Will there be a Covid wave this winter? Time will tell, but this is an interesting article from The Washington Post that tells us what might happen and why. Following that is an article from The New York Times which offers some practical advice for avoiding a possible Covid surge during the holidays.
XBB, BQ.1.1, BA.2.75.2 — a variant swarm could fuel a winter surge
Instead of a single new Greek letter variant, a group of immune-evading omicron spinoffs are popping up all over the world
October 18, 2022 at 6:00 a.m. EDT
For two years, coronavirus variants emerged, one by one, sweeping the globe.
But this fall and winter are expected to be different: Instead of a single ominous variant lurking on the horizon, experts are nervously eyeing a swarm of viruses — and a new evolutionary phase in the pandemic.
This time, it’s unlikely we will be barraged with a new collection of Greek alphabet variants. Instead, one or more of the multiple versions of the omicron variant that keep popping up could drive the next wave. They are different flavors of omicron, but eerily alike — adorned with a similar combination of mutations. Each new subvariant seems to outdo the last in its ability to dodge immune defenses.
“It is this constant evolutionary arms race we’re having with this virus,” said Jonathan Abraham, an assistant professor of microbiology at Harvard Medical School.
The pace of evolution is so fast that many scientists depend on Twitter to keep up. A month ago, scientists were worried about BA.2.75, a variant that took off in South Asia and spawned a cloud of other concerning sublineages. In the United States, BA.4.6 and BF.7 have been slowly picking up steam. A few weeks ago, BQ.1.1 started to steal the spotlight — and still looks like a contender to take over this fall in Europe and North America. A lineage called XBB looms on the sidelines, and threatens to scramble the forecast.
To focus too much on any one possible variant is, many experts argue, missing the point. What matters is that all these new threats are accumulating mutations in similar spots in what’s called the receptor binding domain — a key spot in the spike protein where virus-blocking antibodies dock. If those antibodies can’t dock, they can’t block. Each new mutation gives the virus a leg up in avoiding this primary line of immune defense.
Most virologists demur when asked about which variant — or variants — will be infecting people this winter. That doesn’t mean they think the virus is standing still.
Much of the world’s population has gained a measure of immunity because of vaccinations and infections with omicron. That protection gave us the relative freedoms of the moment — with many people returning to normal life. But protection is fleeting for two key reasons: immunity wanes and the virus is changing. And then there’s this: Monoclonal antibodies, targeted drugs that can be used as a treatment or to protect immunocompromised people who don’t respond well to vaccines, are likely to be knocked out by future variants.
“It’s important for people to understand that the fact there’s not a Greek letter name that has come out does not mean the virus stopped evolving,” said Jesse Bloom, an expert on viral evolution at the Fred Hutchinson Cancer Center in Seattle, who described the evolutionary rate of SARS-CoV-2 as “strikingly rapid.”
Instead of worrying about which variant will win, or even focusing on particular mutations, many scientists have shifted to watching hot spots — specific sites on the virus, known by numbers like a street address, where any change in the virus’s code might allow it to slip by the neutralizing antibodies that are a first line of defense.
The coronavirus spike protein is made up of about 1,300 building blocks called amino acids, and mutations that change even a single building block can make it harder for antibodies to block the virus. Instead of a Greek alphabet, scientists are maintaining shortlists of worrisome spots for mutation: 346, 444, 445, 452, 460, 486, 490.
Seeing so many lineages of the coronavirus develop similar constellations of genetic changes at these spots is a sign of convergent evolution — when different versions of the virus have slammed into the wall of immune defenses in the human population, and then come up with similar ways to get around them. That happens with influenza but is fairly new to SARS-CoV-2. And in the case of the coronavirus, the more mutations, the bigger advantage a new variant seems to have.
Cornelius Roemer, a computational biologist at the University of Basel in Switzerland, has been ranking the new omicron sublineages by how many mutations they have in the receptor binding domain.
XBB appears to be the best at evading immunity. Researchers in China have found that XBB can elude the protective antibodies generated by a breakthrough BA.5 infection, raising concern that fall boosters engineered to target the BA.4 and BA.5 versions of omicron may be quickly outpaced. Still, those booster shots remain the best tool on the shelf.
