Pandemic-Year 4: It Is Not Over Until It’s Over as New Variant Sweeps US

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People aren’t taking this seriously’: experts say US Covid surge is big risk

Fewer precautions, recent holidays and subvariants have driven rise but boosters, masks and other precautions are still effective

A billboard promotes Covid-19 vaccinations in Times Square in New York last month.
A billboard promotes Covid-19 vaccinations in Times Square in New York last month. Photograph: Justin Lane/EPA

In the fourth year of the pandemic, Covid-19 is once again spreading across America and being driven by the recent holidays, fewer precautions and the continuing evolution of Omicron subvariants of the virus.

New sub-variants are causing concern for their increased transmissibility and ability to evade some antibodies, but the same tools continue to curtail the spread of Covid, especially bivalent boosters, masks, ventilation, antivirals and other precautions, experts said.

People gather at Grand Central Market in Los Angeles, California. Evidence of increase in Covid cases in the US was seen in earnest after Thanksgiving.
US public health officials brace for possible Covid-19 surge after holidays

Yet booster uptake has been “pitiful”, said Neil Sehgal, an assistant professor of health policy and management at the University of Maryland School of Public Health. Antiviral uptake has been low, and few mandates on masking, vaccination and testing have resumed in the face of the winter surge, which is once again putting pressure on health systems.

New Covid hospital admissions are now at the fourth-highest rate of the pandemic, according to the US Centers for Disease Control and Prevention (CDC). Covid hospitalizations declined somewhat after the summer wave, but never dropped to the low levels seen after previous spikes, persisting through the fall and rising again with the winter holidays.

“Hospitals are at maximum capacity,” said Brendan Williams, president and CEO of the New Hampshire Health Care Association, of his region’s current rates. “I’m not sure what the trajectory of this thing’s going to be, but I am worried.”

The majority of Covid hospitalizations are among those 65 and older, although the share for children under four roughly doubled in 2022.

In the past week, Covid deaths rose by 44%, from 2,705 in the week ending 4 January to 3,907 in the week ending 11 January.

This is one of the greatest surges of Covid cases in the entire pandemic, according to wastewater analyses of the virus. It’s much lower than the peak in January 2022, but similar to the summer 2022 surge, which was the second biggest.

And it’s not done yet. “Certainly it does not appear that we are peaking yet,” Sehgal said.

The Omicron subvariants BQ.1.1 and BQ.1 as well as the quickly expanding XBB.1.5 make up the majority of cases, according to CDC estimates. The north-east, where more than 80% of cases are estimated to be from the XBB.1.5 subvariant, has the highest proportion of cases, according to wastewater data.

“With XBB, there’s such a significant transmission advantage that exposure is really risky – it’s riskier now than it’s ever been” in terms of transmissibility, Sehgal said.

Official case counts have been slower to rise, because of the prevalence of at-home tests and because of a general reluctance to test at all, experts say. Of the tests that are reported, however, positivity rates have been very high, with about one in six tests (16%) turning positive.

Despite the high rates of Covid spread, hospitalizations have not yet reached previous peaks seen earlier in the pandemic, probably due to immunity from vaccinations and prior cases, said Stuart Ray, a professor of medicine and infectious diseases at the Johns Hopkins University School of Medicine.

But that protection should not be taken for granted, he said, particularly because immunity wanes.

Nurses administer Covid-19 tests to members of the public at a testing site in Washington DC.
Nurses administer Covid-19 tests to members of the public at a testing site in Washington DC. Photograph: Michael Reynolds/EPA

“Boosters really do make a difference,” he said. “The severe cases we are seeing are probably at least somewhat avoidable, if folks make sure that they stay updated on vaccination, because that’s still the safest way to gain immunity.”

Boosters, especially the updated bivalent boosters, are highly effective at reducing the risk of severe disease and death. Yet only 15.4% of Americans over the age of five have received the new boosters.

“You’re just fighting a lot of misinformation and also some political missteps when it comes to the vaccines,” Williams said. When Joe Biden declared the pandemic was “over” in September, he said, it probably stalled public enthusiasm for the new booster and spurred further inaction from Congress on more funding to address the pandemic.

“It’s challenging to strike that parallel narrative that you shouldn’t worry about Covid but also go get a shot,” said Sehgal, calling the declaration “another unforced error”.

