What will Covid look like this fall?

Jordan Heath-Rawlings By now, as sad as it is to say it, we sort of know what to expect. Summer ends, the kids return to school, more people return to the office, and more COVID. But is there reason to believe this fall might be our last time doing this dance? On the one hand, we have a new vaccine that takes aim at Omicron. We have relatively steady levels of COVID already circulating in the community, and we have a high level of vaccination and boosting among the most vulnerable groups. On the other hand, we have basically no restrictions anymore. Unless you really know where to look, we don’t have much reporting on hospitalizations or case counts either. We are flying blind a little bit. So will we see a real spike in COVID cases this fall? Are we headed for a disaster? Or do we now have enough tools to manage the level of virus that we’ve got? Please forgive me because I’ve asked this question before, but is this really the beginning of the end of the pandemic?

I’m Jordan Heath-Rawlings, this is The Big Story. Dr. Raywat Deonandan is a global health epidemiologist and an associate professor with the Interdisciplinary School of Health Sciences at the University of Ottawa. He has joined us at various times throughout this pandemic to share his wisdom. Hello, Dr. Deonandan.

Dr. Raywat Deonandan Hello.

Jordan I want to begin, I guess, with the most recent development. On Thursday of last week, the government approved a new vaccine for Canadians. Can you tell us about it and if it’s a big deal or not?

Dr. Raywat Deonandan This is the so called Bivalent vaccine, which combines elements of the original Wuhan strain of SARSCoV-2, as well as elements of the BA.1 sub variant of Omicron, which terrorized us for much of this year. And it was a big deal because the assumption was that this would be able to recapture much of the lost efficacy of the vaccines against the Omicron variant. The problem is that, as I mentioned, it’s tuned towards BA.1, and BA.1 really doesn’t exist that much more in Canada. It’s been replaced by BA.4 and BA.5. And the vaccine attuned to BA.4 and BA.5 is now licensed in the USA or approved in the USA, not yet in Canada. So we may be doing a bit of catch up here. Having said that, there is some laboratory evidence to suggest that even a vaccine against BA.1 will be somewhat more effective against BA.4 and BA.5. So it’s a better booster, we think, than the existing boosters, but probably not as good as the one that the Americans just approved.

Jordan Will we be playing catch up like this for years?

Dr. Raywat Deonandan We don’t have to. The problem is the slowness of the approval process. We don’t need months of clinical trial data for slight tweakings to an already approved formulation. We don’t do that for the flu vaccine, for example. A few weeks of laboratory evidence using animals is sufficient, to my mind, to test for additional safety signals. So this should not and will not be the future of how we unroll updates to this vaccine.

Jordan What does this mean for people who may have already had their third shot or fourth shot of the previous vaccine? Will they be getting another one sooner rather than later? Or my fifth shot will be this one or whatever one’s available at that time?

Dr. Raywat Deonandan It’s a difficult question. Yes, if you are going to get a fifth shot, somewhere down the line, it will probably be an updated version. The question is, do you want a fifth shot? And if you want one sooner, can you get one sooner? The FDA recommends that if you’ve already been boosted with the previous version of the vaccine, wait at least two months and then you’re eligible for an updated version. So no one is going to be disqualified. The question is, do you actually need one if you’ve already been boosted? That’s unclear.

Jordan So let’s talk about this fall and COVID now. School is now back in session or about to be back in session in most of the country. How do you feel from an epidemiological point of view going into this fall compared to the past two? Where are we?

Dr. Raywat Deonandan It’s really hard to compare them. We’re in a different situation, existentially. And I mean to use that word deliberately. Before the advent of vaccination, COVID was providing an existential crisis to our healthcare system, to society as a whole. And that’s not the case anymore. We no longer have, for most people, a terror of this disease at a mortal level. It’s not going to kill most of us. It is, however, going to make many of us sick enough to take time off work and to compromise the health of vulnerable people, immunocompromised and the very elderly in our communities. So that group still remains susceptible. But what we’re looking at here is a threat to the systems, not so much a threat to individuals. So what I’m afraid of this fall is enough people getting sick that our already stressed healthcare system teeters on the brink of collapse. And again, I’ve chosen those words somewhat carefully. I don’t think collapse is an entirely problematic and fearmonger-y kind of word. We’re in a situation where we have some cases of individuals calling ambulances, and the ambulances take forever to arrive. My worry is that if we get the levels of transmission that I expect we’re going to get this fall, there is a sense that perhaps we will not be getting as prompt healthcare as we’ve become used to, even when we are pretending that things are back to normal, which they are not.

