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The Omicron situation
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The Omicron situation

What the experts are saying, and what I think

Noah Smith
Nov 28, 2021
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The Omicron situation
noahpinion.substack.com

When it comes to the Covid pandemic, it’s important to react quickly. Last time a major new variant emerged, we watched millions of Indian people die while we sat there and waited for U.S.-specific data before taking any kind of serious action. This was the result:

Fortunately, it appears that the world is reacting to the new Omicron variant with much more urgency than it reacted to Delta. But it can be difficult to cut through the noise. Back when Covid first started, I used to tweet out a series of “coronavirus tweets from the experts” every day, to help people keep up with what the most knowledgeable voices were saying. So I thought I’d reprise that here, and point to a few articles and Twitter threads that have helped me better understand this new threat.

First, of course, check out my video interview with Eric Topol. But in addition, here are some other points I’ve gleaned from the past three days of reading.

Point 1: Yes, Omicron is extremely worrying.

So why is Omicron worth freaking out about? Two reasons. First, it’s spreading fast, and taking over very quickly from the Delta variant. And second, unlike Delta and other variants, Omicron has evolved a whole suite of mutations that are thought to facilitate evasion of known antibodies, along with some mutations that may make it more transmissible. Read this thread by Christina Pagel to see why scientists and public health officials first became alarmed:

Twitter avatar for @chrischirpProf. Christina Pagel @chrischirp
Because of this increase, COVID sequencing has been concentrated on samples from Guateng. Almost all recent samples from there (77) have been this new variant (blue dots) - taking over from a background of Delta (red) and C.1.2 (also a concerning variant, yellow). 4/16
Image

November 25th 2021

404 Retweets2,297 Likes

Here is a Nature article explaining what we know about the new variant.

Trevor Bedford, a mathematical epidemiologist who is generally regarded as one of the most trusted voices on the subject of Covid mutations, has a thread explaining why the mutation pattern seen in Omicron is so alarming. Here, reposted from above, is a key graph showing just how big a genetic jump Omicron is compared to other variants:

The upshot:

Twitter avatar for @trvrbTrevor Bedford @trvrb
Growth rate (in absolute terms and relative to Delta) will be become clearer in the following days, but at the moment, I believe we're looking at a variant that potentially has significant immune evasion and that appears to be spreading rapidly. 15/16

November 26th 2021

779 Retweets2,140 Likes

The WHO, meanwhile, believes that Omicron has a higher reinfection risk than other variants.

And here is a more technical thread about Omicron’s escape potential, from the Bloom Lab:

Twitter avatar for @jbloom_labBloom Lab @jbloom_lab
Here's how mutations in #SARSCoV2 Nu variant (B.1.1.529) will affect polyclonal and monoclonal antibodies targeting RBD. These assessments based on deep-mutational scanning experiments; underlying data can be explored interactively at
jbloomlab.github.io/SARS2_RBD_Ab_e… (1/n)OverviewInteractive visualizations of Bloom lab deep mutational scanning measurements of RBD mutations that escape antibody binding.jbloomlab.github.io

November 25th 2021

1,208 Retweets2,760 Likes

(Note: At this point, the Omicron variant was still being called the Nu variant. That name was changed, for obvious reasons.)

A rumor is going around that Omicron is less deadly than other variants, but so far this is unsubstantiated. It’s based on an out-of-context quote from a South African doctor who found only mild cases among a group of young, healthy people. Once again, wishful thinking springs eternal, but don’t fall for it.

That said, the more dramatic graphs you’ve seen about Omicron spreading like wildfire may overstate the speed of its spread:

Twitter avatar for @ScottGottliebMDScott Gottlieb, MD @ScottGottliebMD
Comprehensive article on Omicron's emergence. "Based on a comparison of different Omicron genomes, Andersen estimates that the virus emerged sometime around late September or early October, which suggests it might be spreading more slowly than it appears."
‘Patience is crucial’: Why we won’t know for weeks how dangerous Omicron isLab tests and patterns of spread will show whether the new SARS-CoV-2 variant’s many mutations are a serious threatscience.org

November 28th 2021

67 Retweets222 Likes

Nevertheless, we don’t want to make the mistake we made with Delta. We’ll only know for sure how dangerous this variant is until after it does its damage. So we can’t wait to be sure; we must act now.

Point 2: No, this doesn’t mean we’re headed back to March 2020.

