Category: Uncategorized

Mild for most, but…

Every variant of SARS-CoV-2 has produced mild symptoms in most of those infected. By now many of us — perhaps most of us (who do not live in New Zealand or Tonga) — have been infected but have remained asymptomatic (or barely symptomatic) and don’t even recognize our encounter with covid. But for two to three percent of those infected, results have been much more difficult, even life-ending.

There is accumulating evidence that — so far — the earliest encounters with omicron produce modest morbidity — especially when people are vaccinated. Here (again) is the most recent study out of South Africa. Here are two just-released studies from the United Kingdom, one from the University of Edinburgh and a second from Imperial College (London). I cannot yet find original source material for an analysis just completed of omicron cases in Denmark, but here is a helpful overview of three of these four reports (including Denmark’s) in this morning’s Financial Times.

In most places for most people individual risk of omicron causing serious covid is no worse or less than previously. People who are vaccinated have reduced risk. People who are boosted have very low risk of experiencing serious disease.

But omicron is very contagious, the most contagious variant yet. Omicron has also demonstrated a rather amazing ability to re-infect those with prior immunity (natural or vaccinated). Even if the hospitalization rate for omicron is the same or a bit less than prior variants, omicron’s transmission rate could push the health care system over the edge. A two percent hospitalization rate for 300 million cases will cause six-times the hospitalizations of two percent for 50 million.

Which is just a long way of saying, epidemics are less about individual risk than population risk. I am well over sixty, but otherwise my individual risk profile for serious disease is modest. I wear a mask, keep my distance, and minimize circulation to protect others from me. Mass vaccination does have individual benefits, but mass vaccination is especially important to manage risks for the most vulnerable among us. I am — all of us are — potential hosts and mutation factories for viruses. We will continue thus until we have suppressed SARS-CoV-2 worldwide. In most cases, our personal risk to this virus is negligible. But to reduce the risk to the most vulnerable — and those who are called upon to care for the most vulnerable — I want to do what I can.

There are obviously epidemiological and ethical implications here. I also perceive supply chain implications. Supply capacity is almost always the outcome of expensive long-term investments… for example in clinical facilities, pharmaceutical innovation… manufacturing… distributing, extensive professional education, and much, much more. Certainly, we want to build-in buffers for variation in demand. But there is seldom an affordable, reasonable way to develop supply capacity for a sudden doubling or more of well-established large-scale demand. So, I want to do my part to reduce demand on an already stressed system.

Keeping track

As some readers have requested, here are a few links that should help track omicron’s behavior.

While skyrocketing case counts clearly matter, in my judgment the key metric in the weeks ahead will be hospitalizations. This is our best indicator of systemic risk, both for those infected (and re-infected) and health care systems. Hospitalization is the “supply” that will be most constrained for this “demand”.

From South Africa the National Institute for Communicable Diseases Daily Hospital Surveillance Report.

From Denmark the Danish Health Authority COVID-19 Surveillance report (including hospitalizations).

From the United Kingdom there is a Coronavirus Data portal (link will take you to hospitalizations).

From the United States, the Centers for Disease Control tracks new hospital admissions (please note link to second chart).

Our World in Data at the University of Oxford also provides interactive charts for several nations (in both linear and logarithmic formats).

Dr. William Hanage, professor of the evolution and epidemiology of infectious disease at Harvard University, writes in today’s Guardian,

You cannot simply compare Omicron with Delta by adding up the numbers of cases and hospitalisations for each over a short timeframe. The numbers of Omicron cases have been growing faster – much faster – than those of Delta, and it takes time for people to become seriously ill. To accurately gauge the severity, we will need to compare the numbers of cases that end up in hospitalisation or death. 

Dr. Hanage goes on to explain it will be a few weeks before a meaningful comparison of omicron’s severity with delta’s severity will be possible.

There is increasing evidence that omicron’s impact on the South African population is less severe than prior variants. A just released study used S Gene Target Failure (SGTF) as a proxy for omicron infection as early as October 1. The not yet peer-reviewed report concludes:

Early analyses suggest a reduced risk of hospitalisation among SGTF-infected individuals when compared to non-SGTF infected individuals in the same time period, and a reduced risk of severe disease when compared to earlier Delta-infected individuals. Some of this reducton is likely a result of high population immunity.