Jordan I want to ask about, I know we’ve covered on this program for sure, the stress on the healthcare system, even over the summer without us being in a wave, and we’ve heard about that. What we haven’t heard about as much as we used to is the number of cases, the number of people in hospital in an ICU, which used to be sort of a daily part of our lives, that reporting. How have we done this summer? I feel like if we haven’t heard from it, it’s pretty good.

Dr. Raywat Deonandan I really can’t answer that question because I struggled to get that information as well. It’s not as easily publicly available as you might think, and for good reasons too. We are still struggling with the ‘with COVID’ versus ’caused by COVID’ distinction, which is more important now than it was before, because Omicron infects so many people, most of whom have a mild reaction. So if you don’t understand that, maybe you go to the hospital for heart disease or palpitation, or a broken leg even, and you just happen to be tested for COVID, and you’re counted amongst those with COVID, doesn’t mean COVID got you there. It’s complicated, because for someone who is sick with heart disease, for example, COVID will complicate your prognosis and will still cost the hospital additional resources to contain you, et cetera. So it’s not a completely meaningless measure. So we have to make a distinction between those who happen to have COVID and those who arrived or were hospitalized by COVID. So unless that nuance is communicated, the numbers can be dangerous.

Having said that, it does seem that we have stability in the number of people being hospitalized for COVID and an overall decline in the number of deaths. In fact, globally, the number of cases and deaths seem to be coming down, but that might be a seasonal thing. People are outside more, and so the transmission is less, and we may be seeing an increase in the fall, hopefully not.

Jordan Here in Ontario, the science table has disbanded. Other provinces have also sort of dropped precautions or scaled back. Last week, Ontario ended the mandatory five day isolation. Are our governments sort of, quote unquote, ending this pandemic for us, and do they have the power to do that?

Dr. Raywat Deonandan They may be ending the administrative aspects of the pandemic, but the essential aspects, its actual existence has not been ended. So pretending the thing is over does not make it over. It just means you don’t have to pay attention to it and spend resources on it. It also means you can download the responsibility for managing that thing onto the citizens and not have to make it part of their governmental mandate, which is unfortunate, because there’s still a role to be played here by government in making everything safer. Do they have the power to end the pandemic? Well, what is a pandemic? It is an administrative declaration by a governing body saying we have a situation of undue transmission of a disease at a global level, and how you determine that threshold is up for debate. But they don’t have the power to make it magically go away. We are still in the throes of crisis, and we will be until we get better and more durable vaccines into many arms.

Jordan You mentioned BA.4 and BA.5 circulating in Canada and the United States. We heard about those several months ago. We haven’t heard about any totally new variants since Omicron. That’s a good thing, right? Is that possible that this is the end of it? I realize this might be a totally naive question.

Dr. Raywat Deonandan It’s always possible that it’s the end. And I’ve made predictions about this being the end in the past, and I’ve been wrong, so I’m hesitant to make another prediction. But these versions of Omicron are so contagious, it’s possible that new variants are having a difficult time finding purchase within the population to outcompete the existing variants. New variants are always popping up. The question is, are the new variants going to be of greater consequence than the existing ones? And so far we’re not seeing that at least where we live. So it’s possible. But the more population immunity we have, the more vaccination we have, the more hybrid immunity, that means people who have been vaccinated and who become infected, the less likely there is going to be the opportunity for these kinds of variants to emerge. But so long as transmission is occurring as it is, then the threat remains.

Jordan I feel like I’ve asked this to a few epidemiologists now, and I don’t know when the answer will change, but are we in the endemic stage of this now?

Dr. Raywat Deonandan What does that even mean? Endemic really means no waves, and we’re still having waves. And endemic tends to be defined locally. So it can be endemic in one part of the world, but not endemic elsewhere. It’s also a bit of an administrative choice to call something endemic. Endemic is not good, necessarily. You don’t want high levels of endemicity. You can tolerate very low levels. To my mind, what we want here are low levels of endemicity to the point where we don’t have to think about this disease, let public health deal with it, and in our day to day lives, it’s not something we have to consume a lot of energy thinking about. I don’t think we’re there yet. Maybe we can have a conversation in the spring when we have more people with the new vaccine in their arms, when there’s more hybrid immunity floating around. I think the future looks good in that sense, but I don’t think we’re there yet.

