COVID-19 concerns linger, especially for the medically vulnerable, as flu season nears

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Some health officials are worried that the United States could see a "twindemic" outbreak of flu and Covid at the same time as we get into the winter months. I'm talking about this with Upstate University Hospital's chief of infectious disease, Dr. Elizabeth Asiago-Reddy. Welcome back to "The Informed Patient," Dr. Asiago-Reddy.

Elizabeth Asiago-Reddy, MD: Thank you for having me, Amber.

Host Amber Smith: Are you one of the health officials concerned about a combination of people with flu and people with Covid, all of whom become sick enough to require hospitalization this winter?

Elizabeth Asiago-Reddy, MD: Yes, I'm definitely concerned, and I think the main reason behind that is that we've seen a huge change in people's behaviors over the last six months with respect to the degree of social distancing or masking that's happening. There's been a huge reduction. And some of that is very much reasonable in the sense that we have seen that there has been, on average, a significantly reduced risk of hospitalization overall from Covid in the last several months. And we have not currently been in a flu season for the last several months. So I don't think that it's unreasonable that people have started to get back to their lives, but, we are worried about this upcoming winter season. We typically will see peaks of Covid, over the last several years, during the winter months.

And, I think what's different, when we think about the combination of Covid and flu rearing their ugly heads together is that influenza is less contagious than Covid. And so it has been a little bit easier to suppress influenza with the measures that have been taken for Covid thus far. But with those measures dropped completely and the fact that many people have not experienced any exposure to influenza over the last several years, it raises the possibility that we will see a lot more flu. So if we see a lot more flu, then of course a certain proportion of those individuals are going to unfortunately be sick enough to go in the hospital. So that is the concern, that we would have our typical peak in Covid, or at least some degree of peak in Covid, with a peak in influenza, which we haven't seen for the last couple of years.

Host Amber Smith: Covid has killed more than six and a half million people worldwide, including more than a million in the United States. Are you still seeing people who are severely ill with Covid?

Elizabeth Asiago-Reddy, MD: I am. And in fact, I've been seeing it more this fall as I've been covering the inpatient service in the hospital. And we have seen our hospitalizations tick up a little bit over the last couple of weeks, putting us into a high risk zone for the last several weeks. So yes, I am seeing that. And it's not the way that it was at our most severe. So we haven't breached the heights of what we saw, for example, in the winter of 2021, or early 2022. But yes, we are seeing some significant increases, and we are still seeing people, unfortunately, really sick enough to end up in the ICU (intensive care unit) and to even die from Covid. It is still happening.

Host Amber Smith: Are these people who never got vaccinated?

Elizabeth Asiago-Reddy, MD: Certainly the risk overall of death and hospitalization remains markedly increased for people who have never been vaccinated from Covid, and the data are available on the CDC (Centers for Disease Control and Prevention) website as well as several other websites. So you're looking at anywhere from a five to 20 times reduced risk of hospitalization associated with vaccination, some of which depends on whether or not the individual has recently had a booster vaccine. So recent booster vaccine is going to decrease your likelihood of severe illness significantly. And then also whether or not the individual has experienced past episodes of Covid infection. So it is true that there's some cumulative immunity from illness that has occurred as well.

Host Amber Smith: So what about the risk for people with compromised immune systems? Is that still very real?

Elizabeth Asiago-Reddy, MD: It is very real. Andthese individuals form a large proportion of the individuals who I see in the hospital with Covid. It's true that still with both Covid and flu, there are cases where somebody becomes extremely, severely ill and requires hospitalization with no known medical problems. We don't know why it's happened. It still happens. That is happening less than what we saw at the beginning of the Covid epidemic. We are seeing more of individuals with higher age groups as well as immune compromising conditions as a risk factor for severe Covid.

Host Amber Smith: Are infants and elderly still at higher risk for Covid?

Elizabeth Asiago-Reddy, MD: Absolutely, yep, on both counts, but particularly increasing age is a very significant risk factor for severe Covid. For the youngest individuals at this point we are actually, potentially, even more worried about flu, although we're worried about both, because the rates of Covid vaccination and infants have been very disappointing. So there is, for sure, concern for those young age groups as well.

Host Amber Smith: In the early days of the pandemic, there were public testing sites, contact tracers, and it seemed like everyone who got infected was being counted by someone. But now with home testing and milder infections, thanks to vaccinations, it seems like health officials no longer have an accurate count. Does that affect how the pandemic is being managed?

Elizabeth Asiago-Reddy, MD: Yes, absolutely. It is well recognized that we are not able to fully count Covid infections for two different reasons. One is that we don't have access to information about home tests. In the large majority of cases, people don't report those. And then the other is the recognition of the number of people who are having asymptomatic Covid infections, which is extremely high. So some data suggests that up to 50% of Omicron infections may be asymptomatic, and yet those individuals could still transmit illness. So we really don't know the exact numbers of people, so what we've started to look at to get a better sense is actually the hospitalization rates. So, hospitalization rates have become a critical component of making a decision as to whether an area is high risk or not high risk.

So as we see overall the level of severe illness declining, even when numbers of cases are high, what becomes most important is have we preserved our ability to hospitalize those who need to be hospitalized by having room in the hospitals and adequate staff to care for them? And then number two, do we have adequate staff and room in the hospitals to care for people who have other medical conditions that need care aside from Covid or other respiratory illnesses?

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Elizabeth Asiago-Reddy. She's the chief of Infectious Disease at Upstate University Hospital, and we're talking about where things stand with the covid-19 pandemic.

So let's talk about the Covid vaccine and its boosters. If an adult got vaccinated as soon as the vaccine was available, how many boosters should they have had by now?

