I mean, we certainly had a million infections. Many multiples of a million, no doubt. But confirmed cases?

The United States hit 1 million new Covid-19 cases on Monday, according to data compiled by @NBCNews. https://t.co/wFCJLdSHrX pic.twitter.com/AfrHAqEvUt

— NBC News (@NBCNews) January 4, 2022

To put that in perspective, until last month the most cases the U.S. had ever seen in a 24-hour span was 300,000 during last January’s brutal wave. The most any country had ever seen was India during its own horrendous surge of Delta in May, when it recorded 414,000. We’re in uncharted territory now.

But we shouldn’t put much stock in it, and not just because the hyper-infectiousness of Omicron combined with the scarcity of tests means the case numbers are less reliable than ever. It’s a cinch that some meaningful share of “yesterday’s” cases were recorded over the holiday weekend and were only reported yesterday. That “one million” figure probably reflects the total over two or three days.

Even accounting for the data anomaly, though, the numbers are head-spinning:

New York City has record over 446,000 cases since December 12, when Omicron really skyrocketed. If real infections are 10X confirmed cases, that would mean 4.4 million infections. Youyang Gu estimated that the Mar/Apr 2020 wave infected about 2.2 million people. pic.twitter.com/0OliAOcj26

— Aaron Astor (@AstorAaron) January 4, 2022

If Astor’s estimate is right, that would mean upwards of half the population of New York City has been infected in the last three weeks or so. Other cities will follow in short order: Cases have soared more than 600 percent in L.A. over the last two weeks and more than 750 percent in Miami. Which might explain why the Omicron waves in South Africa and London seem to be peaking and then falling so quickly. The variant is so insanely contagious that herd immunity even in large populations can seemingly be brought about within a month.

There’s good news and bad news in this.

The good news is that the milder variant continues to grow as a share of total infections in the U.S. It’s not clear if that’s because Omicron is crowding out Delta or simply growing at a much faster rate alongside Delta, but if immunity gained from Omicron can reduce the odds of severe illness from Delta then we’ll be in a better place as a population once this wave is over:

NEW: Omicron now accounts for 95.4% of new #covid19 cases in the U.S.

Omicron was 8.0% of cases the week ending 12/11/21; 37.9% of cases the week ending 12/18; 77.0% of cases the week ending 12/25; and now 95.4% of cases the week ending 1/1/22. https://t.co/HM4Ly3QXjC pic.twitter.com/aYU7a1sTOU

— Leana Wen, M.D. (@DrLeanaWen) January 4, 2022

More good news: There are reports from doctors on social media lately that the number of patients they’re seeing who need ICU care is down sharply from last year, something borne out in the data too. This comparison from the UK is dramatic:

We also continue to track “excess ICU pressure” — total number of people in ICU, for any reason, Covid or otherwise, compared to past winters:

Latest data show that the number of people in London ICUs has fallen in recent weeks, and is not following the same path as last winter. pic.twitter.com/9GFaEMLq6R

— John Burn-Murdoch (@jburnmurdoch) January 4, 2022

A milder variant plus an enormous increase in population immunity between 2020 and 2021 means there’s no crisis in ICUs this time, a huge relief.

As for the bad news, testing remains in sufficiently short supply that rationing tests might be necessary. Yesterday Florida’s surgeon general endorsed prioritizing the vulnerable for testing, at least for now. Another doctor writing in The Atlantic echoes the point. There just aren’t enough tests to go around to try to effectively limit the spread, which leaves the people at highest risk of a dangerous infection from Omicron exposed.

Everyone should do what they can to free testing resources for those with symptoms. We should also try to allocate tests based on underlying risks. The unvaccinated are, overall, most in danger of being hospitalized and dying from the virus, so they are also, overall, the people who benefit the most from having those around them screened for infection. Social bubbles being what they are, I suspect that many people with arsenals of at-home tests spend much of their personal time around other vaccinated and relatively low-risk individuals, making the public-health benefits of their personal screening programs marginal at best.

