RSV! Flu! COVID! It’s fall, and respiratory illnesses are raging. RSV, in particular, is filling up pediatric hospitals as it infects our society’s youngest and most vulnerable. Abdul dissects why we’re facing a “tripledemic” this fall sits down with epidemiology professor and author of the Your Local Epidemiologist substack Dr. Katelyn Jetelina to dig into what we can do to protect ourselves.

TRANSCRIPT

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Dr. Abdul El-Sayed, narrating: Five states pass reproductive freedom or defeat anti-abortion referenda in the 2022 midterm elections. COVID cases and hospitalizations begin to climb as new Omicron sub variants spread. A new natural experiment study found that dropping mask mandates increased COVID spread in Boston schools last year. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. [music break] Today we’re talking about the incoming tripledemic that is already hitting us this fall. But first, I want to say a gigantic thank you to each and every one of you who went out there to participate in democracy this fall. Whether it was calling or texting folks, knocking on doors, reaching out to your loved ones or just showing up to vote. Thank you. It’s not an exaggeration to say that public health was on the ballot in local, state and national elections. And thanks to so many of you, public health won. That’s not to say that some won’t keep coming for it or that we don’t have to keep showing up to defend it, but that we’ve demonstrated that we can defend it. We’ll be dissecting the impact of this election on public health in a future episode. Stay tuned. Today, though, I want to talk about what public health is up against right now. 

[clip on unknown speaker] The surge of RSV cases, the virus in children across this country, pediatric hospital beds filling with children, their highest level in two years. 

Dr. Abdul El-Sayed, narrating: If you talk to any pediatrician, there’s one big thing on their mind, RSV. Short for respiratory syncytial virus, RSV is a common virus that can cause serious illness and even death in young children. And that’s exactly what it’s doing right now. Children’s hospitals are packed with infants and toddlers with RSV. As we discussed a few weeks back, the spike in RSV is a logical consequence of the fact, this is the first year in three there aren’t any major COVID restrictions in place. Less masking, less social distancing and more time together indoors in groups, big and small means more spreading of viruses that our COVID restrictions had been holding at bay. But immunity is like anything else in our bodies. Use it or lose it. Then the fact that children were so much less likely to be exposed to RSV because of the COVID restrictions means they missed a few well, we’ll call them software updates. The virus kept evolving with school back in full swing and weather starting to get colder. All of this is leading to a perfect storm with America’s kids at the center. But it’s not just RSV. 

[clip of unspecificed news reporter] Tonight, the CDC says the number of positive flu tests so far this season is the highest in 13 years. 

Dr. Abdul El-Sayed, narrating: It’s also the flu which our COVID precautions had kept at bay, too. This year it’s back in full force. Unlike RSV, which tends to be more dangerous in young kids. The flu hits everyone. But unlike RSV, we have a safe and effective vaccine for the flu that I really urge you to consider. Meaning go get it. You may not be at high risk for a catastrophic case of the flu, but you could be at risk of passing it on to someone who might be. Oh, and of course, we can’t forget there’s still COVID. Cases and hospitalizations are starting to tick upward again. Really, it was only a matter of time. But this year, rather than a singular COVID variant, we’ve got a family of Omicron cousins that are all spreading, competing with each other to be the top of the heap. All of this has led to fears of a quote “tripledemic”, three different infectious diseases barreling down on us at once, each making the other one that much more dangerous for us overall. Beyond the risk of just getting sick, each of these diseases is deadly on its own, and that means treating them requires critical health care resources. But together, they could flood the health care system in ways we haven’t seen since the Omicron surge last winter. So just like with COVID. Doing all we can to stop the spread and quote “flatten the curve” is critical. Today, I want to talk to someone who could help us sort it all out. Dr. Katelyn Jetelina is a fellow epidemiologist, and she’s been translating our science through her incredible substack, your local epidemiologist. If you’re not reading it, I highly recommend it. She sat down with me to dig a bit deeper into this tripledemic, why we’re facing it now and what we can do about it. Here’s my conversation with Dr. Katelyn Jetelina: 

Dr. Abdul El-Sayed: All right. Ready to go? Can you introduce yourself for the tape?

Dr. Katelyn Jetelina: My name is Katelyn Jetelina, epidemiologist uh and scientific communicator. 

Dr. Abdul El-Sayed: Awesome. Thank you so much for taking the uh time to join us today. First, I just have to say that uh I really love your substack. Um. Grateful that you take the time so regularly to uh break down what you’re seeing out in the literature. And um you’ve covered everything from reproductive justice to, of course, a lot of COVID um to everything in between. So thank you for uh your work in translating science and excited to get your perspective on what we’re facing right now. 

Dr. Katelyn Jetelina: Yeah, absolutely happy to be here. Uh that substacks become a labor of love, I will say. So I’m always like, hearing that it’s useful. [laughing]

Dr. Abdul El-Sayed: So I want to jump in. Um. You know, we’re in this this moment that that folks are calling a tripledemic. And um I want to to sort of step back and get a sense of what makes this particular season such a challenge when it comes to uh respiratory viral illnesses. 

Dr. Katelyn Jetelina: Yeah, you know, every winter is when respiratory viruses really thrive. Um. And that’s because of a lot of reasons people go indoors, humidity changes. Um. We’re seeing a lot of families or social networks change. Um the last two years, though, were really interesting on a viral dynamic level because we really just saw COVID during the winters. 

Dr. Abdul El-Sayed: Mm hmm. 

