Here we go again.
As hospitalizations for Covid-19 inch up around the country, some states are readying plans for field hospitals. Communities are delaying reopening plans and even imposing new measures, though some governors remain opposed to additional restrictions. Deaths — currently standing about 220,000 — have not surged again yet, but that might just be a matter of time.
The current rise in coronavirus cases around the U.S. is reminiscent of the summer crest, and has flashbacks to the emergence of the national crisis in the spring. There are attempts to characterize what’s happening — a third wave or a third peak of a single wave that never fully ebbed — but whatever your semantic preference, cases are racing up in many states and breaking daily records in the Midwest and Mountain West. They’re even creeping up in places that experienced the brunt of the earlier outbreaks, like Massachusetts and New York.
“We thought it was horrible then, but when you look at it from this perspective, they were fairly low,” said Kimberley Shoaf, an expert in public health crises at the University of Utah, reflecting on her state’s caseload in the spring. Now, for the first time, Utah is consistently seeing more than 1,000 new daily infections, according to STAT’s Covid-19 Tracker.
“Our health care system is almost at a breaking point,” Shoaf said.
Experts had warned that the country needed to take steps at the end of the summer and the beginning of the fall to make headway in suppressing its infection rate. They expect transmission to pick up as temperatures drop and the winter arrives, both because of behavioral changes (people spending more time indoors and having contact with more people) and because they anticipate that the virus will spread even more efficiently in cold, dry weather.
Instead, cases have gone in the other direction, already starting to increase and portending even more dire months ahead.
Seven months into the eye of the U.S. epidemic, people are tired of the precautions meant to slow the spread of SARS-CoV-2, the virus that causes Covid-19. But slipups and relaxed attitudes are in turn driving new illnesses. Deborah Birx, the physician coordinating the White House’s coronavirus efforts, has cited social and family gatherings where people let their guards down as burgeoning sites of spread.
The fundamental transmission of the virus hasn’t changed. The virus will go where it’s given room to run, and will find people who are susceptible there. Despite over 8 million confirmed U.S. cases, the vast majority of Americans — up to 90% according to federal estimates — remains vulnerable to an infection. (The thought is that generally people who recover from Covid-19 will be protected from another case for some amount of time.)
It’s difficult to compare directly where the epidemic stands versus March or July, given that the continued expansion of testing means that a greater proportion of cases are being diagnosed now than before. The geography of the outbreak is also different, with many new cases occurring outside dense cities that inculcated spread in the spring.
But the raw numbers are deeply worrying. Last week, the country hit 70,000 daily cases for the first time since July. The new climb in cases also started from a higher point than the summer peak did; with more virus circulating, it’s more likely that some cases will spark new chains of transmission or that superspreading events will occur.
The latest surge also comes as more people are going back to work and school. Universities are finding that the precautions taken in classrooms and dining halls — masks, limited capacities, physical distancing, and the like — seem to be working for the most part, but, reflecting the broader U.S. outbreak, it is student gatherings that are fueling outbreaks in residence halls and Greek houses.
“What we’re seeing with each passing week is that social gatherings are the risk, not simply living in these settings,” said Preeti Malani, an infectious disease physician and chief health officer at the University of Michigan.
Like in the outbreaks in Texas and Florida over the summer, younger adults appear to be accounting for a bulk of new infections, which, in a way, is a positive sign, given that they are less likely to have severe cases or die than older adults. But thinking that spread among younger adults is harmless ignores the fact that some of them will still die or get very sick, straining the health care system. Plus, if the virus is spreading among a certain population, it won’t stay there. A Centers for Disease Control and Prevention study released this month showed how rising infections among people ages 20 to 39 preceded an increase in cases among people 60 years and older — a trend that “is likely to result in more hospitalizations, severe illnesses, and death,” the researchers wrote.
“Infection spreads,” said Stephen Kissler, an epidemiologist at Harvard’s T.H. Chan School of Public Health. If younger people are getting infected now, he said, “ultimately, what that will mean is that there will probably be a longer delay between the observed cases and, for example, hospitalizations and deaths, because there have to be a couple extra chains of transmission between the people who are first getting infected and then getting the disease passed onto the people who are going to be most strongly affected.”
It’s a reminder that the data points we look at to gauge the severity of outbreaks are inherently outdated. Cases that are diagnosed now reflect spread that occurred probably a week ago. People who are being hospitalized now typically contracted the coronavirus two weeks ago. It will take another two weeks or so for those who will die from Covid-19 to succumb. It all means that the effect of any new measures to stop the spread of the virus won’t be reflected in those data points for some time.
But those interventions — including those far short of full lockdowns — can work, experts are increasingly finding. In Arizona, for example, daily cases exploded by 151% in just two weeks in June after the state’s stay-at-home order was lifted. Eventually, however, the state allowed for local mask mandates, reclosed some businesses like bars, and restricted public events, helping drive cases down by 75% over a few weeks in July and August, according to a study from CDC and Arizona health officials. It’s why public health officials have been stressing that relatively simple measures — such as masks, avoiding crowds, reducing opportunities for superspreading, maintaining distancing, and hand hygiene — can stave off a sizable amount of transmission.
The fact that the epidemic is now hitting states like the Dakotas and Montana so hard reflects what experts envisioned at the outset of the U.S. crisis. The virus would spread the most at first in dense cities that received a high number of imported cases, and from there would travel to other cities, and then trickle to more rural areas.
“Slowly, day after day, you’ve seen the gap in the infection rates decline” between metropolitan areas and rural areas, said Fred Ullrich, a program director at the University of Iowa’s College of Public Health. It might be a combination of a better handle on the virus in cities or a more lax approach in rural areas, “but we’re seeing it all over the Midwest, and all over the United States.”
The spread of the virus now is more diffuse than in the spring, when it was so walloping in places like the Northeast or New Orleans. Clinicians have also gotten better at treating Covid-19 patients over the past months. But experts warn that local surges could still overwhelm health systems, exacerbating staffing shortages, imperiling patient care, and potentially leading to worse outcomes.
“When your health care capacity isn’t sufficient to meet demand, you’re going to see higher fatalities,” Shoaf said.
There is one aspect of U.S. reopening plans that experts, if you ask them how it’s going, will say they’re “encouraged” about: K-12 schools. The available data, including from a dashboard put together by researchers at Brown University and colleagues, indicates that schools aren’t experiencing frequent widespread outbreaks.
But experts are also cautious about simply declaring in-person schooling safe. The data that do exist are generally voluntarily supplied by districts, so it’s not clear what’s missing. Because there’s no national reporting, researchers can’t parse which approaches — hybrid models, mask mandates, classroom size restrictions, limiting in-person instruction to just the youngest students while having middle and high schoolers learn virtually — are working best in terms of minimizing cases.
“It is encouraging, there’s no doubt about that,” Wendy Armstrong, an infectious disease physician at Emory University, said about the K-12 school experience so far. But having such limited information available “severely limits our ability to give additional guidance to schools that are based on very clear, evidence-based data. And with limited reporting, in my mind, it makes it impossible to interpret the available data to truly understand current risk.”
Armstrong pointed to one point of success so far. Teachers and parents wondered if young students would tolerate wearing masks while they were in school. So far, Armstrong said, it seems like the kids are doing all right.