Christopher Kerns:
From Advisory Board, we're bringing you a radio advisory. My name is Christopher Kerns. You can call me Christopher. I'm once again, filling in for Ray Woods, who's currently on tour with Beyonce. This is just about the last topic I wanted to cover on the podcast, especially for the first podcast of the new year but you knew it was coming. Omicron, that ominous sounding letter of the Greek alphabet that in a matter of a few weeks has become the dominant strain of COVID worldwide. Omicron's rapid spread has inspired a host of policy responses ranging from the draconian to the laissez-faire.

Christopher Kerns:
What does Omicron and more important, the political and policy response to it mean for the healthcare industry? And how will that vary across markets? That's what I'd like to discuss today. Given how quickly Omicron is spreading and how quickly the news is changing related to it, you should know that we are currently recording this on January 4th, 2022. To help us work through all of Omicron's implications, I've asked a long time researcher, Pam Divack, who has spent most of the past two years tracking COVID infections for Advisory Board, to join me. Pam, welcome.

Pam Divack:
Thanks for having me.

Christopher Kerns:
You've been working on tracking COVID infections since the beginning of the pandemic, have you not?

Pam Divack:
Yeah.

Christopher Kerns:
What were some of the early things that you worked on for us?

Pam Divack:
In the beginning, it started off really looking at COVID vaccine and therapeutic development but that's expanded to covering pretty much all of the COVID-19 pandemic overall.

Christopher Kerns:
And now you've become pretty much our go to expert when it comes to all things epidemiological here at Advisory Board, have you not?

Pam Divack:
I try. My tagline for the last two years is, COVID doesn't sleep so neither is my news tracking.

Christopher Kerns:
And it seriously hasn't been sleeping lately. In fact, I think this is something we can all relate to, just about everyone we know seems to either have been ill in the past couple of weeks with or without COVID. But the reality is it's gotten to the point where Omicron has spread so quickly that I don't know too many people who don't know people who've had it now. Part of that I think is related to the fact that Pam, you and I live in New York and Washington DC, respectively, which has certainly seen the biggest uptick cases over the past few weeks.

Pam Divack:
Absolutely. I'm looking out my window right now at three urgent care lines that are three blocks long. Definitely seeing surge here.

Christopher Kerns:
Let's start with the basics. Here in the US, this is just the latest in a series of COVID surges. The most recent was of course the highly contagious Delta variant. What's different about Omicron?

Pam Divack:
The biggest thing to note here is the degree of contagiousness. Data has shown that Omicron is three to five more times as transmissible as Delta and it's spreading really quickly through populations in a short bit of time. As of today, which is January 4th, just moments ago the CDC released a new estimate that Omicron makes up 95% of new cases in the US. But the good news is that Omicron is shown to cause less severe illness and carries fewer dangers of death or complications than previous strains.

Christopher Kerns:
Its transmissibility is the main reason why it's spread through the population so quickly. You mentioned something about a shorter incubation period. What are some of the implications of that?

Pam Divack:
With a shorter incubation period, that means that people might be infectious for a shorter bit of time. However, they can go ahead and infect more people. Luckily, we're seeing that vaccinations do work in protecting against severe illness and hospitalization but there are a lot of mild cases and that's really where we're seeing a lot of higher numbers right now.

Christopher Kerns:
Let's talk about the danger of this. How dangerous is Omicron relative to other strains of COVID that we've seen so far?

Pam Divack:
There's definitely lower lethality in vaccinated people versus unvaccinated people. A majority of the hospitalizations that we're seeing as a result of Omicron are in those unvaccinated patients. However, even though it causes less severe illness, just how many people are getting the virus and how many people are getting it at once can be enough to overwhelm healthcare systems.

Christopher Kerns:
What about in unvaccinated people? Is it less dangerous for the unvaccinated as well?

Pam Divack:
The data that I've seen shows that it is less dangerous. However, because there are a significant portion of Americans that are unvaccinated still and the virus is spreading so quickly, just that number of hospitalizations in unvaccinated patients is enough to quickly fill up hospitals and we're already seeing many either hit or exceed capacity. The data that I've seen shows that the patients with Omicron in the hospital do have less severe illness but again, it's just a sheer number of patients adding up.

Christopher Kerns:
Where are we actually seeing systems getting overwhelmed overall?

