Even before the arrival of Omicron, the winter months were going to be tough for parts of the United States. While COVID transmission rates in the South caught fire over the summer, the Northeast and Great Plains states were largely spared thanks to cyclical factors and high vaccination rates. But weather and the patterns of human life were bound to shift the disease burden northward for the holidays--and that was just with Delta. Enter a new variant that appears better able to evade immunity, and that seasonal wave could end up a tsunami.
Back in July, CDC Director Rochelle Walensky announced that COVID had become "a pandemic of the unvaccinated," an unfortunate turn of phrase that was soon picked up by the president. Now the flaws in its logic are about to be exposed on what could be a terrifying scale. Unvaccinated Americans will certainly pay the steepest price in the months to come, but the risks appear to have grown for everyone. The pandemic of the vaccinated can no longer be denied.
The 60 percent of Americans who are fully vaccinated could soon find their lives looking very different. For much of the summer and fall, those who had received two Pfizer or Moderna doses or one Johnson & Johnson shot were told that they were essentially bulletproof, especially if they were young and healthy. But preliminary data from South Africa and Europe now suggest that two vaccine doses alone might still allow for frequent breakthrough infections and rapid spread of the disease--even if hospitalization and death remain unlikely. Getting three shots, or two shots plus a previous bout of COVID, seems to offer more protection. For Saad Omer, the director of the Yale Institute for Global Health, that's enough evidence to justify changing the CDC's definition of full vaccination. "With Omicron and the data emerging, I think there is no reason why we shouldn't have a pretty strong push for everyone to have boosters," he told me.
At this point, the CDC has recorded that less than a quarter of adults who are fully vaccinated under the existing definition have gotten a third shot. That leaves about 150 million people who are vaccinated but unboosted. Given that the people in this group are less protected against infection, they're at greater risk of passing on the disease to unvaccinated or partially vaccinated kids, as well as to unvaccinated or immunologically vulnerable adults. They will also pass the coronavirus more readily among themselves. Settings that might have previously seemed safe for vaccinated folks--say, a restaurant or performance venue that strictly checks vaccination status--could become fertile ground for transmission, because the people inside them are more likely to catch and spread the virus. Indeed, anecdotal reports already suggest that large indoor gatherings of fully vaccinated people can become super-spreader events in the age of Omicron.
Population-level immunity could suffer in another way too, Omer said: People who were previously protected because of a prior infection could now be quite vulnerable to getting reinfected and passing on the disease. In fact, it's possible that the only parts of the country where community transmission might be blunted are those that faced devastating early waves of the virus and subsequently had strong vaccination rates--mostly a handful of areas in the Northeast. "It's really very, very challenging to consider how those differences might play out," Joshua Schiffer, a disease-modeling expert at the Fred Hutchinson Cancer Research Center, told me.
Here's the upshot: Each fully vaccinated person might still be at minimal risk of getting seriously ill or dying from COVID this winter, but the vestiges of normalcy around them could start to buckle or even break. In the worst-case scenario, highly vaccinated areas could also see "the kind of overwhelmed hospital systems that we saw back in 2020 with the early phase in Boston and New York City," Samuel Scarpino, a network scientist at the Rockefeller Foundation's Pandemic Prevention Institute, told me. If only a small percentage of Omicron infections lead to hospitalization, the variant is still spreading with such ferocity that millions of people could need a bed.
Such a scenario would be especially dangerous if those millions of people all needed a bed at the same time. Omicron is so transmissible that cases could peak across the country more or less in tandem, Schiffer and Scarpino both said, which would make it harder for the U.S. to shuffle personnel and ventilators to particularly hard-hit regions. ICU capacities in some states are already stretched thin and health-care workers are resigning en masse, so the harms could be even worse. "If we don't get serious, if we don't get the masks on, if we don't get testing up, we're going to be back into lockdown again because people will be dying in the hallways of hospitals," Scarpino said. The prospect of such a surge in hospitalizations is "keeping me up nights, to be honest," Schiffer told me.
This all would be mitigated if Omicron turns out to cause significantly milder disease than Delta--still a possibility, but far from confirmed--and if the vaccines' protection against severe disease holds strong. But even in that sunnier version of the future, cases are almost certain to increase in highly vaccinated areas and undervaccinated ones alike, and bring with them a host of disruptions to daily life. Schiffer suggested that in areas with sufficient political will--mostly highly vaccinated ones--high case rates could spur local leaders to institute new shutdowns. In any event, fully vaccinated people are still required to isolate for at least 10 days after a positive test, and anyone they've been in contact with might have to stay home from school or work. A positive test in a classroom could send dozens of kids into quarantine, and keep their parents out of work to care for them. Jon Zelner, an epidemiologist at the University of Michigan, told me that massive disruptions caused by surging Omicron cases this winter could force Americans to reconsider these sorts of procedures.
Whatever the effects on vaccinated Americans, the Omicron fallout is going to be much more severe for everyone else. In places with low vaccine coverage and strong anti-shutdown politics, inconvenience could be replaced by mass death and even greater grief. And the devastation will almost certainly be greater, on average, in rural communities, poor communities, and communities of color. "It's unvaccinated people who are going to be at the worst risk for the worst outcomes. And it's also going to be the folks who don't have the ability or the luxury to quarantine or just kind of hide out when it looks like the numbers are getting too high," Zelner said. People working multiple jobs might not have time to get a booster or sick days to use while recovering from side effects. People who live in areas that are underserved by hospital systems will have more trouble finding a bed and receive worse care if they do get sick.
None of these futures are yet written in stone. The scope of the coming hardship will depend on how capable Omicron is of causing severe disease and death. And though Omicron seems likely to overtake Delta, "cases are still low enough with Omicron that we can have a big effect if [we] act early," Scarpino said--though "acting early was last week." A month ago, one could still pretend that burden fell on those who lived in some other place, far away from vaccinated people in vaccinated communities. Now that delusion looks shakier than ever.