By Robert Nelson, MD
January 13, 2022
We have a choice to make, and we need to make it soon. Do we want to live in perpetual cycles of psychosocial and economic stress triggered by a reactionary approach to the case count and exacerbated by hapless containment policies, or do we choose to embrace a measured, do-no-harm realistic approach knowing that eliminating the virus is impossible?
The U.S, and many parts of the world, are experiencing a massive spike in covid cases caused by the highly contagious Omicron variant. Despite 81% of the eligible population fully vaccinated plus in-door mask mandates and proof-of-vaccination laws, San Francisco has seen cases spike to levels higher than that of the delta spike last summer or last winter. Contrary to predictions, hospitalizations are only a fraction of what they were during the past two waves and based on previous rates should be twice what they are now. This decoupling of cases from hospitalizations is partially a vaccine effect, but a recent study indicates Omicron is significantly milder than Delta, regardless of vaccine status.
“Reductions in disease severity associated with Omicron variant infections were evident among both vaccinated and unvaccinated patients, and among those with or without documented prior SARS-CoV-2 infection.”
“Several lines of evidence support the hypothesis that the Omicron variant might have a lower propensity to result in severe illness as compared with the Delta variant. Consistency of the association of Omicron variant infection with reduced risk of hospitalization across age and comorbidity categories, and regardless of prior immunity from vaccination or SARS-CoV-2 infection, during the same month and in the same population, argues against host or behavioral factors as causes of the observed disease attenuation with the Omicron variant.”
What to do?
The realities brought in focus by data accumulated over the past 18 months have made the choices clearer about how to deal with this contagion and suggest that Omicron may be the storm before the calm. Let’s follow the chain of evidence.
As the emerging data suggests, everyone has a date with SARS-CoV-2, vaccinated or not. Breakthrough cases will account for an increasingly higher percentage of newly diagnosed cases. As time since vaccination elapses, the percentage of vaccinated individuals who contract the virus and pass it to another person increases. These finding should tell us that the vaccine alone is inadequate to stop the spread of COVID-19. I think it is safe to say, the pandemic will end when a significant percentage of the vaccinated population recover from COVID.
“In the UK it was described that secondary attack rates among household contacts exposed to fully vaccinated index cases was similar to household contacts exposed to unvaccinated index cases (25% for vaccinated vs 23% for unvaccinated). 12 of 31 infections in fully vaccinated household contacts (39%) arose from fully vaccinated epidemiologically linked index cases.”
“In Germany, the rate of symptomatic COVID-19 cases among the fully vaccinated (“breakthrough infections”) is reported weekly since 21. July 2021 and was 16.9% at that time among patients of 60 years and older [2]. This proportion is increasing week by week and was 58.9% on 27. October 2021“
“A similar situation was described for the UK. Between week 39 and 42, a total of 100.160 COVID-19 cases were reported among citizens of 60 years or older. 89.821 occurred among the fully vaccinated (89.7%), Peak viral load did not differ by vaccination status or variant type [1].“
Thankfully, the vaccine lowers risk of severe disease and death in the intermediate term, though it does very little to protect against contracting subsequent infection; and this might be a good thing considering that natural immunity has been shown to be superior to vaccine-only immunity at protecting us from symptomatic infection, hospitalization and death. A Kaiser Permanente Southern California study showed the 2-dose vaccine regiment had zero vaccine effectiveness beyond 6 months, with only 30 – 40% VE for the initial 90 days after vaccination.
Research from Denmark suggests that vaccination actually increases the secondary attack rate with Omicron but not with Delta, while no difference in SAR was seen in unvaccinated households when comparing Omicron to Delta. Some suspect this could be a manifestation of immune escape and possibly a consequence of the phenomenon of Original Antigenic Sin.
“Unvaccinated potential secondary cases experienced similar attack rates in households with the Omicron VOC and the Delta VOC (29% and 28%, respectively), while fully vaccinated individuals experienced secondary attack rates of 32% in household with the Omicron VOC and 19% in households with the Delta VOC. For booster-vaccinated individuals, Omicron was associated with a SAR of 25%, while the corresponding estimate for Delta was only 11%.”
“Comparing households infected with the Omicron to Delta VOC, we found a 1.17 (95%-CI: 0.99-1.38) times higher SAR for unvaccinated, 2.61 times (95%-CI: 2.34-2.90) higher for fully vaccinated and 3.66 (95%-CI: 2.65-5.05) times higher for booster-vaccinated individuals, demonstrating strong evidence of immune evasiveness of the Omicron VOC.”
But there’s reason to be optimistic when we catch the virus. Studies from Canada and Kaiser Southern California, looking at large cohorts of patients with confirmed COVID, measured outcomes for Omicron compared to Delta. Results are in line with previous reports that Omicron (which has largely displaced Delta) is associated with reduction in the rate of hospital admissions of about 60 – 70% compared to Delta. And the length of hospital stay was 3 days (69%) shorter compared to Delta. Even more importantly, the studies showed general agreement that mortality from Omicron, regardless of vaccination status, was 75 – 90% less compared to Delta.
One issue conspicuous by its absence in the Kaiser study was any discussion of case fatality rates between the two study groups. The Omicron group was huge, with 52,297 cases but only 235 hospital admissions (0.5%) and only 1 death. That represents a CFR of 0.002% which is nearly identical to the CFR of COVID in school children. If this fatality rate is accurate, that is very good news! This is even more encouraging when we consider this in light of the decreased vaccine effectiveness for Omicron; it appears the mortality/morbidity of Omicron is not related to host factors but rather a characteristic of diminished virulence of the virus. Even the CFR for the Delta came in at 0.08%, which is in line with the CFR of seasonal Influenza.
