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Tag: infectious-disease modeler

  • How Bad Are America’s COVID-Vaccination Rates?

    How Bad Are America’s COVID-Vaccination Rates?

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    Relatively speaking, 2023 has been the least dramatic year of COVID living to date. It kicked off with the mildest pandemic winter on record, followed by more than seven months of quietude. Before hospitalizations started to climb toward their September mini-spike, the country was in “the longest period we’ve had without a peak during the entire pandemic,” Shaun Truelove, an infectious-disease modeler at Johns Hopkins University, told me. So maybe it’s no surprise that, after a year of feeling normalish, most American adults simply aren’t that worried about getting seriously sick this coming winter.

    They also are not particularly eager to get this year’s COVID shot. According to a recent CDC survey, just 7 percent of adults and 2 percent of kids have received the fall’s updated shot, as of October 14; at least another 25 percent intends to nab a shot for themselves or their children but haven’t yet. And even those lackluster stats could be an overestimate, because they’re drawn from the National Immunization Surveys, which is done by phone and so reflects the answers of people willing to take federal surveyors’ calls. Separate data collected by the CDC, current as of October 24, suggest that only 12 million Americans—less than 4 percent of the population—have gotten the new vaccine, according to Dave Daigle, the associate director for communications at the CDC’s Center for Global Health.

    CDC Director Mandy Cohen still seems optimistic that the country will come close to the uptake rates of last autumn, when 17 percent of Americans received the updated bivalent vaccine. But for that to happen, Americans would have to maintain or exceed their current immunization clip—which Gregory Poland, a vaccine expert at Mayo Clinic, told me he isn’t betting on. (Already, he’s worried about the possible dampening effect of new data suggesting that getting flu and COVID shots simultaneously might slightly elevate the risk of stroke for older people.) As things stand, the United States could be heading into the winter with the fewest people recently vaccinated against COVID-19 since the end of 2020, when most people didn’t yet have the option to sign up at all.

    This winter is highly unlikely to reprise that first one, when most of the population had no immunity, tests and good antivirals were scarce, and hospitals were overrun. It’s more likely to be an encore of this most recent winter, with its relative calm. But that’s not necessarily a comfort. If that winter was a kind of uncontrolled experiment in the damage COVID could do when unchecked, this one could codify that experiment into a too-complacent routine that cements our tolerance for suffering—and leaves us vulnerable to more.

    To be fair, this year’s COVID vaccines have much been harder to get. With the end of the public-health emergency, the private sector is handling most distribution—a transition that’s made for a more uneven, chaotic rollout. In the weeks after the updated shot was cleared for use, many pharmacies were forced to cancel vaccination appointments or turn people away because of inadequate supply. At one point, Jacinda Abdul-Mutakabbir, an infectious-disease pharmacist at UC San Diego, who’s been running COVID and flu vaccination in her local community, was emailing her county’s office three times a week, trying to get vaccine vials. Even when vaccines have been available, many people have been dismayed to find they need to pay out of pocket for the cost. (Most people, regardless of insurance status, are supposed to be able to receive a free COVID-19 vaccine.)

    [Read: Fall’s vaccine routine didn’t have to be this hard]

    The vaccine is now easier to find, in many places; insurance companies, too, seem to be fixing the kinks in compensation. But Abdul-Mutakabbir told me she worries that many of the people who were initially turned away may simply never come back. “You lose that window of opportunity,” she told me. Even people who haven’t gotten their autumn shot may be hesitating to try if they expect access to be difficult, as the emergency physician Jeremy Faust points out in his Inside Medicine newsletter.

    Plus, because the rollout started later this year than in 2022, many people ended up infected before they could get vaccinated and may now be holding off on the shot—or skipping it entirely. And some Americans have simply decided against getting the shot. The CDC reported that 38 percent don’t plan to vaccinate themselves or their children; earlier this fall, more than half of respondents in a Kaiser Family Foundation poll said they probably or definitely wouldn’t be signing up themselves or their kids. More than 40 percent of those polled by KFF remain doubtful, too, that COVID shots are safe—dwarfing the numbers of people worried about flu shots, and even about RSV shots, which are newer than their COVID counterparts.

    The consequences of low COVID-vaccine uptake are hard to parse. This year, like last year, most Americans have been vaccinated, infected, or both, many of them quite recently. COVID’s average severity has, for many months, been at a relatively consistent low. The last catastrophic SARS-CoV-2 variant—one immune-evasive enough to spark a massive wave of sickness, death, and long COVID—arrived two years ago. Barring another feat of viral evolution, perhaps these dynamics have reached something like a stable state, Justin Lessler, an infectious-disease modeler at the University of North Carolina at Chapel Hill, told me. So maybe the most likely scenario is a close repeat of last winter: a rise in hospitalizations and deaths that’s ultimately far more muted than any earlier in the outbreak. And the COVID-19 Scenario Modeling Hub, which Lessler co-leads alongside Truelove and a large cohort of other researchers, projects that “next year will look a lot like this year, whatever this year ends up looking like,” Lessler said.

    But predictability is distinct from peace. COVID has still been producing roughly twice the annual mortality that flu does; roughly 17,000 people are being hospitalized for the disease each week. SARS-CoV-2 infections also still carry a risk, far higher than flu’s, of debilitating some people for years. “And I do think we’re going to experience a winter increase,” Truelove told me. Even if this year’s COVID-vaccine uptake were to climb above 30 percent, models suggest that January hospitalizations could rival numbers from early 2023. Go much lower than that, and several scenarios point to outcomes being worse.

    Based on the limited data available, at least one trend is mildly encouraging: Adults 75 and older, the age demographic most vulnerable to COVID and that stands to benefit most from annual shots, also have the highest vaccine uptake so far, at about 20 percent. At the same time, Katelyn Jetelina, the epidemiologist who writes the popular Your Local Epidemiologist newsletter, points out that CDC data suggest that only 8 percent of nursing-home residents are up to date on their COVID shots. “That is what keeps me up at night,” Jetelina told me. Early National Immunization Surveys data also suggest that uptake is lagging among other groups that might fare less well against COVID—among them, rural populations, Hispanic people, American Indians and Alaskan Natives, the uninsured, and people living below the poverty line.

