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Tag: given year

  • Sick Season Will Be Worse From Now On

    Sick Season Will Be Worse From Now On

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    Last fall, when RSV and flu came roaring back from a prolonged and erratic hiatus, and COVID was still killing thousands of Americans each week, many of the United States’ leading infectious-disease experts offered the nation a glimmer of hope. The overwhelm, they predicted, was probably temporary—viruses making up ground they’d lost during the worst of the pandemic. Next year would be better.

    And so far, this year has been better. Some of the most prominent and best-tracked viruses, at least, are behaving less aberrantly than they did the previous autumn. Although neither RSV nor flu is shaping up to be particularly mild this year, says Caitlin Rivers, an epidemiologist at the Johns Hopkins Center for Health Security, both appear to be behaving more within their normal bounds.

    But infections are still nowhere near back to their pre-pandemic norm. They never will be again. Adding another disease—COVID—to winter’s repertoire has meant exactly that: adding another disease, and a pretty horrific one at that, to winter’s repertoire. “The probability that someone gets sick over the course of the winter is now increased,” Rivers told me, “because there is yet another germ to encounter.” The math is simple, even mind-numbingly obvious—a pathogenic n+1 that epidemiologists have seen coming since the pandemic’s earliest days. Now we’re living that reality, and its consequences. “What I’ve told family or friends is, ‘Odds are, people are going to get sick this year,’” Saskia Popescu, an epidemiologist at the University of Maryland School of Medicine, told me.

    Even before the pandemic, winter was a dreaded slog—“the most challenging time for a hospital” in any given year, Popescu said. In typical years, flu hospitalizes an estimated 140,000 to 710,000 people in the United States alone; some years, RSV can add on some 200,000 more. “Our baseline has never been great,” Yvonne Maldonado, a pediatrician at Stanford, told me. “Tens of thousands of people die every year.” In “light” seasons, too, the pileup exacts a tax: In addition to weathering the influx of patients, health-care workers themselves fall sick, straining capacity as demand for care rises. And this time of year, on top of RSV, flu, and COVID, we also have to contend with a maelstrom of other airway viruses—among them, rhinoviruses, parainfluenza viruses, human metapneumovirus, and common-cold coronaviruses. (A small handful of bacteria can cause nasty respiratory illnesses too.) Illnesses not severe enough to land someone in the hospital could still leave them stuck at home for days or weeks on end, recovering or caring for sick kids—or shuffling back to work, still sick and probably contagious, because they can’t afford to take time off.

    To toss any additional respiratory virus into that mess is burdensome; for that virus to be SARS-CoV-2 ups the ante all the more. “This is a more serious pathogen that is also more infectious,” Ajay Sethi, an epidemiologist at the University of Wisconsin at Madison, told me. This year, COVID-19 has so far killed some 80,000 Americans—a lighter toll than in the three years prior, but one that still dwarfs that of the worst flu seasons in the past decade. Globally, the only infectious killer that rivals it in annual-death count is tuberculosis. And last year, a CDC survey found that more than 3 percent of American adults were suffering from long COVID—millions of people in the United States alone.

    Read: Is COVID a common cold yet?

    With only a few years of data to go on, and COVID-data tracking now spotty at best, it’s hard to quantify just how much worse winters might be from now on. But experts told me they’re keeping an eye on some potentially concerning trends. We’re still rather early in the typical sickness season, but influenza-like illnesses, a catchall tracked by the CDC, have already been on an upward push for weeks. Rivers also pointed to CDC data that track trends in deaths caused by pneumonia, flu, and COVID-19. Even when SARS-CoV-2 has been at its most muted, Rivers said, more people have been dying—especially during the cooler months—than they were at the pre-pandemic baseline. The math of exposure is, again, simple: The more pathogens you encounter, the more likely you are to get sick.

