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Tag: health-care systems

  • Winter Illness This Year Is a Different Kind of Ugly

    Winter Illness This Year Is a Different Kind of Ugly

    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.

    Katherine J. Wu

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  • Warning Signs About the First Post-pandemic Winter

    Warning Signs About the First Post-pandemic Winter

    This fall, unlike the one before it, and the one before that, America looks almost like its old self. Schools and universities are in session; malls, airports, and gyms are bustling with the pre-holiday rush; handwashing is passé, handshakes are back, and strangers are packed together on public transport, nary a mask to be seen. On its surface, the country seems ready to enjoy what some might say is our first post-pandemic winter.

    Americans are certainly acting as if the crisis has abated, and so in that way, at least, you could argue that it has. “If you notice, no one’s wearing masks,” President Joe Biden told 60 Minutes in September, after proclaiming the pandemic “over.” Almost no emergency protections against the virus are left standing; we’re dismantling the few that are. At the same time, COVID is undeniably, as Biden says, “a problem.” Each passing day still brings hundreds of deaths and thousands of hospitalizations; untold numbers of people continue to deal with long COVID, as more join them. In several parts of the country, health-care systems are struggling to stay afloat. Local public-health departments, underfunded and understaffed, are hanging by a thread. And a double surge of COVID and flu may finally be brewing.

    So we can call this winter “post-pandemic” if we want. But given the policy failures and institutional dysfunctions that have accumulated over the past three years, it won’t be anything like a pre-pandemic winter, either. The more we resist that reality, the worse it will become. If we treat this winter as normal, it will be anything but.

    By now, we’ve grown acquainted with the variables that dictate how a season with SARS-CoV-2 will go. In our first COVID winter, the vaccines had only just begun their trickle out into the public, while most Americans hadn’t yet been infected by the virus. In our second COVID winter, the country’s collective immunity was higher, but Omicron sneaked past some of those defenses. On the cusp of our third COVID winter, it may seem that SARS-CoV-2 has few plot twists left to toss us.

    But the way in which we respond to COVID could still sprinkle in some chaos. During those first two winters, at least a few virus-mitigating policies and precautions remained in place—nearly all of which have since come down, lowering the hurdles the virus must clear, at a time when America’s health infrastructure is facing new and serious threats.

    The nation is still fighting to contain a months-long monkeypox outbreak; polio continues to plague unvaccinated sectors of New York. A riot of respiratory viruses, too, may spread as temperatures cool and people flock indoors. Rates of RSV are rising; flu returned early in the season from a nearly three-year sabbatical to clobber Australia, boding poorly for us in the north. Should flu show up here ahead of schedule, Americans, too, could be pummeled as we were around the start of 2018, “one of the worst seasons in the recent past,” says Srinivasan Venkatramanan, an infectious-disease modeler at the University of Virginia and a member of the COVID-19 Scenario Modeling Hub.

    Read: Fauci addresses ‘The pandemic is over’

    The consequences of this infectious churn are already starting to play out. In Jackson, Mississippi, health workers are watching SARS-CoV-2 and other respiratory viruses tear through children “like nothing we’ve ever seen before,” says Charlotte Hobbs, a pediatric-infectious-disease specialist at the University of Mississippi Medical Center. Flu season has yet to go into full swing, and Hobbs is already experiencing one of the roughest stretches she’s had in her nearly two decades of practicing. Some kids are being slammed with one virus after the other, their sicknesses separated by just a couple of weeks—an especially dangerous prospect for the very youngest among them, few of whom have received COVID shots.

    The toll of doctor visits missed during the pandemic has ballooned as well. Left untreated, many people’s chronic conditions have worsened, and some specialists’ schedules remain booked out for months. Add to this the cases of long COVID that pile on with each passing surge of infections, and there are “more sick people than there used to be, period,” says Emily Landon, an infectious-disease physician at the University of Chicago. That’s with COVID case counts at a relative low, amid a massive undercount. Even if a new, antibody-dodging variant doesn’t come banging on the nation’s door, “the models predict an increase in infections,” Venkatramanan told me. (In parts of Europe, hospitalizations are already making a foreboding climb.)

