COVID-19 Update 1/26: Omicron, Herd Immunity, Monoclonal Antibodies, and More

In this week's COVID-19 update, Dr. Bishop discusses the hopeful decline of the Omicron wave, herd immunity, monoclonal antibody treatments, vaccines, and more. Watch the video below or read on for our full recap. 

Omicron Wave Receding

First things first, I think we've got some good news on the omicron wave. If you look at the cases across most of the US. and particularly here in Virginia, it looks like we're on the back half of the wave, which is great.

That's pretty much in line with what most people have been predicting, that by the end of January or early February, the omicron wave will be pretty much over.

And we've had a pretty significant collapse in cases the last few days according to data from the Virginia Department of Health and from CDC, and it looks like the numbers are coming down pretty dramatically, which is again what we would expect to happen.

The overall wave looks like it'll last 30-45 days, maybe 60 days, something like that, which is consistent with the length that it's lasted other places, give or take a week or two.

Hospitalizations have come down in Virginia, as well. We're down to 3,500 total hospitalized people in the state for COVID.

VDH has updated their dashboard and the Virginia Hospital Administration has updated their dashboard, as well, so that everyone who's listed as a COVID hospitalization on that dashboard is in fact in the hospital for COVID primarily, and not COVID as a secondary or incidental diagnosis. I think that is an important piece of data transparency that we've got, so that's good.

The people actually in hospital for COVID is running around 3,500 as of today. The last couple of weeks it's been approaching almost 4,000, so things are definitely improving and that's great news. So we'll continue to see that come down.

The hospitalizations will continue to lag the case numbers, right? And then the final fatality count from this wave will follow that lag, as well.

That being said, the Virginia Department of Health has actually continued to report pretty low fatalities overall from COVID. They're not zero, of course, but they have been actually lower than they have been in a long time, despite the extremely large number of cases that we've had.

Again, that speaks to the fact that omicron, A) it seems to be milder than other prior variants, and B) at this point, many, many, many people are, are vaccinated.

Herd Immunity

The other thing I want to talk about is just to address a blog question that came in. Someone basically was asking, why do we not have herd immunity yet? Why do people keep getting this?

So many people have gotten COVID over the past couple of years. How can most people not have been exposed at this point? Is it just pure luck? What is it? Or are we miscounting them? Like, what's going on here?

It's complicated, is the answer. You have to remember a few things. First, there are a lot of people in the United States.

It's a big country with many, many people. Over 300 million people live here. And let's just take Virginia as a microcosm, because it's a little simpler to get our eyes around those numbers,

There are about eight and a half, nine million people that live in Virginia proper, and of those, the Virginia Department of Health has counted about 1.5 million total cases since the beginning of the pandemic in March of 2020. That's 1.5 million cases that they have counted.

Now, let's take that number apart a little bit.

So, 1.5 million cases roughly, and we've got some cases that are missing from that number because they either never got tested or they tested themselves at home and that never got reported, so we've got some under-reporting in that way. Some cases are missing from that number.

And we've got some cases that are probably double counted and a number of people have gotten COVID twice, for various reasons.

People got delta, and then omicron, for example, which has happened many, many times, so in that way, there's some over counting of cases.

On balance, I think probably that 1.5 million is a pretty significant under-count of the total number of cases, just because so many people have had omicron or even delta and had minimal to no symptoms, or they tested at home and that's not reported anywhere so it's just not captured in the data files.

Even if you were to take that number and double it and say there were three million cases of COVID in Virginia, that's a big number, but that's nowhere near the majority, right? Three million out a nine is still only a third roughly, so only a third of people have had it.

We're nowhere near that 80% of people that have to get an infection to really have "solid" herd immunity from a natural infection standpoint. We're way away from that still.

Now, if you add in the vaccination numbers? Then you get much closer in terms of herd immunity for the purposes of it being a fatal illness, which is ultimately the goal, right?

We want this to not be a fatal illness, and we've been talking about that for months. Our goal is to make this as much of a non-event for people as possible. Okay, you've got COVID, you're vaccinated, great. You may have a bad cold. You may feel a little yucky for a few days, but then you're going to go on about your life, and I think that's the goal here.

With the current vaccine technology that we have and with the fact that omicron seems to be milder than the prior variants, our goal really is to reach a point where we have sort of come to an equilibrium with the illness.

