Jeremy Faust on the Omicron Paradox

In this video, MedPage Today Editor-in-Chief Jeremy Faust, MD, of Brigham and Women’s Hospital in Boston, explains the paradox of Omicron and what it means for hospitals.

The following is a transcript of his remarks:

Hi, I’m Jeremy Faust, editor-in-chief of MedPage Today, and today we’re going to be talking about what I think everyone is thinking about, which is the Omicron variant. I wrote about this in my newsletter over on Bulletin, which is called Inside Medicine, in a piece that I call the “Omicron Paradox.” In this article, I go through why this strange paradox seems to occur, which is that it’s milder and yet it is so much more contagious, but that contagiousness is overwhelming things.

One of the things that I needed to know for writing this was a little bit more about the details of what they were seeing in South Africa. So for the second time in a little while, I reached out to these people in South Africa, these wonderful researchers to ask them about data that they did not publish. And what they told me was that, indeed, Omicron is about 53% less likely to cause hospitalization across the board than Delta.

And that was adjusted for age, and that was adjusted for vaccination status, and that was adjusted for medical comorbidities. So that really does tell you that native Omicron is milder. And on top of it, the level of ICU care that’s required — intensive care is also lower on top of that. So we definitely know that that’s a real thing, but we also have seen in the United States that case counts have just skyrocketed, unlike anything we’ve seen so far. And that’s including in the pre-vaccine era and during the vaccine era. So we now know that this is out of control.

There’s a great graphic that I had made by Kristen Panthagani, and in the graphic, you can really see that for a virus like Delta — we call Virus D — the hospitalization rate per case is higher. So you might have a hospitalization rate of 10%. So 10% of the cases you detect are going to the hospital. It could be lower than that because you don’t detect all the cases, but of the ones you detect, 10% go to the hospital. Meanwhile, a virus like Virus O or virus Omicron is about 5%. So of all the cases you detect, 5% will be hospitalized. Well, you think that Virus D is worse because it hospitalizes twice as many, but as we show, if the Virus D and Virus O are differently contagious. In other words, Virus O is much more contagious — twice as contagious — then only a few replication cycles later, you see that actually the piling on of hospitalizations from Virus O absolutely dwarfs Virus D, and that’s precisely what we’re beginning to see. If you look at data from the United States, we are now seeing hospitalizations at record highs, despite the fact that it’s a vaccinated population.

Why? Because Omicron finds everybody, but it highlights the unprotected. It puts a big old arrow on them for us in the medical field to see, because they show up in our emergency departments and our hospitals and our clinics looking sick. So that’s why this has happened. And what we don’t know is, is the pace of case growth going to leapfrog the fact that it’s a milder disease?

And another thing that I wrote about in this piece, in the Omicron paradox piece, is this concept of how Omicron on one hand has given us a little bit of a buffer zone, but on the other hand made it so that we spent that buffer zone. There’s a graph in the piece, and I look at Florida, but we can do this for a lot of states. A lot of states look like this. And what it shows is the blue line is showing the number of cases that have to happen in Florida per day in order that, a week or two down the road, the hospital beds will be full. And we do that with a model that I wrote with Bill Hanage and with Benjy Renton, and that model’s what we call Circuit Breaker model.

The idea is that 20 days ago to 10 days ago, we had a certain number of cases that caused a certain number of hospitalizations. In the last 10 days, the new cases would replace those old ones. So those ones start to cycle out from the previous cycle, the new ones replace it. If those numbers are equal, you won’t have an increase in hospitalizations. You’ll have, you know, a hundred come in, but a hundred leave. So it’s kind of equal. You’re at a steady state.

With Omicron it’s super interesting, because it looks like because it causes less serious disease, because it’s a little less virulent, the number of cases you need to predict that you would actually exceed your hospital capacity is higher. And that is what this graph shows. You can see in late December, this blue line skyrockets. That means, hey, because Omicron is milder, we actually could tolerate more cases. And you can see that the yellow line, the average new number of cases per day absolutely did rise, but because Omicron was milder, we got away with it. We weren’t actually filling up our hospital beds to a place where the capacity was at risk.

But at the end of this graph is where I get the butterflies and where I get a little nervous because I see that the cases have now caught up. So any sort of money in the bank we had, we spent. And so we’re seeing that, when this happens, if this happens for a number of days, we project that hospital beds will be full. And that is obviously a problem. Because we can no longer provide lifesaving care for anything, whether it’s a heart attack, appendicitis that needs to go to the ER, or a flare up of emphysema. I mean, there’s always things we know we could treat, we know we could save, but if there aren’t enough hospital beds, there aren’t enough doctors, nurses, you know, other providers, we are not going to be able to give that care. I think that one thing we all should agree on is that if we can keep the hospital safe, we should.

And the idea of a circuit breaker is that when we reach that moment, when in a particular location, that cases exceed what hospitals will be able to take care of, it’s worth putting the breaks on in order to achieve that. A circuit breaker model can tolerate an increase in cases. We don’t say, oh, we can’t have increases in cases. We say, you can have an increase in cases. That’s unfortunate. We don’t love it, but we can tolerate that for safety of the hospitals, but not past a certain point. The goal of these little circuit breaker ideas is that we ask people to make changes for a very brief period of time in exchange for saying the off ramp is actually soon. Like we can go back to normal life quicker than say this, you know, long, prolonged shutdowns and lockdowns, which nobody has any appetite for and and some people would resist outright.

So we advocate for a nimble approach, for a local approach. It’s not a one size fits all, it’s brief. And that’s really what this is about. How do we overcome the Omicron paradox that’s going to possibly, certainly will overwhelm our hospitals unless we add capacity to slow this down. It’s small but focused action that we can all take and feel good about. So I think we want some wins. And we’re tired of just watching our efforts feel like they’re wasted.