Dr. Katelyn Jetelina: And this was because we’re in the middle of a pandemic and transmission was crazy, but also because of social distancing and staying at home, etc.. The challenge with this upcoming winter season is this is really the first time that we’re seeing what our normal viruses do in addition to SARS-CoV-2. And so it’s an added and very different challenge uh than the previous two winters have been and even pre-pandemic. Um I think the big question we’re asking is, can our health care systems hold up with another respiratory virus uh in winter circulating? And we are to be determined, we’ll see. 

Dr. Abdul El-Sayed: Yeah, I mean, that’s the sort of cruel um door slamming on the way out, right? I think it’s rather clear that we are still in the SARS-CoV-2 pandemic, although we’re certainly not where we were this time last year or uh the year before. Um. And at the same time, so much of what we have been doing to protect ourselves from SARS-CoV-2 creates consequences across all of these other viruses. Um. The two in particular that we’re seeing a resurgence of this fall uh are flu and RSV. Can you walk us through um what the impact of our COVID precautions have been on uh the spread of these other two viruses? And frankly, you know, all the other common cold viruses that don’t really rise to the same level of threat. Um. But what is the reason why COVID um and what we were doing in particular to protect ourselves from COVID now means that the door’s kind of hitting us on the way out. 

Dr. Katelyn Jetelina: Yeah, this is a really big discussion right now among epidemiologists. So it was a very apparent, you know, social distancing, staying at home, lockdowns uh did stop the spread of flu and stop the spread of RSV as well as it did with COVID. And I want to be clear that I still think that was necessary. Before we got COVID 19 vaccines, that was the right call 100%. Unfortunately, what that creates is a higher population with less immunity, so a lot less kids with first infections that were delayed, but also less kind of boosting, you can say of RSV, etc.. Um and so that’s kind of created a lot more susceptible people this winter that can be infected and that can get uh severe disease. There’s also another phenomenon that us epidemiologists are kind of whispering about in the back room is that we don’t know a lot about viral to viral interaction. So, for example, if RSV and flu are super high, is that maybe why we haven’t seen a COVID surge quite yet, that it’s getting pushed out? And um is there kind of something that’s going along also on a population level of this co-circulation of these multiple viruses? It may be um and that may have also contributed uh to the past two years, not just these um mitigation measures like wearing masks. So we still have a lot to learn. But what is very, very clear right now, like you said, is RSV is surging, flu is on its way up and uh COVID hasn’t started surging yet. But we are starting to get signs that it that the surge in increase, we don’t know if it’s going to be a surge is coming too. 

Dr. Abdul El-Sayed: So I want to I want to get to the viral to viral interaction in a bit, but I actually want to break down each of these uh on its own terms and clarify just um the that that pathway, uh why we’re seeing such surges in these other viruses it’s kind of that we’re all regularly exposed to RSV and flu every single year. Right. And so there’s sort of a baseline immunity that we uphold. And the fact that we’ve been using barrier protection that protects not just against COVID, but all of these other infectious ailments, means that for some time our immunity has waned from some of these other viruses, which means that now that the precautions that we were using that were so much more commonplace, whether it’s masking or social distancing uh in the past, now that those have um fallen by the wayside, largely, um justifiably or not, uh we’re starting to see these viruses hit what is ultimately a less protected and less immune population. 

Dr. Katelyn Jetelina: Yeah, that that’s basically correct. Now and I think that kind of it can be a little confusing because for example, immunity wanes really quickly with RSV. I mean, we’re talking months, it wanes. And so why would an infection two years ago be helping right now? I think that with RSV specifically, we have seen that kids, that little kids have to be infected at least three times until they’re probability of severe disease uh goes down. And so I think that’s also kind of what we’re seeing. Um. We do know that flu immunity wanes about every two years. And so I think that makes sense right now, too. 

Dr. Abdul El-Sayed: Hmm. So in terms of the kids right, who are at the highest risk of RSV, I mean, adults can be infected it shows up like a common cold, but it’s it’s toddlers in particular that are at highest risk. The issue here is that you have a whole generation of toddlers that didn’t get that sort of three spike bump in immunity. It’s like it hits you three times and then you are sort of protected after that third time. It’s it’s like your immune system sort of realizes, okay this things here to stay and I got to I got to level up for this. But they haven’t had that right because of social distancing. Um. All the kids who didn’t go to preschool or daycare that otherwise might have, uh where they would have almost definitely been exposed. And so this is all happening at once, almost to this generation of of COVID babies. 

Dr. Katelyn Jetelina: Yeah, that’s exactly right. And it’s not just those Covid babies. I mean, we haven’t seen the epidemiological data yet on the ages right now of severe disease. But I have a hypothesis that it’s also slightly older because, for example, five year olds two or three years ago were two year olds. And so we’re getting this kind of wave of people that’s infections were delayed and all getting hit at once. 

Dr. Abdul El-Sayed: Mm hmm. 

Dr. Katelyn Jetelina: Um. And I will, you know, there’s a really good question out there that we don’t have the answer to either way is, is SARS-CoV-2 infection also impacting our immune systems uh in the way that it interacts with RSV and flu? Maybe. But we we haven’t seen that data yet. 

Dr. Abdul El-Sayed: So let’s zero in on on RSV. What is it? Um. How does it usually spread? Um. What’s it associated with and what are we seeing right now in terms of the numbers? 

