As a very weary public heads into the fourth year of living with COVID-19, the emergence of two new variants leading to a recent spike in cases in the Houston area is not the kind of news anyone wanted.
Even more so when medical professionals say these variants may not be as responsive as past ones to the current Moderna and Pfizer boosters, leaving care givers leaning on other treatments.
At the same time, hospitals and clinics are seeing more and more patients with influenza A and Respiratory Syncytial Virus or RSV – both of which usually surface later in the year.
Though it is standard to see some RSV cases at this time of year, this season there was a larger number—particularly those that were more severe, said Dr. Michael Chang, a pediatric infectious disease specialist at UTHealth and Children’s Memorial Hermann Hospital. Like the new variants of COVID-19, healthcare providers are limited in how they can provide help to patients with RSV, said Chang.
And although it is rare, all three of these viruses can exist together. Houston Methodist’s data reports that co-detection and co-infection are seen more in cases of COVID-19 and flu, said Dr. Wesley Long, clinical pathologist and medical director of diagnostic microbiology at Houston Methodist.
Dr. Peter Hotez refers to the emerging COVID-19 variants in this new wave as the scrabble variants— this includes B.Q. 1, B.Q. 1.1. and X.B.B.
“In different parts of the world, you see B.Q. 1 and B.Q. 1.1. and other places more of X.B.B, so it could be that different states will have a higher percentage of one versus the other,” said Hotez, Co-Director of the Center for Vaccine Development at Texas Children’s Hospital and Dean of the National School of Tropical Medicine at Baylor College of Medicine.
According to Hotez, unlike waves in the past that saw one specific variant, this wave will have several variants active at one time. “We're seeing some heterogeneity across the country; some states could have X.B.B, in addition to B.Q. 1 and B.Q. 1.1, so we could be looking at a kind of a mix and match of different variants,” said Hotez.
Hotez said that it is too early to tell if there will be one variant that is dominant over the rest.
These variants could cause either one single large wave of COVID-19 or multiple waves over the winter and early spring months, said Hotez.
The current bivalent boosters show some effectiveness to cross-neutralize these new variants, Hotez said. However, because they are different from past Omicron variants, there is a chance that they could successfully evade immunity.
The data doctor
Starting with the almost daily press conferences that began right after the first case of COVID-19 was detected in Houston in early March 2020, Dr. David Persse became a household name.
Called upon repeatedly to detail the latest medical findings at the public briefings hosted by Houston Mayor Sylvester Turner and Harris County Judge Lina Hidalgo, the chief medical officer for the city of Houston was a reassuring presence, even as he issued warnings and urged people to take this virus seriously and adopt preventative measures such as masks, social distancing and vaccinations.
Houstonians were also encouraged to visit the city’s COVID-19 emergency website and the COVID-19 data hubs—where they could see regular updates of the number of cases, hospitalizations and deaths. Later, information circulated on wastewater reports which detected the presence of COVID in the discharge.
Now, that same wastewater analysis is showing a raised percentage positivity rate of the virus, indicating another wave began in November of this year.
“We’ve got the beginning of a new higher wave going on right now, we have for the past several weeks,” said Persse. “The wastewater numbers are increasing by about 30 percent per week and we’re seeing hospitalizations increase.”
Despite this, as of December 2022, the Houston Health Department has no plans to resume the COVID-19 related press conferences or weekly press releases on testing and vaccination sites – although the department is continually updating this information on its website and social media, said a spokesperson from the Houston Health Department.
COVID treatment alternatives going forward
Hotez, alongside Dr. Maria Bottazzi, developed the technology for a low-cost, mass-produced vaccine which the Indian company Biological E. Limited licensed and produced under the name Corbevax in India. In Indonesia, company BioFarma has produced it under the name IndoVac. This vaccine, developed to combat a lack of accessibility to vaccinations in other countries, now has two iterations and is widely effective in both India and Indonesia and is pending approval in several other countries.
Hotez has been quoted repeatedly as stressing the importance of countering COVID-19 worldwide and that low vaccination rates will just allow the virus to continue to spread. It has already killed more than 15 million people worldwide.
Corbevax is different from the three approved COVID-19 vaccines—Pfizer, Moderna, and Johnson and Johnson—as it delivers the spike protein directly to the body to prepare for potential encounters with the virus.
Production of a bivalent booster equivalent of this vaccination is currently in works, said Hotez. If they do produce this booster, it could serve as a potential replacement for the one that is used now. “We think it could be very useful, it could be long-lasting in the U.S., but we do not have a U.S. pharma partner or operation warp speed funds to operate yet,” said Hotez.
Without an updated booster or effective Monoclonal antibody treatments, doctors are turning to oral medications to reduce severe cases and hospitalizations.
Paxlovid and Molnupiravir are the two most used prescription oral medications that are given to patients to reduce the symptoms once infected. Paxlovid is prescribed predominantly to elderly or immunocompromised patients. Though Molnupiravir has fewer medication interactions, making it the slightly safer option to use in a patient that takes a lot of medication, the data has shown that it is not as effective, Dr. Wesley Long, clinical pathologist and medical director of diagnostic microbiology at Houston Methodist, said.
“Supposedly, several pharmaceutical companies are working on updating monoclonals that will fight against these new variants, but it remains to be seen how long it will take for those to come to market,” Long said.
When they do come to market, Long said, pharmaceutical companies may have issues in mass producing the new treatment. As a result, they would be used exclusively in treatment of higher risk cases.
