Dr. Peter Hotez on the COVID XBB.1.16 variant, a strange new symptom and possible annual boosters

Hotez discussed the new variant, the need for a bivalent booster, best practices going forward, struggles with messaging and, of course, the dreaded pink eye.

Q: How have you been? I feel like we haven’t done this in a long time. But I guess it has just been a few months.

A: I’ve been good. I saw your story on Leon Russell. He was an interesting guy. So hard to pin down with all the different styles. He’s just one of those guys who loved all music.

Q: He was. I keep telling people that book weighs in around 550 pages, but it never felt like a slog to me.

A: What I’m reading now ... actually, I bought it before the pandemic, but I was just so inundated with developing COVID vaccines and talking to TV news people around the nation, I kept putting it off and putting it off. But I’ve been reading “Big Wonderful Thing” by Stephen Harrigan, who I think writes for Texas Monthly.

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Q: I have that one but have not yet taken the plunge.

A: It’s one of the best histories. I liked the (T.R.) Fehrenbach book (“Lone Star: A History of Texas and the Texans”). And James Haley’s “Passionate Nation.” But this so far is my favorite. It’s so readable for being so huge. I keep bringing it on planes — it's like it requires another carry-on.

Q: I feel like our culture has shifted to using the past tense with COVID-19. Where do you stand on this?

A: Well, I think we both have colleagues who are getting sick with COVID. So there’s still a fair bit of transmission. The strange part is that nobody is measuring it. The Johns Hopkins tracker stopped. Newspapers aren’t carrying the same type of data. So we’re not getting real-time information from these cases, as flawed as that was because there has been so much testing at home. One of the frustrations is that it’s harder now to get a sense of exactly what’s going on compared to what we used to have available to us. That’s a concern.

I break it down now with COVID in terms of what we need to be thinking over the next few weeks, thinking about the next few months, thinking about the next year. We really should be thinking about the coming decade. What are the near-term, intermediate-term and long-term strategies? Then it starts to make sense to people. Too often we conflate all three and people get confused.

Q: Shall we start with the near term?

A: Near term, we have to recognize that COVID-19 is still with us. XBB.1.5 and the new one, XBB.1.16, are slowly creeping up. The most important message we’re trying to send out now is that for those of us who were early adopters of the bivalent vaccine, it may be time for a second bivalent booster. The previous boosters for mRNA are not holding up as well after six months as far as protection against severe illness and hospitalization. We’ve just heard from the FDA and CDC about that, groups that qualify in terms of age or immunocompromised status.

But I think many Americans don’t quite understand the difference between the bivalent and the monovalent vaccines. The bivalent was specifically tailored for new omicron variants. And it protects better against those. But for some reason, people haven’t gotten that message. They don’t understand the difference between previous monovalent boosters offered more than a year ago and the bivalent booster that became available starting last September. You really need the bivalent to ensure protection, and if you are eligible, get a second bivalent booster. That’s one public health message we’re pushing hard. Only 17 percent of the eligible population has gotten the bivalent booster, which is going to be a problem in encouraging people to get a second. The number of Americans accepting a second bivalent booster will be single-digit percentages.

Q: Just so I’m clear: Only 17 percent of Americans have accepted their bivalent vaccine? And those wanting a second booster will be in the single digits?

A: That’s right. Two issues: First, something about the mRNA technology isn’t holding up as well. Why? We don’t know yet. That is the reality. With the omicron variants, it seems every six months it’s important to do it. But we’re not getting that message out. Second, many people don’t understand the importance of taking the new bivalent booster. The other message we need to get out for the near term is that if you’re at risk — due to age or an underlying illness — people aren’t getting Paxlovid early enough. Too many people are taking a wait-and-see attitude. That’s a mistake. If you start getting sick, you can go downhill quickly. And Paxlovid only works in the early replication stage. I think some internists, some family medicine doctors are not aware of that. They’re too slow to recommend Paxlovid. 

Q: That’s near term. What next?

A: Beyond the spring booster and in terms of an intermediate strategy over the next year, I think we will hopefully get more clarity soon. The FDA mentioned a strategy for an annual booster that might occur in the fall. What’s a little unclear is that if you get boosted now, does a spring bivalent serve as your annual booster? Or will the FDA look into making a different booster for the fall into next winter? I wouldn’t wait. Get a spring booster and then we’ll await instructions. 