    And where the demand for care increases, supply does not always follow suit. Health workers continue to evacuate their posts. Some have taken early retirement, worried that COVID could exacerbate their chronic conditions, or vice versa; others have sought employment with better hours and pay, or left the profession entirely to salvage their mental health. A wave of illness this winter will pare down forces further, especially as the CDC backs off its recommendations for health-care workers to mask. At UAB Hospital, in Birmingham, Alabama, “we’ve struggled to have enough people to work,” says Sarah Nafziger, an emergency physician and the medical director for employee health. “And once we get them here, we have a hard time getting them to stay.”

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

    Clinical-laboratory staff at Deaconess Hospital, in Indiana, who are responsible for testing patient samples, are feeling similar strain, says April Abbott, the institution’s microbiology director. Abbott’s team has spent most of the past month below usual minimum-staffing levels, and has had to cut some duties and services to compensate, even after calling in reinforcements from other, already shorthanded parts of the lab. “We’re already at this threshold of barely making it,” Abbott told me. Symptoms of burnout have surged as well, while health workers continue to clock long hours, sometimes amid verbal abuse, physical attacks, and death threats. Infrastructure is especially fragile in America’s rural regions, which have suffered hospital closures and an especially large exodus of health workers. In Madison County, Montana, where real-estate values have risen, “the average nurse cannot afford a house,” says Margaret Bortko, a nurse practitioner and the region’s health officer and medical director. When help and facilities aren’t available, the outcome is straightforward, says Janice Probst, a rural-health researcher at the University of South Carolina: “You will have more deaths.”

    In health departments, too, the workforce is threadbare. As local leaders tackle multiple infectious diseases at once, “it’s becoming a zero-sum game,” says Maria Sundaram, an epidemiologist at the Marshfield Clinic Research Institute. “With limited resources, do they go to monkeypox? To polio? To COVID-19? To influenza? We have to choose.” Mati Hlatshwayo Davis, the director of health in St. Louis, told me that her department has shrunk to a quarter of the size it was five years ago. “I have staff doing the jobs of three to five people,” she said. “We are in absolute crisis.” Staff have left to take positions as Amazon drivers, who “make so much more per hour.” Looking across her state, Hlatshwayo Davis keeps watching health directors “resign, resign, resign.” Despite all that she has poured into her job, or perhaps because of it, “I can’t guarantee I won’t be one of those losses too.”

    This winter is unlikely to be an encore of the pandemic’s worst days. Thanks to the growing roster of tools we now have to combat the coronavirus—among them, effective vaccines and antivirals—infected people are less often getting seriously sick; even long COVID seems to be at least a bit scarcer among people who are up-to-date on their shots. But considering how well our shots and treatments work, the plateau of suffering at which we’ve arrived is bizarrely, unacceptably high. More than a year has passed since the daily COVID death toll was around 200; nearly twice that number—roughly three times the daily toll during a moderate flu season—now seems to be a norm.

    Part of the problem remains the nation’s failed approach to vaccines, says Avnika Amin, a vaccine epidemiologist at Emory University: The government has repeatedly championed shots as a “be-all and end-all” strategy, while failing to rally sufficient uptake. Boosting is one of the few anti-COVID measures still promoted, yet the U.S. remains among the least-vaccinated high-income countries; interest in every dose that’s followed the primary series has been paltry at best. Even with the allure of the newly reformulated COVID shot, “I’m not really getting a good sense that people are busting down the doors,” says Michael Dulitz, a health worker in Grand Forks, North Dakota. Nor can vaccines hold the line against the virus alone. Even if everyone got every shot they were eligible for, Amin told me, “it wouldn’t make COVID go away.”

    Read: America created its own booster problems

    The ongoing dry-up of emergency funds has also made the many tools of disease prevention and monitoring more difficult to access. Free at-home tests are no longer being shipped out en masse; asymptomatic testing is becoming less available; and vaccines and treatments are shifting to the private sector, putting them out of reach for many who live in poor regions or who are uninsured and can least afford to fall ill.

    It doesn’t help, either, that the country’s level of preparedness lays out as a patchwork. People who vaccinate and mask tend to cluster, Amin told me, which means that not all American experiences of winter will be the same. Less prominent, less privileged parts of the country will quietly bear the brunt of outbreaks. “The biggest worry is the burden becoming unnoticed,” Venkatramanan told me. Without data, policies can’t change; the nation can’t react. “It’s like flying without altitude or speed sensors. You’re looking out the window and trying to guess.”

