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For all the talk of a second wave of coronavirus cases hitting the United States this fall, one consideration is often lost: The country is still in the throes of the first wave of this pandemic.

Even as roughly half of states start to peek out from under their lockdowns, the United States confirmed more than 25,000 new Covid-19 infections nearly every day in April, a clip that does not seem to be dropping in May, according to STAT’s Covid-19 Tracker. More than 1,000 people have died each day since April 2. On some days, including both Tuesday and Wednesday this week, the toll topped 2,000.

So if the curve has been flattened somewhat, it is not coming down.

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Some states and cities are reporting hints of progress. In Massachusetts, hospitalizations have dropped, even if the number of deaths has not yet buckled. Newly confirmed cases are down in New York City. The Bay Area’s early shelter-in-place appears to have staved off the worst impacts of the crisis for now, and ensuing policies elsewhere helped minimize the pain.

But cases are increasing in other areas, according to the tracker, a partnership between STAT and Applied XL, a Newlab Venture Studio company, that compiles data from 15 sources. Texas has reported more new cases in each of the past few days than it typically did in mid-April. Cases are accelerating in Kansas. Outbreaks continue to build in prisons and meat processing plants.

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There have been more than 1.2 million confirmed Covid-19 infections in the United States; experts say the true number could be 10 times that. But even if those people are immune from a second infection for some amount of time — which scientists still need to confirm — that still leaves the vast majority of Americans susceptible to contracting the virus.

The plateau in case counts at such a high level nationally also means there is still lots of virus lurking around. Infections have remained stubbornly elevated even as, in most places, people who could stay home and avoid contact with others generally have.

Now we will get a glimpse of what happens as people start to move around more.

About 30 states have started to ease the lockdown restrictions imposed to suffocate the spread of the virus, or will soon. What’s allowed and when varies by state, but most governors have outlined gradual approaches, with limited capacities at restaurants, malls, and theaters. They have the backing of President Trump, even though many don’t meet the White House’s recommended milestones for when it would be safe to emerge from stay-at-home policies, one of which was a decline in cases for 14 days.

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It’s an attempt by governors to balance out the economic, social, and psychological impact of shutdowns, which have also caused lasting effects on people’s health and well-being. But it’s also an experiment that will examine whether phased reopenings can occur without setting off an explosion in cases — and overwhelming health care systems.

“I’m somewhat sympathetic, as I think everyone is, to the impulse to try to open up,” Marc Lipsitch, an epidemiologist at Harvard’s T.H. Chan School of Public Health, said last week. But, he added, “I don’t think at this point that it’s good public health advice to reopen in most parts of the United States, because cases numbers are high, and testing is poor. And that’s where we were a long time ago.”

Reopening at a starting point of such a high number of infections not only increases the likelihood of wider spread (an initial 1,000 cases can balloon into exponential growth much faster than an initial 10 cases), but it also makes it more difficult for public health agencies to track all cases and trace their contacts. Experts say these are crucial steps if infections are going to be driven down and a resurgence of transmission is going to be held off and minimized.

And although the testing situation has improved in the country, experts say the number of tests being run every day remains below where it needs to be to effectively hunt the virus and snuff out transmission chains.

“One thing that has been at least an idea I’ve heard expressed many times is, ‘Well we’ve reached a peak and therefore it’s time to reopen,’” Lipsitch said. “But viruses don’t know where they were in the past, they only know where they are in the present. And what I mean by that is if we had X number of cases per day at the start of imposing restrictions, and now we have a lot more than X cases per day, as seems to be the case in most places, but we’ve slowed down the increase, we’re in a worse position now than we were then.”

With more virus spreading now than when lockdown restrictions were first imposed, Lipsitch continued, “there’s not much logic in the idea that slowing down the growth is good enough and now we can reopen. The logic is in reopening when the number of cases has come down sufficiently that we can expect that the growth that will result when we reopen is manageable and will not overwhelm our health care system. If we were worried about it being overwhelmed a month ago or a month and half ago when the restrictions started, and there are more cases per day now, then we should be more worried, not less.”

