Omicron Causes Mild Infection? Maybe for Now

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Anthony Harris, MD, MBA, MPH: “There are nights where I go to bed thinking, ‘Will tomorrow be the day that I read about a tremendous increase in severity in Omicron, and antibody dependent enhancement could be the cause of it?’”

There’s long COVID, and then there’s dealing with the COVID-19 pandemic over a long period of time. Anthony Harris, MD, MBA, MPH,says that the Omicron surge presents ominous implications for both. Harris is the Owner of HFit Health and the chief innovation officer and associate medical director for WorkCare. He’s agreed to not talk about the organizations that he’s affiliated with but rather about the subject of the hour: How do we handle Omicron? Harris’s advice to infection preventionists is to not let their practices drift. Also, be prepared for a long battle. He echoes Infection Control Today® Editorial Advisory Board member Linda Spaulding, RN-BC, CIC, CHEC, CHOP, in believing that we’ve got a long way to go before we can finally say farewell for good to COVID-19. Harris says that it’s “going to be a five-year journey. I have no expectation that this will be over in 2022.” Also, for right now, Harris says that “we have a lot going on during the holidays. We have our folks on call overnight and long nights to cover those who may not be at work during the holidays. But we want to continue to be mindful about our own symptomatology, and how we can protect ourselves.”

Infection Control Today®: Let’s focus on health care workers. What do they need to do in the face of an Omicron surge?

Anthony Harris, MD, MBA, MPH: Health care workers hopefully won’t see a huge change from the precautions that they’ve had to endure since the pandemic began. And that is, obviously the barrier protection. The masked mandate we know that is kind of in play in the courts as are vaccination mandates, as well. Those are going to be the keys to making sure that health care workers are not putting themselves at increased risk more than they need to during this highly infectious period of the pandemic; meaning coming from Omicron. So, continuing with the hand hygiene and other things that we know in health care that we’ve had to do to protect ourselves. They’ll still be in play for much, much longer, it seems. At the end of the day, obviously, we have our freedoms to make our choices. And in the health care industry, I think one of our duties is to communicate risk. And we remain kind of agnostic as to how an individual so chooses to either partake or not of the interventions that are available to modulate their risk level. But going back to the numbers, we know, it is far riskier from a standpoint of risk of hospitalization and death, if you are unvaccinated than to be vaccinated. And certainly, even the difference between fully vaccinated and boostered presents another level of risk if you are not getting that booster. So, we’ll keep communicating what we’re seeing from the clinical data in being objective in that way. And, certainly still cajoling everyone to do what the public health professionals like myself have been saying, which is, do as much as you can to help get on the other side of this pandemic.

ICT®: Has there been anything about the way this pandemic has played out that has surprised you? And what’s surprised you the most? And where does Omicron fall in that spectrum?

Harris: From a viral standpoint, unfortunately, I’ve not been too surprised. I give a monthly webinar—it used to be weekly last year—for a cadre of leaders in large organizations, large companies. And I’ve shared with them that we’re going to be in this for five years—and most experts would agree—until we have more of a global immunity, or lack of susceptibility to the type of coronaviruses that will be in this pattern. What we’re seeing now is not a unique scenario. [We’re looking at] a minimum of three years of COVID-19. And unfortunately, at this point, what perhaps did surprise me a little is not the virus itself, but the response from an antibody standpoint, to the virus. I had hoped that our immune system would recognize more readily than it is, particularly with Omicron, the viral mutations that occurred and unfortunately at this point it is looking like the viruses are outstripping our own either natural or acquired immunity. And that’s a little concerning.

ICT®: You’re saying that Omicron might be outstripping our immunity?

Harris: It’s clear that with the over 30 mutations in the spike protein of the receptor binding site, it is escaping our immune system. And that is why we’re seeing out of South Africa data about increased reinfections. And we’re seeing that now locally here in the US. And we’re seeing that people are susceptible, and they are transmitting, and obviously, the viral load, which we know and we’ve learned is much higher than even Delta, with Omicron, and that’s contributing to the tremendous spread that we’re seeing. I said I wasn’t too surprised by the viral mutations, the evolution of the virus. But what has surprised me more is the responsiveness of the general population and the fatigue that has set in. Now, I know that’s a natural part of who we are in terms of enduring the pandemic. But I know that we are full of will and determination when we have our sights set on a particular goal as a nation. And I think that coming together as a nation with the goal to minimize COVID-19 in the US is something that we have within our grasp if we are able to come together around some of the things that we know to be protective in regards to limiting transmissions.

ICT®: Are you concerned that the virus exists in animals and can apparently jump from human beings into animals, mutate in animals, and then jump back to humans, which is one theory about how Omicron came about?

