In this file photo, a flu vaccine is readied at the L.A. Care Plan and Blue Shield of California Promise Health Plan’s Community Resource Center, where they were offering members and the public free flu and COVID-19 vaccines Friday, Oct. 28, 2022, in Lynwood, Calif.
The flu is back with a vengeance.
As the San Francisco Bay Area faces a winter “tridemic” of COVD-19, influenza and respiratory syncytial virus (RSV), Marin County health officer Dr. Matt Willis says that for the first time since before 2020, he’s just as worried about the flu’s impact as he is COVID’s impact. According to Willis, a staggering 1 in 3 people in Marin County who are experiencing symptoms of a respiratory virus are testing positive for influenza. For reference, during the peak of the COVID-19 pandemic, a test positivity rate of 8% was considered very high.
In a Q&A with SFGATE, Willis explained that because most people haven’t been exposed to the flu in over two years, they’re more susceptible to infection. Willis also discussed why mask mandates are a thing of the past and shared advice for minimizing risk at holiday gatherings this year. The interview has been lightly edited and condensed for clarity.
SFGATE: As a health officer, what worries you the most among COVID, flu and RSV on a population level? Which do you expect will drive the most hospitalizations this winter?
Willis: We’re in an interesting place right now where influenza is eclipsing COVID as the biggest threat. There’s an equivalent number of people hospitalized between flu and COVID, and that’s the first time we’ve seen that since COVID emerged.
Choosing between what I’m most scared of is like choosing between lions, tigers and bears. In terms of mortality, it’s COVID and flu for older residents, and RSV in babies. When it comes to RSV, the most severe outcomes are primarily among our youngest residents, so infants 6 months or younger, and then older people infected with RSV can also have severe outcomes.
SFGATE: To poke on that lions, tigers and bears analogy, let’s say I handed you three vials, one containing COVID, one containing flu and one containing RSV and then said, “You have to take one of these.” Which one would you take?
Willis: I would take RSV, but it depends on who you are. If you’re a child, you should pick COVID because we know COVID doesn’t cause as severe illness in younger residents. But for young adults and adults, RSV is almost universally experienced as a mild illness; many people don’t even recognize they’re infected.
If you’re 70 or older, though, that’s a scary experiment. All three can make you sick.
SFGATE: For young adults and adults, which vial would you want to take between COVID and flu?
Willis: Assuming I’m vaccinated against both, I would probably choose the flu because COVID is so unpredictable still. While it’s grown less severe because of immunity from vaccines and prior infection, there’s still a wide range of outcomes, and I’m still worried about long COVID. We don’t quite see that with the flu.
Flu can be a really serious illness, and that’s what we’re seeing right now, so with me taking that vial, I’d still be bracing myself.
SFGATE: For years, it was true you’d rather have the flu than COVID, but the fact that now you have to stop and think about it is pretty significant, no?
Willis: Absolutely. We haven’t had the same type of policies to address flu like we had with COVID. In the past, even in bad flu years, we never did flu-related lockdowns or isolation orders. This is a good chance for us to signal what the future of COVID looks like; it’s more like influenza now in terms of impact to the community.
We’re pulling back on COVID restrictions because the nature of the threat has changed, and those restrictions are no longer necessary.
SFGATE: In Los Angeles County, Barbara Ferrer says she’s going to impose a mask mandate if COVID transmission continues to rise. In Santa Clara, Sara Cody, who’s typically been aligned with Ferrer in the past, says she doesn’t think mandates are warranted three years in because people have the necessary information to make informed decisions. Where do you stand?
Willis: I agree with Sara. We are offering a strong recommendation that people cover their faces in indoor public settings in response to the surge in winter viruses but not a mandate.
N-95 masks are effective against all three viruses in this tridemic. So if people are very concerned, they can wear a high-quality mask. Our community is aware of the benefits of masking, but a lot has changed since mandates were used. We have vaccines, and so many of us have been infected, meaning our immune systems are primed, and people can navigate choices on their own. The consequences of infection have diminished.
Another factor in weighing mandates is that the relationship between policy and behavior is not clean. When the most recent mandates were imposed, they didn’t do a lot in terms of changing behavior. We think that as a principle, it’s better to work in an environment of choice and people understanding their own risk.
SFGATE: Are you wearing a mask in any settings? If so, where?
Willis: In the past two to three weeks, I’ve started wearing an N-95 anytime I’m in an indoor public setting. When I get coffee, I’m covering my face; when I’m at grocery store, I’m covering my face; when I’m dining indoors, I cover my face until I sit down.
I’m still considering whether I should continue indoor dining because I have some older relatives coming into town for the holidays. As transmission increases, I’m thinking about forgoing some indoor restaurant experiences. I don’t like to cover my face, and when transmission rates were lower, I was not covering my face, and I didn’t care if others were around, but now I’m doing it universally.
