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Some pediatric units are reaching capacity already and experts are warning of a possible “Tripledemic” of respiratory viruses this winter. With an early surge in RSV cases, the upcoming flu season and the possibility of a COVID-19 surge, emergency rooms are preparing for a flood of visits in the coming month. Dr Bob Wachter sits in for Andy and talks with Dr Caitlin Rivers, an Infectious disease epidemiologist at Johns Hopkins about how to protect you and your family this Thanksgiving.

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Check out these resources from today’s episode: 

• Read Dr. Rivers’ Subtack “Force of Infection” at https://caitlinrivers.substack.com
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Transcript

SPEAKERS

Andy Slavitt, Bob Wachter, Caitlin Rivers

Bob Wachter  00:23

Hi, I’m Dr. Bob Walker, Professor and Chair of the Department of Medicine at the University of California San Francisco, you might remember me having guest hosted the show for about four months in early 2021 when Andy was in the White House. As a devoted listener to the show. It’s great to be back well Andy’s taking a well-deserved break for a couple of weeks. Well, we find ourselves in yet another interesting time and the pandemic cases beginning to tick up a bit. And the alphabet soup of new variants has emerged with some uncertainty about their impact on cases and severe disease. We have a new booster, but it was engineered against the last variant which is rapidly be replaced by a new variant. So the question arises about how well it will work. Winter is coming as they like to say, and colder weather will push people indoors, which generally means more spread of viruses. Even as we all get a handle on how to manage COVID. In our lives, we now hear talk about a tripledemic with two other viruses rearing their heads, RSV and flu. There’s a lot to talk about. And we’re lucky to have one of the world’s top infectious disease epidemiologists, someone who’s well known to in the bubble listeners to help explain it all. Caitlin Rivers is an infectious disease epidemiologist at Johns Hopkins where she specializes in outbreak preparedness. She’s been a very busy person for the past three years. She recently completed a stint as one of the founding leaders of the new center for forecasting and outbreak analytics at the CDC. So Caitlin, Welcome. Nice to see you again.

Caitlin Rivers  02:54

Thank you, it’s great to be back.

Bob Wachter  02:56

Let’s start with this scary word triple, tripledemic. Walk us through what it means and what the three viruses that we’re talking about our

Caitlin Rivers  03:06

Tripledemic describes a scenario we may be heading into this winter where we are facing not just COVID-19, but also a resurgence of influenza and RSV or respiratory syncytial virus. And the idea is that these three viruses may give us a bit of a walloping this winter, affecting children in particular that I’m worried about. And so watching the science closely to see how this season gets started.

Bob Wachter  03:30

So we’ll talk a little about sort of the interplay between these three, and then we’ll talk about each of them individually. But let’s just start this a COVID infection, protect you against flu or protect you against RSV, and that also does vaccination for one of them protect you against the others.

Caitlin Rivers  03:47

It does not to both of those questions. COVID infection does not protect you from flu, and it does not protect you from RSV. Many people think of RSV as a virus that mostly infects children. And that is true, but you do get reinfected with RSV across your life. So it’s would not be out of the question to get all three in a single season. And similarly, vaccination for one does not protect against either of the other two.

Bob Wachter  04:10

We’ve been told for the last few years, we’ve all gotten a crash course and the immune system, we’ve been told it’s incredibly smart and clever and adaptive. Why isn’t it smart enough that if you have immunity against one thing, it helps you against another thing.

Caitlin Rivers  04:24

Viruses are smart, too. And they have all sorts of ways of getting into your body and making you sick. And they also change very quickly. And that’s why we have to get re-vaccinated for influenza every year because it changes in such a way that your body doesn’t necessarily recognize it from year to year.

Bob Wachter  04:39

So of the three viruses, SARS-CoV-2 are the one that causes COVID flu or RSV, which one is the one that concerns you the most right now|?

Caitlin Rivers  04:48

It depends on who you are for children and older adults. RSV is really concerning to me right now. Because it’s we’re in a big wave. We’re in the largest RSP wave that we’ve seen in Alberta. For years, maybe longer, it’s a very hard virus for small children and for people who are older. And so that right now is the biggest threat. But looking ahead a couple of weeks, maybe even a couple of months, Influenza looks like this is going to be the year that it’s that it will make a big comeback. And that really can make you not feel good. And so that’s why I think Influenza, it’s important to get vaccinated to try to prevent that.