“We do not have a better choice at the current stage,” Yunlong Cao, a scientist at the Biomedical Pioneering Innovation Center in Peking University in Beijing, said in an email.
On Friday, data from the Centers for Disease Control and Prevention showed that BQ.1 and BQ.1.1 had grown to about 11 percent of the viruses sampled in the United States. Whether it is XBB, BQ.1.1, or some as yet unknown twist on omicron, most experts agree variants will help fuel a difficult fall and winter.
“These lineages are going to have a greater ability to reinfect people than what is currently circulating … which is very likely to drive or contribute to infection waves over the winter,” Tom Peacock, a virologist at Imperial College London, said in an email.
It’s a matter of debate what will happen when one or more of them gets a toehold in a population with a protective layer of underlying immunity. Protection against the worst outcomes is likely to hold up, particularly if bolstered by boosters, many scientists predict.
Cases are ticking up in Europe already. Many scientists think the upswing is driven largely by factors such as children going back to school, people spending more time indoors and the seasonality of the virus. The variants may just be starting to contribute.
“We are certainly in a better place than we were many months ago; we are still in a downward trend” in the United States, said Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, who exhorted people to get an updated booster if eligible. “We need to watch and follow these things very carefully, because we want to make sure we have a good handle on what is going on with regard to the emergence of variants, and what impact they’re going to have on any trends we are going to see in winter.”
But the impact on society could still be considerable even with a surge in cases that doesn’t lead to a massive wave of hospitalizations.
“To put it in context, the summer wasn’t considered a wave — but at the same time, there were lots of issues with work absences, and that kind of thing did have an impact on the world as a whole,” said Manon Ragonnet-Cronin, a scientist at the University of Chicago. “Our primary measurement of how bad these waves are tends to be hospitalizations and deaths, but those other effects shouldn’t be discounted.”
There’s nothing certain about a late-fall wave — whether one will happen, what its magnitude might be or what could spark it. The new crop of variants clearly escapes immunity, but Justin Lessler, a professor of epidemiology at the University of North Carolina’s Gillings School of Global Public Health, said the question will be how that advantage plays out in the world.
“A strain can have a growth advantage compared to the other strains, but still not enough of an advantage to lead to a resurgent epidemic,” Lessler said.
What’s more predictable: Any variant that winds up dominating in coming months will probably challenge a key line of treatment and protection for people with compromised immune systems — the drugs known as monoclonal antibodies. Evusheld is a long-acting version used to prevent illness in people with compromised immune systems. Another monoclonal, bebtelovimab, is used as a treatment.
The pharmaceutical companies making these drugs stress that they remain useful against variants that are prevalent now. But for many scientists, the writing is on the wall. The swarm on the horizon threatens to wipe out one or both of those therapies — and may even subvert the next generation of candidates yet to make it into the medicine cabinet.
Regeneron Pharmaceuticals, a major maker of monoclonal antibodies, paused start-up activities in late September on clinical trials for its new drug — pointing not to a particular new lineage of omicron but to a mutation at one of the hot spots.
“We ask that all start-up activities … be paused to allow Regeneron to evaluate the new variant and its potential impact to our planned clinical development trials,” a company memo sent to investigators running the trials said.
Scientists are worried that Evusheld could be useless by the end of the year, as new variants take over. The Food and Drug Administration warned this month that the drug is unlikely to protect against infection from BA.4.6, a strain that represents about 12 percent of the viruses circulating in the United States.
Bebtelovimab, the monoclonal made by Lilly, could also face a ticking clock as yet other mutations threaten to undermine its effectiveness.
Companies can choose from many libraries of monoclonal antibody drugs, but questions about how to pick them, prove they work and whether they are safe have become more pressing as the drugs turned out to have a short shelf life, because of the pace of viral evolution.
In an effort to make their drugs more variant-proof, companies are trying to design antibody products that are not similar to the dominant antibodies the human body naturally creates to rout the virus.
Laura Walker, chief scientific officer of Invivyd, a biotechnology company working on monoclonal antibody drugs, described one of the compounds her company is hoping to start testing in people in January as a “freak of nature” — because it binds to an unusual spot on the virus.
“You want to try and look ahead, and the question is: How far do those headlights go?” Walker said.
