Brian Lehrer: Brian Lehrer on WNYC. Good morning again, everyone. A COVID wave is upon us, a tripledemic wave is upon us. Wastewater surveillance data in the United States suggests that we're in the midst of the largest COVID surge since the very first Omicron spike two years ago. Despite the surge in virus levels in wastewater, and we'll talk about why they measure wastewater and what that means, the good news seems to be that hospitalizations and deaths, though rising compared to last fall and summer, have remained lower than in previous waves, but it does seem like half the people you know have been sick with something this winter already.

The official public health emergency may be over, but COVID is very much still here and so are some of the important metrics helping public health officials track the spread of the virus, and the other two, flu and RSV. We'll spend a few minutes now talking about where we are with COVID and the tripledemic and shedding some light on some of those significant metrics. We are with Dr. Daniel Griffin, MD, PhD, infectious disease physician with a PhD also in molecular medicine, researcher at Columbia, chief of the Division of Infectious Disease at Optum Health, president of the group Parasites Without Borders, which sounds like a bad thing, but it's really a good thing, and co-host of the podcast This Week in Virology. Dr. Griffin, always good of you to share your time and expertise. Welcome back to WNYC.

Dr. Daniel Griffin: Oh, thank you, Brian. Always a pleasure to be invited on.

Brian Lehrer: Listeners, any questions on the current COVID wave or RSV or the flu or anything related for Dr. Griffin, welcome as always when he comes on. 212-433-WNYC. Call or text 212-433-9692. When we say wastewater data, what are we talking about?

Dr. Daniel Griffin: I think that that's worth spending a few minutes talking about. Wastewater is a way of monitoring. No one is going to get COVID from wastewater. What this is, is all the effluent from your toilets are going to go to the sewage plant before treatment, and at that point, you can actually do an analysis, and you can see are people out there, do they have COVID, do they have polio, do they have whatnot, and you can actually do basically a PCR, and then quantify that. It can give you a sense of what's going on. A great thing here is it can give you a little bit of an early warning, it can give you some accurate information upon the levels of the virus in the communities.

Brian Lehrer: There seems to be a mismatch between the amount of COVID that's being detected in the wastewater when they take those samples, which is a lot, and the number of people being hospitalized or dying from COVID right now. You can talk about this locally in the New York area or nationally, whatever stats you're looking at. That wouldn't seem to reflect the same rates of virus. Can you discuss that mismatch and what it might signify?

Dr. Daniel Griffin: Yes. The mismatch in many ways is a success. What we're seeing here is, four years back, we had a naive population. There was no immunity. I say the mixed message is that the most vulnerable were still with us. Here we are four years later. The negative part, unfortunately, is that over a million Americans, the most vulnerable, have succumbed to the virus. The good side is we have a really tremendous level of population immunity. Lot of people got in line, got those vaccines.

A vaccinated individual is much less likely to have a bad outcome. As fortunately, you've given us this forum for the last four years to educate about vaccines, vaccines don't keep you from getting a mild case, but they turn the wild into mild. There might be someone out there with sniffles, but their chance of ending up in the hospital, their chance of dying is reduced by over 90%. I saw a lot of individuals who have had multiple infections with COVID, some of them with long COVID, but a lot of them doing okay, and now they have that acquired protection from the prior infections.

Then the next is we now have effective treatments, and we've stopped doing harmful things. Early antiviral treatment, we're up to about 30% of the high-risk folks getting Paxlovid in the first five days. We're no longer using those harmful things, hydroxychloroquine, which increased mortality by over 10%, unnecessary antibiotics, at least that seems to be getting a little bit better, using parasite medicines and other things, using steroids too early instead of understanding the time course of the disease.

In many ways, this is a victory. We are moving forward. While COVID is here to stay, I think that instead of seeing 2,000 deaths a day in New York alone, we're seeing 2,000 deaths a day in the entire United States.

Brian Lehrer: 2,000 deaths a day [unintelligible 00:05:37].

Dr. Daniel Griffin: Actually, a week, I should say. Sorry about that.

Brian Lehrer: A week.

Dr. Daniel Griffin: We've gone from 2,000 deaths a day in New York to 2,000 deaths a week in the entire United States.

