Why is everyone so sick this winter?

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Jordan Heath-Rawlings Well, I came down with something over the holidays, actually, my child did. I only got a little taste of it, but it was enough. I’m still coughing. It was my third, I think, little bug of the season and I’m just grateful they’ve all been little. So how about you? You’ve been sick the past little while. Anyone you know doesn’t have to be serious just enough to mess up your week. The odds would tell me that yes, you’ve been sick at least once over the past few months, and so have most of your friends and family. The odds would also say you probably avoided the hospital, but not everyone is playing with the same odds and a lot of those folks are sitting in hallways right now waiting for beds. Last winter cold season, we were hit with what we called a triple demic of Covid and flu and RSV and many people attributed that to viruses that were largely contained during the pandemic reentering, mass circulation. If that was true, why are we seeing the same thing again this year? Are our levels of fall and winter illness really higher than ever or do we just look back fondly at pre pandemic times when we ignored most low level colds? What’s really going on here? I’m Jordan Heath Rawlings. This, excuse me, is The Big Story. Dr. Raywat Deonandan is an epidemiologist and a science communicator specializing in global health and an associate professor at the University of Ottawa’s Faculty of Health Sciences. Hello, Dr. Deonandan.

Raywat Deonandan Hello, how are you?

Jordan: I’m doing very well. Now I want to ask you a question because it can feel very anecdotal at times. Everybody’s been telling me that they’ve been sick this entire fall and winter, my been sick this entire fall and winter. Do we know how this actually compares to what would be normal levels of illness in the community and what we’re seeing here?

Raywat Deonandan Right, so before we answer that question, let’s ask ourselves how we know everybody’s sick. As you noted, it’s anecdotal to a large extent. We also have things like the test positivity rates of people who actually show up at clinics to be tested. We have hospitalization rates and so forth. We also have wastewater levels for things like flu RSV and covid. It does look like there is more respiratory illness right now than before. If you look at RSV in particular, the wave now is bigger earlier and affecting a wider range of ages. So it’s definitely something new and bigger and every few years with RSV, there is a severe viral season, but what we’ve been seeing recently is bigger than even those severe years. So with hospital ambulatory data that can be exacerbated by other health systems issues. People have no family doctors, for example. There’s less preventative care, so people go to the ER for issues that probably should go to urgent care. So the hospitalizations are being further exacerbated by the human resources crisis. There’s a lot going on right now. Bottom line is yes, it looks like there is more respiratory illness and it looks like it’s having a bigger impact to us because of these other structural issues.

Jordan: I want to talk about why that is and what it used to be like in the past. But because you mentioned HR issues and because I know you speak to tons of people who are on the ground in hospitals, a nanos poll came out that suggests that 41% of Ontario’s hospital staff say they quote dread going into work and 43% say they are considering a new career path.Does this jive with what you’re hearing from people in hospitals?

Raywat Deonandan 100%. It is deeply troubling 100%, especially family doctors who aren’t in hospitals, but nurses and subspecialists. I mean, there are some strategies we could address to help mitigate this concern, but I’ve never seen anything like this, and it’s a systemic wide problem. It’s a society problem. This is not going to be fixed with a couple of policy leavers. This is a generational shift when we talk about the levels of hospitalization that we’re seeing and part of it being due to lack of family, doctors, et cetera, and we talk about the cycles of illness, one of the things that someone said to me when we were talking about everybody being sick this fall and winter is maybe we just don’t remember properly pre pandemic times back when you really wouldn’t go to the hospital or go get a test unless it was something really serious. And as weird as it seems, people just sort of accepted going to work with colds and coughs, and maybe this is just our pandemic awareness focusing on the illness that we’re seeing now. What do you think about that? I mean, there’s probably a little bit of truth to that. If you’re covid really cautious and you get a fever and a runny nose, you may assume, oh my goodness, I need paxlovid or intubation or something ridiculous like that. I don’t think that’s a large percentage of the people who are driving this concern. I think a lot of it is people who again, don’t have access to a family doctor, and so the ER becomes their primary source of care. If your child has a fever, you go to the er, you probably shouldn’t need to, should go to an urgent care center or to your family doctor. If you haven’t got access to those things, the ER becomes your primary go-to. I think that’s driving more of this, not a new sense of panic and inability to process risk. How much Covid is actually circulating in Canada right now and what do we know about what role it’s playing in this winter of illness we’re discussing? Has it weakened our immune systems? Is it just on top of what we’d normally be coping with? I guess I’m trying to figure out how much of this crisis is still being driven by the fact we’re in a pandemic. Oh, those aren’t controversial questions at all. Well, according to modeling done by Professor Tower Moriarty at U of T, about one in 20 Canadians right now currently has covid. Wow. Whether that’s being tested or not, that’s based on modeling.

