WASHINGTON, Dec. 15 (UPI) -- The United States is starting to see a surge of COVID-19 as winter nears, and that is packing emergency departments and filling hospital beds as millions of people prepare for holiday travel and get-togethers.
And, while it's not clear whether this wave of SARS-CoV-2 infection will be as substantial as in the past two pandemic winters, there are worrisome signs that widespread disease will continue well into the first few months of 2023.
These include an "alphabet soup," rather than a single coronavirus variant to confront, an early, severe start to the respiratory syncytial virus, or RSV, and a severe influenza season that may produce more co-infection with COVID-19.
Experts also say Paxlovid, used to treat COVID-19 infection, isn't being as widely prescribed as needed for seniors -- and the federal government will stop picking up the tab next year for the antiviral medication, which has been free to patients.
Moreover, the vast majority of people in the United States haven't received the updated COVID-19 bivalent booster shots targeted to the new variants and available to adults since September.
And there are seven -- not the widely reported three -- respiratory virus pathogens to manage.
So, although new drug approaches to SARS-CoV-2 treatment are being explored by the Dana-Farber Cancer Institute, among others, experts say the pressing issue now is tackling a slew of complicating factors heading into 2023.
If the latest numbers for flu cases are any indication of things to come, the next few months will be filled with misery for millions of people in the United States.
As of Friday, the Centers for Disease Control and Prevention estimated at least 13 million cases, 120,000 hospitalizations, and 7,300 deaths since flu season began in October.
That's well above figures reported only several days earlier at a Dec. 5 press briefing by Dr. Rochelle Walensky, CDC's director, who called it the highest level of flu in a decade at this time of year.
Meanwhile, COVID-19 cases, deaths and hospital admissions have been rising since October, CDC says.
Nationwide, nearly 460,000 new cases of COVID-19 are being reported weekly. Deaths are increasing by nearly 3,000 weekly. And about 38,000 people are hospitalized with the virus that is bringing nearly 4,900 new admissions daily.
That's a far cry from when COVID-19 weekly cases in the United States peaked at more than 5.5 million near the beginning of this year. And while the trend has turned upward, health professionals can't say how large the numbers will grow.
"COVID-19 continues to circulate, and we're keeping a close eye on it as we move into the winter months," Scott Pauley, a CDC spokesman, told UPI in an email.
Pauley said the coronavirus "is clearly not the disruptive threat it once was" with tools available now "to prevent most COVID deaths."
Yet, he said, while the number of COVID deaths "has remained at relatively low levels in recent months" compared to earlier in the pandemic, "that doesn't mean COVID is over."
What comes next with the coronavirus, beyond this winter and during 2023, though, is a big unknown.
"COVID-19 may settle into a seasonal pattern and be more 'like the flu' but this only time will tell," the District of Columbia Department of Health said in a statement to UPI.
"There are signs that COVID-19 may be starting to mutate in a more predictable mutation pattern similar to the flu, but it is certainly possible that we will continue to have severe and unpredictable variants continue to appear," DC Health said.
Vaccine expert Dr. Peter Hotez predicts seasonal cycles of COVID-19 -- at least for a while.
"We certainly should expect annual RSV influenza peaks each winter, [since] that's been the pattern for a long time," Hotez, co-director of the Center for Vaccine Development at Texas Children's Hospital, told UPI in an email.
"Whether or not COVID-19 becomes seasonal is still an unknown. I think it is a likely scenario for at least the next few years."
More immediately, Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine, said, "I do think we're in for a [COVID-19] wave in the winter, just as in 2021 and 2022, but I don't know whether it will be as dramatic and large as the [previous two] waves were."
He added: "It will depend quite a bit on whether we can improve {COVID-19 vaccine] booster rates."
Nationwide, 13.5% of the population 5 years old or older had received an updated COVID-19 booster dose as of Friday, the CDC said. That's up only slightly from a week earlier.
On Dec. 8, the Food and Drug Administration amended emergency use authorization to allow bivalent Moderna and Pfizer-BioNTech COVID-19 vaccine boosters in children as young as 6 months old.