Unmitigated transmission of the virus will allow it to find vulnerable people — whether because of age or medical risk factors. It could also result in the wild-card scenario that many experts fear: A new and very different variant could emerge from some other branch of the coronavirus evolutionary tree.
A leading theory of omicron’s origin is that it evolved as the result of a long-term infection in an immunocompromised patient — and the possibility of a huge jump happening again can’t be ignored.
“If we sit on our hands and say, ‘Well, we are all fine,’ and forget about the vulnerable people who don’t make good immune responses, then that might increase the likelihood a new, scarier variant emerges,” Abraham, of Harvard, said. “I’m not sure if it’s going to happen this winter, but I think it’s likely. There’s still a lot of room for evolution.”
Another Covid Wave Could Be Coming. Here’s How to Make Your Holiday Plans.
As our third pandemic winter approaches, you can mitigate risk without missing out.
At this stage in the long slog of the pandemic, many of us are forgoing masks in places we previously wore them and getting together indoors when we had formerly avoided it. But the holidays throw new variables at everyone’s risk calculus. People trek across the country to see each other. Families crowd around dinner tables, with older, more vulnerable people sitting beside their younger relatives.
As we enter our third pandemic holiday season, some doctors are fearing a seasonal surge in Covid. In Europe — which many experts consider a bellwether for Covid cases in the U.S. — cases are starting to mount, prompting the European Centre for Disease Prevention and Control and the World Health Organization to warn that a new wave of infections could be starting.
“This is the holiday that everyone’s going to come back together again,” said Dr. Peter Chin-Hong, an infectious disease specialist at the University of California, San Francisco. With a bit of advanced planning, he said, family gatherings can be safe this year, and resemble something like pre-pandemic times. “We have the tools for a normal life,” he said. “We just have to use them.”
Here’s what to keep in mind as you map out your family’s plans for the holidays.
Plan around the highest-risk member of your family.
Individual risk tolerance may vary among your family members, but in general, plan around the person at your gathering who is highest-risk. That means taking more precautions if you have a family member who is older than 60, on immunosuppressant medications, received a transplant, or is a cancer patient, said Dr. Michelle Prickett, pulmonary and critical care specialist at Northwestern Medicine.
“It requires everyone who’s going to these gatherings to buy into the idea that we’re going to do the best to protect each other,” said Dr. Adam Ratner, a pediatric infectious disease specialist at N.Y.U. Langone.
You should talk with your family members ahead of time before gathering and figure out your game plan. Ask if people are up-to-date on their vaccinations, and encourage people to take additional precautions if a high-risk family member is attending, which could include limiting the amount of people you invite to Thanksgiving dinner or investing in a few heat lamps so that you can move the meal outside. “This is something you can manage,” Dr. Prickett said. “But you can’t put your head in the sand.”
Get the new booster.
“The biggest way to protect yourself and others is to stay on top of your shots,” said Dr. Joseph Khabbaza, a pulmonary medicine doctor at Cleveland Clinic. The new bivalent booster is a critical tool for warding off infection — although many people are not even aware that it is available. You can find the new booster at pharmacies and health centers across the country, and anyone 5 and older can currently receive it. (You can get your booster at the same time as your flu shot.)
Dr. Ashish Jha, the White House coronavirus response coordinator, has urged people to get the new booster by Halloween, so that it kicks in before Thanksgiving gatherings. The Centers for Disease Control and Prevention recommends the shot for people who are at least two months out from their last infection or vaccination, but many doctors say you should wait at least three months — even if you’re trying to maximize protection before a family gathering. If you get a new shot too soon after recovering from Covid, “your antibodies are just going to chomp up that booster,” and it won’t necessarily raise your level of protection, Dr. Chin-Hong said.
Pay attention to your symptoms.
In the days leading up to a family event — and especially the morning of — watch out for Covid symptoms: sore throat, congestion, coughing, fatigue, headaches and muscle pain. People infected with BA.5, the dominant variant of Covid, are less likely to report losing their sense of taste and smell, but those are also crucial symptoms to watch for.