Bob Wachter  05:24

So let’s go ahead and start with the flu. And then before we’ll segue to RSV in the world spend a little bit of time on the current state of Covid. So what are you seeing as you look at the current data about the flu, is this a particularly terrible year, or is this just sort of a normal bad flu year, but we’re we’ve had a two or three year vacation from the flu?

Caitlin Rivers  05:46

That’s right, we have had a two or three year vacation, and that has set us up to have a big wave. Normally, a sizeable fraction of the population gets infected with influenza every year, and so they may retain some immunity going into the next season. And that means there at any given normal season, there aren’t as many people who are available, if you will, to get infected. But because we’ve skipped to the last few flu seasons, there’s been a buildup of the susceptible population. And that puts us in a bad spot for flu to really sweep through this year. And indeed, that is what we are seeing, we’re about a month or two ahead of our normal flu season. And we’re already ranking to be one of the worst flu seasons of the last few years. And so it is definitely circulating. But I will say we don’t yet know about the severity; certain flu seasons cause more severe illnesses than others. And the data are not in yet to determine where we are in that scale.

Bob Wachter  06:37

And is that because of variants that each year, the flu that we’re confronted with is a little bit different than the one before it. So it the sit the thinking that we’ve all come to know and love and COVID about how infectious it is and how severe it is, and how immune evasive is, is the same thing true every year as you think about the flu.

Caitlin Rivers  06:55

It is it is it can vary based on the variant, if you will, that is circulating, and also based on whether or not the vaccine is a good match for the strain that that ends up circulating.

Bob Wachter  07:05

And tell us about the process of creating the flu vaccine each year. And then we’ll talk a bit about how this particular one seems to be holding up.

Caitlin Rivers  07:13

The strain selection that goes into our seasonal that flu vaccine is done months in advance, the process usually happens late winter, early spring from the previous year. And that makes it a bit of a guessing game. There are experts who convene to determine what strains they think should go into the seasonal flu based on what has happened in the southern hemisphere based on what they’re seeing in early surveillance data. And that process because it needs to be done so far in advance in order to have time to manufacture and distribute the vaccines sometimes does not get it 100%. Right. But I will say that two strains that we’re seeing in the US right now are H3N2 and two and H1N1 and both of those are in the seasonal flu vaccine this year. So we can’t say for sure that it’s a good matchup. But based on what I’m seeing right now, I feel pretty good about it.

Bob Wachter  07:59

Interesting that they’re taking their cues partly on what happened in the southern hemisphere, it’s because they’ve had, they have their winter when we have our summer. And is that that turned out to be fairly predictive that what hits Australia and in their winter is what tends to hit us in our winter.

Caitlin Rivers  08:15

That’s right. And I had my suspicions about this flu season, particularly being rough because I saw it in Australia, they had an early flu season, and it was fairly widespread and what they experienced can often foretell what we will experience, but their severity was not as high as it could have been. And so that gives me hope that perhaps the severity of the flu strains that hit us this season will not be as bad as they might be.

Bob Wachter  08:39

What do we know about flu vaccine uptake on in a usual year? And do we think all of the chatter about COVID vaccines has influenced flu vaccine uptake, either positively or negatively?

Caitlin Rivers  08:53

Flu vaccine in a normal year, the uptake is not great. I would say it’s around 40% of adults a little bit higher fraction of children. That leaves a lot of room for improvement, flu vaccine, I think people are not always excited to get it because they hear that it may not work and you have to get it every year. Why bother? I’ll tell you I’ve got my flu vaccine. And I make sure my family does too because it really can save you from a week or two of feeling very crappy.

Bob Wachter  09:18

Is it indicated for everybody or remember the old days it was sort of if you’re over a certain age, you should get flu vaccine, but under a certain age, maybe not so much. What are the indications to get it now?

Caitlin Rivers  09:29

It’s indicated for everyone. Yes.

