February 14th, 2022
The Omicron variant found me finally in a consciuosly un-boosted state. It was a kitty cat compared to my first brush with Covid in March of 2020. First illness lasted 8 days with mild myocarditis and with a month of fatigue. It was frankly rough. Round 2 was 2+ days of flu like symptoms with minimal secondary symptom continuance. The memory T and B cells from round one plus an mRNA vaccine dose a year later made a huge difference considering how well Omicron evaded the immune antibodies circulating. (of which I had a lot based on testing in October, 9
months after vaccination). Again, I tell you this only as it is my story and how I perceived the literature as I made my decisions. Each person must decide their path based on their risk and understandings. I will continue to present the data for you all to use in every decision moving forward.
I now have excellent antibody responsiveness to all parts of the Omicron virome because of a natural infection response versus just a spike protein vaccine presentation. This will also generate many iterations of antibodies with slight mutations to omicron itself with anticipation of Omicron's mutations as well. The beautiful system of natural immunity has taken place and I should have excellent immunity moving forward. Now comes the question of for how long and to what level? How long will it take for Omicron or another variant to reinfect me? No idea. The previous high mark for antibody duration systemically was 3-5 months after vaccination based on study data. My initial situation was sick 3/20 followed by mRNA vaccination 1/21 and antibodies tested robustly 10/21. Mild Omicron infection 2/22. Now let's see what the antibody levels look like as I test this year and next. Stay tuned - experimentation in progress.
Where are we going? Let's be honest, we have no idea where things will go. The hope is that we are past the phase of more severe disease based mutations like Delta. This is likely, not not set in stone. History has shown that movements towards an Omicron level are more common, i.e. more infectious. However, getting more infectious is going to be tricky as there is not very far to go as only varicella and measles are historically more contagious. But, nature will play out as nature decides. We will just plan to react in kind. All of the writers that espouse modeling and control over predictive outcomes have been humbled by Covid like they have never been before. Nature is in essence uncontrollable. We are in the throws of Darwinian and Lamarkian resolutions. By that, I mean that, if you are genetically weak for viral surveillance and killing because of a genetic mutation at birth or lifestyle based epigenetic weaknesses, then you likely are gone which is Darwinian survival of the fittest. The gene that was responsible for the demise no longer circulates. The survivors, on the other hand, will undoubtedly begin developing epigenetic changes that provide a survival advantage over time which is Lamarkian and in line with human evolution in the face of any obstacle. It is truly fascinating, albeit morbid, in a scientific way, to watch a real time survival event play out in rapid sequence. I hope that we never do this again, but the science remains what it is, fascinating.
My initial thought had been that a globally utilized novel vaccine directed against multiple parts of Omicron is likely to be very important over time to reduce the ability of the SARS2 virus to infect and replicate at the current R0 leading to more tricky mutagenesis. This may not be true as a new study with Moderna's vaccine shows. See #13 below.
We are not out of the woods yet. The world needs to have immunity at some level. Natural Omicron really helped us get closer to this goal, but more vaccination globally can only help those that are unvaccinated. it appears that continuing to use the current vaccines in use makes the most sense.
We need to maintain a sharp focus as a culture on inflammation reducing lifestyle choices to aid our long term survival. The powers that be need to push a stronger narrative around healthy living through education. These issues should be straight forward education with a love bend. This is not a time for the policy makers to act as if they know what is best for us. More that we could all benefit by making these choices for our collective health. We need congress to subsidize healthy food over processed junk as is occurring now.
Be prepared to vaccinate if you are at risk moving forward pending changes in the global COVID battle.
Now that we are passed the opinion Covid newsletter from 2 weeks ago, let us get back to the business of literature review. This week is a heavy focus on Long Covid or PACS. Next covid update will focus on mental health.