    A larger roster of microbes might also extend the portion of the year when people can expect to fall ill, Rivers told me. Before the pandemic, RSV and flu would usually start to bump up sometime in the fall, before peaking in the winter; if the past few years are any indication, COVID could now surge in the summer, shading into RSV’s autumn rise, before adding to flu’s winter burden, potentially dragging the misery out into spring. “Based on what I know right now, I am considering the season to be longer,” Rivers said.

    With COVID still quite new, the exact specifics of respiratory-virus season will probably continue to change for a good while yet. The population, after all, is still racking up initial encounters with this new coronavirus, and with regularly administered vaccines. Bill Hanage, an epidemiologist at Harvard’s T. H. Chan School of Public Health, told me he suspects that, barring further gargantuan leaps in viral evolution, the disease will continue to slowly mellow out in severity as our collective defenses build; the virus may also pose less of a transmission risk as the period during which people are infectious contracts. But even if the dangers of COVID-19 are lilting toward an asymptote, experts still can’t say for sure where that asymptote might be relative to other diseases such as the flu—or how long it might take for the population to get there. And no matter how much this disease softens, it seems extraordinarily unlikely to ever disappear. For the foreseeable future, “pretty much all years going forward are going to be worse than what we’ve been used to before,” Hanage told me.

    Read: The next stage of COVID is starting now

    In one sense, this was always where we were going to end up. SARS-CoV-2 spread too quickly and too far to be quashed; it’s now here to stay. If the arithmetic of more pathogens is straightforward, our reaction to that addition could have been too: More disease risk means ratcheting up concern and response. But although a core contingent of Americans might still be more cautious than they were before the pandemic’s start—masking in public, testing before gathering, minding indoor air quality, avoiding others whenever they’re feeling sick—much of the country has readily returned to the pre-COVID mindset.

    When I asked Hanage what precautions worthy of a respiratory disease with a death count roughly twice that of flu’s would look like, he rattled off a familiar list: better access to and uptake of vaccines and antivirals, with the vulnerable prioritized; improved surveillance systems to offer  people at high risk a better sense of local-transmission trends; improved access to tests and paid sick leave. Without those changes, excess disease and death will continue, and “we’re saying we’re going to absorb that into our daily lives,” he said.

    And that is what is happening. This year, for the first time, millions of Americans have access to three lifesaving respiratory-virus vaccines, against flu, COVID, and RSV. Uptake for all three remains sleepy and halting; even the flu shot, the most established, is not performing above its pre-pandemic baseline. “We get used to people getting sick every year,” Maldonado told me. “We get used to things we could probably fix.” The years since COVID arrived set a horrific precedent of death and disease; after that, this season of n+1 sickness might feel like a reprieve. But compare it with a pre-COVID world, and it looks objectively worse. We’re heading toward a new baseline, but it will still have quite a bit in common with the old one: We’re likely to accept it, and all of its horrors, as a matter of course.

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    Katherine J. Wu

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  • The Fight Over Fukushima’s Dirty Water

    The Fight Over Fukushima’s Dirty Water

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    The numbers were climbing on a radiation dosimeter as the minibus carried me deeper into the complex. Biohazard suits are no longer required in most parts of Japan’s Fukushima Daiichi power plant, but still, I’d been given a helmet, eyewear, an N95 mask, gloves, two pairs of socks, and rubber boots. At the site of the world’s worst nuclear disaster since Chernobyl, you can never be too safe.

    The road to the plant passes abandoned houses, convenience stores, and gas stations where forests of weeds sprout in the asphalt cracks. Inside, ironic signs, posted after the disaster, warning of tsunami risk. In March 2011, a 9.0-magnitude earthquake struck off Japan’s Pacific coast and flooded the plant, knocking out its emergency diesel generators and initiating the failure of cooling systems that led to a deadly triple-reactor meltdown.

    Now, looking down from a high platform, I could see a crumpled roof where a hydrogen explosion had ripped through the Unit 1 reactor the day after the tsunami hit. The eerie stillness of the place was punctuated by the rattle of heavy machinery and the cries of gulls down by the water, where an immense metal containment tank has been mangled like a dog’s chew toy. Great waves dashing against the distant breakwater shook the metal decks by the shore. Gazing out across this scene, I felt like I was standing at the vestibule of hell.

