Image Source: Our World in Data (Creative Commons License)

This image alarms me. The omicron variant is out of control, and its consequences will be devastating. Even though the disease may be less severe especially among vaccinated and boosted individuals, it is not benign. Our emergency departments are inundated, our hospital and ICU beds are filling up, and I live in a county with a 92% vaccination rate for eligible residents. I can't imagine what other parts of the country and world are dealing with. Pediatric hospitals are seeing more hospitalized children with COVID than ever before, and we still don't know if omicron will cause long-haul COVID symptoms. The disease may be less serious, but we cannot dismiss it.

Unfortunately, we have become lax with risk reduction behaviors, masking, and avoiding large social gatherings. These interventions absolutely work to reduce contagious respiratory illnesses; last winter, we hardly saw any pneumonias from other viruses. But this winter, along with seeing a lot of COVID, we're also seeing influenza, rhinovirus, respiratory syncytial virus, and other infections. People are traveling, going to holiday celebrations, and participating in indoor in-person activities. The horse is out of the barn; too many people carrying too infectious of a virus doing too much have fed into the surge we see above.

With COVID this prevalent, it's hard for even those following all the rules to avoid it. There are stories of people who have tried so hard the entire pandemic to do the right thing who nevertheless get infected. Right now, no one is safe. I've seen multiple instances of gatherings with vaccinated people who all test negative before the event, yet an exposure still happens. 

So if the virus is everywhere and there's no way to eliminate risk, why bother trying? This is not an unreasonable question for those at low risk of getting severe disease and who do not live with unvaccinated people. For the most part, the arguments are more or less the same - our health care resources are limited, your activities may have unforeseeable and dire consequences, and there may be long term effects of COVID infection. But also, pre-COVID, you wouldn't go to a party if you were sick or if you knew other people there were sick. The prevalence of COVID is so high right now, every single party likely has an infection present. It's just not worth it. 

There's been a lot of excited chatter about new therapies, and I'm optimistic, but these treatments will not make a difference for months. They will be exceedingly scarce for some time. With half a million COVID cases daily, there's no way manufacturing, distributing, prescribing, and filling the medications will catch up any time soon. As an example, sotrovimab is the recommended monoclonal antibody for the omicron variant. We ran out of it in less than a week, and we don't know when we'll get more.

To use a word we haven't seen in a while, this rise in cases is "unprecedented." It can be detected in signals as strange as Amazon reviews for scented candles ("One star - could not smell the candle") and the mass cancellation of holiday flights. We don't know how far or how high this peak will climb. Although the CDC relaxed its quarantine guidelines, I think now is not the time to relax our vigilance. Things are getting worse, not better. Adjusting the rules might mean more people follow them, but I worry these guideline changes send the wrong message at this time. Our New Year's resolution needs to be responsible, intentional, and measured actions at the individual, community, and national levels toward the changing state of the pandemic.

"A chicken is an egg's way of making another egg." - Samuel Butler

Omicron is here. I'm not surprised newer and more infectious variants continue to arise. Like most biological entities, a virus has genes that evolve to optimize transmission. Although our understanding of Omicron is still preliminary and limited, what we suspect worries me a lot.

Omicron's increased contagiousness means it will overtake Delta as the predominant variant in the United States (and world). Caseloads will skyrocket like they did last winter and put enormous stress on the health care system. The virus is so contagious it's being compared to measles, which is saying something (we don't see measles very often because of vaccines). But in addition to its infectivity, Omicron also appears to break through immunity. Two-dose mRNA vaccines (or the one dose Johnson and Johnson) as well as remote COVID infection (ie. infection before the Delta variant) provide only limited protection. A booster will increase protection, but not to the effectiveness the vaccines had before Omicron. Nevertheless, vaccines are still an important tool, and Omicron has tipped the scales to recommending boosters to all adults.

There's a lot of talk about whether infections are less severe. Early data suggest it is more mild, but we don't know for sure. From a viral biology standpoint, as a virus evolves to be more transmissible, it may become less deadly. In order for a virus to propagate its genes, it needs to make its host sick and symptomatic but not dead before it can find other hosts. This isn't a steadfast rule, but it gives us hope that Omicron may indeed be less severe. 

Despite this, our health care system is going to be crushed (again). It's a numbers game, and even if a smaller percentage of Omicron patients need hospitalization and intensive care, skyrocketing cases mean the absolute number of hospitalized and ICU patients may exceed our capacity to care for them.

So what do we do?

I don't think Omicron significantly changes the message we have been emphasizing this whole pandemic. Vaccines, boosters, masks, distancing, risk-modification, and testing are paramount right now. In addition, we need to continue basic biology, clinical trial, and public health research. And although I know this is not politically tenable, from a public health standpoint, I think a partial lockdown will save lives. It breaks my heart to see Broadway shows, sports events, and other gatherings canceled, but I applaud them for making the right decision. 

Omicron is a clarion call that people are dying and more will die in the next few months. Our collective responsibility is to mitigate that coming wave as much as we can. It's not what we want to hear. Everyone is sick and tired of this, but it's better to be sick and tired and healthy than sick and tired from COVID-19. I worry this is like the boy who cried wolf, and now (another) wolf is at the door and it finds a whole holiday gathering of hosts.

So this holiday season, I am paring back my gatherings, keeping the number of people limited, the settings outdoors, and the dress code masked. I am not traveling. I am spending Christmas in the intensive care unit. And I am preparing for another long, hard winter.

Currently, one of the biggest problems our hospitals face is loss of expertise. With the length of the pandemic and increased burnout among health care workers, nurses and doctors are leaving at a dangerous rate. I've already blogged about a lot of the reasons for burnout (or what people are calling moral injury). In the beginning, we feared for our own safety and those of our families and lamented lack of personal protective equipment. We struggled with the distress of having few tools against the virus, ethical dilemmas of rationing care, and the consequences of seeing so much death especially in young patients. Then we struggled with misinformation, conspiracy theories, disregard for public health guidance, variants and mutations, and resulting surges. Early on, there was an outpouring of support, encouragement, and gratitude for our work, but now, we see people engaging in higher risk activities, refusing to get vaccinated, and fighting public health mandates. No wonder we are ready to leave medicine.

Through this entire pandemic, hospitals have struggled to staff enough nurses, but recently, I've noticed that this problem is escalating with a departing workforce. Even at my hospital, many nurses who worked through the initial waves have decided to transfer to other units or retire. We're leaning on traveler nurses and ramping up programs to train nurses from other parts of the hospital, but there's no question that we're losing expertise. The nurses who are leaving are some of our best, who have cared for ICU patients for decades, who bring a lot of value to our institution.

Likewise, we've had a few doctors leave, including critical care specialists like me. The training pipeline for ICU doctors is at least five years (and often more) after medical school. And though the pandemic has inspired more people to go into health care, these new doctors and nurses won't join the workforce for years. Furthermore, even the best-trained new graduates have a lot to learn. Expertise is built over years and decades of practice. Even though COVID is a new entity, we draw upon a wealth of accumulated knowledge and experience, and when our physicians leave early, that void is difficult to fill.

Obviously, it's not new for physicians, nurses, and other health care workers to retire, leave for a different career, or move on to another job. But the pandemic and its physical, emotional, financial, and social harm on our lives has accelerated this process, and I worry it will have a long-lasting negative impact on healthcare. We need to create systems that incentivize the retention of expertise, mitigate the burnout we're suffering, and predict, train, and distribute our workforce in a more even and equitable fashion.