December 23, 2021
The Omicron rocket has officially launched in Alabama. Since my last letter to you four days ago, 5,326 cases have been reported (including 2,060 today), more than twice the number produced by the same four days last week (2,571). Our 7-day average positivity rate is now 12%. I suspect that most of the reported cases are at least mildly symptomatic because the high cost of testing in Alabama tends to reduce the number of tests performed. In other words, the reported cases are likely just the tip of the iceberg.
The data does not yet reflect Omicron’s impact on Alabama's hospitals. Today, there are 433 confirmed patients in 104 reporting hospitals (4.2 per hospital), a slight increase from 4.0 patients per hospital on December 19. Hospitalizations generally lag infections by at least a week or two. The arithmetic of pandemics is complicated. A variant that is 60% milder but 300% more infectious will create more severe cases, requiring more hospitalizations overall.
In the four short weeks since the Omicron variant was identified in South Africa, we have received resounding answers to two important questions. On the issue of transmissibility, judging from the vertical graphs of spread throughout the world, Omicron is clearly much more transmissible than its predecessors. (“If previous variants caused waves shaped like Kilimanjaro, Omicron’s is more like scaling the North Face of Everest”, said one scientist). As for immune response, skyrocketing cases in highly vaccinated areas conclusively demonstrate that Omicron is adept at evading antibodies produced by prior infection as well as most vaccines.
The future of this global pandemic then turns on the answer to one final question: Does Omicron send its hosts to the hospital at the same or higher rate as Delta and its ancestors Alpha & Beta? That is the most difficult question to answer, but we received some encouraging news this week from South Africa, England & Scotland.
According to South Africa’s National Institute of Communicable Diseases, in the first 4 weeks of the Omicron wave in Gauteng province, 5.7% of new cases were admitted to the hospital, compared with 15.6% in the Delta wave and 16.2% in the Beta wave. There was also a “downward trend” in patients needing critical care and in deaths from Covid. Some epidemiologists initially questioned the relevance of this data in the U.S. and Europe because of Gauteng’s younger population and other factors.
But then, South Africa’s findings were supported by a study out of Imperial College London showing that Britons infected by Omicron were 15-20% less likely to go to an emergency room with severe symptoms and 40% less likely to be hospitalized, compared with those infected by Delta. Yesterday, scientists in Scotland reached a similar conclusion, finding that people infected with Omicron were 60% less likely to enter the hospital than those infected with Delta.
Honestly, I have as many reservations about applying the results of the U.K. studies to Alabama as I do the South Africa studies, but for a different reason. In Scotland and the rest of the U.K, about 83% of eligible residents (age 12 and older) have received at least 2 doses of vaccine and nearly half of those have been boosted. In Alabama on the other hand, just 50% of the eligible population (age 5 and older) have received two shots and just one-quarter of those have been boosted. There is widespread agreement that, although two shots of an mRNA vaccine (Pfizer of Moderna) provide diminished protection against Omicron infection (e.g. 30-35% efficacy), they remain a significant shield against severe outcomes (e.g. 70-75%); and a booster shot is the key to avoiding infection in the first place.
In New York and New England, where Omicron first appeared in our country, anecdotal reports indicate most cases are mild, yet hospitalizations are still rising there due to the rapid rise in overall cases. Like the U.K, those states have vaccination rates that are much higher than Alabama’s. Alabama’s population is uniquely vulnerable - over half our residents are still unvaccinated, including 21% of those aged 65 and older. And we also suffer from high comorbidities (e.g. the 3rd highest obesity rate in the nation) . We have seen what the Omicron variant can do, yet our state is still administering just 10,000 daily vaccine doses, an 18% decline over last week.
Some will argue that Alabama’s population is better protected because of our horrific experience with Delta. Don’t bank on it. Omicron’s numerous mutations allow for more reinfections among those previously sickened by the coronavirus. According to a study released this week by the University of Texas, the level of natural immunity of an unvaccinated individual with a prior exposure was 16 times lower against the Omicron variant than the Delta variant.
To be clear, the last four weeks have convinced me more than ever that vaccinated individuals, especially those who are boosted, should be free to resume their lives and enjoy the holidays. However, I am deeply concerned for the fate of our front-line health care professionals and the millions of Alabamans who made the choice to roll the dice. Alabama - indeed, most of the Deep South - will be home to a giant human experiment in January. What happens when an unstoppable force meets an immovable object? Alabama’s hospitals are about to find out. The totals:
12/9 - 549
12/10 - 592
12/11 - 713
12/12 - 330
12/13 - 294
12/14 - 814 (excluding 841 older cases)
12/15 - 647
12/16 - 816
12/17 - 908
12/18 - 692
12/19 - 552
12/20 - 552
12/21 - 1,254
12/22 - 1,460
12/23 - 2,060