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Steve E. Bishop, M.D.

By: Steve E. Bishop, M.D. on December 22nd, 2021

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COVID-19 Update 12/22: Omicron,  Monoclonal Antibodies, New Treatment, and More

COVID-19 | Facebook Live Recap

This week's COVID-19 update is all about Omicron. What do we know about it? Do monoclonal antibodies work? What about the new anti-COVID pill from Pfizer? How should you think about your risk level? Watch the update below or read on for the full recap. 

The Omicron Variant

The biggest thing that we're going to talk about is the elephant in the room, Omicron. Like we talked about the last couple of weeks, Omicron is around, Omicron is going to spread, and it's probably going to become dominant pretty quickly.

Unfortunately, that has turned out to be accurate, and it is now everywhere. Just like with all these variants, as soon as they gain an advantage over the older variants, they become the most prevalent variant around.

Omicron is now outcompeting Delta in most places, almost everywhere. There are a couple important things to know about this.

First, Omicron seems to be even more transmissible than Delta. 

Again, this brings us to the point of, if you haven't been exposed to COVID yet, you're going to get exposed here in the next couple of months, or next couple of weeks even.

You're going to get exposed. It's going to happen. So really the question is, if you haven't been vaccinated yet, you really need to take a hard look at why and think very seriously about what your risk factors are for doing poorly with COVID.

If you are over age 50, or you had any underlying medical problems, please, please, please, please, please strongly consider getting vaccinated.

Don't worry about all of the political hullabaloo, all the other stuff going on. Just focus on the medical piece of it and take a good hard look at yourself, a good, hard look at the real risks of the vaccine, which, I have to say, for the vast majority of people are very small, and think about whether you want to get it or not.

And if you do, please go ahead and do it. Go ahead and do it. It may save your life. And again, especially if you're 50 and up or you have an underlying medical problem. And that underlying medical problem may just be that you're overweight.

Take a good hard look at that and make a decision now before you get exposed, if you haven't already been exposed.

The reason I say this is, partially, we do know that the vaccines still do provide protection from severe illness, meaning hospitalization and fatality.

The vaccines aren't perfect. We've talked about that for many, many, many months now. They're not perfect, but they do a great job at reducing morbidity and mortality, meaning bad disease and death. And that's a good outcome for a vaccine. Nothing wrong with that.

They're not as good as we hoped, but they still work really well. So please, please consider getting one if you haven't already, and you are at elevated risk.

Reason number two that I want you to really seriously think about it, again, is because what we have found in initial laboratory studies of this new Omicron variant is that a lot of these monoclonal antibody treatments do not work for the Omicron variant.

Here is an article rom Nature, which is a well-regarded academic journal of science. What they have found in laboratory testing is that most of the monoclonal antibody treatments probably do not work for the Omnicom variant, or they do not work very well.

There is one, Sotrovimab, that probably works pretty well. But its supply levels are low right now. Regeneron and some of these others that we've been relying on for the last few months will probably become relatively useless over the next two to four weeks in most places because they just don't work very well for the variants, according to this early data.

They will ramp up production of the Sotrovimab soon, and we'll have that supply again, but for the next couple of months, getting monoclonal treatments is going to be a little more challenging for the Omicron variant. So just know that, and let that play into your calculus of whether you want to get a vaccine because you may be thinking, "Well, if I get sick, I'll get one of the monoclonal treatments." And that may not be an option for the next couple of months for you.

As we switch over to basically Omicron as the vast majority of the cases, the older monoclonals are not going to work, and the new one is not widely available just yet. Put that into the calculus in the equation of when you're making your decision. 

FDA Approves Pfizer's Anti-COVID Pill

A couple of other interesting things have come out. So just hot off the presses, the FDA did approve Pfizer's medication, called Paxlovid, for use in the treatment of people who are at high risk for hospitalization and death from COVID.

It is a pill medication that inhibits the replication of the COVID virus, and it appears to be relatively safe in the initial trials, and it seems to reduce hospitalization and fatality pretty significantly.

It does have emergency use authorization now for those 12 and up who are at high risk for death and disease. That is a good development as well. We need more treatments, especially, again, as we now are going to struggle with this issue with the monoclonal antibodies.

