How to Make Sense of Omicron and Changing COVID Protocols

Jan. 12, 2022 — If you’re confused about guidance on the Omicron coronavirus variant — which seems to change almost daily at this point — you are not alone.

The widely reported, record-breaking jump in daily cases seems easy to understand. Beyond that, many unanswered questions remain: Are cloth face masks ever OK? How can rapid antigen tests help, assuming you can find one? What’s up with the CDC’s 5-day quarantine recommendations? What is going on with the flu?

Jeanne Marrazzo, MD, and Joshua Barocas, MD, addressed these and other pandemic questions during a media briefing this week sponsored by the Infectious Diseases Society of America.

These infectious disease experts also shared one thing about the pandemic that gives them hope.

Fast and Furious Flow of Information

Contributing to the confusion is the rapid-fire pace of new scientific developments on Omicron and related recommendations.

“New evidence is coming on a daily basis,” Barocas said. “We are still building the plane as we’re flying it.”

People can handle this deluge of information, including the controversial CDC recommendations shortening quarantine time to 5 days, said Barocas, vice chair of the Infectious Diseases Society’s Public Health Committee.

“The American people can digest guidance, even if it’s coming rapidly,” he said. “I like to believe that the American people can internalize that guidance and … figure out what works best in their lives.”

Without discounting any of the official recommendations, Marrazzo said it’s also important to “keep it real.” For example, studies show that people are unlikely to spend an entire 10 days in isolation after they test positive, especially if they have no or only mild symptoms.

Given this reality, the CDC recommendations for 5 days make more sense, Barocas said.

“The most likely time that you’re going to be infectious is those 5 to 6 days. We ask that you mask afterwards, we ask that you remain diligent.”

“We have to be somewhat realistic about what people are willing and able to do,” said Barocas, an associate professor of medicine at the University of Colorado School of Medicine.

Four Ways to Reduce Risk

Vaccination, masking, isolation, and testing are “the four pillars or four corners of a building” that all need to be in place to hold it up during this pandemic, said Marrazzo, director of the Division of Infectious Diseases at the University of Alabama at Birmingham.

Barocas thinks of these four things as parts of a suspension bridge, and you need all four to keep the bridge standing, he said.

Regardless of the analogy, vaccination and the other measures remain essential, given the relative lack of other options at the moment. Vaccination can also affect quarantine requirements, Marrazzo said.

“If you are fully vaccinated, you get a pass on some of the more draconian quarantine requirements.”

Down to One Monoclonal Antibody Treatment

Vaccination is critically important right now, Marrazzo said, “because we’ve got nothing else to treat ambulatory patients with COVID. We have limited access to monocular antibodies that work.”

Also, a shortage of the one monoclonal antibody treatment still considered effective against the Omicron variant — sotrovimab from GlaxoSmithKline — is not making the picture any rosier.

To illustrate the disparity between supply and demand, she said, “We had 16 doses of sotrovimab, which is the antibody that works against Omicron last week, when our prevalence of Omicron was 99.8%, and we are seeing increasing numbers of cases.”

At the same time, the recently authorized COVID-19 treatments in pill form from Pfizer and Merck are not yet available.

“We don’t have the oral drugs yet, and we don’t have any other options,” Marrazzo said.

N95s, KN95s, and Cloth Masks

The benefits of masking are nothing new, but what is novel are recent recommendations that people upgrade their face coverings to N95 and KN95 masks during the Omicron surge.

Wearing an N95 or KN95 is recommended “if you can get them and you can wear them and they’re comfortable enough for you,” Marrazzo said.

But in another nod to reality, she said “there are cloth masks out there that fit like a glove.”

“If that feels better to you and it’s really impermeable and you have trouble running upstairs when you’re wearing your very well-fitted cloth mask, should you throw it away and get an N95? I’m not so sure,” she said.

Barocas repeated a common refrain: that a cloth mask is better than no mask. But he also said there is a time and place where an upgraded mask would be better.

