Glossary

• Virus– a type of germ that consists solely of a bit of genetic material (DNA or RNA) wrapped in a protein coat.  The coat gets the genes into the target cell where the genes force the cell to make zillions of new viruses (genes and protein coat), and on it goes.
• Variant- also known as a mutation, a variant strain of a virus is the same species of virus but with a change in the genetic code.  The change is minor if it has no impact on contagious the new variant is, or how deadly it is, or if it allows the virus to neutralize our vaccines. Variants that substantially increase harm are now listed by Greek letters, the most troublesome one now is Omicron.

• Coronavirus– a species name of a number of different viruses.  Called corona because its protein coat is studded with spike shapes that form a crown, halo, or corona of spikes
• SARS-CoV-2– the specific name of the new coronavirus
• COVID-19-the name of the illness that the new coronavirus is causing
• Endemic– an illness always present in a region.  One could say strep throat is endemic in the US
• Epidemic– a sudden burst of an illness that comes and goes over a limited time
• Pandemic– an epidemic that bursts across the world not just one region
• Spreadability– how contagious is the disease, how many people will end up infected
• Symptoms- the experience of being ill, for example- fever, cough, headaches, loss of smell etc.
• Asymptomatic– literally means “without symptoms”.  For COVID-19 it refers a person infected with the virus but has no and will have not symptoms
• Presymptomatic– This is a person who was infected with SARS-CoV-2, and will feel sick, but hasn’t yet
• Severity– what harm does the disease cause, in terms of  how sick you get and how many it will kill
• Mask- a mask is a loose-fitting cloth or textile that covers the mouth and nose loosely.  A surgical mask is a mask used in surgery
• Respirator-  for the purposes of the COVID-19 pandemic and other respiratory illnesses, a respirator is a mask that fits very snugly or tightly to the user’s face.  An N95 mask is a respirator.
• PCR Test–  swabs the nose to detect the genes of the COVID virus.  The genes if detected are almost certainly there, but they can persist long after contagion ends.  Very few false positives, positives can be trusted.
• Antigen Test (the home kit)- swabs the nose to detect the proteins on the coating of the COVID virus, the spike proteins.  If it does not detect those proteins, you are almost certainly not infected, negatives can be trusted.  These proteins are also on the coating of many common cold viruses, so one positive test may indicate you have a cold rather than COVID.  Two positive home tests though reliably indicate you have COVID.
• Vaccine Terms
• Vaccine or Immunization– a dose of a substance that activates your immune system, as if you have the actual infection you are hoping to prevent, leaving you in fact protected from having that infection.
• Efficacy– the percentage of people immunized with a particular vaccine who will not get infected if exposed to the target infection.  For example, a COVID-19 vaccine will be said to be 95% effective if 95% of people immunized with that particular COVID-19 vaccine will not get COVID-19 if exposed to COVID-19
• mRNA– DNA works by dictating exactly which proteins your cell will make.  The message on how to construct each protein is delivered to the cell machinery that makes proteins by a piece of genetic material called messenger RNA, or mRNA
• mRNA vaccine– an mRNA vaccine places a small bit of mRNA code that makes your cells make a protein that is the protein from a virus that alerts your immune system and activates it to make protections against you being infected
• Viral vector vaccine– a viral vector vaccine takes a harmless virus that is known to infect people reliably and places that weakened virus in a person where that virus will in fact infect the person.  The virus is not only weakened, but also attached to a set of genes  that makes your cells make a protein that is the protein from a virus that alerts your immune system and activates it to make protections against you being infected.

Good News for Children!

The Omicron variant is not very old, so all of our information about it is new.

One of the most worrisome early bits of data have been the dramatic rise of hospitalizations of children with COVID with the Omicron explosion.  It makes us all worried, does the Omicron variant which seems mild for adults turn out to be very harmful to kids?

Now comes a series of keen observations that gives me much comfort.  It looks like the rise in numbers of children in the hospital with COVID does NOT mean the Omicron variant is more harmful to kids.  In fact, the conclusion, given the information currently in hand, is that Omicron appears just as milder for kids as adults.

So how can that be, how can more kids end up in the hospital and the new variant be milder?