Dr. Katelyn Jetelina: Yeah, RSV is a respiratory cold. It’s an RNA virus, it mutates quickly. Um. It’s not new. It usually hits in the winter. However, like we’ve been saying, the pandemic really threw off viral dynamics. And for the past two years, it’s increased during the summer months, actually, and not in the winter months. Um. RSV has a R naught of three. So what that means is on average, one infected person will infect three other people. This is more contagious than the flu, but it’s certainly not as contagious as COVID, which we think has an R naught about eight right now. Um. And and this can be uh very severe for our littlest kids because of one, they’ve never been exposed before. But two, they have very small airways. And so when those airways inflame, it’s even harder for their air to get through, um especially in their lungs. And so it can uh create really severe disease for our youngest of kids, even among the most healthy, previously healthy. Um. So that’s that’s kind of RSV right now. It is. It is high, it is surging and it’s earlier than normal uh and it’s really impacting on our pediatric health care systems right now as well. 

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Dr. Abdul El-Sayed: One of the the aspects of this that um I think sometimes we forget is for so many people, their awareness of infectious disease risk, I think, has occurred uh in the COVID pandemic. And one of the subtexts of the COVID pandemic was that it while it could infect children, children were certainly spared um as compared to other viruses. You know, you think about the 1918 flu pandemic, and you were talking about spikes in children still to this day, uh flu is extremely serious in children. And so there’s almost this notion that for a lot of folks who came uh to clarity about the real risks of infectious disease epidemics that, like kids, get spared. But actually, for most diseases, kids are the ones who are hit hardest. And RSV is one of them. How how deadly is RSV and RSV infection among children? And what can people do to protect their kids? 

Dr. Katelyn Jetelina: Yeah. Before I get into that, I wanted to echo what you’re saying is that it’s very weird that SARS-CoV-2 was not deadly for kids. That is not typically how uh respiratory viruses happen. It’s usually most deadly for kids and older adults across the board. So it was very weird for SARS-CoV-2. Um. I think we got lucky, honestly, with that. But yeah, RSV is dangerous, just like the flu for kids. Um. Thankfully, RSV is pretty rare to die of uh before the pandemic about every year, 100 to 500 kids in the United States died. Um. But it is a lot more common to get hospitalized then COVID 19. So um there is that kind of severe disease burden. 

Dr. Abdul El-Sayed: What are the things that parents can do to protect their kids? 

Dr. Katelyn Jetelina: You know, with RSV compared to COVID, it lasts on surfaces a whole lot longer. It can last on hours. So on crib beds, on toys. So if you have one sick kid with RSV, make sure you clean all the toys so the other kid doesn’t get sick. Um. And we unfortunately don’t have a vaccine yet. But staying home when you’re sick as well is is huge game changer. 

Dr. Abdul El-Sayed: Yeah. And how about masks? Do they work? 

Dr. Katelyn Jetelina: We think so. We actually don’t know. So with RSV, the biggest transmission studies were done in the eighties. So a long time ago. And what those transmission studies showed was that it’s mainly spread through droplets, through coughing and droplets that um are heavy so that they land you know only a couple of feet away as well as fomite transmission so surfaces. But I think every scientists, physician, parent right now coming out of the pandemic is like, well, could it be airborne like we’re seeing with SARS-CoV-2 and flu? And it could be. We just don’t have the studies for that. So I think it makes sense that masks could help, especially in short distances. Um will it help for airborne RSV um or is RSV airborne? We just don’t know at this point. 

Dr. Abdul El-Sayed: You know, we talked a little bit about the way that um an overwhelming experience can shape the motif in the way that you think about a particular disease. And it’s interesting because one of the big debates during the pandemic was about whether or not COVID is airborne. And most of what we understand about viral respiratory illnesses is they tend to be aerosol driven. And, you know, for folks who don’t understand the difference between aerosols and uh an airborne, airborne means that literally it just lives it can it can persist in the air for hours. But aerosol is like if you took a Windex uh bottle and you sprayed a Windex bottle, you see the droplets. But it doesn’t mean that Windex is going to stay in the air for hours afterwards. Right. The droplets, even if they’re the really small ones, they land. And so our model um for infectious diseases tends to be aerosol driven. And there was a lot of reticence to believe in airborne transmission of COVID 19, in large part because this is just what we’re used to. And the thing I’m trying to illustrate here, if you reflect back to the conversation we had with Jane Coaston, is the way people think about a thing tends to be so driven by what they just they just saw and whether that was um the notion that uh because COVID didn’t cause severe illness in children, that most respiratory illnesses don’t cause severe illness in children. That’s decidedly untrue. And because most respiratory illnesses tend to be aerosol driven uh doesn’t mean that COVID had to be aerosol driven as well. And so even among scientists, I actually find sometimes that um we tend to rationalize our preexisting beliefs with data that we can cherry pick from our minds. And so even among scientists, the last experience of a thing tends to dominate what you think of the future experience of a thing. And sometimes it’s really important to sort of shake yourself out of that and say, nope, nope, nope. I’m not going to fall prey to uh that form of bias. But um I think as we think about this tripledemic, one of the reasons I wanted to have this conversation with you, Katelyn, is because I want us to recognize that you’re dealing with three different diseases. And, yes, these diseases are happening in a certain time, in a certain population, which implies a certain level of interaction. And then they may also have some biological system of interacting, uh which we’ll get to, but um one should not assume uh that any disease is happening in the same time and place have the same dynamics. And so it’s worth really thinking through all of them on their own terms. 

Dr. Katelyn Jetelina: And it’s complicated, you know, for the layman, because each one of these have different risk factors and different risk groups. And, you know, we just got done thinking about COVID 19 24/7, and now you’re adding two more to it. You know, it’s a lot it’s a lot to keep track of. Um and I think it’s also what, you know, people are just more aware now of, I think, health in general and certainly infectious diseases that we can control it a little more and there things we can do um to help mitigate the spread. 