Before we talk about what actions we can take, here’s one more point that’s worth mentioning: Even if Omicron is an escape variant, that does not mean we’re “back to square one” with regards to this pandemic. It’s all a matter of degree. As Katherine J. Wu explains, our bodies develop a very diverse array of defenses against new viruses, and even a variant which evades some of those defenses won’t simply breeze past all of them. And as this paper in Nature shows, it takes many many mutations to fully escape antibodies to existing variants, and there’s also T-cell immunity to contend with. So the vaccination we’ve already done was not wasted, and the immunity we’ve built up is not useless. Booster shots of the existing vaccine will be useful, and we should all get them.

BUT, as that very same Nature paper shows, there’s a good chance that Omicron will be able to bypass existing immunity to a much greater extent than other variants. Michael Worobey has a good thread on this. Basically, the authors made a synthetic spike protein with a bunch of mutations they thought would allow it to escape existing known antibodies — many of which are now found in the Omicron variant — and they found that it was indeed very good at escaping antibodies. (It’s worth noting that at least one of that papers’ authors is quite pessimistic about Omicron.)

So while it’s still important to get a booster shot, we may need more if we’re going to beat Omicron.

Point 3: Travel bans on African countries are not going to stop Omicron.

OK so how do we stop this scary new variant? It’s important to realize that travel bans on African countries have no chance whatsoever at stopping Omicron from reaching our shores. This should be obvious from the fact that country-specific travel bans never stopped any other Covid variant. But it bears repeating. Omicron is already out there, and soon will be everywhere.

Twitter avatar for @TrevorABranchTrevor Branch @TrevorABranch
countries banned because of the omicron variant vs. countries with confirmed omicron cases
Image

November 28th 2021

883 Retweets1,768 Likes

Florian Krammer has a thread suggesting that although Omicron was first detected in Southern Africa just a few days ago, it has probably been circulating internationally for a while.

Twitter avatar for @florian_krammerFlorian Krammer @florian_krammer
1) My gut feeling from hearing of Omicron cases in Botswana, ex-Malawi, ex-Egypt (2 now it seems) and in South Africa is, that the variant was flying under the radar in undersequenced countries for some time until Botswana and South Africa detected it and sounded the alarm.

November 27th 2021

2,766 Retweets12,076 Likes

So we should ditch the travel bans; at best they’re simply theater, and at worst they could give us a false sense of security. Even worse, banning travel from countries that find new variants simply punishes countries with good variant surveillance!

Twitter avatar for @snolenStephanie Nolen @snolen
It's hard not to see this as South Africa being punished for the fact that it has world-class scientists, doing some of the best Covid surveillance in the world, and is transparent about what they find.

Stephanie Nolen @snolen

So I'm in my 3d hour on a tarmac at Schipol. While my flight from Jo'burg was somewhere over Chad, Europe went into variant panic; by the time we landed, we weren't allowed off the plane. They won't even let a catering truck bring us water.

November 26th 2021

4,108 Retweets17,170 Likes

Point 4: Variant-specific booster shots are already in the works.

So if travel bans won’t work, what will? The obvious approach to an escape variant is to use variant-specific boosters, sort of like we do for flu shots every year.

Twitter avatar for @florian_krammerFlorian Krammer @florian_krammer
6).....since it is likely that one 'variant-booster' would do the job. Our B-cells can be retrained to recognize both, the old version and the variant, and it doesn't take much to do that.

November 27th 2021

191 Retweets1,795 Likes

Here is a thread from Meg Tirrell about how vaccine manufacturers are already working on variant-specific boosters:

Twitter avatar for @megtirrellMeg Tirrell @megtirrell
What vaccine makers are saying about B.1.1.529: -Moderna notes it's shown it can get into clinic (human trials) within 60 days; question is regulatory process from there. Manufacturing new doses could take a few months. -BioNTech expects lab data within 2 weeks (1/2)

November 26th 2021

1,394 Retweets3,562 Likes

Moderna is also working on a multi-variant booster, sort of like what we use for flu shots.

So both vaccine manufacturers and the administration are on high alert. That means the ball on variant-specific boosters is now in the FDA’s court. It’s very important that they streamline the approval process. After that, it will be up to the CDC to recommend variant-specific boosters to the general public.

Meanwhile, as Topol noted in our interview, a pan-Covid “supervaccine” of the type currently being worked on by multiple labs would be even better than having to get Covid shots every 6 months or 1 year. It would allow us to put an end to this pandemic decisively, once and for all. So we need a new version of Operation Warp Speed to fund and coordinate the development one or more supervaccines.

My thoughts

OK, so those are the views of the experts. If you want more, you can follow my Twitter list of Covid experts. But I’d also like to give some of my own thoughts here.