Bob Wachter  09:34

So they make a guess as to when as to what the variants are likely to be. It’s interesting that you frame it that the reason it might be worse now is that we all had a couple of flu free years and our immune systems got a little sloppy when it comes to the flu. What do you think the absence of masking or the relative absence of masking is doing to the flu pandemic, did masking prevent the flu from now outbreaks in the last couple of years. And is that why we’re seeing such a big outbreak this year?

Caitlin Rivers  10:03

Yes, I think so, I think masking is effective at preventing respiratory viruses from circulating and what helped for Covid. What was implemented for Covid“ also helped for flu. But just to return briefly to one point, it’s not our individual immune systems that got sloppy, it’s that so many people were spared infection that there is now a lot of population level susceptibility. There’s some misinterpretation that I see online sometimes that our individual immune systems may not have gotten the workout that they needed to stay healthy. And that’s not the case. It’s really a population level effect that has put us in a position to face a fairly big year.

Bob Wachter  10:40

There was talk early on in September when the new Covid vaccine came out. Some folks said don’t take the flu vaccine yet it works reasonably well, soon after you get it but then it begins to wane in a few months. And the flu normally doesn’t hit big time till January, February, March. So you’re really going to want to get your COVID shot now. But wait till November, December your flu shot. Was that good or bad advice? And what about timing now is now the time to get it if you haven’t gotten it yet.

Caitlin Rivers  11:08

I was one of those people. I got my COVID Booster in September and chose not to get my flu vaccine then even though it was available, because we do see in the data that the flu vaccine protection wanes over the course of a season. And so if you are someone who’s you’re going to get it now or you’re going to get it never please get it now, thinking about earlier in the season. But if you are willing to hold off a little bit, then I think October is a great time to get your flu vaccine. Of course, now we’re into November. And so if you haven’t got it yet, it is absolutely time there is still time to derive protection and to really carry that protection into the rest of the season.

Bob Wachter  11:44

And I don’t think I caught an answer in terms of the uptake to the flu vaccine this year. What are we seeing are people you said the normal years 40 or so percent? Are we seeing that higher or lower than usual or just about the same as usual?

Caitlin Rivers  11:59

You know, I’m not up to date on where flu vaccine uptake is this year. But I do know that the COVID-19 booster uptake is not anywhere near where we want it to be. And so I think if you haven’t gotten either, then it would be a great time to go get both.

Bob Wachter  12:14

And just to be clear, getting them both at the same time is okay?

Caitlin Rivers  12:17

Yes.

Bob Wachter  12:18

Okay. As you recall, a couple of months ago, the shot and the other White House folks made the pitch that you can get a yearly COVID shot and in some ways making the analogy with a flu shot. It’s always struck me as sort of a reasonable strategy because it’s getting one shot a year is better than no shots a year and people are getting confused by having to re-up their shots every several months. But the sort of dis analogy felt like well, flu seasonal, you […] shot only has to last for months. COVID pretty much isn’t. How did you feel about that analogy and that kind of marketing strategy for the COVID vaccine?

Caitlin Rivers  12:57

I think it makes sense from a public communication standpoint, it has been hard for people to keep up with the changing recommendations around vaccines in which dose are we on, are you eligible? And so I think for the purposes of clarity, it makes sense. But I do worry about people who are medically vulnerable and at risk for severe illness because based on what we’ve seen so far a single shot is not likely to protect against severe illness for an entire year. And so I hope that there is some flexibility for people who may need that mid-year booster.

Caitlin Rivers  14:51

I’m gonna pivot off flu in a second. But you mentioned that we’re not sure yet about severity. When will we get sure and what will be the numbers that you’ll be looking at to figure out whether this is a particularly severe flu year? It’s clear, it’s an early flu year and it’s clear, there’s a lot of cases around but how about the numbers you look at for severity?

Caitlin Rivers  16:37

I’m keeping an eye on the number of people who are hospitalized for influenza, I believe it was about 7000 new hospital admissions in the last reporting week, it had been trending up. And so as time passes, and we see more from the hospitalization data, we’ll get a better sense of how the season is shaping up. The other number that I will be looking at is the seasonal vaccine effectiveness estimations how well this formulation matches the strain that’s circulating, we often get those in the January timeframe. So a couple of months left before we have any insight on how well it matches.

