I'm curious to hear more about what you make of the COVID 'calming down' we're seeing in Europe and the unexpected smaller wave in Singapore. I know Germany had implemented some enhanced NPIs, but it seems those were too recent to have a material effect on the infection curve? What can we make of these seemingly better than expected trends and is it possible to extrapolate anything to what might happen in the US in the coming months?
I think this is such a good question. We think the Singapore situation is due to strong NPI's in place. They were on top of it. The situation in Europe is interesting and we think it's decreasing now because of behaviors (not because of subvariants). Subvariants are still rising in Europe, so we will probably see another bump in cases soon.
Thanks so much Katelyn, I am a school district medical director and have shamelessly re-worded and quoted from your post for a school website announcement. I gave you the credit today and I give you SO much credit every day for the great work you are doing.
Thank you for this update. Passing this along in case it's helpful to others.
I got my flu shot Monday, two weeks after my covid booster. The pharmacist entered the room with a long thin syringe. I said, "Just double checking that you're giving me the *flu* shot today." The pharmacist blinked, disappeared, and returned with a short fat syringe. Pharmacists are busy people - never hurts to confirm with them which shot they're giving you.
I am going to my physical in about an hour, and will get my flu vaccine then. My insurance does not cover the vaccine in a pharmacy, only a doctors office, which I find baffling. Wouldn't it be cheaper for them to have it done at a pharmacy? And that extra hurdle - go t the doctor or pay ca. $50 out of pocket - might be just the thing that keeps people from getting it. Which in turn would mean more expenses for the insurance company?
I agree SD. my insurance is the same. I already had my yearly physical so I would have needed to make a separate visit out to the physician's office for the flu vaccine.
My husband's insurance allows him to go to the pharmacy, grocery store, etc. for his.
I ended up making us both appointments at the grocery store. It would have been $50 out of pocket but I looked up coupon codes for the three major RX coupon sites, GoodRX. SingleCare and America's Pharmacy. For Fluarix Quad,, America's Pharmacy was the cheapest for my grocery store at $22. The store gave me a coupon code for $10 off of my next grocery order so I ended up paying $12 for the shot and for me this was worth it..not making a separate trip out to the md's office.
So..always look into those Rx coupon code sites! They are great...sometimes you can even get your prescriptions for less than your insurance copayment.
I got both my booster and flu shot separately at one of the big national pharmacy chains in California. In both cases, I was 15 minutes early, and it took over an hour from the time I entered until the time my arm was jabbed. The poor pharmacists have so many things to deal with - a lady who had to have IVF drugs “TODAY” but the medicine was not in stock, people complaining about long lines, screaming kids. Total chaos. I was one of the only ones wearing a mask, but if the transmission rates had been a lot higher in our area, I think I would have bailed on getting my shots.
In areas with high population density, it probably makes sense to de-couple the administration of seasonal vaccines with normal pharmacy activities. I’m in favor of bringing back the big drive through vaccine sites for the next few months.
I can't tell if the the "TODAY" comment was snark but if someone is undergoing IVF they have a ton of time sensitive (yes, to the exact day) medications. Fertility treatment is hard enough, that person doesn't need any judgement.
It's not a snark, it's to convey time sensitivity and importance. Pharmacists are already overloaded and understaffed. Placing the burden of seasonal vaccines on them is perhaps asking too much. Plus it's not reasonable to ask elderly and high risk people seeking vaccines to wait an hour or more inside a poorly ventilated store where people aren't wearing masks. The vaccine delivery system needs to be redesigned, especially ahead of the coming surge.
I ended up getting the bivalent because they had opened a package to vaccinate a couple of elderly vulnerable patients, and if they didn't use the remaining three by the end of the day, they would have thrown them out.
But I can walk to multiple pharmacies. I am near the doctor's office much less often because it is a distance away.
There is no mask wearing in schools right now at least in Texas, especially with the little ones as they need to see our mouths to develop their language. It appears (no data) that more kids are struggling developmentally with their language and social/emotional growth. In the classroom it feels like we are addressing it at every turn. What can we do? I am going to try the "Clearmask" as it claims to be FDA approved and fingers crossed it does not fog! How do we balance building our immune systems with safe practices? I am guessing vaccines AND IF TRUE WHY IS THERE SO MUCH PUSH BACK?