“If you’re someone who feels that it’s necessary to wear a KN95 or an N95 around your immunocompromised family member or your vaccine-ineligible children, then absolutely, that’s something that you should do.

“Personally,” he said, “I would wear it in large crowded areas where there’s poor ventilation — something like a concert or a museum.”

The recommendations for wearing N95s or KN95s come at a time when they are again in short supply.

“For example, in our hospital, we don’t have enough N95s for every single health care provider at this point,” Marrazzo said. “So we’re still having people wear surgical masks in some settings.”

Another reality check is that not every upgraded mask is comfortable for every person. Using the example of workers serving people from behind a counter, she said, “Yes, I would love those people to wear an N95, but the N95s have quite a range of comfort. Having worn them from many hours on end, I can tell you that there are some that you absolutely want to not wear for 8 hours.”

Stop Shaming Others

Marrazzo and Barocas agreed it’s time to stop criticizing the personal decisions people make on vaccination, masks, and other protective measures.

“We have to stop, and we have to sort of just come together,” Marrazzo said. “And say, look, we are all experiencing a challenging reality right now, and we need to give each other the tools, whatever tools people will use to protect themselves. We need to give them support.”

Barocas agreed it’s time to stop picking sides. “I think that we need to look at this is a pandemic of everyone,” he said.

Two things that most Americans agree upon, Barocas said, is protecting people who are vulnerable to severe disease and avoid getting sick themselves so they can remain in the workforce.

The pandemic is “now affecting every sector of our nation, of our world,” he said.

Their Take on Testing

Marrazzo recommends that anyone who has symptoms isolate themselves if possible right way.

“Don’t go get tested and then wait for your test results to come back” before acting, she said. “Stay home, and ideally use a home self-test if available.

“Ideally, if you test and find out you’re negative, that’s fantastic,” she said.

If you test positive and isolate for 5 or 6 days, it is much less likely you will be infectious to others. The CDC recommends people in this situation use caution and mask up for the full 10 days.

Effective monoclonal antibody treatment and N95/KN95 masks are not the only items in short supply, as many Americans know — rapid antigen tests are also scarce.

“We hope that the supply of tests is going to increase soon,” Marrazzo said.

“When we rapid test at home with an exposure, or with symptoms, rapid tests are incredibly good at detecting infectiousness,” Barocas said. “We’re seeing numbers that are to some of us astronomical — over a million cases. … The use of rapid tests is incredibly important for infection control purposes.”

“So while it may not protect you to get tested, it protects the people around you,” he said.

Knowing your status is important and is something infectious disease experts have been recommending with other infectious diseases for decade.

Don’t Forget Your Flu Shot

While the flu is circulating, it’s nowhere near the levels of an epidemic, Marrazzo said. Still, the flu does a number on your immune system, and anything that does that “is only going to make you more susceptible to a bad case of COVID,” she said. “We don’t really talk about the flu vaccine as a way to keep your respiratory system generally healthy and able to ward off things like COVID.”

Reasons for Optimism

Asked to name the thing they are most positive about at this point in the pandemic, Marrazzo chose the oral antiviral treatment Paxlovid from Pfizer. The authorized 5-day regimen “is very similar to Tamiflu,” she said, “and it could make a really big difference.”

Treating people early with this oral medication could help keep them out of the hospital and could ease staffing shortages as well, she said.

In studies, she said, Paxlovid reduced the severity of illness and hospitalization by about 90%.

Barocas was positive about how much progress has been made in under 2 years of the pandemic.

“I can’t express in words how big my toolbox actually has become, compared to March 2020,” he said.

“I felt helpless” back then, he said. “All I was doing was shuffling deck chairs and trying to keep a boat afloat at the same time.”

Vaccines and other preventive measures, treatments, growth in public health infrastructure, and more access to genomic sequencing are all bright spots, Barocas said.

“The fact is that I can go to the hospital and no matter how overwhelmed or how exhausted we all are, it is vastly different,” he said. “It’s a vastly different landscape than what we had in March of 2020.”

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