These findings suggest (more) that South Africans infected with omicron have been 80 percent less likely to be hospitalized and 70 percent less likely to experience severe disease than those who contracted the delta variant. Omicron has, however, been much more contagious than delta, both in South Africa and elsewhere.

As previously noted, health care capacity is comparatively fixed. We do not yet have a data-derived understanding of real demand. Potential demand (as measured by new cases) is exploding. Over the next two or three weeks hospitalizations will confirm “effectual” demand. The links above should help signal what’s coming. The most effective demand management measure currently available is vaccination (especially boosters). Masking, social distancing, good ventilation, and avoiding crowded interior spaces also help.

Adapting flow to omicron

Part of the current disequilibrium of supply with demand involves flow capacity from warehouses, distribution hubs, and fulfillment centers to retail and direct-to-demand. Omicron threatens to further constrain. But there is still time to avoid the very worst.

Early last week a friend confessed his large-scale grocery distribution enterprise is getting enough inbound volume, but can not always gin-up sufficient outbound velocity to fulfill the fastest retail turnovers. The problem, he said, started last Spring/Summer when he lost many of his most experienced selectors and drivers. He has not been able to hire fast enough to fill the gaps (in both numbers and skill). (See: Journal of Commerce, Transport Topics, CNBC, Bloomberg, Wall Street Journal, Lehigh Valley Live)

According to the Bureau of Labor Statistics, in November 2021 there were just over 1.5 million “warehousing and storage” employees. This compares with about 1.28 million in November 2019. That’s almost a fifteen percent increase. Problem is retail sales are up nearly twenty-three percent over the same two years. Plenty of toil, turmoil, and trouble is embedded in that eight percent gap, especially for places where the overall national rate is doubled or worse.

Friction is added to this already tight flow by various measures intended to mitigate transmission of SARS-CoV-2 among employees. No one wants an outbreak in their facility. But omicron’s behavior suggests that over the next six to twelve weeks there will be many outbreaks. Most workplaces will be unable to avoid outbreaks of this highly contagious version of the virus.

The Centers for Disease Control offers workplace recommendations. OSHA has developed and enforced related workplace regulations. State and local public health agencies typically have the strongest legal authorities for mitigation measures, including isolation and quarantine. The recommendations and regulations are conditional. What should be done depends on context, including the vaccination status of employees. This is empirically justified. It is also administratively very complicated, especially for large-scale enterprises with operations in many different jurisdictions.

Last week I was asked about the isolation and quarantine policies of food processors, distributors, and retailers. I did not know, so I asked seven market-leaders. I heard back from five. This very informal survey found that their policies reflect CDC recommendations (unless local officials are unusually insistent). While this reach-out found variation, this essentially means that workers with a confirmed case or contact with covid are typically off the job for ten days. With a negative test, this can be reduced to seven days (but the quick survey suggested this is atypical given lack of access to testing). Two respondents suggest non-compliance is widespread due to both ignorance and intention.  But especially in union-organized work-forces, isolation and quarantines have and do impact capacity and through-put.

I was asked this question by smart, well-informed people who are aware of both the best science and official policy on workplace good practices. But as we talked, they disagreed. This is not surprising. In many ways — given our risk environment — it is realistic, even encouraging. But this realistic uncertainty is resulting in industry practices that are more rigorous than recommended by the most current CDC advisories and OSHA regulations. Until someone points me to more authoritative texts, here are the two sources that I have found especially relevant: CDC’s Interim Public Health Recommendations for Fully Vaccinated People and OSHA’s Guidance on Mitigating and Preventing the Spread of COVID-19 in the Workplace. (The CDC text was updated in October and November.)

Here is what I perceive the CDC is telling work-place managers. These are my words, not official language. The words below represent my understanding of the written text as interpreted by my management-mind into operational guidance. I am a one-time CEO, not a lawyer or epidemiologist. I am interested in safely preserving and enhancing flow. Lawyers and epidemiologists have different roles.

After exposure to a confirmed case of covid, employees should be tested within five to seven days.

Fully vaccinated employees who come in contact with a confirmed case of covid but are asymptomatic can continue working but should wear a mask when in close proximity to others.

Unvaccinated employees who come in contact with a confirmed case of covid should isolate at home for ten days or until receiving a negative test.

