A fierce viral storm of the COVID-19 omicron variant is hitting the United States and is expected to worsen, creating a flood of patients while undermining healthcare staffing as personnel are furloughed after breakthrough infections.
In response, the Centers for Disease Control and Prevention (CDC) on Dec. 23 revamped its isolation guidelines for infected and exposed healthcare workers (HCWs), reducing the days they may miss work based on symptoms, testing, and other factors as defined in categories of Traditional, Contingency, and Crisis.1 (See the CDC’s recommended work restrictions chart in this issue.)
With omicron causing much higher breakthrough infection rates than previous variants, there is concern infected HCWs must isolate amid an ongoing nursing shortage. The previous recommendation for 10 days has been changed to seven, and shorter than that under certain conditions.
“With the growing number of COVID-19 cases from the omicron variant, and consistent with current understanding of the disease trajectory, CDC [recommends that] healthcare workers with COVID-19 who are asymptomatic can return to work after seven days with a negative test, and that isolation time can be cut further if there are staffing shortages,” the agency said in a statement.2 “Healthcare workers who have received all recommended COVID-19 vaccine doses, including a booster, do not need to quarantine at home following high-risk exposures.”
These updates provide healthcare facilities “with the strategies to limit the effects of staff shortages caused by COVID-19,” the CDC noted, indicating the decisions on isolation and quarantine of medical workers can be made based on the local situation.
Saying the CDC succumbed to pressure from hospital employers, the president of National Nurses United wrote a letter to the agency, stating “weakening COVID-19 guidance now, in the face of what could be the most devastating COVID-19 surge yet, will only result in further transmission, illness, and deaths.”3
The CDC also shortened isolation guidelines for infections in the general public, saying those without symptoms could return to work after five days and wear a mask for an additional five days.4 This is partly to address the widespread number of breakthrough infections with mild symptoms and less risk of transmission. But the measure was criticized because it did not require a negative test and it relied on an honor system that could be ignored. However, the CDC said most COVID-19 transmissions occur in a five-day window: the first two days before symptom onset and in the next three days thereafter.
These moves came as concession to a painful reality, that waves of omicron could overwhelm healthcare delivery and business operations if too many people are isolated.
“Results from scenario analyses indicate that current increases in omicron cases are likely to lead to a national surge in the coming weeks with peak daily numbers of new infections that could exceed previous peaks; these scenarios may be realized as soon as January,” the CDC reported.5 (Editor’s note: As of press time, omicron case rates had not peaked yet, although the CDC predicted this to happen sometime in January.) “Projected large surges in cases indicate surges of hospital demand even if severity is reduced, because of the large number of anticipated cases occurring in a short period.”
Omicron has caused breakthrough infections in even fully vaccinated and boosted healthcare workers in the community. “It has the potential to hit the healthcare sector really hard,” says Debra Furr-Holden, PhD, an epidemiologist at Michigan State University. “Our healthcare system is already overburdened.”
Who Invited Omicron?
Furr-Holden speaks from personal experience. In November 2021, she attended a wedding in Milwaukee County, WI, that became one of the first reported omicron outbreaks in the United States. The epidemiologist and at least a dozen other people — including 11 healthcare workers from Oakland, CA — were infected.
“I didn’t know anybody else at the wedding but the bride,” Furr-Holden recalls. “[My infection] was confirmed as omicron. I have mild symptoms. I had received my two doses of vaccine and was scheduled to get the booster the following Thursday [after the wedding].”
The wedding protocol required COVID-19 testing before travel, which Furr-Holden did two days before attending. She experienced headache and sore throat two days after returning.
“The reception is where I think the outbreak happened — not at the actual wedding ceremony,” she says. “It was a social gathering. People came in with their masks on, and once the food was served, they took them off to eat. A lot of times, those masks don’t come back on as you continue eating cake, drinking, and dancing.”
The 11 healthcare workers are staff members at Kaiser Permanente’s Oakland Medical Center. A 12th case linked to the wedding resides in Berkeley, public health officials reported. The 11 healthcare workers, six of whom tested positive for omicron as this report was filed, ranged in age from 18 to 49 years.6
“All of the affected staffers were fully vaccinated and had received boosters,” says Marc Brown of Kaiser Permanente national media relations. “All spent the CDC-prescribed period of isolation at home, and all have been cleared to return to work.”