Harris: There are a couple of theories out there about the origin of Omicron. One theory is with animals. Another is that one individual that had a prolonged infection of COVID-19. And that basically created an in-situ petri dish mutation to occur over that prolonged infectious time. And that was the origin of Omicron with the tremendous number of mutations that we see. And that’s not going to be a rare case. And because we don’t have substantially more than 50% of the global population immune, are not susceptible through natural lower acquired immunity, then we know we’re going to have pockets of individuals that experience infections going forward, and mutations will happen; genetic drift and genetic shift. And if you look at the clades, the last time I looked about a week ago, I think it was the order of 123 or 128 different clades or branch points that were documented by GISAID in Omicron. And we’re going to see more mutations happen that lead to variants such as Omicron. And we just need to be prepared for it.

ICT®: When Omicron first surfaced, some experts saw it as a gift; a way to end the pandemic. Here is a variant that causes only mild symptoms but that can push the much deadlier Delta variant aside. How much credence does that theory have now?

Harris: It’s a theory that is not too far a cry from some of the early theories—or even political, if you would, approaches to the coronavirus—that we saw in the early pandemic days of 2020. We had leadership here in the US come out and say, “Look, we’re just going to sit back and have enough people become infected with coronavirus and everybody will be immune eventually.” Your readers and viewers will remember those days. Unfortunately, we’re seeing that again. But natural immunity only lasts so long. Ninety days to be sure; six months; 180 days is the going wisdom as it stands right now. But that’s for both natural and acquired immunity. And so, unfortunately, anecdotally I’m having conversations and encounters with my colleagues in the health care industry who are now preparing for their fourth shot, their second booster, because we know that very likely our immunity will wane even after a third dose. And likewise, we’re going to see globally definitions of fully vaccinated change. [Rochelle Walensky, director of the Centers for Disease Control and Prevention] has already suggested that over a month ago. We know Israel has already changed their definition well over a month and a half ago to three doses of mRNA. In their case, Pfizer. And we know it’s necessary to get our immune system, our antibody count, high enough to help stave off our susceptibility to future infection.

ICT®: You always hear about misinformation. What are the three most damaging and repeated bits of misinformation that you’ve heard and have had to respond to?

Harris: One, that COVID is not real. That the virus actually doesn’t exist. That it’s all a governmental ploy to enumerate the number of people here in the US and abroad with some type of tracking system. I mean, outlandish as that sounds, for me personally, I have had serious conversations with people that believe that to be the case. And I think that not only casts a dark shadow over our health care community, but certainly one of deep mistrust for the institutions themselves. Secondly, I think the biggest one that is damning for many people is believing that COVID-19 is just a cold. That if you get it, you’re just going to have the sniffles and you’ll be fine. Now, a majority of individuals do have mild disease after and during an infection of COVID-19. But the over 814,000 lives that we’ve lost as a result of COVID-19 paints a very different picture of COVID being a simple cold. And so that’s what we want to message against in terms of the risk to everyone, but particularly to the vulnerable populations, and those who have lost their lives already. And then moving forward. The other is the notion that we are on the other side, or very near to the other side, of this pandemic. That causes people to change their behavior, be out and about, pretend that everything is back to normal. We know mandates have fallen away and precautions are falling away. And that has led to the tremendous number of transmissions that we’re seeing today. And so, the mindset there is key in terms of not being susceptible to these false messages that can give us a sense of environmental safety that just doesn’t exist.

ICT®: [Tedros Adhanom Ghebreyesus, the general director of the World Health Organization] recently stated in no uncertain terms that vaccines and booster shots alone are not going to get us out of this. That we still have to do the social distancing, masking, and hand hygiene. Will people go for that? Will Americans go for that?

Harris: I know some will. Certainly, we know that there are still many of us who, including myself and others in my family, who wear their masks when they go out and about. In certain states or certain counties, and particularly certain cities, that is still mandated. I’m in Chicago and we’ve had in play a standing mask mandate for indoors. We know that there will be a large component of the populace that still adhere to those practices that we know to be protective. And if we can do a better job and more robust job of messaging, the right information, I’m hopeful that we will be able to get an even more overwhelming majority of Americans on board with that message. At one point, that was the case; where the majority of us during the lockdown, as we can recall, did adhere for the most part to these types of regimens. It’s not for a matter of trying to keep people beholden to an overarching system, but only to communicate the risks that still stand, and are even more present with Omicron. That going to your holiday party and not taking any precautions and going back home to Grandma might not be the best opportunity to protect Grandma. And that’s what we want to message. Because on a daily basis as a physician, I’m hearing from my colleagues about the loss of life that’s still happening in the ICUs and hospitals, day in and day out and including people who are, again, fully vaccinated and boosted. We want to continue to message again so that we can pull more people into those practices. And I’m hopeful that we’ll get back to the majority if we keep with that trend of messaging.

ICT®: How concerned are you about long COVID? And is that just something that we can’t worry about right not? That we have to deal with the emergency?

