Voices: How Will We Know When The Pandemic Is Really Over?
Dr. Katelyn Jetelina joins Inside Medicine to discuss that and more.
Among all the great science communicators to have emerged during the pandemic, few are better than Dr. Katelyn Jetelina. Her Substack, “Your Local Epidemiologist” is superb. She breaks things down in such intuitive ways and her pieces are incredibly user friendly.
While we’ve worked together on a couple of small projects, I had never had the chance to have a real meaty conversation with her. And that we did, last month! It was a wide-ranging and insightful interview, hosted by MedPage Today.
We covered so much ground on questions we both get asked all the time.
•How will we be able to tell when the pandemic is over?
•What do we know about boosters right now?
•Can you game your booster timing—i.e., choose when to get it based on perceived personal risk? (Spoiler: we both think that you can, even though that’s not a good recipe for population public health policy.)
•Where do we come down on the CDC’s current mask guidance?
All that and more! While MedPage Today is largely a medical audience, Katelyn and I are always tailoring our answers for general readers and viewers as well. So, I think you’ll find our Q&A illuminating.
Here’s the transcript and a link to the video. Or, if you just want to listen in, here’s the audio:
Faust: We're joined by Dr. Katelyn Jetelina, the author of "Your Local Epidemiologist" on Substack. This is MedPage Today. I've taken over their feed, which is fine because I'm Jeremy Faust, the editor-in-chief of MedPage, so they let me sneak onto the Insta to talk about the pandemic and very specifically, President Biden. President Biden said 'The pandemic is over.' This is a declaration he said that really confused a lot of people. People also want to know about where we are with the bivalent booster and everything.
So to go through all of that, we are joined by epidemiologist Dr. Katelyn Jetelina, who writes this great Substack that you should all check out about COVID, about other issues. Thanks for joining us.
Jetelina: Yeah, of course. And Jeremy, you write a newsletter as well.
Faust: I do. I write a newsletter called "Inside Medicine" over on Bulletin [We’re on Substack now obviously]. But let's talk about, just in general, where do you think we are right now in the grand trajectory?
Jetelina: We are in a really weird spot of the pandemic. I think that's where we're getting this tug of war between this urgency of normal and state of urgency, right? Because we're not where we were in March of 2020, right? The boats are not driving by in New York, and we're not all watching it on TV, but we still have 400, 500 Americans dying per day. So we are in this weird spot of are we in a manageable pandemic or are we not?
I would argue, and I think a lot of epidemiologists argue, we're not out of a pandemic yet. I think that what happens this winter will be very telling about what stage we actually are in, especially when we start taking into account normal levels of flu and what our healthcare systems look like with this new repertoire of disease.
So yeah, we're in this weird stage between pandemic and endemic, and I think that's what's really driving a lot of the confusion, and a lot of the suboptimal messaging right now, too.
Faust: What kind of metric do you look at to say 'OK, we are now in a sort of endemic phase as opposed to an emergency pandemic' Like what are your go-tos on this? You're shaking your head.
Jetelina: Yeah, I don't know. You know, we've never really had to do this before in real time. I think one of the most important metrics I will say is healthcare capacity, and that's why I think we don't know yet if we're endemic or not, because we haven't had a winter yet where our healthcare systems did fine. For Omicron, they did not do well, and for different reasons than why we didn't do well in December of 2020, and so it'll be interesting to see what happens this winter.
I think death is a low-hanging fruit with metrics on how well we're doing, specifically when we start comparing ourselves to other countries. It kind of gives us a baseline of how well we are doing and we're losing a lot of people right now.
So I guess the healthcare capacity, deaths, and if I put my epidemiologist hat on, it's also predictability. We have no idea what this winter's going to look like, what our wave is going to look like, what booster uptake's going to look like, and I think we need to be really patient. I think a lot of us are really eager to declare this over, and we can put it in the past, but it takes patience to know where we're at, and this is certainly not predictable, and so that's why I think we're still in this pandemic phase.
But I would actually be very curious to hear your thoughts, Jeremy, on what metrics you use, too.
Faust: There are different lenses, right? And to me, the most important lens, because it ends all conversation, is whether or not there's all-cause excess mortality. In other words, are more people dying than usual altogether? Because there's this whole argument of 'Oh, that person just happened to have coronavirus when they died. Should we count it?' And all-cause excess mortality kind of gets by that by saying 'Look, there's just a certain number of people we know die every day. It's very, very stable over the century. It goes down from 1900 to 2020, but we know January is worse than March and all that. We're still in this phase where a lot of the country has excess mortality, although we've gotten a lot lower.' That's one place.
