'Still a Public Health Emergency': With BA.5 COVID Variant On Rise, Here's What You Need to Know

The Bay Area is finally trying to have a normal, pandemic-free summer. And we seem to be inching closer. But it’s still not quite working out as planned.

The most recent culprit: the highly transmissible BA.5 omicron subvariant, now the dominant strain of COVID-19 across the country and the region. Unlike other strains, this one appears to be largely impervious to the antibodies that people may have gained from previous COVID infections, resulting in noticeably higher rates of reinfection.

BA.5 is also four times more resistant to COVID-19 vaccines, according to a new Mayo Clinic study, which categorizes the variant as “hypercontagious.” (Vaccines, however, still provide people with much better protection.)

That, in turn, has sparked a moderate surge in cases and hospitalizations in the Bay Area and beyond — nothing like the one we experienced last winter, but still enough to stoke some concern and warrant a heightened degree of caution.

To make some sense of the latest phase in this seemingly endless pandemic, Forum host Alexis Madrigal spoke earlier this week with Dr. Bob Wachter, chair of the UCSF Department of Medicine, and Dr. Yvonne “Bonnie” Maldonado, a professor of pediatrics and epidemiology at Stanford University School of Medicine. The two medical experts spent the hour answering a slew of questions from listeners, some of which are highlighted below.

The following has been edited for brevity and clarity.

On what has — and hasn’t — changed

More than two years into this thing, what hasn’t changed about the pandemic and our response to it?

Dr. Bob Wachter: We’ve never seen anything quite like this virus before. Everyone is at some level of risk. Everybody has to do this three-dimensional chess game pretty much every day to try to figure out what’s safe to do, what’s not safe to do. It’s causing massive disruption of our society and a lot of anxiety. So that hasn’t changed.

But a lot of the aspects of the virus have changed in terms of how infectious it is, how our immunity is working against it, and how severe it is. I think it’s very hard for people to process all of this, in part because we came to some of these understandings kind of the hard way. And once you’ve come to them, it’s hard to give them up as the facts change on the ground — and a lot of the facts have changed.

Dr. Yvonne Maldonado: This is still a public health emergency. As you know, the Biden administration just decided to extend our public health emergency that started in January 2020. That situation is not different. It is still a very deadly disease when you compare it to any other circulating viral illness that we see today.

It’s still worse than, say, our annual influenza epidemic. So it’s still a force to be dealt with.

Unfortunately, what has changed is our risk perception. We’re very good at getting used to lots of things that we feel like we can’t control. And that’s the problem. We think we can’t control this and we really can. We need to keep it high on the list of things you should do to keep yourself and your loved ones healthy.

On kids and school

What do we know now about kids and COVID that maybe we didn’t understand earlier in the pandemic?

Dr. Maldonado: We heard initially that children don’t get infected. That’s not true. That they don’t get sick. That’s also not true. And that they can’t transmit to others. That’s also not true.

Almost every single day since the beginning of the pandemic we’ve had children admitted to our hospital, not just with COVID [discovered after they’re admitted for something else], but for COVID. And so it’s a serious disease — and not just runny noses and coughs.

Unfortunately, what we’re seeing in kids is over 13 million cases with tens of thousands of hospitalizations since the beginning of the pandemic, just in the United States. And over 1,500 children who have died.

Some people say that, you know, that pales in comparison to deaths in adults. But still, this virus is in the top five causes of death right now in the U.S. for every single age group under 18. So when you break down the cases, it may be that the numbers look small, but they are the most preventable causes of death that we have right now in children.

What advice do you have for parents about how to safely send their kids back to school this fall?

Dr. Maldonado: Let me just start off by saying that what’s really changed is we have lots of vaccine options now for children. The FDA and the CDC just approved vaccines for everybody six months of age and older, similar to the flu.

I would even make it a rule that classrooms should be, if not enforcing vaccinations, at least tracking them, masking, and other kinds of mitigation in the classroom. Because we know that these vaccines can maybe not fully prevent infections, but can prevent serious complications.

And the other issue, as we heard before, is that BA.5 is very infectious. We don’t know what’s going to happen in the fall. We think there’s a new variant now called BA.2.75 that seems to be working its way across the world and appears to be even more contagious. And it also actually has a number of more mutations in the spike protein that attaches to human cells. So it could also have more immune evasion.

So I can’t imagine there wouldn’t be new variants coming along in the fall. Just make sure kids are masked when they’re in school, make sure ventilation works in classrooms. Everybody now who is in school should be able to be vaccinated, and that is going to be really a great way to get kids back in, get them learning again.

On boosters, antivirals and other drugs

Should I get the second booster now, or wait for the new ones that may be available this fall?

Dr. Wachter: Yes, I think you should get it now [even if you’ve recently recovered from COVID]. The data on the value of the second booster is more and more persuasive. A recent study showed that the mortality rate was one-fourth if you’ve gotten the second booster versus the first. That first booster was incredibly valuable and you definitely need to get the first one. But if you got it more than six months ago, its efficacy has waned in the face of the new variant that evades immunity better. So I’m recommending that people get it.

We’re also not sure how much better the rejiggered booster will be in the fall. And I can’t see a circumstance where you get boosted this week with booster No. 2 and somehow you’re not then able to get a better booster that comes out in November. So I think for anybody over 50, definitely get it.

What are your current thoughts about Paxlovid, the antiviral therapy? Some people have reported a “Paxlovid rebound,” in which they take it, it appears to work quite well and then they end up testing positive for a long time.

Dr. Wachter: Yes, I’m still prescribing it. Yes, I think it’s a useful drug, even though it seems like this rebound is happening all over the place.

