“Epidemiologists are trying to say, ‘Easy, tiger.’ This could be bad. This could be very bad. But we don’t know enough to roll that tape forward."
- William Hanage, epidemiologist, Harvard T.H. Chan School of Public Health
“By failing to prepare, you are preparing to fail.”
- Benjamin Franklin
We are only one month into the march of the SARS-CoV-2 Omicron variant across the globe. Yet we already know that this variant is fiercely contagious, appears to be more resistant to vaccine-induced immunity resulting in more frequent “breakthrough infections,” but nonetheless causes less severe disease. The focus of this Germ Gems post is on how to prepare yourself for COVID-19 infection in the Omicron era.
How do I protect myself against COVID-19 Omicron? Although many scientists studying viral transmission say that Omicron is more contagious than the highly contagious Delta variant, it appears that Omicron doesn’t differ from earlier viral variants in the ways that it is transmitted. Therefore, it is back to the basics of prevention.
Get vaccinated and, if eligible, get a booster. To date, the evidence suggests that people who are fully vaccinated, including a booster, are protected against severe COVID-19 due to Omicron. To find a location for a vaccination near you, visit Find my vaccine.
Wear a well-fitting mask (N95 or NK95). in indoor public settings and crowded outdoor settings. Mounting evidence supports that proper masking and social distancing do work. (See: “ Why We Need to Upgrade Our Face Masks—and Where to Get Them,” Scientific American, September 30, 2021.)
Wash hands frequently.
Stay away from crowds.
Improve ventilation in your home and workplace.
Get tested. If you have any symptoms suggestive of an upper respiratory tract infection (that is, a “cold”), or if you’ve been exposed to someone with COVID-19, or traveled as noted under the Center for Disease Control and Prevention (CDC) guidelines (see CDC guidelines) get yourself tested.
Symptoms may appear 2-14 days after exposure to the virus. People with any of these symptoms may have COVID-19 Omicron (loss of taste or smell seems less common than with other variants); none of these symptoms is pathognomonic (diagnostic) of COVID-19:
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
The rapid at home antigen test kits work quite well at detecting Omicron. For more information about antigen tests, which provide results more rapidly than PCR tests, I highly recommend the December 24 New York Times article ““How Accurate Are At-Home Covid Tests? Here’s a Quick Guide.”
Home-based kits for testing are available at CVS, Walgreens, and other pharmacies or on-line via Amazon. Also, testing sites can be found on-line. (The Federal Government is purchasing 500 million test kits to be distributed at reduced cost to Americans—details to follow.)
What should I do if I test positive for COVID-19? None of the routine tests can distinguish among the different COVID-19 variants, but from a practical standpoint, that doesn’t matter as the steps you should follow are the same. First, you need to notify your local public health agency that you’ve tested positive (sites for reporting can be found via the Internet; they also provide you instructions regarding quarantining.)
It is also strongly recommended that you inform your individual close contacts that they may have been exposed and should seek testing. If you’re employed, inform your manager or supervisor to arrange for time off and request assistance with identifying and notifying those with whom you have had close contact if needed.
You should also notify your healthcare provider that you tested positive for COVID-19 (and if you’re seriously ill—for example, short of breath or develop mental confusion—consider a visit to Urgent Care or an emergency room). If your illness (symptoms noted above) is relatively mild there are three options for outpatient antiviral treatment discussed below (note that all of them require contacting your doctor or healthcare provider for a prescription):
Fluvoxamine (trade name Luvox): 10 mg, twice a day, for 10 days. (See my October 29, 2021 Germ Gems post, “News Flash—Fluvoxamine: an Oral Drug for COVID-19 That’s Effective, Safe, and Cheap” for why I believe this drug is a first-line treatment.) In Brazil, the large TOGETHER randomized clinical trial (RCT) using fluvoxamine showed a two-thirds reduction in need for hospitalization in unvaccinated COVID-19 patients.
Several decades ago, the U.S. Federal Drug Administration (FDA) approved fluvoxamine for the treatment of depression and obsessive compulsive disorder. This drug has been proven to be safe. The FDA has not, however, approved this drug for the treatment of COVID-19. Prescribing drugs for non-FDA indications, so-called “off-label prescribing,” is common, accounting for 10% to 20% of all prescriptions written. So when fluvoxamine is prescribed in the U.S. for COVID-19, it’s considered off-label.
After discussing fluvoxamine with my like-minded internist, I received an “off-label” prescription for fluvoxamine. If upon in-home testing, my next “cold” turns out to be COVID-19, I’ll promptly start taking it. Because it is important to start treatment promptly after diagnosis, I suggest you have a similar conversation with your primary care doctor, and if they concur ask for a prescription.