Bob Wachter  17:10

And what is a typical year, we’re now used to how well the vaccines work for COVID. The early numbers that it was 95% effective and these days tends to be more 50% or 60%. How well does the flu vaccine typically work?

Caitlin Rivers  17:24

40% to 60% against symptomatic illness and of course higher protection against severe illness, which is general range.

Bob Wachter  17:33

And we’re all unfortunately used to now what appears to be a plateau of 300 to 350 deaths a day from Covid. In a medium to bad flu season, how do those numbers stack up and again, in flu, it’s sort of most of the deaths occur over a four or five month period not played out over the course of a whole year?

Caitlin Rivers  17:53

Yeah, the CDC has a great webpage that describes burden of disease and shares how many cases hospitalizations and deaths we can expect in a given flu year hospitalizations is usually in the 10s of 1000s, which is a pretty startling number. And so that’s why I think it’s so important to use the tools that we have to prevent influenza because people think of it as a mild illness, but it’s really not it can be very severe and even deadly.

Bob Wachter  18:20

And we all were used to the very early part of the pandemic where we heard oh, Covid, you know, just like the flu and all that. And some of that was misinformation, trying to get people to minimize COVID. Today, if you get a case of Covid, versus you got a case of the flu, which one is more likely to hospitalized and kill you?

Caitlin Rivers  18:41

That’s a really interesting question. I don’t know the answer to it. Again, I think it depends on your health status. I think that for children, influenza can be quite dangerous, whereas we know for COVID-19 children are generally spared from severe illness. Both are very, very risky for older adults, and for working age adults, if you will, I think both of them are not going to make you feel good at all, but you’re unlikely to die.

Bob Wachter  19:07

And obviously a ton of talk about long COVID, is there long flu?

Caitlin Rivers  19:11

Oh, that’s a really interesting question. Any viral illness can cause what we call sequelae or long term effects. There is not a syndrome that I think has become widely recognized in the same way that long Covid is but really any viral infection can cause these kinds of lingering effects that can turn into long term disability.

Bob Wachter  19:31

Yeah, I think probably, it’s safe to say flu has been around for 100 years there. There are, you know, whatever the estimates of long COVID are 5% or 10% of the 15% of the population. There doesn’t seem to be that kind of burden of disease from long term consequences of flu.

Caitlin Rivers  19:47

No, that’s right. It’s possible, but it’s much less common than for long COVID.

Bob Wachter  19:51

Yeah. Okay. Let’s switch gears to RSV, and I’m an adult internist doctor. So I know much less about RSV than I do about flu is having taken care of a lot of flu patients over 30-40 years of practice. So tell us a little bit about what RSV is and what it does.

Caitlin Rivers  20:07

RSV is a viral infection that spreads very easily through droplets through aerosols, and through contaminated surfaces. It can last a long time on surfaces, door handles and metro rails, toys and that kind of thing. And almost all children are infected by RSV by the age of two. So it’s a very common illness. But in those young kids, it can cause breathing difficulties that can be quite severe. It hospitalized is particularly young children under the age of one. And we see similar effects with older adults where it can really impact their breathing and hospitalized people who are severely ill. There is no vaccine against RSV, there is a monoclonal prophylaxis, there is a treatment that you can get to prevent severe RSV for the youngest children at highest risk. But it’s a medication or a therapeutic that’s used sparingly. And so the punchline is we don’t have a lot of pharmaceutical protections against RSV.

Bob Wachter  21:02

So when you say sparingly for the monoclonal, I assume that these would be kids who are immunosuppressed or for some reason have medical illnesses that would make them super vulnerable. If they got RSV, people, parents shouldn’t run around today if their kids are well and one or two years old looking for a prophylactic monoclonal treatment.

Caitlin Rivers  21:20

Now, the indications are things like substantial prematurity, underlying lung or heart disease, these are children that are medically vulnerable because of some underlying condition.