    Last winter was widely considered to be a bullet dodged, and the reactions to the coming months may be similar: At least it’s no longer that bad. Since the winter of Omicron, the country has been living with lower vaccine uptake while experiencing lower COVID peaks. But those lower peaks shouldn’t undermine the importance of vaccines. Infection-induced immunity, past vaccinations, improvements in treatments, and other factors have combined to make COVID look like a gentler disease. Add more recent vaccination to that mix, and many of those gains would likely be enhanced, keeping immunity levels up without the risks of illness or passing the virus to someone else.

    [Read: The one thing everyone should know about fall COVID vaccines]

    As relatively “okay” as this past year-plus has been, it could have been better. Missed vaccinations still translate into more days spent suffering, more chronic illnesses, more total lives lost—an enormous burden to put on an already stressed health-care system, Jetelina told me. For the flu, more Americans act as if they understand this relationship: This year, as of November 1, nearly 25 percent of American adults, and more than 20 percent of American kids, have gotten their fall flu shot. Most of the experts I spoke with would be surprised to see such rates for COVID vaccines even at the end of this rollout.

    If last winter was a preview of future COVID winters, our behaviors, too, could predict the patterns we’ll follow going forward. We may not be slammed with the next terrible variant this year, or the next, or the next. When one does arrive, though, as chances are it will, the precedent we’re setting now may leave us particularly unprepared. At that point, people may be years out from their most recent COVID shot; whole swaths of babies and toddlers may have yet to receive their first dose. Some of us may still have some immunity from recent infections, sure—but it won’t be the same as dosing up right before respiratory-virus season with protection that’s both reliable and safe. Systems once poised to deliver COVID vaccines en masse may struggle to meet demand. Or maybe the public will be slow to react to the new emergency at all. Our choices now “will be self-reinforcing,” Poland told me. We still won’t be doomed to repeat our first full COVID winter. But we may get closer than anyone cares to endure.

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    Katherine J. Wu

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  • One More COVID Summer?

    One More COVID Summer?

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    Since the pandemic’s earliest days, epidemiologists have been waiting for the coronavirus to finally snap out of its pan-season spree. No more spring waves like the first to hit the United States in 2020, no more mid-year surges like the one that turned Hot Vax Summer on its head. Eventually, or so the hope went, SARS-CoV-2 would adhere to the same calendar that many other airway pathogens stick to, at least in temperate parts of the globe: a heavy winter peak, then a summer on sabbatical.

    But three and a half years into the outbreak, the coronavirus is still stubbornly refusing to take the warmest months off. Some public-health experts are now worried that, after a relatively quiet stretch, the virus is kick-starting yet another summer wave. In the southern and northeastern United States, concentrations of the coronavirus in wastewater have been slowly ticking up for several weeks, with the Midwest and West now following suit; test-positivity rates, emergency-department diagnoses of COVID-19, and COVID hospitalizations are also on the rise. The absolute numbers are still small, and they may stay that way. But these are the clear and early signs of a brewing mid-year wave, says Caitlin Rivers, an epidemiologist at Johns Hopkins University—which would make this the fourth summer in a row with a distinct coronavirus bump.

    Even this far into the pandemic, though, no one can say for certain whether summer waves are a permanent COVID fixture—or if the virus exhibits a predictable seasonal pattern at all. No law of nature dictates that winters must come with respiratory illness, or that summers will not. “We just don’t know very much about what drives the cyclical patterns of respiratory infections,” says Sam Scarpino, an infectious-disease modeler at Northeastern University. Which means there’s still no part of the year when this virus is guaranteed to cut us any slack.

    That many pathogens do wax and wane with the seasons is indisputable. In temperate parts of the world, airborne bugs get a boost in winter, only to be stifled in the heat; polio and other feces-borne pathogens, meanwhile, often rise in summer, along with gonorrhea and some other STIs. But noticing these trends is one thing; truly understanding the triggers is another.

    Read: COVID sure looks seasonal now

    Some diseases lend themselves a bit more easily to explanation: Near the equator, waves of mosquito-borne illness, such as Zika and Chikungunya, tend to be tied to the weather-dependent life cycles of the insects that carry them; in temperate parts of the world, rates of Lyme disease track with the summertime activity of ticks. Flu, too, has pretty strong data to back its preference for wintry months. The virus—which is sheathed in a fragile, fatty layer called an envelope and travels airborne via moist drops—spreads best when it’s cool and dry, conditions that may help keep infectious particles intact and spittle aloft.

    The coronavirus has enough similarities to flu that most experts expect that it will continue to spread in winter too. Both viruses are housed in a sensitive skin; both prefer to move by aerosol. Both are also relatively speedy evolvers that don’t tend to generate long-lasting immunity against infection—factors conducive to repeat waves that hit populations at a fairly stable clip. For those reasons, Anice Lowen, a virologist at Emory University, anticipates that SARS-CoV-2 will continue to show “a clear wintertime seasonality in temperate regions of the world.” Winter is also a time when our bodies can be more susceptible to respiratory bugs: Cold, dry air can interfere with the movement of mucus that shuttles microbes out of the nose and throat; aridity can also make the cells that line those passageways shrivel and die; certain immune defenses might get a bit sleepier, with vitamin D in shorter supply.

    None of that precludes SARS-CoV-2 spread in the heat, even if experts aren’t sure why the virus so easily drives summer waves. Plenty of other microbes manage it: enteroviruses, polio, and more. Even rhinoviruses and adenoviruses, two of the most frequent causes of colds, tend to spread year-round, sometimes showing up in force during the year’s hottest months. (Many scientists presume that has something to do with these viruses’ relatively hardy outer layer, but the reason is undoubtedly more complex than that.) An oft-touted explanation for COVID’s summer waves is that people in certain parts of the country retreat indoors to beat the heat. But that argument alone “is weak,” Lowen told me. In industrialized nations, people spend more than 90 percent of their time indoors.

