Disease expert tells us what could be next in Oregon's battle with COVID and the flu

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A file photo of a positive result on a COVID-19 test strip.

A file photo of a positive result on a COVID-19 test strip.

Marta Lavandier/AP

More than 9,000 Oregonians have died from COVID-19 since the pandemic began. Hospitals are currently overwhelmed with patients suffering from the “tripledemia” of RSV, flu and COVID-19. And a new variant of COVID known as “kraken” has surfaced.

What should we expect from the global pandemic in 2023? To help resolve the issue, OPB’s Jenn Chávez spoke with Dr. Bill Messer. He is a physician and scientist specializing in viral infectious diseases at Oregon Health & Science University.

Jenn Chavez: So let’s start with this new variant of COVID XBB.1.5. It is also known as “kraken”. It appears to be the most transmissible variant so far, but like the previous omicron subvariants, it has relatively mild symptoms. Is this in line with what we can probably expect going forward: COVID has been around forever, but is starting to look more and more like the flu?

Bill Messer: I think generally speaking, this is 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 have to do with transmissibility: We think we’ve seen the most transmissible coronavirus so far, and then another variant emerges that’s even more transmissible. So far, as you’ve pointed out, these variants don’t tend to make us any sicker than the earlier 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. Showing us symptoms such as cough and runny nose improves their transmissibility, but taking us to the hospital, for example, is not necessary. So the virus is always evolving to be transmissible, to pass from one person to another, and whether or not it makes us sicker is not necessarily what it’s trying to do. But if, in that evolutionary process, there is something about the way we get sick that also contributes to its transmission capacity, then this could emerge. That seems less likely at this point, but I think it remains a possibility, which is one of the reasons we really need to keep an eye on this virus: it keeps changing.

Chavez: At what point does it stop being useful to carefully track the COVID numbers and start to think of it as just part of the noise of respiratory illness we experience?

Messer: This is a very good question, because there is such a heightened degree of vigilance that has come about as a result of the pandemic, and now we 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 extent, a lot of what’s happened in the hospital this year, or last year into this year, was — what’s happening with hospitalizations? Because that’s always the pressure point in our healthcare system. And so, we report flu numbers to people in large numbers who come to emergency departments and clinics complaining of symptoms that prompt them to seek medical evaluation. This is the case with RSV as well. Ultimately, I think we’re going to fall into that boat for COVID as well, as a way to monitor virus activity. I think this will become part of our regular vigilance for things that can make us sick. Historically, this has always been surveillance for seasonal respiratory viruses. Whether COVID is a seasonal respiratory illness or not is still unknown, but we test for the flu even in summer if the symptoms are correct. And so, I think it’s going to be something in terms of clinical monitoring and reporting that’s going to take shape probably in the next year, when we start to normalize the way we think about this virus.

Chavez: China ended its zero COVID policy last month and infection rates have skyrocketed. As an example, obviously that’s a huge population for the virus to travel and mutate. How often should we expect new variants to emerge?

Messer: It may very well not behave like the flu, which has a predictable cyclical pattern of emergence of variants. It’s very difficult to say. Whether it comes from China, the United States, or some other area of ​​the world where host immunity has waned as transmission increases, it is these situations that will always be the most likely to give us variants. China certainly has a lot of streaming going on right now, and it seems plausible that this is something of a hotbed for variant generation. But rather than thinking of it in terms of seasonality, I would think of it in terms of where transmission is high and where transmission is low, and monitoring the high transmission areas of the world for variants to emerge and then expand. It’s a more concentrated effort than what we do now for the flu. Ultimately, for something like this to work, coordination at the global health level would be needed to monitor all possible hotspots in the world. That’s really, I think, where it would come from, but I don’t know how often these variants are going to come up.

Chavez: Thinking about vaccines: How quickly do you think new boosters will be developed for new variants and are vaccines still effective against transmission or just preventing serious disease?

Messer: I think we’re better served by thinking of vaccines as preventing or limiting disease rather than blocking transmission. There was a brief period early on in the pandemic where this was suggested by vaccines, but I think the lesson we’ve learned over the last couple of years is that we need to think about this in terms of protection from symptoms, protection from serious illness, protection from death. How often do new vaccines need to be rolled out? There are two issues, I think, built into this. One is the evolutionary question of, how often is the virus going to mutate from our vaccines? The second is the logistical question, how often can we rationally manufacture, deliver and administer a new vaccine that doesn’t let us vaccinate against last year’s virus and not this year’s virus because of that time gap? In practice, it seems to me that a year might represent the logistical barrier to designing, launching and distributing a new vaccine, but the virus is always evolving before that. So I don’t know ultimately that even this strategy would be a foolproof strategy, but it’s probably the best we would have to keep people out of hospitals.

Chavez: How do you understand global immunity to the various strains we are seeing of COVID right now?

Messer: That’s a very difficult question to answer, because as you know, and as we’ve all seen in the last few years, the virus moves in waves around the world, and if it takes four months for a wave to go from Africa to Oregon, there will be a real disconnect between the immunity that exists in Africa, for example – I’m thinking omicron – and the West Coast. Therefore, global immunity will be out of sync, with different continents or different populations sharing transmission risks with different susceptibilities. It could be that over time it develops, a sort of harmonic frequency where it becomes kind of predictable: it pops up in one place, moves across the globe in this pattern, like the flu did. But it’s hard to say at this point whether or not there will be some sort of harmony in global susceptibility to new SARS-CoV-2 infections. It is very difficult to predict something like this.

Chavez: We are currently dealing with RSV, flu and COVID at the same time. OHSU’s latest forecast said RSV and influenza have peaked and are declining. But still, do you see anything else on the horizon to add to that mix? For example, a stronger variant of the flu?

Messer: The short answer, based on our prior knowledge of how RSV and flu have fared so far this year, and how traditionally RSV and flu, along with other respiratory viruses, is: I don’t necessarily predict a really significant deviation from what it’s been predicted. In general, I think this pattern seems like such a distant pattern, plus it comes before, repeating a well-known description: The disease strikes a susceptible population, peaks when that population develops some level of immunity or is recovering, and then , rates fall. This appears to be what is happening now with RSV and the flu.

Chavez: One casualty of the global pandemic has been our health care industry. Workers are burnt out, hospitals are overwhelmed with all these respiratory illnesses causing people to need emergency care, and it seems that even a small increase in the number of infections causes hospitals to run out of beds. And I know this isn’t exactly your area of ​​expertise, but how do we get out of this hole?

Messer: What an interesting and challenging question because, as you just described, we have this backlog of disease that doesn’t necessarily have anything to do with COVID, RSV, and flu waves, but has filled hospitals, leaving us very little room to open room for these seasonal floods of patients. I think that in the long run, we still have some ground to make up for in caring for our chronically ill population. We can regain that ground, slowly, so that they are no longer victims of neglected care due to the urgency of the pandemic. And that will bring the numbers down, I think, to some extent. But there’s a much bigger elephant in the room around this, which is, are our health services adequate to meet the needs of our population? COVID-19 has really tested that question and it says maybe we really need to increase our capacity in hospitals but also our ability to provide primary care to people who live especially on the margins of access to care. Many people are ending up in hospitals with respiratory illnesses and chronic illnesses. I think there’s a much bigger conversation out there, how do you improve the delivery and maintenance of health care in this country, embedded in that question. We’ll take care of some backlogs, but there’s still a resource constraint in the baseline that puts us at risk of going through these cycles again and again.

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