As temperatures fall, the ominous warning from “Game of Thrones” has grown louder: “Winter is coming.” The phrase captures the insistent fear that wintertime will make the pandemic much worse, forcing people back into isolation and bringing an even more devastating wave of cases and deaths.
That concern is well-founded, but a winter surge is far from guaranteed. The colder months will present serious new challenges in the fight against COVID-19 — the arrival of flu season and the potential for high-risk indoor gatherings chief among them. And as cases in Massachusetts have climbed in recent weeks, on Saturday reaching the highest daily count since May, some experts fear the state will enter winter on dangerous footing.
"We’re seeing hospitalizations starting to climb. This is not where we want to be going into the winter,” said Dr. Ashish Jha, dean of the School of Public Health at Brown University. "Winter in our community lasts through March. We’ve got many months to go.”
Yet Jha and others stressed that a catastrophic winter is far from inevitable, as long as Massachusetts and the country are prepared to make the necessary sacrifices.
“There is no single thing that can stop this,” Jha said. But specialists laid out a multi-pronged approach for staving off a winter surge: The state can ramp up contact tracing, impose targeted restrictions on settings found to be high risk, and make plans to protect vulnerable populations, including essential workers and the homeless. Individuals can get flu shots, avoid indoor socializing, and take extra precautions like keeping the windows open when being inside with others is unavoidable. Businesses can do their best to keep workers home and extend how long patrons can be served outdoors or in well-ventilated spaces.
Winter is coming, but it need not bring devastation.
“This virus can be controlled, even in the winter,” said Dr. David Hamer, a physician at Boston Medical Center and a Boston University epidemiologist. “If we were to intensify [social distancing], we could keep it under control.” Hamer said intensified measures might include lowering the state’s limit on social gathering sizes — currently 25 for indoor groups and 50 for outdoor groups — as well as closing any settings found to be high risk through the state’s contact tracing program, which keeps track of the places infected people visited in the days before testing positive.
Scientists have long warned that the colder months could mark new, volatile territory in the pandemic’s trajectory. The 1918 influenza pandemic claimed far more lives in fall and winter than in its initial springtime surge, and other coronaviruses tend to peak in cold months, suggesting this one might as well. Preliminary studies have shown that in laboratory settings, lower temperatures allow the virus to linger longer on surfaces and in the air.
But cold weather’s effect on the virus itself remains mostly unknown and is unlikely to play a large role in increasing transmission, experts said. Of far more concern to epidemiologists are two other wintertime patterns: flu season and, in the Northeast, society’s retreat indoors.
“The concern [about flu season] is sort of three-fold,” said Sam Scarpino, a Northeastern University epidemiologist. First, it’s unclear how influenza viruses and the novel coronavirus will interact: They could inhibit one another or have no interaction at all, or each could amplify the other’s spread. Second, both illnesses can inflame the lungs, and anyone who has been sick with either COVID-19 or flu would likely be at higher risk for complications if they later contract the other disease.
The third concern — the most worrisome to many specialists — is that flu cases already heighten the burden on hospitals each winter.
“If, at the same time, we have COVID outbreaks, it’s the same ventilators. It’s the same ICU beds. It’s the same respiratory specialists. It’s the same nurses and hospital workers who are going to be responding to both diseases,” Scarpino said.
Still, there is reason to be optimistic about the coming flu season. Public officials have ramped up campaigns encouraging people to get flu shots. Massachusetts this year made the vaccine mandatory for all students under the age of 30. Several experts pointed with cautious optimism to the Southern Hemisphere, where winter has already passed and flu season was mild.
“All the measures that we’re now becoming used to and our new way of life under COVID-19 — social distancing, mask use, hand hygiene, cleaning surfaces, and so forth — are all going to help, I think, to reduce the spread of other viruses," Hamer said. “So it may be that we end up having a lesser burden than normal of respiratory viruses."
But even if a milder flu season reduces the risk of hospitals becoming overwhelmed, experts said one key challenge remains: keeping people from congregating and spreading coronavirus indoors, especially as the fall and winter holidays approach.
“The major risk that people need to watch out for is the risk of being together in close contact in enclosed spaces," said Dr. Sarah Fortune, chair of the department of immunology and infectious diseases at Harvard T.H. Chan School of Public Health. “People are clearly gathering inside already, but as the weather intensifies that pressure, I think it will worsen transmission."
Fortune echoed the fear that Massachusetts has done a poor job holding down the virus this fall, when vigilance should be at its height. “The numbers are up. Hospitalizations are up. Deaths are up. And this is not the flu season yet,” she said. “It is neither the intersection with flu [driving current cases], nor is it the effects of cold weather and much greater indoor living. It’s a hard way to enter the winter season.”
Still, Fortune said she is “not a cold weather alarmist.”
“I think people have radically changed their behaviors, so people who have a limited and circumscribed social network can probably maintain them,” she said.
Aside from confining social interaction, especially indoor gatherings, to a limited number of people, experts said people can also take small steps to reduce the risk of a winter surge: Keep windows and doors open, avoid activities that require removing masks, and get tested ahead of time if you plan to meet people indoors.
Many specialists said they expect people to hunker down in the coming months, especially if the winter is harsh.
“I think in social and home life, we are going to see a dramatic change,” said Dr. Jose Figueroa, an assistant professor of health policy and management at Harvard T.H. Chan. “There’s going to be a lot of temptation to bring [previously] outdoor social gatherings indoors.”
Figueroa noted that the state’s homeless population, which was hit hard by the virus in the spring, will be forced into close indoor quarters to avoid the elements.
“When the winter comes, do we have enough shelters?" he asked. “And are the shelters prepared to house a lot of people in a safe way?”
Experts said that detailed contact tracing remains the state’s most important tool in targeting restrictions, stemming outbreaks, and preventing a surge.
“We learned a lot the hard way from the initial surge,” Figueroa said. “I’m hopeful we come together and combat a second wave.”