    That said, an accumulation of many small influences can together create a seasonal tipping point. Summer is a particularly popular time for travel, often to big gatherings. Many months out from winter and its numerous infections and vaccinations, population immunity might also be at a relative low at this time of year, Rivers said. Plus, for all its similarities to the flu, SARS-CoV-2 is its own beast: It has so far affected people more chronically and more severely, and has generated population-sweeping variants at a far faster pace. Those dynamics can all affect when waves manifest.

    And although certain bodily defenses do dip in the cold, data don’t support the idea that immunity is unilaterally stronger in the summer. Micaela Martinez, the director of environmental health at WE ACT for Environmental Justice, in New York, told me the situation is far more complicated than that. For years, she and other researchers have been gathering evidence that suggests that our bodies have distinctly seasonal immunological profiles—with some defensive molecules spiking in the summer and another set in winter. The consequences of those shifts aren’t yet apparent. But some of them could help explain when the coronavirus spreads. By the same token, winter is not a time of disease-ridden doom. Xaquin Castro Dopico, an immunologist at the Karolinska Institute, in Sweden, has found that immune systems in the Northern Hemisphere might be more inflammation-prone in the winter—which, yes, could make certain bouts of illness more severe but could also improve responses to certain vaccinations.

    All of those explanations could apply to COVID’s summer swings—or perhaps none does. “Everybody always wants to have a very simple seasonal answer,” Martinez told me. But one may simply not exist. Even the reasons for the seasonality of polio, a staunch summertime disease prior to its elimination in the U.S., have been “an open question” for many decades, Martinez told me.

    Rivers is hopeful that the coronavirus’s permanent patterns may already be starting to peek through: a wintry heyday, and a smaller maybe-summer hump. “We’re in year four, and we’re seeing the same thing year over year,” she told me. But some experts worry that discussions of COVID-19 seasonality are premature. SARS-CoV-2 is still so fresh to the human population that its patterns could be far from their final form. At an extreme, the patterns researchers observed during the first few years of the pandemic may not prelude the future much at all, because they encapsulate so much change: the initial lack and rapid acquisition of immunity, the virus’s evolution, the ebb and flow of masks, and more. Amid that mishmash of countervailing influences, says Brandon Ogbunu, an infectious-disease modeler at Yale, “you’re going to get some counterintuitive dynamics” that won’t necessarily last long term.

    Read: The next stage of COVID is starting now

    With so much of the world now infected, vaccinated, or both, and COVID mitigations almost entirely gone, the global situation is less in flux now. The virus itself, although still clearly changing at a blistering pace, has not pulled off an Omicron-caliber jump in evolution for more than a year and a half. But no one can yet promise predictability. The cadence of vaccination isn’t yet settled; Scarpino, of Northeastern University, also isn’t ready to dismiss the idea of a viral evolution surprise. Maybe summer waves, to the extent that they’re happening, are a sign that SARS-CoV-2 will remain a microbe for all seasons. Or maybe they’re part of the pandemic’s death rattle—noise in a system that hasn’t yet quieted down.

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    Katherine J. Wu

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  • Will COVID’s Spring Lull Last?

    Will COVID’s Spring Lull Last?

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    By all official counts—at least, the ones still being tallied—the global situation on COVID appears to have essentially flatlined. More than a year has passed since the world last saw daily confirmed deaths tick above 10,000; nearly a year and a half has elapsed since the population was pummeled by a new Greek-lettered variant of concern. The globe’s most recent winters have been the pandemic’s least lethal to date—and the World Health Organization is mulling lifting its COVID emergency declaration sometime later this year, as the final pandemic protections in the United States prepare to disappear. On the heels of the least-terrible winter since the pandemic’s onset, this spring in the U.S. is also going … kind of all right. “I am feeling less worried than I have been in a while,” Shweta Bansal, an infectious-disease modeler at Georgetown University, told me.

    That sense of phew, though, Bansal said, feels tenuous. The coronavirus’s evolution is not yet predictable; its effects are nowhere near benign. This might be the longest stretch of quasi-normalcy that humanity has had since 2020’s start, but experts can’t yet tell whether we’re at the beginning of post-pandemic stability or in the middle of a temporary reprieve. For now, we’re in a holding pattern, a sort of extended coda or denouement. Which means that our lived experience and scientific reality might not match up for a good while yet.

    Read: The next stage of COVID is starting now

    There is, to be fair, reason to suspect that some current trends will stick. The gargantuan waves of seasons past were the rough product of three factors: low population immunity, genetic changes that allowed SARS-CoV-2 to skirt what immunity did exist, and upswings in behaviors that brought people and the virus into frequent contact. Now, though, just about everyone has had some exposure to SARS-CoV-2’s spike protein, whether by infection or injection. And most Americans have long since dispensed with masking and distancing, maintaining their exposure at a consistently high plateau. That leaves the virus’s shape-shifting as the only major wild card, says Emily Martin, an infectious-disease epidemiologist at the University of Michigan. SARS-CoV-2 could, for instance, make another evolutionary leap large enough to re-create the Omicron wave of early 2022—but a long time has passed since the virus managed such a feat. Tentatively, carefully, experts are hopeful that we’re at last in a “period that could be kind of indicative of what the new normal really is,” says Virginia Pitzer, an infectious-disease epidemiologist at Yale.

    Top American officials are already gambling on that guess. At a conference convened in late March by the Massachusetts Medical Society, Ashish Jha, the outgoing coordinator of the White House COVID-19 Response Team, noted that the relative tameness of this past winter was a major deciding factor in the Biden administration’s decision to let the U.S. public-health emergency lapse. The crisis-caliber measures that were essential at the height of the pandemic, Jha said, were no longer “critical at this moment” to keep the nation’s health-care system afloat. Americans could rely instead primarily on shots and antivirals to keep themselves healthy—“If you are up to date on your vaccines and you get treated with Paxlovid, if you get an infection, you just don’t die of this virus,” he said. (That math, of course, doesn’t hold up as well for certain vulnerable groups, including the elderly and the immunocompromised.) The pharmaceuticals-only strategy asks much less of people: Going forward, most Americans will need to dose up on their COVID vaccines only once a year in the fall, a la seasonal flu shots.

