America’s third wave of Covid-19, explained

America is in the middle of its third nationwide surge in Covid-19 cases — what some are calling a “third wave” — with reported cases hitting a recent peak of more than 70,000 on Friday.

With that, the much-feared fall and winter surge of coronavirus cases that experts warned of for months may now be here. Despite the US already suffering at least 220,000 Covid-19 deaths — the highest death toll in the world — it looks like things are getting worse.

As of October 20, the seven-day average of coronavirus cases was more than 60,000 — a new peak since the summer surge of Covid-19 abated. That’s up from a recent low in the seven-day average of fewer than 35,000 cases on September 12. The increase doesn’t appear to be driven by a single state or region — although the Dakotas, Montana, and Wisconsin appear to be in particularly bad shape — but rather spikes across much of the country at once, with increases reported across the Northeast, Midwest, South, and West. (Some of the spike is also caused by more testing exposing more cases.)

Unlike the summer’s surge of coronavirus, the US isn’t alone in its latest wave — cases are rising in much of Europe, too. Still, that doesn’t mean this was inevitable: With aggressive measures, developed nations like Canada, Germany, and especially Australia, Japan, New Zealand, and South Korea have kept their Covid-19 caseloads much lower than America’s or Europe’s as a whole.

Experts have long warned that a surge was coming in the US in the colder seasons. Even though the country never fully suppressed its summer surge in Covid-19 cases, most states have moved to reopen more businesses, including risky indoor spaces like restaurants and bars, as well as schools, with colleges and universities proving particularly problematic so far.

President Donald Trump, for his part, has encouraged the rapid reopenings — even after his own illness. Before he left the hospital, Trump tweeted, “Don’t be afraid of Covid. Don’t let it dominate your life.” He’s kept pushing a false sense of normalcy in the weeks since — even going as far as mocking masks and claiming, falsely, that they’re ineffective. (In reality, the evidence for masks keeps getting stronger.)

The fall and winter still threaten to make things worse. Schools will continue to reopen. The cold in northern parts of America will push people back inside, where the virus has a much easier time spreading than the outdoors. Families and friends will come together for the holidays. A flu season could strain the health care system further.

States will likely move to reopen more widely, especially as officials face pressure from businesses to reopen indoor spaces before colder temperatures make outdoor activities less feasible. Experts worry that Americans as a whole will get even more fatigued with social distancing and masking, now that the US is more than seven months into its battle against Covid-19.

“It’s less excusable this time,” Crystal Watson, senior scholar at the Johns Hopkins Center for Health Security, previously told me. “We have an example of what happens when we reopen these types of businesses for indoor activities.”

It doesn’t have to be this way. Cities, counties, states, and the federal government — or, short of all that, the public — could take social distancing seriously again. Governments could mandate masks, and the public could opt to wear them without a mandate. Bars and restaurants could close, voluntarily or not. Places that do open, such as schools, could try to adopt aggressive testing-and-tracing regimes to try to keep the coronavirus under some control.

Without that, America’s coronavirus epidemic will keep getting worse. That would lead to not just more Covid-19 cases and deaths, but deal yet another blow to the prospects of the US returning to normal anytime soon.

“If you do things the right way, you can do them,” Cedric Dark, an emergency medicine physician at the Baylor College of Medicine, previously told me. “If you do them the wrong way, then you’re going to get cases.”

America keeps making the same mistakes

After the spring outbreaks hit the northeastern US, much of the country, led by Republican leaders in states like Arizona, Florida, and Texas, moved forward with aggressive reopenings. The problem, experts said, is many of these places never suppressed their Covid-19 outbreaks. As epidemiologist Pia MacDonald at RTI International told me at the time, many states “never got to flat.” Case counts continued to climb, and states continued to reopen anyway.

This created an environment that made it much easier for the coronavirus to spread. If there’s already some community transmission going on, then it’s simply going to be more likely that one person will infect another. Add more spaces in which infections are very likely — particularly close indoor spaces like bars and restaurants — and that risk can be increased dramatically. So cases started to increase in the summer.