Dr. Abdul El-Sayed: Yeah, um I really appreciate that point. I want to move to the flu now. Um. You know, it’s it’s almost like uh if you’re the flu, you got to kind of you got to kind of be sitting there being like, yo, I used to be the one. I used to be the one everyone was talking about. And I am back. And I will remind you that I am just as dangerous. Um so so walk us through this moment in influenza um uh what are we seeing in terms of the rise and um uh and and who is it affecting most? 

Dr. Katelyn Jetelina: Yeah. So influenza is on the rise as well. Um. It’s a little behind RSV, but it is increasing incredibly quickly. It’s regional differences right now too. So the South and the Atlantic is getting hit the hardest right now. Um West is starting to increase as well. And so it is it is back and it is back with vengeance and it’s early. And so a lot of us epidemiologists are very curious whether it’s just going to be early or if this is a sign of just going to be a really bad winter, because flu typically peaks in January. So uh well well, I guess we’ll see. Um. And yeah, the people most infected again are kids, especially getting hospitalized as well as older adults. I think a lot of people always forget even with RSV, just like with COVID, their immune systems are weaker. And so no matter what the virus is that they are still at high risk for RSV, flu, and COVID 19. 

Dr. Abdul El-Sayed: When it comes to the history of the flu, um it’s sort of a full circle moment because we are in the early years of COVID 19, COVID 19 is here to stay with us, likely into the future of humanity in some form, uh this flu um is uh still some distant, distant, distant relative um or descendant from the last major, huge uh respiratory pandemic that we had, which was the 1918 um flu pandemic. Can you help us understand um how the flu survives a century or how a virus survives a century um and, you know, and sort of wreaks havoc on um the descendants of people who had to live through a pandemic? 

Dr. Katelyn Jetelina: Yeah, that’s right. So the flu that created the 1918 pandemic is still around today. The difference is attenuated. So it became less severe over time. And uh that doesn’t necessarily always happen. But we were a little lucky with the flu that that did happen. And what it does is it mutates. Flu actually mutates incredibly quickly. Uh unfortunately, COVID 19 mutates four times quicker than the flu. So uh we’re moving very quickly with SARS-CoV-2 uh and we see that impact of mutations already just two and a half years in.

Dr. Abdul El-Sayed: Katelyn um there are a lot of questions, of course, about how to prevent the flu, but the they almost always lead back to the fact that we have a flu vaccine. Um. And folks will point to the flu vaccine and say, well, it’s, you know, not as effective as uh we might like. Um. Sometimes they get it wrong. Uh. What are they talking about when they say they’re getting it wrong with the flu vaccine? And uh what does that mean in terms of um if someone should take it and when someone should take it? 

Dr. Katelyn Jetelina: Yeah. So the way we create the flu vaccine is we try to predict where the flu is going to mutate in a couple of months. We try to be proactive. And what that means is that sometimes we get it right how that flu is going to mutate and sometimes we get it wrong. Uh this year it looks like we got it right. It’s working really well down in South America. And so we are pretty confident in its effectiveness up in northern America um and Northern Hemisphere right now. But it comes down to the point where a vaccine is not a vaccination. Uh you know, a vaccine in a vial is not effective it has to be in an arm. And how do we increase that? Because flu vaccine uptake right now is lower than it was pre-pandemic. And it’s, I think, a tragedy, especially since we do have a effective tool against severe disease. 

Dr. Abdul El-Sayed: You said something uh real quick. I just want unpack. It’s it’s that um it’s working really well in South America. And that’s because their flu season is flipped, right? Because their summer is our winter and our winter is their summer. And so they’re coming out of their uh winter as we’re going in. And so we can use data from South America to verify that that we identified the right uh variants that we we designed a vaccine against? 

Dr. Katelyn Jetelina: That’s right. So Northern Hemisphere is actually a bit lucky because the Southern Hemisphere flu season comes first. So we typically look at how, for example, Australia does, how for example, Chile does, and then we can brace ourselves for the northern hemisphere of what we’re going to see. And so, so yeah. And unfortunately, we only know how a vaccine works after this flu season. And so we’re just getting the data in on the southern hemisphere, how that flu vaccine worked and it’s working well. So that’s kind of how we know or how we can predict what’s going to happen in the Northern Hemisphere. 

Dr. Abdul El-Sayed: So who should get the flu vaccine? 

Dr. Katelyn Jetelina: Everyone. Everyone should get the flu vaccine. You know, I think it’s most important, I will say, among those younger kids, again, who are more at risk, as well as the older Americans over 60. But but really, everyone should be getting the flu vaccine. 

Dr. Abdul El-Sayed: Cosigned. Um I want to ask right because the flu vaccine tends to be that one vaccine that everybody has qualms with. How many times have I heard from friends and friends of friends and acquaintances and random folks I talked to in my work, like, well, I don’t get the flu vaccine because then I get the flu. Um. Can the flu vaccine give you the flu? 

Dr. Katelyn Jetelina: No, it cannot. Uh it is it’s not a live virus vaccine. There’s literally no biological plausibility in that happening. I do believe people, though, when they say they have the flu while they got the flu vaccine because there’s flu circulating, I mean, we just see it with COVID that there are some unlucky people that get COVID at CVS while waiting to get their COVID shot. And, you know, correlation does not equal causation. And so you do hear that a lot. But we are in a high flu season, too, and so it’s just going to happen. 

