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Tag: flu-shot uptake

  • Winter Illness This Year Is a Different Kind of Ugly

    Winter Illness This Year Is a Different Kind of Ugly

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    Earlier this month, Taison Bell walked into the intensive-care unit at UVA Health and discovered that half of the patients under his care could no longer breathe on their own. All of them had been put on ventilators or high-flow oxygen. “It was early 2022 the last time I saw that,” Bell, an infectious-disease and critical-care physician at the hospital, told me—right around the time that the original Omicron variant was ripping through the region and shattering COVID-case records. This time, though, the coronavirus, flu, and RSV were coming together to fill UVA’s wards—“all at the same time,” Bell said.

    Since COVID’s arrival, experts have been fearfully predicting a winter worst: three respiratory-virus epidemics washing over the U.S. at once. Last year, those fears didn’t really play out, Sam Scarpino, an infectious-disease modeler at Northeastern University, told me. But this year, “we’re set up for that to happen,” as RSV, flu, and COVID threaten to crest in near synchrony. The situation is looking grim enough that the CDC released an urgent call last Thursday for more vaccination for all three pathogens—the first time it has struck such a note on seasonal immunizations since the pandemic began.

    Nationwide, health-care systems aren’t yet in crisis mode. Barring an unexpected twist in viral evolution, a repeat of that first terrible Omicron winter seems highly unlikely. Nor is the U.S. necessarily fated for an encore of last year’s horrors, when enormous, early waves of RSV, then flu, slammed the country, filling pediatric emergency departments and ICUs past capacity, to the point where some hospitals began to pitch temporary tents outside to accommodate overflow. On the contrary, more so than any other year since SARS-CoV-2 appeared, our usual respiratory viruses “seem to be kind of getting back to their old patterns” with regard to timing and magnitude, Kathryn Edwards, a vaccine and infectious-disease expert at Vanderbilt University, told me.

    Read: The worst pediatric-care crisis in decades

    But even so-so seasons of RSV, flu, and SARS-CoV-2 could create catastrophe if piled on top of one another. “It really doesn’t take much for any of these three viruses to tip the scale and strain hospitals,” Debra Houry, the CDC’s chief medical officer, told me. It also—in theory—shouldn’t take much to waylay the potential health-care crisis ahead. For the first time in history, the U.S. is offering vaccines against flu, COVID, and RSV: “We have three opportunities to prevent three different viral infections,” Grace Lee, a pediatrician at Stanford, told me. And yet, Americans have all but ignored the shots being offered to them.

    So far, flu-shot uptake is undershooting last year’s rate. According to recent polls, as many as half of surveyed Americans probably or definitely aren’t planning to get this year’s updated COVID-19 vaccine. RSV shots, approved for older adults in May and for pregnant people in August, have been struggling to get a foothold at all. Distributed to everyone eligible to receive them, this trifecta of shots could keep as many as hundreds of thousands of Americans out of emergency departments and ICUs this year. But that won’t happen if people continue to shirk protection. The specific tragedy of this coming winter will be that any suffering was that much more avoidable.

    Much of the agony of last year’s respiratory season can be chalked up to a terrible combination of timing and intensity. A wave of RSV hit the nation early and hard, peaking in November and leaving hospitals no time to recover before flu—also ahead of schedule—soared toward a December maximum. Children bore the brunt of these onslaughts, after spending years protected from respiratory infections by pandemic mitigations. “When masks came down, infections went up,” Lee told me. Babies and toddlers were falling seriously sick with their first respiratory illnesses—but so were plenty of older kids who had skipped the typical infections of infancy. With the health-care workforce still burnt out and substantially pared down from a pandemic exodus, hospitals ended up overwhelmed. “We just did not have enough capacity to take care of the kids we wanted to be able to take care of,” Lee said. Providers triaged cases over the phone; parents spent hours cradling their sick kids in packed waiting rooms.

    And yet, one of the biggest fears about last year’s season didn’t unfold: waves of RSV, flu, and COVID cresting all at once. COVID’s winter peak didn’t come until January, after RSV and flu had substantially died down. Now, though, RSV is hovering around the high it has maintained for weeks, COVID hospitalizations have been on a slow but steady rise, and influenza, after simmering in near-total quietude, seems to be “really taking off,” Scarpino told me. None of the three viruses has yet approached last season’s highs. But a confluence of all of them would be more than many hospitals could take. Across the country, many emergency departments and ICUs are nearing or at capacity. “We’re treading water okay right now,” Sallie Permar, the chief pediatrician at Weill Cornell Medical Center and NewYork-Presbyterian Hospital, told me. “Add much more, and we’re thrown into a similar situation as last year.”