Yes, it's an issue, but we can manage it because we don't have vast swaths of people getting horribly ill, fatally ill, or needing hospitalization.

So, again, like we've talked about from the beginning, especially adults and especially older adults and anyone with a medical problem, we really need to get those vaccination numbers up.

And we have a majority of Virginians that have gotten vaccinated, about 66% have had two doses, which is great. It would be great if it was higher. It would be great if it was higher, especially amongst older adults, as well.

So we need to push those numbers up as much as we can. I think eventually, again, we'll get around to the fact that we'll need annual boosters for the COVID vaccine at some point, which I think it's just going to be a feature of our vaccination campaigns going forward. Flu shot, COVID shot.

I hope that helps explain a little bit why there's a little bit of, like, oh my gosh, how has everyone just not had COVID yet? And it's just pure numbers. There are a lot of us, and a lot of us have had COVID, but nowhere near a majority.

That's why vaccination continues to be so important for most people because eventually, you will get exposed, but not yet for everybody.

Monoclonal Antibody Treatments 

Let's talk about monoclonal antibody treatments for a minute because that's been in the news. There's been a little bit of controversy this past week.

I know that the FDA rescinded the Emergency Use Authorizations for a couple of the antibody products, Regeneron being one of them.

And Sotrovimab is still available, and the reason those EUAs were rescinded, and I know it caused some consternation, those other monoclonals don't work very well for the omicron variant.

I think, all things considered, it would be better to give some high-risk person some antibody treatment rather than no antibody treatment. In an ideal world, we would give everybody who got COVID who's high risk, they would get Sotrovimab, right? But the supply of that is still pretty low.

I do think the FDA was a little premature in making the EUA for that, because A, we do still have some delta out there, but it's not like that the omicron results in zero efficacy for the other antibodies. It's just that it's very low.

I think again, some antibody treatment is probably better than none for high-risk people, but Sotrovimab is better. That's a judgment call that was made.

I think if we had lots of Sotrovimab doses, I think it becomes less controversial because we could have just replaced all the doses we took of Regeneron and the other things with Sotrovimab, but they have not gotten the supply up of that yet.

Doctors and patients are being put in an impossible situation with having basically now nothing to offer again in terms of antibody treatments.

We do have Paxlovid and we do have Molnupiravir, so those treatments can be used in high-risk, older people, and I think they're fine to use. Paxlovid, in particular, I think is pretty safe in general and seems to be fairly effective, so I think that's going to be a fine option for a lot of people, but that may not be an option for everybody.

So it's always good to have more treatment options rather than fewer. That's kind of what's going on with the monoclonal antibodies

Omicron-specific Boosters

And one more update on vaccines. Pfizer is launching their trial of a COVID vaccine targeted to omicron, so an updated omicron-specific vaccine. Here is the article from Reuters about the new trial that they are starting.

This would be a small trial. It looks like they're going to try to get about 1,400 people in the trial, and this is going to be a safety and tolerability trial. That's sort of phase one and phase two trials, where they're trying to make sure that the new vaccine product is safe and that it does elicit an immune response, so more to come about that for sure.

And I think you'll see this again as we get into the annual booster program. You'll see them tailored more toward whatever variants are circulating, kind of like we do with the flu every year, right? Similar idea.

N95 Masks Available from the Government

"The government's giving out free N95 masks now?"

Yes, I think some are being mailed and I think some are going to be available in lots of local pharmacies, so CVS, Walgreens, and that sort of thing. I think you can go and pick 'em up there.

I don't know if they are available yet, but I think they will be available soon. I know there was a message from our CVS basically saying that they would be available soon, but they didn't give an exact date on that. I suspect it'll be in the next few days when those things will be available.

N95 Masks: FIlitration Level

"What filtration do the N95s have? The one I wear is 99%."

I don't know exactly what brand they are. I know they are N95, so they should have that same level of protection as a typical N95, so 95% particle filtration, versus an N100 or something like that.

Now, they do work better than the KN95s most likely, but the KN95s are roughly equivalent, so good question.

