In omicron's shadow, a look at vaccine successes, the variant's patterns, updated guidelines

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. We've entered our third year with a pandemic underway and a more contagious variant. So I'm talking again with Dr. Stephen Thomas. He's a virologist and an infectious disease specialist who is also the director of Upstate's Institute for Global Health and Translational Science. I appreciate you making time for The Informed Patient, Dr. Thomas.

Stephen Thomas, MD: Well, thanks for having me back. I appreciate it.

Host Amber Smith: When we spoke a year ago, you said that life could start looking normal again within 12 months, if we, as a nation, got vaccinated, improved our use of masks and followed social distancing guidelines. So as a society, where did we fall short?

Stephen Thomas, MD: Well, we had, we had successes, I think, in a lot of areas, primarily I think vaccination. You know, you can look at it either way, half full or half empty. I mean, we have 63% of the United States, as of today, is fully vaccinated, and folks over the age of 65, it's almost 90%. Almost 80 million Americans have had a booster, which is good. And the numbers of the doses of vaccine that we've been giving out each day has kind of gradually been rising since July. So it's just over 1 million doses a day. Closer to home, we're in the seventies. So New York's about 73% fully vaccinated, and Onondaga County is about 71%.

Stephen Thomas, MD: So I think that that's a good thing. We certainly did get very lax with safe gathering and social distancing, physical distancing, and, and mask wearing. We did get lax, and I think a combination of reduced vigilance with those non-pharmaceutical interventions, changes in the weather, unsafe gathering, and now this highly transmissible variant has kind of put us back into a bad spot.

Host Amber Smith: The mask recommendations and requirements have changed a lot over time, and they seem to vary depending on where you're living. What is your best advice right now for someone who's determined not to catch COVID-19, but who also can't remain isolated? What sort of masking is recommended?

Stephen Thomas, MD: There is no 100% guaranteed way of preventing yourself from getting exposed or reducing your risk to zero. I mean, there are extreme ways we could all think of, but that's just not, that's not reality. So what we try to do is, we try to take the most effective measures we can and layer them one on top of the other. The most important would be getting fully vaccinated. And I think, now at least with the messenger RNA vaccines, I think that those are three dose vaccines, and I think the Johnson and Johnson vaccine is at least a two dose or, a mix and match of Johnson and Johnson with a messenger RNA vaccine.

Stephen Thomas, MD: As it relates to masks, you know, that messaging has also kind of changed. On the one end you have, people who don't wear masks. And I would say that that's not a good decision right now, to not wear a mask when you're in a public place or to not wear a mask when you are outside of your pod and what you know is a safe environment. The cloth masks and the gators -- depending upon how they're made, because they're not all created equal -- they offer probably the lowest level of protection, but they're better than nothing. The next level would be an ear loop mask. The next level after that would be a surgical mask. So those are the masks that you tie, and the difference between those two is the adequacy of the fit. So lack of open areas on the side, and also their filtration. They differ in filtration with the surgical masks being better. And then you start getting into the higher grade masks, the KF 94s and the KN95s. And then the top, which is what the clinicians who are taking care of patients that are known to have COVID or are being ruled out for COVID, that's when you get into the N95s and the pappers, these positive air pressure respirators. The problem, and it's, it's like Groundhog Day, right? I mean, at the very beginning, there was all sorts of messaging around masks, and part of the messaging and it differed, right. It was health care and high-risk occupations, versus the general public. And part of the reason the general public was being asked to not procure those higher grade masks was because there was not going to be enough for the medical establishment, right? The people who are at known risk every single day.

Stephen Thomas, MD: And that went away for a while. Supply chain was good. And, you know, we were kind of undulating with lower level outbreaks and surges and declines. And now we're kind of back in that same spot again, where the press has grabbed onto this and public health authorities and whatnot have basically said, as I have said, that the cloth masks are not sufficient to protect you, probably, against omicron because it's so highly infectious, and it is so prevalent and it is so everywhere.

Stephen Thomas, MD: So now there's this huge rush on these higher grade, kind of medical grade masks from the general public, and institutions are starting to have issues with supply chain again. So that's sort of the download on masks. To me, just the practical aspect is, if you are going to a public place, I suggest that you wear a mask. If you are going to a restaurant, I would go to a place that requires their staff to wear masks and people to wear masks when they are moving about. But when they sit down, I think if they have properly spaced the tables, I think a vaccinated person in a space to table, with masked staff, I think it's still risky, but it's probably a level of risk that people could consider taking. I probably would not go to highly densely populated events where there was not a vaccine, or a mask mandate, or those mandates were not being enforced.

Host Amber Smith: Looking ahead a little bit. What is your advice for someone who wants to plan a trip for spring break? Is that a bad idea at this point? Or is there some sort of a getaway that might be safe?

Stephen Thomas, MD: I would get refundable tickets, is what I would do. I mean, you know, if you look at the map, like, let's say you're planning a trip in the United States. If you look at the heat map of where the hotspots are in the US right now for omicron, the whole map is lighting up, right? The entire country, except for some very few areas, is basically illuminated. With omicron, it's just absolutely everywhere. And and it is, you know, it is what it is.

