Biden faces COVID dilemma as a winter wave nears

• Biden administration officials are warning there's trouble ahead while touting the progress that's been made to knock down new cases and hospitalizations.
• They're also trying not to trigger voter frustration over the persistent health crisis just weeks before the midterm elections.

By the numbers: While daily U.S. case counts remain at some of the lowest points since last spring, below 38,000, new strains that appear better suited to evade immune defenses are making up a bigger proportion.

• The BQ.1 and BQ.1.1 subvariants now account for more than 16% of cases while the BA.5 strain that predominated over the summer is down to 62.2%, per the Centers for Disease Control and Prevention.
• Only 19.4 million Americans have received the updated bivalent booster shots that were rolled out seven weeks ago and are engineered to best protect against infectious omicron variants. More than half of the public says it knows little or nothing about the reformulated shots, per the Kaiser Family Foundation.
• A surge of COVID cases across Europe could coincide with the start of holiday travel and augur a serious winter wave in the U.S., health experts warn.

What they're saying: "Right now it’s looking good, but we have to be cognizant the train is coming down the tracks," said Peter Hotez, dean at the National School of Tropical Medicine at Baylor College of Medicine. "People are tired and it’s going to be hard to persuade them to do a full-court press."

• "We are going to see an uptick in cases and hospitalizations, we'll see higher rates of hospitalizations and deaths among those 50-plus who have not gotten the newest booster, but it's probably going to be milder than last winter," said Megan Ranney, academic dean at the Brown University School of Public Health.

Look ahead: The administration will have to clearly define the threat ahead after President Biden declared the pandemic over.

• Hotez said the message should be threefold: Get the bivalent booster, vaccinate your kids and administer more treatments like the antiviral Paxlovid to older patients with breakthrough infections.
• The question is whether those Americans who've been steadily tuning out public health messaging will even listen, or will bother to get tested for COVID if they don't feel well.
• Hotez and others said people may be lulled into a false sense of security, thinking if they get sick, it will just be a mild infection. In fact, the BQ.1.1 strain has enough mutations to jeopardize our immune response.

The Biden administration says it's taking steps like setting up pop-up clinics and media campaign to promote the new shots. Officials say the ideal time to get vaccinated is by Halloween, before colder weather, holiday gatherings and travel send more people indoors.

• "The number one thing that people need to do is get vaccinated. And the number two is if you have a breakthrough infection, you need to get treated," White House COVID-19 response coordinator Ashish Jha said at a recent briefing.

Between the lines: Some public health officials are looking for more vigorous messaging from Biden and the CDC, even if talk of COVID and shots exposes raw nerves in the run-up to the midterms.

• It's also critical to distinguish who would most benefit from interventions like vaccines, such as older adults and the immunocompromised, tweeted Celine Gounder, an infectious disease specialist and clinical professor at NYU.
• "When you tell everyone that they're at equal risk and this doesn't align with their real-world experience, I think that this leads everyone to question whether anyone is at high risk," she wrote.

The big picture: It's not surprising that people have gotten burned out on the COVID messaging, Michael Mina, a former Harvard epidemiologist and chief scientific officer at the biotech software company eMed, told Axios.

• "But there’s almost been this backlash against anything COVID, a backlash against anything ultimately suggesting ways to stay healthier and remain healthy," Mina said. "Usually the population is angry at the disease."

But the administration prepares for an expected convergence of more transmissible variants, a major uptick in RSV cases and worse-than-usual flu season, it makes for a challenging message, Mina said.

• "They’re between a rock and a hard place right now because you try to push too much of a COVID message then you’re risking the election because [voters] want the pandemic to be done, but it’s not," Mina said.