More than 9,000 Oregonians have died from COVID-19 since the pandemic began. Hospitals are currently overcrowded with patients suffering from the “tripleemia” of RSV, influenza and COVID-19. And a new variant of COVID known as “kraken” has come to the fore.
What should we expect from the global pandemic in 2023? For help, OPB’s Jenn Chávez spoke to Dr. Bill Messer. He is a physician and scientist specializing in viral infectious diseases at Oregon Health & Science University.
John Chávez: So let’s start with this new COVID XBB.1.5 variant. It is also known as “kraken”. It appears to be the most transmissible variant to date, but like earlier omicron subvariants, it has relatively mild symptoms. Is this in line with what we can probably expect in the future: COVID is here forever, but it’s just starting to look more and more like the flu?
Bill Messer: I think that’s basically a reasonable assumption to make. But one of the things we’ve learned about SARS-CoV-2 is that it has the ability to throw curveballs all the time. Most of these curveballs were about transmissibility: we thought we’d seen the most transmissible coronavirus yet, and then another variant emerges that’s even more transmissible. So far, as you pointed out, these variants have not tended to make us sicker than the previous variants. And it’s important to remember that the purpose of the virus – if you want to think of it as something that has goals and motivations – is to be transmitted from one person to another so that it can be replicated. It’s not necessarily to make us sicker; only if making us sicker actually improves its transmissibility. Giving us symptoms like a cough and a runny nose improves its transmissibility, but landing us in the hospital, for example, doesn’t necessarily do that. So the virus is still evolving to be transmissible, to jump from person to person, and whether it makes us sicker or not, that’s not necessarily what it’s trying to do. But if in this evolutionary process there is something about the way we get sick that also contributes to its transmission capacity, then it could emerge. It seems less likely at this point, but I think it’s still a possibility, which is one of the reasons we really need to keep an eye on this virus: it’s not done changing.
chavez: At what point does it stop being useful to carefully track COVID numbers and just start seeing it as part of the noise of the respiratory illnesses we experience?
mass: This is a very good question, because there is such an increased degree of vigilance that has come as a result of the pandemic, and we now always want to know, when we have a runny nose, is it COVID, or is it just a cold, or is it the flu? I think to some degree a lot of what’s happened in the hospital this year, or the last year before this year, has been – What’s going on with the hospitalizations? Because it’s still the pressure point in our health care system. And so, we report flu numbers for people who largely present to emergency departments and clinics complaining of symptoms that lead them to seek medical evaluation. This is also the case for the RSV. Ultimately, I think we’re going to fall into this boat for COVID as well, as a way to monitor virus activity. I think it will be part of our regular monitoring of things that could make us sick. Historically, this has always been surveillance for seasonal respiratory viruses. Whether or not COVID turns out to be a seasonal respiratory disease remains to be seen, but we test for the flu even in the summer if the symptoms are correct. And so, I think that will be something at the clinical surveillance and reporting level that will take shape probably next year as we start to normalize how we think about this virus.
chavez: China ended its zero COVID policy last month and infection rates there have soared. As an example, this is obviously a huge population through which the virus can travel and mutate. How often should we expect new variants to emerge?
mass: It may very well not behave like the flu, which has sort of a predictable cyclical pattern of variant emergence. It’s very difficult to say! Whether it comes from China, the United States, or another region of the world where host immunity has waned to the point that transmission is increasing, these are the situations that are always going to be most likely to give us variants. China certainly has a lot of transmission going on right now, and it seems plausible that this is some sort of hotbed for variant generation. But rather than thinking about it in terms of seasonality, I would think about it in terms of where transmission is high and where transmission is low, and monitoring high transmission areas of the world for the emergence and then expansion of variants. It’s a more concerted effort than what we’re doing now for the flu. Ultimately, for something like this to work, it would require coordination at the global health level to monitor all potential hotspots around the world. That’s really, I think, where it would come from, but I don’t know how often these variants are going to emerge.