Dr. Abdul El-Sayed: Yeah. And a special note to um uh generally young, healthy people about uh getting your flu vaccine. I hear often well I’m young and healthy and I don’t need uh to get this. And there are a couple of points that I’ll make is that in the 1918 flu, um there was an interesting and uncommon spike in deaths among young men. And this tends to be a group of people who say, well, I have a I have a fit immune system. You should see me at CrossFit. I run a mile in less than 6 minutes. Um. One of the problems, though, is that the experience of getting an infectious disease is not just what the disease does to your body. It’s everything your body does to fight the disease. And um one of the challenges with having a really robust immune system, which, you know, you may have, is that you get really, really sick um when you get the flu. And that’s one point. So if you want to prevent yourself from getting really, really sick, maybe uh this is a good approach because, you know, you can’t do CrossFit if you’re really, really sick, just putting it out there. Um. The second point, though, is that in getting the disease, you’re increasing your probability or in having the disease in a major way, you’re increasing your probability of passing it on. And so the more of us who get uh the vaccine, the fewer of us um who ultimately get the disease, and that person you’re protecting could be a toddler that you love or a parent uh or grandparent that you care a lot about. Um. And so this is something that that all of us need to invest in. Obviously, we’ve heard this logic about about the COVID vaccines. And the funny thing is, people will point to individual probabilities of getting illness um and say, well, if it doesn’t protect me from getting uh the disease, then it doesn’t protect us, which is actually just not true. Because you’re talking about numbers multiplied, right? Probabilities multiplied over large numbers of people that then span out to now large numbers of people who are protected from getting the illness. Um. If all of us uh take the bet on that marginal risk and then, of course, there’s a risk of having very, very serious illness, which goes way down with the COVID vaccine. So the point that I hope everyone takes from this is that everyone should get a flu vaccine, that the people you’re protecting are you and also everyone else who comes in contact with you and though you may still get the flu if you are vaccinated. It does not mean that when we collectively are vaccinated that we collectively don’t get less flu. Um. And so I know that that the translation from individual to uh to community numbers is is challenging to do. Um. But it’s really important for folks to to make that calculation, to think through it um and to do the thing that’s best for them and best for everyone else. 

Dr. Katelyn Jetelina: Yeah. You know, infectious diseases violate the assumption of independence, right? I mean, this isn’t this isn’t diabetes that you can’t give it to someone else next to you. I mean, this is it has to be a team effort. And that individualistic approach has been our approach throughout the pandemic. And it’s not worked out well compared to other countries who’ve taken more of a population level approach. 

Dr. Abdul El-Sayed: What are some of the other myths that you hear um and how do you take those on? 

Dr. Katelyn Jetelina: For flu? I don’t know. The biggest one is having flu from the vaccine. Um I think what other people don’t realize another benefit is to not getting the flu is we also have long flu. I know there’s a lot of talk about long COVID, but there is long flu. It’s much less likely than long COVID, but it’s there. Um and so there’s there’s not really a benefit to getting infected versus getting the vaccine. Um. So, yeah, just go get your flu shot, please. [laughing]

Dr. Abdul El-Sayed: Yeah get your shot. It’s um, moving on. Um. The third, of course, of our tripledemic um is now the OG of all of them, uh which is which is COVID. Um. And we’re starting to see cases and hospitalizations tick up um and we’re starting to see this sort of plethora of new variants with interesting names. I had thought that we were going to go to the Greek alphabet thing so that we could like keep doing Greek alphabet then all of a sudden everyone’s like, nope, not doing that. And so now we’ve got like, you know, BQ.1, which just that sort of seems like the name of an interesting barbecue shop that I’d like to go to someday. But like, can you walk us through um why we’re seeing this this cornucopia, if you will, of new uh Omicron sub variants and um and and why it’s leading to new cases? 

Dr. Katelyn Jetelina: Yeah. So Omicron SARS-CoV-2 continues to mutate incredibly quickly, and all that it’s really trying to do is survive. All it wants to do is transmit from person to person so it doesn’t die off. And so it’s trying to find the best way to do that. And so currently we– 

Dr. Abdul El-Sayed: –Covid is just like us just– 

Dr. Katelyn Jetelina: It is!

Dr. Katelyn Jetelina: –trying to survive. 

Dr. Katelyn Jetelina: Virus. Yeah. [laughter] And it’s doing a great job at it I will say, you know. And so–

Dr. Abdul El-Sayed: Unfortunately. 

Dr. Katelyn Jetelina: Yeah. Uh. So currently there is about 300 different sub variants of Omicron. There’s two that seem to be winning the race is and here’s your Om your alphabet soup is Xbb which is in the sou– uh Southeast Asia right now and then BQ.1 which is taking over Europe and the United States right now. Um. These ha– continue to be mutations on the spike protein. So it’s getting better and better still at evading our immunity, which means that even if you’re vaccinated or infected or previously infected, you can get infected again. And uh because it’s invading that immunity, it’s finding ways to move from person to person, even if we have some sort of immunity wall. And because of that, it is upticking it’s starting to uptick very quickly in France and Germany right now and we’re starting to see signs, if you squint really closely in the northeast. 

Dr. Abdul El-Sayed: What is what is driving um this what seems to be non directional mutation? Right. We sort of went from a clear set of victors in terms of the sub variants that were enriching themselves to to this world where you’ve got a bunch of them sort of coexisting. What do we think is driving that? 