Pam Divack:
We're already seeing this where I am, in New York and New Jersey. And we're seeing that hospitalizations are rising faster than ever. And some of them are even quickly approaching the levels of last winter's peak. In fact, data from a COVID-19 circuit breaker dashboard shows that as of January 2nd, 2022, nine states have actually hit their circuit breaker and 15 are at high risk, which means that the hospitals in that state are projected to be at capacity in the next one to 10 days, based on their current infection rates.

Christopher Kerns:
I want to talk about what this means for the healthcare delivery system overall and how they are going to manage through this over the next few weeks. But I want to go back to something you mentioned before about the total number of cases and how quickly they are are rising. One of the things that I've been reading about quite a bit is that even with all the reported cases, we're probably still seeing significant number of under reporting given how mild the symptoms are for most people. What's the impact of that?

Pam Divack:
Yeah, definitely as we're seeing more people rely on at home testing kits, for example, those numbers may be under where they actually are. But I think the implication is that we've been focusing a lot on case counts as our way of measuring the pandemic but it's really time to turn to looking at those hospitalizations. And again, they're not as high overall as they have been in the past but in some states we're approaching there. And I think that's the thing to be aware of.

Christopher Kerns:
I also would think that given the mildness of the symptoms, a lot of people who have the sniffles and it is in fact COVID, may not actually even go ahead and get a test. There's also, I think that lingering stigma of contracting COVID-19 and not wanting to report that to other people but you and I were chatting a little bit beforehand and you said you thought that that was actually disappearing a bit.

Pam Divack:
Yeah, I think in the past we thought we would be able to outrun catching COVID and even the most careful of people, including some of my friends and family have contracted the virus. I think a lot of that stigma is disappearing as we're recognizing that it's spreading so fast, it's kind of unavoidable.

Christopher Kerns:
Given how quickly this virus is transmitted, I would think that the peak is going to be much, much faster than what we've seen in previous iterations of this and given how fast it can work its way through the population. When are we expected to see Omicron peak?

Pam Divack:
There are new estimates from researchers at Columbia University, which show that the US could peak as early as January 9th, at around 2.5 million cases per week. And although that number might go as high as 5.4 million, we're expecting a peak in early January, even in some states like New York could be in the next few days.

Christopher Kerns:
The bad news is that it spreads quickly. The good news is that it also spreads quickly. It will be bad for a short term but it's not going to last for a long term.

Pam Divack:
Right. But I think it is also so important to talk about the fact that this is impacting everyone, including healthcare workers, including businesses, which might need to shut down if they don't have enough staff or figure out how to reallocate resources. And although it's a quick burn, it does have significant impact.

Christopher Kerns:
Let's talk about the impact this is having on healthcare workers. We have known that the impact of the pandemic has led to severe labor shortages across the entire country. The entire healthcare delivery system is short staffed right now. How is Omicron impacting staffing at healthcare systems around the country?

Pam Divack:
From a staffing perspective, we're already seeing that this rapid infection is leading a lot of hospitals to be short staffed. There was data in Forbes the other day that said that more than 25% of hospitals in 13 states are already experiencing the shortage of doctors, nurses and other critical staff and eight states here even saying that the situation might worsen. We're also seeing urgent care centers like CityMD close.

Christopher Kerns:
Are we seeing differences right now in terms of the impact on hospital capacity in areas that have large numbers of vaccinated residents versus those that have large numbers of unvaccinated residents?

Pam Divack:
The actual vaccination rates definitely play a big role in how healthcare systems are impacted but even in states with high percentages of vaccinations, like New York, where in New York, there are 72% of adults are vaccinated versus the national average of 62, just that rapid rate of infection that we've been talking about means that there is such a quick surge in hospitalizations that even a high percentage of vaccinations might not be enough to prevent a surge.

Christopher Kerns:
And I think this partially explains the fact that we are not seeing significant differences in overall case rates and hospitalizations correlated with policy responses at the state level. Is that fair to say?

Pam Divack:
Right. And typically hospitalization rates lag about two of weeks behind case rates so we might start seeing those numbers come in soon.

Christopher Kerns:
What about pediatric hospitalizations? This is something that's been getting a lot of attention recently.

Pam Divack:
During this wave, this is the first time we've seen such a big spike in pediatric hospitalizations, mostly in unvaccinated kids but this might be a result of that slow pediatric vaccine rollout. During the week of December 22 to December 28 in 2021, we've been seeing a 66% increase in the number of younger kids that were admitted to the hospital each day with COVID. In fact, Texas Children's Hospital in Houston, which is the nation's largest pediatric hospital, just reported more than a fourfold increase in child hospitalizations over the last two weeks.