chavez: Thinking about vaccines: how quickly do you imagine new boosters will be developed for new variants, and are vaccines still effective against transmission, or do they just prevent serious disease?
mass: I think we are best served by thinking that vaccines prevent or limit disease and do not block transmission. There was a brief period at the very beginning of the pandemic where that was kind of hinted at by vaccines, but I think the lesson we’ve learned over the last two years is that we have to think about that in terms of protection against symptoms, protection against serious illness, protection against death. How often should new vaccines be deployed? There are two issues, I think, embedded in that. One is the question of evolution, how often will the virus mutate away from our vaccines? The second is the logistical question, how often can we manufacture, deliver and administer a new vaccine in a rational way that doesn’t let us vaccinate against last year’s virus and not this year’s virus because of this gap ? On a practical level, it seems to me that a year can be the logistical barrier to designing, deploying and distributing a new vaccine, but the virus always evolves ahead of that. So I don’t know, ultimately, if even this strategy would be a foolproof strategy, but it’s probably the best strategy we’d have for keeping people out of hospitals.
chavez: How do you understand global immunity to the different strains of COVID we’re seeing right now?
mass: This is a very difficult question to answer, because as you know, and as we have all seen over the past two years, the virus is moving in waves around the world, and it takes four months for a wave to disappear from Africa to Oregon, there is going to be a real disconnect between the immunity that exists in Africa, for example – I am thinking of omicron – and the west coast. Global immunity is therefore going to be out of sync, with different continents or different populations sharing transmission risks having different susceptibilities. Maybe over time it develops, a kind of harmonic frequency where it kind of becomes predictable: it emerges in one place, it moves through the world in this pattern, like the flu did. But whether or not there will be any sort of harmony in global susceptibility to new SARS-CoV-2 infection is hard to say at this time. It’s very difficult to predict something like that.
chavez: At the moment we are dealing with RSV, influenza and COVID at the same time now. Latest forecast from OHSU said RSV and influenza have peaked and are in decline. But still, do you see anything else on the horizon to add to this mix? For example, a stronger variant of the flu?
mass: The short answer, based on our prior knowledge of how RSV and influenza have gone so far this year, and how traditionally RSV and influenza, as well as other respiratory viruses, is: I don’t foresee not necessarily a really significant deviation from what was predicted. In general, I think this pattern resembles a pattern that is so far away, except that it comes earlier, repeating a well-known description: disease strikes a population that is susceptible, it peaks when that population develops a certain immunity level or they’re picking up, then the rates drop. This seems to be what is happening now with RSV and the flu.
chavez: One of the casualties of the global pandemic has been our healthcare industry. Workers are exhausted, hospitals are overwhelmed with all these respiratory illnesses causing people to need emergency care, and it seems that even a small spike in the number of infections causes hospitals to run out of beds. And I know that’s not exactly your area of expertise, but how do you get out of this hole?
mass: What an interesting and challenging question, because as you just described, we have this backlog of disease that has not necessarily had anything to do with the waves of COVID, RSV and influenza, but has filled hospitals, we leaving very little room to make room for these seasonal influxes of patients. I think that in the long term, we still have some ground to catch up in the management of our chronically ill population. We can catch up to this ground, slowly, so that they no longer fall victim to neglected care due to the emergency of the pandemic. And that will bring the numbers down, I think, to some extent. But there is a much bigger elephant in the room around this, namely, are our health care services sufficient to meet the needs of our population? COVID-19 has really tested this question and says that maybe we really need to increase our capacity in hospitals, but also our ability to provide primary care to people who live particularly on the margins of access to care. That’s a lot of people ending up in hospitals with both respiratory illnesses and chronic illnesses. I think there’s a much larger conversation around how to improve the delivery and maintenance of health care in this country. We’ll take care of some of the backlog, but there’s always a resource limitation at the outset that puts us at risk of going through these cycles again and again and again.