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Steve E. Bishop, M.D.

By: Steve E. Bishop, M.D. on December 1st, 2021

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COVID-19 Update 12/1: All About Omicron

COVID-19 | Facebook Live Recap

On this week's COVID-19 update, Dr. Bishop dives into all things Omicron. What is it? How do variants happen? What do we know? What don't we know? And what does this all mean? Watch the update below and read on for a recap. 

What is the Omicron variant?  

There's a lot going on related to this. There have been lots of pronouncements and different travel bans and all sorts of things going on. The bottom line is Omicron is yet another variant of concern.

Most countries that have centralized laboratories or that use the WHO labs or CDC labs, they're doing routine surveillance of the COVID virus. As samples come up in different patients, they're surveilling the genetic code of the COVID virus and seeing if there are major changes that show up.

The idea is to identify these potentially concerning variants before they spread rapidly, either so we can either do things to minimize the spread, or so that we can change our vaccine or treatment strategy or something else to minimize the impact of any of the variants that pop up that might be concerning.

How do variants emerge? 

This routine surveillance is going on all the time. Let's go back a little bit to sort of high school or college biology.

When viruses invade the human body, they take over the human's own cellular machinery and use that machinery to replicate themselves millions, upon millions, upon millions of times in each person.

Every time that the virus gets into a new person, or even after it's been in one person for a short period, there are millions, and millions, and probably billions of new copies of the virus that are created during the course of the infection.

Every DNA or RNA copying mechanism and this is true for humans too, has an error rate. It makes errors at a certain rate of 1% of the time, 0.01% of the time, whatever that is. Different enzymes have different error rates, different types of organisms have different error rates, and viruses have their own error rate. Each virus is probably different.

The protein machine that does the copying just makes mistakes every so often. This is how mutations happen in both DNA in humans or RNA in viruses. In humans, when this happens too much, we wind up with cancers. Too many mutations lead to abnormalities, the cells start to act funny, and then they cause cancer.

In viruses and things of that nature, the variants have other implications. What can happen is as these variants show up randomly, eventually one or more of these variants that shows up with a slightly different gene, or slightly different coding on a protein, is different. And it's better than the other viruses that were before it. And this is just a process of evolution that happens with viral infections.

As the errors accumulate sometimes by happenstance, by random chance, the mutations that happen in a particular virus change the proteins in some way that gives it an advantage. It does a better job of infecting humans, or it does a better job of spreading, or it's more lethal, or less lethal. They just change. So it gives it some distinct advantage or another.

And that's yet again what has happened with Omicron. We saw this with Delta already as well and some of the other variants. The random changes that are occurring are giving an advantage to the virus because the spike protein that results from those slightly different codes in the RNA of the virus results in a protein that does a better job of attachment to human cells.

And so then that virus spreads easier. It gains a foothold, and then it becomes the most common one out there. That's what we saw with Delta. We will probably see the same thing with Omicron over time. It'll probably be the most common one around. It was initially discovered in South Africa. It was already in Botswana and some other Southern African countries, and then it was in the UK, and now it's been found in Canada.

And it's likely already in the United States. We just perhaps haven't seen it just yet. These variants, as we've said, they're going to continue to happen for as long as the virus exists on the earth. That's just the nature of viruses. They mutate, they change, they adapt to their host, and that's what they're doing. They're adapting to their host, which is us, right?

Are mutations always a bad thing? 

This is not always a bad thing. Many times that means that things get less lethal over time. But sometimes it doesn't mean that. There's no way to know until the thing happens. So these mutations, while so far, what we've seen is that it increases transmissibility in terms of it's easier to catch COVID from one of these variants. 

It does not appear, and this is straight from the medical authorities in South Africa, that the illness caused by Omicron is any different than any of the other COVID variants. So yet again, what we're seeing is probably an increase in transmissibility. It's going to be easier to catch over time, but probably not any worse of a disease than the original Alpha variant, Delta variant, whichever the one that you were exposed to previously.

It is not likely to be a worse disease. It will most likely be essentially the same clinical disease, just easier to catch. We saw a big jump in the transmissibility from Alpha to Delta. Omicron is probably going to be an even bigger jump in transmissibility.

So, what does this mean? What should you do? 

What this really means to me from a medical standpoint is, again, if you're a person who's at high risk for a bad outcome from COVID — and you either have not been vaccinated yet or you have not recovered from COVID yet — and you are still at high risk for catching COVID and doing poorly, you need to really, really seriously consider getting vaccinated.

Now is the time, okay? Before Omicron really does take hold everywhere. Because you're going to get exposed. It might not be tomorrow. It might not be next week. But it will be soon. You will get exposed to COVID at some point.

And if you're like me, I really don't want to actually get COVID and test my immune system in that way and see if I do okay. I took the vaccine. I would recommend if you're either worried about your risk, or you're someone at high risk and you haven't been exposed yet to COVID or vaccinated, do so, because you will eventually get exposed. Your time is running out.