    That forecast isn’t certain. RSV, which has been dancing around a national peak, could start quickly declining; flu could take its time to reach an apex. COVID, too, remains a wild card: It has not yet settled into a predictable pattern of ebb and flow, and won’t necessarily maintain or exceed its current pace. This season may still be calmer than last, and impacts of these diseases similarly, or even more, spaced out.

    But several experts told me that they think substantial overlap in the coming weeks is a likely scenario. Timing is ripe for spread, with the holiday season in full swing and people rushing through travel hubs on the way to family gatherings. Masking and testing rates remain low, and many people are back to shrugging off symptoms, heading to work or school or social events while potentially still infectious. Nor do the viruses themselves seem to be cutting us a break. Last year’s flu season, for instance, was mostly dominated by a single strain, H3N2. This year, multiple flu strains of different types appear to be on a concomitant rise, making it that much more likely that people will catch some version of the virus, or even multiple versions in quick succession. The health-care workforce is, in many ways, in better shape this year. Staffing shortages aren’t quite as dire, Permar told me, and many experts are better prepared to deal with multiple viruses at once, especially in pediatric care. Kids are also more experienced with these bugs than they were this time last year. But masking is no longer as consistent a fixture in health-care settings as it was even at the start of 2023. And should RSV, flu, and COVID flood communities simultaneously, new issues—including co-infections, which remain poorly understood—could arise. (Other respiratory illnesses are still circulating too.) There’s a lot experts just can’t anticipate: We simply haven’t yet had a year when these three viruses have truly inundated us at once.

    Read: The big COVID question for hospitals this fall

    Vaccines, of course, would temper some of the trouble—which is part of the reason the CDC issued its clarion call, Houry told me. But Americans don’t seem terribly interested in getting the shots they’re eligible for. Flu-shot uptake is down across all age groups compared with last year—even among older adults and pregnant people, who are at especially high risk. And although COVID vaccination is bumping along at a comparable pace to 2022, the rates remain “atrocious,” Bell told me, especially among children. RSV vaccines have reached just 17 percent of the population over the age of 60. Among pregnant people, the other group eligible for the vaccines, uptake has been stymied by delays and confusion over whether they qualify. Some of Permar’s pregnant physician colleagues have been turned away from pharmacies, she told me, or been told their shots might not be covered by insurance. “And then some of those same parents have babies who end up in the hospital with RSV,” she said. Infants were also supposed to be able to get a passive form of immunity from monoclonal antibodies. But those drugs have been scarce nationwide, forcing providers to restrict their use to babies at highest risk—yet another way in which actual protection against respiratory disease has fallen short of potential. “There was a lot of excitement and hope that the monoclonal was going to be the answer and that everybody could get it,” Edwards told me. “But then it became very apparent that this just functionally wasn’t going to be able to happen.”

    Last year, at least some of the respiratory-virus misery had become inevitable: After the U.S. dropped pandemic mitigations, pathogens were fated to come roaring back. The early arrivals of RSV and flu (especially on the heels of an intense summer surge of enterovirus and rhinovirus) also left little time for people to prepare. And of course, RSV vaccines weren’t yet around. This year, though, timing has been kinder, immunity stronger, and our arsenal of tools better supplied. High uptake of shots would undoubtedly lower rates of severe disease and curb community spread; it would preserve hospital capacity, and make schools and workplaces and travel hubs safer to move through. Waves of illness would peak lower and contract faster. Some might never unfold at all.

    Read: The pandemic broke the flu … again

    But so far, we’re collectively squandering our chance to shore up our defense. “It’s like we’re rushing into battle without armor,” Bell told me, even though local officials have been begging people to ready themselves for months. Which all makes this year feel terrible in a different kind of way. Whatever happens in the coming weeks and months will be a worse version of what it could have been—a season of opportunities missed.

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    Katherine J. Wu

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  • Annual COVID Shots Mean We Can Stop Counting

    Annual COVID Shots Mean We Can Stop Counting

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    A couple of weeks ago, a friend asked me how many COVID shots I’d gotten so far. And for a brief, wonderful moment, I forgot.

    “Three,” I told them, before shaking my head. “No, actually, four.” I had no trouble recalling when I’d received my most recent shot (September). But it took me a moment to tabulate all the doses that had preceded it.

    By this point in the pandemic, a lot of people must be losing track. “I actually think this is a good thing,” says Grace Lee, a pediatrician at Stanford, and the chair of the CDC’s Advisory Committee on Immunization Practices. Now that so many Americans have racked up several shots or infections, she told me, the question is no longer “‘How many doses have you gotten cumulatively?’ It’s ‘Are you up to date for the season?’”