Stephen Thomas, MD: So what can you do to reduce your risk or reduce your family's risk? Again, it's methods of transportation where they are monitoring and enforcing vaccination or test negative, mask wearing. Those are the types of transportation that I would utilize. If you can drive yourself, well, that's great, right? Because it's just going to be you and your family or your pod in the vehicle.

Stephen Thomas, MD: And if you're going someplace where the weather is nice and you're going to be outside -- and by nice weather, it could still be snow, it could be a ski vacation, but something that allows you to be outside. I mean, obviously that's a much lower risk, being outside, but just kind of monitoring what's going on. And just be prepared for needing to pivot or needing to change your plans at the last minute.

Host Amber Smith: This is Upstate's The Informed Patient podcast. I'm your host, Amber Smith talking with Dr. Stephen Thomas, the director of Upstate's Institute for Global Health and Translational Science, and we're discussing the omicron variant.

Host Amber Smith: Now that we're hearing so much about the new omicron variant, can you compare what the COVID-19 illness looks like in someone infected with the previous variant, that delta strain versus someone who has the omicron. Are the symptoms the same, or is there something more prominent with the omicron?

Stephen Thomas, MD: There are a lot of symptoms that overlap between the two. You can get fever, you can have cough, you can have a runny nose, you can have a headache with both of them, but it seems to be a little more prominent with omicron than with delta. People with delta seem to have more, I think, gastrointestinal complaints, nausea, vomiting, diarrhea. I think they also have a higher rate of losing taste or smell or having disruptions or abnormalities in their taste or smell. And, delta -- and I'm going to choose my words carefully here because there's a lot of people that are out there saying, "oh, omicron is mild," and that really is not the message -- that is not what people should be thinking because, it is making plenty of people very sick, putting people in the hospital, and killing people. But, delta on average seems to be more severe, and there are animal studies and real world data and science that supports that fact and actually gives us some insight into why we think that may be the case, which I would just summarize by saying the delta variant seems to have a greater predilection for infecting the cells deep in our lungs, versus omicron, which seems to be a little more comfortable in the upper respiratory track.

Host Amber Smith: If somebody had COVID early in the pandemic, are you seeing that they're protected against this variant, the omicron?

Stephen Thomas, MD: That is a great question because it gets to this myth that "natural infection is better than vaccination and I've already had COVID so I don't need to get a vaccinated." Uh, no. You are not protected in general. At least with what we're seeing with SARS CoV-2 is that there are some variants that seem to offer some cross protection between them, but delta, which is what has been predominant in this country from July of 21 until just recently. We do not believe that the immunity a person gets from being infected with delta will protect them from omicron. And there is, again, real world evidence, and there's also laboratory data that supports that. So you're not going to get significant cross protection if you've had delta before. But there is some hope, and there's some lab evidence to support, that if you've been infected with omicron, it could in fact, help protect you against delta. But as interesting as that is, I think it's almost irrelevant because at least in this country, although there are lots of pockets of delta that still exists for the most part, it looks like omicron is going to be the winner of this battle between the two and become the, it already is the predominant variant in the United States.

Host Amber Smith: There's some talk out there of the people that want to go get infected with omicron since there's been talk that it's so prevalent, everyone's going to get it at some point, you know, let's get it over with. Can you address that?

Stephen Thomas, MD: I would not advise that. I know plenty of people who have been infected. They were highly vaccinated. They were boosted. They were young, and they didn't have a lot of other medical problems. And, they tolerated it fine. But I also know, and having worked in the hospital this past weekend, there are also lots of people who do really poorly. So, the unvaccinated, omicron can still kill them, and put them in the hospital. And that's what we're seeing. People with, who are immunosuppressed for whatever reason, either because they have an illness that suppresses their immune system, or they take medications that suppress their immune system, they are also at increased risk for a bad outcome with omicron. And then there's older people, people over 65, for example, and people with other medical problems, lung disease, heart disease, diabetes, kidney disease, they're also at high risk. So even if you may not perceive yourself as somebody who will do poorly, if you get omicron, it is still possible for you to transmit it to somebody else who could do very poorly. So I would never recommend a returning to the days of the chicken pox slumber parties.

Host Amber Smith: Well the groups that you just mentioned -- the immune compromised, the unvaccinated, which includes some children that are not eligible yet. , and the older people -- this population that is at a higher risk, is there anything more that they can do to protect themselves?

Stephen Thomas, MD: Well, they obviously should be fully vaccinated. They should have a third dose, or a second dose depending upon what they received and to boost themselves, for sure. And if they're highly immunosuppressed, we do have some medications out there that are available to people who do not Mount an immune response following vaccination. And so they remain at risk. And that that medication -- I think it's from AstraZeneca, Evusheld -- it's in very low supply. And so we're all trying to figure out who should get it, who needs to be at the front of the line, and how we ration this the scarce resource. There's also the antibodies and the new oral antivirals that can be used and even Remdesivir, for that matter, that can be used if somebody is at high risk and they have an exposure. Or somebody who is known to be infected and might have mild disease now, but may progress to more severe disease. So there's ways we can use these available medications. But again, there's a supply chain issue with lots of these, especially the new oral medications, the Evusheld, which I just mentioned.

