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.

advertisement

“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.

advertisement

“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.

Support STAT: If you value our coronavirus coverage, please consider making a one-time contribution to support our journalism.

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.”

  • DING DING DING!!! The admitting diagnosis-if can also add a positive CV test- means the hospital now receives a much higher reimbursement rate!! Break an arm get tested and that simple setting of a bone now brings a much higher reimbursement. Can’t blame the hospital as the shutdown cut down the needed but deemed “elective” surgeries that paid the bills. I am currently in Florida and the news is very careful to say “rising hospitalizations-even higher than precovid levels!!!” without saying WHAT the hospitalizations are for-like all the people who deferred shoulder or knee surgery or biopsies etc are now trying to get them in before another lockdown. My state is ramping up testing of all staff and residents of nursing homes (FINALLY) and OMG surprise! finding asymptomatic cases-and in these communities no hospitalizations or deaths attributed to positive CV19 (some from loneliness and tired of “prison” though). so of course our state will “spike” and news will breathlessly report the higher cases etc. CONTEXT IS EVERYTHING but if we had context the fear wouldn’t be there nor would the anger and we MIGHT have clearer answers and compliance with measures that work.

  • Deaths are trending down. News cases are still trending down. Many of the states trending up in new cases like Alabama are not really spiking. Although they went from 200 to 1,000 cases recently they have dropped back below 400. But look at the deaths, they went from 4 deaths and spiked up to 10, only to drop back down. It’s meaningless. Clearly using states to make your point is cherry picking of the worse kind.

  • You make good points, Stuart.
    Some are too weak and whiney to social distance and wear masks when that isn’t possible… and, sob, to not hug your relatives, for the greater good… including your own.

  • I think it is ridiculous that you name everything as causes of increased outbreak except the number of protestors, rioters and looters that have been out and about…much worse than the “crowds outside bars.” Apparently people who are protesting, rioting and looting are immune to the virus?

  • One often overlooked reason hospitalizations are rising is that people are being hospitalized for other reasons (like elective surgery and examinations), and are testing positive for the virus. Apparently, hospitals test everyone admitted for obvious reasons. So, lots of people are hospitalized with COVID instead of being hospitalized for COVID, and the statistics do not distinguish between the two. And of course the former can turn into the latter. The data collection needs to be revised to distinguish between these situations.

  • Red states are not going to play your hoax game anymore, it’s over. If you want to hide in your basements wearing a mask in blue states, feel free. Just don’t expect a bailout when your mortgage goes into foreclosure. It’s over and you can stamp your feet all you want.

    • Are red states too weak and stupid to modify their lifestyles to include social distancing and (gasp) wearing as surgical mask from time to time?
      I don’t think so. My inlaws are in a red state and doing so very well. Though many would love to hug their granddad when they shouldn’t put him at risk, they understand that those who’ve been through wars have had to ‘isolate’ from their grandparents for literally years. Grow some and think about others.

    • Did you actually read all the article? Hoax game? Over 100,000 deaths and you are calling it a hoax? Seems our President may have used that term also. He was dead wrong. If it is over why are we still seeing about 20,000 new cases each day? Why are from 1 to 2 thousand per day dying? Why has the positive testing numbers gone up into double digits in many areas? Why do we lead the world in infections and deaths? Well if we don’t have to send our tax money to the majority of red states that receive far more back than they pay in, we blue states will do fine, thank you for being concerned.

  • Could it be that as the weather gets hotter in the sunbelt that more people are spending more time together in air-conditioned buildings? Whereas in the North we all spent more time indoors in the winter?

    • It could be, although I suspect the drop in relative humidity both furnaces and air conditioners induce might be the pertinent causative factor in buildings given that citizens of developed countries spend most of their time indoors year-round. The low RH favors droplets drying to become a dust which swirls around in the air instead of sticking to the surfaces the droplets fall onto. People then breathe this dust.

      But that’s only a guess. Many things, including people approaching one another in larger groups, likely add to the spread, and northeastern states where new case counts have recently gone down may see them on the upswing again as they reopen, too.

  • It is stupefying many Americans are so flagrantly hell-bent on their “freedom” that they refuse to take even the most simple, pain-free precautions like wearing a mask and keeping social distance. In not making those really small sacrifices, the death toll will sky-rocket. In even keel: the dwindling group of health care workers (there WILL be a dire shortage) has rights too: choose whom to treat (the ones with masks). The stupid masses clearly don’t understand Covid. This is Darwin at work in 2020 : survival of the fittest (= smartest).