    Making sweeping assessments at this particular juncture, though, is tough. Experts expect SARS-CoV-2 cases to take a downturn as winter transitions into spring—as many other respiratory viruses do. And a half-ish year of relative quietude is, well, just a half-ish year of relative quietude—too little data for scientists to definitively declare the virus seasonal, or even necessarily stable in its annual patterns. One of the most telling intervals is yet to come: the Northern Hemisphere’s summer, says Alyssa Bilinski, a health-policy researcher at Brown University. In previous years, waves of cases have erupted pretty consistently during the warmer months, especially in the American South, as people flock indoors to beat the heat.

    SARS-CoV-2 might not end up being recognizably seasonal at all. So far, the virus has circulated more or less year-round, with erratic bumps in the winter and, to a lesser extent, the summer. “There is a consistency there that is very enticing,” Bansal told me. But many of the worst surges we’ve weathered were driven by a lack of immunity, which is less of an issue now. “So I like to be extremely careful about the seasonality argument,” she said. In future years, the virus may break from its summer-winter shuffle. How SARS-CoV-2 will continue to interact with other respiratory viruses, such as RSV and flu, also remains to be seen. After an extended hiatus, driven largely by pandemic mitigations, those pathogens came roaring back this past autumn—making it more difficult, perhaps, for the coronavirus to find unoccupied hosts. Experts can’t yet tell whether future winters will favor the coronavirus or its competitors. Either way, scientists won’t know until they’ve collected several more years of evidence—“I would want at least a handful, like four or five,” Bansal said.

    Amassing those numbers is only getting tougher, though, as data streams dry up, Martin told me. Virus-surveillance systems are being dismantled; soon, hospitals and laboratories will no longer be required to share their COVID data with federal officials. Even independent trackers have sunsetted their regular updates. Especially abysmal are estimates of total infections, now that so many people are using only at-home tests, if they’re testing at all—and metrics such as hospitalization and death don’t fully reflect where and when the virus is moving, and which new variants may be on the rise.

    Shifts in long-term approaches to virus control could also upend this period of calm. As tests, treatments, and vaccines become privatized, as people lose Medicaid coverage, as community-outreach programs fight to stay afloat, the virus will find the country’s vulnerable pockets again. Those issues aren’t just about the coming months: COVID-vaccination rates among children remain worryingly low—a trend that could affect the virus’s transmission patterns for decades. And should the uptake of annual COVID shots continue on its current trajectory—worse, even, than America’s less-than-optimal flu vaccination rates—or dip even further down, rates of severe disease may begin another upward climb. Experts also remain concerned about the ambiguities around long COVID, whose risks remain ill-defined.

    Read: Long COVID is being erased—again

    We could get lucky. Maybe 2023 is the start of a bona fide post-pandemic era; maybe the past few months are genuinely offering a teaser trailer of decades to come. But even if that’s the case, it’s not a full comfort. COVID remains a leading cause of death in the United States, where the virus continues to kill about 200 to 250 people each day, many of them among the population’s most vulnerable and disenfranchised. It’s true that things are better than they were a couple of years ago. But in some ways, that’s a deeply unfair comparison to make. Deaths would have been higher when immunity was low; vaccines, tests, and treatments were scarce; and the virus was far less understood. “I would hope our standard for saying that we’ve succeeded and that we don’t need to do more is not Are we doing better than some of the highest-mortality years in history?” Bilinski told me. Perhaps the better question is why we’re settling for the status quo—a period of possible stability that may be less a relief and more a burden we’ve permanently stuck ourselves with.

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    Katherine J. Wu

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  • The COVID Question That Will Take Decades to Answer

    The COVID Question That Will Take Decades to Answer

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    To be a newborn in the year 2023—and, almost certainly, every year that follows—means emerging into a world where the coronavirus is ubiquitous. Babies might not meet the virus in the first week or month of life, but soon enough, SARS-CoV-2 will find them. “For anyone born into this world, it’s not going to take a lot of time for them to become infected,” maybe a year, maybe two, says Katia Koelle, a virologist and infectious-disease modeler at Emory University. Beyond a shadow of a doubt, this virus will be one of the very first serious pathogens that today’s infants—and all future infants—meet.

    Three years into the coronavirus pandemic, these babies are on the leading edge of a generational turnover that will define the rest of our relationship with SARS-CoV-2. They and their slightly older peers are slated to be the first humans who may still be alive when COVID-19 truly hits a new turning point: when almost everyone on Earth has acquired a degree of immunity to the virus as a very young child.

    Read: Is COVID a common cold yet?

    That future crossroads might not sound all that different from where the world is currently. With vaccines now common in most countries and the virus so transmissible, a significant majority of people have some degree of immunity. And in recent months, the world has begun to witness the consequences of that shift. The flux of COVID cases and hospitalizations in most countries seems to be stabilizing into a seasonal-ish sine wave; disease has gotten, on average, less severe, and long COVID seems to be somewhat less likely among those who have recently gotten shots. Even the virus’s evolution seems to be plodding, making minor tweaks to its genetic code, rather than major changes that require another Greek-letter name.

    But today’s status quo may be more of a layover than a final destination in our journey toward COVID’s final form. Against SARS-CoV-2, most little kids have fared reasonably well. And as more babies have been born into a SARS-CoV-2-ridden world, the average age of first exposure to this coronavirus has been steadily dropping—a trend that could continue to massage COVID-19 into a milder disease. Eventually, the expectation is that the illness will reach a stable nadir, at which point it may truly be “another common cold,” says Rustom Antia, an infectious-disease modeler at Emory.

    The full outcome of this living experiment, though, won’t be clear for decades—well after the billions of people who encountered the coronavirus for the first time in adulthood are long gone. The experiences that today’s youngest children have with the virus are only just beginning to shape what it will mean to have COVID throughout a lifetime, when we all coexist with it from birth to death as a matter of course.

    At the beginning of SARS-CoV-2’s global tear, the coronavirus was eager to infect all of us, and we had no immunity to rebuff its attempts. But vulnerability wasn’t just about immune defenses: Age, too, has turned out to be key to resilience. Much of the horror of the disease could be traced to having not only a large population that lacked protection against the virus—but a large adult population that lacked protection against the virus. Had the entire world been made up of grade-schoolers when the pandemic arrived, “I don’t think it would have been nearly as severe,” says Juliet Pulliam, an infectious-disease modeler at Stellenbosch University, in South Africa.