Lag Time Between Infection Decline & Death Decline

"What is the lag time between declines in COVID infections and declines in COVID deaths? There were almost 4,000 documented COVID deaths last Friday, the worst since vaccinations have been available and currently the nation losing each day more than we lost in 9/11. How long can we expect this to continue now that we may be past peak infection?"

Probably two to three weeks. We will see a lag time. That's typically what happens for what we've got there. That's the typical lag. Hospitalization numbers are going to lag about two weeks and then probably we will see a lag of another week or so in terms of fatalities.

Vaccinated Percentage Include Children? 

"Does the percentage of people vaccinated in Virginia include children?"

I believe it does include children.

Unvaccinated and Uninfected Driving Variants

"I think I read today there are three billion people worldwide who have had zero vaccinations or infections and that population is likely to drive mutations that could create new variants of concern that could affect vaccinated folks."

Certainly, yeah. That's probably true. And I think that that's part of the reason that the World Health Organization has been very vocal about saying we really need to prioritize vaccine delivery to the third world and to poorer countries because so many of those people don't even have access to them yet.

I think that's why the WHO has actually been fairly vocally and openly critical of booster campaigns in general in Western countries because they feel like those doses would be better used in populations that have had very little access to vaccines.

And part of it is this reason that the more infections we have and the longer the infections go on, the more sick people we have in terms of very sick people, the more variants we're going to have. I think that is a valid concern.

Monoclonal Antibody Research

"Do they have any real research on monoclonal antibodies?"

I'm not sure what you mean. They've got clinical trials showing efficacy. They're small trials, of course, so it's under Emergency Use Authorization, so the trials are small.

I can tell you in my clinical experience and looking at the trial data, the monoclonal antibodies are probably amongst the safest treatments for COVID all around in terms of whether you're thinking about Paxlovid or Molnupiravir or even other off-label things that you often see in the news, ivermectin, hydroxychloroquine, things like that.

The monoclonals are safer than those things and do you have better efficacy than all those things, so aside from a few prescriptions for Paxlovid, we are now pretty much exclusively using the monoclonal antibodies whenever we can get our patients in for those infusions because again, they're safe, they work, and we have seen good clinical outcomes from that.

Delta vs. Omicron

"Is the delta variant still a threat or is it out of the picture replaced by omicron?"

It's pretty much almost out of the picture. Not completely, but it is making up quite a small percentage of infections all over the place, which again, is part of the reason why the FDA revoked the Emergency Use Authorization for those other two antibodies because the delta is fairly rare at this point,

NIOSH Stamp on Masks

"Make sure your masks have a NIOSH stamp on them."

Yeah, good advice, otherwise they may be knock-offs. Yep, that's good advice, good advice.

Repeated Antigen Testing

"I've been sick with cold/upper respiratory type symptoms for a couple of weeks. I've used antigen tests and they've all been negative. Are multiple tests still enough for me to feel confident it isn't COVID?"

There is some data indicating if you do two or three antigen tests, the sensitivity is roughly equivalent to one PCR.

I will tell you in practice, we have seen lots of patients with similar symptoms test at home for COVID, even with several tests, two, three, and they're negative, and then they have a positive PCR.

I think at this point, the only thing you can really trust in terms of the home test is if it's a positive test. If it's positive, you've got it.

I don't think you can trust the negative test at all at this point in a symptomatic person, and probably definitely not in an asymptomatic person.

If you're worried you have COVID and you have symptoms, I think you really need to get a PCR. There is a company working on providing an updated version of the home test that does better at detecting omicron, but the current home tests, again, you can't really trust the negative test at this point. I would only trust it if it's positive.

If you have symptoms and you're worried, I would go ahead and get a PCR test. That's what I would do.

Monoclonal Antibodies and the FDA

"Based on what you said about monoclonals, why would the FDA make their decision?"

They removed them from authorization because the couple that they revoked don't work on the omicron variant, which is accounting for the vast, vast, vast majority of the infections at this point.

In their estimation, there's no longer any purpose for them being under an Emergency Use Authorization because they don't work. Only Sotrovimab works now pretty much because almost all the infections are omicron.

The EUA was not revoked for Sotrovimab. It was just revoked for the other ones, so Regeneron is the most prevalent one that's out there. They didn't revoke them for all. They revoked the ones that they feel are basically feel are futile or not useful anymore, so that's a good question.

When is the next update?