We’re in for an infection-filled holiday season: Will leaders step up?

By all accounts, the risk of another winter surge of COVID-19 in the U.S. is high. And this time coronavirus is on the prowl alongside two pals — influenza and respiratory syncytial virus (RSV). In some areas, hospitals are already overwhelmed.

Just how severe this “tripledemic” is going to be is unclear. But what is very clear is that a pandemic-weary public isn’t taking the threat seriously enough. Shockingly, neither is government. Biden administration officials have expressed concerns for months, but there’s been no loud alarm bells, so far. That includes at a White House briefing on Tuesday where officials barely mentioned the triple threat as they sought to jumpstart efforts to get more people boosted with the new bivalent COVID-19 vaccine.  To date, about 12 percent of those eligible have gotten the new booster.

Meanwhile, the Senate voted on Nov. 15 to end the federal government’s COVID-19 pandemic emergency declaration, in place for the past three years. This gave the Biden administration money and policy levers to combat the virus.

Lack of decisive action so far feels unwise, especially with Thanksgiving and the upcoming holidays when indoor gatherings heighten the risks of contagion. Continued inaction into 2023 will lead to unnecessary illness, work absences, economic loss — and thousands of preventable deaths.   

Let’s recall previous COVID-19 winter rampages. Last year’s surge began just after Thanksgiving and by March encompassed 75 million to 100 million infected people, some infected for the second or third time. Of the 1.1 million officially recorded deaths from COVID-19 to date, half occurred during the last two winter surges. The 2020-21 surge (November to March) brought 328,805 deaths, even as the first vaccines came into use but too late to make a big difference. Last winter’s surge killed another 227,352 people.

Deaths declined last winter from the previous year despite a higher infection rate because many more people got vaccinated, had some immunity from prior infection and took preventive steps such as masking and strict quarantining. Unfortunately, the omicron variant, which peaked last January and February, sliced through enough of that existing immunity to wreak havoc. Reinfections became common.

COVID-19 experts are now worried this pattern is repeating. This month, two new omicron variants — BQ.1 and BQ.1.1 — officially overtook BA.5, the dominant variant for the past few months. These new variants now account for almost half of COVID-19  cases nationwide.

The very bad news: Lab studies indicate mutations in the two variants could make them seven times more “immune-evasive” than BA.5.

The good news: The new variants don’t seem to cause more severe illness. Even so, the expected increase in the absolute number of new infections (in people who’ve never had COVID-19), breakthrough infections (among the vaccinated) and reinfections will lead to more hospitalizations and deaths.

As Dr. Jeremy Luban of the University of Massachusetts, a leading variant tracker, told NPR on Nov. 11: “It’s a little bit eerily familiar. … There is this sort of déjà vu feeling from last year.”

The big unknown is the degree to which prior infection with omicron or its previous variants is going to protect people from the new variants. An estimated 150 million to 170 million Americans — about half — have had been infected with some version of omicron. Many of these people have also gotten vaccinated. Having both is good: The immune system builds a multi-layered response to infection plus vaccination that researchers are still trying to figure out for COVID-19.

The bottom line is this: (a) it’s unlikely that the previously infected will be protected robustly from repeat infection and illness with the new variants and (b) it’s likely that some protection will be conferred against a bad outcome such as long-COVID, hospitalization and death.

Based in part on this calculus, and in part on sheer hope, the Biden administration has pegged its estimate of the additional deaths from a fourth winter surge at between 30,000 and 70,000. That’s on top of the underlying COVID-19 death rate of around 300 a day, prevalent in recent months. Thus, November through March could bring as many as 115,000 deaths from COVID-19 alone.   

These numbers assume a continued low level of vaccination with the new bivalent booster. If everyone eligible for that booster — all people age 5 and up — were to get it, as many as half those deaths could be prevented.

Widespread mask use would prevent infections and deaths as well. Researchers at the University of Washington’s Institute for Health Metrics and Evaluation project 46,100 additional deaths from COVID-19 by Feb.1, 2023. They calculated that 80 percent adherence to recommended masking could save about 30,000 of those lives.

As for the flu, if the numbers track the experience since Oct. 1 as many as 33 million Americans (one in 10) will get it by the end of March 2023 and up to 18,000 will die, according to CDC projections. But it’s early. Flu doesn’t usually peak until January or February. Countries in the Southern Hemisphere had it bad this summer. Thus, if the number of cases per month doubles or triples — as is likely — deaths could top 35,000 to 40,000. The very mild 2021-2022 flu season led to an estimated 9 million cases and 5,000 deaths.

Meanwhile, RSV incidence is now trending at three to six times the rate of the past three winters.  It strikes children and people over 65 the hardest. 

Preventing death is job No. 1. But it’s not trivial — to families or the economy — that COVID-19, flu and RSV could sicken 100 million or more Americans in the next five months. For COVID-19, especially, two other worrisome risks exist. The first is long-COVID and the second is the possible heightened risk of health issues and death associated with getting infected multiple times with different variants.

Numerous studies now show that between 10 and 20 percent of people who get COVID-19 continue to have symptoms or problems after they recover from the initial acute illness — and not all are older people. As I have written about before, that level of risk strikes me as well worth avoiding. While a few studies indicate omicron (and presumably its variants) appear to present a lower risk of long-COVID, the risk is still pretty high. Vaccination lowers that risk, studies have found, although how much is still uncertain.

The possible cumulative health risk associated with getting COVID-19 multiple times is also concerning. The science is much less settled on this, but one study published this month of 41,000 veterans garnered wide media attention. It found that those who got COVID-19 two or more times had, after six months, a roughly two-fold risk of both long-COVID and/or death (not necessarily together) compared to those who had COVID-19 once.

Infectious disease specialists were quick to note that the study did not involve actually tracking people in person over time. Instead, the study mined the electronic medical records of about 6 million people to find 443,588 who had one bout of COVID-19 and, among that group, 40,947 who had two or more bouts of COVID-19. The caveat is that such studies don’t prove cause and effect; other factors than multiple bouts of COVID-19 could have yielded the excess risk.

The COVID-19, flu and RSV alarm bells I mentioned above could come in the weeks ahead. The question is whether government and public health officials will have the courage to defy public apathy, inertia and resistance to implement a return to public health measures — such as mandated masking in public places, restricted access to public venues and events unless vaccinated, and travel warnings. 

I think mandated masking for public transportation nationwide should already have been reinstated. Of course, every American can and should adopt a DIY COVID-19, flu and RSV protocol this winter. Tailor it to yourself and your family. As inconvenient and depressing as this may be — yet again — risking long-COVID, hospitalization and death seems foolish. With luck, it’ll be just one more winter.

Steven Findlay, MPH, is an independent health policy analyst and journalist. He previously worked as a senior health policy analyst at Consumers Union, as well as director of research and policy at the National Institute for Health Care Management.