Employees (vaccinated or not) presenting with covid symptoms should be tested before continuing to work.

With a negative test, employees can continue working.

If an employee tests positive for covid s/he should isolate at home for ten days or until receiving a negative test.

There are exceptions, caveats, and a range of special considerations, but I understand these six statements to accurately summarize current guidance.

Some obvious implications, but just to be explicit: Vaccinated employees have greater flexibility than non-vaccinated. The more vaccination, the better potential for flow. If I have accurately understood the CDC and OSHA texts, the standard-operating-procedures reported by the five big food suppliers do not reflect the enhanced flexibility already recommended for vaccinated employees. Rapid testing can also reduce absenteeism and related friction.

But here’s the rub, based on where omicron is likely to take us between now and March, even vaccinated employees will be increasingly infected and re-infected. Many of our current work-place mitigation measures are intended to contain transmission. With omicron this intention seems to be overcome-by-events. There is a real risk of accumulated mild symptoms and positive tests decimating flow potential for food, pharmaceuticals, medical goods, and a wide range of freight. Given the contagious speed of omicron and current policies, too many nodes and links are at risk of too many ten day purges.

By the end of this week the rapidly worsening situation in Denmark and the United Kingdom may give us epidemiological confidence in omicron’s severity (aka virulence). If these real-world tests confirm that vaccinations (especially with boosters) prevent serious disease, it is probably time to allow vaccinated-boosted workers (even with a positive test) to continue working with other mitigation measures in place. I do not suggest this is an easy or obvious decision. But failing to proactively facilitate essential flows will also have profound human consequences.

Still too early to decide

We still don’t have sufficient data on the severity (aka virulence) of omicron. Here is a very helpful overview from Nature on the accumulating evidence after three weeks of intense, but necessarily incomplete analysis. As my other posts reveal, I perceive that even if omicron is less severe than Delta (or even Alpha), it is so insistently contagious that there is the potential for health care systems to be overwhelmed by a triple whammy of delta, seasonal flu, and complications of omicron. While this risk should surely spur vaccinations, boosters, and non-pharmaceutical mitigation measures, we do not yet have the data to confidently know what to expect in January and February. By Christmas eve we may have better data from South Africa, United Kingdom, and Denmark. A whole range of options for the United States is set out in scenario-based projections from the University of Texas at Austin, COVID-19 Modelling Consortium.

Three charts: deciphering demand

Most news coverage of Wednesday’s November retail sales report included something like this:

Retail sales rose modestly at the start of the holiday season, as shoppers faced rising inflation and supply shortages, and some snapped up gifts earlier. Sales at U.S. retail stores, online sellers, and restaurants rose by a seasonally-adjusted 0.3% in November from the previous month, the Commerce Department said Wednesday. That was smaller than last month’s increase in consumer prices, and a slowdown from October’s robust 1.8% sales increase. [Wall Street Journal]

Inflation and supply shortages are not exactly blamed, but the implication — repeated again and again — is that consumers are being suppressed by higher prices and lack of supply. There is, I agree, cause to believe that Americans would have purchased even more if prices had been lower and inventories had been higher. But, at least for this supply chain guy, that angle obscures the bigger story — captured in the first chart below.

An equally valid headline would be: Americans continue buying more than ever before.

This persistent level of unprecedented demand, even as pandemic savings is being spent-off (see second chart below), is the principal cause of recent retail price increases and supply chain challenges. How long can this level of demand continue? At the end of the third quarter US household debt payments were still below historic averages (see third chart below). I bet that upward curve in debt payments has continued in the current quarter. As the saving rate declines and debt payments increase, actual retail sales will return to something much closer to pre-pandemic normal.

Omicron… both/and?

The contending narratives are fundamentally different.

A headline from summery Johannesburg (and its region): As Omicron advances, SA sees limited severe disease (more)

A headline from wintery London (and its region): Significant increase in omicron hospitalisations expected

Omicron is now largely confirmed as the most contagious version yet of Sars-CoV-2.

There is also accumulating evidence that omicron is very effective at evading prior immunity — resulting either from previous infections or vaccination. So, reinfections and so-called break-through infections will be tough to avoid.