    • So-called “Truth Detector” : this has ZERO to do with racism ! It has everything to do with common sense in practicing disease-preventing behavior. And by the way: only idiots loot, riot, vandalize, burn, mug and kill.

  • The problem is that there is no longer a defined goal in addressing the epidemic – everyone could get on board with “flatten the curve” to buy time for the hospitals. Now, it’s not clear what we’re trying to accomplish and the potential goals seem conflicting. Are we recognizing that C19 is going to spread as we open up, and we’re simply trying to slow it down to keep the hospitals from being overwhelmed? Although cases are rising, only a few areas are seeing increased hospitalizations, and according to the CDC, hospitalizations are declining overall. Or, are we trying to keep the number of new cases as close to zero as possible “just like” China, New Zealand, South Korea etc.? – which the US is nothing like culturally and/or geographically. Or, are we trying to keep our R0 factor below 1? If so, most states are doing a pretty good job of this.

    And, please, it’s not that Washington that has caused national burnout. The biggest and most obvious factor is that we just had massive nationwide protests – which everyone understands – but where people were NOT social distancing one bit and many didn’t even wear masks, and this was deemed just fine by every media outlet on the planet. So it appears that being vigilant about C19 can be put on hold if there’s a greater cause. Now everyone has an excuse for why they are “so over it”.

    Lastly, most people have become wise to the fact that certain media outlets are abusing their power and trying to keep everyone in a state of constant panic and clicking about the purple clouds of doom that hover in the air for hours waiting to strike down even those in their 20s with the most horrible complications – these media outlets are now being dismissed and they should be. Shame on them – instead of doing their job and reporting scientific facts, they’ve caused most Americans to simply tune out.

    • Hmm, I have seen the protest mentioned many, many times as a possible infection spreading behavior on various news sources. It is true. But no different than the behaviors in many parts of our country that insisted it was fake or a hoax and sadly some of those areas are seeing increases in cases, positives and deaths.

      It is still here, we are still getting infected, and we are still dying by the thousands. And don’t even go near the scientific fact avenue after listening to the demented bleating from some in positions of power.

    • You hit every point! This is something that isn’t readily admitted to-without screaming nellies about “killing grandma” – better hope those people don’t google how many MORE people will die globally due to shut down and disruption of supplies, delays of treatment etc. If you aren’t directly dead from Covid you DO NOT COUNT in their book

  • The death rate for the virus is .26 if you include asymptotic cases from CDC stats. Let people get herd immunity so we can have some semblance of a normal life again. No one is talking about the Catastrophic level of psychological effects this is having on children and the rest of the population. Our economy has been devastated. All for some thing with the death rate similar to a bad flu season.

    • life really looks clear cut in the eyes of simple minds

      BTW, as there is no herd immunity for this virus, building it implies letting more than 800k people die, according to your fallacious numbers/reasoning. Now, I am sure you are perfectly fine with that. But, that doesn’t take into account a healthcare system collapse that such herd immunization would cause. And using less manipulated numbers from the European epidemic, an estimated 1.5+M people could die in the US, when adjusted for population, without doing nothing. And, assuming the healthcare wouldn’t collapse.
      WWII caused about 450k US deaths over five years.
      Again, always amusing watching simple minds at work

    • If the death rate is .26 percent, that means just about everyone in NYC had COVID (death rate .2% if that were true). So try again.

    • dipthroat – the evidence suggests that there is herd immunity, but we are far from it – except in NYC. If a vaccine can be developed by the Fall or Winter, we can get there without 800k deaths. If not, then those deaths will happen eventually, but over a longer period of time, as long as people wear masks in indoor public spaces. Everyone is guaranteed to get it eventually unless a vaccine is developed. All mitigation measures do is to buy time and prevent overloading hospitals – they do not prevent eventual infection.

    • Sweden tried a different method, the herd immunity angle. And it now has a death rate of 500 per million, where Denmark has a death rate of 104 per million. Both countries economies are in the tank. If the US had had a competent administration in place, that had a sensible plan in place, much of the damage, death, and economic costs could have been avoided. But competence is not part of the game at this time.

      As far as a bad flu season, you need to get some real information. This is from the CDC, CDC estimates that the burden of illness during the 2018–2019 season included an estimated 35.5 million people getting sick with influenza, 16.5 million people going to a health care provider for their illness, 490,600 hospitalizations, and 34,200 deaths from influenza. And we just topped 120,000 in just over three months. It is far more deadly than the flu as the facts show.

Comments are closed.

Sign up to receive a free weekly opinions recap from our community of experts.
Privacy Policy