"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.