    Across several viral diseases—polio, chicken pox, mumps, SARS, measles, and more—getting sick as an adult is notably more dangerous than as a kid, a trend that’s typically exacerbated when people don’t have any vaccinations or infections to those pathogens in their rearview. The manageable infections that strike toddlers and grade-schoolers may turn serious when they first manifest at older ages, landing people in the hospital with pneumonia, brain swelling, even blindness, and eventually killing some. When scientists plot mortality data by age, many curves bend into “a pretty striking J shape,” says Dylan Morris, an infectious-disease modeler at UCLA.

    The reason for that age differential isn’t always clear. Some of kids’ resilience probably comes from having a young, spry body, far less likely to be burdened with chronic medical conditions that raise severe disease risk. But the quick-wittedness of the young immune system is also likely playing a role. Several studies have found that children are much better at marshaling hordes of interferon—an immune molecule that armors cells against viruses—and may harbor larger, more efficient cavalries of infected-cell-annihilating T cells. That performance peaks sometime around grade school or middle school, says Janet Chou, a pediatrician at Boston Children’s Hospital. After that, our molecular defenses begin a rapid tumble, growing progressively creakier, clumsier, sluggish, and likelier to launch misguided attacks against the tissues that house them. By the time we’re deep into adulthood, our immune systems are no longer sprightly, or terribly well calibrated. When we get sick, our bodies end up rife with inflammation. And our immune cells, weary and depleted, are far less unable to fight off the pathogens they once so easily trounced.

    Whatever the explanations, children are far less likely to experience serious symptoms, or to end up in the hospital or the ICU after being infected with SARS-CoV-2. Long COVID, too, seems to be less prevalent in younger cohorts, says Alexandra Yonts, a pediatrician at Children’s National Hospital. And although some children still develop MIS-C, a rare and dangerous inflammatory condition that can appear weeks after they catch the virus, the condition “seems to have dissipated” as the pandemic has worn on, says Betsy Herold, the chief of pediatric infectious disease at the Children’s Hospital at Montefiore, in the Bronx.

    Should those patterns hold, and as the age of first exposure continues to fall, COVID is likely to become less intense. The relative mildness of childhood encounters with the virus could mean that almost everyone’s first infection—which tends, on average, to be more severe than the ones that immediately follow—could rank low in intensity, setting a sort of ceiling for subsequent bouts. That might make concentrating first encounters “in the younger age group actually a good thing,” says Ruian Ke, an infectious-disease modeler at Los Alamos National Laboratory.

    COVID will likely remain capable of killing, hospitalizing, and chronically debilitating a subset of adults and kids alike. But the hope, experts told me, is that the proportion of individuals who face the worst outcomes will continue to drop. That may be what happened in the aftermath of the 1918 flu pandemic, Antia, of Emory, told me: That strain of the virus stuck around, but never caused the same devastation again. Some researchers suspect that something similar may have even played out with another human coronavirus, OC43: After sparking a devastating pandemic in the 19th century, it’s possible that the virus no longer managed to wreak much more havoc than a common cold in a population that had almost universally encountered it early in life.

    Such a fate for COVID, though, isn’t a guarantee. The virus’s propensity to linger in the body’s nooks and crannies, sometimes causing symptoms that last many months or years, could make it an outlier among its coronaviral kin, says Melody Zeng, an immunologist at Cornell University. And even if the disease is likely to get better than what it is now, that is not a very high bar to clear.

    Some small subset of the population will always be naive to the virus—and it’s not exactly a comfort that in the future, that cohort will almost exclusively be composed of our kids. Pediatric immune systems are robust, UCLA’s Morris told me. But “robust is not the same as infallible.” Since the start of the pandemic, more than 2,000 Americans under the age of 18 have died from COVID—a small fraction of total deaths, but enough to make the disease a leading cause of death for children in the U.S. MIS-C and long COVID may not be common, but their consequences are no less devastating for the children who experience them. Some risks are especially concentrated among our youngest kids, under the age 5, whose immune defenses are still revving up, making them more vulnerable than their slightly older peers. There’s especially little to safeguard newborns just under six months, who aren’t yet eligible for most vaccines—including COVID shots—and who are rapidly losing the antibody-based protection passed down from their mothers while they were in the womb.

    A younger average age of first infection will also probably increase the total number of exposures people have to SARS-CoV-2 in a typical lifetime—each instance carrying some risk of severe or chronic disease. Ke worries the cumulative toll that this repetition could exact: Studies have shown that each subsequent tussle with the virus has the potential to further erode the functioning or structural integrity of organs throughout the body, raising the chances of chronic damage. There’s no telling how many encounters might push an individual past a healthy tipping point.

    Racking up exposures also won’t always bode well for the later chapters of these children’s lives. Decades from now, nearly everyone will have banked plenty of encounters with SARS-CoV-2 by the time they reach advanced age, Chou, from Boston Children’s Hospital, told me. But the virus will also continue to change its appearance, and occasionally escape the immunity that some people built up as kids. Even absent those evasions, as their immune systems wither, many older people may not be able to leverage past experiences with the disease to much benefit. The American experience with influenza is telling. Despite a lifetime of infections and available vaccines, tens of thousands of people typically die annually of the disease in the United States alone, says Ofer Levy, the director of the Precision Vaccines Program at Boston Children’s Hospital. So even with the expected COVID softening, “I don’t think we’re going to reach a point where it’s, Oh well, tra-la-la,” Levy told me. And the protection that immunity offers can have caveats: Decades of research with influenza suggest that immune systems can get a bit hung up on the first versions of a virus that they see, biasing them against mounting strong attacks against other strains; SARS-CoV-2 now seems to be following that pattern. Depending on the coronavirus variants that kids encounter first, their responses and vulnerability to future bouts of illness may vary, says Scott Hensley, an immunologist at the University of Pennsylvania.

    Read: Are our immune systems stuck in 2020?

