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As holiday celebrations wind down in the U.S., COVID is on the rise, even as people head out to ring in what they hope will be a healthier new year.
While many would like to take a vacation from even thinking about COVID, the question of what’s next with the virus is always looming. Will there be another winter surge? If so, can we minimize it? How big a role might the boosters play in that? Are more mandates coming, along with a return to closed offices and businesses? Read on for a look at the latest info.
Cases, Hospitalizations, Deaths
As of Dec. 27, the latest statistics, the CDC reports more than 487,000 weekly cases, compared to about 265,000 for the week ending Oct. 12. On average, 4,938 people were admitted to the hospital daily from Dec. 19 to 25, down about 6% from the 5,257 admitted daily the week before.
Deaths totaled 2,952 weekly as of Dec. 21, up from 2,699 on Dec. 14.
"What’s sobering overall is still seeing about 400 deaths a day in the U.S.," says Peter Chin-Hong, MD, professor of medicine and infectious disease specialist at the University of California, San Francisco. "It’s still very high."
As of Dec. 17, the variants predominating are BQ.1, BQ.1.1 and XBB. Experts said they are paying close attention to XBB, which is increasing quickly in the Northeast.
Predicting a Winter Surge
Experts tracking the pandemic agree there will be a surge.
"We are in the midst of it now," says Eric Topol, MD, founder and director of the Scripps Research Translational Institute in La Jolla, CA, and editor-in-chief of Medscape (WebMD’s sister site). "It’s not nearly like what we’ve had in Omicron or other waves; it’s not as severe. But it’s being particularly felt by seniors."
One bit of good news: "Outside of that group it doesn’t look like—so far—it is going to be as bad a wave [as in the past]," Topol says.
Predicting the extent of the post-holiday surge "is the billion-dollar question right now," says Katelyn Jetelina, PhD, MPH, a San Diego epidemiologist and author of the newsletter Your Local Epidemiologist.
"Much of these waves are not being driven by subvariants of concern but rather behavior," she says.
People are opening up their social networks to gather for celebrations and family time. That’s unique to this winter, she thinks.
"I think our numbers will continue to go up, but certainly not like 2021 or 2020," Chin-Hong says.
Others point out that the surge doesn’t just involve COVID.
"We are expecting a Christmas surge and we are concerned it might be a triple surge," says William Schaffner, MD, professor of infectious diseases at Vanderbilt University Medical Center in Nashville. He’s referring to the rising cases of flu and RSV (respiratory syncytial virus).
Jetelina shares that concern, worrying that those illnesses may be what overwhelms hospital capacity.
Another wild card is the situation in China. With the easing of China’s "zero COVID" policies, cases there are rising dramatically. Some models are predicting up to 1 million COVID deaths could occur in China in 2023. (The U.S. is now requiring travelers from China to show a negative COVID test before entering. Countries like Italy and Japan have taken similar measures.)
"The suffering that is going to occur in China is not good news at all," Topol says. "We are going to be seeing that for many weeks if not months ahead."
Theoretically, uncontained spread such as what is expected there could generate a whole new family of variants, he says. But "the main hit is going to be in China," he predicts. "But it’s hard to project with accuracy."
"China is 20% of the global population, so we can’t ignore it," Jetelina says. "The question is, what’s the probability of a subvariant of concern coming from China? I think the probability is pretty low, but the possibility is there."
What happens with cases in China may "throw a wrench" in the transition from pandemic to endemic, Chin-Hong says. But even if the rising cases in China do result in a new variant, "there’s so much T cell and B cell immunity [here], your average person is still not going to get seriously ill, even if the variant looks really scary."
Minimizing the Damage
Experts echo the same advice on stemming the surge, especially for adults who are 65 or older: Get the bivalent booster, and get it now.
"The same with the influenza vaccine," Schaffner says.
Both the booster vaccine and the flu vaccine have been underused this year, he says. "It’s part of the general vaccine fatigue."
The low uptake of the booster vaccine is concerning, Topol says, especially among adults age 65 and older, the age group most vulnerable to severe disease. Just 35.7% of U.S. adults 65 and older have gotten the booster, according to the CDC. Topol calls that a tragedy.
Younger people have not taken to the booster, either. Overall, only 14.1% of people ages 5 and up have gotten an updated booster dose, according to the CDC.
Recent studies find value in the boosters. One study looked only at adults age 65 or older, finding that the bivalent booster reduced the risk of hospitalization by 84% compared to someone not vaccinated, and 73% compared to someone who had only received the monovalent vaccine. Another study of adults found those who had gotten the bivalent were less likely to need COVID-related emergency room care or urgent care.
In a Dec. 21 report in the New England Journal of Medicine, researchers took plasma samples from people who had gotten either one or two monovalent boosters or the bivalent to determine how well they worked against the circulating Omicron subvariants BA.1, BA.5, BA.2.75.2, BQ.1.1, and XBB. The bivalent worked better than the monovalent against all the Omicron subvariants, but especially against BA.2.75.2, BQ.1.1, and XBB.
