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Steve E. Bishop, M.D.

By: Steve E. Bishop, M.D. on January 5th, 2022

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COVID-19 Update 1/5: Omicron, Testing, Quarantine Guidelines, and More

COVID-19 | Facebook Live Recap

In this week's COVID-19 update, Dr. Bishop explains a shift in testing protocols due to the Omicron variant, the CDC's recent changes to isolation and quarantine guidelines, the effectiveness of vaccines and boosters against Omicron, and more. Watch the update below or read on for the full recap. 

Testing Protocols During Omicron: PCRs & Rapids

As we all know, the Omicron variant has made its way pretty much everywhere at this point. I'm confident it will become the dominant variant here in the next couple of weeks, most likely.

And along with that, whenever there's a new variant, there's a lot of concern about: do our current tests, do our current treatments, do they still work for this new variant? Do our vaccines still work for the new variant?

As part of this question, the FDA looked at the rapid antigen tests to determine if they still work as well for this new variant. They issued an alert actually on December 28 saying they looked at the rapid tests and they found that, yes, they still work in terms of they still detect the virus, but they don't work as well as they used to.

They have what's called a lowered sensitivity. That means the virus can be present, but the antigen tests, the rapid ones like that you do at home, may not detect the virus as frequently as in the older variants.

In other words, they're not as reliable. A negative test is not necessarily truly negative, meaning you can still have the virus, still be infected, but test negative on a rapid home test or a rapid antigen test.

If a test is positive, you can absolutely still believe it. If it comes back positive, false positives on these tests are quite rare, so you can believe that and move forward with that information.

But if you have symptoms, and you are testing yourself at home and you get a negative test, I'm going to encourage you to try to seek out a PCR test.

That is what we're going to start doing again, making sure that we always are doing paired testing. If you have symptoms and you are doing testing, you need to do both a rapid test and a PCR test to make sure that you are getting the most accurate information.

You don't want to just do a rapid and it's negative and say, "oh, guess I'm good," when in fact you may still have COVID and it won't be picked up except by a PCR test that looks for the viral RNA.

We are updating our testing protocols for anyone that comes into a PartnerMD office. We are now going to test them both with a rapid antigen test, so we can find out immediately if it's positive.

That's good information and we can start treatment and evaluation based on that. Whether it's positive or negative, we will also send a PCR confirmatory test at the same time so that we get that information back in a day or two to confirm the answer of the rapid test.

By that same token, if you have low symptoms or no symptoms, specifically if you're asymptomatic and you were being tested because you were exposed to someone with COVID, the sensitivity and accuracy of these rapid tests are even lower than if you have symptoms.

Essentially, a negative rapid test on an asymptomatic person is very, very unreliable. You can basically flip a coin and that's the accuracy. What I'd say is this — don't use rapid tests for asymptomatic screening at this point.

We're going to do the same thing at PartnerMD offices. We're going to switch to using PCR's only for asymptomatic screening of people who have been exposed, because the accuracy of the rapid antigen test is so low in this scenario that it is more likely to provide false reassurance, meaning it's going to turn negative.

Most of the time, in fact, it may be negative, despite you actually having or carrying the virus. And so it's just not very accurate. It's not good science, not good medicine.

We're going to switch to doing the PCR tests in these circumstances. And if you're testing for travel or something like that, continue doing whatever test your airline, cruise, whatever it is they're requiring, continue doing that based on their requirements.

But for medical indications, meaning exposure, we're going to do PCRs only because the rapids are of very little value in this scenario.

If you have illness, you're symptomatic, we're going to do two tests on you from now on at PartnerMD.

And that's really what most people should be doing out there. Either PCR only or rapid plus PCR. You really should not be doing a rapid only in most cases, unless you're sick and the rapid comes back positive, then you could make a case to not do the PCR and that would be fine. You have your answer and you can believe that positive test.

But I would not rely on a negative rapid test alone in the setting of being sick or in the setting of exposure. It just is not a good idea at this point, based on the updated information we have from the FDA and from the fact that the Omnicom variant now seems like it's going to take hold.