    A dozen years after the roughly 50-foot waves crashed over Fukushima Daiichi, water remains its biggest problem. The nuclear fuel left over from the meltdown has a tendency to overheat, so it must be continuously cooled with water. That water becomes radioactive in the process, and so does any groundwater and rain that happens to enter the reactor buildings; all of it must be kept away from people and the environment to prevent contamination. To that end, about 1,000 dirty-water storage vats of various sizes blanket the complex. In all, they currently store 343 million gallons, and another 26,000 gallons are added to the total every day. But the power plant, its operator claims, is running out of room.

    On August 24, that operator—the Tokyo Electric Power Company, or TEPCO—began letting the water go. The radioactive wastewater is first being run through a system of chemical filters in an effort to strip it of dangerous constituents, and then flushed into the ocean and potentially local fisheries. Although this plan has official backing from the Japanese government and the International Atomic Energy Agency, many in the region—including local fishermen and their potential customers—are frightened by its implications.

    “The IAEA has said this will have a negligible impact on people and the environment,” Junichi Matsumoto, a TEPCO official in charge of water treatment, told reporters during a briefing at Daiichi during my visit in July. Only water that meets certain purity standards would be released into the ocean, he explained. The rest would be run through the filters and pumps again as needed. But no matter how many chances it gets, TEPCO’s Advanced Liquid Processing System cannot cleanse the water of tritium, a radioactive form of hydrogen that is produced by nuclear-power plants even during normal operations, or of carbon-14. These lingering contaminants are a source of continuing anxiety.

    Last month, China, the biggest importer of Japanese seafood, imposed a blanket ban on fisheries’ products from Japan, and Japanese news media have reported domestic seafood chains receiving numerous harassing phone calls originating in China. The issue has exacerbated tensions between the two countries. (The Japanese public broadcaster NHK responded by reporting that each of 13 nuclear-power plants in China released more tritium in 2021 than Daiichi will release in one year.) In South Korea, the government tried to allay fears after thousands of people protested in Seoul over the water release.

    Opposition within Japan has coalesced around potential harms to local fishermen. In Fukushima, where the season for trawl fishing has just begun, workers are worried that seafood consumers in Japan and overseas will view their products as tainted and boycott them. “We have to appeal to people that they’re safe and secure, and do our best as we go forward despite falling prices and harmful rumors,” one elderly fisherman told Fukushima Broadcasting as he brought in his catch.

    Government officials are doing what they can to protect that brand. Representatives from Japan’s environmental agency and Fukushima prefecture announced last week that separate tests showed no detectable levels of tritium in local seawater after the water release began. But even if its presence were observed, many experts say the environmental risks of the release are negligible. According to the IAEA, tritium is a radiation hazard to humans only if ingested in large quantities. Jukka Lehto, a professor emeritus of radiochemistry at the University of Helsinki, co-authored a detailed study of TEPCO’s purification system that found it works efficiently to remove certain radionuclides. (Lehto’s earlier research played a role in the development of the system.) Tritium is “not completely harmless,” he told me, but the threat is “very minor.” The release of purified wastewater into the sea will not, practically speaking, “cause any radiological problem to any living organism.” As for carbon-14, the Japanese government says its concentration in even the untreated wastewater is, at most, just one-tenth the country’s regulatory standards.

    From 1976: Richard Rhodes on the benefits, costs, and risks of nuclear energy

    Opponents point to other potential problems. Greenpeace Japan says the biological impacts of releasing different radionuclides into the water, including strontium-90 and iodine-129, have been ignored. (When asked about these radionuclides, a spokesperson for the utility told me that the dirty water is “treated with cesium/strontium-filtering equipment to remove most of the contamination” and then subsequently processed to remove “most of the remaining nuclides except for tritium.”) Last December, the Virginia-based National Association of Marine Laboratories put out a position paper arguing that neither TEPCO nor the Japanese government has provided “adequate and accurate scientific data” to demonstrate the project’s safety, and alleged that there are “flaws in sampling protocols, statistical design, sample analyses, and assumptions.” (TEPCO did not respond to a request for comment on these claims.)