The current surge seems to be a repeat of the summer spike. Cases started to fall in late August, eventually reaching a brief plateau between mid-August and mid-September. But that plateau was still much higher than the peak of Covid-19 cases in the spring (partly, but likely not entirely, due to more testing). Yet states seemingly declared victory and started to reopen anyway — and now cases are rapidly climbing again.

MacDonald is now repeating the same thing she told me in the summer: “We never got to low enough levels [of Covid-19] to start with in most places.”

Of particular interest is indoor dining at restaurants and bars, which are reopening at varying levels across the country. Experts characterize these settings as perhaps the worst imaginable spaces for Covid-19 spread: People are close together for long periods of time; they can’t wear masks as they eat or drink; the air can’t dilute the virus like it can outdoors; and alcohol could lead people to drop their guards further. It was a recognition of all these risks that led many states to scale back and close indoor dining and bars during their summer outbreaks.

This time, though, there’s another major variable: Schools are reopening. Some places have even reopened, or set plans to reopen, schools alongside bars or indoor dining, making it hard to separate the effects of either and potentially compounding new outbreaks.

Already, there have been reports of outbreaks in K-12 settings, where students and teachers can potentially transmit the coronavirus to each other in the classroom. But there’s still a lot we don’t know about how younger kids, particularly in elementary schools, spread the virus. And it doesn’t seem, at least so far, as though the K-12 outbreaks are driving the national increase.

Instead, some experts have pointed to colleges and universities as bigger drivers of the recent Covid-19 wave. Students in these institutions aren’t just potentially spreading the coronavirus in their classrooms, although that’s likely happening to some degree. They’re also showing up at bars, clubs, and indoor restaurants, partying at dorms, and drinking a lot more than they should.

“College kids are college kids,” Carlos del Rio, executive associate dean of the Emory University School of Medicine, previously told me. “That’s what I always tell every university president I talk to: You can make all the plans you want, but at the end of the day, it’s what happens outside your plans that matters.”

The good news, for now, is that infections in colleges and universities will skew younger, and younger people are less likely to suffer major complications, including deaths, from Covid-19. That helps explain, along with general improvements in treatment, why daily Covid-19 deaths are still down since August (though they’re still at more than 700 a day in the US).

But young people can still get seriously ill and die from the coronavirus. Even if their death toll remains low overall, young people will also likely interact with their teachers, parents, and grandparents at some point, potentially infecting them. A study from the Centers for Disease Control and Prevention suggested many of the summer outbreaks started among young people but eventually spread to older populations, who were more susceptible to illness and death.

After the summer surges, Brown University School of Public Health dean Ashish Jha previously told me, “I was like, ‘Okay, now we’ve all been through this — every part of the country: the South, the West, the Midwest, the Northeast. There’s no denialism anymore that will work, because there’s been this long denial while it’s been there but not here.’” Yet, he said, “We’re starting to see this again.”

He added, “I, at this point, feel like I clearly no longer understand why our country can’t learn its lessons and why we keep repeating the same mistakes.”

Winter is coming

Things could still get worse.

People are bound to get more fatigued with social distancing, and more ready to move on from thinking about the pandemic more broadly, as time drags on. When the summer surge of Covid-19 abated, it became easier for people to convince themselves it’s safe out there. The recent spike hasn’t translated yet to a rise in deaths. With this complacency and false sense of safety, more people will likely put themselves in dangerous settings, infecting each other along the way.

At the same time, colder temperatures, particularly in the northern parts of the US, will more likely push people indoors, where the coronavirus is much more likely to spread due to poor ventilation. (One upside: This could have the opposite effect in southern parts of the country, where temperatures will get less unbearably hot, so the outdoors may actually get more tolerable.)

As Thanksgiving rolls around, followed by Christmas, Hanukkah, and New Year’s, families and friends will likely come together from around the country. That includes college and university students, who could come home from Covid-19 hot spots back in their dorms or classrooms.

If you put this all together, there’s a real risk of Covid-19 getting even worse. It would be truly nationwide, too: As people carry the virus across state borders, they could cause a much more dispersed — and larger — coronavirus epidemic than the US has seen so far.

“People will bring this back during Thanksgiving, during Christmas, during winter break,” Dark said. “This is a disease that has an incubation period of up to two weeks. So it’s not really safe to say, ‘Okay, I’m going to come home and come back.’ … By the time you develop symptoms, you’ve already exposed your parents.”