Dr. Katelyn Jetelina: So coronaviruses and flu virus at that, mutates in this latter like form typically. So one mutation comes from the previous. We always expected that SARS-CoV-2 would do that. However, it didn’t do that the first two years, right? So we got Alpha uh and Delta, which didn’t come from Alpha and then Omicron that didn’t come from Delta. And so we started getting these offshoots in the first two years. And really what the virus is trying to do is again figure out the best way to survive. And it seems that Omicron is their best bet is SARS-CoV-2’s best bet. And so what it’s doing is it’s starting to create this ladder like form. And, you know, Omicron worked. Let’s make it work a little better. Let’s make it work a little better. A little better. And so we’re starting to see this ladder like form. I will say to epidemiologists, to virologists, this is good news because it means that we can finally know where this virus is heading. We think um because that makes it a lot more predictable than, for example, a beta variant or another delta variant coming out of nowhere. Um. So yeah, this is the first year in which we’ll just hopefully I’m I do not want to jinx this, but just see Omicron um and that is a silver lining. It is slightly good news for us because that means we can create future vaccines that we can target on Omicron specifically and hopefully know where it’s going. 

Dr. Abdul El-Sayed: But that doesn’t foreclose on the ability for potentially a new clade to come up, right? One that’s not emerging from Omicron? 

Dr. Katelyn Jetelina: That’s right. And that’s why I don’t want to jinx it. Uh what’s the saying? We don’t want PI for Thanksgiving? So there is always the possibility of a variant popping out of nowhere, um especially a novel. We just haven’t had the time to see if we’re actually seeing this ladder like pattern or it’s coming out of nowhere. We thought we were seeing a ladder like pattern with Delta, and then Omicron came out of nowhere. And so, yeah, it’s very possible. I think there’s a 20% possibility that it’s going to happen this winter, that we’re going to get PI. And we think that if that happens, it’s going to be another Delta derivative. And and this is basically going to happen from a probably an immunocompromised patient that hosts Delta in their body for months and months and months, and it’s mutating within the body. And then all of a sudden it starts jumping from person to person. Uh. We actually just saw a big mutation from Delta in Texas about a week ago. Um. It doesn’t look like it’s upticking, but Delta is certainly still around. Um. So we have to just wait and see. 

Dr. Abdul El-Sayed: And when you say PI, you don’t mean the delectable dessert that we tend to eat in the fall. You mean PI the Greek letter as in the next one up after Omicron. 

Dr. Katelyn Jetelina: That’s right. Yeah. That would be the next next in line. So, so hopefully we never reach there. 

Dr. Abdul El-Sayed: I was going to say Katelyn I do want some pie, [laughter] just not PI, the, the virus uh I want to ask, we designed this new COVID vaccine that is this, this bivalent vaccine, meaning you have the original version of the vaccine and then you have this tailored vaccine to BA.5. Uh. And now we’re starting to see at least um variation that builds on BA.5 toward um what it looks to be doing is changing up the ability for our antibodies to bind. How effective is this new Bivalent vaccine against these new sub variants? 

Dr. Katelyn Jetelina: So we don’t know yet. Uh. Just like the flu vaccine, it we’re just going to be able to know retrospectively because we tried to just like the flu vaccine, predict where Omicron was going. And I will say we got very lucky in the United States that it is BA.5 that’s continuing to mutate. It looks like from lab data it’s going to work better than our original booster um in several ways. One, it’s making our antibodies more broad so it can uh recognize Omicron more specifically, um two it is increasing our neutralizing antibodies, which is our first line of defense, which will help a little against infection and transmission. And then three, we think it will help with durability, so it’ll last longer. Uh. But again, these are really all hypotheses and we we are waiting on real time data to see how well it’s working. The reason why we also included that original strain in the vaccine was in case PI came was in case another Delta variant came and we would be protected on the backdoor end as well. 

Dr. Abdul El-Sayed: Mmm. The challenge with this moment in the pandemic is one where for those of us who have uh laddered up to a fourth dose, the marginal improvement in protection of that fourth dose is far smaller than the initial improvement that someone who is unvaccinated could get by getting a first dose. And so I find that there’s a bit of a mismatch in what we’re talking about when we talk about COVID prevention in the sense that most of the hospitalization and death is attributable to people who have never been vaccinated at all. But by definition, those of us who care about COVID are doing all we can to protect ourselves and have also done all we can in the past to have protected ourselves. And so, you know, it’s interesting, right, because the pandemic is still with us, but it’s it’s largely um the the ongoing illness and or major serious illness and uh hospitalization and death is among folks who have foreclosed on the existence of the pandemic in the first place. What do you make of that and how do you think we should be talking about it and engaging with what is you know, it’s not two pandemics, but it’s a bimodal distribution of danger in one pandemic. 

Dr. Katelyn Jetelina: It’s a it’s a great question. And, you know, I actually worked with the CDC and White House, we’re coming out with a report next week on who is dying right now from COVID 19 and among the younger people it is the unvaccinated. But, you know, among 60 plus, they are the vaccinated who are dying um 60 plus that have the primary series and at least one booster. So I think that this is, like you said, it’s not a one blanket statement anymore. And we’re kind of seeing that with booster uptake right, it’s very low among younger people. And I don’t know if I blame them, especially if they’ve been infected before. But what it is really important for still are older adults, um there is no question that a booster helps a lot about 4 to 7 times higher protecting against death than just having one booster. And so, you know, I think that’s this new phase. And when we start navigating the holiday season is think about those older people that are are trying to do everything that they can but are still ending up in the hospital and dying. Um they’re still very much in this pandemic, even if us younger people really aren’t. Um. And we really need to focus now on those at highest risk and try and figure out how to decrease the number of deaths still, because 400 a day is just too much. 