    Early vaccinations—that ideally target multiple versions of SARS-CoV-2—could make a big difference in reducing just about every bad outcome the virus threatens. Severe disease, long COVID, and transmission to other children and vulnerable adults all would likely be “reduced, prevented, and avoided,” Chou told me. But that’s only if very young kids are taking those shots, which, right now, isn’t at all the case. Nor are they necessarily getting protection passed down during gestation or early life from their mothers, because many adults are not up to date on COVID shots.

    Some of these issues could, in theory, end up moot. A hundred or so years from now, COVID could simply be another common cold, indistinguishable in practice from any other. But Morris points out that this reality, too, wouldn’t fully spare us. “When we bother to look at the burden of the other human coronaviruses, the ones who have been with us for ages? In the elderly, it’s real,” he told me. One study found that a nursing-home outbreak of OC43—the purported former pandemic coronavirus—carried an 8 percent fatality rate; another, caused by NL63, killed three out of the 20 people who caught it in a long-term-care facility in 2017. These and other “mild” respiratory viruses also continue to pose a threat to people of any age who are immunocompromised.

    SARS-CoV-2 doesn’t need to follow in those footsteps. It’s the only human coronavirus against which we have vaccines—which makes the true best-case scenario one in which it ends up even milder than a common cold, because we proactively protect against it. Disease would not need to be as inevitable; the vaccine, rather than the virus, could be the first bit of intel on the disease that kids receive. Tomorrow’s children probably won’t live in a COVID-free world. But they could at least be spared many of the burdens we’re carrying now.

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    Katherine J. Wu

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  • Is the Worst of Winter Over for COVID?

    Is the Worst of Winter Over for COVID?

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    For months, the winter forecast in the United States seemed to be nothing but viral storm clouds. A gale of RSV swept in at the start of autumn, sickening infants and children in droves and flooding ICUs. After a multiyear hiatus, flu, too, returned in force, before many Americans received their annual shot. And a new set of fast-spreading SARS-CoV-2 subvariants had begun its creep around the world. Experts braced for impact: “My biggest concern was hospital capacity,” says Katelyn Jetelina, who writes the popular public-health-focused Substack Your Local Epidemiologist. “If flu, RSV, and COVID were all surging at the same time—given how burned out, how understaffed our hospital systems are right now—how would that pan out?”

    But the season’s worst-case scenario—what some called a “tripledemic,” bad enough to make health-care systems crumble—has not yet come to pass. Unlike last year, and the year before, a hurricane of COVID hospitalizations and deaths did not slam the country during the first month of winter; flu and RSV now appear to be in sustained retreat. Even pediatric hospitals, fresh off what many described as their most harrowing respiratory season in memory, finally have some respite, says Mary Beth Miotto, a pediatrician and the president of the Massachusetts chapter of the American Academy of Pediatrics. After a horrific stint, “we are, right now, doing okay.” With two months to go until spring, there is plenty of time for another crisis to emerge: Certain types of influenza, in particular, can be prone to delivering late-season second peaks. “We need to be careful and recognize we’re still in the middle,” Jetelina told me. But so far, this winter “has not been as bad as I expected it to be.”

    No matter what’s ahead, this respiratory season certainly won’t go down in history as a good one. Children across the country have fallen sick in overwhelming numbers, many of them with multiple respiratory viruses at once, amid a nationwide shortage of pediatric meds. SARS-CoV-2 remains a top cause of mortality, with its daily death count still in the hundreds, and long COVID continues to be difficult to prevent or treat. And enthusiasm for new vaccines and virus-blocking mitigations seems to be at an all-time low. Any sense of relief people might be feeling at this juncture must be tempered by what’s in the rearview: three years of an ongoing pandemic that has left more than 1 million people dead in the U.S. alone, and countless others sick, many chronically so. The winter may be going better than it could have. But that shouldn’t hold us back from tackling what’s ahead this season, and in others yet to come.

    Not all of this past autumn’s gloomy predictions were off base. RSV and flu each rushed in on the early side of the season and led to a steep rise in cases. But both viruses made rather hasty exits: RSV hit an apparent apex in mid-November, and flu bent into its own decline the following month. The staggered peaks “helped us quite a bit, in terms of hospitals being stressed,” says Sam Scarpino, the director of AI and life sciences at the Institute for Experiential AI at Northeastern University. In recent days, coronavirus cases and hospitalizations have been tilting downward, too—and severe-disease rates seem to be holding at a relative low. Just under 5 percent of hospital beds are currently occupied by COVID patients, compared with more than four times that fraction this time last year. And weekly COVID deaths are down by almost 75 percent from January 2022. (Death, though, has always been a lagging indicator, and the mortality numbers could still shift upward soon.) Despite some dire predictions to the contrary, the fast-spreading XBB.1.5 subvariant didn’t spark “some giant Omicron-type wave and crush everything,” says Justin Lessler, an infectious-disease modeler at the University of North Carolina at Chapel Hill. “In that sense, I feel good.”

    Read: How worried should we be about XBB.1.5?

    No one can say for sure why we dodged winter’s deadliest bullets, but the population-level immunity that Americans have built up over the past three years clearly played a major role. “That’s a testament to how vaccination has made the disease less dangerous for most people,” says Cedric Dark, an emergency physician at Baylor College of Medicine. Widespread immunization, combined with the fact that most Americans have now been infected, and many of them reinfected, has caused severe-disease rates to plunge, and the virus to move less quickly than it otherwise would have. Antiviral drugs, too, have been slashing hospitalization rates, at least for the meager fraction of recently infected people who use them. The gargantuan asterisk of long COVID still applies to new infections, but the short-term effects of the disease are now more on par with those of other respiratory illnesses, reducing the number of resources that health-care workers must marshal for each case.

    The virus, too, was more merciful than it could have been. XBB.1.5, despite its high transmissibility and penchant for dodging antibodies, doesn’t so far seem more capable of causing severe disease. And the fall’s bivalent shots, though not a perfect match for the newcomer, still improve the body’s response to viruses in the Omicron clan. Competition among respiratory viruses may have also helped soften COVID’s recent blows. In the days and weeks after one infection, bodies can become more resilient to another—a phenomenon known as viral interference that can reduce the risk of simultaneous or back-to-back infections. On population scales, interference can push down surges’ peaks, or at the very least, separate them, potentially keeping hospitals from being hit by a medley of microbes all at once. It’s hard to say for sure: “Many things go into when an epidemic wave happens—human behavior, temperature, humidity, the biology of the virus, the biology of the host,” says Ellen Foxman, an immunologist at Yale. That said, “I do think viral interference probably does play a role that has not been appreciated.”