That information will be coming out through all of our usual PartnerMD channels to everybody, but it's good public information for people to know about as well.

There's a big push to get rapid tests right now, which is fine. And I encourage everybody to have those on hand, but at the same time, just know the limitations of the technology based on the current variant and everything related to it.

CDC Quarantine & Isolation Guidelines

The CDC reaffirmed this week that if you're feeling better, your symptoms are gone, you can leave isolation five days after you test positive or you become symptomatic.

You do not need a test at that point. If you want to do a test, they said you could do a rapid antigen test, but I would caution you the same thing as with the other situations. The test may be negative and that may not reflect anything because of the accuracy of these rapid tests with the Omicron variants. I think that's why they did not update the recommendations to change anything based on that information.

So after five days, if you're feeling better, you can go ahead and leave isolation. You should still wear the mask for up to day 10 in that circumstance, but you can still leave isolation after five days.

Rules are different for healthcare workers. In certain situations, you may even be able to work if you have minimal symptoms, depending on the certain staffing situations at the given time.

That is a whole different ball of wax and we're not really going to address that in this forum, because it's for very specific things around hospitals and stuff like that. And each hospital's going to have to decide their policies based on staffing issues and patient volume and that sort of thing.

Vaccines & Boosters

Vaccines still seem to be holding fine in terms of efficacy against Omicron, and this relates to illness severity. My personal clinical experience, the last few weeks since Omicron has become more common here locally, is that the vast majority of people are mildly ill or moderately ill. They might have a mild to moderate influenza-like illness.

Most people are doing very well if they had been vaccinated, meaning at least two doses of one of the vaccines. They seem to be doing fine.

Unvaccinated people are getting sicker, and they do have a much higher risk and a much higher rate of both going in the hospital and dying from the virus regardless of the variant.

So please, this is just another appeal, if you have not been vaccinated yet, and you are a high-risk person, meaning you either have a medical problem or you're say 50 or older, strongly consider getting vaccinated now.

I know there's a lot of stuff out there in the world on both sides, a lot of conflicting information, a lot of people are confused about what to do, but just seriously consider it. Talk to your own doctor. Get their recommendation and really consider going ahead and doing that if you haven't to date.

I think what we're seeing, at least here in Virginia, the dashboard from the Department of Health is showing that we essentially have record cases. Two days ago, we had 42,000 new cases. I think we had 15,000 cases in Virginia yesterday, but hospitalizations and fatalities remain on the low side, which is excellent.

I know it's different in different areas. I don't know whether that reflects just more disease spread. I don't know if it reflects different vaccination rates, different population types.

By and large, nationwide, fatalities and severe illness have remained roughly stable or dropped even while cases have skyrocketed. I think that speaks to the relatively mild illness severity that most people with Omicron are experiencing, especially if they've been vaccinated.

Again, it's another plug for vaccination. If you haven't done it again, being at least two doses of one of the vaccines.

Omicron Peak? 

"When will these exorbitant rates start to fall? 30% is shocking."

I assume you're meaning the percent positivity. And yeah in Virginia, our percent positivity is averaging around 32% as of today, which is very high.

I don't think that's going to fall for a while. We're going to continue to see significant spread of Omicron because it seems to be so transmissible. I don't think it's going to drop for a couple more weeks. And then we should start to see a decline after that.

In most of the other places that had the Omicron wave, it lasts two to four weeks. And then it slowly dissipated after that. We'll probably experience the exact same thing as everyone else, which is exactly what happened when Delta came through.

It was about a 90-day cycle. That's the way it happened in the UK. And that's the way it happened here. From start to finish, it was about a 90-day cycle between ramp up, peak, and ramp down.

We'll probably have something similar here. 30-45 days cycle ramp up, peak, ramp down just like they had over in the UK and other places with Omicron.

South Africa was the other place I was trying to think of that had a similar wave. Their rates of infection have gone back down to a lower level already from Omicron. We're going to go through this wave. It's going to happen. And then it'll come back down and we'll get on the other side of it with more people immune, hopefully, and minimal loss of life, hopefully as we convince more and more people to get vaccinated.