What it is: You test positive, you start on this antiviral drug, Paxlovid. You take it for five days, you turn negative, you feel better. And then sometimes, a few days later, you often start feeling crummy again and you test positive again.

The good news about it is in pretty much every case I’ve heard of, it only lasts for four, five, six days. I’ve not heard of a severe rebound case, meaning that someone got so sick on that rebound that they needed to go to the hospital.

You are infectious during the rebound. I definitely know of cases where people have infected other folks, so you have to go back into isolation.

Why it’s happening, nobody knows exactly. How to prevent it, nobody knows that either.

And is it bad enough to not use the drug? I still think that the best clinical trial of the drug said it lowers the hospitalization rate among high-risk people by 90%. So for someone who’s at higher risk, I would definitely use it. I’m a little bit on the fence for a fully vaccinated boosted person who, let’s say, is younger than about 60. I probably wouldn’t. I’m 64. If I got COVID today, I probably would.

Long answer: I think I’d still use it, but I’m a little bit more concerned about it than I was before.

What’s your advice now for people with specific underlying immune conditions?

Dr. Maldonado: A monoclonal antibody combination called Evusheld is available. We know there’s plenty of supply. It’s available for people who have underlying specific immune conditions that don’t allow them to make a good antibody response, whether they’re vaccinated or not, or for people who can’t get vaccinated, which is less common.

That antibody combination is extremely effective at protecting people. It’s an injection that they can get once every six months or so, and that can be highly protective. So on top of mitigation, I do think people should consult their providers. And if their providers are not aware of Evusheld, they should ask them to seek counsel from, say, a public health agency or a specialist who knows about it. Because it’s highly efficient in protecting people and being able to let them and their families go out and live their lives.

On travel, recreation and invincibility

I’m 71 with no co-morbidities, and have a trip planned to Morocco and Italy in the fall. Do I go?

Dr. Wachter: Yes. I think that this virus is going to be with us for the foreseeable future. I think limiting your life in terms of not traveling, I don’t think makes any sense — especially if you’re going places where the prevalence is less than it is in California. I think traveling is fine.

I think that wherever you are, whether you’re in San Francisco or in Morocco, being in a crowded indoor space where there’s a lot of virus around, you should wear a good mask. When you can eat outside rather than inside, you should. Traveling is not the main risk. It really is how much virus there is in the community. And there’s really no place you can go where you can’t keep yourself safe if you’re vaccinated, boosted and are careful when you’re in crowded indoor spaces.

How safe is swimming in an outdoor public pool?

Dr. Wachter: I’m pretty sure it’s totally safe. I’ve not heard of a case transmitted that way, and I wouldn’t worry about that at all.

Is outdoor transmissibility more of a concern with BA.5?

Dr. Maldonado: No question. We know that with what we call the immediate reproductive number — the ability to infect others — the original virus was probably around the order of 1 to 2. This virus, the BA.4 and BA.5, is at a rate of about 3 to 4. So this virus can really infect almost twice as many people as the original virus did. And it’s not only more transmissible, but also can escape prior immunity. So I do think that it could be acquired at a farmers market if you’re around a lot of people.

Why do some people seem good at being able to avoid getting COVID, even after multiple exposures?

Dr. Wachter: It’s probably some combination of your immune system, things we don’t understand, and luck. The household attack rate — that is, the chances you’ll get COVID if a member of your household has it — is probably 30% to 40%, maybe a little higher now with the more infectious variant.

So, people sometimes believe, “I must have some immunity superpower because my partner had it and I didn’t get it.” That’s just the way it goes. And there’s a level of randomness that we don’t understand. But there’s also probably something about individual immune systems that make a difference.

I’ve been fairly careful, but my wife had it three months ago. I was exposed to her for a full day before we knew that she had it. And I managed to dodge the bullet. So I’ve never been prouder of my immune system, but I assume most of that was luck. And if I had enough exposures like that, eventually I would get it.

On risk for seniors

Given how dangerous loneliness can be for elderly people, should retirement communities and nursing homes still continue to shut down communal dining and other activities when new COVID cases are reported?

Dr. Wachter: I spoke last night at a multilevel retirement community in San Francisco that has seen a fair amount of COVID, but where not many people have gotten very sick. And they’ve kept the communal dining open.

The point I made is that life is short and we have to try to figure out what’s the balance between the things that we do that give us pleasure and prevent isolation in settings like that, and the risk. And I said, you are taking a risk, particularly with this virus being so prevalent. If you’re in a restaurant with a hundred people, it’s a near guarantee that someone there has COVID, and feels fine. On the other hand, you then have to weigh the risk of isolation for what may be, you know, several months, who knows?

And so I said, if it were me and I was running the place, I would not ban the communal dining, but I would do everything I could to make it as safe as possible: people wearing masks on their way in and out, spacing tables a little further apart, and really focusing on ventilation.

You can’t make it zero risk. But there is a cost and a consequence of saying to people who are living in that kind of setting, “You’re not going to see anyone for several months.” And we shouldn’t minimize that. It’s a very, very tough call.

How big a deal is getting reinfected with COVID, especially for seniors?

Dr. Wachter: I don’t think there’s good data on that. You would expect in some ways that it would be less severe because your immunity is better because of the first infection. But there just was a study that came out that showed that the long-term consequences seemed to be greater in people who had recurrent infections.

So to me, the bottom line is, the old saw that “you’ve had a first infection and now you’re good to go and don’t worry about it” is no longer true. You should continue to try to avoid getting reinfected. I think getting another booster is a good idea. And while I don’t think there’s any evidence that the second infection is likely to be worse than the first infection, I still think you would like to avoid it if you can.