority over testing and contact tracing. Vaccination, while less able to prevent infection and transmission, is an integral part of this strategy since fully vaccinated individuals who are not part of the elderly and comorbid high-risk groups are 99.9 percent likely to survive with just supportive care at home. Since Omicron is three times less likely to cause hospitalization than Delta, the risk of severe cases in fully vaccinated individuals who are not in the high-risk groups is even smaller compared to the previous Delta wave.
More and more data are showing that breakthrough infection (infection despite vaccination) in fully vaccinated people who are not part of the vulnerable population is generally mild. Basically, for a person who is fully vaccinated with or without a booster, COVID-19 is no deadlier than the flu. Routine testing isn’t done for flu suspects, and society isn’t locked down when there is a flu outbreak. People recuperate at home until they are asymptomatic and can return to work. Testing in this population doesn’t change management since there are no drugs that will further improve an already good outcome. When cases are high, isolating quickly is the single most important action to decrease transmission. Testing can be optional, especially if there are test shortages or there is a risk of transmitting to others while accessing the test.
For those in the vulnerable population, testing with RT-PCR should be continued because this population can benefit from antiviral medications like Paxlovid and molnupiravir. These medications can decrease the risk of hospitalization by at least 30 percent or up to 90 percent if given within five days of symptoms onset. These are currently under either emergency use authorization or compassionate special permit use, and so anyone with suspected COVID-19 who is part of the high-risk population should contact his or her physician as soon as possible to access treatment. These medications are of little value to the low-risk population. These are also not appropriate for hospitalized patients since a different set of medications is used.
People with COVID-19 severe symptoms necessitating hospital admission also need to be tested, since they can benefit from proven interventions with medications like dexamethasone, remdesivir, baricitinib, and tocilizumab. The problem with testing even the low-risk population is that laboratory results for the high risk and severe disease population get delayed when there is high demand for testing, further compromising care. Prioritizing testing for the most impacted population is therefore part of the overall paradigm shift, especially in countries with good vaccination rates.
Israel, Canada, and some other countries have already adopted this paradigm shift where they reserve RT-PCR for 60 years and above and those with comorbid conditions. For the rest of the population, they get an antigen test or (when there are shortages) no testing at all, as long as they isolate and are fully vaccinated.
The unvaccinated are more problematic. As long as there are many of them, they are at higher risk for severe disease, long COVID, and death. They are also more likely to generate new variants. Encouraging holdouts in this population to get vaccinated is a priority. For children five to 11 years old, the pediatric vaccines are arriving in February and should be quickly administered. For those below five years old, studies are ongoing. Overall risk of severe COVID-19 in unvaccinated children is at the same level as that of a vaccinated adult, so the testing should also be prioritized for children with comorbids while for the rest, testing is optional.
The paradigm shift means eventually viewing COVID-19 as an endemic disease, much like the flu or cold viruses. The most important requirement to do this safely is vaccination. Living at ease in the new normal requires vaccination. Being unvaccinated carries an uncomfortable risk to the unvaccinated person and to others. Wearing a mask and following public health standards should still be done when community transmission is high, regardless of vaccination status. This is essential to help the healthcare workers cope with an increase in sick patients, as well as to prevent the healthcare workers from getting sick.
The choice is clear. Vaccination saves lives, and it gets life back to normal.