U.S. Covid Hospitalizations Reach 7-Week High As Cases Surge In Midwest

TOPLINE

More Americans are now in the hospital with Covid-19 than at any other point since late August, causing some states to nearly run out of hospital beds, as coronavirus infections continue to increase nationwide ahead of a potential end-of-year surge.

KEY FACTS

Some 37,048 coronavirus patients were hospitalized as of Wednesday, the highest level in almost two months according to new data from the COVID Tracking Project, though total hospitalizations are still below their mid-April peak of almost 60,000.

Among hospitalized patients, 7,156 were in ICUs and 1,776 are currently on ventilators — both of those numbers have increased slightly in recent weeks.

Texas leads the nation with more than 4,000 patients in hospitals, followed by California and Florida, though all three states’ hospital counts declined since the summer.

Hospitalizations and new cases soared in Wisconsin over the last month, and officials opened an emergency field hospital near Milwaukee this week as medical centers across the state fear they will run out of space.

Hospital numbers are also on the rise across other parts of the Midwest and South: Missouri reported a new record this week, and levels in Kentucky and Ohio are both within striking distance of their summertime peaks.

BIG NUMBER

217,933. That’s the total number of Americans who have died from Covid-19, according to figures from Johns Hopkins University. Daily fatalities are still below their peak in April, but they remain steady at more than 700 per day.

KEY BACKGROUND

When the coronavirus first surged in the New York City area, some hospitals nearly buckled under the pressure, contending with thousands of sick patients and inadequate protective equipment. Covid-19 cases gradually decreased nationwide but never fully subsided. The West Coast and Deep South dealt with cascading upticks after states loosened coronavirus restrictions during the summer, and the Midwest and small states like South Dakota are now struggling to open up more hospital capacity as new infections surge. Some experts warn cases could spike yet again over the fall and winter, straining the nation’s medical system and making it tough to get sick patients the medical attention they need.

CRUCIAL QUOTE

“When we see an overwhelming number of patients get infected, a lot of them are going to need hospitalization and support,” Dara Kass, a New York-based emergency room physician, told CBS News on Thursday. “We’re seeing hospitals in Wisconsin be overwhelmed with no ICU beds … This is a big concern of those of us who are looking to prevent as many deaths as possible.”

America’s newest wave of Covid-19 cases, explained

https://www.vox.com/coronavirus-covid19/2020/10/11/21511641/covid-19-us-cases-update-testing-deaths-hospitalizations

A new wave of Covid-19 cases is building across the United States, a harbinger of difficult winter months ahead.

America is now averaging nearly 48,000 new confirmed cases every day, the highest numbers since mid-August, according to the Covid Tracking Project. More than 34,500 Americans are currently hospitalized with Covid-19 in the US, up from less than 30,000 a week ago. Nearly 700 new deaths are being reported on average every day, too — and while that is down from August, when there were often more than 1,000 deaths a day, deaths are going to eventually start increasing if cases and hospitalizations continue to rise. It’s a pattern we have seen before.

Public health experts have been warning for months that fall and winter could lead to a spike in Covid-19 cases. Why? Because the best way to slow down the coronavirus’s spread is to keep your distance from other people and, if you are going to be around others, to be outside as much as possible — and both become harder when the weather gets cold.

We may now be seeing those predictions start to come true. The US already has more than 7.7 million confirmed cases and 214,000 deaths. Both numbers will continue to climb.

Eight months into the pandemic, America’s failures to contain Covid-19, and states’ eagerness to reopen even if they haven’t gotten their outbreaks under control, is once again leading to a surge in cases and hospitalizations.

Covid-19 cases are rising everywhere across the country

Earlier in the year, there was limited value to discussing “waves” because some states would have a decline in cases while other states were experiencing surges. What distinguishes this autumn wave is that it seems to be happening everywhere.

Case numbers are up in the Northeast, the Midwest, and the West. The South appears to be, at best, plateauing at a level even higher than that which the Northeast endured during the worst of New York’s outbreak.