Harris: I think long COVID, and not even just long COVID, because long COVID, kind of denotes a long-term infection or being positive for COVID over a period of time or being symptomatic with COVID over a period of time. Certainly, we know that a tremendous amount of cases—about one in five is the statistic that I’m familiar with—will experience long COVID. And what we know today, just like you mentioned with HIV, that has a targeted kind of mantra if you would as it infects an individual. We know that COVID does very similarly, particularly in the brain, things that are a little alarming to myself as a clinician. There’s published data to show that it can cause a pan-inflammatory response in the brain and that’s strongest in the temporal lobes of the brain itself. And this is a very interesting point that people may not understand. The reason why very likely you lose your sense of smell and taste is not from the virus infecting your nerves—the actual peripheral nerves here for the sense of taste and smell—but it affects the centers in your brain. That is one of the theories and evidence that we see from MRIs. And that showed this inflammatory pattern with people with even short-term infections of COVID-19. And so, some theory says that every infection has some level of brain impact, we just don’t know to what extent that’s going to play out over time. And it may be even more devastating than [we think as of now]. Only time will tell. Now I still hope for the best. But on top of that, there are still other things that keep me awake at night, looking at the clinical data. You know, one of the things that I think we may have mentioned on a previous program together here is antibody dependent enhancement—ADE. Essentially what an antibody dependent enhancement is, is a weakness of our antibodies binding with a virus, much like we see with dengue fever. With the dengue virus, we have an infection initially, and we recover usually with mild symptoms. But if you get infected twice, you may suffer from dengue heroragity and die from the more severe infection. And one of the theories behind SARS-CoV-2 is that if we have a virus, not too much unlike Omicron, that binds very weakly to our antibodies, because of mutations that have occurred, we can have either too few antibodies because of mutations that have occurred, we can have either too few antibodies that are effective or not enough binding for effectiveness of antibodies. And as a result, our antibodies help pull the virus basically—I’m paraphrasing—pull the virus into our immune systems, into the cells that normally would help fight the virus and not allow it to replicate. But in this case of ADE, the virus now has a new environment to replicate and causes a far greater viral load and far greater disease impact on the individual. There is no clear evidence I’ve yet seen about ADE occurring in the general population. But, again, it’s a little scary to me that we have such a mutated variant like Omicron that would potentially set us up for the likelihood of ADE more than any other variants out there that I’ve seen previously. We’ll keep fighting the fight but, again, there are nights where I go to bed thinking, Will tomorrow be the day that I read about a tremendous increase in severity in Omicron, and antibody dependent enhancement could be the cause of it?

ICT®: Many of my readers are infection preventionists at hospitals. I would ask you what advice you have to give them but I’m assuming that you will say, “Just keep on doing what you’ve been doing.” But is there anything they need to tweak particularly when it comes to educating their fellow health care workers about the value of vaccination?

Harris: I just encourage you to keep at it, keep up the good fight, keep protecting yourselves and protecting others in the hospital setting, but also be mindful of your loved ones. When you go home in the evening, I think all of us, myself included, can get a little lax with my own self-awareness. I am sniffling a little bit today. Or my throat is a little itchy more so than just having a dry throat. Just being mindful to listen to your own body in terms of: Is this something that you’re experiencing that could be a representation of a mild COVID infection and require you to then obviously take precautions both at home and at work? Because I know, we have a lot going on during the holidays. We have our folks on call overnight and long nights to cover those who may not be at work during the holidays. But we want to continue to be mindful about our own symptomatology, and how we can protect ourselves.

ICT®: You and I have has a lot of conversations over the course of this pandemic. And when I talk to experts about COVID-19, I tend to divide them along lines of being optimistic or pessimistic in terms of how long this pandemic will go on and how much damage it’s going to eventually do. I’ve always pegged you as an optimist. But it seems as if you’re not as optimistic anymore. Fair assumption?

Harris: I’d say that I am pragmatically optimistic. Again, with my webinars I’ve given over the years about COVID-19, I’ve always said be ready for the worst. Prepare for the worst but still expect the best in terms of being able to get to the other side of this knowing that it is going to be—and I’ve always said this—it’s going to be a five-year journey. I have no expectation that this will be over in 2022. Or the years after. But I do expect to continue to have more and more robust responses, more interventions, and hopefully—hopefully—more precautions in terms of how we as a general population approach our own health and wellness in general. Again, we’re not seeing just increased cases of COVID-19. We’re seeing more respiratory syncytial, we’re seeing more influenza this year than we did last year. We’re seeing more streptococcus; strep throat. We need to be vigilant not just with COVID-19, but with other transmissible illnesses that we can prevent and that could lead to poor outcomes, not just for the general population, but primarily for those who are vulnerable, particularly if you’re immune compromised which we are seeing as well. I’d say I’m cautiously optimistic or pragmatically optimistic.

This interview has been edited for clarity and length.

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