    The flip is subtle, but it marks a rethink of the COVID-vaccination paradigm. We’re at a define-the-relationship moment with these shots, when people are trying to commit—to normalize them as a routine part of our lives. At a September ACIP meeting, CDC officials noted that “we are changing the way we are thinking about these vaccines,” and trying to “get on a more regular schedule.” If COVID shots are here for good, then at least we can be rid of the bother of counting them.

    Read: It’s a bad time to be a booster slacker

    Counting doses was more apt early in the vaccine rollout, when it seemed that two jabs (or even one) would be enough to get Americans “fully vaccinated” and out of the danger zone. When more shots followed, they were often advertised with confusing finality: What some initially described as the booster was later retconned as the first booster after a second one was recommended for certain groups. But with immunity against infection more fragile than some hoped, and a virus that quickly shapeshifts out of antibodies’ grasp, those ordinal adjectives have stopped making sense. Until our vaccine tech becomes much more durable or variant-proof, repeat doses will be, for most of us, a fixture of the future—and it won’t do anyone much good to say, “‘I’m on shot 15’ or ‘I’m on shot 16,’” Angela Shen, a vaccine expert at Children’s Hospital of Philadelphia, told me.

    The numbers certainly matter when they’re small: It will continue to be important for people to count off their first few shots, for instance, especially those without a history of infections. But after that initial set of viral-spike-protein exposures, the total count is moot. In most cases, about three vaccinations or infections—preferably vaccinations, which are both safer and easier to accurately track—should be “enough to fully charge up the immune system’s battery” for the first time, says Rishi Goel, an immunologist at the University of Pennsylvania. Further COVID shots will help only insofar as they can recharge the battery toward max capacity when it starts to lose its juice. Scheduling a vaccine, then, becomes a matter of “how long it’s been since your last immunity-conferring event,” regardless of how many exposures a body has racked up, says Avnika Amin, a vaccine epidemiologist at Emory University.

    People who are immunocompromised may need four or more shots to establish that initial immunity charge, and their own (maybe smaller) peak capacity. But ultimately, the threshold effect they experience—a point of “diminishing returns”—is similar, says Marion Pepper, an immunologist at the University of Washington. Given how many vaccinations and infections the U.S. has now logged, the majority of Americans “can be done with counting,” she told me.

    If we’re going to shift our focus to timing shots, instead of counting them, we’ll have to schedule our shots smartly. Several prominent figures have already come out and said that yearly doses are a top choice. Albert Bourla, Pfizer’s CEO, has been pushing that idea since early 2021; Peter Marks, who heads the FDA’s Center for Biologics Evaluation and Research, has been delivering a similar line for several months. Even President Joe Biden has endorsed the annual approach, noting in a September statement that the debut of the bivalent shot heralded a new phase in COVID vaccination, in which Americans would receive a dose “once a year, each fall.”

    That plan is not unreasonable. Shots will have to come with at least some regularity, as variants keep rolling in and immunity against infection ebbs. But re-dose prematurely with a shot with similar ingredients, and the body—still hopped up from the previous dose—may destroy the vaccine before it has much effect, making it about as useful as charging a battery that’s already at 95 percent. SARS-CoV-2 antibody levels drop off steeply in the first six months following a vaccine dose, and then, the rate of drain slows down. It’s as if the immune system goes into “power-saver mode,” Goel told me, which means there might not be a huge difference between revaccinating twice a year or only once. Plus, living out much of the year with lower antibody levels is not as worrisome as it might sound. Although antibodies can be a rather useful proxy for our level of protection, especially against infection, they don’t paint the whole defensive picture: T cells and other fighters tend to stick around for far longer, maintaining safeguards against severe disease. (The immunocompromised and older people may still need more frequent COVID-immunity top-offs.)

    Read: Are we really getting COVID boosters every year forever?

    The optimal pace for COVID vaccination will also depend on the speed at which the virus spews out variants. A yearly schedule works for influenza, Shen told me, but “we know flu’s cadence.” SARS-CoV-2 hasn’t yet settled down into a predictable, seasonal pattern; its waves aren’t relegated to the chilliest months. The degree to which we, as the coronavirus’s hosts, tamp down transmission also matters quite a bit. Having more virus around puts more pressure on vaccines to perform, especially when there aren’t many other mitigation measures in place. If all this talk of “once a year, each fall” turns out to be another red-herring recommendation, Amin told me, it could undermine any messaging that follows.