No masking in schools here in very blue NY. With the exception of middle schoolers, who seem to prefer that no one see their faces. I think people are just so tired, and so many kids (and adults!) don't wear the masks properly. I am also wondering about language development. This is completely anecdotal, but my colleague has a kid in kindergarten, and they are seeing so many language delays in the younger classes that they have taken to a roving speech therapist coming by the classes to do "speed appointments" (5 minute sessions) with wide swathes of the class.
"I think people are just so tired, and so many kids (and adults!) don't wear the masks properly."
I see this trope repeated a lot but don't get it. Wearing a properly fitted mask is just not a big deal. It's not that difficult to wear one properly and there are a host of different designs out there. So it's really not hard to find one that fits comfortably, allows your voice to be heard clearly, and won't fog up your glasses. Yes, it takes some comparison shopping like any other consumer product (which is what they are now) but if people are willing to do that to buy a damn set of earbuds they ought to be willing to do so to protect their health.
It's not a priority for little kids. They also don't put on their shoes, shirts, hats, and pants correctly.
I do find it hard to understand what others are saying with a mask on and vice versa. I wear masks in places like medical facilities or tightly packed theaters, but otherwise I don't bother. I've had 5 vaccines plus COVID, so am feeling it's sometimes not worth the cost-benefit at this point.
When I was in Italy last month, mask wearing was much lower than here, which surprised me. I could probably count on my fingers the number of people I saw wearing them, and I was there for 10 days. So I think a lot of people find them bothersome.
Nobody asks. I made a choice to prioritize my health over idiotic restrictions since tens of millions of doses have gone to waste. I'm an essential worker with a high level of exposure and nobody to look after me if I fall ill.
A simple word of thanks seems inadequate for your insightful and invaluable posts, which have truly added so much to public knowledge during this pandemic! I just wanted to comment that there is a "vaccine" (as the public generally understands the term) for RSV, by the brand name of Synagis. It is a monoclonal antibody, so confers passive immunity, and therefore it is not technically a vaccine, as it does not stimulate our own antibody production. However, it is so expensive that it is only available to premature infants born at or before 35 weeks of gestation who will be 6 months or younger during the RSV "season", which isn't even a thing anymore! Nevertheless, this technology exists and maybe we will someday figure out how to lower the cost.
Re: RSV - a respiratory virus.....not thought to be transmitted primarily as an aerosol/airborne. I have difficulty understanding that "older" assessment and current advice for prevention. It seems intuitive that masking should be the norm as well as hand washing and PPEs. If the infection is seasonal, then I would personally advocate masking if/when RSV is reported in the community. Not really addressing JMoore's concerns for learning in the school setting, I would not downplay masking in general. Masking really is not a big inconvenience. Annoying a bit, sure. My reviews of the "clear masks" as a stop-gap for language instructions hasn't been very positive. Fogging because there is no porosity appears to be the issue, but I would defer to more knowledgeable folks. What about HEPA air filtering, ductwork UV-C devices?
You bring up what the current discussion is about RSV. Do we rely on research decades ago? Or, given so much of our new knowledge around COVID19, do we just assume its airborne? We just don't have the level of science for other viruses like we do COVID19. This was an unprecedented amount of scientific information. I'm wearing a mask because I don't want all of the above! To me, it's just not that big of a deal if it will help me not get sick.
"I'm wearing a mask because I don't want all of the above! " Yup. This ultimately comes down to the old balance between a type 1 and type 2 error and which is the more costly. In this case, the choice seems obvious. Masking even when it wasn't actually necessary involves minimal cost (monetary and otherwise) and the benefit far outweighs any costs. The cost of not masking when you should have, however, can be exceptionally high.
So whenever we're in a crowded area, especially indoors, we mask up. Simple choice and no big deal. And we're getting our boosters this afternoon. :-)
Wise approach and valid points. Keep up the good work. If your original comments inferred that the data was old and we should re-think the approach to RSV, I guess I missed that..... RS
Quite a surprise… Of course, unknown if these hybrids will pose any threat or will be unable to function well, and there will have been years in the past when such co-existence in people’s lungs occurred without emergence of chimeras… Still, potentially very important to know can happen in case a future one in the population is successful:
Coinfection by influenza A virus and respiratory syncytial virus produces hybrid virus particles
24 October 2022
Abstract
Interactions between respiratory viruses during infection affect transmission dynamics and clinical outcomes. To identify and characterize virus–virus interactions at the cellular level, we coinfected human lung cells with influenza A virus (IAV) and respiratory syncytial virus (RSV)...