Bob Wachter  21:32

You mentioned that a dominant mode of transmission is by touching surfaces. And we all remember the early days of Covid, where everybody was cleaning up everything. And then over time, we kind of were told that’s a little bit of pandemic theater, it’s not a particularly important route of transmission, it’s largely through breathing it in, is that a fundamental difference in the way the two viruses are transmitted? And do we learn something about surface transmission from Covid that’s relevant to our understanding of RSV?

Caitlin Rivers  22:03

It’s really all of the above. And I think this is true for Covid, too, it’s very difficult to tease out what fraction of transmission comes from these different modes. If you are in close enough contact with someone that droplet transmission becomes possible, while you’re also in close enough contact that it could be aerosol, and probably you’re touching the same surfaces. So it’s difficult to say that RSV spreads more, you’re more likely to get RSV from a surface than for Covid-19. But what we can say is that the virus persists on surfaces, it can live on surfaces for hours. And so that does point to sanitation and disinfection as an important risk reduction strategy along with hand washing.

Bob Wachter  22:39

Okay, and what are we actually seeing with RSV now, where you see these reports of pediatric hospitals, children’s hospitals being overrun is that really happening? And how scary is that?

Caitlin Rivers  22:50

It is, we are seeing a significant wave of RSV. Again, this is a virus that can be severe for the youngest children. There’s 10s of 1000s of hospitalizations that have been that are reported each year. We don’t yet know what that how this year will, will end up. But we are seeing a really big wave right now that concerns me.

Bob Wachter  23:10

You mentioned kind of a version of the hygiene hypothesis, but maybe has a different flavor and kids, the idea that the kids need to sort of develop to develop a healthy immune system, they have to be exposed to certain kinds of germs and viruses. And so is that part of the worry that they haven’t had that opportunity? Because we’ve been unusually clean for the last two or three years?

Caitlin Rivers  23:34

No, it really is the buildup of the susceptible population, which is the epidemiological term for saying that because so many people were spared these viral infections over the last few years, there is a lot of opportunity for the virus to circulate. There is a lot of people who it can reach who may otherwise have some degree of protection. And all of that is coming all at once so and spread instead of being spread out over three years. It’s hitting now and that’s why we’re seeing so many people getting sick and children’s hospitals being overrun because we’re having three years of RSV season smushed into this season.

Bob Wachter  24:10

Do we know you mentioned we don’t yet know whether the flu this year is more severe? Do we know whether we’re seeing more cases of RSV where the actual cases are more severe?

Caitlin Rivers  24:19

It’s not clear to me at least I think the providers on the frontlines would probably have a sense but my starting hypothesis would be that there is just so much illness that there there’s a lot of people who can progress to severe illness.

Bob Wachter  24:34

And the at risk groups you mentioned young and old in terms of young kids, is it really babies as opposed to 10 or 15 year old adolescent?

Caitlin Rivers  24:44

The highest hospitalization rate is in children under the age of six months, and children under the age of one are also at risk. So the risk reduces but does not go away between the ages of six months and one year. Now. This is an important point in older children and adults RSV is no big deal often, of course, that’s not true if you have an underlying health condition. But if you’re a healthy working age person RSV presents like a cold. And it might not make you sick enough to feel like you should stay home or wear a mask, you just have the sniffles. But if that virus makes it into someone who is young, then it can be very severe. And I think that is a good reminder for […] that even if you just have a little bit of a stuffy nose, stay home when you can wear a mask, because you may be really protecting the people who are more vulnerable.

Bob Wachter  25:28

And it’s pretty unusual for an illness to be that kind of differentially bad for a one year old, let’s say versus a 5 or an 8 year old. Is it just the size of their airways that the same amount of gunk will plug up a little bit babies airways or is there something about the immune system or something else that’s fundamentally different about how a baby handles RSV? Do we know?

Caitlin Rivers  25:48

I think it is their small airway.

Bob Wachter  25:52

There’s no vaccine you mentioned for RSV, anything in the works and of has the amazing progress with COVID vaccine says that accelerated the path toward an RSV vaccine?

Caitlin Rivers  26:03

There are two vaccines in the works that look like they may make it over the finish line in the next year or two. Pfizer just released phase three results. So they finished their clinical trials for a vaccine that is given to pregnant women to protect their babies in the first months of life. And so I believe they will be applying for FDA approval in the coming months or a year. And GFK also has a product in the pipeline that would be for older adults to protect them for severe illness. And so if both of those or either of those vaccines make it over the finish line that would those will be really important tools in our arsenal.