I agree with you on healthcare capacity. I think that these winters have not looked anything like the past winters. People will say 'Oh, the hospitals weren't that much more full.' But I kind of don't agree with that. First of all, we added capacity. Second of all, the kind of care that was being provided was a lot more aggressive, so we were sending people home who normally we would like to have kept around, but we were like 'OK, it'll work to make them go home. It's kind of unsafe, but let's just make room.'
It's like you had 10 car accidents one day and 10 the next, but on the second day all of them were like, airbags and totaling, whereas the first day was all full of fender benders. 'Oh look, it was 10 and 10.' No, that's not really what happened; that's how I think about it.
I also agree with you about the predictability. I mean, that's the epidemiology hat. And look, I think the coronaviruses are all seasonal. They're all seasonal, but that doesn't mean that they're gone in the summer. It means that they're really low. This virus is so contagious -- the sea level is higher, so it's like any little swell can be a tidal wave. Whereas with flu, the level is so low and it's hard for a surge to happen outside of, like, the really worst part of the season. OK, that's how I think about it.
Now, I know that you and I could do this topic for like --
Jetelina: I know, I can keep talking!
Faust: I think people are really confused by that though. The whole excess mortality thing. Because if you look at the whole 400, 500 deaths per day, I actually think at this point probably some of those are not truly excess, which just means that COVID had anywhere from a zero to 50% involvement in that death, maybe less than 50%, but it still counts. But it's hard to say.
And then there's the whole...My big thing is that most people don't understand that today's COVID death doesn't look like COVID death in early 2020; it's a tip over. So if someone dies of heart failure, that's not necessarily COVID pneumonia, but if they had been boosted and they didn't get infected, they wouldn't die. It's this in-between thing. It's because of COVID, but not truly of COVID, if that makes sense.
Jetelina: I mean, it makes sense to me. But I think the other really interesting discussion we need to have on a national level regarding excess death is that we have a new disease now. What is acceptable excess death? Because we are going to see death. Is it truly zero? Should we strive to what was pre-pandemic? What is it now?
Faust: What's our new sea level?
Jetelina: Yeah, and that's a discussion; it's a tough one to have. I think that's also what we're trying to really decide as a nation right now is where is that new sea level and what do we find acceptable, right? We do that with flu. We prevented, what, 60,000 deaths from the flu or whatever because of a lockdown. We can prevent that many deaths, but that's not what we, as a culture, accept.
So I don't know, I think it'll be really interesting and I don't think anyone has the right answer, but this is what is basically happening in real time as we're all discussing and deciding as a culture where this lays.
Faust: Yeah, I agree with that. I think that we've rarely seen this, but it's possible that the opposite can happen, because the people who have died of COVID basically were a little bit sicker than average, that you actually see a sea level that's lower than before, like a pull forward effect. But we haven't seen that very often, and the reason we haven't seen that very often is because repeat infections are happening among people who are sick, who have heart failure, diabetes. So it's a complicated conversation that we won't solve here. But I've seen this happen a few times in our datasets. We look at excess mortality in my team and say 'Oh look, it went below where we thought it might be,' which is such a tragedy. It's called harvesting. Essentially, low-hanging fruit. The virus found people to die, and who's left over? A healthy survivor cohort, right? We're alive because we're lucky. So you can look at it that way. It's very depressing.
Let's talk about something a little bit less depressing, which is the tools we have. You've written a lot about the vaccine, as I have, and the boosters, as I have. Let's talk about the bivalent booster, which just to remind everyone, there's this new booster that's been approved, or authorized I should say, that combines the recipe of the original Wuhan strain, which is the vaccine that has saved millions of lives all over the world, and then it also has components of Omicron. So bivalent, two parts. That's just been authorized, that's being rolled out, and there's a lot of hope around here. So tell us what we know so far about this.
Jetelina: I guess there's a lot of hope, but there's also a lot of confusing messaging around this too right now. This is the first time we've updated our vaccine, and this is pretty significant because this is also the first time we're trying to get ahead of the virus, or at least two steps behind it instead of 10 steps behind it. The only way we could do that is try and predict where this virus is going. We do that with the flu every year using very minimal data.
In the United States, we decided that we're going to go with the BA-5 vaccine, which is the Omicron subvariant. WHO [World Health Organization] went with BA-1, and the same with Europe, and that's what's being rolled out right now. We don't have effectiveness data on it. Just like the flu, we have to wait to see once it's rolled out and see how well it works and how long it works.