The flip side of this - that viruses all speak the same basic language - is heterologous adaptive immunity.
Our adaptive immune system acts on "epitopes". I think of an antigen as being a bunch of epitopes the way a piece of music is a bunch of chords. The more chords it learns, the more tunes it can play. Therein lies the power of a multivalent vaccine!!!
Locally in San Diego influenza is surging exponentially but the sickest kids have RSV or rhino/enterovirus. ED wait times exceed 8 hours. Wish media would encourage parents to seek care if their kids are having trouble breathing or other severe symptoms and not go to the ER for mild URI, athlete’s foot, etc
Should we be asking our pediatricians to test for RSV? Was at doctor's with my 3yo w/2-day 103+ fever and cough. They tested for covid (negative) but nothing else (RSV, flu).
Regardless, we just keep following the school/CDC guidelines (stay home 24-hours after fever and until cough starts to improve, stay home if cough worsens).
Wise choices those boosters and the masking...no brainer as far as I'm concerned. Those that decry the common sense approach, are, well, you know........
I live near Birmingham, Alabama and the Children’s Hospital there is slammed with RSV patients. They’re converting some areas of the hospital to add patient rooms and using announcements on the news and online asking people to use the urgent care clinics if their child has fever but is not having difficulty breathing.
Heard you say you were the only one at a conference wearing a mask. I'm usually the only one wearing one - your example helped me to buck peer pressure. Yeah, even old ladies feel that pressure. Thanks.
Molnupiravir is known to work for flu and covid. If it turns out to work for RSV, what are the implications for testing? Could it be prescribed based solely on local prevalence and symptom severity?
For us, this just means we continue doing what we've been doing for three years now. I think this is the New Normal and we can either accept it or pretend it's not true and roll loaded dice. Getting our latest boosters this afternoon at the local Walgreen's.
I'm curious to hear more about what you make of the COVID 'calming down' we're seeing in Europe and the unexpected smaller wave in Singapore. I know Germany had implemented some enhanced NPIs, but it seems those were too recent to have a material effect on the infection curve? What can we make of these seemingly better than expected trends and is it possible to extrapolate anything to what might happen in the US in the coming months?
I think this is such a good question. We think the Singapore situation is due to strong NPI's in place. They were on top of it. The situation in Europe is interesting and we think it's decreasing now because of behaviors (not because of subvariants). Subvariants are still rising in Europe, so we will probably see another bump in cases soon.
Thanks so much Katelyn, I am a school district medical director and have shamelessly re-worded and quoted from your post for a school website announcement. I gave you the credit today and I give you SO much credit every day for the great work you are doing.
Ann Engelland, MD. aengelland@gmail.com
great! so glad it could be useful.
Thank you for this update. Passing this along in case it's helpful to others.
I got my flu shot Monday, two weeks after my covid booster. The pharmacist entered the room with a long thin syringe. I said, "Just double checking that you're giving me the *flu* shot today." The pharmacist blinked, disappeared, and returned with a short fat syringe. Pharmacists are busy people - never hurts to confirm with them which shot they're giving you.
I am going to my physical in about an hour, and will get my flu vaccine then. My insurance does not cover the vaccine in a pharmacy, only a doctors office, which I find baffling. Wouldn't it be cheaper for them to have it done at a pharmacy? And that extra hurdle - go t the doctor or pay ca. $50 out of pocket - might be just the thing that keeps people from getting it. Which in turn would mean more expenses for the insurance company?
I agree SD. my insurance is the same. I already had my yearly physical so I would have needed to make a separate visit out to the physician's office for the flu vaccine.
My husband's insurance allows him to go to the pharmacy, grocery store, etc. for his.
I ended up making us both appointments at the grocery store. It would have been $50 out of pocket but I looked up coupon codes for the three major RX coupon sites, GoodRX. SingleCare and America's Pharmacy. For Fluarix Quad,, America's Pharmacy was the cheapest for my grocery store at $22. The store gave me a coupon code for $10 off of my next grocery order so I ended up paying $12 for the shot and for me this was worth it..not making a separate trip out to the md's office.
So..always look into those Rx coupon code sites! They are great...sometimes you can even get your prescriptions for less than your insurance copayment.
Thanks for the tip. I didn't even think of that!