As states pursue different reopening timelines, the scope of their local outbreaks will continue to diverge, even as an outbreak in one community can spill over to others.

The impact of reopening in a given state also won’t be clear for some time, even if transmission of the virus takes off. Cases can build silently; people can spread the disease before they show symptoms, and that can take a few days. Some portion of people do not feel that sick or show symptoms at all. So if a wave of people needing care suddenly floods into hospitals, that’s a reflection of transmission that occurred some two weeks prior — spread that could have only grown in the interim.

An unknown in what will happen as states lift restrictions is how residents will respond. Many people feel it’s not safe to go eat at a restaurant even if they now can. If people continue to wash their hands regularly and stay home if they are not feeling well, those individual steps can accrue into a major influence.

But that might not be enough. A model released Thursday by Columbia University researchers, which analyzed loosening stay-at-home orders, forecast a resurgence of cases by the end of the month.

  • Yes, the virus will continue to spread. That is unstoppable. People are wearing masks inside businesses a lot more now, and lots of businesses require it, and that should slow the spread somewhat, even as more businesses reopen. It is unlikely that large events like festivals, conventions, rock concerts, spectator sports, etc will be allowed for a very long time, and that should prevent huge surges where one person infects thousands. As long as people on public transport are required to wear masks, huge surges like happened in NYC should not occur.

    I do wonder about major new strains, though. Coronaviruses are very different from flu, and major evolution usually takes place from recombination when a host is infected with 2 viruses at once. So far, very little evolution has taken place in CV-19. The selection pressures on this virus are the ones from our social distancing, testing, and other mitigation measures. Therefore, I would expect the virus to evolve in a direction that makes it more contagious, more stealthy, or gains the ability to induce its hosts to distance less. There is no way to predict in advance if an evolved virus becomes more deadly, less deadly, or acquires other major changes in how various population groups are affected.

  • The premature opening in the US when the curve is still not down significantly will exacerbate the Covid crisis tremendously. Hospitals and health workers are already at wits end, yet their warnings are blown into the wind. The already prevalent shortage of PPEs and tests – and on top of that just one drug – which also is in screaming short supply – will bring the curve up to almost vertical. The death toll – at this point 1000 per day (!!! third world country number !!) will be staggeringly higher as many people refuse to behave protectively (no masks, no distance, packed on beaches etc). America is doomed.

  • This article seems to say what a lot of people already knew: if we get away from restrictions too soon we’re going to be back in the middle of it for a long time. The first weekend Texas was “open” cars were stacked end-to-end on the rivers, the lakes, and the coast. That showed me that common sense has not caught on and probably won’t. America is filled with egotistical “me first” people which is exactly what COVID-19 will thrive on. Until America changes its mindset and realizes this is real, it will continue.

    • Key word there being “some”. It’s also spreading “fastest” in many states that are still locked down: Illinois, Minnesota, Wisconsin, California, Washington.

      It’s also going down in many states that are loosening up. It’s plunging in wide-open Montana.

      The surefire way to drive the rates down quickly is to go ahead and infect a high proportion of your population: NY, NJ, CT, MA. Lockdowns there worked just great.

  • Testing is ramping up more and more every day. So if the number of cases is plateauing even though we’re putting more tests out there, then doesn’t that mean that the percentage of people tested is decreasing every day?

    • Correction: “then doesn’t that mean that the percentage of people tested is decreasing every day” was supposed to say “then doesn’t that mean that the percentage of people that test positive is decreasing every day?”

    • In Texas that’s the case. At both the state level and my county’ the percentage of positive cases are declining as the number of tests increase. And they just opened up a ‘drive through testing’ facility in my city.

      And people are starting to question the lockdowns as doing more damage than the disease.

      The economic effects of the lockdowns won’t truly be felt until July-August. This is because companies make quarterly reports and the reports being made this month are for Jan-March. This means that as bad as those reports are – they only cover two weeks of the lockdown.

      And grocery stores now have extensive bare spots on the shelves. And there already is a shortage of products in the meat department.

  • Looking back, the biggest mistake was not putting New York on lockdown in February.

