Cutting through the noise of COVID risk: Real-life consequences of oversimplification
Omicron is an unwelcome but predictable lesson in the Greek alphabet
"We are going to fight this variant with science and speed, not chaos and confusion," President Biden said on Thursday as he laid out his COVID-19 omicron variant pandemic response plan. But will the package of new vaccination sites, boosters for all adults, insurance coverage for at-home testing and new testing requirements for international travel avoid chaos and confusion or be just another chapter in a haphazard, scattershot U.S. response?
The term "pandemic preparedness" has entered our lexicon with a grave urgency over the past two years as SARS-CoV-2 has battered the country in successive waves. Policymakers and public health institutions are belatedly recognizing a key lesson of COVID-19: We must be prepared for "the next big one" by developing plans to prevent, identify and respond to any pathogen capable of bringing the world to its knees. There is much activity going on regarding commissions and other frameworks to address this vital goal.
But the future is now. Can we meet the challenge of applying two years of lessons learned in our pandemic response? Biden's comments indicate that while we are falling short in some areas we are also being remarkably successful in others. But we still have a lot of work left to do.
First and foremost the U.S. response should be based on a clear-eyed assessment of the most-likely case scenario while incorporating realistic stopgaps to deal with a worst-case possibility. This is the most crucial omission in the administration's policy platform. We need to make some critical decisions immediately and then modify them to deal with new knowledge and contingencies as they arise. This was our reality in the early days of the novel coronavirus, but now we have wisdom on the pandemic's outlook gained through hindsight and grievous past mistakes.
Omicron should now be seen as a natural step in SARS-CoV-2's evolution from a pandemic to an endemic pathogen. It is not a rewind to the early days of 2020 and the novel coronavirus' initial appearance on the world stage. We now know with a high probability that the virus will eventually become "endemic," which means it will circulate sporadically or seasonally much like the flu virus. It will have a moderate and mostly preventable toll but no longer be perceived as a major public health threat. Rather than cause a new pandemic, this is what a virus with an intrinsically high mutation rate does as it undergoes increasing survival pressure. Evolutionary biology would predict this, as it would that selection pressure tends to favor increased transmissibility and decreased virulence over time. If omicron follows this course it will displace delta as the world's and United States' dominant variant. This could be good news if it is less virulent. Omicron will take its place in a sequence of variants of concern that could eventually exhaust the 26 letters of the Greek alphabet.
The immediate impact of omicron on both U.S. Covid policy and individual risk reduction is the same: an intensified focus on what we already know to be highly effective in mitigating serious outcomes. Full vaccination including boosters. Broad-scale testing of both vaccinated and unvaccinated people, including self-administered rapid tests to screen for asymptomatic infection and avoid household and community spread. Continued masking and distancing indoors. This will allow the non-elderly and immunocompromised to safely carry on with their lives as close to business-as-usual as possible.
We are seeing several policy responses in the "what doesn't work" category. Some of the media is fanning the flames of the worst-case scenario with headlines such as "the risk is very high" and "race against time." We get breathless reports of new omicron cases leaping across states. This alarmism can feed widespread hopelessness and panic which can turn into a self-fulfilling prophecy of societal paralysis. Travel bans and border controls are fighting the last war. They may serve a political purpose but with the epidemiologic characteristics of omicron, they will not be effective for significantly slowing its spread. Similarly, stringent domestic containment strategies that were deployed with earlier COVID waves will not be effective and buy meaningful time. The lead-time in unrecognized asymptomatic transmission enabled by rapid global and local travel is such that aggressive containment measures are too late to use to test and track methods to halt the spread.
The international ostracism of countries reporting the new variant is not only punishing their economies but is a massive disincentive for future cooperation necessary to identify and control emergent pathogens.
The "what does work" list is fortunately much longer and impactful. This is where the Biden administration should double down. Not piecemeal, but with sustained commitment and large-scale programs. Our genomic and epidemiologic surveillance have ramped up dramatically over the past year, but we should be doing a lot more. This would help to identify new variants early, and transmissibility and virulence can be determined in a matter of weeks. The establishment of the efficacy of existing vaccines will now also become characterized in a remarkably similar timeframe. With the revolutionary mRNA technology manufacturers have assured us that modifications in dosage or boosters can be evaluated quickly. Wholly new omicron-specific vaccines can be produced in about three months. Reassuringly, it is expected that new anti-viral treatments will maintain efficacy against omicron and future variants. Rapid testing is not a nice-to-have luxury, but an indispensable part of a national prevention culture. It should be recognized and addressed as such.
With these new levels of pandemic preparedness on the surveillance, vaccine, treatment and testing front, even an unlikely worst-case scenario should be manageable. If omicron has an unexpectedly high virulence and a high degree of immune evasion, we should have effective vaccines and treatments available in record time.
Although omicron is unlikely to be the "big one," it is a valuable dress rehearsal to test the resilience and robustness of our pandemic response. We should view it as yet another unwelcome but not unexpected opportunity to tune up our defenses. Not as a cause for alarm, ill-conceived over-reaction or scattershot policy response.
Steven Phillips is vice president of science and strategy at Covid Collaborative.