The answer lies in these key details:

• Included in the count of “children in the hospital with COVID,” are kids admitted for reasons having nothing to do with COVID, say appendicitis, or a broken bone, or treatment for a chronic illness, who get tested on admission and are positive for COVID.  They are admitted because of some other reason, but count as “children in the hospital with COVID.”  In fact, according a report on December 28, 2021, the vast majority of children whose test for COVID in the hospital was positive were You can’t have a milder experience of a viral infection than NO symptoms.   https://www.nytimes.com/2021/12/28/health/omicron-kids-hospitalizations.html
• The rise in numbers of children in the hospital with COVID is mostly the result of rather massive numbers of everyone getting the Omicron variant, particularly the unimmunized, which includes everyone up through age 4 years old, and all children 5 and up whose parents have chosen to expose them to the risk of significant COVID by not immunizing.  Even if only a tiny percentage of young children will get sick from COVID infection, if many times the usual number get infected, the total number of those who get very ill from COVID will rise.
• To put the numbers into some perspective, right now, even with the reported dramatic rise of children in the hospital with COVID, there are fewer children in the hospital for respiratory infections than this time during a more typical, pre-COVID, flu year.

Putting it all together, the one good thing about COVID from the very start of the pandemic appears to remain quite true today.

The younger you are, the milder COVID is, even down to the early ages of infancy and towards newborn ages.  Omicron does not appear to be changing this very welcome trend.   But what Omicron clearly is changing is the sheer scale, the huge numbers of people who get Omicron COVID across all ages.

Testing After Infection

The new CDC guidelines, easing the demands on staying away from everyone when infected with or exposed to COVID made testing at the end of your illness optional.

Many are now asking, why not use testing to prove you are no longer contagious?

The answers are very persuasive to me that testing after you are infected is not very helpful.

To be clear, if you wonder if you have caught COVID, if you have begun an infection, testing is the ONLY way to know and deeply essential.   On this point PCR testing, the test to see if the COVID genes are present, is the MOST reliable way to know.  Emerging data are suggesting that the long vaunted rapid test, the test to see of COVID proteins are present, may have more false negatives during this Omicron era.  So if you wonder if you caught COVID before you visit a vulnerable person, you should get a PCR done.

But the question here is about someone who knows already they have COVID by a positive test.  What is the value of re-testing a positive person?  The answer, not much.

The reasons, again, are persuasive.

First on the PCR.  As we have said all along, the PCR can detect bits of COVID genetic material long after your COVID infection has been over, long after you are no longer contagious.  That is why we have typically not recommended any re-testing once you are known to have COVID, unless the question is whether later on if you have developed a new case.   What does long after mean?  We know that the PCR test can remain positive for as long as 12 weeks after you get COVID.  Nobody is contagious months after their infection.

Further, if your PCR is negative during the short period of time you are expected to be most contagious, you cannot rely on that to prove you are not contagious.  Say you get infected with COVID on March 1, you will at your most contagious from March 3-10 and likely contagious if you have symptoms til March 15.  If you get a negative PCR during March 5-15, you could very well still be contagious!

So if you have COVID, proven by a PCR test that tells you started an infection, there is no value in repeating a PCR later on to prove you are not contagious.  The test if positive after 10 days of the first symptom is meaningless, does not mean you are still contagious.  The test if negative after an initial positive at onset of the illness does not reliably predict you are no longer contagious.

Now the Rapid Test.  Sadly, very sadly, we are learning the limits of accuracy of the home test.  In this situation, where a PCR showed you had COVID, taking a rapid test a few days later to prove you are no longer contagious is just as unreliable as doing so with the repeat PCR.  It is not clear that the rapid test positivity lingers as much as the PCR positivity does.

But we do know that if you have an active case of COVID, and you do a rapid test say 5 days into the illness, if it is positive that does not prove you are contagious, and if you are negative, it does not prove you are not contagious.

Neither the PCR nor the rapid test can predict if you are contagious in the middle of, or even after your course of COVID.

How do you know if you are contagious then?

The MOST reliable technique is to count 10 days, if you have symptoms, from the first day of symptoms, by day 11 essentially no one is contagious, unless you were severely ill (hospitalized and in the ICU).

A VERY GOOD technique now available is limited to those with no symptoms, or whose symptoms really are going away. For those with COVID who have no or disappearing symptoms, you will very, very likely no longer be contagious after Day 5 where Day 1 is the day of your positive test.   We do not recommend repeat testing to prove this point.  We do recommend isolating to Day 10 where Day 1 is the first day of symptoms if you fear exposing someone for whom catching COVID could be very dangerous.

Can a Variant Be Good?

At a time when we are all quite exhausted by living through this catastrophe, the COVID Pandemic, it seems a very bad time to ask if any COVID variant could be good.  And I do not want to put any good words in for this Omicron variant.  Yes, it is milder, but the level of its contagion is staggering.  We are used to talking about COVID surges, but this really is an explosion.

As noted in earlier posts of Real Answers, Omicron COVID is like measles, perhaps the MOST contagious of common viruses.  And as also noted, the experience of an epidemic changes radically when the rate of contagion goes up like it has with Omicron.  To very briefly re-cap, if a virus spreads on average to 2.5 people each round of infection, then in 10 rounds, 1 case will become 1,000 cases.  That was the rate of spread for the original COVID virus, and look how well it spread even at this rate.

