By Gary Evans, Medical Writer
The emerging narrative of the Omicron variant of COVID-19 being less severe — and possibly signaling a transition to an endemic phase of the pandemic — is of little solace to patients dying of the virus daily.
On Jan. 14, 2022, 2,954 people died of SARS-CoV-2, an increase of 55% from the prior two weeks.1 They almost certainly succumbed to the Omicron variant, which represented 98% of U.S. isolates in genomic surveillance by the Centers for Disease Control and Prevention (CDC) on Jan. 8.2 This happened in a remarkably short span of time, since Omicron represented less than 1% of genomic isolates on Dec. 4, 2021. As of Jan. 8, 2022, the CDC said 99% of U.S. counties were reporting high COVID-19 transmission.3
The 2,954 deaths on January 14 are lower than the records set in January 2021, when deaths were in the 4,000 range for several days. Overall, there were a staggering 924,343 cases and 156,682 people hospitalized on Jan. 14, 2022. The hospitalizations represented a 79% increase from the prior two weeks. Although some project Omicron will peak and begin to decline by the end of January, hospitals were swamped and healthcare workers are getting infected and furloughed as this report was filed. (See in this issue: “Sick Healthcare Workers Worsen Shortage, May Spike Healthcare-Associated Infections.”)
Although several studies show less adverse outcomes relative to the Delta variant, Omicron still is a killer in individual patients, particularly in the unvaccinated, said Daniel Griffin, MD, PhD, a clinician and research scientist at Columbia University in New York City.
“A [patient] I saw this morning almost died last night,” Daniels said in a recent video presentation.4 “[He] is in his 50s [with] no other medical problems, but he made that decision not to get vaccinated. Everyone tells me, Omicron doesn’t really go to the lungs. [He] is coughing up thick, rubbery, nasty mucus. He’s now on high-flow nasal cannula. We’ve done steroids, we’ve done [tocilizumab], we’re doing everything we can. We’ll see how he’s doing tomorrow.”
‘A Morphine Drip’
Another adult female patient apparently was convinced by her family not to get vaccinated, Griffin said.
“I talked to her and she seemed like she had [mental] capacity, so it would have been nice if she had weighed in a little,” he said. “But now she’s on a morphine drip, comfort care, she’s in the process of dying. Yes, Omicron causes severe disease.”
Daniels said he usually can tell the vaccination status of patients as soon as he walks into their rooms.
“If they are on a nonrebreather — these high-flow nasal cannulas — they’re requiring a lot of support, and I pretty much know they’re unvaccinated,” he said. “I usually sort of try to gently say, ‘Hey, so any vaccines under the belt?’ They usually say no. The person who’s on maybe just a little bit of oxygen or maybe not on oxygen, they’ve usually been vaccinated. So there really is a different presentation.”
Daniels also asks his patients about reinfections, seeing if past Delta infection was protective and whether any Omicron reinfections may occur.
“I’m actually taking care of individuals that I met for the first time back in April of 2020, now back in the hospital with COVID again, on oxygen, because they did not take advantage of the vaccination opportunity,” he said.
The CDC currently is studying whether those with Omicron can be reinfected with the same variant. Traditionally, there would be an expectation of acquired immunity for some period of time, but little is being taken for granted with the highly mutated Omicron.
As far as the question of severity of illness, a study of infection outcomes in those who are unvaccinated and have not been previously infected would be revealing, Daniels said.
“Would it really be milder in them?” he said. “I think that’s what people are trying to intimate — they’re trying to suggest that there’s a difference in the virus. Looking at the hospitalizations and deaths in a population of unvaccinated individuals [would] really answer that question.”
Icepick or Longer Drift?
Studies out of South Africa have reported less severe disease, marked by a rapid rise and fall of Omicron over several waves, with one suggesting “if this pattern continues and is repeated globally, we are likely to see a complete decoupling of case and death rates, suggesting that Omicron may be a harbinger of the end of the epidemic phase of the COVID pandemic, ushering in its endemic phase.”5
Daniels warned against extrapolating such findings and projections, citing another South African paper in which those infected represented a younger age group, had a 44% vaccination rate, and many had a history of prior Delta infection.6
“In this wave, 61% of the infections were in females,” he said. “We know women do better, we know they’re less likely to end up in the hospital. What about comorbidities? In the prior waves, the majority of the patients had comorbidities. In this wave, only about a quarter of the individuals had comorbidities.”
Certainly, it is better that fewer people ended up hospitalized, but there are many confounding variables that caution against extrapolating the South African findings to the United States, he said.
“Is this, in part, due to immunity — either a viral infection survivor immunity or also [because] the most vulnerable people have died in the previous waves?” he said. “We’re sort of left with the survivors. But I think everyone wants to say the virus has become less virulent.”
The other major question is, will Omicron in the United States fall off rapidly, as it has in South Africa? Disease modeling expert Jeffrey Shaman, PhD, director of climate and heath at Columbia University in New York City, shows the U.S. Omicron surge peaking no later than the end of January, then dropping off — although maybe not as rapidly as in South Africa.
“It’s hard to say — we project and expect a rapid drop-off, as in Gauteng Province, South Africa, and London,” he says. “However, the decline may not be as precipitous as the rise. Nationally, the United States is a big place with lots of people. New York City may already be past peak, whereas other places are just rising. Superposition of all these signals will manifest as a longer, smoother outbreak. While local declines may be rapid, they may not return to pre-wave levels for some time.”
Rochelle Walensky, MD, director of the CDC, said in a press briefing that some areas of the United States may experience the same “icepick”-shaped curve of South Africa’s Omicron surge, which essentially is a rapid ascent followed by a rapid decline. That may not happen in other areas, since the United States is a diverse, large nation with varying levels of vaccination.