    • And yet our Health Commissioner Oxiris Bardot, and our mayor Bill Blase are basking in the light of being “not trump.”

      Both of them will pay for their neglect and stupidity when this is looked at more carefully. We’ve lost 20,000 of our fellow New Yorkers to their criminal neglect.

  • It’s insane to open any state until the numbers are safe plenty of hospital gear and people realize to follow guidelines.Trump has been the probleM all along neglect,not supporting our states complete ignorance and neglect him and his ridiculos task force has put us far behind a cure compared to the rest of the world he’s destroying america and is blaming everyone else when it’s so obvious he’s the problem we will be in a war because of his acusing other countries and we’ll lose america will b no more and I blame the American people for not kicking him out on his a.. and letting this happen

    • Have you noticed the bare spots on grocery store shelves? Have you heard about the hospitals laying off staff? Schoolchildren have already missed a semester’s worth of education. They haven’t stopped growing. How will we make up the lost education?

      The horrible quarterly reports coming from Wall Street are only for January through March. That means all of the damage occurred in the last two weeks of March. The true extent of the economic damage won’t be known until we see the quarterly reports for April – June.

      Come summer we are going to have a recession so bad that it will make 2008 look like the ‘good old days.’

      Also remember that 70% of businesses that have to shut down for a month – no longer exist three moths later.

      BTW – your first sentence was the only one worth reading.

  • This would be the same Mark Lipsitch who told The Atlantic in February: “Lipsitch predicts that within the coming year, some 40 to 70 percent of people around the world will be infected with the virus that causes COVID-19.”

    We’ve shown that hospitals can handle it and ramp up capacity quickly. So what is the point, exactly?

    • I am not sure what your Comment is supposed to mean, but the point to me is clear – we have more cases now – a lot, lot more cases – than we did when the lockdowns began – so if we do less to stop the epidemic from growing, by ending the lockdowns, with more cases to start, we will have far more cases than we have now in a very short period of time.

      You seem hostile to this conclusion but do not say why. As far as I can see, it is very logical. The only thing which might be wrong in my view is that, no matter what the government does, people at some point, after seeing enough deaths, want to protect themselves – and so, they start wearing masks, even if not ordered to do so.

      I personally believe the masks are more important than anything else that has been done, or will be done, outside of the vaccine, and maybe treatment, research.

      That is why, IF people would use their masks diligently, we could reopen and still not have a big resurgence. Masks are worn all over Asia, and they have a tiny fraction of our cases.

    • Actually the cases have dropped from a high of 40,000 a day to around 25,000. And we know that this number is well within the capacity of our healthcare services. Even 40,000/day can be handled.

      We are already headed for a massive recession caused by the lockdowns (say goodbye to your retirement savings). The grim statistic is that 70% of small businesses that have to shut down for 30 days no longer exist 90 days later.

      Have you noticed the empty spots on the shelves at your grocery store? The longer we are locked down the worse that will get – and the harder it will be to restore production due to bankruptcies of the farms and in the food supply chain.

      The lockdowns are simply unsustainable.

    • I try to avoid political comments because Stat is a website which discusses medical news and all the political comments by non-medical people have driven away medical professionals who were once very helpful in augmenting the articles. Now, a lot of doctors and scientists avoid making comments and that is a big loss.
      And, besides avoiding political questions, I am also just not sure what the answers are – though my basic attitude is, we can take actions to stop the virus which are much, much less extreme than shutting everything down – but only if the people all comply with the correct measures to stop the virus, which they will not, as best I can see. I went out yesterday and saw pretty much everyone walking on the street, (or jogging, which really angers me, since they will be throwing out much exhaust) had no masks. Almost everyone – and in their cars as well – no masks, with the windows open.
      Anyway, my point is, the basic conclusions seem inescapable, if you have people who simply will not do what makes sense to stop the virus, the only thing you can do with them is keep them inside. It is very frustrating. Some of the people complaining the most about the lockdown are doing the most to make it necessary.

