Cases of COVID-19 are on the Rise

What to Know

Unfortunately, with end of the public health emergency, we can no longer see the earliest and best indicator of disease transmission levels – cases (reports to the CDC of all those testing positive by a PCR test performed at a hospital or commercial laboratory). Instead, we now have to resort to wastewater surveillance, hospitalizations for COVID and deaths from COVID, the latter two measures being late indicators of COVID-19 transmission levels. Nevertheless, all three measures are up and increasing leaving little doubt that we are having a new surge (please note that I use surge to denote a measurable and sustained increase in cases, hospitalizations and/or deaths, but the use of the word surge does not in any way indicate the magnitude of the increase relative to baseline or past surges).

Hospitalizations

An increase in hospitalizations due to COVID-19 is certainly an indication that COVID-19 cases have also increased in roughly the week prior. COVID-19 hospitalizations are up in the US and globally, but keep in mind, not only are hospitalizations a late indicator of COVID-19 cases (~ 1 week), but the reporting of hospitalizations is also delayed. I am writing this on August 14, and the most recent data on COVID-19 hospitalizations in the US from the CDC is from July 29, in other words, roughly 2 weeks ago. Further, the reporting to the CDC is not always timely or complete. Thus, there is no way of determining just from the COVID-19 hospitalizations data during a surge, whether the number of cases is still increasing, has peaked, or is even on the decline (we will have to put all of the data together to make that assessment – see below).

In the week ending July 29, there were 9,056 people hospitalized for COVID-19 in the US. That was a 12.5% increase from the week prior. To put this in perspective, the highest number of hospitalizations in the US in a week occurred in the week ending January 15, 20222 with 150,674 COVID-19 hospitalizations (which was high enough to overwhelm many of our hospitals), but keep in mind that it appears that the current surge in hospitalizations may be just beginning and very likely has not peaked yet.

In Idaho, too, there does appear to be a slight uptick in COVID-19 hospitalizations, but it is far less pronounced that what I am seeing nationally, confirming reports that seem to suggest disease transmission may be higher in other parts of the country than the Pacific NW at this time.

Wastewater Surveillance

Detection of SARS-CoV-2 virus has increased significantly in the wastewater testing from every region of the U.S. Currently, levels in the midwestern US are increasing most rapidly, and have overtaken all other areas of the country. It appears possible that wastewater levels of virus have peaked in the eastern US and the southern U.S., while levels in the western U.S. have been lower, but steadily increasing and have now reached the levels seen in the eastern and southern U.S.

In Idaho, reporting is significantly lagging, with the most recent data being roughly 3 weeks old. Keep in mind that the delay from sampling to reporting has historically been about a week, so these data are likely one month old. Nevertheless, it showed that wastewater levels of SARS-CoV-2 virus were increasing in Ada County and steady in all other parts of the state for which wastewater sampling is available. The wastewater surveillance testing/reporting is similarly lagging for the City of Boise (last reported July 24) and that time, I could not discern anything suggesting the beginnings of a surge.

Deaths

The CDC reports that COVID-19 deaths accounted for 1.1% of all deaths in the U.S. and that COVID-19 deaths had increased 10% over the last reported week. That does reflect an increase in COVID-19 deaths in the U.S., however, the numbers remain low on a relative basis, and all of this would be consistent with what would be expected early in a new surge, as we typically don’t see increases in deaths until a couple weeks after we see the increases in cases.

Looking at the Idaho reporting, we are not seeing any increase in COVID-19 deaths over the recent baseline, however, this data is two weeks old.

Variants

It’s a bit challenging to know what variant to attribute to this current surge, although I certainly have my guess. In the past, surges have generally been easily attributed to a single variant that was dominating, and we usually did not see a surge until that variant accounted for over 50% of the genetic sequences recovered and identified from infected persons. However, at this time, in the US, we have at least 18 variants circulating, of which at least 5 appear to be on the rise as a percentage of all the variants circulating. As, I mentioned, I have a guess as to the variant causing the current surge, but it is only a guess, and I base that upon the fact that it is the prevailing variant (perhaps as high as 21% – however, it may be much more now because that was as of August 5) and seems to be the fastest growing variant. That variant is EG.5, another recombinant of two Omicron variants with numerous subsequent mutations.

Unfortunately, the wastewater reporting from the City of Boise is nearly a month old, but interestingly, even then, EG.5 accounted for 11% of the variants detected. The then prevailing variant was XBB.1.9, but I would certainly expect EG.5 to have increased and XBB.1.9 to have decreased by now.