Over time, we will continue to see these waves of illness, but hopefully, they will become milder and milder over time as more and more people get a vaccine or have immunity.

Skewed Stats from Self-Testing

"Aren't the stats skewed because more people are self-testing and not necessarily reporting results to their doctors?"

Yeah, absolutely. One thing is skewed. One thing probably is not. The overall case numbers are probably skewed way down. I would guess that there's a significantly higher rate of positivity than what we're seeing in the data. You could even potentially consider doubling the number of cases and that would probably be a reasonable number to be talking about for the number of actual cases every day.

So Virginia is reporting 15,000, you could easily imagine it would be 20,000-25,000 cases because many cases are not getting reported because people are testing at home and just isolating at home and treating at home and all that stuff. And it's not getting reported to the Health Department.

That number probably has skewed actually down. What the Health Departments are reporting is much lower than what's happening in reality, which is actually kind of good because then that means that the hospitalization and the fatality rate is even lower than what's being reported, which is good.

Now on the flip side, that test positivity rate, that's probably accurate. That's the positivity rate of all the tests that are getting reported to the Health Department through some official lab source.

So 32% of all the tests being done through some official channel — doctor's office, urgent care facility, a Health Department clinic, whatever — 32% of those tests are coming back positive.

That number is probably accurate in terms of what we're actually dealing with, but the numbers of cases being reported are probably well under reported. 

Assuming Omicron? 

"Testing is nearly impossible to find. Should we just assume it is Omicron?"

Testing has become, like you said, almost impossible to find. It is a huge challenge. We are facing some of those same challenges here.

None of the tests will tell you whether it's Omicron or Delta. None of the routine tests. You have to do special genome sequencing to figure that out, which the normal PCR tests and the normal rapid tests don't do.

We only know that based on epidemiological surveillance data that the Health Department is putting out. They're doing random screening of the samples they have and reporting out what percentage of them are Omicron versus Delta.

I think right now it's kind of 50/50, about half of people probably have Delta, probably half the people in Virginia have Omicron. As you move further north, it's almost all Omicron. You move further south is probably still mostly Delta, but there's a little flux in there.

Next couple of weeks, it'll probably be all Omicron, probably by the end of January for certain, but there's no way to pinpoint in an individual person, okay, you have Omicron, you have Delta, you have Alpha, or whatever. Unfortunately, we don't have that information

Please consider getting vaccinated. 

If you have not gotten vaccinated yet, please do it. Especially if you are an adult 50 or over, or if you have any sort of medical problem, even if it's just you're a little bit overweight. That counts, and that is going to put you at higher risk for a bad outcome.

Again, as I said with Delta, I'm saying the same thing with Omicron, the odds of you getting exposed over time are exponentially higher than they were with Delta.

It's a matter of when not if you'll be exposed. So please do get vaccinated if you haven't done it already and do that soon.

Other Viruses with Similar Symptoms? 

"Are you seeing other viruses right now that have similar symptoms?"

Yes, certainly. We're certainly seeing some influenza, not as much this week compared to earlier in December, but we are still seeing some influenza and some regular run-of-the-mill colds.

We're certainly seeing that as well, but a lot of people with COVID and mild COVID at that, which is kind of like a cold for a lot of people, a mild to moderate cold for a lot of people.

And then some people are having a little bit more severe illness, mild flu, something like that. But yeah, we are certainly seeing things that are not COVID, but not as often.

How do you know the difference? Clinically, you can't tell the difference. We can only tell the difference after the tests are done. And that's really the only way you can tell.

Symptoms, but Negative

"I know people with COVID symptoms that have tested negative."

That gets back to what we were talking about at the beginning. Depends on how they were tested. If they just had a rapid test and it was negative, I wouldn't believe that, honestly. And they have symptoms, I would only believe it if a PCR came back negative.

If they had a rapid and a PCR come back negative, then you can be fairly confident it's not COVID. It's some other virus. But that's why we're doing what we're doing and what is consistent with guidelines is if you come in with symptoms that are questionable, we're testing you for influenza and we're testing you for COVID with both a rapid and a PCR, because you really can't distinguish them and you can't rely on a rapid alone.