Quick Hits -
1) "Post-acute sequelae of COVID-19 (PASC) represent an emerging global crisis. However, quantifiable risk-factors for PASC and their biological associations are poorly resolved. We executed a deep multi-omic, longitudinal investigation of 309 COVID-19 patients from initial diagnosis to convalescence (2-3 months later), integrated with clinical data, and patient-reported symptoms. We resolved four PASC-anticipating risk factors at the time of initial COVID-19 diagnosis: type 2 diabetes, SARS-CoV-2 RNAemia, Epstein-Barr virus viremia, and specific autoantibodies. In patients with gastrointestinal PASC, SARS-CoV-2-specific and CMV-specific CD8+ T cells exhibited unique dynamics during recovery from COVID-19. Analysis of symptom-associated immunological signatures revealed coordinated immunity polarization into four endotypes exhibiting divergent acute severity and PASC. We find that immunological associations between PASC factors diminish over time leading to distinct convalescent immune states. Detectability of most PASC factors at COVID-19 diagnosis emphasizes the importance of early disease measurements for understanding emergent chronic conditions and suggests PASC treatment strategies." (Su et. al. 2022) Su Cell
In English, this study basically says that long covid is associated with dysfunctional immune polarization due to antecedent risk factors including chronic hyperglycemia and autoimmune T cell polarity. These issues are known to be related to intestinal dysbiosis, poor nutrition and over use of medicines including antibiotics and antacids. Dysbiosis was also noted by Dr. Fasano in children with multi inflammatory syndrome. The children with difficult delayed disease also had systemic viral proteinemia which is a hallmark of intestinal permeability. We could do a whole podcast on this topic alone. Oh, right! We are going to in 2 weeks with Dr. Fasano. So excited to dive deeper here.
The autoantibody theory is also well studied as we have seen over the pandemic. Individuals with autoantibodies against immune surveillance mechanisms have higher viral loads, worse disease and longer time to recovery. Men are most effected demographically.
2) Long Covid remains a study of human lifestyle choices that drive dysfunction within the intestinal microbiome. "At 6 months, 76% of patients had PACS and the most common symptoms were fatigue, poor memory and hair loss. Gut microbiota composition at admission was associated with occurrence of PACS. Patients without PACS showed recovered gut microbiome profile at 6 months comparable to that of non-COVID-19 controls. Gut microbiome of patients with PACS were characterised by higher levels of Ruminococcus gnavus, Bacteroides vulgatus and lower levels of Faecalibacterium prausnitzii. Persistent respiratory symptoms were correlated with opportunistic gut pathogens, and neuropsychiatric symptoms and fatigue were correlated with nosocomial gut pathogens, including Clostridium innocuum and Actinomyces naeslundii (all p<0.05). Butyrate-producing bacteria, including Bifidobacterium pseudocatenulatum and Faecalibacterium prausnitzii showed the largest inverse correlations with PACS at 6 months." (Liu et. al. 2022) Liu Gut
Low levels of F. prausnitzii are also highly associated with inflammatory bowel disease. We are still learning a lot about the risks of modern American intestinal dysbiosis and disease risk, but, there clearly are some keystone species that we need to preserve to prevent negative outcomes. High fiber diets are the key to health.
3) Long Covid - "of 9751 total participants, 5266 (54.0%) were male; 30 of 45 studies reported mean or median ages younger than 60 years. Among 16 studies, most of which comprised participants who were previously hospitalized, the median proportion of individuals experiencing at least 1 persistent symptom was 72.5%. Individual symptoms occurring most frequently included shortness of breath or dyspnea 36.0%, fatigue or exhaustion 40.0%, and sleep disorders or insomnia 29.4%.(Nasserie et. al. 2021) Nasserie JAMANetwork
The male predominance is interesting and aligned with the higher frequency of autoimmune antibodies to gamma interferon and lower testosterone levels being associated with increased risk for men of worse Covid disease than females. The more robust the inflammatory response, the more cellular damage follows increasing the risk for auto immune antibody production which is likely tied to chronic covid disease symptoms.
4) Long covid is much less likely in the previously vaccinated. This new study showed a 50+% reduction in Long Covid PACS symptoms in those individuals who had had 2 doses of the vaccine prior to becoming infected. (Kuodi et. al. 2022) Once naturally infected in an unvaccinated person and without PACS symptoms, the risk of PACS is likely equally low with subsequent infections. However, we are playing Russian Roulette every time we enter the COVID fray in an unvaccinated state. This data really only matters now for the unvaccinated population.
5) MIS-C, multi inflammatory syndrome - c., in children is associated with poor intestinal function from a microbiome perspective. Research from the lab of Dr. Alessio Fasano has shown direct evidence of intestinal permeability in children with multi inflammatory syndrome - c:
• They looked at 100 children: 19 children with MIS-C, 26 with acute COVID-19, and 55 controls.
• They analyzed the stool for SARS2 presence by PCR, polymerase chain reaction.
• They analyzed the blood for zonulin and other chemicals that indicate intestinal mucosal breakdown.