SFGATE: And if other people decide, “I think my risk is low, and I’m not seeing anyone high-risk for the holidays, so I’m not going to mask up,” that’s all good with you?
Willis: Yeah. And it’s really important for people who are high-risk to know they can protect themselves by wearing a high-quality mask. All the numbers are going in the wrong direction, so it’s important to recognize that as conditions change, some people should change their behavior and have the tools to protect themselves regardless of what others are doing.
My job is to inform people with all the relevant information so they can evaluate risk for themselves.
SFGATE: So in terms of risk evaluation, is it possible to compare current infection-fatality or infection-hospitalization rates between flu and COVID? Or is that too hard to do because we don’t have accurate case counts for either of the two viruses?
Willis: We don’t have an answer to that, and no one does, because like you said, we just don’t have the data. But the volume of influenza has changed significantly. We had two years without the flu, so we’re seeing major surges.
SFGATE: You said that flu is eclipsing COVID as the biggest threat. Do you expect that to hold all the way through the winter?
Willis: It’s hard to know. It’s an unprecedented experience with regard to flu. This year, we’re seeing a much earlier surge, and the proportion of people who have flu-like symptoms who test positive for influenza is higher than it’s ever been at any point in the past. Right now, we’re seeing that 1 in 3 people reporting flu-like symptoms have influenza.
It’s hard to know what direction this will go, but if things continue on their current trajectory, flu will be more of a concern than COVID for the remainder of the winter. But whether the average severity of disease has increased is hard to know. It could just be that more people than ever are being infected, so that means we’ll see more people coming into the hospital and dying. That may be what we’re seeing, as opposed to an increase in disease severity.
SFGATE: So you don’t quite buy the idea that there’s this “immunity debt” or the idea that flu season is worse because we haven’t been infected for the past two years, so our immune systems are unprepared?
Willis: I believe that’s true for infection, so we’re more likely to get infected now than we were before, but I’m not sure that’s true for disease severity. Our immune systems are trained seasonally through exposure, but because COVID changed our way of life, we’re out of training, and our bodies need to know how to respond when exposed.
Now we have an entire population, all at once, that hasn’t seen the flu or RSV for two years. So the viruses have catching up to do.
SFGATE: So the only way out of this is for us to get exposed to these viruses again?
Willis: And that’s why vaccines are so important. Getting a flu or COVID shot before being exposed to the virus is a much safer way to get immunity than being infected without vaccination. That’s why it’s concerning that the flu vaccine uptake is so low right now.
SFGATE: The flu vaccine is like the COVID vaccine, where it doesn’t do a lot to prevent infection, but it’ll reduce disease severity?
Willis: That’s right. I’d say the flu shot does reduce the risk of infection, but most importantly, it reduces severity and the duration of time you’re infected. What I’ve seen over the past two weeks tells me that we should all expect to be exposed to influenza. The wastewater shows it’s clearly flowing out there.
SFGATE: How long do you expect flu, COVID and RSV transmission to remain high? Is the answer different for each of those viruses?
Willis: We’re seeing promising signs elsewhere that RSV may be peaking. If you look east, RSV cases and hospitalizations have plateaued. In Marin County, we saw our highest rate of RSV levels last week, but it’s accelerating less quickly, which is the first step to plateauing. One of our pediatricians just told me that he’s seeing less flu than RSV, but there’s a slight decrease in RSV. So the signs are that RSV will plateau first.
I’d say that, normally, flu cases rise in mid-December and continue through mid-January, then move downward through March. That’s the normal pattern for flu, but we don’t know if it will peak earlier because it’s starting earlier. If it continues to rise at its current rate through January, that’s going to be bad.
We’re telling people to have safe gatherings this winter, so the question is what does that look like if you have people coming together across multiple generations? The biggest thing is that everyone who can be vaccinated should be vaccinated. If you have older people there, and they have flu shots and COVID boosters, that should stop them from ending up in the hospital. Those who are lower risk should also be vaccinated because it will lower their chances of passing viruses on. Hand washing is also important this year because RSV primarily spreads through contact. If there are babies around, it’s extremely important, and maybe you want to forgo the baby passing this year.
Beyond that, people can cover their faces for four days in public settings before the gathering, and people can take COVID antigen tests beforehand too. Finally, gatherings should be well-ventilated. Outdoors is best, but if you’re indoors, try to ensure there’s good air circulation. If all of those things are in place, people can relax, enjoy the gathering and not worry about getting sick.
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Eric Ting is SFGATE’s politics editor. He is an East Bay native who has a Master’s degree in journalism from Stanford University. Eric did his undergrad at Pomona College, where he majored in politics and minored in economics. Email: eric.ting@sfgate.com