Jordan It’s interesting that you define it as kind of a place where we don’t have to think about it, because I wanted to ask you about that. When you’re doing epidemiology, how do you factor in the populace’s willingness to think about these things and follow public health measures? And I ask this because I know a lot of people who I respect, who have been careful through this whole pandemic and in recent months have just stopped and they’re tired of it and they’ve stopped thinking about it and they take minimal, if any, precautions.

Dr. Raywat Deonandan Yes, it’s a good question. And when doing modeling, very often the modelers will include assumptions of the extent to which the population will adhere to public health guidelines. For example, assume 60% mask wearing, or 30% vaccination rate or 40% social distancing and those really are pulled out of the air. We don’t really know how well people are doing until we look at things like cell phone mobility data. But that’s how the models are made, with assumptions of public compliance. What you’re asking though is a greater psychological and social question, is how can we make predictions about the trajectory of the disease if we can’t be confident in public cooperation? That’s a huge question. And this is why we need social psychologists involved in pandemic response, not just epidemiologists. It’s also why this is a democratic process. Ultimately this disease goes away when people decide it’s time that it goes away. Meaning people decide we’re going to do what it takes to make it go away. And so far it looks like, as you say, the willingness is not there to quash it quickly. Therefore we’re going to struggle with this for a few more months, possibly years.

Jordan Is this a chicken or the egg kind of thing? And the government doesn’t take it very urgently, so people don’t take their individual measures as urgently? Or does it start with the people kind of being ready to move on so the government scales it back because of that?

Dr. Raywat Deonandan There’s a bit of both here. We get our values and our marching orders from our leaders. We model behavior that we see from our leaders. At the same time, our leaders hopefully are responding to the demands of the population. The problem is the population is heterogeneous. And who will our leaders listen to? Those who want greater safety or those who want freedom at all costs. It looks like the second group seems to be winning out, in terms of a governmental response. That’s a bit unfortunate. I think we need both and what we need are leaders to provide options and transparency in how they came to their decisions. And we need a population that has the educational wherewithal to understand why they need to make certain choices. It’s a complicated question and a complicated answer.

Jordan I want to ask another question that’s probably going to have the same kind of complicated answer. But this is a delicate topic. So I hear your child in the background there. I have a child that’s going back to school this week for her second year of school. I obviously don’t want her or anyone else to get sick. She’s young. She hates wearing a mask. She’s done it for two straight years now. Not many other kids in her class are going to be wearing one if what I’ve seen holds up and I feel like I’m fighting a losing battle there, and it’s not even a battle that I really want to fight. How do we protect our kids and acknowledge the reality that there will be transmission this fall, but also let them live their lives at a point where, as you said earlier, we kind of know this is not going to kill us?

Dr. Raywat Deonandan Yeah, I’ve been visiting daycares all week for my child, and no one’s masked there. And frankly, I don’t expect the kids to be masked there. I think children probably need to see some faces at a certain age, so I’m sympathetic. There are other tools we can use, though. Primarily among them is ventilation. Putting HEPA filters, portable HEPA filters into classrooms and daycares has been proven to reduce viral load in the environment. If we can encourage vaccination amongst the adults that they deal with. Right now we have very low uptake of vaccinations in the pediatric population. For kids between five and eleven, I think it’s 40% or so in Canadians who have been vaccinated. For those between 12 and 17 it’s higher, like 83% or so. And for those under five who just recently became eligible to be vaccinated, the number is astonishingly low. So I encourage parents to really consider vaccinating their kids if they haven’t been so already.

You’re probably hearing a lot of misinformation about the power and utility of vaccination. So let’s get this straight. Vaccination is amazing at preventing the worst outcomes for your child, keeping them out of the hospital and out of the morgue. It’s also pretty good at slowing transmission, despite what people might tell you. We have some new data coming out of California suggesting that vaccination slows down transmission by about 24%, even against Omicron. And with the new formulations coming out, that’s going to go up dramatically. So vaccination, ventilation and symptom checks. If your child is sick, keep them home. If there’s a sick child in your kid’s class, consider keeping your kid out if you can. You can really extend the illness free periods for your child by doing those simple things, if you cannot mask.

Jordan About those pediatric vaccination rates. I know that antivaxx misinformation is something you’ve written about a lot on your blog. I sort of understood through this pandemic that the hardcore anti-vaxx community was very vocal, but also not that big, as you can see, in kind of adult uptake levels. But when I look at those rates, it really makes me feel like they’re getting through to some people. Does that discourage you?