Speaking of mortality rates, CDC Director Walensky had this to say recently.
“The overwhelming number of deaths, over 75%, occurred in people with at least four comorbidities. So really these are people who were unwell to begin with.”
If we factor in mortality by age group, we find that 93% of the COVID deaths in the U.S. have occurred in people age 50 or older and 65% of the deaths occurred in individuals 65 or older. Combining age risk with comorbidity risk figures quoted by Dr. Walensky, we can estimate that most deaths (70%) occurred in those over 50 with at least four comorbidities. Contrast that with a Flu-like case fatality rate of 0.08% for age birth to 18 or a CFR of 0.001% over the past 6 months for ages 5 – 24.
In light of this COVID mortality data, it makes no sense to mandate vaccines for school-age children who represent the lowest risk population if mandates are justified solely on risk assessment (and I disagree that they should be). Exactly how does one measure the benefit of a vaccine when the recipients have nearly a 100% recovery rate? The only way is to cite RELATIVE risk reduction without regard to absolute risk reduction, which is a statistical gimmick.
I often hear that vaccinating healthy children will protect the elderly. That is an odd defense if we really believe the vaccine provides individual protection against hospitalization and death, yet is not very effective at preventing infection. Everyone at risk has had ample opportunity to receive the vaccine and a booster if indicated. So, with the vaccine readily available to at-risk adults, when did it become the responsibility of children to protect society at-large?
Moreover, using the collective good as a justification for a mandate, without first considering individual welfare, violates the first principle of individual sovereignty regarding medical treatment. It then becomes obvious that the broad acceptance of a vaccine mandate has nothing to do with its virtue and everything to do with its power to coerce. There are definite risks associated with covid vaccines and where there is risk, there needs to be choice. The risk-benefit decision varies tremendously from person to person. There needs to be informed consent and ability to exercise informed refusal. It must be an individual choice.
So, how do we stop a rapidly spreading respiratory infection like COVID?
“You don’t”, says Lone Simonsen, a professor of population health science at Roskilde University in Denmark. “Once a disease reaches that level of transmission, there is no way to stop the spread completely.”
And if we can’t stop the spread, what do we do? Well, it appears we’ve done what is necessary to move past the pandemic, but collectively we have yet to embrace the reality and put it into practice!
We’ve lowered mortality rates with vaccine and better treatment protocols. Those at risk of complications and death have had ample opportunity to receive the vaccine. And data is clear, the majority of those who have recovered from COVID have robust and durable immunity; if they do succumb to subsequent infection, it is not nearly as likely to be life-threatening. And now nature has provided us with a variant with high transmissibility and lower pathogenicity with a case fatality rate on par with seasonal Flu. Given are present situation, we should take a cue from Norway. Here is what they did in the fall of 2021.
The Norwegian Institute of Public Health FHI has made the remarkable, but statistically supported, decision to classify Covid-19 as a respiratory disease that is as dangerous as the common flu. It is clarified that the pandemic is not over, but that it has entered a new phase where Covid-19 is now equated with a common respiratory disease, such as a flu or respiratory infection. This is done, among other things, due to the mutations that the Coronavirus has undergone, which makes it less dangerous, together with increased natural and vaccination-induced immunity that has been achieved in Norwegian society.
Coronavirus no longer creates a large burden on healthcare in Norway. This is because the vast majority of those at risk are protected. Those who are vaccinated also get severe symptoms and those who are not in the risk groups also usually only get ordinary mild cold symptoms. FHI thus makes the assessment that the Coronavirus now joins the ranks of other respiratory viruses such as the common cold and seasonal flu.
Controlling cases is the wrong message because it’s the wrong metric, as the Omicron wave, in the face of rising vaccination rates and breakthrough cases, should tell us. It’s time to try a new approach.
In addition to having the political will and a sober perspective to view the virus as Norway has done, there are additional imperatives in our approach. We must protect the most vulnerable by vaccination where appropriate, maximize preventive strategies and utilize effective treatments early to avert complications. And we must do this with an intentional focus on policies designed to do the least harm to those at lowest risk for infection complications and which allow people to pursue their livelihood. We cannot permit unproven mitigation efforts to be forced on the population indiscriminately without an honest accounting of their impact and unintended consequences on the lives of real people and without an assessment of their efficacy.
This means abandoning ineffective and often harmful school mask mandates and closures considering children are very unlikely to spread the virus or die. Data shows school mask mandates don’t make any difference in infection rates and there is no statistically significant difference in hospitalization rates of mask-mandate states vs no mandate states during the Omicron surge. And, given the m-RNA agents are disease-modifying “vaccines” that don’t protect against future infection or transmission, they should be used to mitigate risk only; not with expectation of preventing infection in those at lowest risk. We need to recognize that most who have recovered from natural infection have immunity superior to, or on par with, vaccine-induced immunity and thus it makes no sense to mandate vaccination as a requirement for work.
The stresses of having our lives pre-occupied with the latest news and admonitions about how to deal with the virus are enormous. We cannot allow the recent massive spike in Omicron cases to trigger more of the same failed interventions that were used in the first two major COVID waves. Not only did most of these interventions fail at their stated goals , but they caused overt harm to real people on multiple levels. We can’t tolerate any more unnecessary carnage to the socioeconomic ecosystem which is so vital to a prosperous and free civil society.
The sooner we decide to get comfortable viewing COVID as a virus that will be around for a long time, the better off we will be, because hiding from it and trying to shut it down have been colossal failures.
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