    All of that said, the autumn regimen may yet stick around because it’s the easiest approach. Flu-shot uptake is far from perfect, but the messaging around it is “simple and clean,” says Rupali Limaye, a behavioral scientist and vaccine-attitudes researcher at Johns Hopkins. After dosing up twice in four weeks as infants, people are asked to get a yearly shot, and that’s it. Compare that with the most convoluted days of COVID vaccination, when people couldn’t dose up without accounting for their age, health status, number of previous doses, vaccine brand, time since last dose, and more. “That’s absolute overload,” Limaye told me. Complicated schedules burn people out—or dissuade them from showing up at all. This fall, when the bivalent shot debuted, a troubling proportion of Americans didn’t even know they were eligible.

    Encouraging COVID vaccines at the same, straightforward pace as flu shots would make it easy for people to sign up for both at once, and maybe, eventually, to get them in the same syringe. Vaccines tend to ride one another’s coattails, Shen told me. “In the fall, there’s a bump in other routine vaccines,” she said, because people “are already there for their flu shot.” It would also make a big difference if the COVID-vaccine recipes changed for everyone at the same time, as they do for flu.

    Read: When’s the perfect time to get a flu shot?

    If we’re going to pivot from numbering doses to timing them, we might as well take the opportunity to discard the term booster as well. Some people don’t understand what it means, Limaye told me, or they default to a logical question—How many more boosters will I need? Plus, booster may no longer fit the science. “When we start updating formulas, it’s not really a booster anymore,” Amin told me. That’s not how we generally talk about flu shots: I certainly couldn’t tell you how many “boosters” of that vaccine I’ve had. (I don’t know, maybe 14? 15?) Pivoting to a terminology of “seasonal shots” could make COVID vaccination that much more routine.

    So, fine, if anyone should ask: I’ve had (count ’em: one, two, three) four doses of the vaccine so far. But more important, I’ve gotten the shot most recently available to me.

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    Katherine J. Wu

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  • The Worst Pediatric-Care Crisis in Decades

    The Worst Pediatric-Care Crisis in Decades

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    At the height of the coronavirus pandemic, as lines of ambulances roared down the streets and freezer vans packed into parking lots, the pediatric emergency department at Our Lady of the Lake Children’s Hospital, in Baton Rouge, Louisiana, was quiet.

    It was an eerie juxtaposition, says Chris Woodward, a pediatric-emergency-medicine specialist at the hospital, given what was happening just a few doors down. While adult emergency departments were being inundated, his team was so low on work that he worried positions might be cut. A small proportion of kids were getting very sick with COVID-19—some still are—but most weren’t. And due to school closures and scrupulous hygiene, they weren’t really catching other infections—flu, RSV, and the like—that might have sent them to the hospital in pre-pandemic years. Woodward and his colleagues couldn’t help but wonder if the brunt of the crisis had skipped them by. “It was, like, the least patients I saw in my career,” he told me.

    That is no longer the case.

    Across the country, children have for weeks been slammed with a massive, early wave of viral infections—driven largely by RSV, but also flu, rhinovirus, enterovirus, and SARS-CoV-2. Many emergency departments and intensive-care units are now at or past capacity, and resorting to extreme measures. At Johns Hopkins Children’s Center, in Maryland, staff has pitched a tent outside the emergency department to accommodate overflow; Connecticut Children’s Hospital mulled calling in the National Guard. It’s already the largest surge of infectious illnesses that some pediatricians have seen in their decades-long careers, and many worry that the worst is yet to come. “It is a crisis,” Sapna Kudchadkar, a pediatric-intensive-care specialist and anesthesiologist at Johns Hopkins, told me. “It’s bananas; it’s been full to the gills since September,” says Melissa J. Sacco, a pediatric-intensive-care specialist at UVA Health. “Every night I turn away a patient, or tell the emergency department they have to have a PICU-level kid there for the foreseeable future.”

    I asked Chris Carroll, a pediatric-intensive-care specialist at Connecticut Children’s, how bad things were on a scale of 1 to 10. “Can I use a Spinal Tap reference?” he asked me back. “This is our 2020. This is as bad as it gets.”

    Read: The strongest signal that Americans should worry about flu this winter

    The autumn crush, experts told me, is fueled by dual factors: the disappearance of COVID mitigations and low population immunity. For much of the pandemic, some combination of masking, distancing, remote learning, and other tactics tamped down on the transmission of nearly all the respiratory viruses that normally come knocking during the colder months. This fall, though, as kids have flocked back into day cares and classrooms with almost no precautions in place, those microbes have made a catastrophic comeback. Rhinovirus and enterovirus were two of the first to overrun hospitals late this summer; now they’re being joined by RSV, all while SARS-CoV-2 remains in play. Also on the horizon is flu, which has begun to pick up in the South and the mid-Atlantic, triggering school closures or switches to remote learning. During the summer of 2021, when Delta swept across the nation, “we thought that was busy,” Woodward said. “We were wrong.”