    If, as these groups worry, the water from Fukushima does end up contaminating the ocean, scientific proof could be hard to find. In 2019, for example, scientists reported the results of a study that had begun eight years earlier, to monitor water near San Diego for iodine-129 released by the Fukushima meltdown. None was found, in spite of expectations based on ocean currents. When the scientists checked elsewhere on the West Coast, they found high levels of iodine-129 in the Columbia River in Washington—but Fukushima was not to blame. The source of that contamination was the nearby site where plutonium had been produced for the nuclear bomb that the U.S. dropped on Nagasaki.

    Concerns about the safety of the water release persist in part because of TEPCO’s history of wavering transparency. In 2016, for instance, a commission tasked with investigating the utility’s actions during the 2011 disaster found that its leader at the time told staff not to use the term core meltdown. Even now, the company has put out analyses of the contents of only three-fifths of the dirty-water storage tanks on-site, Ken Buesseler, the director of the Center for Marine and Environmental Radioactivity at the Woods Hole Oceanographic Institution, told me earlier this summer. Japan’s environmental ministry maintains that 62 radionuclides other than tritium can be sufficiently removed from the wastewater using TEPCO’s filtration system, but Buesseler believes that not enough is known about the levels of those contaminants in all of the tanks to make this claim. Instead of flushing the water now, he said, it should first be completely analyzed, and then alternatives to dumping, such as longer on-site storage or using the water to make concrete for tsunami barriers, should be considered.

    It looks like that radioactive ship has sailed, however. The release that began in August is expected to continue for as long as the plant decommissioning lasts, which means that contaminated water will continue to flow out to the Pacific Ocean at least until the 2050s. In this case, the argument over relative risks—and whether Fukushima’s dirty water will ever be made clean enough for dumping to proceed—has already been decided. But parallel, and unresolved, debates attend to nuclear power on the whole. Leaving aside the wisdom of building nuclear reactors in an archipelago prone to earthquakes and tsunami, plants such as Daiichi provide cleaner energy than fossil-fuel facilities, and proponents say they’re vital to the process of decarbonizing the economy.

    Some 60 nuclear reactors are under construction around the world and will join the hundreds of others that now deliver about 10 percent of global electricity, according to the World Nuclear Association. Meltdowns like the one that happened in Fukushima in 2011, or at Chernobyl in 1986, are very rare. The WNA says that these are the only major accidents to have occurred in 18,500 cumulative reactor-years of commercial operations, and that reactor design is always improving. But the possibility of disaster, remote as it may be in any given year, is ever-present. For instance, the Zaporizhzhia Nuclear Power Station, Europe’s largest, has been threatened by military strikes and loss of electricity during the war in Ukraine, increasing the chances of meltdown. It took just 25 years for an accident at the scale of Chernobyl’s to be repeated.

    Read: Reckoning with the legacy of the nuclear reactor, 75 years later

    “We are faced with a difficult choice, either to continue using nuclear power while accepting that a major accident is likely to occur somewhere every 20 or 30 years, or to forgo its possible role in helping slow climate change that will make large swaths of the globe uninhabitable in coming decades,” says Azby Brown, the lead researcher at Safecast, a nonprofit environmental-monitoring group that began tracking radiation from Fukushima in 2011.

    The Fukushima water release underscores the fact that the risks associated with nuclear energy are never zero and that dealing with nuclear waste is a dangerous, long-term undertaking where mistakes can be extremely costly. TEPCO and the Japanese government made a difficult, unpopular decision to flush the water. In the next few decades, they will have to show that it was the right thing to do.