While vaccines are very important, other precautions also help prevent infection, disease, and death, Sehgal said – particularly important during a surge like this. Yet because of poor messaging from officials, many people may not even realize the US is experiencing a surge and precautions are still necessary, he added.

“I think the majority of people who aren’t masking today, just don’t know that they should.”

Even if the US reaches the point where surges do not cause a corresponding increase in hospitalizations and death, they will still increase the number of people sickened and disabled by long Covid, experts said.

“There’s accumulating data that repeated Covid accumulates risk for short- and long-term complications, including cardiovascular, mental health and other problems,” Ray said. “We will only know in retrospect exactly how big this cost is. But evolving data suggests that there is a cost that’s incremental as we accumulate infections.”

Williams is worried that hospitals are reaching maximum capacity even as long-term care facilities see outbreaks among residents and staff, after years of worker shortages.

“In New Hampshire, nursing homes will not admit those that they feel that they cannot staff to care for, which I think is admirable, but the consequence of that is that the hospitals are jammed up,” he said. Hospitals that might release patients to care facilities for transitional or long-term care will see beds filled for longer, putting even more pressure on the hospitals, patients and health workers.

“It’s a continuum, but right now the continuum is broken,” Williams said.

Health workers have experienced three years of burnout, disability and death, and some have needed to exit the workforce. Others have been alarmed by unsafe working conditions and the continued crises caused by the pandemic. Nurses in New York reached a tentative agreement this week after striking for safer working conditions.

Joe Biden received his vaccine booster in public but perhaps undermined the message by declaring the pandemic was ‘over’.
Joe Biden received his vaccine booster in public but perhaps undermined the message by declaring the pandemic was ‘over’. Photograph: Jonathan Ernst/Reuters

Nursing homes and residential care facilities have roughly 300,000 fewer workers today than there were in March 2020, Williams said. “It’s hard to see how it’s going to get better,” he said.

In the meantime, Covid continues circulating, with nursing home residents and staff seeing one of the biggest rises in cases of the pandemic.

“The first key to keeping people healthy in a nursing home is to keep people in the community healthy,” Williams said. But “it just doesn’t seem like people are wearing masks and getting boosted – people aren’t taking any of this seriously. We just seemed to declare that when it comes to Covid mortality, we’re number one, and that’s a title that we’re not going to relinquish to any other country.”

Sehgal calls it a “collective forgetting” about how and why we need to protect ourselves and one another. “There are people for whom a mild infection actually isn’t so mild, either because of their underlying health, or because of social factors in their life,” he said. “It’s just a tremendous self-inflicted wound.”

And the more the virus spreads, the more opportunities it has to evolve, potentially picking up mutations that make it easier to overcome immunity.

Yet the same measures that helped curb previous surges still work today. And they don’t just prevent illness and death – they also minimize social disruption, like lost hours at work and school. “Those steps that we can take to protect ourselves and protect other people – they don’t seem onerous in the face of a Covid infection,” Sehgal said.

As Ray put it: “When we could be wearing a mask, why aren’t we?”

People who haven’t had COVID will likely catch XBB.1.5 – and many will get reinfected, experts say


Variant XBB.1.5 is very contagious, meaning everyone is at risk even if you’ve already been infected. As the U.S. enters year 3 of the pandemic, here’s an update on the state of COVID.

The newest COVID-19 variant is so contagious that even people who’ve avoided it so far are getting infected and the roughly 80% of Americans who’ve already been infected are likely to catch it again, experts say.

Essentially, everyone in the country is at risk for infection now, even if they’re super careful, up to date on vaccines, or have caught it before, said Paula Cannon, a virologist at the University of Southern California.

“It’s crazy infectious,” said Cannon, who is recovering from her first case of COVID-19, caught when she was vacationing over the holidays in her native Britain.

“All the things that have protected you for the past couple of years, I don’t think are going to protect you against this new crop of variants,” she said.

The number of severe infections and deaths remains relatively low, despite the high level of infections, she said, thanks to vaccinations – and probably – previous infections. But the lack of universal masking means that even people like her, who do wear masks, are vulnerable.

A look at the state of the COVID-19 pandemic, according to data from the CDC.

The latest variant, called XBB.1.5, grew exponentially over the month of December, from about 1% of cases nationwide to 27% as of Jan. 7, according to data from the Centers for Disease Control and Prevention. The variant is likely behind the vast majority of cases in New York and New England.

Its growth is probably due to XBB.1.5’s characteristics – it appears to bind even more tightly to receptors in the human body than its predecessors – as well as human behavior, such as traveling and not masking.