This treatment is directed at the replication cycle of the virus, which is a little different than the way the monoclonal antibodies work. And you can still use this for the Omicron variant, which is excellent news. It's good that this is coming out now as another option while we wait for Sotrovimab to be manufactured more widely.

Coming out soon too is going to be Evusheld, which is a pre-exposure prophylaxis for people who can't get vaccinated or who have severe immunocompromised issues. That will be coming out soon. It's not widely available yet. If you're in one of those categories of people, then that will be coming. Again, not ready just yet, but it should work to protect you against most of the variants at this time. I suspect it'll be available in the next two months or so.

New Vaccine from the U.S. Army

And then one final thing to talk about, and then we're going to take questions, is the Army. The U.S. Army actually released some interesting data out of a Phase I trial, here's the article, where they've been doing testing at Walter Reed for a new vaccine for COVID that actually would cover almost every known Coronavirus type, all the variants, and some of the other SARS viruses as well.

It essentially is what's called a "nanoparticle." Basically what they have done is they've taken a little tennis ball, and they have attached the spike proteins of all these different variants onto this little tennis ball. And then that tennis ball is injected into the body, all those spike proteins get recognized, and then you create antibodies against all of them, which is really cool.

It's a way to vaccinate against many, many, many variants all at once, and other coronaviruses as well, potentially not just COVID, which is really cool.

It's using more traditional vaccine technology. I think of this as similar to the Hepatitis B vaccine, which is a subunit vaccine, where they've taken out a protein component of the hepatitis virus, and they're injecting that directly. This is more like that versus the mRNA technology. It's really interesting.

And for folks who have been worried about the mRNA technology, and that's a hesitancy issue around getting a vaccine, this is a potential game-changer because this is a much more traditional type of vaccine. Even though the particle type is a little new, it's a much more traditional method of vaccination where you're injecting someone with a particle that's pre-prepared for the virus.

It's pretty neat stuff. They're just now submitting their Phase I data to the FDA. Hopefully we'll see more to come on that, but that would be a really exciting development in the vaccine technology for us, and that would be great.

More boosters? 

"Israel is offering a fourth shot now. Will we soon be offered a second booster? How long after the first booster?"

Yeah, I think that's an open question right now. My guess is that we will probably have this cycle develop where high-risk people are recommended to get boosted every six months or so. I think the problem is that we're going to have to continue doing that for as long as we're using this type of vaccine, which doesn't seem to robustly prevent transmission.

As soon as the transmission protection wears off, I think you're going to see calls for boosters. It looks like it lasts about six months-ish, and so I think you're going to see this every six months for folks who had the mRNA vaccines to consider getting a booster to reduce transmission. And for those in the older age brackets, getting a booster reduces an elevated risk of hospitalization and death. I think you're probably going to see that, my guess would be, in a couple of months.

You'll start seeing data come out and a push for a fourth dose to be gotten six months after your third dose. So that's kind of where we are on that issue/

Current Community Risk Level

"Putting aside individual risk, is the risk from community spread high enough that we should reduce interactions with others to reduce the risk of medical resources being overwhelmed? Why or why not?"

Yeah, it's a good question. I think the issue becomes the transmissibility of the variant. And I think what we're discovering is that the vast majority of the mitigation measures, unless you are going to essentially just not leave your house at all, the odds of any other mitigation measure making a difference in terms of transmission is pretty low, because the transmissibility is so high. I've seen something, it's roughly equivalent to, say, measles, which is extremely transmissible.

Barring very, very aggressive and draconian lockdowns of some variety, which I don't think anybody is interested in doing at this point here in the United States, I don't think any of your mitigation measures are going to make much of a difference.

Now, again, if we get back to a little bit of personal risk level, if your personal risk level is super high, then I would take some steps to minimize your contact with others, especially if you're not vaccinated. But especially if you haven't had a booster and you're high risk, I would make some changes at the personal level.

But your question is a good one. I think we've just discovered that those mitigation measures just don't seem to make much of a dent in the case rates. Even up in New York where they've still got lots of mitigation measures in place, and they're using the vaccine passports at the restaurants and other places, they're still seeing a huge surge in cases of Omicron, higher than they've ever been.