• They further analyzed the blood for the spike protein as well as the markers of the immune inflammatory response which when elevated is the chemical hallmark of MIS-C.
• The paper notes that there is increasing knowledge that the intestine serves as ground zero for SARS-2 COVID disease in adults and that in severe cases, microbial dysbiosis(abnormal bacterial makeup) and disruption of the gastrointestinal barrier drive inflammatory activation.
• MIS-C in children is delayed for weeks after initial infection when the virus is no longer found in the nose/respiratory tract making the source of the virus a different replication location in MIS-C.
• They showed that weeks after initial infection, they could isolate RNA for SARS2 in the intestine. There the virus causes intestinal inflammation and permeability leading to spike proteins leaking into the blood stream triggering the inflammatory immune response leading to system wide damage.
• Most therapies including steroids and IVIG (pooled immune globulin) are not clearing the spike protein from the blood pointing to the inability of current therapies to address the virus at the gut level as they are only addressing the downstream inflammation not the upstream generator of inflammation.
• In the study, in one 17 month sick child, they used Larazotide, a zonulin antagonist, an investigational therapy used in this case to block the zonulin peptide that was increasing the intestinal tight junction permeability looking for a reduction in spike protein in the blood and a corresponding inflammatory reduction. This occurred as hoped and clinical resolution occurred. (Yonker et. al. 2021) Yonker J Clinical Investigation (full article)
Remember this from last spring: After listening to a discussion by Dr. Ed Behrens from the Children's Hospital of Philadelphia regarding multi inflammatory syndrome in children, it appears to be the case that certain individuals have genetic mutations putting them at risk for immune dysregulation whereby the chemokine CXCL9 response to gamma interferon after being infected with SARS2 is up regulated due to missing repressive proteins in this inflammatory cascade. This leads to elevated immune activation very reminiscent of macrophage activation syndrome. In other words, many children will respond to SARS2 with normal and appropriate gamma interferon proteins to attack and kill the virus. CXCL9 is one signaling molecule in this process that recruits the white blood cells to enter the fray and fight SARS2. When the virus is killed, there are repressive proteins that are called in to stop this whole inflammatory process. This is the normal state for 99.99% of our children. The rare child with this genetic mutation can not shut off this process leading to all of the inflammatory sequelae seen in COVID19.
Unpacking all of this for MIS-C:
• This is clearly a disease occurring in individuals with prior co-morbidities putting them at risk for baseline inflammation.
• There is a genetic predisposition in some individuals to be missing a gene to suppress the immune inflammatory response once it starts.
• Dysbiosis, poorly balanced intestinal bacteria, is a risk factor for MIS-C and dysbiosis is caused by chronic poorly chosen lifestyle decisions, especially diet.
• We cannot change a genetic risk for a negative outcome, but we can absolutely change our decisions that promote dysbiosis and chronic health decay.
Yet again, we see data pointing to our own personal control of our health outcomes. We can as parents make the following decisions to reduce our risk of MIS-C for our children:
1. No matter what has happened in the past, clean up your child's diet by switching to an Anti inflammatory diet, Whole 30 diet or at the least a no processed whole food diet of predominantly fruits and vegetable matter. A highly processed modern diet is the most important antecedent trigger of dysbiosis and intestinal permeability.
2. If you plan to have a child soon, breastfeed your infant from birth and practice healthy weight gain during pregnancy to set the stage for a healthy child's microbiome. The prepregnant time is a perfect time to practice an anti inflammatory diet.
3. Get adequate sleep based on age requirements. For most kids, that is 8 to 10 hours nightly. This will help reduce sleep deprived immune activation.
4. Practice chemical and toxin avoidance by avoiding the consumption of unnecessary drugs that affect the gut including antacids, antibiotics, non steroidal medicines. These medicines will negatively affect intestinal microflora balance promoting dysbiosis.
5. Practice mental health stress reduction through prayer, meditation, art therapy, counseling and more.
6. Exercise and move often stimulating gut motility and evacuation which prevents constipation and small intestinal bacterial overgrowth.
7. Avoid dairy and gluten as a food source if you suffer Long Covid or ME/CFS. These two food antigens trigger the most cellular damage intestinally in susceptible humans leading to increased low level inflammation and immune dysregulation. See Dr. Rowes Podcast for more on this topic.