It’s a good idea to do what you can to avoid getting infected, said Dr. Ziyad Al-Aly, chief of research and development at the VA St. Louis Health Care System and a clinical epidemiologist at Washington University in St. Louis.

It’s still early and there are a lot of unknowns about XBB.1.5, he said. Every infection makes someone vulnerable to a bad course of the disease and to the lingering, miserable symptoms of long COVID, Al-Aly’s research shows.

“Reinfection buys you additional risk,” he said.

As the United States enters the fourth year of COVID-19, we’re providing an update on the state of the pandemic. Here’s a preview of what you’ll learn in this article: 

What to know about XBB.1.5 symptoms and how long they last

COVID-19 symptoms typically last around five to seven days and can include fever, sore throat, muscle aches, exhaustion, nausea, cough and sinus congestion, among other problems.

Symptoms with XBB.1.5 are the same as with earlier variants and can range from almost nothing to shortness of breath and low oxygen levels that require emergency medical attention.

Early in the pandemic, COVID-19 often cost people their sense of taste and smell, at least temporarily, but that symptom seems less common, possibly because of vaccination or previous infection rather than a change in the virus, said Dr. Peter Hotez, an infectious disease specialist and co-director of the Center for Vaccine Development at Texas Children’s Hospital.

How long does COVID last? How long are you contagious?

It takes anywhere from two to 14 days for exposure to lead to symptoms and a positive test.

People with COVID-19 are contagious as long as they remain positive on a rapid test, typically for about 10 days, but often longer.

The CDC recommends people isolate for at least five days and wear an N95 or similarly protective mask for at least 10 days when around others. Day One is considered the first full day after symptoms start.

A PCR test, which is considered the gold standard for diagnosing COVID-19, can remain positive for months because it detects viral fragments as well as the whole, infectious virus. To confirm the end of the contagious period, experts instead recommend a negative rapid test after 10 days or two within 48 hours if sooner.

Can you get COVID more than once?

Yes. While a previous infection provides some protection, that fades over time and as the virus evolves into different variants.

Some people who had a mild case with a first infection get hit harder the second or third time, while others might suffer less.

“Even if you’ve had it before, that doesn’t mean your next bout is going to be the same,” Cannon said. There are lots of factors at play in determining the seriousness of an infection, she said, including prior immunity, the nature of the variant and how long it’s been since your last infection or vaccination.

It’s possible that her recent infection was much milder than her husband’s, for instance, because she had caught a head cold a few days earlier, while her husband hadn’t. A respiratory virus can put the immune system on high alert and might have provided some protection when she was exposed to COVID-19.

“It’s part of the bigger dance between our bodies and our immune system,” Cannon said.

How to avoid infection

The methods for avoiding infection haven’t changed, though it can be hard to stick with them when no one else is: Get vaccinated, wear a mask and avoid crowded spaces.

First is getting vaccinated. This will protect against severe infection as well as reduce the risk of passing the virus to others, said Hotez, also dean of the National School of Tropical Medicine at Baylor College of Medicine.

The newer boosters, which take aim at both the original virus and the BA.4/BA.5 variants common this summer, are more protective against XBB.1.5 than earlier boosters. People who are up to date on their COVID-19 shots probably don’t shed as much virus for as long, so they’re also less likely to pass it on, he added.

Past infection provides some protection against severe disease, but that protection is “highly unreliable,” Hotez said.

Second is wearing a mask. Good quality, well-fitting masks, like an N95 or KN95 can reduce the risk of infection.

Third is avoiding crowded indoor spaces. You’re less likely to get infected in large indoor spaces with high ceilings and lots of ventilation than in cramped, airless ones.

What to do if you get sick

It’s a good idea to have a plan ready in case you get sick, Cannon said. She suggests every plan include:

  • How to isolate from others in your household
  • The contact number for a health care provider who can prescribe an antiviral
  • Equipment such as rapid coronavirus tests, extra masks, a thermometer and a pulse oximeter to make sure the patient’s blood oxygen level doesn’t drop below the low 90s

Every U.S. household is eligible for four free coronavirus tests from the government that can be ordered from this link: covid.gov/tests.

For someone over 60 or with medical conditions like obesity that raise the risk for serious disease, the first step after a positive test should be a call to the doctor to get the antiviral Paxlovid, she and others said. The government has pre-bought millions of doses, so they are available for free.

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