RSV and its limited treatment options
RSV patients also face limited effective treatment options, as cases overcrowd Houston-area pediatric wards.
“In the last couple of weeks, we've had really high numbers of RSV patients hospitalized,” said pediatric infectious disease specialist Chang. “A significant proportion of our beds are taken up and about 40 to 50 percent of those patients are admitted to the intensive care unit.”
Chang said in most cases of RSV, doctors can only provide supportive care and wait the virus out. Though there have been several RSV vaccines in development, none have gone into production.
There is one vaccine that is RSV-related but does not target RSV directly or protect all populations from contracting the disease. This unnamed Pfizer vaccine, which is in stage 3 of clinical trial, is given to pregnant mothers so they can make antibodies in their placentas. “They did a report, and it protected these newborns from zero to 90 days of life from severe illness of RSV,” Chang said.
Pfizer announced that they are planning to apply for approval of this vaccine to the Food and Drug Administration by the end of this year.
RSV is seen primarily in younger children and infants, with severe cases usually targeting patients who are under two years old. Many of these younger children are hospitalized and have high chances of ending up in the Intensive Care Unit, Chang said.
There is an antiviral medication called Ribavirin, that will treat RSV directly, but it poses serious risk factors, said Chang. Doctors put patients on Ribavirin very rarely and only when they are severely immunocompromised.
According to Chang, health care providers are also hesitant to put patients on this medication as the benefits haven’t outweighed the costs. “Ribavirin reduces the ability of the virus to replicate in patients, though it has never clearly demonstrated to improve their clinical course or reduce the probability of going to the ICU,” Chang said.
Depending on the way that Ribavirin is administered, it can trigger issues with anemia, form crystals inside ventilator tubes and be hazardous to health care workers who are pregnant.
Although most cases of RSV are seen in younger patients, adults and older adolescents can also contract the disease. Those with asthma, who are immunocompromised or have preexisting respiratory conditions are at a higher risk of infection. Most older patients who do have RSV often don’t know that they have it as they may experience only a mild, but persistent cough and cold-like symptoms, said Chang.
There are several strains of RSV, however they are not categorized in the way that COVID-19 is, said Chang. With the recent uptick in cases, Chang said the strain that was seen this RSV season could be a bit more contagious or severe when compared to others.
“If we continue to have RSV similar to this season, within the next five years we’ll most likely see widespread RSV vaccination developments that target actual pediatric patients and potentially even older adults,” said Chang.
According to Long, it is difficult to recognize which viruses are active if there are multiple viruses that a patient tests positive for.
“Even if you test positive for two or more viruses, it can be a question of whether it is true co-infection or a case where you recovered from one virus and then got the other one, so that can muddle the picture a bit,” said Long.
Another issue in co-detection is not all patients are tested for all three viruses. Unlike COVID-19, RSV and flu tests do not have self-administered at home test options, meaning patients have to go into their local clinic or hospital to get tested.
Testing for each virus depends on the age, severity of the symptoms, exposure history, or whether the patient has pre-existing medical conditions, said Dr. Christina Propst, a Houston pediatrician.
If doctors are not testing for all viruses in every patient, a patient could have more than one of the viruses, but not know. This could lead to underreporting of co-infection as the other viruses are not detected, despite potentially being active, said Propst.
According to Propst, all three illnesses can cause respiratory distress and hypoxia, as well as result in secondary conditions such as pneumonia. “For these viruses, the lower respiratory illness is most concerning, not the nasal congestion, sore throat or postnasal drip cough,” said Propst.
When co-infection occurs, there is a chance that the patient will experience these symptoms more severely, however there is no way to predict this, said Propst.
Though there was a drop off in the number of RSV cases hospitals are seeing, cases of COVID-19 and influenza continue to rise, as there are 2,730 new cases of COVID-19 reported daily, according to the Texas Department of State Health Services.
Boosting still better than not
Despite the current booster’s potential reduced effectiveness against the new variants, which Houston Methodist reports now make up 71 percent of the new positive COVID-19 cases, it is still important for people to get boosted, medical officials say. The booster will still provide some protection from contraction, and if infected could lessen the severity of a person’s symptoms, said. Hotez.
In Texas there are currently 7,849,647 people who received at least one of their boosters, the department said, however this number does not indicate which booster they received.
Because there are still people needing to get the most recent booster, along with their flu vaccinations, Harris County is providing vaccines to the public daily. These vaccines are free, with no insurance requirement needed and include all the COVID-19 vaccines along with the flu vaccine, said Allison Reese, Director of Harris County Health Department’s COVID-19 Division.
There are several locations where residents can get these vaccines and they move throughout the community to ensure that if people want to be vaccinated, they have a way to receive that healthcare.
Getting boosted for new variants as they arise will also reduce a person’s chance of reinfection. As the buildup of immunity is created with each vaccine, that person has a better chance of protecting themselves from a new infection if they’ve been infected with COVID-19 before, said Hotez.
This is important to realize as the more reinfections occur in a patient, the higher the risk of contracting long COVID-19, said Hotez.
Long COVID-19 introduces long-lasting impacts of the virus that medical professionals are still unclear what their impact over time will be on a patient’s health.
The threat of new waves, even of another possible one next spring, have not decreased, said Hotez. The booster will protect against other waves that could come following this winter wave.
“People need to remember that much of the world is still under-vaccinated, if there are outbreaks in other parts of the world, they could spin off to create even more new variants here,” said Hotez.