Basically, you need three tests. If you get sick with any kind of symptoms right now — fever, cough, sore, throat, body aches, anything like that — you really should be tested with three tests: a rapid COVID, a COVID PCR, and a rapid flu.

That is that the guidance. That is what we're doing. It is definitely what is recommended and you can't tell the difference and you really can't rely just on that one negative test if you have symptoms.

Healthcare System with the Surge

"How are the hospitals and doctors doing with the surge? News reports are pretty dire here in Maryland."

Yeah, I know. I saw the reports you shared last week. Thank you for sharing those. Locally here, I know the hospitals are all busy and full, but we haven't gotten any messages from the local hospital systems saying that they're overwhelmed, saying that they can't manage things, or anything like that.

I think here, at least in Central Virginia and further south, as far as I'm aware, things are okay in terms of they are managing, because here at least, the hospitalization rate hasn't picked up for COVID.

Now what they are seeing is overwhelmed ER's. The ER's are totally overwhelmed, but on the admission side, it's not all full with COVID. What's happening is everybody's going to the ER to get tested because they can't find tests anywhere.

And so that is causing huge problems in the emergency rooms, which causes a backup across the health systems.

The surges that we're experiencing here locally are more related to that inability to access care just because so many people are trying to get tested because there's nowhere to get tested. There just aren't enough tests available because so many people need to be tested right now.

That's really mostly what we're experiencing right now here in Central Virginia. I know it's a little different up where you are in Maryland and some other places further north as well. Who knows. Time will tell. I hope we don't have a surge here like you guys are unfortunately experiencing, my hope is not, but we'll see. We'll see how it goes.

Fourth Booster?

"In your estimation, are we going to need a fourth booster as our immunity wanes? Or when the strains become resistant to the current vaccine?"

My guess is that we're going to probably stop talking about this in terms of booster three, booster four, booster five.

I think we're going to start talking about this in terms of your annual COVID vaccine. I think it's going to take us a few more months to get there.

I think asking people to get vaccinated every five or six months is impractical over the long term. I think most people that have had three shots are very well protected.

I am not convinced of the need for a fourth booster. I haven't seen any data on it either, but the two shots actually seemed to be working very well for most. Three shots seem to be working fine for most as well.

For those people who are high risk, it's probably essential that they get a third dose, the highest risk people.

But I think by the time we're getting around to this idea of a fourth booster, it's been a year since my initial vaccination and we're going to be getting up on a year for most people. So I think we'll start to see a little bit of a shift in the narrative and how we talk about these vaccines to your annual booster or your annual COVID shot, kind of like we talk about the annual flu shot, right?

I think we'll get there. I think it's just going to be a few more months because I think we will see that the vaccines don't resist or prevent transmission for very long and the protective immunity in terms of hospitalization and severe disease may start to wane at some point as well.

I haven't seen any clear data on when that wanes just from even the first two doses, except in that 65 and up crowd, which is why initially that was the crowd really recommended to get the third dose from the FDA committee and the scientists on that committee. They were really concerned about that crowd getting the third dose. I think we'll start talking about this eventually as an annual thing with your flu shot.

Omicron = Enough Immunity to Prevent Future Strains? 

"Do you think Omicron might cause enough natural immunity to prevent future strains? Is 2022 likely to see more variants of concern?"

You know, hard to say. What we're seeing so far and what's been reported at least is that the Omnicom variant seems to give backward-looking immunity. So immunity to Delta, Alpha, and the other strains that have been there.

What we don't know is how much forward immunity it will give if there are new variants. We won't know that until the new variants arrive. We will continue to have new variants. I think we will continue to see that.

That's why I think we're going to probably wind up with this as an annual vaccine campaign sort of thing. And they're going to have to reformulate the vaccine every now and again like we do with the flu vaccine.

It's going to have to get reformulated and kind of re-upped with what's the circulating variant right now and do the same thing as we do with flu vaccines because we're not going to stop seeing variants ever, I don't think, with this virus. It's going to keep happening.