What are the implications of all of this?

There is little doubt that we are in the early part of a new surge. I can’t tell you to what magnitude this surge will manifest, and neither can anyone else. If the wastewater measures truly are peaking in the eastern and southern part of the country, then that is fantastic news and this surge is likely to be rather mild in a relative sense. Even if the surge has not peaked anywhere in the US yet, given what we know about EG.5, we would not expect a surge that would come close to the surges we dealt with in 2020, 2021 and early 2022.

However, we should take the following factors into consideration in reserving judgment as to how significant this surge may or may not be because many factors have changed since these earlier years of the pandemic:

1. We are undeniably dealing with more transmissible and more immune evasive variants now than we did in those earlier years.
2. Schools in many parts of the country will start the new school year over the next couple of weeks. While early on, the evidence seemed to defy logic and experience in that school children did not seem to play a major role in transmitting the virus (children are a significant factor in driving community transmission of most respiratory viruses, especially influenza), but now the data seem clear that in fact children do play a major role in the transmission of SARS-CoV-2), and it is likely that we will see a significant uptick in community spread once schools open.
3. Unlike earlier years when schools were implementing some mitigation measures, from what I can see, it appears that few schools are taking any mitigation measures this school year. This will promote transmission within schools and subsequently within communities. Further, while we know that schools could significantly reduce transmission through changes to their air handling systems, it appears that relatively few schools have adopted these best practices, which could have been subsidized with federal monies that likely are no longer available.
4. Similarly, work places are taking less mitigation measures, and many companies have cut back or ended remote work opportunities. This will undoubtedly promote transmission within work places.
5. Of great concern to me is the fact that up until this year, hospitals required masking in all patient care areas. It was also common for hospitals to limit visitors and screen employees and visitors. Now, many hospitals have abandoned most, if not all, of these measures. We know that as transmission increases in communities, the rate of infections in health care workers increase, as well. Further, while the U.S. does not require reporting of nosocomial SARS-CoV-2 infections (infections that patients acquire while hospitalized), and regrettably, few if any hospitals have been transparent in reporting this data publicly, we know that these infections are well documented in countries that do. It seems all but certain that as community transmission rates increase, it will become more and more dangerous for those who are hospitalized for reasons other than COVID-19.
6. We can all remember the days when masking in the community was not rare, when people avoided large gatherings, and when most larger events were held outdoors. Of course, little of this is the case today. Not only does this increase the risk for exposure to people who are infected when community transmission levels increase, but when in close contact and not masked, the viral dose is increased (the amount of virus that a person inhales), and we have some evidence to suggest that higher viral loads correlate with higher risk of severe disease.
7. Ironically, in 2021 and 2022, we had more treatment options for patients with severe disease.
8. In 2021 and 2022 there was more quarantining of those who were infected and more isolation for those who were exposed by a close contact. Now, people are returning to work and school much sooner and, in many cases, it is likely that they may still be contagious. Contact tracing and isolation are things of the past.
9. Another concerning recent behavior I have seen is that people symptomatic this summer have done a single test that was negative and declared that they have the summer flu. First of all, a single rapid antigen test early on in the development of symptoms is not sufficient to rule out COVID-19. There is a high rate of false negative tests (meaning that the person really is infected despite the fact that the test indicates no evidence of infection) when done early on in the development of symptoms or following an exposure. Thus, serial testing following onset of symptoms is required. Further, while it is possible to acquire a number of respiratory infections, including influenza, during the summer, levels of these viruses circulating in the US during the summer are typically quite low.
10. Finally, keep in mind that in 2021 and 2022, people had fairly regular boosts to their immune protection against SARS-CoV-2 from prior infection, vaccination or both. Today, that immune protection is much less than previously, and keep in mind that only the minority of the population has taken the bivalent vaccine first made available in September of 2022, and even those who did take advantage of that booster have not had another dose of vaccine since. Thus, though we can be grateful for what appears to be long-lasting protection against severe disease, there is not doubt that the immune protection for the majority of our population is waning.

We also must keep in mind that while the focus of the analysis of whether a surge is occurring is based upon hospitalization and death data now that there is so little testing and reporting of data, and while it is true as a general statement that people are less likely to be hospitalized or die today of COVID-19 than in prior years, none of this takes into consideration the risks of potentially life-altering Long COVID (PASC) or the many other potential long-term health effects from infection, and especially repeated reinfections.