What's the Omicron Outlook in the Bay Area and Beyond for the Start of 2022?

In the roughly six weeks since scientists in southern Africa sequenced and reported the omicron variant, the newest COVID-19 strain has dominated case counts — and headlines — around the world, quickly overtaking the delta variant and driving a massive surge in new infections.

While much remains unknown about omicron, the new variant is spreading as quickly as epidemiologists initially feared, although it also appears to be potentially less lethal than previous variants.

To try to make some sense of what these new conditions mean for our lives at the start of 2022, KQED Forum's Alexis Madrigal checked in on Monday with Dr. Bob Wachter, professor and chair of the Department of Medicine at UCSF, and Jessica Malaty Rivera, an epidemiologist and senior adviser at The Pandemic Prevention Institute — and former science communication lead for The Covid Tracking Project.

The following interview has been edited for brevity and clarity.

Alexis Madrigal: What's the latest outlook in the Bay Area? 

Dr. Bob Wachter: We have seen a remarkable increase in our testing positivity rate. We test everybody who comes into UCSF's hospital for anything — for a heart attack or cancer surgery or getting a medical procedure — and that is my sort of poor man's way of trying to figure out what percentage of people in San Francisco are positive. That number has been as low as 0.2%, meaning 1 in 500. But today, it's up to about 7% or 8%, meaning that 1 out of about 12 or 13 people who were tested, who feel fine, who have no symptoms of COVID, are testing positive for COVID.

Our hospitalizations were staying steady, and then about seven days ago, they started going up and they've doubled since a week ago. We're not seeing the kinds of surges that people are seeing elsewhere in the country, but we definitely are seeing an uptick because of omicron.

We are seeing a surge here, but nothing like what they are seeing in Cleveland or New York or Houston or Miami. The Bay Area is the most heavily vaccinated region in the country, so although there might be an increase in breakout infections here, people won't usually get very sick, as compared to in places with low vaccination rates.

What data should we pay attention to over the next few weeks to give us some indication of how things are going?

Jessica Malaty Rivera: A lot of people right now are gazing at these giant numbers that are upwards of two times what they looked like in January of 2021, and panicking. But we expected that, right? That's the holiday effect. That's the testing effect. That's the fact that omicron is super transmissible and a lot of people are testing positive.

But my eyes are on hospitalizations. I want to see what those trends look like because that's kind of as close to a real-time indicator of what's going on on the ground as we can get. And we are concerned that hospitals are starting to send crisis-care signals because there's too many people and capacity is exceeding the norm, and the National Guard is being deployed. That's happening in some places, and we're watching to see if it happens nationwide.

What do you think about the U.S. Centers for Disease Control and Prevention's new guidance that people who test positive for the virus but don't have symptoms need only isolate for five days rather than 10?

Wachter: I understand it. You know, if every doctor and nurse or other essential workers in other industries has to be on the sidelines for 10 days, I really worry about how we can staff the ER? I mean, can we staff our clinics? Can we take care of patients? And that, of course, creates its own harm.

I think that we've got a really difficult balance to try to figure out here. If you say everybody has to stay in isolation until they test negative, then you just have too many people out of commission. And this is really not about the economy. This is about making sure that if you come into the emergency room with a heart attack or a stroke, that there will be somebody there who can take care of you.

And because so many people today are walking around on the street who feel fine, but they actually have COVID, and some of them are infectious, at some point you try to come up with the number of days in which the vast majority of people who get the virus will no longer be infectious, and then insist that they wear a mask for the next several days after that in case they still have a lingering amount of virus.

I believe that the state of California did the right thing and the CDC did the wrong thing. California said five days of isolation, but then you have to do an antigen test [a rapid test], and it has to be negative. If people do that, the majority will test negative on Day Five and be able to go out and resume their life, while wearing a good mask. I think the CDC should have been clearer about masking — you really should be wearing an N95 or equivalent if you go back out into the workplace after isolating for five days.

California also said that if you still test positive after five days, you need to stay in isolation until you test negative. I think that's going to be the smarter call, and I suspect the CDC is going to go there in the next few days.

CDC Director Dr. Rochelle Walensky said that only an estimated 30% of people were following the original 10-day isolation guidance. Is that a good enough reason to split that time in half?

Rivera: No, in my opinion. The "let's try to find the number of days that makes it work" strategy makes me uncomfortable. Making rules easier so that you can increase compliance is not a public health strategy. It is in some cases when you're dealing with harm reduction and risk reduction. But in the context of a highly transmissible variant, in the context of a huge surge, an unprecedented surge, it's not the time to modify the rules just to make them easier to follow.

I have not seen the data to justify the 50% reduction in isolation time and also the complete disregard for testing, which has been a strategy used for travel and employment. If you have a dark pink second line on your antigen test, chances are you've got a high viral load and you are a risk to others and should stay home.

What kind of masks should people be wearing nowadays to stay safe?

Wachter: I wear an N95 or the equivalent — anything that has "94" or "95" in it — pretty much anywhere I go now when I want to wear a mask. It seems silly to me to not wear the best possible protection.

I didn't do that until a month or two ago. I felt like if I wore a surgical mask and then a good, tight-fitting cloth mask on top of it, that gave a level of protection that's not far off the N95. But since omicron is so much more transmissible than the prior variants, it just seems like the right call. If the virus has upped its game, we might as well up our game and wear a mask that gives us a fighting chance of keeping the virus at bay.