Hotez disputed reports that the updated boosters are ineffective, saying people who are vaccinated and boosted with the bivalent mRNA vaccine have a 15 times reduced risk of dying from COVID-19, and three times a reduced risk of catching it.
"I think the messaging has been poor," he said. "There's real data to support the benefit of the booster, yet people mischaracterize it."
More broadly, the Commonwealth Fund said in a report Tuesday that two years of COVID-19 vaccines -- during which the U.S. administered 655 million-plus doses and 80% of the population got at least one dose -- have prevented 18 million additional hospitalizations and 3 million additional deaths.
According to Hotez, seven respiratory illness pathogens are currently in play in the United States: BQ.1/1.1 COVID-19, influenza, parainfluenza, RSV, rhinovirus, metapneumovirus, and bacterial pathogens like pneumococcus.
"We don't have vaccines for all [seven respiratory viruses circulating now], but we have vaccines for COVID-19, flu and pneumonia," Hotez said. "So take as many 'off the table' as you can."
Some good news is the flu vaccine seems to be a more effective match this season than last year, Hotez and other health experts noted.
And on Dec. 7, the FDA accepted the first RSV vaccine candidate for priority review; it aims to be available in 2023 for older adults and pregnant women, as does monoclonal antibody therapy to prevent severe RSV in high-risk infants.
In the meantime, Hotez said "avoiding droplet contact" by masking, handwashing and using disinfectant wipes are helpful in reducing transmission of respiratory viruses.
Given all of the pathogens now circulating, Hotez and other experts expect co-infections this winter, such as flu and COVID-19.
In Missouri during the 2021-2022 flu season, there was a high prevalence of COVID-19-flu co-infections, says a study published Nov. 2 in the journal Virology.
Co-infection peaked at 48% in October 2021 when the Delta variant was dominant, researchers from the University of Missouri School of Medicine found.
"It is likely co-infection would occur again in this season," Professor Henry Wan, the study's senior author and director of the University of Missouri's NextGen Center for Influenza and Emerging Infectious Diseases, told UPI via email.
The Los Angeles Department of Public Health is "very concerned about the current [COVID-19] surge for several reasons," spokeswoman Hayley Devlin told UPI.
Notably, Devlin said, the increase in COVID-19 cases and hospitalizations started earlier than last winter.
"Our average number of [COVID-19] cases reported per day is currently more than double what we saw at this time last year, and average daily hospital admissions are currently nearly three times as high as this time last year," she said in an email. Both have increased by over 200% in just the past month.
Rising case rates, wastewater concentrations of the SARS‑CoV‑2 virus and the proportion of emergency department visits for COVID-19 also indicate widespread transmission, she said.
Also, her department is seeing much more respiratory illness from influenza and RSV than in previous years, "and this will create further strain on our hospitals," Devlin said. "The current percent positivity for flu and RSV is higher than what we saw at this time in the past six years."
And, people have been slow to get the updated bivalent booster vaccine, she said.
"Even among those 65 and older who are most at risk of severe COVID illness, only approximately 30% have received the updated booster," Devlin said.
Aside from vaccines, Erin Fox, senior pharmacy director at University of Utah Health, told UPI it is hard to predict how national drug shortages might affect the respiratory virus burden this winter and into the spring.
"Certainly, there are shortages right now of some strengths of certain antibiotics, oseltamivir [an antiviral medication for influenza better known as Tamiflu] and liquid Tylenol and ibuprofen, but those seem to be improving with increased production," said Fox, who tracks drug shortages nationally for the Association for Health-System Pharmacists.
Utah Health recently halted administering Evusheld -- the only COVID-19 pre-exposure preventive treatment with emergency use authorization -- "since the product is resistant to about 85% of the current COVID-19 variants circulating," Fox saidin an email. "We also stopped bebtelovimab [a monclonal antibody therapy for COVID-19] with the rest of the country."
She added: "That really just leaves Paxlovid and remdesivir -- and remdesivir is very challenging because it requires three days of infusion. Our infusion areas are already full. It's difficult to try to fit this therapy in."
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