    There’s an alternative winter the country might envision—one unencumbered by the policy backslides the U.S. has made in recent months, and one in which Americans acknowledge that COVID remains not just “a problem” but a crisis worth responding to.

    In that version of reality, far more people would be up-to-date on their vaccines. The most vulnerable in society would be the most protected. Ventilation systems would hum in buildings across the country. Workers would have access to ample sick leave. Health-care systems would have excesses of protective gear, and local health departments wouldn’t want for funds. Masks would come out in times of high transmission, especially in schools, pharmacies, government buildings, and essential businesses; free tests, boosters, and treatments would be available to all. No one would be asked to return to work while sick—not just with COVID but with any transmissible disease. SARS-CoV-2 infections would not disappear, but they would remain at more manageable levels; cases of flu and other cold-weather sicknesses that travel through the air would follow suit. Surveillance systems would whir in every state and territory, ready to detect the next threat. Leaders might even set policies that choreograph, rather than simply capitulate to, how Americans behave.

    We won’t be getting that winter this year, or likely any year soon. Many policies have already reverted to their 2019 status quo; by other metrics, the nation’s well-being even seems to have regressed. Life expectancy in the U.S. has fallen, especially among Native Americans and Alaskan Natives. Institutions of health are beleaguered; community-outreach efforts have been pruned.

    The pandemic has also prompted a deterioration of trust in several mainstays of public health. In many parts of the country, there’s worry that the vaccine hesitancy around COVID has “spread its tentacles into other diseases,” Hobbs told me, keeping parents from bringing their kids in for flu shots and other routine vaccines. Mississippi, once known for its stellar rate of immunizing children, now consistently ranks among those with the fewest young people vaccinated against COVID. “The one thing we do well is vaccinate children,” Hobbs said. That the coronavirus has reversed the trend “has astounded me.” In Montana, sweeping political changes, including legislation that bans employers from requiring vaccines of any kind, have made health-care settings less safe. Fewer than half of Madison County’s residents have received even their primary series of COVID shots, and “now a nurse can turn down the Hepatitis B series,” Bortko told me. Health workers, too, feel more imperiled than before. Since the start of the pandemic, Bortko’s own patients of 30 years, “who trusted me with their lives,” have pivoted to “yelling at us about vaccination concerns and mask mandates and quarantining and their freedoms,” she told me. “We have become public enemy No. 1.”

    Read: The pandemic’s soft closing

    At the same time, many people with chronic and debilitating conditions are more vulnerable than they were before the pandemic began. The policies that protected them during the pandemic’s height are gone—and yet SARS-CoV-2 is still here, adding to the dangers they face. The losses have been written off, Bortko told me: Cases of long COVID in Madison County have been dismissed as products of “risk factors” that don’t apply to others; deaths, too, have been met with a shrug of “Oh, they were old; they were unhealthy.” If, this winter, COVID sickens or kills more people who are older, more people who are immunocompromised, more people of color, more essential and low-income workers, more people in rural communities, “there will be no press coverage,” Hlatshwayo Davis said. Americans already expect that members of these groups will die.

    It’s not too late to change course. The winter’s path has not been set: Many Americans are still signing up for fall flu and COVID shots; we may luck out on the viral evolution front, too, and still be dealing largely with members of the Omicron clan for the next few months. But neither immunity nor a slowdown in variant emergence is a guarantee. What we can count on is the malleability of human behavior—what will help set the trajectory of this winter, and others to come. The U.S. botched the pandemic’s beginning, and its middle. That doesn’t mean we have to bungle its end, whenever that truly, finally arrives.

    Katherine J. Wu

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  • When’s the Perfect Time to Get a Flu Shot?

    When’s the Perfect Time to Get a Flu Shot?

    For about 60 years, health authorities in the United States have been championing a routine for at least some sector of the public: a yearly flu shot. That recommendation now applies to every American over the age of six months, and for many of us, flu vaccines have become a fixture of fall.

    The logic of that timeline seems solid enough. A shot in the autumn preps the body for each winter’s circulating viral strains. But years into researching flu immunity, experts have yet to reach a consensus on the optimal time to receive the vaccine—or even the number of injections that should be doled out.