Jordan: So a lot of us get it and don’t know we have it.

Raywat Deonandan So PET doesn’t enter the official tallies. And right now there are about 180 deaths per week caused by covid, and that’s up from 30 per week back in the summer, but declining since October. That’s a large number, 180 per week. So it’s definitely present and driving things like the death numbers and driving some of the hospitalization numbers. So if the question is how much of the hospital crisis is due to covid, it’s unclear because how do you measure that? Again, people showing up for heart disease and you test positive for covid. Does that count towards Covid being a burden on the hospital system? It probably does a little bit because you’ve got to have some covid protocols in place as well.

Jordan: Well, I’m kind of wondering what role Covid might be playing in or not playing in our ability to cope with other illnesses and what we’ve learned about its impact on us in general, assuming as I think we can, that the vast majority of people have had covid at least once by now.

Raywat Deonandan Sure, I haven’t.

Jordan: I only had it once and I dodged it successfully for three years and then lost.

Raywat Deonandan So what you’re touching on is the theory of immunity impairment that may be caused by covid infection. And this is highly controversial amongst the immunologists and specialists and it’s hard to get a sense of how true it is or isn’t. So the theorists are debating wildly about how likely this is or even how possible it is. Epidemiologically, that would seem to answer a few questions you see at the population level. For example, if repeated infections are somewhat impairing your ability to fight off other infections, then that would explain the rise in overall sickness you see in the population. But that’s pretty convenient. It might not be true. So the bottom line is we just don’t know. We just don’t know. And the immunologists have to fight it out and give us a solid answer. It might be true that it’s true for some people and not others. It might be true. It’s true for certain kinds of infections like a serious infection and not others or certain genetic predispositions. So much work has to be done to answer that question still.

Jordan: I talk to epidemiologists and people who study covid less frequently than I once did on this show, which I guess I should be thankful for. But no offence to your lovely company, but one of the things I always ask is how much more have we learned about Covid over the past year since we talked about the tripledemic last year? And in light of what you just said about immune impairment, what are we still trying to figure out here as we enter into what I guess is going to be the fifth year of the pandemic in March? Since last year, what have we learned?

Raywat Deonandan I think a lot of the work last year has been done at the nitty gritty laboratory level. So about the nature of mutation, about the impacts of specific aspects of the virus on the immune regulation systems. The stuff beyond my expertise, frankly, the epidemiology, the way that it spreads, that’s pretty solid. We have a good handle on that now. And finally, there’s consensus around airborne transmission, which was controversial the first couple of years. It’s still controversial in some circles, frankly, and that’s worrying. You see warnings spread out by the CDC other places saying Covid thought there, wash your hands. But covid is not spread for the most part by touching things and spread by breathing. So what we’ve learned is that we may learn some things scientifically, but those things often don’t translate into policy and practice. I feel like that’s the most giant lesson of the entire pandemic right there that you just summed up. Yeah, I’ve had to adopt some philosophical practices to maintain my, it’s like calming meditation and stuff like that. Exactly.

Jordan: So given that I will ask, should we just expect this level of illness and hospitalizations to kind of become our baseline winter status?