I got both my booster and flu shot separately at one of the big national pharmacy chains in California. In both cases, I was 15 minutes early, and it took over an hour from the time I entered until the time my arm was jabbed. The poor pharmacists have so many things to deal with - a lady who had to have IVF drugs “TODAY” but the medicine was not in stock, people complaining about long lines, screaming kids. Total chaos. I was one of the only ones wearing a mask, but if the transmission rates had been a lot higher in our area, I think I would have bailed on getting my shots.
In areas with high population density, it probably makes sense to de-couple the administration of seasonal vaccines with normal pharmacy activities. I’m in favor of bringing back the big drive through vaccine sites for the next few months.
I can't tell if the the "TODAY" comment was snark but if someone is undergoing IVF they have a ton of time sensitive (yes, to the exact day) medications. Fertility treatment is hard enough, that person doesn't need any judgement.
It's not a snark, it's to convey time sensitivity and importance. Pharmacists are already overloaded and understaffed. Placing the burden of seasonal vaccines on them is perhaps asking too much. Plus it's not reasonable to ask elderly and high risk people seeking vaccines to wait an hour or more inside a poorly ventilated store where people aren't wearing masks. The vaccine delivery system needs to be redesigned, especially ahead of the coming surge.
Ah makes complete sense. Thank you for clarifying.
I ended up getting the bivalent because they had opened a package to vaccinate a couple of elderly vulnerable patients, and if they didn't use the remaining three by the end of the day, they would have thrown them out.
But I can walk to multiple pharmacies. I am near the doctor's office much less often because it is a distance away.
There is no mask wearing in schools right now at least in Texas, especially with the little ones as they need to see our mouths to develop their language. It appears (no data) that more kids are struggling developmentally with their language and social/emotional growth. In the classroom it feels like we are addressing it at every turn. What can we do? I am going to try the "Clearmask" as it claims to be FDA approved and fingers crossed it does not fog! How do we balance building our immune systems with safe practices? I am guessing vaccines AND IF TRUE WHY IS THERE SO MUCH PUSH BACK?
No masking in schools here in very blue NY. With the exception of middle schoolers, who seem to prefer that no one see their faces. I think people are just so tired, and so many kids (and adults!) don't wear the masks properly. I am also wondering about language development. This is completely anecdotal, but my colleague has a kid in kindergarten, and they are seeing so many language delays in the younger classes that they have taken to a roving speech therapist coming by the classes to do "speed appointments" (5 minute sessions) with wide swathes of the class.
"I think people are just so tired, and so many kids (and adults!) don't wear the masks properly."
I see this trope repeated a lot but don't get it. Wearing a properly fitted mask is just not a big deal. It's not that difficult to wear one properly and there are a host of different designs out there. So it's really not hard to find one that fits comfortably, allows your voice to be heard clearly, and won't fog up your glasses. Yes, it takes some comparison shopping like any other consumer product (which is what they are now) but if people are willing to do that to buy a damn set of earbuds they ought to be willing to do so to protect their health.
It's not a priority for little kids. They also don't put on their shoes, shirts, hats, and pants correctly.
I do find it hard to understand what others are saying with a mask on and vice versa. I wear masks in places like medical facilities or tightly packed theaters, but otherwise I don't bother. I've had 5 vaccines plus COVID, so am feeling it's sometimes not worth the cost-benefit at this point.
When I was in Italy last month, mask wearing was much lower than here, which surprised me. I could probably count on my fingers the number of people I saw wearing them, and I was there for 10 days. So I think a lot of people find them bothersome.
Similar but 7 shots, no Covid
7 shots. I didn't even know that was possible!
Nobody asks. I made a choice to prioritize my health over idiotic restrictions since tens of millions of doses have gone to waste. I'm an essential worker with a high level of exposure and nobody to look after me if I fall ill.
Thank you for your reply. We are seeing that too! It is such a balance.
A simple word of thanks seems inadequate for your insightful and invaluable posts, which have truly added so much to public knowledge during this pandemic! I just wanted to comment that there is a "vaccine" (as the public generally understands the term) for RSV, by the brand name of Synagis. It is a monoclonal antibody, so confers passive immunity, and therefore it is not technically a vaccine, as it does not stimulate our own antibody production. However, it is so expensive that it is only available to premature infants born at or before 35 weeks of gestation who will be 6 months or younger during the RSV "season", which isn't even a thing anymore! Nevertheless, this technology exists and maybe we will someday figure out how to lower the cost.
That’s good information but isn’t a vaccine as commonly understood. As you said it’s a monoclonal antibody even if given prophylacticly.