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    Tim Hornyak

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  • Fall’s Vaccine Routine Didn’t Have to Be This Hard

    Fall’s Vaccine Routine Didn’t Have to Be This Hard

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    In an ideal version of this coming winter, the United States would fully revamp its approach to respiratory disease. Pre-pandemic, fall was just a time for flu shots, if that. Now, hundreds of millions of Americans have at their fingertips vaccines that can combat three cold-weather threats at once: flu, COVID, and, for a subset of us, respiratory syncytial virus. If everyone signed up to get the shots they qualified for, “it would be huge,” says Ofer Levy, the director of the Precision Vaccines Program at Boston Children’s Hospital. Hospital emergency rooms and intensive-care units wouldn’t fill; most cases of airway illness would truly, actually feel like “just” a common cold. “We would save tens of thousands of lives in the United States alone,” Levy told me.

    The logic of the plan is simple: Few public-health priorities are more pressing than getting three lifesaving vaccines to those who need them most, ahead of winter’s viral spikes. The logistics, however, are not as clear-cut. The best way to get vaccines into as many people as possible is to make getting shots “very, very easy,” says Chelsea Shover, an epidemiologist at UCLA. But that’s just not what we’ve set up this fall lineup of shots to do.

    Read: The flu-ification of COVID policy is almost complete

    Convenience isn’t the only issue keeping shots out of arms. But move past fear, distrust, or misinformation, solve for barriers such as insurance coverage, and getting a vaccine in the United States still means figuring out when shots are available and which you qualify for, finding and booking appointments, carving out the time to go. For adults, especially, who don’t routinely visit their doctor for wellness checkups, and whose workplaces don’t require vaccines to the extent that schools do, vaccination has become an onerous exercise in opt-ins.

    Bundling this year’s flu, COVID, and RSV vaccines into a single visit could, in theory, help ease the way to becoming a double or triple shotter. “Any time we can cut down on the number of visits for a patient to take care of them, we know that’s a big boost,” says Tochi Iroku-Malize, the president of the American Academy of Family Physicians. But the easiest iteration of that strategy, a three-in-one shot, similar to the MMR and DTaP vaccines of childhood, doesn’t yet exist (though some are in trials). Even the shorter-term solution—giving up to three injections at once—is hitting stumbling blocks. Pharmacies started receiving flu vaccines earlier this summer and are already giving them out to anyone over the age of six months. RSV vaccines, too, have hit shelves, and have been approved for people over the age of 60 and those 32 to 36 weeks pregnant; so far, however, they are being offered only to the first group. And although nearly all Americans are expected to be eligible for autumn’s updated COVID vaccines, those shots aren’t slated to make an appearance until mid-September or so, according to Kevin Griffis, a CDC spokesperson.

    Timing two or three shots together isn’t a perfect plan. Get them all too early, and some people’s protections against infection might fade before the season gets into full swing; get all of them too late, and a virus might beat the vaccine to the punch. Respiratory viruses don’t coordinate their seasons: Right now, for instance, COVID cases are on a sharp rise, but flu and RSV ones are not. Some data on the new RSV vaccines also suggests that co-administering them with other shots might trigger slightly worse side effects, or mildly curb the number of antibodies that the injections raise. Still, Levy argues that those theoretical downsides are outweighed by known benefits. “If someone is at clinic in the fall, they should get all the vaccines they’re eligible for,” he told me. Getting a slightly less effective, slightly more ornery shot a few months early is better than never getting a shot at all.

    All of that supposes that people understand that they are eligible for these shots. But already, family-medicine physicians such as Iroku-Malize, who practices in Long Island, have been fielding queries about the RSV vaccines from confused patients. Some new parents, for instance, have gotten the impression that the RSV vaccines are designed to be administered to infants, which isn’t quite right: Babies are the target of protection for the shots for pregnant people, but only because they temporarily inherit antibodies—not because they can get the injections themselves. Regulators also haven’t yet nailed down how often older adults might need the shot, though the current thinking is that the vaccine’s protection will last at least a couple of years. “It’s very hard to tell people, ‘I don’t know,’” says Jacinda Abdul-Mutakabbir, an infectious-disease pharmacist at UC San Diego.

