Can California avoid a third devastating COVID-19 winter wave? Cautious signs of hope

For the last two years, Thanksgiving served as a sobering reminder of the COVID-19 pandemic’s staying power.

For each, the holiday essentially marked the turbocharged start of the severe fall-and-winter COVID-19 wave, which both resulted in the deadliest surges of the pandemic, killing thousands of Americans a day.

But there’s some guarded optimism that this winter might be different — or at least not as bad as the 2020 and 2021 surges.

“You never can definitively say what to expect,” said Dr. Anthony Fauci, President Biden’s outgoing chief medical advisor for the pandemic. “But you should really take some comfort in knowing that we have within our wherewithal to mitigate anything that comes up our way.”

Some of the advantages we have this year is an updated COVID-19 booster shot that’s pretty well matched to the circulating strains of the coronavirus, ample supplies of at-home rapid tests, and general awareness of steps we can take to avoid illness, including masking up in indoor public settings, staying home when sick, and improving air flow by taking events outdoors, opening windows and turning up air filtration units.

When it comes to gatherings now, “I think there’s ways that we can really improve how we do it, rather than spend our time talking about whether we should or shouldn’t,” said California Health and Human Services Secretary Dr. Mark Ghaly.

There’s even some promising news about the unrelenting emergence of coronavirus subvariants, none of which has dramatically raised alarm bells the same way the original Omicron strain did when it stormed onto the world stage last Thanksgiving.

One note of optimism comes from Singapore, which recently experienced a big wave in coronavirus cases fueled by the Omicron subvariant XBB, a recombinant of the sublineages BA.2.10.1 and BA.2.75. XBB has generated concern that vaccines may not be as effective against it.

“They had [an] increase in cases, but they did not have a concomitant major increase in hospitalizations,” Fauci said Tuesday. “So we’re hoping that a combination of people who’ve been infected and boosted and vaccinated — or people who’ve been vaccinated and boosted and not infected — that there’s enough community protection that we’re not going to see a repeat of what we saw last year at this time.”

Two other Omicron subvariants, BQ.1 and BQ.1.1, accounted for about 57% of estimated coronavirus cases for the most recent week available, according to data from the U.S. Centers for Disease Control and Prevention. Both are descendants of BA.5 — a long-dominant strain that fueled a surge this summer.

But some experts who had previously warned about the rise of new Omicron subvariants say the latest data appear reassuring for now. New York state, for instance, has the highest proportion of BQ.1.1 in the nation — yet there is no sign of hospital admissions likewise increasing, said Dr. Eric Topol, director of the Scripps Research Translational Institute in La Jolla.

In California, however, coronavirus-positive hospitalizations have been increasing. As of Wednesday, there were 2,782 coronavirus-positive patients in hospitals, up 84% from the autumn low of 1,514 on Oct. 24. This summer’s peak was 4,843, set on July 26, and last winter’s peak was 15,435, set on Jan. 21. The all-time high, 21,938, was set during the first pandemic winter on Jan. 6, 2021, and the all-time summer high was 8,353, set on Aug. 31, 2021.

Nationally, hundreds of Americans are still dying every day of COVID-19, which remains a leading cause of death. And there are signs that transmission is once again on the upswing.

Los Angeles County is averaging 2,337 coronavirus cases a day for the week that ended Friday, up 32% from the previous week. On a per capita basis, L.A. County is seeing 142 cases a week for every 100,000 residents. A rate of 100 or greater is considered high.

L.A. County’s coronavirus case rate has been climbing since mid-October, when it hit an autumn low of 60 cases a week for every 100,000 residents. The latest case rate is the highest it has been since Labor Day.

California is recording 95 coronavirus cases a week for every 100,000 residents for the seven-day period that ended Tuesday. The state’s rate climbed 16% over the previous week.

Estimates suggest the share of admitted coronavirus-positive patients statewide who are in the hospital due to COVID-19 illness has remained relatively stable, at around 45%, since April. The other patients are being treated for issues not related to COVID-19.

BQ.1.1 has been concerning because of assessments that it was “one of the most immune-evasive SARS-CoV-2 variants yet seen,” Topol wrote in a blog post, including “resistance to all available monoclonal antibodies,” referring to medicine that can help treat coronavirus-infected patients or prevent infection.

“This is the first time in the pandemic that a variant with clear-cut, marked immune evasion has not induced a major new wave,” Topol wrote. By contrast, several of the Omicron subvariants that became household names, like the original version, and then BA.2 and BA.5, “led to major waves globally.”

It could be that cumulative immunity is now having an effect against the latest strains.

“Under pressure from prior infections, vaccinations, boosters and combinations of these, the virus is having a harder time finding new hosts,” Topol said. “To date, BQ.1.1 has not been able to induce a new wave in two countries, a very positive sign.”

The optimism doesn’t mean that “we’re out of the woods,” Topol said. And it’s not to say that the rise of BQ.1.1 is without consequence.

Already, the variant has rendered monoclonal antibodies intended to be used as medicine to treat or prevent COVID-19 effectively useless. UC San Francisco said it is discontinuing administration of bebtelovimab and Evusheld due to “a rapid increase in circulation of Omicron subvariants predicted to have resistance” against the drugs. Paxlovid, an antiviral oral medication, continues to be an effective treatment against COVID-19.

The rate at which the coronavirus is mutating has risen by 30% in the last year, Topol added, so there’s still room for Omicron “to pose a significant threat.” And there’s still the possibility that problematic variants could emerge in the future.

Much of the optimism surrounding this fall and winter stems from the availability of updated COVID-19 booster shots. Data released this week show that the updated COVID-19 vaccines offer “significant additional protection” against symptomatic infection in people who were previously vaccinated or boosted with the older formulation.

“Everybody was asking the question, ‘Where’s the clinical efficacy data?’ Now it has come out with the CDC [report] this morning,” Fauci said. “We know that it is effective.”

However, uptake of those doses has been slow out of the gate.

Statewide, about 16% of eligible residents have gotten the updated booster.

“We have seen very low uptake of the bivalent booster,” Ghaly said recently. “I know I have conversations every day with Californians asking whether they should get it, whether now is the right time. And it’s a resounding yes.”

The coronavirus is also not the only game in town heading into this winter. Flu is surging at a level not seen in years, and RSV is continuing to stress children’s hospitals across California. Regarding the flu, though, this season’s vaccine appears also well matched to the currently circulating strains.

Nationally, hospitalization rates related to RSV — or respiratory syncytial virus — are exceptionally high, said Dr. Theodore Ruel, chief of UC San Francisco’s pediatric infectious diseases and global health division.

RSV also continues to stretch the available emergency room capacity at Children’s Hospital Los Angeles, meaning the facility cannot always accommodate patient transfers from elsewhere. The primary pediatric hospital in Orange County is observing a high number of emergency room visits daily, according to the county’s Health Care Agency.

Riverside County reported the death of a child younger than 4, possibly from RSV, in the eastern part of the county, officials said Monday. The child died after a short illness at a hospital.

Officials say that babies at high risk for severe RSV — like premature infants and young children with heart and lung conditions — can take a medicine known as palivizumab to help protect them. “If you are concerned about your child’s risk for severe RSV infection, talk to your child’s healthcare provider,” the Riverside County public health agency said.