Brian Lehrer: That 2,000 deaths a day, that wasn't just the beginning in March, April 2020. That was with the Omicron wave two years ago, so 2022, when we'd already had a year of vaccinations.

Dr. Daniel Griffin: Yes, that was really tough. As the vaccines were rolling out, right as they were being rolled out, but people had not gotten access yet, that was actually when we saw a huge increase in the number of deaths.

Brian Lehrer: About the vaccinations. Few Americans, you might have the stat, but it's a very low percentage of Americans, have gotten this fall's updated vaccine. If you only had the previous vaccines, do they still protect you, is there science on this, from the really serious outcomes?

Dr. Daniel Griffin: They still do. I think that's a great question. That's a great thing to reassure people. I also want to qualify is those original three vaccines, and it's really is a three dose series to get you to this enduring greater than 90% reduction in your chance of a bad outcome. You can get above that. You can get another, we've seen recent data, another 50% to 70% reduction for a three to four months by getting that booster. You're not unprotected. Those prior infections, those three primary series, your prior shots, they're still giving you some degree of a durable protection. The new vaccine really gives you a boost for three to four months.

Brian Lehrer: When you say a boost for three to four months, if you're already protected over 90%, odds of not getting a serious case if you get COVID, then what is that other 50% or 70% you're referring to?

Dr. Daniel Griffin: You could basically say instead of a 90% reduction, now you're up to a 95%, a 97%. Particularly for an older individual, that can really be the difference between weathering the storm at home or ending up in the hospital or ending up on a ventilator or not surviving the exposure.

Brian Lehrer: What's RSV?

Dr. Daniel Griffin: Respiratory syncytial virus. It's what my mother refers to as the new virus, but it's not really the new virus. It's the new on people's radar. It's a new getting attention. It's always been one of the big three. Well, now that we've got COVID, it's in there in the big three. We've got COVID, we've got influenza, and we've got RSV. RSV, we think a lot about the tens of thousands of pediatric admissions. About 100 to 300 children die of this respiratory virus every winter here in the US, but adults 10,000 to 20,000 adults, those over the age of 60 will succumb to RSV each winter.

Exciting things about RSV is this is the first season where we have really new impressive tools. We have two different vaccines for adults, so adult vaccines, vaccines for pregnant individuals that they can do during the last trimester and passively protect their newborns, and then even a passive vaccination, this Beyfortus or nirsevimab, which has about a 90% reduction in the little kids ending up in the hospital.

Brian Lehrer: Why are we using the word tripledemic, which I think was only coined this winter. Wasn't there flu around in the past? Wasn't there RSV around in the past in addition to COVID in the COVID years?

Dr. Daniel Griffin: I would like to think people are getting a little smarter. When we entered this pandemic, I remember a lot of conversations with my colleagues about the idea that you can have more than one thing at the same time. Unfortunately, a lot of us were taught in medical school, "Find that one thing that unifies it, the Occam's razor." There was a gentleman, Hickam, Hickam's dictum, which basically pointed out, a person could have as many darn things as they please. He used less child-friendly language.

Going into this, I don't think a lot of people appreciated that more than one thing could be going on. A lot of us, we weren't using the tools, but now we're appreciating you can have COVID and the flu, you can have COVID and RSV, you can have flu and RSV. We're appreciating that a person can have more than one thing at the same time, and more than one thing at the same time can make you sicker than one or the other.

I think we're also appreciating that when all these things hit at the same time, even if you only have one, and you get sick enough to end in the hospital, the hospitals can be struggling with the capacity issues of COVID admissions, flu admissions, RSV admissions, on top of all the things they normally take care of.

Brian Lehrer: Is this winter worse than last winter in that respect? A lot of people have seen the headlines about some of the hospitals and some other places reinstating their mask mandates, at least at certain healthcare facilities. Somebody else told me that, well, actually the tripledemic was worse last winter. What have you got?

Dr. Daniel Griffin: A lot of is regional. I think we've learned a lot. A lot of the hospitals where I spend time I feel like they're better prepared, but some of them actually, no, they are overwhelmed. You have a portion of your service in the emergency room, never even making it up to the floor, despite the fact that they're admitted just because overwhelming capacity. A lot of the areas where the RSV tools for children were not embraced overwhelmed in certain areas. It is regional.

Brian Lehrer: Let's take a phone call. Liz in Upper Manhattan, you're on WNYC with Dr. Daniel Griffin. Hi, Liz.