I think, unfortunately, the virus just is going to thwart all of these attempts to contain it with any of these social measures, for lack of a better word. I think our answer to this is going to be in pharmacology and in vaccine science. The faster that develops, the better off we are all going to be.

Long COVID & Omicron

"Is there any information about the risk of long COVID from infection with the Omicron variant? Strikes me as an individual risk that also matters." 

I have not seen any data on this yet, but I suspect it would be at least probably similar to the other variants that we've had. It's a little unclear to me. I can't really get my hand around the severity of Omicron. In some places the reports are coming out, it's no big deal, it's a cold. And in other places, they're seeing kind of the same hospitalization and fatality rates as Delta.

It's a little bit confusing right now in terms of what the virulence level is, the level of severity. It's clearly more transmissible. I know just here in Richmond, the past 48 hours, it seemed like it just, there was nothing, and now it's everywhere all at once.

I think that speaks to the transmissibility of the Omicron, and that's why I think we've probably made the switch at this point over to Omicron. I think you're going to see that play out pretty much everywhere.

It's a long-winded answer of saying that I think that the long COVID rate is probably going to be the same for Omicron as for everything else most likely. We're also seeing a lot of flu at the same time. So there's a lot going on right now.

People do need to take that long-term aspect of the illness into play. Honestly, the reason I thought of the flu, a lot of people have prolonged recovery from flu as well. And we've had a few patients who've gotten flu and COVID at the same time, and they are taking a very long time to recover. You should take that into account when you're deciding about vaccination and such.

Testing for COVID and the Flu

"What is the test for flu and getting the timing of the results? Should people getting a COVID test also get the test for flu?"

Yes. If you're being tested for flu or COVID, you should be tested for both. That is the general recommendation from CDC, from the health departments, from me, and from most physicians, because we cannot tell the difference clinically between influenza and COVID.

We never could, but the prevalence rate was very low last winter, not so this year. We're seeing widespread activity of the flu and COVID this year, all at the same time. So if you're being tested for one, you should also be tested for the other one because we can't tell them apart just by examining you, talking to you, that sort of thing.

And if you have flu and not COVID, it's treatable. COVID is treatable too, but we also have a couple of easy treatments for influenza that can really reduce the course of that illness as well. And, of course, the vaccine for flu on top of that.

Taking Small Precautions

"Even if no mitigation measures are effective, wouldn't there be less community spread if individuals chose to interact less with others? So, for example, if each of us makes one or two small choices to reduce risks, won't that help reduce community spread? Or is it just so infectious that all who are vulnerable to infection will be infected in a short period? So can our hospitals handle that?"

Yeah, I think that's the question. The question is, really what you're asking is, will the small steps be enough to meet a threshold such that it makes an impact on infection rate given its transmissibility?

I think that, this is my personal opinion based on what I've seen just over the last couple of years, I think that minor steps at the individual level might reduce your risks some, but I think collectively, unless you got enough people doing enough of those steps, I don't think it would make enough of a difference at the population level to change the rates.

And I think we see that, right? We keep seeing that in places. Even in Australia and New Zealand, where they have had very aggressive lockdowns for well over a year now, cases still appear. They still appear, and they still have outbreaks. And it is kind of shocking, honestly.

I think it just speaks to the level of transmissibility of the virus, that even in these places where they have very, very tough lockdown rules and quarantine rules, they're still seeing cases. It's still transmitting. And I think that that, again, that speaks to the level of transmissibility.

I think you can do some things to protect and insulate yourself a little bit if you're high risk, but I think the whole mitigation idea at the population level, I think it just doesn't seem to make a massive difference. I wish I had a better answer for that. Unfortunately, it just doesn't seem that way based on what I've seen and based on what's being reported out of various places.

Flu Test Results

"How long to get results of flu tests? Is that also a nasal swab?"

Yes, and it's also a rapid test. There are rapid flu tests, just like for COVID. So at PartnerMD, we're using a combo machine. It's one swab, and the sample goes in and tests you for COVID and flu at the same time. So 20 minutes, basically.