It's just a natural process that happens with viral infections, especially ones that replicate rapidly. These seasonal retroviruses mutate like the flu. I don't think it's going to stop with COVID. I think we're going to keep seeing these every so often.

I think the key is going to be just realizing that's going to happen and then saying, okay, it's time for our variant booster in 2023 and 2024. We're getting our flu shot and now you get your COVID booster at the same time. And then we just kind of move on. I think that's probably what we're going to see for the most part.

The key will be making sure that we've got access to good treatments for people who have breakthrough cases, because we're always going to have breakthrough cases, just like we have with the flu, right? Plenty of people have been vaccinated for flu and then gotten flu that same year. It happens all the time.

We see it all the time. Flu vaccines aren't perfect either and we're going to continue to see the same problems with the COVID vaccine I believe. Unless we have a totally new breakthrough in the vaccine technology, in which case we need to make sure we have treatments available for the high-risk people who need treatment for breakthrough cases or for people who can't be vaccinated or won't be vaccinated or whatever.

I think the key is really going to be trying to normalize this as part of the annual vaccine campaign rollout like we do with the flu, plus making sure we have treatments available, just like we do with the flu, right? We've got Tamiflu, we've got Difluza, other things to treat the flu with for people who get breakthrough cases or who aren't vaccinated. And we just treat this kind of the same way.

Community Spread = More Variants?

"My assumption is that new variants will emerge as long as there are lots of community spread around the world. Is that a useful perspective to take?"

I think so. Yes, the more spread you have, the more chance of a variant, but I think you're going to see variants pop up regardless. Eventually, we may see them pop up slower. The emergence of new variants may happen less frequently as the spread drops, but I don't think you'll see a complete elimination of new variants if that's what you're asking, just with less spread.

J&J vs. Omicron

"How has the J&J vaccine been holding up to the Omicron variant?"

As far I know, it doesn't work as well as the mRNA products in general. And that's actually why FDA and CDC have changed some of their guidance around that and said unless you have a specific reason not to get an mRNA product, then the mRNA ones are actually preferred for most people.

There are some specific situations where getting J&J might be better for certain types of people. And that's something that you probably want to chat with your doctor about if you're not sure, but for most people, they're recommending one of the mRNA products as a first-line option compared to J&J just because the mRNA products work better. They have better efficacy.

Past the Pandemic in 2022?

"I'm hoping, however, we will get past the pandemic stage in 2022 to something less disruptive and less dangerous. Is that a realistic hope?"

I sure hope so. I sure hope so. I really hope if we can get past this wave with the Omicron then we'll really be able to sort of fold this into the normal things that we're going to live with. We need to vaccinate against it once a year probably and try to learn to live with it.

But also hope it becomes less dangerous because as time goes on more and more people will be either vaccinated or exposed and we'll kind of reach some equilibrium with all of this. I really hope this is the year, because I know everybody's tired. I'm tired. I know all the doctors that I know and the nurses that I know are tired.

I know you guys are tired out there in the community of dealing with COVID because it's just omnipresent. It's omnipresent, so I certainly hope so.

Postponing School

"My son's school, Del Tech, just postponed the next semester for two more weeks, even though all classes are remote. Why do you think that would be necessary?"

That is a good question. I don't know. I'm not familiar with Del Tech. But if they were all remote anyway, I'm not sure what the value would have been in delaying classes unless they were just worried about kids being in dorms and things like that. That may have been the impetus. But if it's all virtually held, I'm not sure what they're gaining by postponing this semester in that situation.

J&J + Different Booster?

"I received the J&J vaccine a few months ago. Should I go ahead and get a booster?"

That is recommended. If you receive J&J, then two months after that initial dose, you should get a second dose of the J&J vaccine. That is the current recommendation.

Masks

"Are we going to wear masks forever?"

Again, I really hope not. I really hope not. I think it's going to be a little while longer, but I hope certainly not forever. So a little while longer.

When is the next update? 

The next update will be on Wednesday, January 12 at 1:00 pm on our Facebook page. For those without Facebook, we will post our written recap on Thursday.