Host Amber Smith: Well, I'd like to ask you about treatments for the severe cases of COVID-19, the ones that end up in the hospital. What is working and what is used these days to help these people?

Stephen Thomas, MD: You can think of severe COVID infections in two phases. The first phase is where the person gets infected. The virus goes and replicates in the lungs, and it can replicate in a lot of other organ systems. There's kind of that phase where the virus is causing direct effects on the cells that it's infecting. And then the second phase is what we call like an inflammatory phase, right? So it's the body recognizes it's not supposed to have this virus here and it responds. And typically what we want is we want our body to kind of maintain this balance of inflammation within our body. We want to be able to fight off the virus or the bacteria, the parasite, whatever it is. But we don't want to mount such a huge, huge, overwhelming storm of these inflammatory cells that we damage our lungs or damage our kidneys or damage our liver. And unfortunately, that's what happens in that second phase in certain people. So if you think of those two phases, then the way we treat people is, early on, we try to limit the amount of viral replication. So we do that with things like monoclonal antibodies, of which there's only one preparation that will work against omicron. We do it with drugs, like Remdesivir. We tried to do it in the past with convalescent plasma, but that had limited success. It's still scientifically plausible. It's probably moreso how people were using it and the lack of quality control with it. So that's what we tried to do upfront is limit the viral replication.

Stephen Thomas, MD: And then on the back end,this inflammation -- you know, COVID is not the only disease that can cause that kind of thing -- so, that really then becomes more of an internal medicine, critical care sort of issue where they use anti-inflammatories like dexamethazone or other steroid preparations, or they can use what they call these interleukin inhibitors, trying to block these pathways that lead to inflammation. And so, this is kind of, where we are.

Stephen Thomas, MD: In terms of how effective they are, you'll get different data depending upon what study you read and how they designed the study and what types of patients they got. The overarching summary would be, the earlier that you can treat somebody with the antivirals or with the monoclonal antibodies, the better that they're going to do for sure. If people stay at home sick for 7, 8, 9, 10 days, then the cat's kind of out of the bag, and it's really difficult to catch up.

Host Amber Smith: So for someone who wakes up tomorrow with a headache, a sore throat, a runny nose, what do they need to do?

Stephen Thomas, MD: They need to stay home. They need to not go to work. They need to not go to school. They need to not go drive the bus or do whatever it is that they do for a living. So that's one thing, for sure.

Stephen Thomas, MD: The second thing is they should try to, if they live with other people, they should try to isolate themselves from those other people. If they have a home test available to themselves and they are sick, then they could take a home test. If they do not have a home test available, then I think it depends upon the circumstances of their life and whether or not they can wait a day or they should run right out and get PCR tested. Because unfortunately, people have allergies with the changes of the season and there's influenza and there's other viruses, metapnuemovirus, which is circulating, and RSV, and all these other viruses are circulating again now because people aren't wearing masks and they're not distancing. So, not everything is COVID, but in January 2022 in Onondaga County, if you wake up with the sniffles or a cough headache, then you should assume it's COVID until it's proven to not be.

Host Amber Smith: Well, I want to ask you, and I know this is a tricky question, but when is this no longer a pandemic? We can't really put a date on when it's going to end, but what numbers do people like you look at to tell you that the pandemic is over?

Stephen Thomas, MD: Fortunately, I am not somebody who's going to be advising the world on when a pandemic is over. The World Health Organization tries to tackle that question because the pandemic, as we all know, it's a global level epidemic.

Stephen Thomas, MD: You know, I was thinking about this recently, of how do we know when the fourth quarter is over? How do we know when the game is done? Because I don't believe that this is going to go away anytime soon, right? So SARS CoV-2, the virus that causes COVID, it will be circulating on this planet for many, many years. And it's going to make people sick. And it's going to put people in the hospital, et cetera. So I've been sort of thinking that the pandemic will be over when we say it's over. I'm editorializing a little bit. I'm sharing an opinion. I think we are going to, as a society, we are going to say, what is a level of transmission and hospitalization and illness that we are willing to tolerate and say, this is the way it's going to be, and let's move on to other problems, because we have a model with that, right? Influenza. Influenza puts about 750,000 people a year in the hospital, and it kills about 30,000 people a year, and nobody thinks twice about it. So I think we're just going to have to determine what we are going to accept from COVID in that way. And then that's when we'll say, it's over, you know, and we'll all move on. And and I don't want to be dark about the whole thing, but I think that that's kind of how it's gonna play out.

Host Amber Smith: You've given us lots to think about and lots of good information. I want to thank you again for making time for this interview.

Stephen Thomas, MD: Thanks for having me. I appreciate it.

Host Amber Smith: My guest has been Dr. Stephen Thomas, a virologist and infectious disease expert at Upstate who leads the Institute for Global Health and Translational Science. The Informed Patient is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York. Find our archive of previous episodes at upstate.edu/informed. I'm your host, Amber Smith, thanking you for listening.