Two major categories of people remain at serious risk of dying from COVID despite vaccination: the elderly and immunocompromised. Older people and those with severe immune-system deficiencies will quite reasonably take extra precautions while socializing—including asking their close contacts to make prodigious use of rapid tests. Outside of nursing homes, though, there has been little effort in the U.S. to prioritize diagnostic access for these groups. Instead, we face an awkward situation where many universities are performing thousands of tests a day on young, vaccinated, and largely healthy student populations while high-risk individuals and their caregivers struggle to keep up with surveillance. Well-heeled companies like Google are even sending employees—many of whom are still working from home—some of the most sophisticated COVID-detection tools on the market. “The worried, wealthy well are doing lots of tests of uncertain value,” the epidemiologist Daniel Morgan of the University of Maryland told me, while “the turnaround time is blowing up for higher-value uses.”

There’s bad news for hospitals too. The load on ICUs has lightened because of Omicron’s “mildness” but the load on ERs hasn’t.

Another recurring point made by those on the front lines is that the pressure on emergency departments is immense.

Data from London is stark: last year A&E attendances plummeted as many people avoided hospitals. This year Covid comes on top of very high winter A&E pressures. pic.twitter.com/AqlMSaL2si

— John Burn-Murdoch (@jburnmurdoch) January 4, 2022

All things considered, that’s a good problem to have. During New York City’s killer surge in March 2020, EMTs often found people dead at home after 911 calls because they’d delayed too long in seeking hospital care for their health problem due to fear of COVID. That fear has abated amid Omicron so more who are in need of emergency treatment are coming to the ER this winter. Meanwhile, although few Omicron patients need critical care, some percentage of them will develop sufficiently bad cases that they’ll need basic ER care (oxygen, steroids, etc). Two members of my own extended family landed in the ER this week because of COVID pneumonia, although one was discharged within 24 hours. Doctors in New York and elsewhere are reporting the same problem on Twitter, that they’re seeing fewer very sick patients than they used to but lots of somewhat sick ones who need more routine treatment. That adds up to extremely busy ERs.

Hiding in the bathroom for a 1 minute deep breath break because the Emergency Department is absolutely bursting at the seams with acutely ill pts with COVID at the moment. Our capacity is paper thin. Still never imagined I’d see something like this in my life time. 😞

— Melina Manolas, MD, MPH (@melina_manolas) January 3, 2022

Today it seemed like everyone had COVID. Like, so many.

And yes, like before, there were some really short of breath and needing oxygen.

But for most, COVID seemed to topple a delicate balance of an underlying illness.

It’s making people really sick in a different way.

— Craig Spencer MD MPH (@Craig_A_Spencer) January 4, 2022

A doctor in Pennsylvania divided his latest patients into three groups:

…Based on increased immunity in the population, and this lower severity strain of Covid, less people are presenting with a need for ICU level care.

But a HUGE number need supportive care over 1-3 days (e.g. IV fluids, brief oxygen support, optimization of chronic illness)…

— M. Kit Delgado, MD, MS (@kit_delgadoMD) January 3, 2022

Burn-Murdoch says he heard from one British hospital that ICU staff might be reassigned to help other wards manage their heavy loads, a reversal from the trend during earlier stages of the pandemic. There’s also evidence in the UK that patients’ ages are trending older lately as the variant spreads, and of course older patients will be more likely to need hospital treatment. (My two family members were both 70+.) Meanwhile, hospital staffers in every Omicron hot spot are falling ill with COVID themselves and patients admitted to the ER for non-COVID reasons are at serious risk of catching the virus from those admitted with the disease given its hyper-transmissibility. We’re likely to dodge a huge death spike from the new variant but we’re less likely to avoid seeing hospitals overwhelmed, even accounting for the large number of “incidental” Omicron hospitalizations. Not great.