    Each year, a new flu shot recipe debuts in the U.S. sometime around July or August, and according to the CDC the best time for most people to show up for an injection is about now: preferably no sooner than September, ideally no later than the end of October. Many health-care systems require their employees to get the shot in this time frame as well. But those who opt to follow the CDC current guidelines, as I recently did, then mention that fact in a forum frequented by a bunch of experts, as I also recently did, might rapidly hear that they’ve made a terrible, terrible choice.

    “There’s no way I would do what you did,” one virologist texted me. “It’s poor advice to get the flu vaccine now.” Florian Krammer, a virologist at Mount Sinai’s Icahn School of Medicine, echoed that sentiment in a tweet: “I think it is too early to get a flu shot.” When I prodded other experts to share their scheduling preferences, I found that some are September shooters, but others won’t juice up till December or later. One vaccinologist I spoke with goes totally avant-garde, and nabs multiple doses a year.

    Read: Should your flu and COVID shots go in different arms?

    There is definitely such a thing as getting a flu shot too early, as Helen Branswell has reported for Stat. After people get their vaccine, levels of antibodies rocket up, buoying protection against both infection and disease. But after only weeks, the number of those molecules begins to steadily tick downward, raising people’s risk of developing a symptomatic case of flu by about 6 to 18 percent, various studies have found. On average, people can expect that a good portion of their anti-flu antibodies “are meaningfully gone by about three or so months” after a shot, says Lauren Rodda, an immunologist at the University of Washington.

    That decline is why some researchers, Krammer among them, think that September and even October shots could be premature, especially if flu activity peaks well after winter begins. In about three-quarters of the flu seasons from 1982 to 2020, the virus didn’t hit its apex until January or later. Krammer, for one, told me that he usually waits until at least late November to dose up. Stanley Plotkin, a 90-year-old vaccinologist and vaccine consultant, has a different solution. People in his age group—over 65—don’t respond as well to vaccines in general, and seem to lose protection more rapidly. So for the past several years, Plotkin has doubled up on flu shots, getting one sometime before Halloween and another in January, to ensure he’s chock-full of antibodies throughout the entire risky, wintry stretch. “The higher the titers,” or antibody levels, Plotkin told me, “the better the efficacy, so I’m trying to take advantage of that.” (He made clear to me that he wasn’t “making recommendations for the rest of the world”—just “playing the odds” given his age.)

    Data on doubling up is quite sparse. But Ben Cowling, an epidemiologist and flu researcher at Hong Kong University, has been running a years-long study to figure out whether offering two vaccines a year, separated by roughly six months, could keep vulnerable people safe for longer. His target population is Hong Kongers, who often experience multiple annual flu peaks, one seeded by the Northern Hemisphere’s winter wave and another by the Southern Hemisphere’s. So far, “getting that second dose seems to give you additional protection,” Cowling told me, “and it seems like there’s no harm of getting vaccinated twice a year,” apart from the financial and logistical cost of a double rollout.

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

    In the U.S., though, flu season is usually synonymous with winter. And the closer together two shots are given, the more blunted the effects of the second injection might be: People who are already bustling with antibodies may obliterate a second shot’s contents before the vaccine has a chance to teach immune cells anything new. That might be why several studies that have looked at double-dosing flu shots within weeks of each other “showed no benefit” in older people and certain immunocompromised groups, Poland told me. (One exception? Organ–transplant recipients. Kids getting their very first flu shot are also supposed to get two of them, four weeks apart.)

    Even at the three-ish-month mark past vaccination, the body’s anti-flu defenses don’t reset to zero, Rodda told me. Shots shore up B cells and T cells, which can survive for many months or years in various anatomical nooks and crannies. Those arsenals are especially hefty in people who have banked a lifetime of exposures to flu viruses and vaccines, and they can guard people against severe disease, hospitalization, and death, even after an antibody surge has faded. A recent study found that vaccine protection against flu hospitalizations ebbed by less than 10 percent a month after people got their shot, though the rates among adults older than 65 were a smidge higher. Still other numbers barely noted any changes in post-vaccine safeguards against symptomatic flu cases of a range of severities, at least within the first few months. “I do think the best protection is within three months of vaccination,” Cowling told me. “But there’s still a good amount by six.”

    For some young, healthy adults, a decent number of flu antibodies may actually stick around for more than a year. “You can test my blood right now,” Rodda told me. “I haven’t gotten vaccinated just yet this year, and I have detectable titers.” Ali Ellebedy, an immunologist at Washington University in St. Louis, told me he has found that some people who have regularly received flu vaccines have almost no antibody bump when they get a fresh shot: Their blood is already hopping with the molecules. Preexisting immunity also seems to be a big reason that nasal-spray-based flu vaccines don’t work terribly well in adults, whose airways have hosted far more flu viruses than children’s.

