The best thing you can do to quash a deadly Covid-19 surge this winter

People wait in line for a Covid-19 test at the beginning of the coronavirus pandemic in the Bronx, New York, in April 2020. | Timothy A. Clary/AFP via Getty Images

Redesigned Covid-19 vaccines could save thousands of lives, but few are getting them.

Another winter, another wave.

With the leaves changing color, temperatures dropping, and people spending more time indoors, health officials are warning of a spike not just in Covid-19 cases but other infections as well.

“The challenge with holiday seasons every year is it’s also a time where contagious respiratory viruses — like influenza, RSV, and, again this year, Covid — spread much more quickly,” said Ashish Jha, the White House Covid-19 response coordinator, during a press conference on Tuesday.

Covid-19 cases are already rising in Europe, a trend that has preceded waves of infection in the US in the past. The key question: Just how deadly will Covid-19 be this winter?

Jha said that Covid-19 is not the same disruptive threat it was in the past two years. It’s likely that cases will increase again, but that they won’t cause the towering spike of hospitalizations and deaths experienced last winter, which were fueled by the omicron variant of the SARS-CoV-2 virus that causes Covid-19. In January, more than 2,000 people per day died from Covid-19. Currently, about 300 people are dying every day in the US from the disease.

What’s changed is that far more people have been vaccinated and exposed to Covid-19 by now, so “basically, no one is seeing this virus for the first time at this point,” said Justin Lessler, a professor of epidemiology at the University of North Carolina who develops Covid-19 models. That means most people now have some degree of protection against the disease, which lowers the likelihood of dying from it.

But that’s not enough to absorb another wave of misery. Protection from Covid-19 exposure or vaccination fades over time. Some groups, like older adults and immunocompromised people, remain at higher risk of severe illness and death from Covid-19 even with vaccines. The virus itself is continuing to change in ways that make it easier to spread and harder to counter. And while most US adults have received at least one dose of a Covid-19 vaccine, only a tiny fraction are up to date on their boosters.

Treatments for those infected with the virus also have caveats: Not everyone is getting this care after they’re infected. And some therapies, like monoclonal antibodies, which counter the virus in early stages of the disease, are becoming less effective against the new variants.

What’s clear is that Covid-19 can continue to surprise, confound, and frustrate, but our actions now can limit much of its potential harm.

“What happens in the weeks and months ahead will have a large impact on how the winter goes,” Jha said. “And really what happens in this winter is largely up to us, as the American people.”

One of the biggest factors shaping the course of Covid-19 is within our control

The Centers for Disease Control and Prevention now recommends that all people over the age of 5 get a booster dose of a bivalent Covid-19 vaccine after completing their initial vaccine regimen. These reformulated mRNA vaccines — from Moderna and Pfizer/BioNTech — are optimized to target the original version of the SARS-CoV-2 virus, as well as some of the newer omicron subvariants.

Boosters ramp up immune protection and reduce the likelihood of severe Covid-19 cases. The problem is that few people are getting boosted. Almost 80 percent of the US population has had at least one Covid-19 vaccine dose. Yet since regulators gave bivalent boosters the green light last month, less than 4 percent of eligible Americans have received the new shots. Even among people over the age of 65, one of the highest-risk groups for severe Covid-19, less than one-third have gotten the bivalent booster.

If rates remain this low, that could lead to more hospitalizations and deaths this winter. The Commonwealth Fund, a nonprofit health research group, mapped out different scenarios for booster uptake. At current vaccination rates, they estimated the US could see upward of 1,200 deaths from Covid-19 per day by this coming March.

However, if Covid-19 bivalent booster rates matched that of the influenza vaccine last year — about 50 percent uptake — daily deaths would continue declining, reaching around 200 per day. By spring 2023, the reformulated vaccines would avert 75,000 deaths. If 80 percent of eligible people get their bivalent shots by the end of the year, deaths would decline even further, saving 90,000 lives by the spring.

Commonwealth Fund

Thousands of deaths could be avoided if more people received Covid-19 vaccine boosters.