On top of all that, another flu season this fall and winter could strain health care systems, hindering hospitals’ abilities to treat Covid-19 patients and potentially contributing to more deaths.

There are reasons to think it won’t get so bad. Maybe since so many people have already gotten sick in the US, there will be enough community immunity, as long as there’s enough social distancing and masking, to mitigate spread. Maybe people won’t ease up on proper precautions after already seeing hundreds of thousands of Covid-19 deaths in the US. Perhaps social distancing and masking for Covid-19 will hold off another flu season, as seemed to happen in the Southern Hemisphere.

But there’s a risk. And the numbers are already heading in the wrong direction.

“The next number in the fall is likely going to shoot way up,” Michael Osterholm, director of the Center for Infectious Disease Research and Policy, previously told me. “Likely well beyond 65,000, 70,000,” the summer’s previous peak. “I think this fall is going to be the biggest spike of all.”

The US can still act — but Trump seems unlikely to change

None of the ideas to prevent all of this are shocking or new. They’re all things people have heard before: More testing and contact tracing to isolate people who are infected, get their close contacts to quarantine, and deploy broader restrictions as necessary. More masking, including mandates in the 17 states that don’t have one. More careful, phased reopenings. More social distancing.

This is what’s worked in other countries, from Germany to South Korea to New Zealand, to contain outbreaks. It’s what studies support: As a review of the research published in The Lancet found, “evidence shows that physical distancing of more than 1 m is highly effective and that face masks are associated with protection, even in non-health-care settings.”

It’s also what’s worked in the US. After suffering huge outbreaks in the spring, states like New York have largely suppressed the coronavirus with such policies. Cities, such as San Francisco, have avoided bad outbreaks entirely with similar efforts. Even single universities, like the University of Illinois Urbana-Champaign campus, have seen promising early results with aggressive testing and tracing. (The federal government would ideally be in charge of all of this, but Trump has by and large punted the pandemic down to the states to resolve.)

“There’s no mystery about what causes new cases,” Nahid Bhadelia, an infectious diseases physician and medical director of the Special Pathogens Unit at Boston University School of Medicine, previously told me. “We have to make trade-off choices.”

Everything that reopens will add to the infection rate. Some places may have tiny, even negligible effects, such as parks. Some are bigger threats, like bars and indoor dining. And some may carry potentially high risk but still seem worth it to the community for their social benefits, like schools.

The goal, then, is to balance out a reopening — doing it slowly, making it possible to see the effects of each extra step — to make sure outbreaks don’t get out of control. Ultimately, it may require not opening bars or indoor dining, perhaps ever, so schools and other more socially crucial places can open. At the same time, the government could offer shuttered businesses a bailout or other financial support.

“For us, as a society, to be able to send children to school, we have to make tough decisions and sacrifices in other areas,” Jorge Salinas, an epidemiologist at the University of Iowa, previously told me. “We can’t have it all.”

Other steps, too, could help. More testing, tracing, and masking, for example, could reduce the infection rate in a community further, letting more places reopen than otherwise could.

By striking this balance, the US can not only avoid more infections and deaths but also potentially avoid an outbreak from getting so bad that it necessitates another lockdown. While experts all agreed that there’s zero political appetite for a lockdown right now, a massive surge in the fall and winter could leave the US with no other option. Israel, for example, shut down in September after seeing a massive increase in cases, and several European countries are now considering or enacting similar measures as their cases rise.

The reality is that the US will likely not go back to normal until it vanquishes the virus through a vaccine or similar treatment — a process that could take months or years, even after a vaccine is proven safe and effective, as the country and world scale up distribution to actually reach sufficient levels of immunity within the population.

But maybe the US will continue muddling along, or worse. The country has already shown a much higher tolerance for Covid-19 cases and deaths than the rest of the developed world. Trump, for his part, seems content with that — recently stating that the coronavirus “affects virtually nobody” and, even after his own illness, showing no interest in changing his hands-off, minimizing approach.

If that holds, America’s already worst-in-the-world Covid-19 death toll of more than 220,000 will continue to rise in the next few months.

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