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The best-case scenario with omicron will still be bad

Don’t be too reassured yet by the thought that the variant mostly causes mild cases

A line outside a coronavirus testing site in New York City on Dec. 20. (Angus Mordant/Bloomberg News)

Hope is not an effective strategy for dealing with a pandemic.

Two years in, we should all know that. Yet I’ve been watching with concern bordering on alarm as the omicron variant has entered the country and started spreading. It has become the dominant variant of the coronavirus, taking over from delta (itself no slouch) in a matter of days in some places. If it’s not in your neck of the woods yet, it will be soon.

Alongside this there has been a steady tide of coverage and commentary suggesting that omicron causes mostly mild disease — the implication being that it’s not much to worry about, that if we only stay the course we can ride this one out, too.

But that’s premature. Let me be clear: I’m not stating definitively that omicron has some grim future in store for us. I’m saying that there are red flashing warning signs, that we underestimate this virus at our peril and that even the best-case scenario is still bad.

Barely a month after it was discovered, there’s still quite a bit we don’t know about omicron. The three key areas to focus on are transmissibility, disease severity and immune evasion.

It is clear from data emerging around the world that omicron is highly transmissible and spreads more quickly than delta, which has caused enormous waves of infection in the United States and other nations, including in the parts of southern Africa where omicron was first reported.

Genome sequencing in South Africa, Britain, Denmark, Norway and other countries makes clear that when omicron takes root, it takes off really fast. We are already starting to see signs of that in the United States: The Centers for Disease Control and Prevention reported Monday evening that omicron made up 73 percent of U.S. coronavirus cases between Dec. 12 and Dec. 18.

If the disease caused by this variant is mostly mild, we could avoid the worst outcomes. It is important to remember that vaccination, especially among those boosted, protects well against severe illness. Unvaccinated people in South Africa and Britain have been shown to be at far higher risk of getting hospitalized than vaccinated ones.

Omicron won’t keep us from ending the pandemic. We’re doing that ourselves.

But a “mild” case of covid-19 can still make you miserable, even bedridden, for days. Huge numbers of “mildly ill” people unable to go to work or school can cause enormous societal disruption, especially while we’re experiencing labor shortages and supply-chain problems. There’s also the risk of long covid, which can cause physical and cognitive issues for many weeks and months after recovery from the acute phase of illness, and which we still don’t understand very well, even two years into the pandemic.

And finally, there’s math. Let’s pull a number out of thin air for demonstration’s sake and say that only 2 percent of omicron cases are severe enough to cause hospitalization. Good news, right? Not if omicron also causes exponentially more infections in a condensed time. Two percent of a huge number is a very large number indeed. With hospitals across the United States already strained to the breaking point, the implications are frightening.

So how severe is omicron, relative to delta? We haven’t seen crushing waves of hospitalizations in the countries where omicron took hold first, such as South Africa. That is good news because it probably means omicron is not causing significantly more severe disease than other variants. But it does not mean we’re out of the woods on severity.

Facing omicron feels like when a patient has relapsed

Time and again throughout this pandemic, TV talking heads, politicians and many others have gotten tripped up on the simple and immutable fact that hospitalizations lag infection. It can take weeks for an infection to progress to the point where the patient needs to be hospitalized. Omicron burst onto the scene only four weeks ago. Not enough time has passed for us to have a firm grip on disease severity.

Again that’s because of math: When a variant spreads extremely rapidly, as omicron seems to do, it can send false signals of reassurance on disease severity.

You’ve probably seen graphs from several countries showing that the number of omicron cases has skyrocketed in a matter of days. By contrast, hospitalizations have barely ticked up. Perhaps those graphs have been presented side by side with charts showing that by the time delta caseloads were this high, hospitalizations were starting to climb dramatically. That may seem reassuring. It is not. Remember: It has been at most a week or two since almost any part of the world started to see omicron infections in any significant number. You would not expect hospitalizations to follow this quickly. That’s not how covid works. The comparison with delta is misleading because it took delta longer to reach a critical mass of cases. We thought delta was fast, but it became dominant over a couple of months. During that prolonged period, a certain percentage of people who had been infected early got sick enough to require hospitalization. With omicron, we are not talking months but weeks; the case growth has been so compressed, there hasn’t been time for disease progression in those who were sickened early on. We need to wait two or three more weeks until we can make even a tentative judgment on disease severity. And by that time, many more people will have been infected.

