Another COVID fall surge may be brewing. Here's what to watch for

We’re heading into a fall and winter COVID-19 surge, most medical experts agree.

Anthony Fauci, President Biden’s chief medical advisor, warned about this in April. The crucial question is how bad will it be? We have vaccines. We have new treatments. The hospitalization and death rates from COVID-19 have been plummeting for more than a year, according to the Centers for Disease Control and Prevention (CDC), although they seem to have plateaued lately.

The daily death rate hovers between 400 and 500 individuals, according to the Johns Hopkins Coronavirus Research Center. Specifically, last Friday 402 people died from the disease, while 52,800 new cases were reported. But as President Joe Biden said recently the pandemic seems to be over, though COVID-19 must still be closely monitored. And the Biden administration also says that about 100 million people could get COVID-19 this fall and winter.

If COVID-19 continues to kill 400 individuals a day, that would come to about 145,000 deaths in a year. Influenza killed between 12,000 to 52,000 Americans each year between 2010 and 2020. (The range represents the uncertainty about whether someone dies from the flu, or from underlying conditions.)

Of course, there’s always the fear of what epidemiologists refer to as frankenviruses: A COVID-19 variant as deadly as Delta, and as transmissible as Omicron. Transmissibility matters. Even though Delta is epidemiologically deadlier than Omicron, the fact that Omicron can infect so many more people made it the biggest killer in the United States, according to the CDC.

Perhaps the most worrisome sign of all is that subvariants and sub-subvariants of Omicron are being reproduced “exponentially,” as Fortune magazine reports.

Two sub-subvariants of Omicron that raise concerns are BF.7 (also known as BA.2.75.2), and BQ.1.1. Preliminary data suggest that BF.7 evades antibodies caused by vaccines and prior infection better than any other iteration of the disease. Except for, possibly, the newest kid on the block, BQ.1.1, which is so new that not much is known about it yet. These observations were made in preprint studies released last week: one by Swedish researchers, the other by Chinese researchers.  

Raj Rajnarayanan, Ph.D., assistant dean of research and associate professor at the New York Institute of Technology campus in Jonesboro, Ark., tells Fortune that these and other emerging subvariants and sub-subvariants have the potential to render ineffective current treatments and vaccines.  

Stuart Ray, M.D., vice chair of medicine for data integrity and analytics at Johns Hopkins Department of Medicine, tells Fortune that what makes BF.7 particularly worrisome involves a spike protein different than what’s been seen in other Omicron variants, as well as a change in the nucleotide sequence. “The same growth advantage in multiple countries makes it reasonable to think that BF.7 is gaining a foothold,” Ray tells Fortune.

The Biden administration encourages everybody to get the new booster that targets not only original COVID but the Omicron version as well. However, some experts question the research used to develop the new booster.

Monica Gandhi, M.D., an infectious disease expert and a professor at the University of California, San Francisco, pointed out to Fierce Healthcare several weeks ago that “although there is absolutely biologic plausibility that the BA.4/BA.5 plus ancestral strain booster shots will increase neutralizing antibody data in humans, we only have mice data at this point (in <10 mice) that neutralizing antibody titers to BA.5 are increased above the original booster shot,” Gandhi tells Fierce Healthcare. “We also have clinical data from the BA.1/bivalent vaccines in humans from which the CDC is extrapolating. Although we do use mice data for updating flu shots every year, this is the first time that the mRNA booster has been updated [using mice data]. So, getting human data with the BA.4/BA.5/ancestral strain bivalent vaccine may increase confidence in the vaccine.”

Rajnarayanan uttered the soundbite when it comes to what worries healthcare experts: That the new variants might be invulnerable to new treatments and vaccines. It was such a money quote that Fortune used it in its headline.

“We used to say we have the tools,” Rajnarayanan said. “The tools are getting picked off.”