Comment: Our response to covid must change with each variant

By Philip R. Krause and Luciana Borio / Special To The Washington Post

The omicron variant, which is blazing through the United States, infecting the unvaccinated and the boosted alike, is causing many crises now — overwhelming hospitals and disrupting businesses and schools through absenteeism — but it is likely to ebb as fast as it rose. That has been the pattern in other countries, notably South Africa and the United Kingdom, that have been hit by it.

The virus is moving so quickly that some current governmental efforts, such as the belated efforts to supply rapid tests to households, and to stress the importance of booster shots, will likely come too late to be useful. Fortunately, omicron appears to produce milder disease in healthy individuals than previous variants did; a factor that should be considered in the national response. A second key consideration, as we move forward, is that a few months from now — between vaccination and infection, or a combination of the two — very few Americans will be truly immunologically naïve to the coronavirus. They will likely have at least some protection, especially against severe disease.

Given these facts, it obviously won’t make sense for our strategy to remain fundamentally the same as it was in most of 2021 (let alone 2020). We should, instead, focus on shielding the most vulnerable members of the population: the unvaccinated, the elderly and those with underlying conditions (such as the 7 million Americans living with compromised immune systems). And we should adapt other policies to ensure that we limit viral spread while not overreacting to the prospect of infection in vaccinated people.

In some ways, the omicron campaign should be about getting back to basics. Vaccination is the most important weapon, and we badly need a more effective communication strategy to convince more Americans to get the shots. In hard-hit New York State, for example, fully vaccinated people were 90 percent to 95 percent less likely to end up hospitalized than their unvaccinated peers. By now it’s clear that top-down pro-vaccine messages from politicians or government officials won’t budge the holdouts; in the past month, the proportion of fully vaccinated Americans has increased by only about 1.5 percent. An effective campaign will require working closely with community health centers and grass-roots organizations.

Masks remain important, but limiting the spread of omicron demands better ones. The White House already requires anyone who spends time with high-ranking officials to wear an N95 (or equivalent) mask; that should be the standard everywhere face coverings are recommended. Supply is no longer a constraint (as it was early in 2020). These masks could be made available at a reasonable price (possibly free) to those who can’t afford to buy them. When worn correctly, they protect against omicron and any future variant that comes our way.

Refocusing on those who are at greatest risk from covid means resuming vaccination programs in nursing homes and long-term care facilities, supplying such institutions with high-quality masks and making sure that these locations have enough tests. Improving the availability and access to effective covid treatments should be a goal as well. Since omicron is resistant to most of the currently authorized monoclonal antibodies, the White House should consider using the Defense Production Act to redirect facilities currently producing antibodies that don’t work on omicron to production of antibodies that do; biding time until more effective ones are formulated.

Americans are tired of this pandemic and, more importantly, the economic and social impact of covid over-response are real. So we should prune policies that no longer make sense.

Most people now realize it’s no longer essential — or even possible — to diagnose each case of covid, especially in people without risk factors for severe disease. But additionally, exposures to the virus are becoming so common that quarantining people for them — as the CDC still recommends for unboosted vaccinated people and for the unvaccinated — risks significant societal disruption: Recurring exposures will keep many uninfected people home from work or school. (Most exposures have a low chance of transmitting the virus, meaning that many people need to quarantine to prevent a single infection. Given omicron’s prevalence, quarantines seem unlikely to affect the pandemic much in any case, since there are so many untraced exposures.)

The CDC’s recent recommendation that covid-positive people could leave isolation after five days without a negative test led to outcry; the CDC now recommends that a positive test, if performed on day five, should lead to five more days of isolation. But the original proposal was very sensible. The fact is that with each passing day after symptoms develop, an infected person is less likely to transmit to others; the likelihood of this is even lower when symptoms are improving and when N95 masks are worn. Prolonging isolation promotes unnecessary absenteeism without appreciably reducing transmission. (In general, people with cold symptoms — whether they’ve been tested for covid or not — should stay home until they are without a fever and clearly improving.)

The exponential spread of omicron should also prompt a relaxation of some travel rules. Bans on travel from countries with high levels of viral circulation have not affected the trajectory of the epidemic in the United States. It’s now clear that omicron had established itself worldwide before it was reported in South Africa. While it is prudent to require certain measures, such as vaccination and masks for travel, testing requirements for international travelers have not delayed the importation of new variants. Such testing also does little to eliminate infections in travelers, whose greatest risk of exposure occurs off planes. (Indeed, Britain is relaxing some of its travel-related testing requirements.)

Vaccine mandates do increase vaccination rates, but omicron may reduce the argument for them; especially over time, as more of the population has a brush with covid. Earlier in the pandemic, vaccinated people were much less likely to transmit the virus to others. There was, therefore, a real possibility of controlling viral spread through vaccination. Today, however, the major benefit of vaccination is to protect the individual from severe illness and death; any possible impact on transmission is short-lived. While we believe that mandates should be used to keep critical health-care sites, businesses, and manufacturing facilities operating, there is no need even in those cases to mandate vaccines for individuals who had a recent covid infection. (Threatening to fire or suspend vaccinated university employees and students — including health-care workers — who’ve had covid but who have not gotten a booster reveals distinctly misguided priorities.)

While we hope that future variants will cause disease that is even less severe than omicron, we can’t be sure; and the next variant could be even better at evading immunity. Therefore, we need to develop a new generation of vaccines that target parts of the virus that are less likely to evolve. In the meantime, vaccine developers will need to prepare to update their vaccines to cover new variants as they appear. This will require major additional government investment. But now is the time to make that commitment, even as we change our pandemic response in other ways.

Philip R. Krause is former deputy director of the Food and Drug Administration’s Office of Vaccines Research and Review.

Luciana Borio is a senior fellow with the Council on Foreign Relations and former acting chief scientist at the Food and Drug Administration.