    Other parts of the RSV-shot messaging are peppered with even more unknowns. The CDC has yet to release its final recommendation for pregnant people; for people over 60, the agency’s language has been “noncommittal,” says Rupali Limaye, a behavioral scientist at Johns Hopkins University. Unlike past guidelines that have straightforwardly recommended flu shots or most doses of the COVID-19 vaccine, RSV guidance says that eligible people may protect themselves against the virus—and are urged to first consult a health-care provider, which not all people have. The wishy-washiness is partly about safety: A few rare but serious medical events cropped up during the RSV vaccines’ clinical trials, including abnormal heartbeats and neurological complications. None of the experts I spoke with had qualms about recommending the shots anyway. Even so, some private health-insurance companies have seized on the CDC’s watered-down recommendation—and the fact that the agency hasn’t yet included RSV in its annual vaccine schedule for adults—as an excuse to not cover the shot, leaving some patients paying $300-plus out of pocket.

    For any of these shots, viral reputation matters too. Despite hospitalizing tens of thousands of Americans each year, especially at age extremes—numbers that, in some years, nearly rival those linked to flu—RSV is a lesser-known winter disease. People tend to take it less seriously, if it’s on their radar at all, Abdul-Mutakabbir told me. Which bodes poorly for future RSV-shot uptake. Annual flu shots have been recommended for 13 years for every American over the age of six months for 13 years. And still, just half the eligible population gets them in any given year. People tend to dismiss shots as subpar interventions against a disease that they don’t much fear, Limaye told me. With COVID, too, “people think it’s gotten mild,” she said. Only 28 percent of American adults are currently up to date on their COVID vaccine. And although older people have historically been more vigilant about nabbing shots, even vaccines against shingles—a notoriously painful disease—have reached just over a third of people who are 60-plus.

    Read: America’s flu-shot problem is also its COVID-shot problem

    To establish fall as an immunity-seeking season, shots would need to become an annual habit, ideally one easy to form. Mandates and financial incentives do prod people toward vaccines, but smaller nudges can persuade people to take initiative on their own. Some strategies may be as simple as semantic tweaks. Studies on HPV and flu vaccines suggest that telling patients they are “due” for a shot is better than offering it as an optional choice, says Gretchen Chapman, a behavioral scientist at Carnegie Mellon University. Other research suggests that carefully worded text-message reminders can evoke ownership—noting that a shot is “waiting for you,” or that the time has come to “claim your dose.” Noel Brewer, a behavioral scientist at the University of North Carolina at Chapel Hill, also thinks that vaccine deliverers could take inspiration from dentists who gently dog their patients with phone calls and postcards.

    Other interventions could be aimed at streamlining delivery. Government funding could make shots more available in rural regions, ensure access for those who lack insurance, and help local health departments offer shots in churches and hair salons, or even bring them door to door. More schools and workplaces, too, might try boosting uptake among students and employees. And although most shots are already given within the health-care system, there’s sludge to clear from that pipeline too. Better universal recordkeeping could help track people’s vaccination status through their lifetime. Kimberly Martin, a behavioral scientist at Yale, is researching ways to revamp medical training to help health-care providers earn their patients’ trust—especially among populations that remain marginalized by systemic racism. “The single biggest impact on vaccine uptake,” Brewer told me, “is a health-care provider recommendation.”

    An ideal vision of a fall in the future, then, would be turning vaccines into a default form of prevention—a more typical part of this country’s wellness workflow, says Saad Omer, the dean of the Peter O’Donnell Jr. School of Public Health, at UT Southwestern. After getting their vital signs checked, patients could have their vaccination status reviewed. “And then, if they’re eligible, you vaccinate them,” Omer told me. It’s a routine that pediatricians already have down pat. If adult health care follows suit, regular immunization is a habit we may never have to outgrow.

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    Katherine J. Wu

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