The Omicron Plan: “Circuit breakers” and other short-term strategies to get us through the next wave.

We’ve learned a lot. Now is the time to apply those lessons.

The SARS-CoV-2 Omicron variant is now poised to become the dominant cause of Covid-19 in the United States. It’s extravagantly contagious, and infections are skyrocketing even among previously infected, vaccinated, and boosted people.

Are we back to square one? Unlikely. We are seeing an alarming increase in case counts, but I’ve yet to see data suggesting that our vaccines fail to provide protection against severe disease which, fortunately, matches my recent frontline experience. Due to high vaccination rates here in Massachusetts, mostly we’ve been seeing mild cases, with some serious cases among the unvaccinated.

But it’s a very dangerous time. Because many parts of the country remain under-vaccinated, Omicron may stretch hospitals well beyond their limits. That could mean a horror show in some places, especially where hospitals are already full of patients receiving care for “usual” (non-Covid) conditions.

And yet on Friday, White House Coronavirus Response Coordinator Jeffrey Zients said, “We are intent on not letting Omicron disrupt work and school for the vaccinated.”

That’s trouble. Nobody wants life to be disrupted. But we should not be intent on ruling out anything which ground conditions warrant.

Meanwhile, President Biden will address the nation on Tuesday.

Tuesday.

Folks, it’s Sunday.

We can’t wait 48 hours to hear what his plan may be and then react to it.

In Omicron time, Tuesday is millennia from now.

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Here’s what we need to do to avoid the worst-case scenario, starting now. These particular recommendations focus on a singular goal: keeping our hospitals from falling apart due to the need for care exceeding capacity.

•Circuit breakers must be introduced in some areas. Circuit breakers are short-term restrictions, regardless of vaccination status, designed to slow the spread of Covid-19. The goal of these circuit breakers is specifically to “flatten curves,” so that hospitals do not become overwhelmed. To accomplish this, restrictions need not last long. In fact, tremendous impact can be achieved in just a matter of days (or perhaps a week or two), if adhered to sufficiently. Such restrictions are familiar and should include eliminating indoor dining or limiting seating capacity drastically. (This means that temporary government relief for affected businesses should again be provided.) Other large gatherings like concerts should go virtual temporarily or should limit their capacity dramatically. Working from home should be encouraged when possible.

Unlike the spring of 2020, circuit breakers should have clear on-ramps and off-ramps, based on case counts. Why? Because case counts today predict hospitalizations a week from now, though the exact correlation depends on local vaccination rates, what fraction of the population has previously been infected, and the average age of newly infected individuals.

Fortunately, unlike 2020 and early 2021, circuit breakers can be instituted well before we reach the kind of mayhem New York and other areas endured. They can also end far sooner than sustained shelter-in-place periods of the past. That’s because we now have ample testing capacity in many places. And even in areas where testing demands exceed capacity, we can use other information, like wastewater testing, as reasonable proxies for infection prevalence in a community.

The on- and off-ramp specifics can be worked out locally, but the math is exceptionally straightforward. Let’s imagine that a city is expected to have approximately 1,000 empty hospital beds 10 days from now, and that 1 in 50 Covid-19 cases leads to a hospitalization that lasts 10 days or more (the actual figures depend on the age and vaccination status of the population, which local officials will need to take into account). If there are 5,000 new cases per day over the next 10 days, we can project that the hospitals will be full in 10 days. If local officials detect a surge that appears poised to exceed capacity unless the tide is turned, an immediate circuit breaker could be instituted. and in time to make a difference.

Hospital capacity is not just about beds and equipment, but also staffing. Omicron will cause more infections among healthcare workers and more of their families will have infections, whether from school or work. To avoid a massive loss in hospital workforce days, hospitals should adapt “test to stay” policies for employees who have been exposed to SARS-CoV-2 whether at home or at work, rather than enforcing lengthy quarantine periods. (Because it appears that even boosting is not a forcefield against Omicron, vaccination status won’t be relevant). For infected healthcare workers, hospitals should also use “test to return” for those feeling well enough to work after 5-7 days, replacing standard 10-14-day isolation periods. We now know that many people remain contagious for just a few days, while others far longer. Why guess when we can use rapid tests to determine whether someone is a risk to their colleagues and patients? This will keep the workforce from thinning out at inopportune times. Similar systems have recently been shown to have saved tens of thousands of in-person learning days for children, without worsening spread.

Other ideas we need to implement now:

•Provide US residents with free or inexpensive KN94, KN95, or N95 masks. These masks should be routinely used in crowded indoor settings. Less effective (surgical or some cloth) masks might be acceptable for low density settings where the risk of encountering someone at the peak of contagiousness is statistically far lower. (While using the best masks all the time would be “optimal,” we are human; let’s reduce harm rather than pretending we can eliminate it by striving for a perfection that nobody can achieve). Insisting on the best masks in crowded high-risk conditions will limit “superspreading” events.

•Send every US resident free rapid antigen tests. Rapid tests should be readily available to the public and free. While rapids don’t rule out infection, they identify almost all of the contagious ones. However, it’s possible that Omicron’s transmission dynamics will render rapid tests somewhat less useful because the “warranty” on the information they provide may turn out only to be good for several hours, rather than a day or two. This is something we are watching and waiting for the FDA to comment on soon.

•Go big on vaccination and boosting by re-opening mass vaccination sites. These sites provided vaccines to communities that now lack vaccine access.

•Go small on vaccination and boosting by going door-to-door to reach people in need. EMS workers can do this. We need to lower the bar for those finally considering vaccinating due to Omicron.

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Yes, we have to respect pandemic fatigue. But I believe these interventions done correctly—circuit breakers in particular—will actually fight pandemic fatigue by giving people a sense of having accomplished something. Circuit breakers achieve an attainable goal, which people will actually feel good about.

It’s one thing to lock down for months and squander it by failing to ramp up testing. I can’t blame people living in areas where case counts were always low who wonder what the point was, or who feel no sense of collective achievement, even if they in fact did help slow the virus down. But if a community hunkers down for a few days and can see the direct results—hospitalization numbers dropping—I think that gratification will leave people willing to do it again from time-to-time in the future.

Am I willing to give up life as we know it for another year or two? Not particularly (especially once all age groups are eligible for vaccines, which is not yet the case). But am I willing to disrupt certain aspects of life temporarily when necessary to achieve a clearly stated goal? Yes. The key is to define that goal and to implement a strategy that can deliver it. Nobody gets tired of winning. What we’re tired of is losing.

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Thanks to Barb Cunningham for copyediting this article.