What remains less clear is the severity (aka virulence) of omicron. What percentage of infections will result in covid requiring medical care and, especially, hospital care? (Projections by University of Texas at Austin COVID-19 Modelling Consortium)

The first large-scale study of omicron cases in South Africa was released yesterday (December 14). One summary of the findings:

Vaccine effectiveness: The two-dose Pfizer-BioNTech vaccination provides 70% protection against severe complications of COVID-19 requiring hospitalisation, and 33% protection against COVID-19 infection, during the current Omicron wave.

Reinfection risk: For individuals who have had COVID-19 previously, the risk of reinfection with Omicron is significantly higher, relative to prior variants.

Severity: The risk of hospital admission among adults diagnosed with COVID-19 is 29% lower for the Omicron variant infection compared to infections involving the D614G mutation in South Africa’s first wave in mid-2020, after adjusting for vaccination status

Children: Despite very low absolute incidence, preliminary data suggests that children have a 20% higher risk of hospital admission in Omicron-led fourth wave in South Africa, relative to the D614G-led first wave.

While the narratives contrast, current data are coherent. In both South Africa and the United Kingdom confirmed cases of omicron are skyrocketing. Hospitalizations are not — yet? — surging in either nation.

But the UK government estimates that by now about 200,000 residents per day are being infected with omicron. Some credible projections suggest that with high booster effectiveness plus high immune escape (consistent with current observations) there will be over 300,000 omicron related hospitalizations in England (alone) between December 1, 2021 and April 30, 2022, peaking sometime in January. There are about 6000 critical care beds in Britain’s National Health System out of a total 100,000-plus hospital beds. For prior variants, the median UK hospital stay for covid has been seven days, but this average has ranged between 10 and 15 days during high-admission waves. The median length-of-stay for those admitted to intensive care units is even higher. Pre-pandemic bed use was typically over 90 percent.

There is no obvious reason that the United Kingdom’s encounter with omicron should be unusually difficult. Given the status of vaccination and therapeutics, the UK ought to be better off than many others.

We cannot yet know how this tale of two cities will end. The original began with, “It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of light, it was the season of darkness, it was the spring of hope, it was the winter of despair.”

Sounds about right.

As the flood slowly subsides

Contemporary high volume, high velocity supply chains organize around demand. The United States combines significant population with well above-average wealth. US demand motivates supply, both foreign and domestic.

Since December 2020 suppliers of US demand have been highly motivated. For example since last Christmas, US retail sales have increased from about $485 billion per month to over $565 billion (retail sales for November 2021 will be released later this week). This roughly 15 percent increase is the sharpest surge in the history of the measure.

In some product categories this increase has been razor sharp. Due to pandemic constraints, demand for many services (e.g., travel and eating-out) experienced stark declines. This reduced spending resulted in a personal saving rate of over 33 percent in April 2020, remaining significantly elevated until quite recently. With more cash on hand and pandemic constraints persisting, over the last twelve months US demand shifted from less tangible to more tangible products. For example, between February 2020 and October 2021, durable good purchases increased by nearly one-quarter.

Supplying this sort of swift increase and swerve in demand is not easy. Flows have experienced considerable friction and volatility. For example, according to the Logistics Managers’ Index, “In October, upstream respondents reported rates of growth 10.3 points higher than their downstream respondents. In November this flipped, and upstream respondents reported inventory growth was 10.9 points lower than downstream respondents. The shortages of retail goods this holiday season have not been as severe as they were predicted to be. This seems to have been largely achieved by firms spending heavily on warehousing and transportation to get goods downstream.”

Supply capacity for both warehousing and transportation is limited. There was certainly not a quarter-more capacity of either idly standing by (including, of course, each function’s work-force). As a result, prices for available warehousing and transportation have increased. Demand is mostly being fulfilled, but at higher costs… and with some delays and, almost certainly, with some shedding of low-margin places and people.

Given the competitive context, not all additional costs are being passed along. Several of the largest retailers are attempting to minimize price increases in an effort to protect and expand market share. But some increased costs are percolating through to retail prices, especially for fuel and food. From November 2020 to November 2021 the Consumer Price Index increased 6.8 percent, the largest increase since 1982. Part of this elevation reflects a one-third increase in the 2020-2021 energy index (2020 gasoline prices were unusually low). Year-Over-Year food prices in November were up 6.4 percent. In November apparel showed a YOY increase of 5.0 percent.