Tired of COVID

"It seems like no matter what we had done, this virus is just going to keep coming. Vaccines have not held up to what we hope. Getting weary of this whole thing."

Yeah, I know. I just told a colleague, I'm so ready for COVID to be over. I think many of us are. I think most of us feel that way. Unfortunately, it's just not over yet, and we have to keep slogging along.

I think, again, our long way out of this is a couple fold. It's either going to be through vaccine technology or treatment technology. It's probably going to be a combination of those things.

And honestly, through all of us getting healthier. In the United States, I think that's playing a major role in the level of morbidity and the level of illness that we're seeing. Even compared to other nations where they have rates that are high, we're seeing more hospitalization and fatality, I think, because our population is so unhealthy in general.

Lots of people with type two diabetes, with metabolic syndrome, with excess weight, with blood pressure issues. All those things are extremely high-risk factors for not doing well with the virus.

And I think that's making things worse for people who get it. And I think it's increasing the transmission rates on top of everything else. And then, of course, we still don't have a great vaccine uptake rate. So I think until we see A) a better vaccine uptake rate, people take better care of themselves, and B) we have another breakthrough in vaccine technology that reduces transmission, I think this is going to continue to be an issue for us.

I think we need some combination of all those things to eventually sort of move our way out of this over time. 

Hospital Surges

"Given the high transmissibility, do you expect hospitals to withstand the surge?"

I hope so. My hope is that, and I hope I don't come off as all doom and gloom, I think the numbers are blowing up, but most of the people that I've interacted with who have it, they're not super sick, which is great.

And I think that does speak to the fact that many people are vaccinated already. And so those who are getting Omicron are not getting very ill, which is great, because there is still protection from the vaccine.

There's no need to minimize the scientific marvel that is the vaccines we have currently that are able to defame the virus in a way for the vast majority of people and turn it into a minor event.

And then we've talked about this before. The goal is to turn this into a minor event. And I think that vaccines do that for the vast majority of people.

My hope is that even if it spreads widely and huge numbers of people get it, that very few people actually need to go into the hospital.

Now, it will probably overwhelm primary care offices pretty quickly, and testing centers are already overwhelmed here in the local area. Basically, every testing center in the area is booked. They're only testing symptomatic people right now. The infusion centers for the monoclonals are all booked as well.

We are booked for testing here and at pretty much all PMD offices. I think primary care is going to take the brunt of this one because people are going to be a little less ill than before. And I'm hoping that that's going to act as a shield for the hospitals.

Hopefully, we can kind of hold the line, so to speak, and keep people out of the hospital with this. I think that that is a good thing. A lot of people are going to get sick, but I think a lot of people are mostly going to have a minor illness. That's my hope. That's my hope. So we'll see what happens with that, but that's my guess.

Monoclonal Antibody Supply

"How is the supply of the monoclonal treatment that works with Omicron?"

Not good right now. They really need to ramp up production of Sotrovimab very quickly. They just need to. There are very few doses left. I think I saw an article a few days ago that there were only a few thousand doses nationwide right now. Not nearly enough just yet.

Take Care of Yourself

And just to plug, since I am the Director of Wellness, if you're a PartnerMD member, we've got health coaches, and all of our doctors have access to health coaches, and you have access to health coaches.

Please connect with one of our health coaches, and they can help you with your diet, your exercise plans, stress reduction, sleep, whatever. All those things will help reduce your risk of COVID and a bad COVID outcome. So connect with one of your health coaches through your doctor.

COVID Testing: Over the counter or at the doctor's? 

"What is your suggestion when it comes to testing if you think you might have COVID? Is it better to just do it over the counter to avoid crowding the doctor's offices? Should we be tested by your doctor?"

The home tests are fine. They work well. In many places, it's the same ones that are being used as in the doctor's offices. They're fine to use. If you think you have symptoms and you're only mildly ill, go ahead and test yourself at home. I think that's perfectly fine. I've done that. I've had some exposures recently. I've done that myself. My family's done it. The tests work great. 

When is the next update? 

The next update will be on Wednesday, December 29 at 1:00 pm on our Facebook page. For those without Facebook, we will post our written recap on Thursday.