Several patient and co-worker contacts were tested and were all negative as of this report.
Additional evidence that even those fully vaccinated and boosted can be infected is in the first report of 43 U.S. cases of omicron the CDC analyzed.7 Only one was hospitalized and none died. However, 34 infections occurred in those who were fully immunized. Of those, 14 received additional booster doses, although five had received boosters recently and likely had not gained full immunity This means nine of the first 43 cases in the United States occurred in people who were fully immunized and boosted. A study of 132 patients in the United Kingdom hospitalized with omicron infections revealed 17 had received a booster dose.8
If those levels of breakthrough infections hit fully immunized and boosted healthcare workers, existing staffing woes will be compounded — despite shortened furlough periods.
There already is a critical shortage of emergency nurses, says Christopher Kang, MD, FACEP, president-elect of the American College of Emergency Physicians.
“Our nursing shortage is reverberating throughout the health system,” says Kang, an emergency physician for several hospitals in Washington state. “It is posing a lot of challenges in terms of patient access as well as slowing down the overall efficiency of care throughout the system.”
A Speeding Bullet with Less Severity?
Several other sociodemographic factors were converging before omicron, and now are coinciding with the emerging variant.
“As the pandemic continues, a lot of people have deferred or delayed their care,” Kang explains. “Those disease processes might emerge now in more advanced stages. Another [factor] is the pure volume of patients coming in, whether it is out of concern for having COVID, or actually having it, as well as regular emergencies — heart attacks, strokes, trauma injuries from car accidents. We are seeing wait times continue to increase. [Another] one is mental health, not only for providers but patients. Because of conditions and access to care [in the community], we are seeing an increasing number of mental health patients. We can’t accommodate and manage them efficiently.”
With omicron, it seems clear there is less margin for error to acquire initial infection. Estimates vary about how much more infectious it is than delta, which was at least twice as contagious as previous variants. An Israeli physician and public health advisor, justifying the need for a fourth shot (or a second booster) in that nation, said omicron is “10 times more contagious” than delta.9
The authors of a study submitted for publication in Hong Kong suggested a possible explanation of omicron’s transmissibility, noting the variant “infects and multiplies 70 times faster than the delta variant and original SARS-CoV-2 in human bronchus, which may explain why omicron may transmit faster between humans than previous variants.”10
As of Jan. 1, 2022, CDC genomic surveillance identified the omicron variant in 95% of U.S. cases, with the once-predominant delta variant falling to 5%.11 This happened in a remarkably short span, as omicron represented less than 1% of genomic isolates on Dec. 4, 2021. As of Dec. 27, 2021, the CDC said 94% of U.S. counties were reporting high (85%) or substantial (9%) COVID-19 transmission.12
With case counts increasing daily, hospitalizations rose to more than 77,000 on Dec. 29.13 That represented a 14% increase in hospitalizations from two weeks prior, but deaths fell 7% in the same period. Although record case counts occurred over several days in this period, the daily average of about 1,200 deaths was well below the record mortality toll of more than 4,000 people in a single day in January 2021.
While finding the variant more contagious, the authors of the Hong Kong study also revealed lung infections with omicron are significantly lower, possibly explaining why, in the first two weeks of the outbreak in South Africa, researchers reported, “the majority of patients in the COVID wards have not been oxygen-dependent.”14
Other recently published studies revealed patients were less likely to be hospitalized with omicron. Researchers in England found that, compared to the delta variant, the risk of hospitalization of one day or longer fell 40-45% for omicron.15
Early national data in Scotland suggest the risk of COVID-19 hospitalization is two-thirds lower for omicron infections compared to those caused by the delta variant. The researchers added the caveat: “the combination of increased risk of transmission and immune evasion of omicron mean that any advantage in reduced hospitalization could potentially [be] exceeded by increased rates of infection in the community.”16
The growing simplification of omicron as “rapid spread, but less severe” poses some challenges for public health communication and clinical discussions with patients. There are too many unknowns, including whether omicron could cause the prolonged symptoms of “long COVID,” or whether those infected will acquire natural immunity — and to what degree and duration. Previous infection with delta does not generally appear to confer immunity to omicron, based on the cases observed thus far.