Bob Wachter  26:40

We got used to vaccines making it over the finish line in record time over the last couple of years. And that’s not the way it normally works. Any idea whether this will be on Covid time in terms of the testing and approval or this will be on the usual time, which is often it takes many, many years for a vaccine to kind of make it through across the finish line even when it’s on the 10 yard line.

Caitlin Rivers  27:02

The COVID-19 vaccines were authorized as an emergency use authorization, which is a special designation that derives from a public health emergency. And because RSV has not been declared a public health emergency, they will go through the normal approval processes, which are I don’t expect to be accelerated in the same way that the Covid vaccines were.

Bob Wachter  27:24

I know you’re a parent of kids, I don’t think they’re that young anymore. But if you were a parent of a one year old, what would you be doing right now?

Caitlin Rivers  27:30

Yes, my children get exposed to a lot of stuff at school. And there’s only so much I can do to control those environments. I do ask them to wear masks, which I know has become an unpopular decision. But they do work to reduce the risk of infections. And so I asked them to do that. And I think they do it sometimes. But really, when we’re I can’t pretend that they do it religiously. Because we know that’s not true. But they do. They do wear masks at least some of the time. And it buys down if not completely eliminates the risk. And I am careful and my husband is careful because we don’t want to be the ones to bring anything home to them. Now you’re right. They’re not so young anymore, that they’re high risk of severe illness. But as a working parent, it is really hard to be home with sick kids all winter. It’s very disruptive. And so even that scenario I’m keen to avoid and I have to tell you the last few winters have been nice not having to deal with the year round stuffy noses.

Bob Wachter  28:24

But if you have a you know, a one year old and daycare, is there anything you can do to me the kids not going to wear a mask because it’s not going to clean his or her hands. So is there, is this just have to be a little fatalistic that this thing’s around and just be on the lookout if the kid gets sick, or is there something practically that we think we can do?

Caitlin Rivers  28:44

Of course, I’m an infectious disease epidemiologist, so I can’t pretend that everyone will do this. But I do keep my daycare up to date with what’s circulating. But as CDC sent out a Health Alert network alert earlier in the fall that warned of a resurgence of enterovirus, which is not one of the viruses we were talking about today. But I forwarded it to my daycare and said, hey, you should know this is going to be a bad flu season. I would love it if you would consider cracking the window or wiping down surfaces a little bit more often to keep our kids healthy.

Bob Wachter  29:11

You think they do it or you think it’s like oh, here she is again.

Caitlin Rivers  29:14

Well, they don’t like it either. Right? Because their employees get sick as well. They lose revenue. And so it’s really in everyone’s best interest to try to tamp down circulation. Again, it’s not going to be a perfect solution. But if we can spare our kids even one bout of illness a year I think that’s worth it

Bob Wachter  32:11

The third leg of the tripledemic is COVID. We’re not spending a lot of time on COVID today, but let’s spend a tiny bit. How would you describe the current state of COVID as new variants of variants emerge. And we’re now a couple of months into the new vaccine.

Caitlin Rivers  32:27

We are coming out of a BA5 wave which is then also conveniently the variant that the new booster protects against. And we’ve had a good stretch, we’ve had probably two months of declining incidence of declining number of new infections. But I do worry that period of quiet may be running out. If you look carefully at the data it has the number of new cases has been plateauing. In some places, it’s been ticking up. And we’re starting to see signs in test positivity and hospitalizations as well that we may be facing another round. So just know it’s not bad yet, but just something to look ahead to keep an eye on because the picture is changing.

Bob Wachter  33:04

And San Francisco where I live, that’s the case rate has gone up about two or three times in the last few weeks. And I have gone from being comfortable eating indoors to not being uncomfortable eating in a restaurant and indoor restaurant. Are you do you think that the situation has changed nationally enough for people to be rethinking some behaviors that they may have adopted of last several months where things were in a pretty good shape?