    Getting a second flu shot in a single season is pretty unlikely to hurt. But Ellebedy compares it to taking out a second insurance policy on a car that’s rarely driven: likely of quite marginal benefit for most people. Plus, because it’s not a sanctioned flu-vaccine regimen, pharmacists might be reluctant to acquiesce, Poland pointed out. Double-dosing probably wouldn’t stand much of a chance as an official CDC recommendation, either. “We do a bad enough job,” Poland said, getting Americans to take even one dose a year.

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

    That’s why the push to vaccinate in late summer and early fall is so essential for the single shot we currently have, says Huong McLean, a vaccine researcher at the Marshfield Clinic Research Institute in Wisconsin. “People get busy, and health systems are making sure that most people can get protected before the season starts,” she told me. Ellebedy, who’s usually a September vaccinator, told me he “doesn’t see the point of delaying vaccination for fear of having a lower antibody level in February.” Flu seasons are unpredictable, with some starting as early as October, and the viruses aren’t usually keen on giving their hosts a heads-up. That makes dillydallying a risk: Put the shot off till November or December, and “you might get infected in between,” Ellebedy said—or simply forget to make an appointment at all, especially as the holidays draw near.

    In the future, improvements to flu-shot tech could help cleave off some of the ambiguity. Higher doses of vaccine, which are given to older people, could rile up the immune system to a greater degree; the same could be true for more provocative vaccines, made with ingredients called adjuvants that trip more of the body’s defensive sensors. Injections such as those seem to “maintain higher antibody titers year-round,” says Sophie Valkenburg, an immunologist at Hong Kong University and the University of Melbourne—a trend that Ellebedy attributes to the body investing more resources in training its fighters against what it perceives to be a larger threat. Such a switch would likely come with a cost, though, McLean said: Higher doses and adjuvants “also mean more adverse events, more reactions to the vaccine.”

    For now, the only obvious choice, Rodda told me, is to “definitely get vaccinated this year.” After the past two flu seasons, one essentially absent and one super light, and with flu-vaccination rates still lackluster, Americans are more likely than not in immunity deficit. Flu-vaccination rates have also ticked downward since the coronavirus pandemic began, which means there may be an argument for erring on the early side this season, if only to ensure that people reinforce their defenses against severe disease, Rodda said. Plus, Australia’s recent flu season, often a bellwether for ours, arrived ahead of schedule.

    Even so, people who vaccinate too early could end up sicker in late winter—in the same way that people who vaccinate too late could end up sicker now. Plotkin told me that staying apprised of the epidemiology helps: “If I heard influenza outbreaks were starting to occur now, I would go and get my first dose.” But timing remains a gamble, subject to the virus’s whims. Flu is ornery and unpredictable, and often unwilling to be forecasted at all.

    Katherine J. Wu

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  • ‘It Just Seems Like My Patients Are Sicker’

    ‘It Just Seems Like My Patients Are Sicker’

    The most haunting memory of the pandemic for Laura, a doctor who practices internal medicine in New York, is a patient who never got COVID at all. A middle-aged man diagnosed with Stage 3 colon cancer in 2019, he underwent surgery and a round of successful chemotherapy and was due for regular checkups to make sure the tumor wasn’t growing. Then the pandemic hit, and he decided that going to the hospital wasn’t worth the risk of getting COVID. So he put it off … and put it off. “The next time I saw him, in early 2022, he required hospice care,” Laura told me. He died shortly after. With proper care, Laura said, “he could have stayed alive indefinitely.” (The Atlantic agreed to withhold Laura’s last name, because she isn’t authorized to speak publicly about her patients.)

    Early in the pandemic, when much of the country was in lockdown, forgoing nonemergency health care as Laura’s patient did seemed like the right thing to do. But the health-care delays didn’t just end when America began to reopen in the summer of 2020. Patients were putting off health care through the end of the first pandemic year, when vaccines weren’t yet widely available. And they were still doing so well into 2021, at which point much of the country seemed to be moving on from COVID.