The dominant variant currently has a shorter incubation period — which means if you go to a packed bar on a Friday night and don’t have symptoms by Monday, it’s unlikely you have the virus, Dr. Chin-Hong said. If you still don’t have symptoms by Wednesday, you’re probably in the clear, he said, although you should take a test to confirm.
However, it is still possible to have an asymptomatic case of Covid — and as more people build up immunity to the virus through vaccination and prior infection, asymptomatic, or very mild, cases will be more common, said Dr. Céline Gounder, an infectious disease specialist and senior fellow and editor at large for public health at Kaiser Health News. Even if you do not have symptoms, you can still spread the virus, she said, which makes it important to test right before gathering with a vulnerable person.
“If you’re going to sit down with Grandma for Thanksgiving dinner, I would test immediately before,” she said.
If you do feel sick, stay home — even if you’re negative on a rapid test. “Anyone who isn’t feeling well should stay home,” Dr. Ratner said, “because the tests aren’t perfect.”
The question isn’t whether or not to test before a family gathering; it’s when to test, and how many times.
Experts differ on the exact timing and combination of tests you should take, but for the most accurate measure of whether or not you’re contagious before an event, take an at-home rapid test right before. “You can just have a little testing party outside, where everyone says, ‘OK, now we’re good, we’re negative, we can go in and see Mom,’” said Stuart Ray, an infectious diseases specialist at Johns Hopkins University School of Medicine. You should also take a rapid test the day before, he advised.
“Rapid tests are very good, but they’re not perfect,” Dr. Prickett said. P.C.R. tests are more sensitive, but it can take several days to get the results back, she said, and so a five-day-old snapshot of your infection status won’t be helpful in determining if you’re contagious at the moment. If you can get a quick-turnaround P.C.R., that can boost your confidence that you’re negative; if not, take at least two rapid tests, 12 to 24 hours apart. (If you have had Covid in the last two to three months, though, P.C.R.s can stay positive beyond the point at which you’re contagious, Dr. Ratner said, so you should rely on rapid tests.)
And think about if the test makes sense to you, Dr. Ratner said. If you’ve been masking and limiting your contact and do not have symptoms, a negative test seems logical. If you wake up with a scratchy throat and have interacted with someone who tested positive, though, take another test the following day, and consider staying home even if the tests are negative, depending on how risky you deem yourself to be.
Consider a “mini quarantine.”
You might want to minimize your exposure in the week before heading home for the holidays, Dr. Prickett said. That means wearing a mask in public indoor spaces and also limiting the time you spend around crowds — like timing trips to the grocery store for when it isn’t super packed, she said.
This is especially important if you live in an area with high levels of Covid cases. You want to check case counts like a weather report, Dr. Chin-Hong said — and keep in mind that these offer an incomplete picture, since rates of testing have plummeted.
Of course, total isolation isn’t feasible for many people. But the level of risk you encounter in a workplace, for example, where you can potentially wear a mask and may interact only with a set group of people, is likely lower than in environments like a restaurant or bar, Dr. Ray said.
Mask up while you travel.
While your risk may change slightly depending on which mode of transportation you take, Dr. Gounder didn’t recommend prioritizing one form of travel over another. But whether you’re taking a plane, bus or train, make sure to wear a mask.
Even if you’re the only person on a plane or train wearing one, a high-quality mask can still protect you, doctors said. “It’s way, way better than nothing,” Dr. Ratner said, “and way, way worse than if everyone was masked.” He recommends people use an N95, KN95 or KF94 mask, and that they keep it on for the entire trip, or take it off for as short a time as possible. You might want to fill up on a big meal before your journey, so you don’t have to take off your mask to eat.
“If you really wear it carefully, if you cinch it down, it’s very unlikely that this virus is going to make it through this mask,” Dr. Ray said.
Ventilate your space.
If you can’t hold your event outside, you can still increase air circulation and reduce the risk of trapping and transmitting the virus in a tight indoor space. Even cracking open the windows can improve air flow. You can also purchase portable air purifiers with HEPA filters. These devices can be expensive (Wirecutter recommends one that retails for just under $200), but they can effectively capture some virus particles in the air.
Experts acknowledged that these precautions can be exhausting, but stressed that advance planning can help us protect each other over the holidays.
“I do not think it’s going to be like this forever,” Dr. Ratner said. “But we’re still in this.”