Raywat Deonandan Now, that is also a controversial topic and it comes down to the difference between immunity debts and immunity theft, which are two opposing camps in this debate right now. Those who adhere to the immunity debt idea are talking about two separate things. One is maybe covid mitigations like lockdowns and mask wearing, et cetera, impaired our individual immune system maturity, and that’s made us more susceptible to additional infections. To me that’s nonsense. And the second interpretation of immunity debt is that covid mitigations like lockdowns held back common illnesses which surge back and that makes a lot more sense except that it’s been a couple of years now since we had covid mitigations. You think the holding back would’ve been addressed by now? And we’re seeing these kinds of waves in places with minimal covid restrictions like Sweden and in US red states. So the argument kind of pales a bit, and the immunity theft camp is kind of like what we talked about already, that repeated covid infection impairs the immunity of many people for some time leading to greater infection by other diseases. But the question is, does this mean that this is the norm for future winter seasons? I think it is for a few years, but I’m the eternal optimist and I do think that we’ll settle back down to some kind of pre pandemic, not normal, but manageable state. Assuming we get the infrastructural things in order like a fixed healthcare system and assuming we get a handle on how to better produce effective vaccines on a yearly basis, it looks like we have to do this on a yearly basis and get them into people’s arms. It might be possible we get a mucosal vaccine.

Jordan: Is that the nasal vaccine that I’ve been hearing about?

Raywat Deonandan Yeah.

Jordan: Explain that then because I’ve seen a couple of people say that this is actually probably one of the keys to really ending the pandemic.

Raywat Deonandan and I’m of that opinion as well. If you think about a nightclub and you’ve got a bouncer to nightclub who’s keeping the troublemakers out, if you love the troublemakers in and they cause a fight, you’ve got to pull them out and that’s a big ordeal. If on the other hand, you can identify them before they get into the nightclub, well that solves a problem right there. A mucosal vaccine is kind of like that. It produces the immune response in the mucosa, so in your throat and your nasal passage where the virus is trying to get in the first place. And so you prevent it getting access to your body. And if you can do that well, you can prevent infection in the first place and if you can prevent infection, you can prevent transmission. That’s the idea. And there is some promising data coming out of some laboratory studies right now. All it takes is a lot of money to be thrown at the research in order to expedite its development and get a drug company to adopt it, get into people’s noses. Is that money still being thrown at this stuff? You would think it would be. You’d think it would be. So I’ve been calling for a project warp speed 2.0 for some time, and there is some movement on that front, but the urgency is not nearly as there in large part because the uptake of the current boosters is poor. Right now in Canada, we have a 15% uptake of the new X BBB tweaked covid booster, and so that is not a signal to a drop company to want to adopt the expense of financing one of these vaccines if they’re not going to recoup that expense and make a profit later on.

Jordan: That’s kind of profoundly depressing.

Raywat Deonandan I mean, there’s a role for the state here as they did in project warp speed 1.0 to step in and adopt all of that expense in order to expedite the process. So to my mind, it comes down to how will is governments largely the American government because they’re richer to step in and finance this in the meantime.

Jordan: In terms of the hospital crisis and the pressure on the healthcare system, I know you mentioned earlier this is not an easy fix. This is not like a one policy thing, but what levers do we have at our disposal based on what you see that we could use to ease some of the pressure on the healthcare system? Because I maybe do wonder if it wouldn’t feel this bad this winter and we wouldn’t be seeing these outcomes if we had the capacity we did pre pandemic.