Basically, the age when we could expect to stop the virus with non-pharmaceutical interventions — lockdowns, social distancing, masks, test-and-trace — is long, long over. Not only has popular appetite for this strategy waned to almost nothing, but new variants are so contagious that these strategies just aren’t sufficient to stamp out the virus. Every country except China is transitioning to a “live with Covid” strategy (and China is hurting itself by trying to maintain its “zero Covid” policy). So while you should still wear a mask, and while some cities may do some limited business closures, we should assume that distancing measures will not be our first line of defense against Omicron.

Vaccines will be our first line of defense. In the short term this means getting a booster shot of the existing vaccine, in order to restore antibody levels in time for the Omicron wave. Unfortunately, America has been doing an absolutely awful job of rolling out booster shots.

This isn’t because of antivaxers, who, while a pernicious force, are only about 20% of the population. Instead, it’s because America’s public health authorities dragged their feet on recommending that Americans get booster shots:

Twitter avatar for @EricTopolEric Topol @EricTopol
The @CDCgov advisors today came out with a recommendation that adults age 18-49 "MAY" get a booster. It should be SHOULD. Here's why:

Eric Topol @EricTopol

Why should every adult get a 3rd shot (booster) when eligible (6 months after 1°💉)? 1. A randomized, placebo-controlled trial, the gold standard for assessing efficacy, showed restoration of efficacy to 95.6%, in >10,000 participants across all age groups https://t.co/zORXc5LuiK

November 19th 2021

208 Retweets745 Likes

As Topol noted in our interview, the biggest reason for this was that U.S. agencies like the CDC are extremely provincial, and basically ignored evidence from other countries. That’s very bad, and it fits with the general narrative of a crisis of competence at the CDC.

But another reason, which Topol acknowledges, is that some public health officials in the U.S. saw boosters as taking away vaccine doses from developing countries. With America now mostly vaccinated, these officials decided that recommending a third shot would harm global equity. The head of the WHO certainly made this argument, calling booster shots a “scandal”. There were op-eds in major papers and articles in reputable journals pushing the idea, and it was so widespread that I even saw articles about how to deal with guilt after getting a booster.

As I see it, this argument is ridiculous. The correct response to vaccine scarcity is not to imagine a zero-sum competition between the developed and developing worlds; it’s to simply make a lot more vaccine doses. As our successful ramp-up of vaccine manufacturing at the beginning of this year showed, we can very quickly expand our production a whole lot when we deem it a priority. But instead of making that our priority, we succumbed to the pernicious fantasy that the number of doses is fixed, and the result was that both Americans and people in the developing world died unnecessarily.

With Omicron, it’s likely that a similar mistake will cause a lot more deaths than it did with Delta. We face the terrifying prospect that an unholy alliance of antivaxers and misguided public health officials will stop us from getting boosters — including variant-specific boosters, when those come out.

We cannot let that happen. The Biden administration needs to overrule the public health establishment where necessary, and urge everyone to get boosters ASAP. And even more importantly, it needs to put a lot more resources into significantly ramping up vaccine manufacturing. As I’ve said since the start, this will be a long war. Omicron has reminded us that it’s far from over.

Update: Here’s a second post with one more week of info.


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Jacob
Writes Streams of Consciousness Nov 28, 2021

Will this just be a perpetual boy who cried wolf? I took fairly low precautions before getting my two moderna doses in Spring '21, and have taken no precautions since. My family and pretty much everybody I care about did similarly.

Nobody in my network even noticed Delta despite all the histrionics, and this feels a lot like a rerun.

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Tim Nesbitt
Writes The Way by OR360 Nov 28, 2021

One barrier to the rapid expansion of booster shots, beyond production and distribution, is the growing wariness about day-after effects. I scheduled my booster on the day before a day when I had nothing scheduled. Sure enough, I spent that second day on my back (as I did with my second Moderna shot earlier this year). Anecdotally, I'm hearing more people who were eager vaccine takers earlier this year say they're putting off their boosters until they can plan a day off from work and family obligations. The problem here may not be limited just to those who had reactions to the first round of vaccines, since word-of-mouth accounts can drive more widespread concerns about those experiences -- or just give busy people people another reason to delay what they know they should do. I have not seen any data on how large that population who suffered these Day 2 effects is. And, although these effects are relatively minor, it they cause you to lose a day of work, that's significant. It seems to me that health authorities should be addressing this, not ignoring it. There are ways to overcome this problem, including working with employers to provide the boosters on a sequenced basis (employers may also become wary of incurring Day 2 absences from their staff if all are given boosters in the same week) and providing pay for those who miss work due to second day effects. But, not talking about it and not dealing with it is sure to slow down the needed uptake of boosters.

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