      And again, this article is 100% correct, the fact we have far more infected people, and are going to do the same things we did to let the numbers get so high, ensures far more cases in a very short period of time. After going out and watching people yesterday, it is easy to believe 3,000 deaths per day in a month or so.

    • Steve White

      I was simply restating the earlier opinion of Mark Lipsitch, quoted in the article above, when he declared in February that infection was inevitable and could not be contained. I think he was right. Sure, attempts at containment can slow the spread. It is extremely difficult to prove that they actually prevent deaths, rather than merely postponing them. That WAS the official line when the containment measures were imposed. The goalposts have been moved.

    • Steven Willing:
      I agree they have changed the goals and I apologize if my previous Comment was kind of rude.
      From my personal well being, I am old enough, and have all the risk factors, (mild to moderate, but all there) that I have between a 10 and 20% chance of dying if I got the disease. (of course all the numbers are based on identified cases and there are significant numbers of unidentified cases but in my opinion not some vast number which changes the case fatality rate drastically)

      So, I am not saying what is best for the country collectively, the shutdowns are clearly horribly harmful to the economy, but personally I have been very careful to try to not get infected, for the same reason I am generally in favor of the shutdowns, in the hopes that doctors and scientists treating the disease will have time to learn what works, while the numbers are contained, so that the effective treatments can be applied to everyone who gets sick later, in my individual case, and for everyone else infected after a few more months.

      Following the media reports is to some extent encouraging. It is not clear to me if remdesivir is going to make a huge difference, but I read cytokine storm is being identified as one of the big problems, and that there are ways to combat cytokine storm. Likewise blood clotting, a lot of patients have problems with that, but now it seems to be recognized and will be looked for and treated by doctors from this point forward.

      And I was also hoping for a vaccine, but it seems like the conservatism, inappropriate in these circumstances, of the medical establishment and government agencies, is going to prevent that from happening any time soon, which is really a terrible shame, as many effective vaccines have probably already been proven in animal trials.

  • Looking at other countries, the US, with some exceptions, has “enforced” the sloppiest lockdown in the world. That is, a Kudlow “I won’t say airtight, but pretty close to airtight.” grade of lockdown is not gonna cut it with a virus epidemic.

    • dipthroat – you are absolutely correct – we have done a terrible job, almost certainly the worst in the world, in the cost of suppressing each new infection.

      For shutdowns costing hundreds of billions, we have saved, let’s say, 100,000 lives in the short term – or some similarly very large death toll.

      It is great these people did not die, (and a comparable number were not made permanent invalids by heart, kidney, liver, lung, etc damage) , but it should not be overlooked, it was at a cost of millions of dollars per life, when, for a much lower economic loss, we could have have more people saved, by a good lockdown. I think the worst single thing was the CDC not emphasizing the importance of face masks, even telling people not to worry about masks if they kept 6 feet away, when they clearly knew masks were crucial.
      I do not understand it, but there seems to have been a belief on the part of the CDC and all the other public health authorities that the people of the US are simply too dumb to follow all but the simplest directions.
      And the last point of this ramp – after they told us “Wash your hands” and “Stay 6 feet away” they pretty much ended all instructions. I saw nothing about other safety measures, not by the government anyway.

    • The US culture is the major reason of the lose enforcement, Americans by nature don’t want to be told what they can or cannot do by the government, especially by an executive order by one person like a governor or president or mayor, and that pesky constitution makes enforcement more difficult, so it’s not just the government lack of effort, it’s Americans sense of freedom, I have not followed the stay at home order, I still meet 3 times a week with about 7 to 10 people for 2 hour 5 mile walk, I have a mask but it’s pulled down, I’ll put it over my mouth and nose when we pass by other walkers but then pull it down, 2 reasons I won’t ware the mask is one it makes my glasses fog up so I can’t see even if I take them off I still can’t see because I need them to see clearly, the second is it’s hard to talk with my friends I’m walking with, oh we are all retired so our age is in the risk category and I have diabetes, but I’m not concerned in the least of catching COVID-19, I just look at the amount of cases versus the total American population and it’s seems to be a low risk in these situations, now I won’t go to a nursing home or hospital because the risk goes way up.

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