By all accounts, the risk of another winter wave of COVID-19 in the US is high. And this time, the coronavirus is on the prowl alongside two friends: influenza and respiratory syncytial virus (RSV). In some areas, hospitals are already overwhelmed.
How serious this “tripleemia” will be is unclear. But what is very clear is that a pandemic-weary public is not taking the threat seriously enough. Shockingly, neither is the government. Officials in the Biden administration have been raising concerns for months, but so far there have been no loud alarm bells. So does a White House briefing on Tuesday, where officials barely mentioned the triple threat as they tried to jump-start efforts to boost more people with the new bivalent COVID-19 vaccine. To date, about 12 percent of those who qualify have received the new booster.
Meanwhile, the Senate voted on Nov. 15 to end the federal government’s COVID-19 pandemic emergency declaration, which has been in effect for the past three years. This gave the Biden administration money and policy leverage to fight the virus.
Lack of decisive action so far feels ill-advised, especially with Thanksgiving and the upcoming holiday season when indoor gatherings increase the risk of contamination. Continued inactivity in 2023 will lead to unnecessary illness, absenteeism, economic loss – and thousands of avoidable deaths.
Let’s think back to previous COVID-19 winter disasters. Last year’s surge began just after Thanksgiving and included 75 million to 100 million infected people in March, some of whom were infected for a second or third time. Of the 1.1 million officially recorded deaths from COVID-19 to date, half have occurred during the last two winter storms. The rise of 2020-21 (November to March) brought 328,805 killed, even when the first vaccines came into use, but too late to make a big difference. Another 227,352 people were killed at the peak last winter.
The number of deaths fell from the previous year last winter, despite a higher infection rate, as many more people were vaccinated, had some immunity to previous infections and took preventative measures such as masking and strict quarantine. Unfortunately, the Omicron variant, which peaked last January and February, cut enough of that existing immunity to wreak havoc. Reinfections became common.
COVID-19 experts are now concerned that this pattern is repeating. This month, two new Omicron variants – BQ.1 and BQ.1.1 – have officially overtaken BA.5, the dominant variant of recent months. These new variants are now good for almost half of COVID-19 cases nationwide.
The very bad news: lab studies indicate that mutations in the two variants can make them seven times more “immune evasive” than BA.5.
The good news: The new variants don’t seem to cause more serious illness. Still, the expected increase in the absolute number of new infections (in people who have never had COVID-19), breakthrough infections (in vaccinees) and reinfections will lead to more hospitalizations and deaths.
Like dr. Jeremy Luban of the University of Massachusetts, a leading variant tracker, told NPR on Nov. 11: “It’s kind of eerily familiar. … There is a kind of déjà vu feeling from last year.”
The big unknown is the extent to which previous infection with omicron or its earlier variants will protect people against the new variants. An estimated 150 million to 170 million Americans — about half of it – are infected with some version of omicron. Many of these people have also been vaccinated. Having both is good: The immune system builds a multi-layered response to infection plus vaccination that researchers are still trying to figure out for COVID-19.
The bottom line is this: (a) the previously infected are unlikely to be robustly protected against re-infection and disease with the new variants and (b) it is likely that some protection will be granted against poor outcome such as prolonged COVID, hospitalization and death.
Based partly on this calculus, and partly on sheer hope, the Biden administration has set its estimate of additional deaths from a fourth wave of winter at between 30,000 and 70,000. That’s on top of the underlying COVID-19 death rate of about 300 per day, which has been prevalent in recent months. So from November through March, COVID-19 alone could cause as many as 115,000 deaths.
These figures assume a continued low level of vaccination with the new bivalent booster. If everyone eligible for that booster — all people ages 5 and older — got it, as many as half of those deaths could be prevented.
Widespread use of masks would also prevent infections and deaths. Researchers at the Institute for Health Metrics and Evaluation at the University of Washington project 46,100 additional deaths from COVID-19 by February 1, 2023. They calculated that 80 percent compliance with recommended masking could save about 30,000 of those lives.
As for the flu, if the numbers follow the experience since Oct. 1, as many as 33 million Americans (one in 10) will get it by the end of March 2023 and up to 18,000 will die, according to CDC projections. But it’s early. Flu usually doesn’t peak until January or February. Countries in the southern hemisphere had a bad time this summer. So if the number of cases per month doubles or triples – which is likely – the deaths could be as high as 35,000 to 40,000. The very mild 2021-2022 flu season led to an estimate 9 million cases and 5,000 deaths.
Meanwhile, the incidence of RSV is now trending three to six times the pace of the past three winters. It hits children and the over-65s the hardest.
Preventing death is job No. 1. But it’s not trivial — for families or the economy — that COVID-19, flu, and RSV could sicken 100 million or more Americans in the next five months. For COVID-19 in particular, there are two other worrying risks. The first is lung COVID and the second is the potentially increased risk of health problems and death from becoming infected multiple times with different variants.
Numerous studies now show that between 10 and 20 percent of people who get COVID-19 continue to have symptoms or problems after recovering from the initial acute illness — and they’re not all older people. Like I have written about before, that level of risk also seems worth avoiding to me. While a few studies indicate that omicron (and presumably its variants) appears to offer a lower risk of lung COVID, the risk is still quite high. Vaccination reduces that risk, studies show, but how much is still uncertain.
The potential cumulative health risk associated with getting COVID-19 multiple times is also concerning. Science is much less settled on this, but a study 41,000 Veterans published this month garnered significant media attention. It found that those who got COVID-19 two or more times had about a twofold risk of both long-term COVID-19 and death (not necessarily together) after six months compared to those who had COVID-19 once.
Specialists in infectious diseases were quick that the study did not involve personally tracking people over time. Instead, the study used the electronic health records of about 6 million people to find 443,588 people who had one bout of COVID-19 and, among that group, 40,947 who had two or more bouts of COVID-19. The caveat is that such studies do not prove cause and effect; Factors other than multiple COVID-19 attacks could have accounted for the additional risk.
The alarm bells for COVID-19, flu, and RSV I mentioned above could be coming in the coming weeks. The question is whether government and public health officials will have the courage to defy public apathy, inertia and resistance to enact a return to public health measures — such as mandatory masking in public places, restricted access to public venues and events unless vaccinated, and travel alerts.
I think mandatory masking for public transport across the country should have been reinstated already. Of course, every American can and should adopt a DIY COVID-19, flu, and RSV protocol this winter. Customize it for yourself and your family. As inconvenient and depressing as this may be, it seems foolish to risk a long-term COVID condition, hospitalization, and death. With a bit of luck it will only last one more winter.
Steven Findlay, MPH, is an independent health policy analyst and journalist. He previously served as senior health policy analyst at Consumers Union and director of research and policy at the National Institute for Health Care Management.