The public health message early was that you should wear a mask to protect your fellow citizen. That's partly true, but you're also wearing it to protect yourself. The evidence that a good mask will protect you is actually extremely strong.

Also, the N95s you can get now, or the K95s, are pretty much as comfortable as a surgical or a cloth mask. It's just not a big deal. Why not wear the better mask?

You definitely don't want to use masks with valves — the kind that sometimes people use during fire season — because they allow you to exhale your breath to the risk of people around you. But yeah, the KN95s [from China] and KF94s [from South Korea] are fine.

There are counterfeit masks that are not good — you can look up the quality of masks on certain websites. But if you go on Amazon or some other site and look up reviews, you can find one that works well. And I wouldn't pay attention to what it says on it. If it says 94 or 95 on it, that means in general, it's filtering out 19 out of 20 particles, and that seems to be enough to prevent transmission in pretty much all circumstances.

Are researchers gaining a better understanding of long COVID — in terms of its causes, symptoms and behavior?

Wachter: My sense is that it still is a little bit up in the air how much of long COVID is from persistence of infection, how much of it is from your immune system reacting in a way that causes you harm and how much of it we just don't understand.

It's real. There's no question that a fair number of people have symptoms that last for more than a month or two, and there are now people who have symptoms that have lasted for more than a year. It's also a tricky thing to study and be sure about. I go with the general numbers of 5% to 10% of people who get the virus continue to feel crummy a month or two out.

So I still think it's worth trying not to get it, in part because of the possibility of long COVID.

Particularly for people who have gotten three shots, if you're out there being careful, wearing the right mask, avoiding big crowds, I think there's a pretty good chance you will dodge this bullet. And I think you'll probably only have to do that for four to six weeks, when we'll be on the other side of this.

What risk does omicron pose for kids under 5?

Wachter: I think most of us are aware that kids tend to be extraordinarily safe. The chances of a kid getting very sick and going to the hospital from COVID are very, very, very, very low, but not zero. There's no evidence yet that omicron is more severe in little kids than the prior variants were. There is an increased risk of autoimmune diseases occurring in children who get COVID. That's turned out to be a threat, but not a massive threat.

Unfortunately, the best we can do for kids is wrap them in a cocoon of vaccinated people who are being careful, and hopefully get to a point where there's either so much immunity in the population or a vaccine is made available to them.

What's the best way to keep kids under 5 safe in their day care centers, and when can we expect a vaccine to be available for them?

Rivera: It's recommended that kids 2 and older wear masks. N95 masks don't come that small, but there are other masks that are equivalent. KF94s from Korea are often made in children's sizes. I stocked up on those for my 3-1/2- and 5-year-old, and I think they're wonderful. They have the same kind of thickness and multilayers that you would see in an adult-sized K95 or an N95 mask. They fit tightly, they cover the nose bridge quite well considering kids' small faces. So I highly recommend those.

And when it comes to when we can see the authorization, we did get some disappointing news that it's going to take a bit longer as health officials have to kind of recalibrate the study to consider a third dose because, unfortunately, the immune bridging for toddlers was not as high. There were no safety signals, but they wanted the efficacy to be much higher. I think that a third dose will probably give us that data that will show that these vaccines at this dosage will provide younger kids with sufficient protection. So authorization for kids under 5 should probably come, I would hope, by sometime mid-2022. That's when they've anticipated it.

What do you say to parents who are concerned about student vaccine mandates, given that the FDA has only issued emergency use of the vaccine for kids 5 to 11?

Rivera: I do think there is a bit of a misconception as to what emergency use authorization [EUA] actually is. It is not a kind of less robust process for review. In the context of an emergency, which we very much are in, and which is why we have these opportunities to expedite the process for review, the same thresholds for safety and efficacy still stand.

Just recently, the CDC published some findings on 9 million vaccinations of 5- to 11-year-olds with no signals that would show severe concerns for safety or for efficacy. I think out of 9 million, there were 11 reports of myocarditis — an inflammation of the heart muscle — all of which were mild and resolved quickly.

So I think that in the context of a public health emergency, an EUA is absolutely still sufficient when it comes to providing these guidelines for what is good for our population. And I think that we will likely see a full FDA approval very soon.

So is the end of the pandemic anywhere in sight? Could it end this year? 

Wachter: I'm reluctant to predict anything a year out because we've all been wrong. I don't know anybody who predicted delta. I don't know anybody who predicted omicron. And, you know, it can all be screwed up with a curveball — some new variant that does things that we didn't think were possible. I mean, nobody that I know thought omicron, a variant this transmissible, was possible. And it appears that we may have gotten very lucky by having a variant that is incredibly transmissible, but also less severe.

What that may lead to in February or March is a population that is almost fully immune, either through vaccination or, for people that chose not to be vaccinated, through infection. And we'll have to see how long your immunity from your infection or your vaccinations lasts. That may determine what happens at the end of 2022.

I think we're in for a pretty terrible month. My crystal ball only goes out a couple of months. I think February or March is likely to be a pretty good time as the surge likely comes down and we're left with a high level of population immunity and also more available testing, and the greater availability of particularly the new Pfizer drug Paxlovid, which is a pill that lowers the probability of a severe case — of hospitalization and death — by 90%. So that's pretty great.

It means that for those people at high risk of a bad outcome, we'll be in a position where if they do get COVID, there will be this pill that they can take that lowers their probability of something terrible happening. The problem is that it's in very short supply, but the supply is going to grow gradually over the next few months.