Christopher Kerns:
In the past, when we were faced with the healthcare delivery system being overwhelmed with new cases, the goal at a policy level was to slow the spread and the guidance around that largely focused on masking but that guidance is changing.

Pam Divack:
Yeah, we are now seeing more calls from public health leaders and scientific experts that those cloth masks that were a little bit more commonplace earlier on, no longer are sufficient and we're seeing calls for more surgical masks or N95s or KN95s that have a bit more protection.

Christopher Kerns:
And that's not the only guidance that's changed too. CDC has released updated isolation and quarantine guidelines for individuals and that's generated some controversy. Tell us about that.

Pam Divack:
The CDC recently released updated guidance for individuals who have tested positive for COVID or have been exposed to the virus and they shortened the isolation requirements from 10 days to five days. However, this has definitely been a bit controversial as some healthcare experts are saying that the new isolation period may be too short or individuals might be contagious after five days or it impacts healthcare workers and their ability to return to work. It's definitely a hot topic and it might even change in the coming days. CDC might actually update the guidance again to say that that five day isolation will require a negative test. Definitely something to keep watching and it might continue to evolve.

Christopher Kerns:
And this will have severe implications on overall clinical staffing over the next few weeks. I think as we learn more about this, we'll continue to report on this in our Daily Briefing.

Christopher Kerns:
If CDC is going to potentially update its guidance yet again to require a negative test after the five days to end isolation, do we have the testing capacity to be able to handle that, given the total number of cases versus seeing right now?

Pam Divack:
Yeah, I know anecdotally and also based on what I've been tracking, the testing is definitely not where it needs to be right now to make this a reality. I think in terms of our current testing infrastructure, we're definitely seeing demand outpacing supply, both of PCR and rapid tests and especially at home tests. But even if that testing requirement is introduced, I don't know, Christopher, I'm unsure whether people might listen because after five days of symptoms resolve, people might go back to their normal life and not worry about the test.

Christopher Kerns:
It may be a situation in which the guidance might be moot anyway.

Pam Divack:
Exactly.

Christopher Kerns:
We've been talking about the potential for hospital and health systems being overwhelmed by these new cases but I think it's important to define what we mean by overwhelmed. The first version of overwhelmed is the inability to care for new COVID patients. Now currently, I know that a lot of hospitals are nearing capacity but most are not at that level and we have not seen any markets at that level. Is that fair to say?

Pam Divack:
Yes.

Christopher Kerns:
But the bigger issue for many of our provider listeners is that once we start nearing capacity, once we start getting past 85% occupancy, we start seeing other cases, elective cases that are being crowded out. And I think we're seeing that in just about every market that has tripped that circuit breaker that you mentioned before.

Pam Divack:
Definitely. What I've been following is New York, Chicago, Ohio, Philadelphia, Wisconsin, hospitals in those areas are all starting to postpone elective surgeries, change the masking requirements for patients while they're in the hospital and take other measures. We have not yet seen hospitals be unable to handle the capacity but we're definitely nearing being there.

Christopher Kerns:
This is mirroring a pattern we've seen over the last couple of years that colder climates tend to peak in colder months, warmer climates tend to peak in warmer months, which seems to correlate pretty strongly with peaks that happen when people go inside.

Pam Divack:
Absolutely.

Christopher Kerns:
At the very beginning of this pandemic, the rarely spoken truth was that if a patient ended up hospitalized with COVID, there was very little that the delivery system could actually do. Either the patient would recover or the patient would not. It was largely based on hydration, clear airways, anything to boost the immune response. But now we have new pharmacological treatments. Why don't you tell us a little bit about those and the impact that could have on overall hospitalization rates going forward?

Pam Divack:
This is something I find particularly exciting because I've been tracking it since day one but in the last few weeks, we've seen a few new tools in our toolbox be authorized by the FDA. I think the two biggest ones to call out are Pfizer's oral antiviral Paxlovid, which was shown to reduce the risk of hospitalization by 89% and Merck's oral antiviral, which was shown to reduce the risk of hospitalization by 30%.

Christopher Kerns:
And how quickly do those drugs have to be administered after exposure?

Pam Divack:
Within five days. There's a really short turnaround window that will be dependent on rapid testing. But as we talked about, there's still quite a few barriers to getting there.

Christopher Kerns:
Tell us about some of those.