Liz: Okay, thank you. I'm just going to pull over. I'm pulling over now. Let me not run this lady over. I'm actually an infectious disease doctor at Jacobi Medical Center. I found COVID really inspiring. I have a million questions. I enjoyed both of your shows. The first one is, can you explain original antigenic sin for the masses, including an ID doctor? In other words, do you really need to update the vaccine every year, or is somehow the dominant immune response to the first vaccine going to overwhelm the subsequent optimized vaccines?

That's question number one. Then question number two is, as we have more and more COVID transmissions, are we just becoming immune as a population, and are seasonal vaccines going to become less necessary? I could ask a million questions, so I will be quiet.

Brian Lehrer: Those are two good ones. Thank you, doctor, for the questions. Dr. Griffin?

Dr. Daniel Griffin: Sure. These are excellent questions. Let's start off with antigenic sin, or what I call the butterfly effect. This is what happens first is going to affect things down the road. Our immune system will remember that first exposure to influenza, or in this case, COVID. Then, when we see a new variant, it's a little bit different, the parts that are the same are going to be the areas where we're going to see the largest boost.

Where this applies to vaccines is if you keep using a bivalent, where you're putting two different antigens in there, the immune system is going to preferentially react to the one that you've already seen before. That was really why we switched from biovalent to monovalent. The monovalent really overcomes the original antigenic sin. You're showing something new to the immune system, you're going to actually be able to shift, and those have turned out to be very effective.

There were concerns. I think it's reasonable to have these concerns. With flu, it's so different that the yearly flu shots do a great job, but has COVID changed enough, has SARS‑CoV‑2 changed enough that we can overcome antigenic sin? We've realized the best way to do that is these updated monovalent vaccines. That feeds directly into the next question, are we going to stick with this, getting a boost every year?

When you're exposed to something, when your immune system is exposed to something, T-cells are pretty durable. They take a few days to jump up. The antibodies, and this is normally, they tend to drop to lower levels, they tend to decline or wane, but if you do a yearly shot for three to four months, you can prime the immune system and get those antibodies up to a high level, get those antibodies up, even at mucosal surfaces, for three to four months.

This way you get that protection without having to get another infection every year. Even if you do get that infection, the antibody part of the immune system is primed by that boost. I think we're headed towards a yearly COVID vaccine in addition to our yearly flu vaccine, which I'm hoping they get better. The RSV vaccine, however, may be more durable. That may last for two or three years.

Brian Lehrer: Is the likelihood of long COVID less with cases you get after multiple vaccinations? Let's say somebody's gotten-- This is a listener asking this question, if you've gotten your multiple vaccines over time, and then you get COVID, are you less likely to get long COVID than you would have been a few years ago?

Dr. Daniel Griffin: That is clearly a yes. Vaccines, and then the more doses are associated with a lower risk of long COVID. People probably remember the huge numbers early on of people that would get COVID, and then three months later, they're still struggling, they still have post-COVID sequelae. The first dose of the vaccine, the second dose, the third dose, you saw incrementally as you added doses, really up to this third dose, you got a pretty significant reduction.

You also, if you get your boost, and for that three to four months, you reduce your chance of even getting a symptomatic COVID infection. It looks like you're still reducing your risk of long COVID. I'm glad this is asked because a lot of us, we look, we say, "Yes, I'm young, I'm healthy." We always underestimate our risk and overestimate our health. I can speak personally. As I went for a run with my wife this morning, who-- Yes, I underestimate or overestimate my fitness.

A big thing people worry about is, I don't think I'm going to end up in the hospital, but I certainly don't want my life destroyed by long COVID. Yes, the vaccines, not only can they prevent the risk, but there are certain studies where post-infection when you have long COVID, there can be a therapeutic role with vaccines.

Brian Lehrer: Faith in Manhattan, you're on WNYC with Dr. Daniel Griffin. Hi, Faith.

Faith: Oh, hi. Hello?

Brian Lehrer: Hi. Yes, you have a question for us?

Faith: Yes. I was wondering about availability of Paxlovid. My husband got COVID, and he called the doctor. She recommended-- she put in a prescription for Paxlovid. Then we were told by the pharmacy, it would be out-of-pocket costs $1,600.

