The pandemic’s next stage is endemic COVID, UT health expert says

Will this pandemic ever end? How much harder does the delta variant make reaching herd immunity? Might the delta surge just peter out soon? Epidemiologist Catherine Troisi, with the University of Texas School of Public Health, spoke with us Wednesday.

It depends on what you mean by “end.” Is the virus going to disappear? Probably not.

Now, viruses surprise us. But if I were a betting person, I would bet a lot of money no.

What’s probably going to happen is, it’s going to become what we call “endemic” instead of “epidemic.” “Endemic” means that it’s around but at a lower level, sort of like the flu in a regular year.

If it’s endemic, we could still have another pandemic: That’s what happened H1N1, an influenza variant, in 2008. Most people didn’t have immunity, so it spread very quickly.

There are always going to be people who are susceptible to this virus. Newborn babies, for instance: If their mom has been vaccinated, they get antibodies for a little bit of time, but they lose those antibodies. And infants and children may be susceptible, depending on when we can vaccinate. There are certain people who can’t be vaccinated — not many, but some. And then there are people who don’t respond well to the vaccine, immunocompromised people and probably older folks.

And then of course, there are people who don’t get vaccinated. They will remain susceptible. Natural immunity does not seem to provide long-lasting immunity: Even if you get infected, there’s always the possibility of reinfections.

So the viruses is going to be here. How we as a society respond to this is pretty much up in the air. It looks as though we are simply going to decide “We’re done with the pandemic. We are tired of taking precautions, and we’re just going to go back to life as usual.”

People will get sick, hospitals will be crowded, and people will die from preventable infections. But we as a society seem to be headed that way.

You’ve been called to testify as an expert witness on epidemiology lately. Could you talk about that?

I testified recently in a couple of lawsuits about masks or face coverings in schools. The governor’s ban on mask mandates is really up in the air. Some school districts are ignoring it, and some courts have ruled that this exceeds the governor’s emergency powers.

I testified as to the need and effectiveness of face coverings in schools. We can’t vaccinate children under the age of 12 right now, but it’s very important kids get back to school. They lost a lot last year academically — never mind socially. So going back to school is good.

But we need to protect them. And the best way to protect them, since we don’t have a vaccine, is through face coverings.

How effective have masks been against the delta variant?

Well, they’re not perfect. We use the term “face coverings.” But that covers a wide range — everything from the N95, which is the gold standard, down to a single layer of cloth or a gaiter. The best is three layers — either two layers of cloth and a filter or three layers of cloth.

Effectiveness also depends on how the mask is fitted. If it’s gapping at your cheeks, air and potentially viruses getting in. I see people who are quote-unquote “wearing a mask,” but it’s underneath their nose. The virus enters and exits your body through your nose! It can come in through your mouth, but the main route is through your nose. So by wearing a mask only over your mouth or even worse, only over your chin, doesn’t do much. You have to wear that mask properly.

Masks, when worn properly, when thick enough to stop you from breathing in or exhaling virus, work very well. Many studies have shown this.

Absolutely no studies have shown that masks hurt children. Children adapt to the masks very quickly, and masks protect them from a disease that not only can put in the hospital, but can have long-term implications. We know that long COVID can happen in children. Why would you want to take that chance with a virus that can infect basically every organ in your body?

Could you give us an overview of what’s going on now with COVID in the Houston area?

We’re seeing a lot of infections. Our hospitals and our emergency departments are full. The husband of one of my students had acute appendicitis last week and spent the whole time before and after surgery in the emergency department because there weren’t any rooms for him.

You may have heard about someone from Bellville — a military veteran — who died because the hospital had no room for him.

That was because of a gallstone, right? Something that shouldn’t have killed him?

Right. It was very treatable and should not have killed him.

You don’t want to get COVID now, and you also don’t want to have a stroke or heart attack or be in an auto accident, because the hospitals are full and our medical staffs are overwhelmed. They have been at this for 18 months, and the burnout is incredible.