Pam Divack:
I think it's important to first start out by saying that even though these treatments were just granted emergency use authorization, there still is a really limited supply and states are just starting to receive their shipments of these treatments but by the time that they could be redistributed to pharmacies or other authorized sites, it might be too late with the surge that we have right now.

Christopher Kerns:
Is it fair to say that the new antiviral drugs may not be in enough supply to help us during the Omicron wave? But the reality is we might have future waves and this could be a significant tool for us in those future waves that we experience?

Pam Divack:
Absolutely. But it's not just the fact that we have limited supply. It's also that complexity of getting patients tested in time, finding a prescriber, finding the right pharmacy that will dispense the treatment. There's also quite a few contraindications that prescribers need to be aware of when figuring out who to give these medications to. There's a lot of complexity and that complexity is only further complicated by the fact that these treatments, not necessarily the oral virals but some of the antibody drugs that we've had for months now, might be more or less effective for different variants. And our testing doesn't detect what variant you have. There's a lot of complexity here, coupled with the fact that there is quite a bit of hesitancy still. In fact, new data from Stat recently found that vaccinated Americans are far more likely to take the Pfizer antiviral than unvaccinated people, which means that the people who might benefit the most from these treatments might not actually be the ones to get them.

Christopher Kerns:
One of the common refrains that I've been hearing about Omicron is that it is possible to get it even though you are vaccinated. And the question I have for you is what is the impact that vaccines and boosters have against Omicron? What is the data actually showing us on that?

Pam Divack:
We know that boosters are shown to reduce the threat of Omicron and further prevent against hospitalization and death. But I think the challenge is booster rates are still so low in the US that that might be where some of those cases are coming from.

Christopher Kerns:
What is the outlook for vaccine seeing boosters going forward?

Pam Divack:
We're already seeing Israel start to roll out a fourth shot to the most vulnerable populations, as immunity garnered through these vaccinations and through the boosters might wane over time, it may be able to give us that bump back. And as we collect data on that, it'll definitely inform booster policy moving forward. The good news, Christopher, as it exists is that the healthcare system is better prepared now to handle this winter surge, both in terms of supplies and the new treatments that we have to manage. But what I really worry about is medical staff.

Christopher Kerns:
It's true. We've seen providers already seeing mass resignations, they've seen burned out and traumatized healthcare frontline workers. I'm really not sure how much more they can take. And this of course is leading to increases in healthcare staffing costs and extreme burnout. And I don't like to be the harbinger of bad news but I don't think that's going to be getting any better in the near term, which means that some of the guidance that we provided here on this podcast in the past, which is around the need to take a tour of duty approach to frontline workers and the need to accelerate the deployment of more automation in the future, that challenge is not going away and I think it's only going to get stronger over the next few months. If you are looking for ways to help with burnout, help with trauma, help with automation, you can listen to some of our previous episodes. We're going to link them in our show notes and we will be continuing to report on this through The Daily Briefing at advisory.com going forward.

Christopher Kerns:
All right, well wrapping this up then, what does Omicron mean for the future of the pandemic overall?

Pam Divack:
What I'm thinking, the future of the pandemic overall looks like is what I'm calling the big bang. This might be a really intense but short lived periods where we see cases and hospitalizations increase but they might come down pretty quickly. New York City and London in particular might be a harbinger of what is to come as London's already seemed to reach its peak and New York is definitely skyrocketing. But as we look to South Africa, for example, they've already reached their peak and they're nearing the end of their wave. There is hope and there is data that this might be a quick and intense few weeks but we might be able to make it through.

Christopher Kerns:
And I want to end it on one optimistic note. One comment that you've made for is the potential to build super immunity. Tell us what that could look like.

Pam Divack:
There's a new study published by scientists from South Africa that suggests that individuals who have recovered from an Omicron infection might actually have better immune protection in the future, both from Omicron and other COVID strains, including Delta. This might and be the way to really turbocharge our immune system and hopefully a way out of the pandemic.

Christopher Kerns:
And one thing that's been very clear is that as Omicron has worked its way through the population, it has inspired a whole lot less panic than what we've seen in the past, despite its intensity. And what that means is that Americans and indeed citizens of the world are learning to live with this. And I think that is the lesson that we're likely going to be living with this for quite some time. And the challenges that we have to meet are not going away but it doesn't mean we are less well equipped to deal with it. Pam, thank you very much for joining us today. I know we'll be calling you back on the podcast in the future, as much as it pains me to say that but we are very much appreciative of all the guidance you've provided over the last couple of years.

Pam Divack:
Thank you for having me.