    By this point, the coronavirus has killed more than 1 million Americans and debilitated many more. One estimate shows that life expectancy in the U.S. fell 2.41 years from 2019 to 2021. But the delays in health care over the past two and a half years have allowed ailments to unduly worsen, wearing down people with non-COVID medical problems too. “It just seems like my patients are sicker,” Laura said. Compared with before the pandemic, she is seeing more people further along with AIDS, more people with irreversible heart failure, and more people with end-stage kidney failure. Mental-health issues are more severe, and her patients struggling with addiction have been more likely to relapse.

    Even as Americans are treating the pandemic like an afterthought, a disturbing possibility remains: COVID aside, is the country simply going to be in worse health than before the pandemic? According to health-care workers, administrations, and researchers I talked with from across the country, patients are still dealing with a suite of problems from delaying care during the pandemic, problems that in some cases they will be facing for the rest of their lives. The scope of this damage isn’t yet clear—and likely won’t come into focus for several years—but there are troubling signs of a looming chronic health crisis the country has yet to reckon with. At some point, the emergency phase of COVID will end, but the physical toll of the pandemic may linger in the bodies of Americans for decades to come.

    During those bleak pre-vaccine dark ages, going to the doctor could feel like a disaster in waiting. Many of the country’s hospitals were overwhelmed with COVID patients, and outpatient clinics had closed. As a result, in every week through July 2020, roughly 45 percent of American adults said that over the preceding month, they either put off medical care or didn’t get it at all because of the pandemic. Once they did come in, they were sicker—a trend observed for all sorts of ailments, including childhood diabetes, appendicitis, and cancer. A recent study analyzed the 8.4 million non-COVID Medicare hospitalizations from April 2020 to September 2021 and found not only that hospital admissions plummeted, but also that those admitted to hospitals were up to 20 percent more likely to die—an astonishing effect that lasted through the length of the study.

    Partly, that result came about because only those who were sicker made it to the hospital, James Goodwin, one of the study’s authors and a professor at the University of Texas Medical Branch, in Galveston, told me. It was also partly because overwhelmed hospitals were giving worse care. But Goodwin estimates that “more than half the cause was people delaying medical care early in their illness and therefore being more likely to die. Instead of coming in with a urinary tract infection, they’re already getting septic. I mean, people were having heart attacks and not showing up at the hospital.”

    Read: America is sliding into the long pandemic defeat

    For some conditions, skipping a checkup or two may not matter all that much in the long run. But for other conditions, every doctor’s visit can count. Take the tens of millions of Americans with vascular issues in their feet and legs due to diabetes or peripheral artery disease. Their problems might lead to, say, ulcers on the foot that can be treated with regular medical care, but delays of even a few months can increase the risk of amputation. When patients came in later in 2020, it was sometimes too late to save the limb. An Ohio trauma center found that the odds of undergoing a diabetes-related amputation in 2020 were almost 11 times higher once the pandemic hit versus earlier in the year.

    Although only a small percentage of Americans lost a limb, the lack of care early in the pandemic helped fuel a dangerous spike in substance-abuse disorders. In a matter of weeks or months, people’s support systems collapsed, and for some, years of work overcoming an addiction unraveled. “My patients took a huge step back, probably more than many of us realize,” Aarti Patel, a physician assistant at a Lower Manhattan community hospital, told me. One of her patients, a man in his late 50s who was five years sober, started drinking again during the pandemic and eventually landed in the hospital for withdrawal. Patients like this man, she said, “would have really difficult, long hospital stays, because they were at really high risk of DTs, alcohol seizures. Some of them even had to go to the ICU because [the withdrawal] was so severe.”

    Later in the year, when doctors’ offices were up and running, “a lot of patients expressed that they didn’t want to go back for care right away,” says Kim Muellers, a graduate student at Pace University who is studying the effects of COVID on medical care in New York City, North Carolina, and Florida. Indeed, through the spring of 2021, the top reason Medicare recipients failed to seek care was they didn’t want to be at a medical facility. Other people were avoiding the doctor because they’d lost their job and health insurance and couldn’t afford the bills.

    The problem, doctors told me, is that all of those missed appointments start to add up. Patients with high blood pressure or blood sugar, for example, may now be less likely to have their conditions under control—which after enough time can lead to all sorts of other ailments. Losing a limb can pose challenges for patients that will last for the rest of their lives. Relapses can put people at a higher risk for lifelong medical complications. Cancer screenings plummeted, and even a few weeks without treatment can increase the chance of dying from the disease. In other words, even short-term delays can cause long-term havoc.