Now, in the last seven days, we have seen a plateau in new hospital admissions, which might be good. Seven days isn’t enough to really tell. But if it truly is plateauing, it’s plateauing at a very high level of cases.

And I think that we are going to see an increase in cases in the next couple of weeks because of kids going back to school. We’ve already seen a huge number of cases in children. Children may be less likely to spread it for various reasons, and that’s great. But if you have enough kids infected, some are going to bring it home to Mom and Dad, or worse, Grandma and Grandpa.

I think we’re in for a rough fall. I feel like a harbinger of doom.

You mentioned that medical workers are burned out. Epidemiologists have been at this for 18 months as well.

Yeah. Our public health practitioners and health departments have been working nonstop for 18 months — and besides COVID, they have to do their regular jobs as well. TB cases don’t go away. HIV doesn’t go away. Syphilis hasn’t gone away: We’ve seen an increase in syphilis. And never mind the work they do with chronic diseases.

Lately I’ve read hopeful stuff that points out that in some countries, such as England, for reasons for reasons not well understood, delta somehow just petered out after two months. What do you think of that? Is it likely to happen here?

I think it was John McCain who said that when he was a prisoner of war, the prisoners who didn’t do well were the ones who said, “Oh, I’m going to be out by Easter!” And Easter came and went.

Then they said, “I’m going to be out by Fourth of July!” And the Fourth of July came and went.

The prisoners who did well — the ones who were more resilient — were more realistic. They weren’t despondent. They had hope. But it was realistic hope.

Now, it would be wonderful if the virus disappears. But it hasn’t disappeared from England. They simply have made different choices. They have decided that they are going to act like nothing is happening, and they are willing to put up with a certain number of cases and deaths.

It also helps that Great Britain has the National Health Service, so everybody has access to medical care; we don’t have that here. We’ve seen throughout that the pandemic has a disproportionate effect on more vulnerable communities, such as people of color. Those are the people who are really going to suffer.

So back to your question: Do I think that in two months, the pandemic is going to disappear? I would be very surprised if that happened.

So here’s my ray of hope: More people are getting first vaccinations in Harris County. How good is our vaccination rate now? And where do we need it to be?

Right now around 60 percent of people in Harris County are vaccinated. That’s not high enough.

That’s 60 percent of people eligible for the vaccine? Not counting kids 12 and under, who aren’t eligible?

Yeah. And kids 12 and under are a significant proportion of the population in Texas. So it’s something over 50 percent of the total population.

Is that enough to stop transmission?

No, because first of all, there are pockets of unvaccinated people. So even if 90 percent were vaccinated, but that 10 percent all congregated together, there’s a possibility of spread.

With the original virus, we used to say that to get herd immunity, we would need maybe 70 percent or even 80 percent of people vaccinated. But the delta variant is much more infectious than the original virus.

So for delta, we’re estimating that we need 95 percent of people vaccinated to reach herd immunity. We can’t reach 95 percent if we can’t vaccinate children.

So yeah, 60 percent of eligible people vaccinated is better than it was before, but we’re not there yet.

At least the people who did get vaccines are now protected. They may get sick, but the odds that they’d be hospitalized or die are much reduced.

What else is on your mind these days?

I am part of the new Texas Public Health Institute, with the University of Texas and other partners. It was approved by the state legislature, and funding hopefully will be coming during this special session or the next one.

One of the things the institute is going to be looking at is detecting outbreaks before they become pandemics. Can we put better surveillance systems in place to have earlier detection of a potential pandemic in Texas?

One of the reasons this would be is important in Texas is, we’re on the border. With border states, there’s a possibility of an outbreak coming over the border.

Now, let me just say, to dispel misinformation out there, it is not asylum seekers who are bringing COVID into the United States. That is simply not true. But with a new infection, it’s possible.

We’re also a big agricultural state, and maybe 60 to 70 percent of new emerging infections come from animals to people. So it’s important not just to look at people who are getting sick, but also at animals that are getting sick, and to ask, could this be transmitted to humans?