The key is to get as many people boosted as possible now, though the benefits may take a while to manifest in lower cases and deaths.

“Today’s boosters won’t necessarily cause or not cause a surge tomorrow, but this slow buildup of immunity in the population will affect what happens two, three, four months from now,” said Lauren Ancel Myers, director of the Covid-19 Modeling Consortium at the University of Texas in Austin, who was not involved with the Commonwealth Fund study.

The trouble is that many people in the US don’t grasp the stakes of the current rounds of vaccination. A poll last month from the Kaiser Family Foundation showed that half of Americans had heard little or nothing about bivalent Covid-19 vaccines. Only one-third of adults said they had received the new booster or were planning to get it as soon as possible.

So before shots can go into arms, health officials will have to raise the dismal levels of awareness of the new vaccines.

Treatments and testing remain critical as well

One of the biggest uncertainties this winter is how the virus itself will change. “What the virus does and how it evolves is very key to what’s going to happen in the next few months,” Myers said.

Already, SARS-CoV-2 has mutated in ways that frustrate the response to it. The latest major variant, omicron, has spawned its own subvariants. Right now, about 80 percent of Covid-19 cases in the US are caused by the BA.5 subvariant, but another subvariant, BA.4.6, is gaining ground. Early reports show that BA.4.6, a descendant of BA.4, is even better at evading the immune system than BA.5. It also appears to reproduce faster.

While the bivalent vaccine boosters target BA.4 and BA.5, the virus could mutate further and render the vaccines less effective. Mutations can also undermine treatments like monoclonal antibodies, which are designed to attach to specific parts of the virus. If those regions change, the antibodies are less effective at slowing infections.

Kevin Dietsch/Getty Images

White House Covid-19 Response Coordinator Ashish Jha emphasized bivalent Covid-19 vaccine booster doses could prevent thousands of deaths.

There are emerging complications with other treatments as well. Antiviral drugs like Paxlovid are less affected by changes in the virus, but they have to be administered early in the course of a Covid-19 infection. That’s getting tougher to do as testing rates drop off and people have a harder time finding infections before they show symptoms. Such therapies have been an important tool to decouple Covid-19 cases from deaths, helping more people who were infected survive. But Covid-19 drugs only work if people know about them and can get them in time.

Changes in Covid-19 testing are also making it harder to get a handle on how the disease is spreading. Many Covid-19 tests are administered at home these days, and most aren’t monitored by health officials. Among the tests that are tracked, states are reporting them less frequently. The CDC has switched from daily to weekly Covid-19 data reports.

For researchers, that’s making it harder to track the ebb and flow of the disease, and some are looking at other metrics. “I have switched my focus from cases to hospitalization,” Lessler said. Scientists are also monitoring wastewater to anticipate new spikes in cases. Virus levels in wastewater are on the rise in some parts of the US now, like the Midwest and Northeast.

Covid-19 is confounding, but how we react still matters

Even though it’s hard to predict exactly where Covid-19 will go, the models and forecasts show that “how we respond will impact the severity, the timing, the size of that new wave,” Myers said.

Getting booster rates up is likely the most impactful tactic. However, there is little political appetite for vaccine mandates, and a number of states are proposing preemptive legislation to prevent vaccines from being required.

Besides vaccines, getting infected people treatments for Covid-19 is crucial. Preventing infections in the first place with social distancing and wearing face masks remains effective as well, but the will to do these things is all but gone. That’s one of the biggest changes this winter compared to the last one. Myers said it would be useful to develop guidelines and trigger points for masking, testing, and isolation recommendations, depending on factors like hospitalization rates.

And Covid-19 isn’t the only bug in the air. As people travel for the holidays and as the few restrictions left continue to be relaxed, other infections like influenza could also take advantage of the season. Hospitals are facing staffing shortages after two exhausting years of the pandemic. The workers who remain will likely have their hands full, so keeping people out of beds remains critical to avoid overwhelming the health care system.

There may still be more surprises in store when it comes to Covid-19, but depending on how we respond, this winter doesn’t have to be so grim.