Rapid testing can help minimize transmission. On Dec. 15, the Biden administration announced its Winter Preparedness Plan, urging Americans to test before and after travel as well as indoor visiting with vulnerable individuals, providing another round of free at-home tests, continuing to make community testing available and continuing to provide vaccines.
Besides the general precautions, Schaffner suggests: "Look at yourself. Who are you? If you are older than 65, or have underlying illness or are immunocompromised, or are pregnant, please put your mask back on. And think about social distancing. It might be time to worship at home and stream a movie," instead of going to the theaters, he says.
Back to Mandates?
On Dec. 9, New York City’s Commissioner on Health & Mental Hygiene urged a return to masking indoors, saying people "should" mask up, including in schools, stores, offices, and when in crowded outdoor settings.
On the same date, the County of Los Angeles Public Health urged a return to masking for everyone age 2 and older when indoors, including at schools, in transit, or in worksites when around others.
While the CDC order requiring masks on public transportation is no longer in effect, the agency continues to recommend that those using public transportation do so.
But some are taking that further. In Philadelphia, for example, School Superintendent Tony Watlington, EdD, announced before the winter break that indoor masking will be required for all students and staff for the first 2 weeks of school return, through Jan. 13, citing guidance from the Philadelphia Department of Public Health.
Universal masking in schools does reduce COVID transmission, as a study published in late November suggests. After Massachusetts dropped the statewide universal masking policy in public schools in February 2022, researchers compared the incidence of COVID in 70 school districts there that dropped the mandate with two school districts that kept it. In the 15 weeks after the policy was rescinded, the lifting of the mandate was linked with an additional 44.9 cases of COVID per 1,000 students and staff. That corresponded to an estimated 11,901 cases and to nearly 30% of the cases in all districts during that time.
That said, experts see mandates as the exception rather than the rule, at least for now, citing public backlash against mandates to mask or follow other restrictions.
"Mandating, we know, it shuts people off," Topol says. "It’s unenforceable. If you have a very strong recommendation, that’s probably as good as you’re going to be able to do right now."
There may be communities where mandates go over better than others, Schaffner says, such as communities where people have confidence in their public health authorities.
Ringing in 2023
Heading to a New Year’s Eve gathering? Before celebrations, especially those that are indoors, "you could have ground rules before a gathering, such as asking guests to be vaxxed," Schaffner says.
Hosts might also ask guests to test before the event. While those are excellent suggestions, Schaffner says he doesn’t think the vast majority of people are following that advice.
"In the ideal scenario, people would get a rapid test within hours of gathering," Topol agrees, citing a small chance they could have COVID after a negative test and not yet show symptoms. At the gathering, if possible, have air filtration with a HEPA filter and good ventilation, he says.
"Think about the highest-risk person at the event," Jetelina says, and plan precautions around those people.
Glimmers of Hope
Despite uncertainties, experts offered some not-so-dismal perspectives as well.
"I think our numbers will continue to go up, but certainly not like 2021 or 2020," Chin-Hong says.
Even the threat of a surge doesn’t have to squash celebrations completely, Schaffner says.
"I encourage people to enjoy themselves but to do so in a careful rather than a carefree way," he says.
Peter Chin-Hong, MD, professor of medicine and infectious disease specialist, University of California, San Francisco.
Katelyn Jetelina, PhD, MPH, San Diego epidemiologist; publisher, Your Local Epidemiologist.
William Schaffner, MD, professor of infectious diseases, Vanderbilt University Medical Center, Nashville.
Eric Topol, MD, founder and director, Scripps Translational Research Institute, La Jolla, CA, editor-in-chief, Medscape.
CDC: "Wearing Masks in Travel and Public Transportation Settings."
The School District of Philadelphia: "A Holiday Message from Dr. Watlington."
The White House: "Biden Administration Announces COVID-19 Winter Preparedness Plan."
Advisory: Commissioner of Health and Mental Hygiene of the City of New York.
The New England Journal of Medicine: "Lifting Universal Masking in Schools—Covid-19 Incidence among Students and Staff."
Morbidity and Mortality Weekly Report (MMWR): "Early Estimates of Bivalent mRNA Vaccine Effectiveness in Preventing COVID-19–Associated Emergency Department or Urgent Care Encounters and Hospitalizations Among Immunocompetent Adults — VISION Network, Nine States, September–November 2022."
Morbidity and Mortality Weekly Report (MMWR): "Early Estimates of Bivalent mRNA Vaccine Effectiveness in Preventing COVID-19–Associated Hospitalization Among Immunocompetent Adults Aged ≥65 Years — IVY Network, 18 States, September 8–November 30, 2022."
The New England Journal of Medicine: "Neutralization against BA.2.75.2, BQ.1.1 and XBB from mRNA Bivalent Booster."
Institute for Health Metrics and Evaluation: "COVID-19 Projections."
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Cite this: What's Next for COVID? Here's What to Know - Medscape - Jan 03, 2023.