Rising Covid-19 cases and hospitalizations underscore the long road ahead

The U.S. is now confronting what public health experts have been warning about but many in the public had not absorbed: the coronavirus pandemic will be with us for many months, and lapses in vigilance will lead to more sickness and death.

The country as a whole is tacking on about 20,000 new Covid-19 cases to its 2.1 million infection tally each day, a clip that’s been steady for weeks, according to STAT’s Covid-19 Tracker. But cases are surging in about half of states, some of which dodged major outbreaks in the spring as the Northeast and other pockets like New Orleans became inundated. The local outbreaks are leading to increasing hospitalizations in Arizona, Texas, Alabama, and the Carolinas — raising concerns about capacity when the original rallying cry of “flatten the curve” was meant to prevent overwhelming health care systems.

Experts had envisioned localized ups and downs as the U.S. epidemic dragged on. But the new bursts of cases have not galvanized a commitment to rein in the spread and steer those rises into downturns. Instead, there is fading attention in Washington, and many Americans seem inured by the steady stream of 800 daily Covid-19 deaths and desperate to return to work and daily life.

“I’m worried that people have kind of accepted where we are as a new normal,” said Tom Inglesby, director of the Center for Health Security at Johns Hopkins School of Public Health.

Much of this was forecast. As states started easing back shelter-in-place restrictions last month, public health experts warned cases would increase. That’s simply the nature of the coronavirus: more people encountering more people provides more chances for the virus to pass from one to another. Plus, unlike in some countries, the U.S. lockdowns were eased at a time when there was still lots of virus circulating, so it was primed to resurge.

“We should expect to see that the virus will go wherever there are susceptible people,” said Yonatan Grad, an infectious disease expert at Harvard’s Chan School of Public Health.

But if initial lockdowns were meant to cut off as much transmission as possible and reduce it to manageable levels, they were also supposed to buy health authorities time to design strategies for the long haul, to come up with plans to keep a brake on spread so people could emerge back into life without an explosion of cases. Hospitals were meant to gear up for future spikes of seriously and critically ill patients. Health agencies had to build testing and contact tracing networks, which could keep spread at a simmer and prevent dangerous flare-ups. Authorities had to communicate to the public that some measures — including masks, distancing, and avoiding crowds — had to be maintained for the duration.

Now, we’re seeing the fruits of those efforts — and the lack thereof.

The U.S. has not hired enough contact tracers to satisfy expert estimates of what’s needed. Mask wearing has become a political flashpoint, with many people simply refusing or not seeing the purpose. The shortcomings are not limited to states that have so far skirted the worst of the coronavirus; this week, New York Gov. Andrew Cuomo chastised local governments to “do your job” and enforce distancing policies after crowds gathered outside New York City bars.

In Arizona, local health departments raced during the state’s stay-at-home period to build up contact tracing fleets and prepare for more cases, said Kacey Ernst, an infectious disease epidemiologist at the University of Arizona. But they didn’t have sufficient time to build the capacities that would prove to be necessary once the state reopened.

“People were using that time, absolutely,” she said. “It wasn’t long enough.”

Now, the state is regularly reporting more than 1,000 new cases a day, compared to a few hundred in May. Hospitalizations are up. There isn’t enough contact tracing in place to try to get a hold of the outbreak, Ernst said.

“As cases are going up, you’re just getting further and further behind the curve,” she said. “If you don’t have all of the things in place, the contact tracing folks trained and operating seamlessly, the more cases will ramp up. And you just keep trying to catch up.”

There are not clear answers as to why some states are seeing more intense outbreaks than others. Georgia and Colorado were two early states to ease back stay-at-home policies, but haven’t seen the rate of increases that others have. Southern California, where restrictions were in place longer, has seen worrying jumps. Density — both at a community level and within households — can influence spread. Some states are more vulnerable to a spike in hospitalizations if their populations have worse underlying health, meaning people who contract the coronavirus are more likely to develop severe disease.

Based on their connections to other hubs of spread, some communities will be later to experience cases than others. Social distancing strategies could have delayed or minimized the course of the outbreak in certain places, as could individual actions by people, including mask wearing, hand washing, and maintaining distance from others beyond what was mandated by local policies. As Harvard epidemiologist Caroline Buckee said, there are “inherent differences in how people are responding to the coronavirus in terms of their fear and lack of fear of mixing in public.”

Some communities have also dodged bullets; two Missouri hairstylists who had Covid-19 managed not to infect any of their 140 customers, perhaps because they were wearing masks and taking other precautions.

One explanation for the case increases is expanded testing — a point President Trump and Vice President Mike Pence have tried to argue. As STAT’s Covid-19 tracker shows, with wider testing, states are getting a more accurate read of the true number of cases, compared to earlier in the U.S. epidemic when many more were being missed. (Even now, experts estimate that for every case detected, another seven or so exist.)