8. Link to many articles on healing the gut biome: link
6) "Of the 452 eligible patients, 301 (66.8%) patients could be included, and 246 (81.5%) patients (mean age, 61.2 years; 176 men [71.5%]; median ICU stay, 18 days) completed the 1-year follow-up questionnaires. At 1 year after ICU treatment for COVID-19, physical symptoms were reported by 182 of 245 patients (74.3%), mental symptoms were reported by 64 of 244 patients (26.2%), and cognitive symptoms were reported by 39 of 241 patients (16.2%). The most frequently reported new physical problems were weakened condition (95/244 patients), joint stiffness (64/243 patients) joint pain (62/243 patients), muscle weakness (60/242 patients) and myalgia (52/244 patients)." (Heesakkers et. al. 2022)
Long Covid is clearly a debilitating and persistent problem that will become a large personal and health care burden moving forward.
7) World health Organization breaks with the US CDC by stating that booster vaccines for young people are unnecessary based on the science to date. (Reuters Article) The logic for young people is clear. The CDC is recommending boosters purely in an attempt to slow the spread of the Omicron variant. Unfortunately, there is no evidence that it does this to any useful degree for any age. Boosters, N95 masks and other mitigation measures make complete sense for the at risk groups as discussed many times to date based on current situations.
8) New York Times: When discussing why Denmark has removed covid restrictions. "We based it upon a really precise picture of the development of the epidemic, and what we saw with the Omicron variant taking over in the country. Overall, the Omicron variant is less severe. So even though we see really high case counts, we don’t need to flatten the curve like we used to, simply because we don’t see as severe a picture as we used to — with Delta for instance. When we look deeper into the numbers of hospitalizations, what we see is that we have a low and stable number of admissions to intensive care units. Yesterday, I think we had 26 admissions to I.C.U.s, which is really low given that we also had 55,000 new cases." (NYTimes Covid newsletter 2/3/22) Keep in mind that Denmark has a healthier population and a better vaccination status (81% vs 64%) than we do, making their decision vastly easier than ours.
9) New variant BA.2 appears to be very similar to omicron but possibly even more infectious by 1-5%. No data that it is more deadly to date. It may cause an extension of the BA.1 Omicron wave. That remains to be seen but appears unlikely based on current numbers.
10) "In this cross-sectional assessment of 816 unvaccinated healthy adults (mean age, 48) recruited on social media, researchers assessed antibody status arising from SARS-CoV-2 infection rather than from vaccination. Participants were categorized as follows, with 250 to 300 people in each group: (1) test-confirmed COVID-19 (“COVID-confirmed”), (2) belief that they were infected but no testing (“COVID-unconfirmed”), or (3) belief that they had never been infected and no testing (“no-COVID”). Participants were tested for spike-protein receptor-binding domain antibodies (anti-RBD) with a commercially available test.
Anti-RBD antibodies were found in 99% of COVID-confirmed people, 55% of COVID-unconfirmed people, and 11% of no-COVID people. In the COVID-confirmed group, median time since diagnosis was 9 months (and as long as 20 months)." (Schwenk et. al. 2022)
This study shows us the large number of people that have antibodies against COVID despite never testing positive for it.
11) In a very small study, a group of researchers found no viral SARS2 particles in breastmilk of symptomatic and infected mothers. (Reach MD Article)
12) As North Carolina's Data for ICU use and the use of ventilators can be found at: NCDHHS. The numbers remain much lower than Deltas peak despite massive case volume.
13) "SARS-CoV-2 Omicron is highly transmissible and has substantial resistance to antibody neutralization following immunization with ancestral spike-matched vaccines. It is unclear whether boosting with Omicron-specific vaccines would enhance immunity and protection. Here, nonhuman primates that received mRNA-1273 at weeks 0 and 4 were boosted at week 41 with mRNA-1273 or mRNA-Omicron. Neutralizing antibody titers against D614G were 4760 and 270 reciprocal ID50 at week 6 (peak) and week 41 (pre-boost), respectively, and 320 and 110 for Omicron. Two weeks after boost, titers against D614G and Omicron increased to 5360 and 2980, respectively, for mRNA-1273 and 2670 and 1930 for mRNA-Omicron. Following either boost, 70-80% of spike-specific B cells were cross-reactive against both WA1 and Omicron. Significant and equivalent control of virus replication in lower airways was observed following either boost. Therefore, an Omicron boost may not provide greater immunity or protection compared to a boost with the current mRNA-1273 vaccine." (Gagne et. al. 2022 )
This data set is frankly very surprising to me. I would have predicted the opposite. Such is the world of science. Hold your beliefs loosely. What this data set tells me in the context of everything that we have discussed to date is this: 1) Boosting with mRNA vaccines should be absolutely encouraged for all at risk and vulnerable persons, 2) The rest of us should choose based on personal fear and lifestyle to boost or get natural disease, 3) Unless this data set is different when looked at in humans, a Omicron specific vaccine has just lost steam for me, 4) The timing of boosting for at risk individuals is likely to be biannual for a significant level of protection, however, this has not been settled to my knowledge. This is my scientific hypothesis.