What’s so worrisome is that no one state or region can be blamed for this new wave. Just 13 states have seen their number of new Covid-19 cases drop over the last two weeks, according to Covid Exit Strategy. Cases are up in all the others.

Raw case numbers can, of course, obscure important differences in population; 100 new cases means something different for California than it does for Wyoming. Experts will use another metric — new cases per million people — to gauge how saturated a given state is with Covid-19.

The goal would be to have fewer than 40 new cases per million people. But just three states — Maine, Vermont, and New Hampshire — meet that threshold. Meanwhile, North Dakota (627 cases per million), South Dakota (596), Montana (474), and Wisconsin (434) are some of the states seeing very high levels of new infections.

As Vox’s German Lopez reported this week, just one state — Maine — meets all of the benchmarks established by experts for a state to consider its Covid-19 outbreak contained. And yet, most states have reopened many of the businesses that were closed in the spring: 40 or so states have reopened restaurants, bars, gyms, movie theaters, and nonessential retail.

“Part of the problem is America never really suppressed its Covid-19 cases to begin with,” Lopez wrote, explaining why experts were anticipating a new surge in cases. “Think of a disease epidemic like a forest fire: It’s going to be really difficult to contain the virus when there are still flames raging in parts of the forest and small embers practically everywhere. The country always risks a full blaze with each step toward reopening and with each failure to take precautions seriously.”

Too many Covid-19 tests are coming back positive right now

Another closely watched indicator for renewed Covid-19 spread is the percentage of coronavirus tests that come back positive. The number of tests being conducted doesn’t actually tell you all that much; if a high percentage of them are positive, that suggests that many others aren’t being caught at all and the virus could continue to spread unchecked.

So while the US is now averaging nearly 1 million tests every day, that is not quite the triumph it might sound like (or President Donald Trump would like to believe it is). The country’s positive test rate is 5 percent, right at the threshold experts say would reflect adequate testing. Ideally, it would be even lower, 2 percent or less.

But even with that passable national positivity rate, most states are still not conducting nearly enough testing. Here are the 10 states with the highest positive test rates, according to Covid Exit Strategy:

  1. Idaho (25 percent)
  2. South Dakota (20.6 percent)
  3. Wisconsin (19.5 percent)
  4. Iowa (17.1 percent)
  5. Kansas (16.1 percent)
  6. Wyoming (15.5 percent)
  7. Utah (14.7 percent)
  8. Nevada (14.4 percent)
  9. Indiana (13.6 percent)
  10. Alabama (13.3 percent)

It’s really only a handful of better-performing states — namely, New York, with more than 115,000 tests conducted per day and a 1.2 percent positivity rate — that’s keeping the US’s overall positive test rate from looking a lot worse.

America has never had a cohesive Covid-19 testing strategy. Since February, there have been regular supply shortages delaying test results. States have been fighting each other for precious testing resources. Contact tracing has not been a priority for the federal government, and most states have still not hired nearly enough people to perform that work.

Wealthy countries like Germany and South Korea have used effective test-trace-isolate programs to keep their Covid-19 outbreaks in check. The US, meanwhile, is still struggling to perform enough tests or scale up its contact tracing capabilities. Just 11 states, plus the District of Columbia, could realistically expect to perform adequate contact tracing, according to Covid Exit Strategy, considering their positivity rate.

Without improvement in both of those areas, it will continue to be difficult for the US to contain the coronavirus before a vaccine becomes available.

More Americans are being hospitalized with Covid-19 too

Both case numbers and the positive test rate can be a little deceptive, depending on how many tests are being performed. They suggest what’s happening on the ground — in this case, Covid-19 is spreading — but they do have their limitations. There is some truth to the president’s claim that more tests will mean more cases, though that is not a reason to stop testing.

Hospitalizations, on the other hand, are more concrete. If more people are developing symptoms severe enough to warrant being hospitalized, that is a strong indicator that the real number of people being infected with Covid-19 is growing, regardless of whether they are getting tested.

And after a dip in September, the number of Americans currently in the hospital with Covid-19 is higher than it’s been in a month. That trend has been seen across the country.