“I think people need to remember that there are substantial proportions of unvaccinated people, particularly in states like mine — we haven’t even reached 50% of the eligible population,” said Jeanne Marrazzo, MD, MPH, infectious diseases director at the University of Alabama at Birmingham, at recent briefing held by the Infectious Diseases Society of America.7 “So, we’re talking about an extraordinarily large proportion of people who remain vulnerable.”
Marrazzo looks at a graphic distributed daily at her hospital, with icons for the number of COVID-19 patients admitted, those in the intensive care unit (ICU), and those on a ventilator.
“The vast majority, overwhelmingly, are unvaccinated people in all three categories,” she said. “Vaccination clearly prevents against severe disease, and by severe disease, we mean hospitalization and illness that confers some of the worst comorbidities that we see with COVID.”
Also speaking at the IDSA briefing, Joshua Barocas, MD, an infectious disease physician at the University of Colorado Anschutz Medical Campus, said that only 10% to 20% of his COVID-19 patients were vaccinated. There likely are many more cases of Omicron out there that are not being reported in the official daily tallies, he added. The total is based on polymerase chain reaction tests, not the antigen tests many people are using to test at home.
“This is the minimum number of cases that we likely have in the United States, not the maximum,” he said.
The Accidental COVID Patient
The sheer volume of patients reflects the extreme transmissibility of Omicron, with patients coming in for other illness or injury who do not realize they have the virus until they are tested, said Timothy Dellit, MD, infectious disease physician and chief of medical officer at the University of Washington (UW) hospitals in Seattle.8
“Maybe they had a broken bone, and they happened to also be positive for COVID-19, because it’s so prevalent within our community,” he said at a briefing to UW faculty and students.
Others have reported this phenomenon as well, including in South Africa.
The authors of a study submitted for publication in Hong Kong suggested a possible explanation of Omicron’s transmissibility and relative “mildness,” 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.”9
Although 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.”2 Other studies published recently 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% to 45% for Omicron.10
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.”11
That seems to be what is happening in the United States, as increased census and inadequate staff have pushed UW hospitals into contingency mode because of insufficient staff and bed space, Dellit said. Still, only about 20% of the COVID 19 case are requiring intensive care.
“About 80% of these patients are actually on [an] acute care floor, so they’re not in the ICU requiring mechanical ventilation or other higher levels of care,” he said.
Emergency Department Plight
However, emergency departments are under siege because many patients show up there to be tested for SARS-CoV-2. Jennifer Schmitz, MSN, president of the Emergency Nurses Association, pleaded with patients to not come to the emergency department seeking testing
“If you’re not sure whether you have COVID, coming to an enclosed area where you know people have COVID is not your best bet,” she said in a video statement.12
Schmitz recommended that those seeking testing check with their local and state health departments about testing sites, which also are listed on this website: https://www.hhs.gov/coronavirus/community-based-testing-sites/index.html.
Emergency departments are being hit hard, and 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.” Several other sociodemographic factors were converging before Omicron, and now are coinciding with the emerging variant, Kang says.
“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 [for] 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.”
- The New York Times. Track coronavirus cases in places important to you. Updated Jan. 10, 2022. https://www.nytimes.com/interactive/2021/us/covid-cases-deaths-tracker.html
- Centers for Disease Control and Prevention. Variant proportions. COVID Data. Updated Jan. 11, 2022. https://covid.cdc.gov/covid-data-tracker/#variant-proportions
- Centers for Disease Control and Prevention. COVID-19 integrated county view. COVID Data Tracker. Jan. 8, 2022-Jan. 14, 2022. Updated Jan. 4, 2022. https://covid.cdc.gov/covid-data-tracker/#county-view?list_select_state=all_states&list_select_county=all_counties&data-type=
- YouTube. TWiV 850: COVID-19 clinical update #96 with Dr. Daniel Griffin. Published Jan. 7, 2022: https://www.youtube.com/watch?v=DTysKBBRL_Y
- Abdullah F, Myers J, Basu D, et al. Decreased severity of disease during the first global omicron variant COVID-19 outbreak in a large hospital in Tshwane, South Africa. Int J Infect Dis 2022;116:38-42.
- Maslo C, Friedland R, Toubkin, et al. Characteristics and outcomes of hospitalized patients in South Africa during the COVID-19 omicron wave compared with previous waves. JAMA 2021; Dec 30:e2124868. doi:10.1001/jama.2021.24868. [Online ahead of print].
- Infectious Diseases Society of America. IDSA media briefing: COVID-19 & omicron – practical advice. Published Jan. 11, 2022. https://www.idsociety.org/multimedia/videos/idsa-media-briefing-covid-19--omicron---practical-advice/
- YouTube. Webinar – Winter quarter and the omicron variant. University of Washington School of Public Health. Published Jan. 6, 2022. https://www.youtube.com/watch?v=0NucT9AYDps
- 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. Published Dec. 15, 2021. https://www.med.hku.hk/en/news/press/20211215-omicron-sars-cov-2-infection
- Ferguson N, Ghani A, Hinsley W, Volz E. Report 50 — Hospitalisation risk for omicron cases in England. The Imperial College of London. Published Dec. 22, 2021. https://www.imperial.ac.uk/media/imperial-college/medicine/mrc-gida/2021-12-22-COVID19-Report-50.pdf
- 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. The University of Edinburgh. Published Dec. 22, 2021. https://www.research.ed.ac.uk/en/publications/severity-of-omicron-variant-of-concern-and-vaccine-effectiveness-
- YouTube. Jenn Schmitz | #HearUsTrustUs. Emergency Nurses Association. Published Jan. 13, 2022. https://www.youtube.com/watch?v=3Pb_DaXXrMo