Elizabeth Asiago-Reddy, MD: So definitely up through the last couple of months, it would've been recommended that they had at least one booster and possibly two. So the primary series for your mRNA vaccines is two vaccines. Most individuals did receive mRNA vaccines, so I'll focus on that. And then after that, all individuals would've been recommended for a booster, or a three-dose series if they're a child. And then, depending on their health conditions and age, many would've been recommended for an additional booster of the same formulation as the initial series of vaccines.

Now starting approximately one month ago, we had the availability of the new bivalent boosters, which we can speak more about. So up until the time when those were available, like I said, most people should have had at least one or two boosters. And, that's with the mRNA vaccines. With the Johnson vaccine, either a second dose of Johnson or a booster of an mRNA vaccine was recommended.

Host Amber Smith: What is the Bivalent booster that's available now, and how does it differ from the earlier boosters?

Elizabeth Asiago-Reddy, MD: The Bivalent booster contains the original, so it contains a message for our body to create -- again, I'm speaking about the mRNA vaccine -- so, a message for our bodies to create a spike protein of the coronavirus, and it contains two messages. One is to create the old version of the spike protein that was circulating initially when the epidemic first began, and then also to create an updated version of the spike protein that more closely matches Omicron strains that are currently circulating. And that offers us the opportunity to really create a very robust immune response that is more likely to protect us against what's actually out in the community right now.

Host Amber Smith: So if someone never got a vaccine and they go to the Pharmacy now, are they going to receive that bivalent as their vaccine?

Elizabeth Asiago-Reddy, MD: No. It's still recommended to start out with the primary series of vaccination. And a big part of the reason for that is that we have an understanding of how many doses one should receive before a full immune picture is realized within our immune system. So if I started out with the mRNA series, I would still be recommended to get two baseline doses, followed at least a month later by the bivalent booster. So I actually would be recommended up front to receive a three-dose series of vaccine. The booster would really be included in that initial recommendation.

There are other vaccines that are available. So I wanted to mention that Novavax is the vaccine that is available now, which was not previously available, which is a protein based vaccine. So there's no mRNA in it. It's not an attenuated virus, which the Johnson vaccine is more similar. The Johnson vaccine is not exactly an attenuated virus, but it's taking a weak virus and putting the message for the Covid spike protein inside that weak virus. The Novavax is strictly a protein, and a lot of people may feel more comfortable with that because it's the basis for the vast majority of the vaccines that we typically administer. So, that is a possibility for someone who has been waiting for that type of vaccine to go ahead and get their primary series. But yes, you would start out with the primary series and then from there one would move to a booster.

Host Amber Smith: At this point, if someone develops symptoms -- fevers, chills, cough, headache -- and they test positive for Covid-19, what advice do you have for how they should treat themselves at home?

Elizabeth Asiago-Reddy, MD: You should call your healthcare provider to see whether you're eligible for any treatments. There still are a number of treatments that are beneficial to people with specific health conditions who are at high risk of the possibility of severe Covid. So that's number one. Make sure that you have discussed whether or not you would be eligible for one of those treatments. That information is also online, so you could try to make some sort of a determination. But of course, speaking with healthcare provider is your best course of action.

And then from a symptomatic perspective, it's a matter of continuing to rest, adequate fluids and keeping an eye on symptoms that would be concerning to you. So certainly if you are experiencing severe symptoms, you're severely short of breath, or you're concerned that you're not able to hydrate yourself, for example, those would be emergencies that would need to be addressed either, again, with a call to your healthcare provider, or even a visit to the ED (emergency department.)

Host Amber Smith: How will we know when the pandemic is truly over?

Elizabeth Asiago-Reddy, MD: I think many of us have accepted the reality that the pandemic is not really going to have an end date because there's no indication that the virus will stop circulating. More what we're looking for is our ability to manage the virus during especially high transmission periods. So we, again, we anticipate that winter months, in places where we have cold winters will be high transmission periods. So we want to be able to manage those to an extent where as few people as possible experience severe illness, and those who do experience severe illness are managed to the best of our abilities with available treatments and need for hospitalization if need be. So I think that's a more realistic viewpoint of how to think about the pandemic being over. It's when we have really, optimized our ability to mitigate severe outcomes.

Host Amber Smith: As an infectious disease specialist, when you look back at the last three years, what surprised you the most about the pandemic?

Elizabeth Asiago-Reddy, MD: To be honest with you, I never thought that this was going to end. I'm being completely serious. I actually made plans in my life thinking that this would be with us for a long period of time because with the degree of contagiousness, I didn't see how we were going to be able to remove it from our very large global family that I think we all recognize that we have become.

So I think what surprised me is, I guess, the extreme nature of both our better and worse sides and how they emerged. I guess maybe I could have predicted that, but I'm not sure that I did. So I saw working with our team here at Upstate, some of what I really felt was the best of humanity, incredible hard work, teamwork, dedication, willingness to make sacrifices, willingness to think about the bigger picture and how to help, everybody pitching in to -- with their different abilities -- whether it be in the laboratory, on the call line, in the hospital, et cetera. And on the other hand, of course, we saw a lot of acrimony, dissent, anger, fear. So I think that, to be honest with you, is what surprised me most, moreso than any of the hard scientific aspects of the pandemic.

Host Amber Smith: Dr. Asiago-Reddy, I appreciate you making time for this interview. Thank you.

Elizabeth Asiago-Reddy, MD: Thank you so much.

Host Amber Smith: My guest has been Upstate University Hospital's chief of infectious disease, Dr. Elizabeth Asiago-Reddy. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/Informed. This is your host, Amber Smith, thanking you for listening.