Paxlovid (nirmatrelvir and ritonavir): 3 pills twice a day for 5 days. (See my November 19
Germ Gems post, “News Flash—Pfizer’s COVID-19 Pill, Paxlovid, Looks Like a Winner”
for why I consider Pavlovix another game-changing medication for COVID-19.) RCTs showed that Pavlovix decreased the risk of severe disease by almost 90%. Produced by Pfizer, Inc., it received FDA Emergency Use Authorization (EUA) on December 22 for patients 12 years-of-age and older.
There are no data from comparative trials of Pavlovix versus fluvoxamine. It’s my opinion that if such studies were done, Pavlovix might have somewhat superior efficacy. But it seems unlikely to me that it would prove safer (after all, fluvoxamine has been around for decades without significant safety issues). Also, Pavlovix almost certainly would be more costly (a full 10-day course of fluvoxamine is only $4). Like fluvoxamine, treatment with Pavlovix should be started as soon as testing confirms the diagnosis of COVID-19.
Molnupiravir: 4 capsules twice a day for 5 days. On December 23, the U.S. FDA issued an EUA for Merck & Co.’s molnupiravir for the treatment of mild-to-moderate COVID-19 in patients 18 years-of-age and older who are at high risk for progression to severe disease and for whom alternative COVID-19 treatment options are not accessible or clinically appropriate. As with all treatments, molnupiravir should be taken as soon as possible after the diagnosis of COVID-19 is established.
The primary data supporting the EUA for molnupiravir were from a RCT of non-hospitalized patients with mild-to-moderate COVID-19 at high risk for progression to severe COVID-19. The main outcome measured in the trial was the percentage of people who were hospitalized or died due to any cause during 29 days of follow-up. While initial assessment of the results suggested efficacy of 50%, that figure was downgraded to 30% after further analysis by the FDA. Thus, when stacked up against Pavlovix, the only other drug with FDA approval for outpatient treatment of COVID-19, enthusiasm for molnupiravir dissipated. France’s decision on December 22 to cancel their order for molnupiravir was based on such an assessment.
What should I do If I’m notified I’ve been in contact with somebody with COVID-19? Based on information from the CDC and other sources, if you’re notified by someone that they have COVID-19, and you’ve been in close contact with them take the following steps:
If you are fully vaccinated:
Continue to complete your normal duties, or
Stay home if you have symptoms. Get tested as soon as possible. Avoid others for at least 10 days since symptoms appeared or until you receive a negative test result.
Without symptoms, get tested 3-5 days after close contact with someone with COVID-19 or as soon as possible if you don’t know when you had close contact.
Wear a mask indoors for 14 days following close contact or until your test result is negative.
If you’re not fully vaccinated:
Get tested as soon as possible and 3-5 days after the exposure. Consider regular testing after that.
Stay home regardless of symptoms. Avoid others for up to 14 days, but you may use guidelines from your public health agency to shorten your quarantine period.
Protect others in your household by wearing a mask, staying away from others, and taking other prevention steps.
What’s next? In a recent New York Times essay, “A Scientist’s Guide to Understanding Omicron,” researchers Jesse Bloom and Sarah Cobey point out that the Omicron variant has mutations that reduce the infection-blocking ability of antibodies to about one-fourth of their effectiveness against an earlier version of the virus. They suggest this increased resistance to antibodies plays a major role in the increased infections among the vaccinated and those previously infected. In other words, we have waning immunity to thank for the recent surge in COVID-19 cases throughout the U.S., and indeed the entire world.
In a December 22, 2021 article in the Journal of the American Medical Association, “Winter of Omicron—The Evolving COVID-19 Pandemic,” Dr. Carlos del Rio and his colleagues suggest that given the high transmissibility of Omicron, the definition of “fully vaccinated” should now include the booster, that is, three injections total, and that the goal of vaccine coverage for the entire U.S. population should be raised to more than 80% to 85%.
Although there’s preliminary evidence in South Africa that Omicron infections are losing steam, several vaccine manufacturers (Moderna, BioNTech, and Johnson & Johnson) are developing new vaccines that target this Variant of Concern. At the same time, the state of Israel, which has been a global leader in vaccine strategy, announced plans to offer a fourth dose of the COVID-19 vaccine to slow the spread of the Omicron variant.
Surviving this year’s “Pandemic Winter.” What surviving this year’s “Pandemic Winter” means will vary from individual to individual. But all of us should adopt the Boy Scout’s motto of “Be Prepared.”
Ordinarily (that is, as in pre-COVID-19 times), my wife and I would be embarking on our annual escape from Minnesota to a warmer climate. But because of COVID-19, that isn’t happening this winter. On the other hand, we’re not postponing flights to see our children and grandchildren. You can be sure, however, that we are packing plenty of N95 masks, and for the first time in our lives, rapid COVID-19 antigen test kits and a 10-day supply of fluvoxamine.
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