While omicron has been described as causing milder disease, the range of illness in specific populations with underlying conditions, or in the unvaccinated as a whole, has not been scientifically established. Concerning the latter, if delta continues to retreat as expected, it will be of considerable interest to see if the marked differences in adverse outcomes between the immunized and the unvaccinated remain relatively unchanged. When the delta variant reigned supreme, around 90% of hospitalizations and deaths due to SARS-CoV-2 were in the unvaccinated.
Facing a predicted tsunami of omicron, clinicians are cautious about reassuring anyone — particularly those who are unvaccinated — that this will be nothing to worry about.
“Most of the information we have of so-called ‘milder’ infections is because infections are occurring in vaccinated people who are boosted,” says William Schaffner, MD, professor of preventive medicine at Vanderbilt University. “What omicron will do in unvaccinated people has not been well described. We are being very cautious about telling people about this. We anticipate that it would not cause more severe disease comparable to the other variants, but we don’t know that.”
President Biden took the 40 to 50 million willfully unvaccinated Americans to task in a Dec. 21 address to the nation.17
“[It] is not just a choice about you — it affects other people,” Biden said. “You’re putting other people at risk — your loved ones, your friends, neighbors, strangers you run into. And your choice can be the difference between life or death. Every COVID-19 [hospitalization] means someone with a heart attack, cancer, or other serious illness may not get that bed and that lifesaving care they need in the hospital.”
Even if those who are unvaccinated agreed to take the vaccine — an unlikely outcome, to say the least — the omicron virus is spreading so fast, it is an open question whether there is sufficient time to go through the two-shot series, let alone the booster six months later. Two doses are certainly better than one or none, but the heretofore standard regimen has been somewhat relegated to subclinical protection, as boosters are emphasized due to an estimated 25× (Pfizer) and 37× (Moderna) increase in protection. Even then, breakthrough infections occur. The authors of the U.K. study8 said the boosters show signs of waning immunity to initial infections after 10 weeks, but they still should be protective against severe disease and hospitalization.
‘The End of the Beginning’
The arrival of omicron marks the “end of the beginning” of the pandemic, as waves of the mutating virus wash across the world, Nicholas Christakis, MD, PhD, MPH, a sociologist and physician at Yale University, said in a recent interview.
“We’re feeling the full biological and epidemiological force of the virus,” Christakis said.18 “Basically, unless you’re a hermit in the mountains, or you’re incredibly lucky, everyone in the United States — in fact, everyone on the planet — is either going to be vaccinated for this condition or infected with the virus. We’re going to have to wait until that happens.”
It seems inevitable that many, if not the majority, of the unvaccinated will acquire the rapidly spreading omicron variant, especially if they ignore masking and other common-sense measures. Many of them may experience only mild infections, but enough could end up at hospitals that may be hard-pressed to care for them.
“It is not sustainable at this time,” Kang says. “Unfortunately, right now, the people who are bearing a lot of this are healthcare workers, whether it be physicians, nurses, or our ancillary staff. Anyone working in the healthcare system — even outside the hospital. That includes our EMS and first responders, and also our nursing and long-term facilities.”
Given the prolonged pandemic conditions, stressed healthcare workers have been variously described as burned out or victims of moral injury. While these are among the most compassionate of people, some may have a short fuse for another wave of patients who refuse to be vaccinated.
“On occasion, [some healthcare workers] are really angry at their patients for not having been vaccinated,” Schaffner says. “Causing all this stress and, in a very personal way, exposing them and their families to COVID.”
Considering the multiple pressures, it does not help that some unvaccinated patients with COVID-19 view basic healthcare measures like masks with derision.
“The verbal abuse, the attitude, and tone [of the patients] takes a toll on the healthcare workforce, especially those on the frontline trying to do their best with limited resources,” Kang says. “There are definitely those [patients] who are very passionate regarding vaccinations and masks and make their opinions known. There are also those who are just frustrated by access to care. ‘Why I am waiting so long? Why am I still stuck here?’”
Kang and colleagues all are vaccinated and boosted, but hospitals in Tennessee have been stymied by a recent state law blocking COVID-19 immunization mandates.