The worry becomes that if hospitals take in too many patients, they’ll have to turn other people away, or that overwhelmed staff and facilities could lead to some patients receiving substandard care. According to Covid Exit Strategy, 20 states currently have reduced ICU capacity that puts them in a danger zone; 21 states have an elevated occupancy rate in their regular hospital beds.

Wisconsin, where the number of hospitalized Covid-19 patients has risen over the last month from about 300 to 876 today, recently established a new field hospital on its state park fairgrounds over fears that the state’s hospitals wouldn’t have enough beds given the recent surge in cases.

Fortunately, hospitals have gotten much better at treating Covid-19. They have proven treatments, like remdesivir and dexamethasone, that reduce the length of hospital stays and reduce mortality in patients with severe symptoms. They have learned techniques like putting patients on their stomach to improve breathing. Hospitals that have endured multiple spikes of Covid-19 cases report patients in the later waves are spending less time in the hospital and dying less frequently.

Nevertheless, more people developing severe symptoms, as we are starting to see, will inevitably lead to more deaths. Over the summer, people wondered why deaths were falling while cases and hospitalizations rose — until deaths did start to increase. There is a long lag between cases rising and deaths rising, because it can take a month or more between when a person first contracts Covid-19 and, if they die, when their death is reported.

That’s why these new Covid-19 trends in the US are so worrisome. Cases are rising, as are hospitalizations. It could be only a matter of time before deaths start to spike as well.

Florida Coronavirus Deaths Spike To Record High After Days Of Declines

https://www.forbes.com/sites/nicholasreimann/2020/07/28/florida-coronavirus-deaths-spike-to-record-high-after-days-of-declines/?utm_source=newsletter&utm_medium=email&utm_campaign=dailydozen&cdlcid=5d2c97df953109375e4d8b68#2d45f7d31d35

Florida Coronavirus Deaths Spike To Record High After Days Of Declines

TOPLINE

The coronavirus death toll Florida reported Tuesday set a new daily record high for the state, while new cases, hospitalizations and the number of ICUs at capacity once again rose, reversing what had been days of the state’s coronavirus crisis appearing to show signs of improvement.

KEY FACTS

Florida reported 186 new coronavirus deaths Tuesday, topping a record that had stood since July 22 and ending a streak of what had been a declining daily death toll every day since then.

Hospitals reporting 0% available ICU beds are also again on the rise, with 55 facilities reporting they were at capacity Tuesday, up from the 49 that reported 0% availability Monday.

Other major metrics that show worsening coronavirus spread, like hospitalizations and the rate of tests coming back positive, are also on the rise after declines during the past week.

Florida is the nation’s coronavirus epicenter, and has been for weeks—posting daily case increases that have been unmatched by any other state during the pandemic thus far.

Florida reported 9,243 new cases Tuesday, a rise from the 8,892 reported on Monday, which was the lowest increase the state had posted in three weeks, yet still more cases than most countries have reported throughout the entire pandemic so far.

The death toll in Florida is still far below what New York had during the worst of the pandemic there in March and April, when on its worst days the state would report around 1,000 deaths on its own.

KEY BACKGROUND

Florida was one of the fastest states to lift restrictions on its economy, and was eager to do so since the state largely avoided the dire impact the spring coronavirus surge brought to areas like New York. But a spike would come. Around Memorial Day, when large crowds packed popular vacation spots, the state was only reporting about 500 new cases a day. By mid-July, the state was regularly reporting over 10,000 new cases a day. A rise in hospitalizations would follow, and, more recently, a spike in deaths.

TANGENT

The southern part of the state has been the hardest-hit, including the city of Miami. Even its baseball team, the Miami Marlins, have not escaped the rampant coronavirus spread in Florida. At least 17 members of the organization, mostly players, have tested positive for coronavirus—thrusting plans for a 2020 Major League Baseball season into doubt.