Now make that average spread per case 6 cases, and 10 rounds becomes 60 million cases, the story of Delta.

But Omicron is a totally different experience than either, it’s spread number is 12.  Take a virus that on average infects 12 people with every case and do that 10 times, the number goes up to 62 billion, or over 8 times the total number of people in the planet.  And Omicron doubles every 2 days, so we are talking about a virus that could infect the entire planet, and quickly.  It won’t explode quite that completely because immunization slows spread considerably, because we wear masks, and are keeping our distance.  But that only slows down a total explosion.  One look at the numbers tells us all this is a spread like we have never seen, fully consistent with a virus that spreads this way.

The upshot is that any place of gathering will see Omicron spread, any.  Football teams, Broadway shows, weddings, and sadly, schools.  And Omicron though milder, when it infects billions of people, will kill hundreds of thousands if not millions.  Here in the US we are on track, should Omicron continue to rage as it is for a whole year, to lose another 400,000 lives, but that will not happen, because viruses that spread this extremely infect all they can so fast that they burn out.  Already in S Africa and England we are seeing signs that the Omicron explosion will last weeks, not months.

But the Omicron story does hold out a valuable clue about how the COVID catastrophe will end.  We know of such an ending, we are still living through the ending of the 1918 flu pandemic, the Spanish flu.  The name of the COVID virus is SARS-CoV-2, the name of the Spanish flu virus is influenza H1N1.  Check out the label on any flu shot this year, or really any year, and one of the viruses listed on it will be influenza H1N1, the very same virus that raged across the world 1918-1921.  The pandemic flu virus of 1918 never went away and is in our community today, since we are seeing clear signs that we are having a winter flu epidemic right now, right on time.  So if the germ of the 1918 flu pandemic is here, why isn’t the pandemic still here?  The answer is very simple, the virus remains, but it is far, far milder.

Omicron does give us a taste of how a pandemic virus gets milder.  Omicron causes less severe disease, but still spreads.  Should the COVID viruses get milder and milder and milder, it is not only possible, but expected, that SARS-CoV-2 will weaken, still spread, but not cause much serious illness.  At that point COVID will eventually truly be a mild illness for all but a few and the pandemic will be over.  Schools and all other activities will resume, fully knowing that ramps up colds and flus, but without fear of mass loss of life, like colds and flus.  We are not there yet, so GET IMMUNIZED NOW.

But I thought it would be helpful to know that Omicron may illustrate the ability of a weaker virus to dominate the landscape, moving us toward a day when COVID will become truly mild.

Bottom Lines

1. The experience of children with Omicron, at this time, suggests that it is milder than Delta, just like adults.
2. The boost in numbers of children in the hospital with COVID is due in a large way to the number of kids admitted for other reasons who tested positive on admission, the vast majority of whom were asymptomatic for their COVID infection.
3. The PCR and rapid test are NOT RELIABLE to tell you, once you HAVE COVID, whether you are still contagious.  We do not recommend routine retesting once proven to have COVID.
4. We fully support the new CDC guidelines, which really speak to those with COVID with no symptoms or whose symptoms are rapidly clearing up.  Isolate for 5 days, wear a mask around anyone for another 5 days.
5. And we fully support the new CDC guidelines for those exposed to COVID.  If fully immunized, no quarantine.  If not fully immunized, 5 days of quarantine.
6. A word on tests to see if you caught COVID.  The gold standard is the PCR.  Sadly, very sadly, the rapid test turns out not to be as reliable for this purpose.  The rapid may be OK if you are not concerned about spreading it to vulnerable people.
7. A word on tests to see if you are still contagious after you are diagnosed with COVID.  No good.  The PCR can remain positive for 12 weeks so you risk being told you are contagious for months after you are not with PCR re-testing.  And the rapid test is also unreliable to say if you are still contagious.
8. The best guide for knowing if you are contagious is the number of days since your initial positive test, and duration of symptoms.
9. Pandemics end when the pandemic virus weakens.  Omicron, we dearly hope, is the first of many steps towards a milder COVID variant that will no longer risk the deaths of hundreds of thousands.  We are not there yet, but Omicron is milder, what a great New Year’s wish that COVID will continue to weaken and reach the point its harms really do shrink dramatically!

My One Takeaway Sentence:
Be ready for the peaking of this wildfire we call Omicron, COVID will be spreading madly, but hopefully briefly, so before 2021 is out, make sure everyone you love who is 5 years old or older gets FULLY VACCINATED NOW, our best way to save their lives!!

To your health,
Dr. Arthur Lavin