Caitlin Rivers  33:29

For COVID, we are in a spot similar to last spring, and I would feel comfortable eating in a restaurant without a mask. But with influenza and RSV, circulating taking altogether, that puts me in a state where I’m trying to be a little bit more careful because I don’t want any of those viruses. And I don’t want my kids to get them either.

Bob Wachter  33:47

Yeah, that’s very interesting. I mean, I think a lot of us have done a whole lot of mental math trying to figure out the risk of Covid. In deciding about whether to mask on an aeroplane or eaten into a restaurant. And what you’re saying is, that’s not a holistic enough approach, because any of these viruses are things you’d like to try to avoid if you can, and it’s worth in your mental calculations, integrating the possibility of these other viruses. And obviously, you have no idea which one of them you might be exposed to, but you could be exposed to any of them if you’re a little bit less careful than you might otherwise be.

Caitlin Rivers  34:19

That is the way that I think about it. And I don’t necessarily restrict myself from anything, I’m not going to turn down invitations to do something fun, because I’m worried about this. But in times when it’s neutral, like flying, for example, why not wear a mask, that’s the way I think about it, I would rather just put the mask on and not have to worry about it then to possibly get to my destination and face being sick. So I take those precautions when it makes sense to me and other times I relax.

Bob Wachter  34:45

When we talk about these three viruses, flu, RSV, and COVID, we sort of talked about there are almost three independent risks. There’s a little bit of connection between them because partly the risk for flu and RSV have to do with the fact that we had relative were rarely spared for the last several years, is there a risk? You’re gonna get two of them? Or three? One of them? Are your risk to get another one? Are we seeing people with multiple viruses at the same time, or these are really all just three independent risks?

Caitlin Rivers  35:12

It’s possible to experience co infection where you have several infections at once. And that can make you quite sick. That’s definitely a scenario you want to avoid. And it’s also very possible to get them serially. So in October, you get Covid. In November, you get influenza and December you get RSV. That’s very possible.

Bob Wachter  35:32

The question has arisen lately, why are we not seeing more of a COVID surge with this new sub variant BQ. One or its various flavors? That seems to be pretty immune evasive, and it seems to be taking over for BA5“ very quickly. Some people have looked at that and said, I would have expected more of a surge by now. And there’s one theory around that these other viruses are competing in some way with a theory I don’t profess to fully understand and maybe it’s because isn’t right, is there? What’s your theory about why we’re not seeing more of a surge from COVID with this new variant that appears to at least be better enough at doing it his job to be replacing BA5 very quickly as the variant as your..

Caitlin Rivers  36:17

Well, as you say, this is controversial, but my take is that it’s too soon, I think we’ve gotten very good at spotting and characterizing new variants. And that’s given us a lead time before we actually see the full effects at the population level. And so I want to see another few weeks or even a month of cases unfold before I decide that that this new variant is not causing a surge, I think it’s too early.

Bob Wachter  36:39

Okay. And you mentioned that you follow to determine that you think COVID is having a little bit of an uptick now and make it worse. You’re following case rates. And as soon as I say that to people say, oh, case rates are unreliable, what about home testing? You’ve heard it all? What’s your response to that?

Caitlin Rivers  36:56

It’s all true. I mean, home testing has really changed the nature of case reporting. But I still find it to be, I wouldn’t say reliable, but at least an early indicator of how things are changing. I use it as part of a constellation. So I look not just at case rates, but also it hospitalizations at test positivity, sometimes at wastewater, and I kind of see how they’re how they’re all matching up. But I still think that it’s worth looking at because it can give indication of where things are headed.

Bob Wachter  37:23

And this is partly, I think, your gig at the CDC to sort of figure out ways of creating something that resembles a weather report. And I can sort of do that with COVID. I can tell how bad How much COVID There is in the air in San Francisco. And that determines whether I’m going to do indoor dining, let’s say. Are there comparable data for flu and RSV? So because at some ways you’ve we’ve been citing national data, but what’s really relevant is your chances of getting either of them in your local community, where do people find out what’s going on with those viruses in their communities?