What does that kind of surveillance look like? You’re not mounting some Big Brother camera over my doorbell?

Absolutely not. And I’m glad you brought that up. In public health, we use the term “surveillance,” and we know what it means. My husband the political scientist pointed out to me one time that maybe we shouldn’t be use the word “surveillance” because it makes people outside of our field think of the NSA tapping your phone. That is certainly not what we mean.

One of the things that is in place now, but could be improved on, is our hospital data. We don’t attach people’s identifying information. But we might know that we’re seeing more than the usual number of admits to an emergency department for, let’s say, a neurological condition. We’re not looking for specific diseases. We’re looking for syndromes — say, a gastrointestinal condition.

We also monitor drugstores. In the ’90s in Milwaukee, there was an outbreak of cryptosporidiosis. It’s a gastrointestinal illness that causes diarrhea, nausea and vomiting. They detected it because drugstores couldn’t keep Pepto Bismol on their shelves. So now we monitor drugstore sales.

Again, we’re not looking for personal information. We don’t know that Cathy Troisi went in there and bought Pepto Bismol. We simply know that usually, this CVS or Walgreens sells 10 bottles of Pepto Bismol a day, and all of a sudden they’re selling selling 50. Then epidemiologists will go in and ask, “What’s happening here?”

We’re also looking at putting community health workers on the ground. Community health workers are people who come from a community and have training in health. (Interestingly, Texas is one of the few states that requires community health workers to be certified.) Then they work in their community, with people who share their culture.

Since they work in those communities, and can be the eyes and ears of what’s happening — “Mr. Jones is sick with a GI illness, and Mrs. Smith is sick with the same thing.” — they notice patterns.

So the idea is that, even if we’re never really free of COVID, maybe we can prevent the next thing?

I’m not sure we can prevent it.

Give me some hope!

No, no, no. “Prevent” means it never happens. We can contain it.

So then I don’t end up stuck in my house for two years?

Exactly. Maybe we prevent the spread, and it stays a localized epidemic.

We’ve learned a lot from this pandemic. But of course, the next pandemic won’t look like this one. Probably we will be able to apply some of the lessons, but other things won’t work with a new pandemic.

What have we learned from this pandemic?

We need to improve funding for public health. Between 2008 and the onset of COVID, the U.S. lost 50,000 local public health workers.

In 2001, a lot of money was put into preparedness. That helped shore up public health laboratories and bought some public health workforce. Then the money went away.

This is what happens in public health. The issue with public health is that if we’re doing our job, you don’t see it. You don’t see the pandemic we prevented. You don’t see the people who didn’t get sick from contaminated water. So it’s easy to cut funding.

Who decides on funding? Politicians. Legislators. Legislators want to get re-elected. And in general — maybe not during the pandemic, but in general — the public cares more about the potholes that they see every day.

I mean, that’s the truth! I’ve done these community meetings.

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Nobody there is asking about preventing an unexpected flu outbreak?

Exactly. Nobody asks about a disease unless people are already getting the disease.

Also, with public health — especially when you’re talking about chronic diseases like diabetes and heart disease — you’re not going to see results in six months. It’s a long-term thing, and it can be hard to measure. It’s hard to measure who didn’t get lung cancer.

Legislators are more apt to fund things that they can point to: “Look, I fixed these potholes!” rather than “I gave some money to the health department, and in 10 years, we’re going to see a decrease in lung cancer.”

So the funding for public health has been very cyclical. I hope we learn from the pandemic that it needs to be sustained at a higher level.

Does your husband the political scientist have any suggestions about changing that? I would love to hear your dinner conversations.

[Laughs.] My husband studies international relations — how war happens — so lately he’s been in the media, talking about Afghanistan. He jokes that he and I study two of the four horsemen of the Apocalypse.

But I actually don’t know what he thinks about public health funding. He leaves the public health stuff to me, and I leave international relations to… Well, actually, that’s not true. I have opinions on international relations. I’m an armchair international relations person.

But he knows better than to be an armchair epidemiologist?


This interview has been edited for length and clarity.

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