Financial and operational data confirm the challenge involved in preexisting supply matching surging demand (especially when complicated by pandemic-related problems). But flow has adapted and push is mostly fulfilling pull in most places for most Americans… who even now have slightly more money than usual to express their demand. Some have even begun to worry about excess inventories becoming a problem in the New Year.

Demand exploded. Flow adapted. To what extent has supply capacity changed?

My best answer is: I don’t know. The data with which I am familiar only offer tantalizing inferences. But my working hypothesis is: not much. At least not yet — and for most product categories significant capacity expansion strikes me as unlikely.

Not yet because the demand surge was so sudden. New warehouses do not materialize out of desert air. Because of structural changes in how high volume, high velocity flows are fulfilled, I expect a continued expansion in US warehouse capacity. But this is mostly due to swerving demand instead of surging demand. I do not expect recent increases in demand to survive far into 2022. I do expect the swerve, in terms of how and where demand is expressed, to persist.

Unlikely because transportation capacity is time-consuming and expensive to increase. Most maritime and air cargo players seem to perceive (accurately, I think) that the 2021 surge in US demand is unsustainable. Investments being made in future capacity are more about enhanced efficiency to serve incremental growth, rather than pedal-to-the-metal to close gaps in current flows. The trucking industry is working hard to avoid real reductions in capacity compared to increasing demand. The slow-down in demand that I expect will more closely match current trucking capacity (even as the demand slow-down could kill-off some trucking firms that have over-extended to serve recent demand surges).

Some data and analyses suggest that recent increases in energy prices reflect diminishing fossil-fuels capacity and very real costs involved in the treacherous transition to a post-fossil fuels future. So, there is both loss and gain in energy supply capacity and the net result will probably not be well-assured until the end of this decade (at least).

There are exceptions to my mostly-more-of-the-same prognosis. Significant new investments are being made in production capacity for semiconductors. As with warehouses, this expanded capacity reflects a fundamental shift in how global consumers behave and what they expect from the products they purchase. These behaviors and expectations justify the sort of large, long-term investments needed to expand this expensive supply capacity.

As plenty of other posts to this blog suggest, we are not yet operating in a post-pandemic context. But when such a day does come, it seems to me demand will look much more like 2019 than most of 2021. Our current flow capacity is much better suited for 2019 than 2021. Far upstream there are plenty of changes underway, but most of these are right-sized to a scope of demand that is much more pre-pandemic than mid-pandemic. So, as the flood of demand subsides, so will the turbidity we have seen in flows and that strange sucking (or is it squeezing?) sound from farther upstream.

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I will readily confess that this is the same argument I have tried to make for many months. There is not much evidence that this supply chain guy has persuaded many. Maybe a big-time financial analyst will do better. Please listen to at least the first 90 seconds of Michael Collins (PGIM) explain. Sound familiar?

https://www.bloomberg.com/news/videos/2021-12-13/totally-flat-yield-curve-is-already-priced-in-pgim-video

December 18 Addendum: Another very similar explanation courtesy of the Wall Street Journal and Phil Levy, Chief Economist at Flexport.

January 11 Addendum: Yet another demand-focused distribution-strained explanation from Karl W. Smith with Bloomberg.

Okay, I will stop tracking these convergent analyses… I recognize this is a bit of a defensive reaction on my part. But c’mon folks.

Calibrating Omicron’s Risk

Here is the carefully accurate current assessment of omicron by the CDC.

In South Africa it is very clear that omicron is spreading more rapidly than any prior variant. There is growing evidence that omicron’s ability to evade prior immunity is resulting in a higher incidence of reinfection and breakthrough infections.

There is accumulating evidence that similar omicron transmission speed is being experienced in Denmark and the United Kingdom (more), each with vaccination rates better than most places (including the United States).

As experienced with every prior version of covid, in the vast majority of omicron infections so far, disease symptoms are mild. One rigorous study found that 2.1 percent of those infected with the Sars-CoV-2 virus have required hospitalization.

With every prior version of covid, as more people are infected with omicron, the number of those experiencing severe disease has also increased. So, for example, a surge in delta-related hospitalizations is currently stressing the US health care system. Delta is not as contagious as omicron, but it is more efficiently transmissible than previous variants. This eventual surge in hospitalization has been predictable and predicted.