Dr. Raywat Deonandan It is concerning. And let’s be clear, there are anti-vaxxers who to my mind are a kind of religion, but there are also the vaccine hesitant and vaccine skeptical, who are actually the majority of people who are unvaccinated, who are just looking for better guidance and better information. We, by we, I mean the public health community, have done a poor job in really communicating well the power and utility of vaccination. And part of the reason for that is the data is moving so fast that even the experts have a hard time getting hold of them. So it’s a full time job really understanding exactly how effective these vaccinations are. I’m asked all the time simple things like how many doses do I need to prevent transmission, but my son got four doses and still got sick. Well, the element of numeracy and understanding probability comes into play here. So we struggle with educating the population with advanced mathematics now, understanding risk versus distribution, all these things come into play. It’s really difficult now. We’re playing an education game, not just a scientific game. And the challenges are enormous. We’re not getting a lot of support from government, which is worrying. I think this should be a priority of government to communicate the power and the limitations of vaccination transparently and honestly and frequently to the population. That’s not being done. And into that void comes the disinformation merchants. Some do so quite honorably and honestly, and others do so quite dishonorably and disingenuously, but they fill that void, and that’s what’s causing this crisis.

Jordan In terms of what happens next this fall, you’ve mentioned we’ll probably see another wave. We won’t know how bad it is. And you also mentioned how difficult it is to get data now compared to how it used to be. When will we know and how will we know if we’re walking into a disaster this fall?

Dr. Raywat Deonandan We will get signals from the healthcare system. And remember, the healthcare system is fragile at its best and has been at its limits the last couple of years. And so it’s, in many parts of the country, on the verge of collapse. I can use those words.

Jordan You’re not the first to have used them on this show.

Dr. Raywat Deonandan So when you hear about people calling for ambulances in urban centers and not getting one, when you hear about people dying in the ambulance waiting in the parking lot of non COVID issues, of the grandmother getting a heart attack and no one coming to help her, that’s when we know things really need to be addressed quite quickly. I hope we don’t get there. I suspect we might get to the fringes of that reality before true action is taken, but we also have the opportunity to prevent that with the new vaccines, with a revitalized and reinvigorated vaccine push, with better population choices, around masking and distancing and so forth and socialization. So we have it in our power as a population to prevent that outcome, despite what our governments do.

Jordan Do you think we have the will to go back to those precautions if necessary?

Dr. Raywat Deonandan We do not have the will to go back to economic restrictions. I think that’s pretty clear. No more lockdowns. We probably don’t have the will to accept widespread school closures. We probably don’t have the will to accept a Mask mandate across society. But we do have the will to accept the normality of Masking voluntarily and the normality of high vaccine uptake. So I don’t want to underestimate people. For the most part, people are rational. We just have to give them the appropriate tools and information and they will make rational choices. I’m fond of saying that public health is the art of the possible and what is possible is gated by public compliance and will. The public has the will. What they need is the opportunity and information to enact that will.

Jordan Last question. I’m not going to ask you to make any predictions, but I do want to ask you, are you optimistic, I guess, that this is the last fall that we will be doing this dance and having this kind of worry about a possible wave? If you want to put yourself five years in the future, looking back towards when was the beginning of the end, what are the chances this is it?

Dr. Raywat Deonandan I think this is it, frankly. I’m a stupid optimist always, but I think I’m justified in this case. As I mentioned, I think things will look pretty good in the spring. The increased levels of population immunity, the better vaccines, the high levels of hybrid immunity. The fact that things are open probably means we’re not going to be hit hard by the diseases in-wait like RSV and influenza that are probably going to hit us hard this fall, but maybe not next fall. So things will get better. As well, we have much better vaccines coming around the corner. Not this year, possibly not next year, but the year after seems pretty good. I’m talking intranasal vaccines, pan-coronavirus vaccines, to once and for all get this thing in check and to put it out of our minds. It doesn’t mean the disease will be eradicated. It means we’ll get to that point where we don’t have to think about it much anymore. So, yeah, I think let’s be diligent this fall and let’s look forward to the rest of our lives starting in the spring.

Jordan That sounds great. Thank you so much for this. All the best to you and your son in the background there.

Dr. Raywat Deonandan It’s my pleasure. Thank you.

Jordan That was Dr. Raywat Deonandan and that was The Big Story. You can find more from us at thebigstorypodcast.ca. You only have a few days left to take our listener survey. If you have not done so already, we would be most appreciative. We will start drawing names for tote bags in just a couple of days. You can find us on Twitter at @TheBigStoryFPN. You can get us via email [click here!] and you can call us and leave a voicemail. That’s 416-935-5935.

Thanks for listening. I’m Jordan Heath-Rawlings. We’ll talk tomorrow.

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