But we are getting, and I just put this in my newsletter this morning, really early data showing that as we expected, and as we saw in my studies, this vaccine is supposed to work as well, if not better than the previous boosters, which is promising. That's the good news.
I will say some not-so-great news is that this virus continues to mutate, and there are already variants on the horizon that may be able to escape some of this vaccine. It will not be all of it, but unfortunately this is how SARS CoV-2 works, and so it'll be really interesting to see what happens this winter.
Faust: I want to just talk about boosters as a kind of a global thing. I wonder why people want them, and not like 'Why do you want it? Don't get one,' but I mean like, what are they hoping to get out of it? Because there is actually a little bit of a difference depending on who you are, right?
I guess my question is if you're a young, healthy person with no medical problems, two, let alone three, doses of Wuhan keeps you out of the hospital, right?
Jetelina: Yeah.
Faust: So are we essentially using boosters in young people to basically decrease infection and spread? Is that fair?
Jetelina: Yeah, at least temporarily. You know, we do see waning with severe disease. It is not as drastic at all as infection, but it does decrease. There was a really great study that came out this week around pregnant people and there was pretty significant waning of the booster protection, so I think a little of it is...if I just talk about myself, why am I getting the booster a little bit is because of that severe disease. I would love to have optimal protection. There's very little risk to me. But also, it helps with infection temporarily, and I think that's important when we start talking about the holidays and being around older grandparents, and navigating flu season with toddlers. I need to be as healthy as I can be so I can take care of my girls.
So there are a lot of other reasons other than just severe disease, I think.
Faust: Yeah, that's fair. I don't know if we'll agree on this one. So I'm curious, people have talked about timing the booster. Because in my view, if you're a person who has medical comorbidities, medical conditions that predispose you to have to go to the hospital -- literally 'Yes/No. Have you been hospitalized for any reason in the past year or two?' -- those individuals probably need to live booster to booster, and yearly isn't enough. It's like every 4 or every 6 months; let's keep this really up to date. That's the group I'm worried about, both as sort of an [epidemiology] person, but also as someone in the hospital receiving people, like, I know who's getting sick.
Everyone else is thinking about maybe protecting someone else like you are, and so the timing thing becomes interesting. Should you time it? If you get it now, really all you're doing is decreasing your infection risk for however many weeks it lasts.
Now that's a really big question because we know with the previous boosters it waned quickly. The big question with the bivalent is will it last longer because now it's more tailored, right? That's a big question. Let's hope that's true. We don't know.
But let's assume it's not true for a second. Is timing your booster crazy? I think it's not. I think you can do it, but I get dirty looks from other people in the field when I say that.
Jetelina: No, I think you can certainly time it, and I think that it may make sense. I mean, we time the flu vaccine with older adults because it wanes so quickly. We tell older adults to get your flu vaccine in October or November because we want you to be ultimately protected when the big flu season comes. So I don't think that is rare.
I think the challenge comes to, what is the most effective scientific communication, and what are people going to hear? How do you get as many millions of Americans vaccinated as possible? I think that's where that messaging kind of can come in and that can be really confusing for people.
I think that's why the White House kind of just went 'Get them both [bivalent booster and flu] right now,' the 'one in each arm' kind of thing. I tell my family how to time their vaccines for optimal protection because that's how our immune systems work. I just think that message is difficult for 330 million people.
Faust: Totally. And when I talk to people in the administration about this, that's exactly what they say. Like 'Look, what am I supposed to do? Go up there and say to 330 million people, think about Thanksgiving and Christmas or whatever.' No. It's very, very bad messaging to do that because they're looking at a systemic question.
How can they possibly know, for example, that in late October, I've got some reunion I really want to go to and that's very important to me. So then I'm going to actually take my shot in mid-October and then if it wanes by February I'm at risk again. But that's a risk I'm willing to take, right? How are they going to say 'Get your shot right before the period of time you're worried about most.' That, I agree, would fall flat.
But I actually ran some really simple modeling on this. I did this like a thought experiment, which was if we replayed Omicron like last year, let's just say that it's a year ago and the case count will be exactly what we had a year ago, would it be bad to have sort of boosted too soon and would it be better to have waited? People argue 'Oh, you'll never know when you miss. You might have missed the peak.' In the modeling that I did, it was crazy. You would've had to basically not boost until March for you to have backfired that. In other words, case counts were so high in January and February that even if you missed December and January and a little bit in February, case counts were still high enough in February where it was better to be vaccinated late in that surge than it would've been to have gotten ahead of it and gotten boosted in October.