Dr. Abdul El-Sayed: Absolutely. Um. I want to also ask you there’s a recent study that just came out in the New England Journal of Medicine that showed that uh when um mask mandates were dropped in Boston public schools, there was uh an increase in the rate of transmission of COVID 19, which tells us the obvious thing that masks work and mask mandates also work. Um. And at the same time, we’re in this sort of moment where masks really only work if you wear them. And every mandate in a setting where people don’t want to wear them, uh it raises the temperature um and I think has some reverberations for the credibility of public health moving forward. There is, you know of course, a clear argument that masks save lives and there are still 400 people dying a day uh in our country of this um pandemic. And at the same time, um you know, you go out in the world and um and rarely is anybody wearing a mask. How should we be thinking about mask policy uh in in this particular moment? Um. Is there an approach uh around around um trying to encourage masking uh in ways that really could um protect the most vulnerable people without and that is that is not sort of choose your own adventure um how would you think about that? What would your guidance be? 

Dr. Katelyn Jetelina: Yeah, it’s a tough question, um and I think it’s a lot of conversations a lot of leaders are having right now, especially when we start seeing our hospital systems crumbling, not just from COVID 19, but RSV and from flu. I think that’s your metric. I mean, we don’t want our health systems crumbling. It it starts impacting you even if you get in a car accident, if you have to go to the emergency room. And so when we think about that collective response that that’s really the lowest hanging fruit is let’s not crumble our systems. Um no I think the harder question is what is that threshold? Because I would argue that a lot of places right now are at that threshold, that we should have masks on a communal level. Politically, it’s just not, it’s just not going to happen. I just don’t see it going forward. Masks became a political symbol rather than a public health one. And unfortunately, I think that’s a tool that we’ve already lost. 

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Dr. Abdul El-Sayed: The other challenge I sometimes feel is that um because of this sort of uh differential distribution, there is a world where the folks who most need masking and other protection are almost least likely to use it. Um. And then you end up having a lot of folks who because it has become a political symbol on both sides, there are folks who, you know, are fully vaccinated um and are still very, very anxious about COVID. Um. And look, I understand that anxiety, but also recognize that there are always tradeoffs in terms of um our public health policies. How should we be having a conversation that offers people or should there be a tool that offers people a realistic sense of their own risks or the risks of people around them? Um. Because I worry that we kind of haven’t done that right, that there is sort of a sense of for folks who take COVID seriously, they take it very seriously, even if their risks may actually be lower than those for whom COVID is not a serious threat anymore. Um. What could that tool look like? Is there one being built um and how do you think folks would even engage something like that? 

Dr. Katelyn Jetelina: Yeah, uh there are some that are being built, but um not at a more systematic level. Um, I actually tried doing this um right after the first Omicron wave about how to understand your own risk. And I used a tool called Mort Lives. So what is the risk as of one event to a million people? So for example, um how is skydiving related to COVID 19 deaths if you’re vaccinated or not vaccinated in your age group? And skydiving is more risky um or, for example, I compared to taking heroin for a year, uh COVID is more risky for those 65 plus than taking heroin for a year. If you’re looking at dying. And so you have to start comparing what people are used to, to this novel disease. And we have not done that. Um. And that is an incredibly helpful tool, I think for people. It’s one of one of my newsletters that went viral is just because it’s useful to compare those things or about driving or about having labor. So one really interesting comparison I made was that the risk of a child dying from COVID is less risky than a woman going into labor in the United States. And so, you know, we don’t think about going into labor in the United States as being risky. And so maybe that will help parents kind of navigate the risk of their kids, too. And so it’s it’s something that hasn’t been done. It’s very difficult to do, but it’s possible. And people are looking continue to look for that. 

Dr. Abdul El-Sayed: The other um aspect of this is that before the wide access to N95 masks and don’t get me wrong, we still don’t have wide enough access, um but uh it’s certainly a lot wider than it was at the jump or even two years into the pandemic. Um. We know that uh wearing an N95 um is really protective, if you’re wearing it correctly, uh against COVID, which opens the door to sort of a one way masking approach. In the past when you’d think about your risk of COVID as a function of both your masking, let’s say you’re wearing a high grade surgical mask, but then also that risk changes substantially based on whether or not other people around you are also masked. N95s increase your protection so much that the the probability of infection is less so a function of whether or not other people are masking. Um. Do you think that there is an approach that we can take around one way masking and recommendations in that respect that sort of pull us out of this inherent uh political/cultural battle that we’re in about about what a mask means. 

Dr. Katelyn Jetelina: I think we have to be frank with who is at risk and where. That’s something that’s still missed. I mean, it would really help to have those 65 and older wearing an N95 everywhere they go in public. That would truly help. Does it help the 30 year old that has four shots like myself? It’ll help you not get sick, but it won’t help you go you know what we’re not going to end up at the hospital. And so we have to, one, define our goals and then two tell those people who are truly at risk. And then three, we have to be frank of when they’re at risk. When is transmission high? We can’t use these stupid community transmission level things from the CDC because that’s just not accurate anymore because of antigen testing. Um and so I really hope I see our response at the national level or even at state level, really laser focused on who is at risk and how can we truly change this needle um so we don’t accept SARS-CoV-2 as the third leading cause of death. 