Raywat Deonandan Yeah, it wouldn’t feel that way for most of us. For the people who are immunocompromised and struggling, they would feel equally as challenged, but the question is how can we help the healthcare system? Number one is get more nurses back in and that means paying them more and not letting labor disputes get in the way of getting good people back in. The people are out there, we just have to lure them back in. Number two is making the workplace safer. So if you mandate masks in healthcare settings that should not be controversial, so you prevent them from getting sick, they might be happier. Number three, we can slap on an urgent care center onto every ER so that people who don’t really need ER care can go to the urgent care center and alleviate the burdens on the ER centers. So that can be staffed by family doctors. Next thing to do is fix the family doctor situation. Family doctors are really unhappy, they’re overworked, underfunded, and they’re fewer of them, and we can increase the pipeline of producing more family doctors. That’s a long, longer care fix, but immediately, that’s what needs to be done, and that’s largely a financial endeavour. So that’s for the bean carriers to figure out how best to do that, and it’s not going to be cheap, but I think it needs to be done.

Jordan: I want to use a phrase I know what you’ve said it many times in this interview that these are controversial opinions, but the phrase learning to live with Covid has many meanings to many different sorts of people, and I’m not insensitive to the idea that this virus is clearly a part of our society by now and will be moving forward. My question for you, based on what you’ve seen these past couple of falls and winters is what would that look like in a way that allows us to keep sending kids to school, possibly sending people to work every day, but that is also from a medical standpoint, focused on protecting the people who still really need to be protected here. What does an ideal future look like for that?

Raywat Deonandan Right, ideal given the technologies we currently have and not a magical mucosal vaccine. Simple common sense measures shouldn’t be controversial, and the first common sense measure is acknowledging the virus exists and is here and you don’t want it. Second is how about simpler policies like having paid sick days mandated so that way workers aren’t incentivized to come to work when they’re sick. We can avoid shaming people who work from home because if you work from home, you’re less likely to get sick and to spread to your coworkers. Normalize staying away from social gatherings when you’re sick. I mean, how many gatherings this holiday season were attended by people with runny noses and coughs and sore throats? All of them. Yeah, exactly right. That’s not helping. I think increasing the uptake of our great covid booster vaccine would be fantastic. 15% is shameful considering it is showing some pretty good effectiveness in keep people out of the hospital and a normalized mask wearing, I’m not saying everybody has to wear a mask all the time, but if you’re not feeling well or if you’re not feeling confident, wear a high quality respirator mask and don’t shame others when they choose to do so as well. So I think what we need are cultural shifts and cultural shifts lead to behavioural changes, which lead to better mitigation measures.

Jordan: Last question is just what do you expect from the rest of this winter? Where are we likely from the data in terms of the cycle of rise and fall of I guess the three different kinds of illnesses we’re battling here?

Raywat Deonandan I suspect the covid wave has peaked or is peaking. I further suspect the RSV wave has already peaked. I could be wrong about that and flu really hadn’t seen any compelling evidence about flu yet. But keep in mind that hospitalizations tend to lag the infection waves, so the stress on the system will continue though the infection rate might decline. So we’re still going to see healthcare system chaos and unhappiness and people dying, but maybe fewer runny noses if that’s something. But much like previous year, it’ll taper off sometime in end of January, February, and then we’ll see a lighter spray. Dr. Deonandan, thank you as always for this, and here’s to some of those bigger measures being taken in the years to come. It’s my pleasure. Thank you, Dr. Raywat Deonandan of the University of Ottawa’s, faculty of Health Sciences. That was The Big Story. For more, you can find us at The Big Story podcast.ca. You can take a look back if you like at previous interviews with Dr. Deonandan and others and see how our opinion of what’s happening here has evolved over the past few years as mitigation measures fell illnesses rose, and we tried to figure out what exactly was to blame. You can also send us feedback, and I’m sure we’ll get some on many of the controversial things we discussed today. The way to do that is on Twitter at The Big Story fpn. You can email us hello at The Big Story podcast.ca. You can call us, leave a voicemail, six nine three five five nine three five. We take everything positive or negative, myself and the producers read it all. The Big Story is available and all of your podcast players, and it’s available on smart speakers if you ask them to play The Big Story Podcast. I’m Jordan Heath-Rawlings. Thank you for listening. We’ll talk tomorrow.

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