It's crazy, right? It's just an interesting example of how this is a concept that most people watching this will not really want to know about, but area under the curve, how many infections are there to prevent? And if you actually boost too soon, it's sort of almost wasted, you know? It's like drinking when you're hydrated. But yeah, I agree on the public messaging piece. It's real hard.
Jetelina: It is. And we keep making the same mistakes every single booster. This whole 'may versus should'. It really needs to be clear messaging, and I think it has been, at least this time around, but the problem is we've already lost the thread of this pandemic. It'll be interesting to see what the numbers are for uptake January 1st. I'm really hoping still that it'll be close to flu uptake, maybe 60%, but we'll see. Right now, it's not great.
Faust: We have a bunch of questions that were sent in before and a few here [in the chat] as well. Oh, I'm sorry! I keep getting this comment and I need to ask about boosters, vaccines, and long COVID -- or post-acute COVID. What do we know about vaccines and boosters and long COVID? Do we know anything?
Jetelina: We do. We know that vaccines help a little. We don't really know how much they help. Some studies have shown that vaccines reduce risk of long COVID by 85%. Other studies have shown about 15%. So there's this huge range. I think what's clear is that vaccines help a little, but they're not perfect. You could be fully boosted, get an asymptomatic infection, and still get long COVID. That's, to me, slightly terrifying, but they do help.
The other thing that also is helping with long COVID is the way this virus is mutating. Thankfully Omicron is less likely to cause long COVID than Delta, there was this really nice study done a couple months ago, but again, it's still there. It's still a risk, even if you kind of do everything you need to do to get vaccinated.
This virus is nasty, and this is where your additional layers come in, like, wearing a mask at the grocery store can do a little bit to help that too.
Faust: Speaking of masks, I was going to go to our viewer questions, but I have to ask this. The CDC has sort of weighed in on masks in healthcare settings saying that unless you're in a really, really high area of transmission, it's optional.
A, how do you feel about that? And B, what is the sort of off-ramp? Is it that the CDC is looking at this and saying 'Well, we're not going to get better than this for a long time. We can't ask people to wear masks for the rest of eternity, sorry.'
Jetelina: My reaction was: 'What are you guys doing? Are you kidding me?' We need to keep masks on in healthcare settings!
I think that the question is the second, what is that off-ramp? I would've liked, again, to see how we go through winter and how this looks on healthcare systems without taking away layers.
The other thing that really disappointed me, at least as an epidemiologist, about that new guidance is that it's completely dependent on reported cases, and we are not reporting a lot of cases because we have changed our behaviors and testing. That is a terrible way to measure transmission right now in the community, especially in places like the South [of the U.S.] where people are just not testing anymore. So maybe the hospital is not in a high transmission officially, but they are unofficially. It also makes it incredibly difficult for hospital administrators.
Yeah, I don't know. Above my pay line.
Faust: No, it's not. But, it's hard for me working in a hospital to imagine taking my mask off any time soon. I think for the foreseeable future, especially during cold and flu and COVID season, that this is going to be something that we need to do.
Okay, let's talk about the future: mucosal vaccines. Where do you think we are on this? You've written a little bit about this.
Jetelina: I have! I'm really excited about it. I went to a White House event a month or two ago about the next-generation vaccines. I think it's very clear we need a next-generation vaccine. Unfortunately, I think it's gonna take us a couple years because we just don't have an Operation Warp Speed 2.0.
Is that next-generation vaccine going to be like a pan coronavirus vaccine? Which means it's variant proof, which would be super cool. Or is it going to be more of an intranasal or oral vaccine, which would really stunt this pandemic because it would stop transmission really well. Is it one of those microneedle vaccine things that I think are pretty cool? I don't know, but there's a lot of innovation happening right now. Unfortunately, it's going slow like it did pre-pandemic just because of funding.
Faust: Yeah, that bothers me. We did something successful and then we were like 'Oh, let's not do that again. That was too successful,' or something.
I agree that the idea of a mucosal vaccine, something that is meant to line our mouth and nose and the places of entry for the virus, there's a lot of biological plausibility here. The kind of antibodies that line those areas have been shown to be protected. For example, if a nursing mother has been recently infected or recently vaccinated, those immunoglobulin actually make it in and protect the baby, which is extremely important because the neonatal period is such a dangerous time for babies.
