Hi friends,
My last email went out in mid-January, just after we brought our kid home from school for a few weeks (it turned out to be just shy of a month) to try to avoid the Omicron surge in our semi-rural community. Our area is now seeing very low transmission. Dozens of people I know have gotten covid in the interim, including people who are immensely careful. Blessedly, none of them have become seriously ill, though plenty had a rotten week or two and some are still recovering.
If you got covid over the winter, I hope you had a quick and easy recovery—and if you have it now, as several friends do, I wish you the same. (And if you’re new here, this is the intro post that explains my aims for these emails.)
Keeping honest
Looking back over earlier letters, I think my expectations for the Omicron wave were pretty close to reality in terms of the virus and its effects on the body. For most people who got it, Omicron was a bummer, but not a deadly threat. At the same time, we saw very widespread transmission, hospitals overburdened in some areas, and many deaths. It looks like Omicron has killed more than half a million people worldwide, with numbers still rolling in—and that’s just the official count, which we know from experience to underestimate actual deaths. In the US, Omicron has killed more people than the Delta wave of 2021.
Supply chains, on the other hand, held up better than I’d expected them to. In the US at least, the consumer experience of Omicron was indeed pretty mild.
Where are we now?
First, covid cases are now rising again in many places, which is sooner than I’d expected to see another surge. A mutated version of the Omicron sublineage called BA.2 is almost certainly behind the upswing of cases across Western Europe, where case counts had declined dramatically after Omicron burned through.
Hong Kong’s ultra-strict quarantines and other public health measures kept Omicron at bay over the winter, but the city is now experiencing a devastating wave of BA.2. So many of the city’s dramatically under-vaccinated elderly residents have died that Kong Kong now has the worst case fatality rate (content warning for suicide on that link) among all developed countries, at one death for every twenty identified infections. BA.2 is also spreading across China, triggering massive city-wide lockdowns. Like Hong Kong, China has vaccinated the vast majority of its population as a whole, but a minority of its elders. There is good reason to worry about China’s elderly citizens right now.
On the other hand, the extraordinary promise of mass vaccination is really showing up right now in the UK, where covid is currently—finally—a little bit less deadly than the flu. In the UK, an individual covid infection right now is about 40 times less likely to result in a death than it was at the height of the first wave, thanks to factors including Omicron’s reduced severity, but most of all due to widespread vaccination. (Covid is still killing more people than the flu because of the enormous scale of the Omicron outbreak.)
As always, I feel compelled to note that we still don’t know how many people who get covid will experience either long-lasting, debilitating symptoms or other long-term health damage as a result—a factor that continues to make covid qualitatively very different from the flu. Preprints abound, but I have yet to see anything to suggest that we genuinely understand long covid’s prevalence, with or without vaccines, though there’s every reason to hope that vaccines will prevent many lingering effects by reducing the severity of acute disease.
Where are we headed?
Earlier this week, my pre-Omicron instincts suggested that with cases rising in Europe, we’d be looking at another case surge here in the US in maybe a month, but those instincts were trained on outdated transmission dynamics, and I think I was wrong. Here in the US, BA.2 is now responsible for about a quarter of new infections, and wastewater surveillance suggests that covid outbreaks are already gearing up in many US communities. Wastewater surveillance is extremely spotty in the US, but sharp increases in detected virus are never a great sign, particularly given what we’re seeing in Europe right now.
Omicron moved so quickly over the winter that my brain couldn’t really keep up, and BA.2 is likely to move faster, so I’m trying to plan around the very good chance that we’re looking at a fresh case surge rolling across the US in the next few weeks.
BA.2 looks very familiar
I’m thinking of BA.2 as a not-quite sequel to the Omicron variant. Maybe Omicron 1.5. It seems to be about 30% more transmissible than Original Omicron, but we have no real-world evidence suggesting that it’s more severe. It’s also harder to track because unlike Omicron, BA.2 doesn’t leave clues in a regular PCR test—you have do genetic sequencing to find it.
Lots of things remain the same as with previous editions of the virus: BA.2 is probably transmitted in the same ways as previous variants and the original strain of COVID, and it’s not killing very many fully vaccinated people. We should expect that both vaccinations and prior infections will provide protection against severe disease—but not so much against infection—for people with good immune function.