Curve balls and sliders,
Bates Science Immunology
Federman AP News
Yonker J Clinical Investigation
CDC Variants Page
Repeated for their importance in case you missed them last Covid Update:
1) According to a study from Kaiser Permanente, the risk of death from Omicron is 91% less than Delta. The authors state: Our analyses included 52,297 cases with SGTF (Omicron) and 16,982 cases with non-SGTF (Delta [B.1.617.2]) infections, respectively. Hospital admissions occurred among 235 (0.5%) and 222 (1.3%) of cases with Omicron and Delta variant infections, respectively. Among cases first tested in outpatient settings, the adjusted hazard ratios for any subsequent hospital admission and symptomatic hospital admission associated with Omicron variant infection were 0.48 (0.36-0.64) and 0.47 (0.35-0.62), respectively. Rates of ICU admission and mortality after an outpatient positive test were 0.26 (0.10-0.73) and 0.09 (0.01-0.75) fold as high among cases with Omicron variant infection as compared to cases with Delta variant infection. Zero cases with Omicron variant infection received mechanical ventilation, as compared to 11 cases with Delta variant infections throughout the period of follow-up. Median duration of hospital stay was 3.4 (2.8-4.1) days shorter for hospitalized cases with Omicron variant infections as compared to hospitalized patients with Delta variant infections, reflecting a 69.6% (64.0-74.5%) reduction in hospital length of stay. (Lewnard et. al. 2022)
The study also noted 74% less ICU care needed and 54% less hospitalization. The reason behind these changes seems to be related to the mutations that made the Omicron variant more likely to infect the upper lung tissue and the nasopharynx leading to less tissue damage in the terminal lung tissue where oxygen and blood are exchanged. This appears to lead to less inflammation and downstream damage systemically. This is all good news overall.
2) From MMWR: Among 1,228,664 persons who completed primary vaccination during December 2020–October 2021, severe COVID-19–associated outcomes (0.015%) or death (0.0033%) were rare. Risk factors for severe outcomes included age ≥65 years, immunosuppressed, and six other underlying conditions. All persons with severe outcomes had at least one risk factor; 78% of persons who died had at least four.
If you had a primary 2 dose vaccine series against SARS2, you have a 0.0033% chance of dying or 0.000033 which is 33 in 100,000 cases. If you add in the age and underlying comorbid disease risk, most of us have zero risk of dying. This data set is earily similar to initial data at the beginning of the pandemic. Age and comorbid disease is the route to a bad outcome in almost all cases. This data was all Delta variant related which means that the numbers are orders of magnitude smaller for Omicron. Keep it all in perspective.
Thus, again we sit here with data points for booster decisions. To vaccinate with boosters that are minimally effective against Omicron is a personal choice that is highly recommended by the medical community to protect the unvaccinated, the immune suppressed and the genetically at risk.
3) If you received a covid vaccine, the longer the time interval between the vaccine and a breakthrough infection was associated with better long term immunity. It appears that the later breakthrough infection occurs when the antibodies circulating against covid have waned significantly leading to the response to come from the memory long lived plasma cells. This also allows for a robust retraining through the lymph nodes germinal centers where antibody variations can occur to mimic the viral mutations.