Caitlin Rivers  37:57

Flu is well surveilled, there’s good disease surveillance for influenza. But I think most of the communication products around flu are for other epidemiologists, so they can be a little bit hard to interpret. For RSV and other respiratory viruses surveillance is much worse. And it’s hard to get a good picture at all, let alone one that is accessible and easy to understand.

Bob Wachter  38:16

Do you think that’s going to change from your time at the CDC? Did you get a sense that the  organization is working on better and more accessible to regular people, not just epidemiologists tools for people to look at different viruses, not just COVID?

Caitlin Rivers  38:32

Yes, I think the first stop for the Center for forecasting group is around outbreak. So things like monkey pox, the kind of fast moving emerging outbreaks where policymakers and the public need information rapidly. That’s the first step. But there will be a public communications team to make sure that that information is available to the public. And then as capacity grows, these more routine viruses will be part of the remit as well.

Bob Wachter  38:54

Great. So we’re moving to the end. Let’s talk a little bit about kind of practical advice for people and Thanksgiving is a week away. So that’s probably the event that people are thinking about most gathering with friends, family, you’ve got grandparents with grandchildren, and toddlers and snot everywhere and toys and Turkey. So if an extended family was coming to you and saying we’re planning on getting together in someone’s house for Thanksgiving dinner, what would you tell them for all three of these viruses, how they should protect themselves while still enjoying this special occasion?

Caitlin Rivers  39:35

Well, I have three ideas. One is ventilation. It’s November, it’s chilly in a lot of places. But if you can crack a window if you can get that air circulating, that will reduce the risk from all three viruses and I think that is a solid strategy. Also hand washing. We’ve all kind of turned our nose up at hand washing after airborne transmission became a more prominent part of COVID-19 transmission. But let’s not give it up completely because As hand washing is a really important way to reduce risk from RSV, if not also influenza and COVID. And third, testing, testing for Covid-19 can help to reduce the risk that someone infectious from that virus comes to your dinner. Of course, that won’t tell you much about influenza or RSP. But we’re all about buying down risk right now not eliminating it entirely. And actually, I’ll add a fourth, which is if anyone is sick, they should stay home. I’m sorry, but it’s not a good idea.

Bob Wachter  40:27

The testing is interesting, because my wife and I had dinner with friends last night, and we all tested before the dinner. And it strikes me that we came up with those tests in a year or so. And now they’re ubiquitous and reasonably reliable. Why don’t we have one for flu? Why don’t we have one for RSV? Do you think they’re coming?

Caitlin Rivers  40:49

You know, it’s a pain point for me as an epidemiologist, that not only do we not have home tests for a lot of the most common viruses, we actually don’t test or characterize upper respiratory infections at all. If you have a stuffy nose, if you have a cough, often, you just never know what it is. And there’s no real effort to figure out what’s what, I would like to see that change because there are different strategies. And there are different number of days that you might need to stay home. And there’s different implications for different people that you come in contact with based on what the virus is. And so I think that’s a big opportunity for growth to really start to characterize what is making us sick with a little more clarity.

Bob Wachter  41:26

Great. Caitlin, thanks so much for explaining all of this to us. Just when we thought we had a handle on Covid. Now we’ve got to, we have these competing risks as well that we have to integrate into our daily lives and our daily thinking, but you’ve made it as clear as can be, I think, thanks so much.

Caitlin Rivers  41:42

Thanks for having me on.

Bob Wachter  41:58

On Friday show former HUD secretary who Leon Castro will be talking about what Democrats did right to keep the Senate in the midterms. Then I’ll be back on Monday. I look forward to talking to you then.

CREDITS  42:14

Thanks for listening to IN THE BUBBLE. We’re a production of Lemonada Media. Kathryn Barnes, Jackie Harris and Kyle Shiely produced our show, and they’re great. Our mix is by Noah Smith and James Barber, and they’re great, too. Steve Nelson is the vice president of the weekly content, and he’s okay, too. And of course, the ultimate bosses, Jessica Cordova Kramer and Stephanie Wittels Wachs, they executive produced the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, with additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia where you’ll also get the transcript of the show. And you can find me at @ASlavitt on Twitter. If you like what you heard today, why don’t you tell your friends to listen as well, and get them to write a review. Thanks so much, talk to you next time.