Brian Lehrer: Yikes. Dr. Griffin, you've talked on this show before about a problem you see, which is too few people who should be getting Paxlovid with their COVID cases getting it. Is cost one of the reasons?

Dr. Daniel Griffin: We have shifted in the last couple of months from where the government bought all the Paxlovid. We bought all the Paxlovid with our tax dollars, and then if someone ended up getting COVID, they were high risk, then they could go to a pharmacy, and at no further cost to the individual, they would get access. They have actually now shifted over to the standard way medicines are dispensed, where you get dispensed the medicine.

$1,683, yes, that is the list price. It is, dare I say, publicly absurd, but anyway. In most cases, insurance will kick in. There are certain other cases where you still can get access if you're uninsured, but yes, that has now created, and hopefully, we'll work through this, ways to get people access and not let a financial barrier like that stand in the way because the reason the government was willing to pay, it is much more cost-effective to treat someone early with an antiviral than to let them get into a hospital, let them end up on a ventilator, or let them go down the road and perhaps develop long COVID.

Brian Lehrer: Did you say, Faith, that your husband has insurance and still got charged that $1,600?

Faith: Yes, he has insurance through his employer.

Dr. Daniel Griffin: Faith, I would have them run that medicine through the medication insurance. This may be a question of a pharmacist being ill-informed about the prescription coverage that your husband has.

Brian Lehrer: Interesting. Faith, I hope you can do that. It sounds like maybe you were able to lay it out, but I fear for people who can't advance that much money, even if they're going to get it back from their insurance company eventually. Thank you for alerting people to that. I guess your answer just now, Dr. Griffin, might be a reminder to people, if they do have to go to the pharmacy for Paxlovid, make sure the pharmacist is looking at your prescription drug plan, not just your general medical services insurance.

Dr. Daniel Griffin: I think that's definitely true. I don't think anyone really wants people having a barrier of $1,683, which is a huge amount of money to basically keep them from letting this progress. Here they are trying to do the right thing. Yes, check with your pharmacist, have them run it through. They may not be aware, but this has moved now to a covered medication on most prescription plans.

Brian Lehrer: Right. Of course, there are people who are uninsured, and that's really bad. I think that the automatic free Paxlovid has gone away, but were you also indicating the last time we spoke that doctors just aren't prescribing it enough for people who should be getting it?

Dr. Daniel Griffin: That continues to be a huge misinformation problem, Brian. As I say, 30% of high-risk people are getting Paxlovid, which has increased, but what about the other 69%? What about the other 70%? What about two-thirds of high-risk people that are not being appropriately treated? One of them is this misinformation where people have gotten-- they've misunderstood COVID and not remembering the cytokine storm where people were sick for a week, and then that second week, while the immune system would kick in, that's when they would feel crummy, that's when they would head to the hospital.

I want to remind everyone we were seeing that back in the early days of 2020 before there were any antivirals. This is not any kind of a rebound. That is the second week of COVID. That is the cytokine storm. If you take Paxlovid, you reduce the severity of that cytokine storm. People who just feel horribly sick for two weeks, and then end up in the hospital, you can't rebound unless you get that little bit of a reprieve that you get with Paxlovid before a milder second week.

Number one is the misinformation. The CDC has come out with some really tremendous reports where they've reviewed all the literature. There is no connection. There's no Paxlovid rebound. That's not a thing. It's the cytokine storm. These medicines are just tremendous. The other is drug-drug interactions. If you call your orthopedist, and you say, "Hey, I was in the hospital, and I must have gotten COVID because now I'm home, and I'm not feeling well. My test is positive."

That may not be the person to guide you at that decision about what is the best thing to do. Call your primary care doc, maybe a lupine infectious disease doc, and they can help you navigate any drug-drug interactions. There's nice free online checkers, Liverpool COVID drug interaction. It guides you exactly what to do. Do I need to reduce the dose? Do I stop my statin for 10 days? All that's easily accessible.

Brian Lehrer: Dr. Daniel Griffin, infectious disease physician with a PhD in molecular medicine, researcher at Columbia, chief of the Division of Infectious Disease at Optum, president of Parasites Without Borders, and co-host of the podcast This Week in Virology. Thank you so much as always.

Dr. Daniel Griffin: Oh, thank you. Everyone, including you, Brian, be safe.