Dr. Abdul El-Sayed: Two last questions I want to ask you about this. One is uh you mentioned testing, but we have so drawn down our testing infrastructure that it’s hard not to say that we’re we’re flying blind. Um. We just most people who are testing positive are testing positive um via at home antigen testing that doesn’t get reported. Um. And I wonder how you think about uh the risk that we face. Should we have another surge in the context of such limited reporting? 

Dr. Katelyn Jetelina: Yeah, you cannot. Don’t look at cases reported. I mean, they do not accurately reflect what’s happening out there. We’ve already seen that with the BA.5 wave that we saw wastewater going up and all reported cases was just plateauing the entire time. Um. And so it’s unfortunately another tool that’s been stripped from us. And it’s hard to know when we’re going into a wave or not, especially since we don’t have a systematic surveillance system for wastewater. We have this fragmented patchwork of wastewater which we can kind of understand. And I think that’s where we’re really focused on at least as epidemiologists of where where transmission is high and where it’s not. 

Dr. Abdul El-Sayed: Last question is, is one about uh the work that both you and I do, which is attempting to translate um fast moving science because this pandemic has been such a a universal experience. Obviously some experienced it far worse than others. But but all of us have had our lives changed in some way by the pandemic. It has become a cultural force to reckon with. And there is, of course, the COVID denialism that um that has characterized so much of I hate to say public policy that has led to unnecessary illness and death, but there’s also another side of it, which is um COVID maximalism, which, you know, does not engage with the nuances in probability of illness, probability of hospitalization or death from illness. Um. And because of the continued existence of the pandemic, folks will argue that we should we should have a very blunt response, which is probably best characterized by what we were doing the first three months of the pandemic. And um you’ve done an amazing job uh weaving through, I think, both of these strains. Right. You’re obviously not a pandemic denialist, but you’re also um a lot more nuanced about what we ought to be doing and how we ought to be tailoring what we ought to be doing um to maximally protect lives. And I want to ask you, like, where do you feel like this sort of COVID maximalist approach comes from? Um. You know, I sort of see it as a like a real profound PTSD from those first three months. Um. And how do we engage that? Because I worry that the whole sort of point that we were all trying to make is, look, watch the evidence, watch the space, watch the science be led by that. And I think folks are like, yep, there’s something there. And therefore we need to do uh we need to continue to fully and 100% interrupt our society around it. Um. Where do you think it comes from and how do you respond to it? How do you think about it? 

Dr. Katelyn Jetelina: Yeah, you know, that’s exactly how I see it, too. You know, there’s always going to be two extremes on anything. You talk about politics. You talk about a public health policy. That’s just how it’s going to be. We’re going to have this spectrum. I think, though, that people see that um and I am a little disappointed, honestly, in public health, because public health isn’t just about one disease. It’s about whole health. It’s about 360 degree view. So yeah, Zero-Covid may, for example, in China reduce the number of deaths. But is that sustainable? No. Is that good for mental health? No. Is that what humans need to be social? No. So there’s always a balance. And I always think that an extreme, doesn’t matter on each end is not the right move on a population level and people aren’t just not going to accept it. And that’s what we’re seeing and I think that’s okay. Um. So yeah, it’s incredibly difficult [laughing] to weave, like you said, and um you make a lot of enemies uh trying to weave that as well. But I think it’s the healthy approach and I think it’s the most feasible approach as well. 

Dr. Abdul El-Sayed: All right. Nobody at me or Katelyn uh when this show comes out, okay? Uh. [laughter] We want to save the maximal number of lives. All of us care a lot about people’s health. We’re not trying to deny the pandemic. We’re just saying that not everybody has the same risk. Am I right there Katelyn? Am I right? 

Dr. Katelyn Jetelina: That’s right. Absolutely. 

Dr. Abdul El-Sayed: All right. Well, our guest today is Dr. Katelyn Jetelina. She is your local epidemiologist. If you haven’t checked out the Substack, you really ought to. Um. It’s an excellent read. I learn a lot from it. You know, if you kind of want to know what like the, what the experts are reading and who they read. Katelyn is one of them. So Katelyn, thank you for coming on the show to uh to educate us um and to share a non maximalist, non denialist approach to the tripledemic that we are uh experiencing right now. Really appreciate you. 

Dr. Katelyn Jetelina: Yeah, thank you for having me. 

Dr. Abdul El-Sayed, narrating: As usual, here’s what I’m watching right now. Abortion was literally on the ballot last Tuesday in Michigan, Vermont, California, Montana and Kentucky and across the nation, the people came out to protect the right to choose. It’s not just that voters came out to protect abortion. It’s that voters came out to punish the GOP for taking it away in the first place. In Michigan, in my home state, we passed Proposal three, a ballot initiative to codify the right to an abortion in our state. But in the process, Michiganders also reelected Democratic women for governor, attorney general and secretary of state and flipped both houses of the Michigan Legislature for the first time since, get this, 1983, literally before I was born. Nationally, while the outcomes of the election still aren’t certain, Democrats will hold onto the Senate and look like they’ll have lost the House, but only narrowly. While this is great news, it still doesn’t mean that reproductive freedom is all the way back. In states across the country, abortion remains illegal and the fight to win it back continues. But we just won an incredibly important battle in that fight. That’s it for today. On your way out. Don’t forget to rate and review. It really does go a long way. [music break] America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producers are Tara Terpstra and Emma Illic-Frank. Vasilis Fotopoulos mixes and masters the show. Production support from Ari Schwartz and Ines Maza. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Sarah Geismer, Sandy Girard, Michael Martinez and me, Dr. Abdul El-Sayed. Your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health.