    None of the experts I spoke with was ready to issue a blanket phew. Overlapping waves of respiratory illness have already led to nonstop sickness, especially among children, draining resources at every point in the pediatric caregiving chain. Kids were kept out of school, and parents stayed home from work; after a glut of COVID-related closures in New Mexico, schools and day cares running low on teachers had to call in the National Guard. Inundated with illnesses, pediatric emergency rooms overflowed; adult-care units had to be repurposed for children, and some hospitals pitched tents on their front lawns to accommodate overflow. Local stopgaps weren’t always enough: At one point, a colleague of Miotto’s in Boston told her that the closest available pediatric ICU bed was in Washington, D.C.

    Read: The worst pediatric-care crisis in decades

    By any metric, for the pediatric community, “it’s been a horrible season, the worst,” says Yvonne Maldonado, a pediatrician at Stanford. “The hospitals were bursting, bursting at the seams.” The flow of fevers has ebbed somewhat in recent weeks, but remains more flood than trickle. “It’s not over: We still don’t have amoxicillin in general, and we still struggle to get fever medication for people,” Miotto said. A parent recently told her that they’d gone to almost 10 pharmacies to try to fill an antibiotic prescription for their child. And pediatric providers across the country are steeling themselves for what the coming weeks could bring. “I think we could still see another surge,” says Joelle Simpson, the division chief of emergency medicine at Children’s National Hospital. “In prior years, February has been one of the worst months.”

    The season’s ongoing woes have been compounded by preexisting health-care shortages. Amid a dearth of funds, some hospitals have reduced their number of pediatric beds; a mass exodus of workers has also limited the resources that can be doled out, even as SARS-CoV-2 testing and isolation protocols continue to stretch the admission and discharge timeline. “Hospitals are in a weaker position than they were before the pandemic,” says Joseph Kanter, Louisiana’s state health officer and medical director. “If that’s the environment in which we are experiencing this year’s respiratory-virus season, it makes everything feel more acute.” Those issues are not limited to pediatrics: Now that COVID is a regular part of the disease roster, workloads have increased for a contingent of beleaguered clinicians that, across the board, seems likely to continue to shrink. In many hospitals, patients are getting stuck in emergency departments for several hours, even multiple days—sometimes never making it to a bed before being sent home. “It seems like hospitals everywhere are full,” Dark told me, not just because of COVID, but because of everything. “The vast majority of the work I do, and that I bet you what most of my colleagues are doing, is taking place in waiting rooms.”

    The U.S. has come a long way in the past three years. But still, “the cumulative toll of these winter surges has been higher than it needs to be,” says Julia Raifman, a health-policy researcher at Boston University. Had more people gone into winter up to date on their COVID vaccines, the virus’s mortality rate could have been driven down further; had more antiviral drugs and other protections been prioritized for the elderly and immunocompromised, fewer people might have been imperiled at all. If relief is percolating across the country right now, that says more about a shift in standards than anything else. “Our threshold for what ‘bad’ looks like has just gotten so out of whack,” Simpson told me. This winter could have been as grim as recent ones, Scarpino told me, with body-filled freezer trucks in parking lots and hospitals on the brink of collapse. But an improvement from those horrific lows isn’t much to brag about. And this winter—three years into combatting a coronavirus for which we have shots, drugs, masks, and more—has been nowhere close to the best one imaginable.

    The concern now, experts told me, is that the U.S. might accept a winter like this one as simply good enough. Regular vaccine uptake could dwindle even further; another wild-card SARS-CoV-2 variant could ignite another conflagration of cases. If that did happen, some researchers worry that we’d be slow to notice: Genomic surveillance is down, and many tests are being taken, unreported, at home. And with so many different immune histories now scattered across the globe, it’s getting tougher for modelers like Lessler to predict where and how quickly new variants might take over.

    The country does have a few factors working in its favor. By next winter, at least one RSV vaccine will almost certainly be available to protect the population’s youngest, eldest, or both. mRNA-based flu vaccines, which are expected to be far faster to develop than currently available shots, are also in the works, and will likely make it easier to match doses to circulating strains. And if, as Foxman hopes, SARS-CoV-2 eventually settles into a more predictable, seasonal pattern, infections will be less of a concern for most of the year and season-specific immunizations could be easier to design.

    Read: Should everyone be masking again?

    But no vaccine will do much unless enough people are willing and able to take it—and the public-health infrastructure that’s led many outreach efforts remains underfunded and understaffed. Kanter worries that the nation may not be terribly willing to invest. “We’ve fallen into this complacency trap where we just accept a given amount of mortality every year as unavoidable,” he told me. It doesn’t have to be that way, as the past few years have shown: Treatments, vaccines, clean indoor air, and other measures can lower a respiratory virus’s toll.

    By the middle of spring, the U.S. will be in a position to let the public-health-emergency declaration on COVID lapse—a decision that could roll back protections for the uninsured, and ratchet up price points on shots and antivirals. This winter’s retrospective is likely to influence that decision, Scarpino told me. But relief can breed complacency, and complacency further slows a sluggish public-health response. The fate of next winter—and of every winter after that—will depend on whether the U.S. decides to view this season as a success, or to recognize it as a shaky template for well-being that can and should be improved.

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    Katherine J. Wu

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  • Will We Get Omicron’d Again?

    Will We Get Omicron’d Again?

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    In COVID terms, the middle of last autumn looked a lot like this one. After a rough summer, SARS-CoV-2 infections were down; hospitalizations and deaths were in a relative trough. Kids and workers were back in schools and offices, and another round of COVID shots was rolling out. Things weren’t great … but they weren’t the most terrible they’d ever been. There were vaccines; there were tests; there were drugs. The worst winter development the virus might produce, some experts thought, might involve the spawning of some nasty Delta offshoot.