Q: Long term?

A: Finally, long term. I’ve said that COVID-19 is the third major coronavirus over the last 20 years, with SARS in 2002 and MERS in 2012. Then COVID in 2019. It looks as though every seven or eight years we get a new major coronavirus epidemic or pandemic. On that basis, a fourth major coronavirus is around the corner before 2030. We need to think about longer-term pandemic preparedness strategies for the end of this decade.

MORE FROM ANDREW DANSBY: Biography puts Tulsa legend Leon Russell in the spotlight

Q: How would you regard our preparedness for this one?

A: Well, I think the lessons learned tell us good things and bad things happened, and much uncertainty. Hopefully, the federal government will support the development of a universal coronavirus vaccine. Hampering this further has been the weaponization of health by anti-vaccine activists, who have made it harder to persuade the American people to accept new vaccines, boosters, and ultimately, universal coronavirus vaccines. I’m concerned about the unknowns. The next major coronavirus pandemic — beyond SARS, MERS, and COVID-19 — is an unknown. It might not be as bad as COVID. It could also be worse.

We know coronaviruses are jumping every day from bats to people through secondary intermediate hosts, and every few years, one catches on and gains critical mass. People don’t appreciate how that has become the new normal for the world. It’s happening because of a confluence of forces and social and physical determinants: political instability, human migrations, urbanization, deforestation and climate change. The social determinants are shifting where humans live, while climate change is influencing bats — reservoirs of coronaviruses, filoviruses such as Ebola and Marburg, and Nipah viruses.

Q: You mentioned messaging. What are your concerns with messaging?

A: I think we risk burnout from the last pandemic. We’re already starting to see from elected leaders that they feel it’s a political liability to even talk about it. Nobody is talking about how many of these we’ve had in the past 10 or 20 years, not to mention avian influenza. The new reality is something I wrote about in my last book, about the confluence of climate change, deforestation, migrations. We have to recognize that pandemic threats are going to be one of our greatest challenges. We don’t think in terms like that. We have to recognize that viruses are as much a public threat and a threat to the global economy as any other threat to security. We need to put better infrastructure in place. Sadly, that is the new reality for us.

Q: I’ve read that it comes with the charming addition of pink eye. That seems one indignity too many.

A: That’s still mostly anecdotal. But with XBB.1.16 in India, it has been reported there are kids with conjunctivitis. It’s hard to make assumptions about that without seeing it. Remember this time of year, you can also see adenovirus, which occurs in the spring. That also gives conjunctivitis. But right now, it’s just another question mark. Is it something with the COVID variant or something concurrent?

Q: I read something about how masks were a big waste of time, energy, resources. How do you regard masking?

A: There was an op-ed by a New York Times, one of their columnists took what’s called a Cochrane Review and tried to make a statement that says masking doesn’t do much. That review was flawed. It didn’t distinguish between types of masks. We know the N95 and the KN95 make a big difference. Also, they were selective with which studies were included and which weren’t. Unfortunately, the columnist took something at face value without understanding the differences of opinion within the scientific community. There’s no question masking makes a difference. If you are concerned about transmission, if you’re high risk, and going to a crowded venue, you may still want to wear a mask. 

Q: What else do you have going on now?

A: My book will be out later in the summer. “The Deadly Rise of Anti-Science” from Johns Hopkins University Press. I’ve gotten good feedback from colleagues. It was a difficult book to write. Not hard to write, but it was difficult dealing with such a devastating message. So many people needlessly perished during that horrible Delta wave in the summer of 2021. They were the victims of an aggressive campaign to not get vaccinated. That big wave came after a vaccine became freely available. Thousands of Texans needlessly died when they could have had 90 percent protection against that. I call it the Great Texas COVID Tragedy. The number nationally is about 200,000 Americans, that’s the estimate from health analysts. It’s pretty devastating.

With that massive loss of life, you have to ask how the country could let that happen, particularly in Texas and in Southern states. Those with the lowest vaccination rates had the highest death rates. They fit hand in glove. Now we’re starting to see those groups who contributed to this loss of life committing revisionist history. It’s playing out in House hearings because they’d rather double down than pause for reflection. Some say it wasn’t COVID that killed people, but rather the vaccine, which is nonsense. They blame scientists, which is nonsense. The book explains how that way of thinking is completely misguided and dangerous.

andrew.dansby@houstonchronicle.com