Please consider this word problem:

Your locality has a supply of 100 staffed and otherwise clinically supported hospital beds.

The incidence of covid-related disease requiring hospitalization is two-percent.

What number of covid-related infections can your local hospital capacity support?

There is a largely fixed supply — expensive, difficult, and time-consuming to adapt — encountering surging and volatile demand.

Hospital bed capacity (per 1000 persons) is very similar in the United States (2.8), United Kingdom (2.4), and Denmark (2.6). I would not be surprised to learn that US capacity has fallen over the last year because of covid-related staffing constraints.

Some say, without much evidence yet, that omicron’s severity is half that of delta. So far there is increasing evidence that omicron may be four times as contagious as delta. Both estimates are early, but still: do the math. Where does this leave us in terms of probable proportions experiencing severe disease?

Two Fridays ago I was frustrated by the knee-jerk fearful reactions to initial reports of omicron (here and here and here). This Friday I am as concerned by the lack of attention to accumulating evidence of risk. The virus is changing, but its behavior is stolidly predictable compared to erratic social, political, and financial responses to the virus.

Risk is an outcome of how threat interacts with vulnerability. The same threat can produce dramatically different consequences, depending on what vulnerability is encountered. This is obviously true in terms of individual covid consequences. It may be less obvious but as true in how different social groups (local to global) respond to the threat of covid. Early, diligent demand-management (e.g., Israel) reduces vulnerability and can avoid flood or drought of flows. Inconsistent or absent demand management increases vulnerability while amplifying extreme gyrations of supply and demand.

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December 11 Notations:

Sometime yesterday, Anjana Ahuja posted “The Omicron Paradox is Starting to Reveal Itself” in the Financial Times. She does a better job offering the same argument as above. Many Brits are concerned that omicron is hurtling toward very high case counts by Christmas. In at least two prior waves, the USA has tracked the UKs demand curve about 4 weeks later. Given current delta-driven demand for medical care in the United States, such a one-two punch would be especially punishing.

Early today (Saturday), Bloomberg posted a helpful round-up on what is known and not-yet-known related to omicron.

Later on Saturday: “New modelling from the London School of Hygiene & Tropical Medicine (LSHTM) suggests the Omicron variant has the potential to cause a wave of transmission in England that could lead to higher levels of cases and hospitalisations than those seen during January 2021, if additional control measures are not taken.” Even the most optimistic projections are sobering. (More)

Hospitalization demand update

Covid-related hospitalizations in the United States have increased from a rough daily average of 45,000 in early November 2021 to about 58,000 now. These are Delta-driven. Omicron is not yet impacting US hospitalizations. The January 2021 peak for US covid hospitalizations (see chart below) was just over 125,000. On December 8, 2020 there were just over 102,000 Americans hospitalized with covid.

The rapid increase in current South Africa covid case counts is being caused by omicron. Hospitalizations are beginning to increase too. Delta and omicron are each tough enough alone, a combined effect would not be welcome anywhere by anyone.

Usually reliable sources had told me that meaningful virologic analysis of severity (aka virulence) would be available by now. Instead I am seeing early (small but rigorous) virologic analysis of vaccine effectiveness. Some aspects of severity can be inferred, but are less than definitive.

A multinational team organized by the Africa Health Research Institute has released a pre-print reporting on results of an analysis of how antibody immunity fostered by the Pfizer vaccine is affected by omicron. According to this analysis, omicron is much more successful at evading vaccine-induced immunity that prior variants. But the study also found, “Previous infection, followed by vaccination or booster is likely to increase the neutralization level and likely confer protection from severe disease in Omicron infection.” (More)

A separate study by the Karolinska Institute and its international partners released yesterday also found diminished immunity to omicron in vaccinated persons, but the reduced protection was less pronounced than the AHRI findings and “highly variable.” The researchers also emphasize, “Almost all serum samples evaluated retained some neutralization activity against the Omicron variant.” (More)

Just before 0700 Eastern Time this morning Pfizer announced, “Preliminary laboratory studies demonstrate that three doses of the Pfizer-BioNTech COVID-19 Vaccine neutralize the Omicron variant (B.1.1.529 lineage) while two doses show significantly reduced neutralization titers.” This is coherent with the AHRI and Karolinska findings. Much more to come.