    Then, one year ago this week, Omicron appeared. The first documented infection with the variant was identified from a specimen collected in South Africa on November 9, 2021; by December 1, public-health officials had detected cases in countries all around the globe, including the United States. Twenty days later, Omicron had unseated Delta as America’s dominant SARS-CoV-2 morph. The new, highly mutated variant could infect just about anyone it encountered—even if they’d already caught a previous version of the virus or gotten several shots of a vaccine. At the beginning of December, and nearly two years into the pandemic, researchers estimated that roughly one-third of Americans had contracted SARS-CoV-2. By the middle of February this year, that proportion had nearly doubled.

    Omicron’s arrival and rapid spread around the world was, and remains, this crisis’s largest inflection point to date. The variant upended scientists’ expectations about SARS-CoV-2’s evolution; it turned having COVID into a horrific norm. Now, as the U.S. approaches its Omicronniversary, conditions may seem ripe for an encore. Some experts worry that the emergence of another Greek-letter variant is overdue. “I’m at a loss as to why we haven’t seen Pi yet,” says Salim Abdool Karim, an epidemiologist at the Centre for the AIDS Programme of Research in South Africa. “I think there’s a chance we still will.”

    A repeat of last winter seems pretty unlikely, experts told me. But with a virus this unpredictable, there’s no guarantee that we won’t see disaster unspool again.

    Read: The worst pediatric care crisis in decades

    A lot has changed since last year. For one thing, population immunity to SARS-CoV-2 is higher. Far more people have received additional doses of vaccine, many of them quite recently, with an updated formula that’s better tailored to the variants du jour. Plus, at this point, nearly every American has been infected at least once—and most of them with at least some subvariant of Omicron, says Shaun Truelove, an epidemiologist and a modeler at Johns Hopkins University. These multiple layers of protection make it more challenging for the average SARS-CoV-2 spin-off to severely sicken people. They also raise transmission obstacles for the coronavirus in whatever form it takes.

    Omicron does seem to have ushered in “a different phase of the pandemic,” says Verity Hill, an evolutionary virologist at Yale. The variants that took over different parts of the world in 2021 rose in a rapid succession of monarchies: Alpha, Beta, Gamma, Delta. But in the U.S. and elsewhere, 2022 has so far been an oligarchy of Omicron offshoots. Perhaps the members of the Omicron lineage are already so good at moving among hosts that the virus hasn’t needed a major upgrade since.

    If that’s the case, SARS-CoV-2 may end up a victim of its own success. The Omicron subvariants BQ.1 and BQ1.1 appear capable of spreading up to twice as fast as BA.5, according to laboratory data. But their takeover in the U.S. has been slow and halting, perhaps because they’re slogging through a morass of immunity to the Omicron family. That alone makes it less likely that any single Omicron subvariant will re-create the sudden surge of late 2021 anytime soon. In South Africa and the United Kingdom, for instance, different iterations of Omicron seem to have triggered just modest bumps in sickness in recent months. (That said, those countries—with their distinct demographics and vaccination and infection histories—aren’t a perfect bellwether for the U.S.)

    For an Omicron 2021 redux to happen, SARS-CoV-2 might need to undergo a substantial genetic makeover—which Abdool Karim thinks would be very difficult for the virus to manage. In theory, there are only so many ways that SARS-CoV-2 can scramble its appearance while retaining its ability to latch onto our cells; by now, its options should be somewhat slimmed. And the longer the Omicron line of succession persists, the tougher it may be to upend. “It’s just getting harder to compete,” Hill told me.

    But the world has gotten overconfident before. Even if SARS-CoV-2 doesn’t produce a brand-new version of itself, low uptake of the bivalent vaccine could allow our defenses to wither, driving a surge all the same, Truelove told me. Our transmission-dampening behaviors too are slacker than they’ve been since the pandemic’s start. This time last year, 50 to 60 percent of Americans were regularly wearing masks. The latest figures, many of them several months old, are closer to 30 percent. “The more opportunities you give the virus to get into somebody,” Hill said, “the more chances you give it to get the group of mutations that could help it take off.” Immunocompromised people who remain chronically infected with older variants, such as Alpha or Delta, could also become the sites of new viral offshoots. (That may be how the world got Omicron to begin with.)

    Going on probability alone, “it seems more likely that we’ll keep going with these subvariants of Omicron rather than dealing with something wholly brand-new,” says Maia Majumder, an epidemiologist at Boston Children’s Hospital. But Lauren Ancel Meyers, an infectious-disease modeler at the University of Texas at Austin, warns that plenty of uncertainty remains. “What we don’t have is a really data-driven model right now that tells us if, when, where, and what kind of variants will be emerging in the coming months and years,” she told me. Our window into the future is only getting foggier too as fewer people submit their test results—or take any test at all—and surveillance systems continue to go offline.

    It wouldn’t take another Omicron-type event to hurl us into disarray. Maybe none of the Omicron subvariants currently jockeying for control will surge ahead of the pack. But several of them might yet drive regional epidemics, Majumder told me, depending on the local nitty-gritty of who’s susceptible to what. And as winter looms, some of the biggest holes in our COVID shield remain unpatched. People who are immunocompromised are losing their last monoclonal-antibody treatments, and although powerful drugs exist to slash the risk of severe disease and death, useful preventives and treatments for long COVID remain sparse.

    Read: The end of Evusheld

    Our nation’s capacity to handle new COVID cases is also low, Majumder said. Already, hospitals around the country are being inundated with other respiratory viruses—RSV, flu, rhinovirus, enterovirus—all while COVID is still kicking in the background. “If flu has taken over hospital beds,” says Srini Venkatramanan, an infectious-disease modeler at the University of Virginia, even a low-key wave will “feel like it’s having a much bigger impact.”

    As the country approaches its second holiday season with Omicron on deck, this version of the virus may “feel familiar,” Majumder pointed out. “I think people perceive the current circumstances to be safer than they were last year,” she said—and certainly, some of them are. But the fact that Omicron has lingered is not entirely a comfort. It is also, in its way, a reminder of how bad things once were, and how bad they could still get.

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    Katherine J. Wu

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  • Warning Signs About the First Post-pandemic Winter

    Warning Signs About the First Post-pandemic Winter

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    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.

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    Katherine J. Wu

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