That's the main thing about Omicron. It's just a reinforcement of, hey, if you haven't been vaccinated yet, please do it. Please go ahead and do it. Especially if you're above the age of 50, or you have an underlying medical problem, please go ahead and get vaccinated here, pretty soon.

Will Omicron affect vaccines? 

So far, we don't know. We will find out as they continue to analyze the virus. There's been some speculation that the vaccines may or may not work, but I don't think that they've seen big upticks in severe illness in South Africa again, or the other places where Omicron has spread.

The current vaccines may work just fine. They're going to continue testing. We'll figure that out. If it turns out that the vaccine effectiveness is diminished, or if the monoclonal antibody therapies are diminished, based on these new variants, then we may need to consider whether people do need to get an Omicron-specific booster.

And getting back to the mRNA technology, it's pretty fast. And both of the companies, Pfizer and Moderna, have said that they can come out with Omicron-specific boosters within about 90 to 100 days. So, time will tell. We just don't have a good answer to that question,

Like we've talked about before in the past...This is going to keep happening. We're going to keep having variants. The virus is not going to go away. We're going to have to figure out some way to manage both detection and surveillance of new variants, and our response to new variants, because it's going to be just like influenza or some other things.

It's a respiratory illness. It's not going to disappear. We're going to have to figure out a long-term strategy. My guess is, over time, we will find that we do need to do boosters at some point because the virus will continue to mutate. Eventually, it probably will escape vaccine control, just like the flu does on an annual basis, and we have to get new flu shots every year. I think we probably will see that at some point. That's just my guess. I don't know if that's true yet.

That's just my guess based on the frequency with which these variants are appearing, and the way in which the vaccine seems to be working. So that's kind of the scoop on Omicron.

The bottom line is don't panic yet. But if you're not vaccinated, please go ahead and do that, especially if you're in one of those increased risk categories. Please go ahead and seriously, seriously consider getting vaccinated.

Merck's Treatment Pill

The next thing I wanted to touch on a bit is this drug from Merck, molnupiravir. It has gotten the green light from one of the advisory committees on the FDA, recommending it for emergency authorization approval for high-risk people. In other words, I think it's probably going to be approved for a narrow subset of people.

It's not going to be something we give out to everybody who has COVID or symptomatic COVID. And the issue is because of two reasons.

First, the committee was very split on this. The vote was 13 to 10 or something along those lines. It was far from unanimous to grant the green light for the EUA for this. That's the first thing.

The second thing is the drug does not work as well as we thought it did initially. The initial press release and data set that came up from the company from Merck was saying, "Oh, we had a 50% reduction in hospitalizations and deaths, and it's great. And there were no side effects, or very few side effects, et cetera. "

And when they had to release more of their data, it got restated a little bit. It's probably more like a 30% reduction in hospitalization and mortality, which is nothing to sneeze at. And especially in the high risk, I think it's still a worthwhile thing to pursue and to consider using in those high-risk people.

People are worried about side effects from it. Remember, again, we were talking about mutations in viruses, and mutations in humans, and how mutations in humans can lead to cancer.

One of the concerns that people have about this medication, in particular, is the way in which it works. It confuses the virus' replication machinery and causes it to make a lot of mutations all at once. What that does is actually destabilize the virus and make it ineffective so that it can't continue to replicate.

The problem and the concern is...does that mechanism only happen to the viral proteins? Or is there a possibility that that might happen with some of the human DNA replication proteins, too? In which case that's a serious concern because our cells have to replicate.

You have to create new cells to fix your kidneys, to fix your liver, to repair your skin, to heal from a cut, all that stuff. We have to replace our cells all the time. And in doing so, we have to replicate our DNA, and we don't want to introduce anything into the system that's going to potentially create genetic mutations. That's a concern.

That's one concern for that drug. It's theoretical. We don't have evidence that that happens, but it is a theoretical concern that people have brought up. That is one of the major things going on there. And then the efficacy is not as strong as we thought, so it's probably going to get a green light for use in high-risk people, who are at very high risk of doing poorly with the virus.

From my perspective, I would rather use monoclonal treatments. I think they're safer. They have very good efficacy. They're quite widely available, but for patients that either can't get access to an infusion, don't want to do an infusion, or it's just not available for whatever reason, this drug might be a useful adjunct and a useful option for those high-risk patients who otherwise wouldn't get access to any treatment.

I think it's a good thing to have. I think we need to be careful about how we use it and who we use it in. And I think most doctors are going to be a little bit skittish about using it, especially at first, due to some concerns that we have about it.

When is the next update? 

The next update will be on Wednesday, December 8 at 1:00 pm on our Facebook page. For those without Facebook, we will post our written recap on Thursday morning.