We’re not going to try to slow it down
Even though much remains the same with the virus and the disease it causes, the world into which BA.2 is arriving has changed. In the US, CDC guidelines are now focused much less on avoiding infections and much more on keeping hospitals from being overwhelmed. Masks are off throughout the US, and pretty much everything is open. Similar easing of restrictions meant to slow community spread is happening across Europe, and the UK has even dropped the requirement to isolate when you know you have covid.
In practical terms, with work and school happening in-person and without high-filtration (or any) masks or serious ventilation requirements in the US and most of Europe, governments in North America and Europe have made increased covid exposure essentially mandatory for most citizens.
I want to emphasize that for most vaccinated people, this increased risk probably won’t be a huge deal even if BA.2 causes a new case surge—they’ve either already racked up enough immunity to fight off BA.2 or they’ll be sick for a week.
The especially vulnerable are on their own
In the US alone, millions of people don’t have normally functioning immune systems, and they may not even mount a strong response to vaccines. Ed Yong’s warm, empathetic feature on the limbo immunocompromised people face is genuinely essential reading.
Here in the US, our federal government has also chosen to accompany a removal of exposure-reduction measures with a bipartisan failure to authorize funding for the preventive and therapeutic treatments many high-risk people will require to survive infections—along with funding for additional vaccines and other aspects of the pandemic response.
Ultimately, it still feels a lot like 2020 for many immune-compromised people. If you need preventives or therapeutics, you can use someone’s apps on GitHub (evushield, paxlovid) to try to find them.
Postscript: We could do so much better
I rarely talk about covid policy but I’m going to for a moment—just skip down a section if you’re not into it.
I think that in the post-Omicron world, mask mandates that fail to specify high filtration are largely theater. I do think giving every household a stack of reusable N95s for and requiring indoor masking with good masks for grown-ass adults during case surges would save a very large number of lives. I don’t think closing schools makes much sense with a variant like Omicron, but I do think our failure to offer high-quality remote learning or safer alternatives to immunocompromised children (or children with immunocompromised caregivers) is shameful.
Also shameful is the widespread failure to take indoor ventilation seriously in the third year of a respiratory pandemic that has probably killed somewhere between 10 and 20 million people, globally. Many other policies have contributed to the pandemic’s misery in the US, and our lack of guaranteed paid leave and our lawmakers’ failure to address the country’s decades-long twin crises of childcare and eldercare deficits jump to the top of the list.
It’s easy to think that we’ve now missed our opportunity to change these policies in response to the pandemic, but that’s not actually the case. Our policy choices remain alive and vitally important to the pandemic response because not one of the infectious disease specialists I trust believe that Omicron and BA.2 are the last covid variants we’ll be dealing with. And there’s no guarantee that the next variant, or the next pandemic, won’t be much worse. As with planting trees, the best time to change our policies was twenty years ago, but the second best-time is now.
(Edited right before sending to note that in a hopeful sign, it looks like the US might be starting to address indoor ventilation as of…a couple of hours ago. We’re still in the recommendations-not-requirements stage, but maybe it’s a start.)
What will happen to us this spring?
Ultimately, I don’t have a good sense of how much the BA.2 wave will look like the first Omicron wave. Outside of zero-covid countries, so many people got Omicron this winter that there should be a whole lot of antibodies running around, which I hope will balance the elimination of public health measures. Overall, I think there’s good reason to hope it will be easier than the last wave.
If you’re immune-compromised or otherwise high-risk, I would encourage you to make sure you’re stocked up on N95s that give you a good seal, and to be prepared to return to whatever protocols you’ve relied on to date as BA.2 ascends.
I am pretty desperate to see friends and family members who live far away, but if we leave our little pod and wonderful small school and travel this spring, it’ll be with the acceptance that I may well get covid as a result, and I don’t know how well my semi-functional immune system will fight it.
Whatever exposure decisions you’re making in this dip between surges—and into the potential BA.2 surge—you have all my empathy and hopes for the best possible spring.
Love,
Erin