The science on the ability of omicron to evade immunity has been moving incredibly quickly. Recent data from a large South African study suggests that the two-dose regimen of the Pfizer vaccine offers 33 percent protection against infection and 70 percent protection against hospitalization. A booster will probably raise those numbers.

It seems clear that breakthrough infections in the fully vaccinated will be more common with omicron than they were with delta. That is not good news, for all the reasons I outlined when talking about high transmissibility. It does also appear, as we would expect and hope, that vaccines remain strongly protective against severe illness. But that finding unfortunately carries a couple of caveats.

As I noted, not enough time has elapsed since omicron first hit the scene, even in South Africa, for us to get a full picture of hospitalization risk. And the coronavirus has swept through South Africa several times in the past two years, so a very large proportion of the population has prior immunity from past infection with other variants. Its population is on average younger than in most other countries, so not as likely to develop severe disease. This could be an important factor in blunting disease severity. All that means that South Africa’s experience may not be applicable to other populations — notably, the reservoirs of people in the United States who remain unvaccinated and who have not yet contracted the coronavirus in any form.

My red state is already pretending covid is gone. Now here comes omicron.

So what does all this mean?

It means we must be vigilant. We must take all the precautions that have become so familiar and yes, so wearying. Get vaccinated. As soon as you’re eligible, get boosted. Wear good masks in crowded indoor places. Keep a distance when you can. Wash your hands often.

And on a national level, it is past time for a clear-eyed rethinking of our pandemic policies.

Omicron’s very existence reminds us that this virus will keep mutating and will continue to pose grave threats for years to come. It is past time to rally the world to deliver billions more vaccine doses to developing nations. It is past time to make rapid tests readily, freely, widely available. It is past time to demand clear and forthright public health communication from officials at every level. And it is past time to develop proactive strategies for living in a world where the coronavirus is continually circulating and we work to minimize its toll.

We have come a long way since the start of the pandemic. Vaccines protect against severe disease in many people, and we can soon expect to have new therapeutic options to combat the virus in those who do need hospitalization. But the dizzying pace of omicron’s advance creates problems of its own if many doses of those therapeutics are needed more quickly than they can be manufactured.

In March 2020, the threat of the virus was indistinct. This time, the leaps and bounds we have made in testing and genomic surveillance mean we can see it coming. It is just moving more quickly than anyone could have imagined — and more quickly than any of us can pivot to respond to it.

Hope is deeply important to all of us as human beings. But hope is not a strategy. We need to maintain hope in the face of omicron. It just won’t be enough on its own.

Coronavirus: What you need to know

Vaccines: The CDC recommends that everyone age 5 and older get an updated covid booster shot designed to target both the original virus and the omicron variant. Here’s some guidance on when you should get the omicron booster and how vaccine efficacy could be affected by your prior infections.

Variants: Instead of a single new Greek letter variant, a group of immune-evading omicron spinoffs are popping up all over the world. Any dominant variant will likely knock out monoclonal antibodies, targeted drugs that can be used as a treatment or to protect immunocompromised people.

Tripledemic: Hospitals are overwhelmed by a combination of respiratory illnesses, staffing shortages and nursing home closures. And experts believe the problem will deteriorate further in coming months. Here’s how to tell the difference between RSV, the flu and covid-19.

Guidance: CDC guidelines have been confusing — if you get covid, here’s how to tell when you’re no longer contagious. We’ve also created a guide to help you decide when to keep wearing face coverings.

Where do things stand? See the latest coronavirus numbers in the U.S. and across the world. In the U.S., pandemic trends have shifted and now White people are more likely to die from covid than Black people. Nearly nine out of 10 covid deaths are people over the age 65.

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