So, I think that's the future. I'd love to see a Warp Speed on that. 100% agree with you.
That was one question from our viewers. Here's another one, I'm looking at my thing here. Oh, this is a great one 'My sister just got the bivalent and then basically got symptoms and then was recommended to get a COVID test and had COVID a couple days later. Was that the bivalent vaccine?'
Jetelina: No, it wasn't. That was just really bad luck. That means that she was probably exposed maybe at the Walgreens or even just a couple days before. That stinks, I'm sorry.
Faust: I know. I wrote about this early in the vaccine rollout that depending on prevalence, this could happen to one in 500 people, which sounds like not many, but one in 500 people -- OK, that's two in a 1,000 right? That's 20 in 10,000, that's 200 in 100,000, 2,000 in a million people who get boosted are gonna actually get COVID in the 24 to 48 hours around their booster and they're going to blame the vaccine. No, it's just bad luck.
Jetelina: We see that with flu, though. People think they can get the flu right after the vaccine and they can't, but you just have that unlucky timing and you hear enough of those stories that you start kind of believing it too.
Faust: Yeah, that makes sense. It's good to space exposures to these things, because it gives our immune system time to sort of mature, to remember what happened, to develop some repertoire; a little more immunology nerdy stuff here. Let's see, there's a couple questions here. Is there any data on the longer-term effects on babies if a woman gets COVID during her pregnancy? I have an answer for that. Katelyn, do you?
Jetelina: No, go for it. I know you just wrote about this.
Faust: So the placenta is an amazing evolutionary project. The virus will not reach the fetus, but the antibodies will, so that's fantastic. The baby gets this antibody transfusion, and babies are born with an immunity that's temporary, that wanes very quickly [in] a couple of months.
You want to avoid infection during pregnancy because pregnancy is a dangerous time, especially in the third trimester. But also, you'd rather just get boosted during pregnancy, especially in the second half, because those antibodies actually do persist for 2 and maybe even 4 months, maybe longer, so the babies actually do better when mom has been boosted during pregnancy.
That's a good one. Let's see if we have time for one more...updates on the under [age] 5 [years]. Under 5, wow. Low uptake, but I'm optimistic because I think that a lot of parents are waiting until their annual visits to get this stuff as opposed to doing what I'm imagining people like me do, which is that the second their kid was eligible, get out of there and go. But it's been slow.
I think that parents don't understand that even though the most likely thing to happen to your kid if they get COVID is nothing, that they'll be OK, which is the most likely outcome, that the rare outcomes aren't rare enough. One in 1,000 or one in 10,000 even is a horrific number on a systemic level. And in today's modern medicine, we can use vaccines to eliminate those bad outcomes. Is that your take?
Jetelina: Yeah, absolutely. I have two under 5 and I got them [vaccinated] right away. I was very excited, and both of my kids already were infected. I think a lot of parents don't know the added value of vaccination plus infection, which creates this thing called 'hybrid immunity,' so, they're optimally protected. I was very excited to get them vaccinated and I hope our numbers increase. [Washington] D.C. is doing really good, like 27% of under 5 are vaccinated, which is amazing compared to the South.
Faust: I agree. Hybrid immunity is great. You prefer to have the other order: vaccination and then if they have to get infected, then the kids already have some immunity to it. That's the safer way to reach hybrid immunity, but yes, all the studies show that the vaccines for children, and for everyone, are far more effective if you've never been infected, when you go from nothing to some degree of immunity -- that's the best use of them.
But even if you've been infected, with the waning of that protection over time and with the slug of protection that the vaccines provide, it's worth doing. You have to vaccinate more people to get an effect, but it's totally a reasonable thing to do and it's better for a society anyhow.
Alright, we're over time. Lastly, give us something that's on your horizon, maybe something optimistic, something you look forward to. But if not, what's on your viewfinder right now for the next little while?
Jetelina: You know, I'm paying very close attention to what happens this winter, like I mentioned before, but I think everyone needs to keep in mind that every pandemic ends. I don't think it's ended yet, but this will end eventually. We just really have to get there and try and save as many lives on our way. We need to continue to keep protecting ourselves and get vaccinated.
Faust: All right, perfect. Thank you so much Katelyn for joining us. Dr. Katelyn Jetelina, "Your Local Epidemiologist" on all the social and on Substack. Great newsletter, super easy to read, on point, evidence-based, reasonable, great. Thank you so much for joining us on MedPage Today.
Jetelina: Thank you for having me. Bye guys.
Thank you. Katelyn Jetelina is treasure.