“We had 99% acceptance of two doses,” Schaffner says. “It was obligatory — a mandate. Just as we were getting our booster campaign ready, our state passed a law that no employer can require vaccination of their employees. We are in a legal limbo because that is being challenged. You can ask for an exemption, which I think every medical center in the state of Tennessee has.”
While Vanderbilt is working hard to convince staff to voluntarily take the booster shot, the evidence is clear that HCWs who defer the booster are at higher risk of infection and furlough from work. There was a noticeable difference after the staff were fully immunized with the two-shot regimen, Schaffner said.
“Once we got a larger and larger proportion of our personnel vaccinated, quarantine, isolation, and absences for reasons of illness just dropped like a stone,” he notes. “It was really very impressive. It became clear that the healthcare environment was safer than the community environment. [Of] our healthcare workers who became ill, we suspect the vast majority of them acquired infection in the [community] and not at work.”
REFERENCES
- Centers for Disease Control and Prevention. Interim guidance for managing healthcare personnel with SARS-CoV-2 infection or exposure to SARS-CoV-2. Updated Dec. 23, 2021.
- Centers for Disease Control and Prevention. CDC releases emergency guidance for healthcare facilities to prepare for potential omicron surge. Dec. 23, 2021.
- National Nurses United. Nurses condemn CDC’s dangerous decision to weaken isolation guidance for employers. Dec. 23, 2021.
- Centers for Disease Control and Prevention. CDC updates and shortens recommended isolation and quarantine period for general population. Dec. 27, 2021.
- Centers for Disease Control and Prevention. Potential rapid increase of omicron variant infections in the United States. Dec. 20, 2021.
- Johnson J. Omicron in Oakland: How a Wisconsin wedding with ‘super responsible’ vaccinated people led to outbreak. San Francisco Chronicle. Dec. 10, 2021.
- CDC COVID-19 Response Team. SARS-CoV-2 B.1.1.529 (omicron) variant — United States, December 1-8, 2021. MMWR Morb Mortal Wkly Rep 2021;70:1731-1734.
- UK Health Security Agency. SARS-CoV-2 variants of concern and variants under investigation in England. Technical briefing 33. Dec. 23, 2021.
- Tercatin R. Why did Israel’s COVID-19 team recommend a 4th vaccine? A member explains. Jerusalem Post. Dec. 23, 2021.
- The University of Hong Kong. HKUMed finds omicron SARS-CoV-2 can infect faster and better than delta in human bronchus but with less severe infection in lung. Dec. 15, 2021.
- Centers for Disease Control and Prevention. COVID data tracker: Variant proportions. Update Jan. 4, 2022.
- Centers for Disease Control and Prevention. COVID data tracker: Integrated county view. Updated Jan. 4, 2022.
- Track coronavirus cases in places important to you. The New York Times. Updated Jan. 10, 2022.
- Abdullah F. Tshwane District omicron variant patient profile — early features. South African Medical Research Council.
- Ferguson N, Ghani A, Hinsley W, et al. Report 50 — Hospitalisation risk for omicron cases in England. The Imperial College of London. Dec. 22, 2021.
- Sheikh A, Kerr S, Woolhouse M, et al. Severity of omicron variant of concern and vaccine effectiveness against symptomatic disease: National cohort with nested test negative design study in Scotland. University of Edinburgh. Dec. 22, 2021.
- The White House. Remarks by President Biden on the fight against COVID-19. Dec. 21, 2021.
- PBS. Yale sociologist: COVID-19 will reshape humanity. Dec. 20, 2021.
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Recommended Work Restrictions for HCP Based on Vaccination Status and Type of Exposure | |||
Exposure |
Personal Protective |
Work Restriction for HCP who have received all COVID-19 vaccine and booster doses as recommended by CDC |
Work Restriction for HCP who have not received all COVID-19 vaccine and booster doses as recommended by CDC |
Higher-risk: HCP who had prolonged close contact with a patient, visitor, or HCP with confirmed SARS-CoV-2 |
|
|
Option 1:
|
Lower-risk: HCP with exposure risk other than those described as higher-risk above |
N/A |
|
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Source: Centers for Disease Control and Prevention. COVID-19. Interim guidance for managing healthcare personnel with SARS-CoV-2 infection or exposure to SARS-CoV-2. Updated Dec. 21, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html | |||
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