From the article:"“It’s an interesting study,” says immunologist Jenna Guthmiller at the University of Chicago in Illinois. She cautions that the results are solely correlative, but adds that they are in line with immunologists’ general understanding of how antibody responses mature over time. Guthmiller explains that vaccination leads to an emergency blast of antibody production, as a natural infection would. If a person gets infected soon after vaccination, these antibodies are probably still circulating in the blood, where they’ll bind to the virus and quickly eliminate it. But when a person becomes infected months after vaccination, the antibodies that respond come from a new and improved batch made by long-lived cells that carry a memory of the pathogen. When the body encounters the pathogen again, these memory cells are called back to duty and have a chance to refine the antibodies, providing better protection against subsequent infections."(Sidik S. 2022)
This may be the exact mechanism behind the data showing that spacing out the vaccine interval was associated with better immune responses over time. Thus, if you had a Covid infection or vaccine recently, your immune response will be correspondingly less robust to generate new protective variant antibodies to the new variant exposure. I.e. if you recently had a vaccine and get Omicron within weeks, you will not get significant symptoms, but you will also not have a great long term immune response. My take on this data is hypothetical in that if you have a booster recently and then see Omicron, you will have minimal to no symptoms but will also have a weaker long term benefit. Therefore, will you need frequent boosters in the absence of natural infection? I think so. If the vaccine wanes in 3 to 4 months normally, then you will be set up for recurrent need. If you have a 0.0033% chance of dying once vaccinated, maybe it makes more sense to obtain natural disease if you are young and or older with no risk factors. Thinking out loud.
4) New data shows that vaccination with two doses of mRNA vaccines followed by natural infection is equivalent to natural infection followed by vaccination in providing super immune responses. "Current COVID-19 vaccines significantly reduce overall morbidity and mortality and are vitally important to controlling the pandemic. Individuals who previously recovered from COVID-19 have enhanced immune responses after vaccination (hybrid immunity) compared to their naïve-vaccinated peers; however, the effects of post-vaccination breakthrough infections on humoral immune response remain to be determined. Here, we measure neutralizing antibody responses from 104 vaccinated individuals, including those with breakthrough infections, hybrid immunity, and no infection history. We find that human immune sera following breakthrough infection and vaccination following natural infection, broadly neutralize SARS-CoV-2 variants to a similar degree. While age negatively correlates with antibody response after vaccination alone, no correlation with age was found in breakthrough or hybrid immune groups. Together, our data suggest that the additional antigen exposure from natural infection substantially boosts the quantity, quality, and breadth of humoral immune response regardless of whether it occurs before or after vaccination." (Bates et. al. 2022)
This is a vitally important study in the march toward understanding the long view on endemic Covid. Natural infection allows the T and B cell repertoire to see all pieces of the viral structure. Therefore, we make vastly different antibody responses to all of these differing structural proteins versus just a fragment of the vaccine seeded spike protein. This provides better long term immunity. The entire purpose of vaccinating in the first place was to prevent hospitalization and death. There was a fleeting belief that we could get a herd immunity this way. That ship sailed long ago. We are in a new endemic world now. Again, we sit at a place where logic dictates that the unvaccinated get vaccinated. The vaccinated with no risk factors will get great immunity with natural Omicron infection. Those with prior natural infection, no prior vaccination and waning immunity could get one dose of an mRNA vaccine to induce excellent immunity. Very logical and real time study based options here.
5) My opinion on masking. Now that Covid is endemic and there is no longer any evidence that non N95 masking helps reduce transmission of Omicron from child to teacher, masking in schools is not necessary for the average child. If a child is high risk or a teacher is unvaccinated or concerned about their risk, they should wear a well fitted N95 mask to mitigate risk. It is no longer feasible to continue masking in schools from now on based on death risk and spread risk of Omicron. This virus is here to stay and masking cannot be our children's future. I agree with everything that Dr. Gandhi states in the Peter Attia Drive podcast. Choose to mask based on your personal risk and that is wear it should end. Your risk tolerance dictates your desire and need to mask. Mandating mask use is no longer necessary nor warranted especially for the children who have suffered far too much. The cloth and surgical masks do not prevent transmission of Omicron well. These are the masks that most children are wearing in an effort to please the policy makers. This is not science driven. With previous variants these policies were somewhat defensible because transmission was less impressive and kids remained low risk spreaders anyway. Omicron has thrown this out the window. Omicron has a reproductive rate that makes anything less than a well fitted and persistently worn N95 mask useless. For me, N95 masks are better at prevention transmission, but that is for the at risk individuals only. The rest of the healthy individuals need not mask from here on out based on an endemic disease state and a vaccine availability. If you are vaccinated, your death risk is tiny. If you have higher risk, wear an N95 regardless of vaccine status, but especially if you are unvaccinated. However, vaccinate to reduce the risk if unvaccinated. Hopefully, the CDC and State School systems will begin to transition to endemic Covid strategies. I know where I stand pending better data to change my mind.