    Read: How long can the coronavirus keep reinfecting us?

    To make matters worse, the health-care delays fueling a sicker America may not be totally over yet, either. After so many backups, some health-care systems, hobbled by workforce shortages, are scrambling to address the pent-up demand for care that patients can simply no longer put off, according to administrators and doctors from several major health systems, including Cleveland Clinic, the Veterans Health Administration, and Mayo Clinic. Disruptions in the global supply chain are forcing doctors to ration basic supplies, adding to backlogs. Amy Oxentenko, a gastroenterologist at Mayo Clinic in Arizona who helps oversee clinical practice across the entire Mayo system, says that “all of these things are just adding up to a continued delay, and I think we’ll see impacts for years to come.”

    It’s still early, and not everything that providers told me is necessarily showing up in the data. Oddly enough, the CDC’s National Health Interview Survey found that most Americans were able to see a doctor at least once during the first year of the pandemic. And the same survey has not revealed any uptick in most health conditions, including asthma episodes, high blood pressure, and chronic pain—which might be expected if America were getting sicker.

    It’s even conceivable that the disturbing observations of clinicians are a statistical illusion. If for whatever reason only sicker people are now being seen by—or able to access—a doctor, then it can be true both that providers are seeing more seriously ill patients in medical facilities and that the total number of seriously ill people in the community is staying the same. The scope of the damage just isn’t yet clear: Maybe a smaller number of people will be worse off because of delayed cancer care or substance-abuse relapses, or maybe far more people—more than tens of million of Americans—will be dealing with exacerbated issues for the rest of their lives.

    None of this accounts for what COVID itself is doing to Americans, of course. The health-care system is only beginning to grapple with the ways in which a past bout with COVID is a long-term risk for overall health, or the extent to which long COVID can complicate other conditions. The pandemic may feel “over” for lots of Americans, but many who made it through the gantlet of the past two-plus years may end up living sicker, and dying sooner.

    This disturbing prospect is not only poised to further devastate communities; it’s also bad news for health-care workers already exhausted by COVID. Laura, the Manhattan internist who treated the colon-cancer patient, told me it’s disheartening to see so many people showing up at irreversible points in their disease. “As doctors,” she said, “our overall batting average is going down.” Aarti Patel, the physician assistant, put it in blunter terms: “Burnout is probably too simple a term. We’re in severe moral distress.”

    Nothing about this grim fate was inevitable. Laura told me that “going to the doctor mid-pandemic may have posed a small risk in terms of COVID, but not going was risky in terms of letting disease go unchecked. And in retrospect it seems that many people didn’t quite get that.” But there didn’t have to be such a stark trade-off between fighting a pandemic and maintaining health care for other medical conditions.

    Some hospitals—at least the better-resourced ones—figured out how to avoid the worst kind of delays. Mayo Clinic, for example, is one of a number of systems with a sophisticated triage algorithm that prioritizes patients needing acute care. In the spring of 2021, Cleveland Clinic launched a massive outreach blitz to schedule some 86,000 appointments, according to Lisa Yerian, the chief improvement officer. And the Veterans Health Administration provided iPads to thousands of veterans who lacked other means of accessing the internet in the spring of 2020, ensuring a more seamless transition to virtual care, Joe Francis, who directs health-care analytics, told me. Thanks in part to these efforts, Francis said, high-risk patients at the VHA were being seen at pre-pandemic levels a mere six months into the pandemic.

    These health-care systems also suggest a path forward. America may still be able to stave off the worst of the collateral damage by reaching the patients who have fallen through the cracks—and already the data suggest that these patients tend to be disproportionately Black, Hispanic, and low-income. Tragically, it’s too late for some Americans: People who died of cancer can’t come back to life; amputated limbs can’t regrow. Others still have plenty of time. Hypertension that’s currently uncontrolled can be tamped down before causing an early heart attack; drinking that’s gotten out of hand can be corralled before it leads to liver failure in a decade; undetected tumors can be spotted in time for treatment. An uptick in premature death and disability, summed over millions of Americans, could strain the health-care system for years. But it’s still possible to prevent an acute public-health crisis from seeding an even bigger chronic one.

    Tim Requarth

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