Both COVID-19 and monkeypox news have been fairly quiet for the last few weeks, with local monkeypox spread now slowed to the point that LA County Public Health Director Barbara Ferrer said in her weekly address this week that it will no longer be routinely included in these briefings. “We are relieved, as I am sure are so many others,” Ferrer said, “to see encouraging changes that reflect both behavior changes and lots of people accessing [monkeypox] vaccines and therapeutics.” (The most current monkeypox information will still be available at all times on the on the County’s monkeypox dashboard at http://publichealth.lacounty.gov/media/monkeypox/data/index.htm.)
hat said, however, there was still plenty to talk about at this week’s briefing, with Ferrer noting that the recent lengthy drop in COVID-19 cases seems to have plateaued, which may be setting the stage for a new winter surge…while both the flu and RSV seasons have started early this year, with a bang.
COVID-19
Newly reported COVID-19 cases averaged just under 906 per day over the past week, Ferrer said, which is only a very slight decline from the previous week, representing more of a plateau now than the kind of significant weekly declines we’ve seen since the peak of the most recent surge in July. Hospitalizations were down slightly this week, and deaths have plateaued at 10-12 per day.
The week’s numbers do keep us at the “low” community level, as defined by the CDC, for the 8th straight week, Ferrer said. But our case rose slightly this week, which – along with the plateauing case numbers – could be another sign that we might be starting to position for a winter surge.
And further signs of a coming increase are seen in this week’s list of early alert signals, Ferrer said, where the wastewater concentrations of COVID-19 (which rose 21% over the last week), and numbers of new outbreaks in skilled nursing facilities and TK-12th grade schools all reached “medium” levels of concern.
But while these are signs a surge could be brewing, Ferrer said, unlike past years, it’s not clear which COVID-19 variant might lead such an increase. Currently, she reported, the BA.5 subvariant of the Omicron strain is still dominant locally, though its percentage of all cases fell from 88% to 83% this week. Cases attributable to the BA.4.6 variant also decreased slightly this week.
At the same time, however, the BF.7 strain (which is also a BA.5 subvariant), is now the second most dominant strain locally, accounting for 4.8% of all COVID-19 cases. And the BQ.1 and BQ.1.1 strains are new this week, though still only accounting for about 2.7% of all cases in LA County. (These two strains, however, also account for about 17% of cases across the Unite States now, Ferrer said, and may have certain “growth advantages” over other new strains, so they could be poised to increase here as well.) And finally, the BA.2.75 and BA.2.75.2 strains, which have been around a bit longer, Ferrer said, are also still present in LA County, but only account for 8 local cases so far. All of which is to say, she said, that so far there is “no one candidate that we can say with certainty that is likely to out-compete other strains.”
At the same time, however, Ferrer also said that because the virus is constantly evolving, it still makes sent to take common-sense protections, including – and especially – getting vaccinated and/or boosted if it’s been a while since your last booster. (Immunity – whether from vaccines or a previous infection – wanes over time, and the newest booster shots are also more specifically targeted than their predecessors to the strains of the virus currently circulating most widely.)
Flu and RSV
But although a COVID-19 surge may be on the horizon, Ferrer said, a more immediate issue may be what appears to be a particularly early and strong onset of both the influenza and respiratory syncytial virus (RSV) seasons this year.
Ferrer said that unlike COVID-19, there is no mandated reporting for seasonal respiratory illnesses such as flu and RSV, so it’s a bit harder to track new cases (the county relies on trends in test samples from health care providers). But the seasonal calendar for the diseases charts their progress from October of one year through September of the following year, and the viral season officially starts each year when the percentage of positive samples rises above 5%.
In 2018-2019 (the yellow line on the chart below), Ferrer said the flu season didn’t start until December, and then peaked in early April. In 2019-2020 (blue line below), the season started in December, quickly hit a big peak in January, and then fell off almost entirely when the first COVID-19 lockdowns went into effect after that. The 2020-21 flu season (purple line) was almost skipped entirely, Ferrer said, also because of strict COVID-19 protocols in effect at the time. But last year (2021-2022, green line), Ferrer said renewed protections during the Omicron surge helped to mute what might have been the earlier part of flu season, but after the removal of many mandatory COVID-19 protections in the spring, flu had a “highly unusual” spring surge in April and May.
And now, with very few mandated COVID-19 protections in place for the last few months, Ferrer reported that this year (short red line below), flu cases jumped right in with more than 5% positivity in early October, and showed a sharp increase over the next week (the most recent data we have so far). “This is the earliest start to the flu season we’ve experienced in the last five years,” Ferrer said. She also said that we can’t yet predict its overall trajectory this year, because every season differs based on the percentage of people who get their seasonal vaccinations, which viral strains are circulating, and whether the vaccines turn out to be well matched to the circulating strains. But so far, she said, signs point to what could be a longer, more severe flu season than usual…so it’s particularly important for people to get their flu shots as soon as possible.
Also noteworthy, Ferrer said, is the percentage of emergency room visits related to influenza-like illnesses by age group over the last three years.  She said children ages 0-4 (light blue line below) tend to represent the greatest number of such visits, which isn’t surprising…but what is surprising is that we’re already seeing a big spike in these visits in October this year.
Ferrer said RSV usually causes mild cold-like symptoms in most people, with recovery in 1-2 weeks, but it can be very serious for older adults and very young children, and is the most common cause of pneumonia and bronchiolitis in children less than one year old.
As with flu, Ferrer said that RSV season usually in late fall or early winter each year, and varies from year to year in severity and duration. But also like flu, she said, RSV was “essentially absent” in 2020-2021 because of COVID protections. The 2021-2022 season, she said, started early, peaked in December, and remained low for most of 2022. But cases started to increase again in September this year, much earlier and rising at a much higher rate than usual for this time of year. Now, Ferrer said, 12% of RSV specimens in LA County are testing positive for the virus, which actually exceeds the peak of the seasons in 2019-2020 and 2020-2021, and seems to be matching last year’s higher than usual numbers. Ferrer said we can’t predict yet whether this rise is heading for an early peak or the start of a severe RSV season, but it is unusually high for this time of year “and warrants caution.”
Finally, even more dramatically than the flu trend line, emergency room visits for children ages 0-4 related to RSV are also spiking dramatically this month, Ferrer said…to the highest level we’ve seen in the last four years, which underscores the need for protective measures, especially for children.
So how do we prevent flu, RSV and other respiratory illnesses, especially in those who are most vulnerable? According to Ferrer, the steps are both simple and familiar from our recent experiences with COVID-19: stay up to date on flu vaccines and COVID-19 boosters, wash hands well and frequently, consider wearing a mask (especially in crowded indoor spaces), stay home if you have any symptoms, test frequently for COVID-19, and see your doctor if your symptoms are severe.
Also, Ferrer said, if you or someone in your household does get sick – with COVID-19, flu, or RSV – stay away from others as much as possible, wear a mask and cover coughs, stay hydrated, use over-the-counter medications to manage low-grade symptoms, wash hands frequently, and disinfect surfaces.
Ferrer also said people should call a doctor if they have difficulty breathing, persistent chest or stomach pain, significant vomiting or dehydration, or severe weakness or muscle pain. Additional symptoms of concern in children include a fever higher than 104 degrees, fast or troubled breathing, cyanosis (bluish skin), dehydration, or irritability and an unwillingness to be held.
In conclusion, though, Ferrer said that with common sense protections people should still feel free to resume their customary Halloween festivities this year, and that we have better-than-ever COVID-19 tools now, so “we’re not helpless here,” even if cases do surge again this winter.