Re: RSV - a respiratory virus.....not thought to be transmitted primarily as an aerosol/airborne. I have difficulty understanding that "older" assessment and current advice for prevention. It seems intuitive that masking should be the norm as well as hand washing and PPEs. If the infection is seasonal, then I would personally advocate masking if/when RSV is reported in the community. Not really addressing JMoore's concerns for learning in the school setting, I would not downplay masking in general. Masking really is not a big inconvenience. Annoying a bit, sure. My reviews of the "clear masks" as a stop-gap for language instructions hasn't been very positive. Fogging because there is no porosity appears to be the issue, but I would defer to more knowledgeable folks. What about HEPA air filtering, ductwork UV-C devices?
You bring up what the current discussion is about RSV. Do we rely on research decades ago? Or, given so much of our new knowledge around COVID19, do we just assume its airborne? We just don't have the level of science for other viruses like we do COVID19. This was an unprecedented amount of scientific information. I'm wearing a mask because I don't want all of the above! To me, it's just not that big of a deal if it will help me not get sick.
"I'm wearing a mask because I don't want all of the above! " Yup. This ultimately comes down to the old balance between a type 1 and type 2 error and which is the more costly. In this case, the choice seems obvious. Masking even when it wasn't actually necessary involves minimal cost (monetary and otherwise) and the benefit far outweighs any costs. The cost of not masking when you should have, however, can be exceptionally high.
So whenever we're in a crowded area, especially indoors, we mask up. Simple choice and no big deal. And we're getting our boosters this afternoon. :-)
Wise approach and valid points. Keep up the good work. If your original comments inferred that the data was old and we should re-think the approach to RSV, I guess I missed that..... RS
Quite a surprise… Of course, unknown if these hybrids will pose any threat or will be unable to function well, and there will have been years in the past when such co-existence in people’s lungs occurred without emergence of chimeras… Still, potentially very important to know can happen in case a future one in the population is successful:
https://www.nature.com/articles/s41564-022-01242-5
Coinfection by influenza A virus and respiratory syncytial virus produces hybrid virus particles
24 October 2022
Abstract
Interactions between respiratory viruses during infection affect transmission dynamics and clinical outcomes. To identify and characterize virus–virus interactions at the cellular level, we coinfected human lung cells with influenza A virus (IAV) and respiratory syncytial virus (RSV)...
The flip side of this - that viruses all speak the same basic language - is heterologous adaptive immunity.
Our adaptive immune system acts on "epitopes". I think of an antigen as being a bunch of epitopes the way a piece of music is a bunch of chords. The more chords it learns, the more tunes it can play. Therein lies the power of a multivalent vaccine!!!
Locally in San Diego influenza is surging exponentially but the sickest kids have RSV or rhino/enterovirus. ED wait times exceed 8 hours. Wish media would encourage parents to seek care if their kids are having trouble breathing or other severe symptoms and not go to the ER for mild URI, athlete’s foot, etc
Should we be asking our pediatricians to test for RSV? Was at doctor's with my 3yo w/2-day 103+ fever and cough. They tested for covid (negative) but nothing else (RSV, flu).
Regardless, we just keep following the school/CDC guidelines (stay home 24-hours after fever and until cough starts to improve, stay home if cough worsens).
Wise choices those boosters and the masking...no brainer as far as I'm concerned. Those that decry the common sense approach, are, well, you know........
I live near Birmingham, Alabama and the Children’s Hospital there is slammed with RSV patients. They’re converting some areas of the hospital to add patient rooms and using announcements on the news and online asking people to use the urgent care clinics if their child has fever but is not having difficulty breathing.
Heard you say you were the only one at a conference wearing a mask. I'm usually the only one wearing one - your example helped me to buck peer pressure. Yeah, even old ladies feel that pressure. Thanks.
Molnupiravir is known to work for flu and covid. If it turns out to work for RSV, what are the implications for testing? Could it be prescribed based solely on local prevalence and symptom severity?
But the basic point stands, doesn't it? Broad spectrum antivirals obviate the need for precise point of care tests?
What hypotheses are offered for the surge in viral outbreaks in 2022? Are we just better at detecting cases?
It seems like if that were the case, you wouldn’t see a spike in respiratory illness now in Southern states that barely masked or locked down before.
For us, this just means we continue doing what we've been doing for three years now. I think this is the New Normal and we can either accept it or pretend it's not true and roll loaded dice. Getting our latest boosters this afternoon at the local Walgreen's.