    Children, on the whole, are more susceptible to these microbes than they have been in years. Infants already have a rough time with viruses like RSV: The virus infiltrates the airways, causing them to swell and flood with mucus that their tiny lungs may struggle to expel. “It’s almost like breathing through a straw,” says Marietta Vazquez, a pediatric-infectious-disease specialist at Yale. The more narrow and clogged the tubes get, “the less room you have to move air in and out.” Immunity accumulated from prior exposures can blunt that severity. But with the pandemic’s great viral vanishing, kids missed out on early encounters that would have trained up their bodies’ defensive cavalry. Hospitals are now caring for their usual RSV cohort—infants—as well as toddlers, many of whom are sicker than expected. Infections that might, in other years, have produced a trifling cold are progressing to pneumonia severe enough to require respiratory support. “The kids are just not handling it well,” says Stacy Williams, a PICU nurse at UVA Health.

    Coinfections, too, have always posed a threat—but they’ve grown more common with SARS-CoV-2 in the mix. “There’s just one more virus they’re susceptible to,” Vazquez told me. Each additional bug can burden a child “with a bigger hill to climb, in terms of recovery,” says Shelby Lighton, a nurse at UVA Health. Some patients are leaving the hospital healthy, only to come right back. There are kids who “have had four respiratory viral illnesses since the start of September,” Woodward told me.

    Pediatric care capacity in many parts of the country actually shrank after COVID hit, Sallie Permar, a pediatrician at NewYork-Presbyterian and Weill Cornell Medicine, whose hospital was among those that cut beds from its PICU, told me. A mass exodus of health-care workers—nurses in particular—has also left the system ill-equipped to meet the fresh wave of demand. At UVA Health, the pediatric ICU is operating with maybe two-thirds of the core staff it needs, Williams said. Many hospitals have been trying to call in reinforcements from inside and outside their institutions. But “you can’t just train a bunch of people quickly to take care of a two-month-old,” Kudchadkar said. To make do, some hospitals are doubling up patients in rooms; others have diverted parts of other care units to pediatrics, or are sending specialists across buildings to stabilize children who can’t get a bed in the ICU. In Baton Rouge, Woodward is regularly visiting the patients who have just been admitted to the hospital and are still being held in the emergency department, trying to figure out who’s healthy enough to go home so more space can be cleared. His emergency department used to take in, on average, about 130 patients a day; lately, that number has been closer to 250. “They can’t stay,” he told me. “We need this room for somebody else.”

    Experts are also grappling with how to strike the right balance between raising awareness among caregivers and managing fears that may morph into overconcern. On the one hand, with all the talk of SARS-CoV-2 being “mild” in kids, some parents might ignore the signs of RSV, which can initially resemble those of COVID, then get much more serious, says Ashley Joffrion, a respiratory therapist at Baton Rouge General Medical Center. On the other hand, if families swamp already overstretched hospitals with illnesses that are truly mild enough to resolve at home, the system could fracture even further. “We definitely don’t want parents bringing kids in for every cold,” Williams told me. The key signs of severe respiratory sickness in children include wheezing, grunting, rapid or labored breaths, trouble drinking or swallowing, and bluing of the lips or fingernails. When in doubt, experts told me, parents should call their pediatrician for an assist.

    Read: The great pandemic hand-washing blooper

    With winter still ahead, the situation could take an even darker turn, especially as flu rates climb, and new SARS-CoV-2 subvariants loom. In most years, the chilly viral churn doesn’t abate until late winter, which means hospitals may be only at the start of a grueling few months. And still-spotty uptake of COVID vaccines among little kids, coupled with a recent dip in flu-shot uptake and the widespread abandonment of infection-prevention measures, could make things even worse, says Abdallah Dalabih, a pediatric-intensive-care specialist at Arkansas Children’s.

    The spike in respiratory illness marks a jarring departure from a comforting narrative that’s dominated the intersection of infectious disease and little children’s health for nearly three years. When it comes to respiratory viruses, little children have always been a vulnerable group. This fall may force Americans to reset their expectations around young people’s resilience and recall, Lighton told me, “just how bad a ‘common cold’ can get.”

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    Katherine J. Wu

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