Many of the new cases are also being driven by outbreaks in “congregate settings” — places including jails and prisons, nursing homes, and meatpacking plants. Those clusters are dangerous for those who work and live and are incarcerated there. But their relative isolation makes them easier to contain than transmission in the community.

But increased testing and those confined outbreaks do not account for the full rise in cases that many U.S. states are reporting. By other metrics, there are signs of growing community spread. In addition to more hospitalized patients and ICU beds filled, the rate of tests coming back positive is higher than 10% in Arizona, South Carolina, and Alabama, and rising elsewhere, according to Covid Exit Strategy. That indicates there is an increasing amount of spread that authorities are not capturing.

Governors have sought to project that caseloads remain manageable and that their states need to keep progressing toward full reopenings. Health systems and officials in states including Arizona and Texas also say they have built enough surge ICU capacity to handle the patients they are seeing. (The concern is that when hospitals get overwhelmed, not only does care for Covid-19 suffer, but other patients are harmed as well.)

But there are signals that more patients could be coming their way.

Hospitalizations now, for example, reflect spread that occurred two weeks ago, since people typically don’t start feeling sick until about five days after they contract the virus, and it takes another week for symptoms to get bad enough to require a trip to the emergency department. In that interim, the spread could have snowballed, especially as all states have now lifted lockdown restrictions to some extent.

Soon, we may see spread related to the nationwide protests against racism and police brutality. Trump is also planning a return to campaigning, beginning with a rally scheduled for Saturday in Tulsa. That city saw a record number of new cases on Monday.

Whether and how widely the virus spreads at any of the protests, vigils, or rallies depends on a range of factors: How many infectious attendees were there? Were they distanced and wearing masks? Were they chanting close to other people? Did police fire tear gas and induce coughing? Did law enforcement mass people together in jails?

And whether those mass gatherings incite just spurts of spread or form bigger clusters depends on what people who contracted the virus at the events do. Do they live with five roommates or in a multigenerational home? Where do they work?

“The initial effects after a protest might be two weeks later, but that’s just the beginning,” Inglesby said. “What we worry about in this epidemic is the compounding next generation, next generation of cases.”

That leaves the bigger question: what can be done to halt major surges in cases, particularly as they threaten health care systems? Because of new infections, Utah and Oregon pushed off the dates when they entered into the next step of their gradual reopenings; some cities and counties have urged businesses to limit capacities beyond what they were required to do by states. This week, New York’s Cuomo raised the specter of imposing new restrictions on parts of the state “if the numbers start to go up.” But widespread lockdowns like those instituted in March — and their accompanying damage to social, educational, economic, and health wellbeing — do not seem palatable.

“It’s still not entirely clear to me whether there’s the political and social will that could sustain another round of community lockdown,” Grad said. “So if not, what are we going to do? And as communities start to open up and go through phase 1, 2, 3 of reopening, what are going to be the triggers for introducing restrictions again, and which restrictions?”

As a way to gauge if new restrictions are needed, some experts have called on health departments to report the number of “unlinked infections” — those for which they can’t determine where the infection came from. More unlinked infections signifies more uncontrolled spread and could require distancing measures to stem.

Experts are also trying to parse which components of lockdowns were necessary to drive down transmission, and which can be avoided. They’re hoping a more nimble, targeted approach can allow officials to gain a hold over outbreaks without collapsing the economic and social fabric again. It could be more localized stay-at-home measures, or culling certain activities, or strategies that protect those most vulnerable to the effects of Covid-19, including older people.

“There is a spectrum of interventions between no social distancing and normal behavior, and complete lockdown,” Buckee said. “We’re going to have to be quite flexible about making decisions along that spectrum.”

Already, bars and restaurants in Texas and Florida where cases have been found since reopening have had to briefly shut down. But those retrospective actions still leave communities on defensive footing. To live with the virus and keep cases at manageable levels requires an attack mentality: Widespread testing, quickly identifying and isolating people who are infected, tracing and quarantining as many of their contacts as possible. Those are the general strategies that other countries have used to drive down their curves.

As more people return to work, it will also be incumbent on employers to protect their staff. One of the reasons that the U.S. epidemic has disproportionately affected Black and Latinx populations is because they fill so many essential jobs.

“The primary way the Latinx community is becoming infected is through going to work,” said Rosa Gonzalez-Guarda, an associate professor at Duke’s School of Nursing.

If employers aren’t implementing distancing rules in workplaces, providing protective gear when necessary, or allowing people to stay home when sick, Gonzalez-Guarda said, “it will be very hard to contain the disease.”