 

 

 

 

Houston, Miami, other cities face mounting health care worker shortages as infections climb

https://www.washingtonpost.com/national/houston-miami-and-other-cities-face-mounting-health-care-worker-shortages-as-infections-climb/2020/07/25/45fd720c-ccf8-11ea-b0e3-d55bda07d66a_story.html?utm_campaign=wp_main&utm_medium=social&utm_source=facebook&fbclid=IwAR14P9OGxTOPU8pMgjsVof7YlOAPv-vfxq2MBm9RlpYFVVa3qvpmvyIjFyA

Shortages of health care workers are worsening in Houston, Miami, Baton Rouge and other cities battling sustained covid-19 outbreaks, exhausting staffers and straining hospitals’ ability to cope with spiking cases.

That need is especially dire for front-line nurses, respiratory therapists and others who play hands-on, bedside roles where one nurse is often required for each critically ill patient.

While many hospitals have devised ways to stretch material resources — converting surgery wards into specialized covid units and recycling masks and gowns — it is far more difficult to stretch the human workers needed to make the system function.

“At the end of the day, the capacity for critical care is a balance between the space, staff and stuff. And if you have a bottleneck in one, you can’t take additional patients,” said Mahshid Abir, a senior physician policy researcher at the RAND Corporation and director of the Acute Care Research Unit (ACRU) at the University of Michigan. “You have to have all three … You can’t have a ventilator, but not a respiratory therapist.”

“What this is going to do is it’s going to cost lives, not just for covid patients, but for everyone else in the hospital,” she warned.

The increasingly fraught situation reflects packed hospitals across large swaths of the country: More than 8,800 covid patients are hospitalized in Texas; Florida has more than 9,400; and at least 13 other states also have thousands of hospitalizations, according to data compiled by The Washington Post.

Facilities in several states, including Texas, South Carolina and Indiana, have in recent weeks reported shortages of such workers, according to federal planning documents viewed by The Post, pitting states and hospitals against one another to recruit staff.

On Thursday, Louisiana Gov. John Bel Edwards (D) said he asked the federal government to send in 700 health-care workers to assist besieged hospitals.

“Even if for some strange reason … you don’t care about covid-19, you should care about that hospital capacity when you have an automobile accident or when you have your heart attack or your stroke, or your mother or grandmother has that stroke,” Edwards said at a news conference.

In Florida, 39 hospitals have requested help from the state for respiratory therapists, nurses and nursing assistants. In South Carolina, the National Guard is sending 40 medical professionals to five hospitals in response to rising cases.

Many medical facilities anticipate their staffing problems will deteriorate, according to the planning documents: Texas is hardest hit, with South Carolina close behind. Needs range from pharmacists to physicians.

Hot spots stretch across the country, from Miami and Atlanta to Southern California and the Rio Grande Valley, and the demands for help are as diffuse as the suffering.

“What we have right now are essentially three New Yorks with these three major states,” White House coronavirus task force coordinator Deborah Birx said Friday during an appearance on NBC’s “Today” show.

But today’s diffuse transmission requires innovative thinking and a different response from months ago in New York, say experts. While some doctors have been able to share expertise online and nurses have teamed up to relieve pressures, the overall strains are growing.

“We missed the boat,” said Serena Bumpus, a leader of multiple Texas nursing organizations and regional director of nursing for the Austin Round Rock Region of Baylor Scott and White Health.

Bumpus blames a lack of coordination at national and state officials. “It feels like this free-for-all,” she said, “and each organization is just kind of left up to their own devices to try to figure this out.”

In a disaster, a hospital or local health system typically brings in help from neighboring communities. But that standard emergency protocol, which comes into play following a hurricane or tornado, “is predicated on the notion that you’ll have a concentrated area of impact,” said Christopher Nelson, a senior political scientist at the RAND Corporation and a professor at the Pardee RAND Graduate School.

That is how Texas has functioned in the past, said Jennifer Banda, vice president of advocacy and public policy at the Texas Hospital Association, recalling the influx of temporary help after Hurricane Harvey deluged Houston three years ago.

It is how the response took shape early in the outbreak, when health-care workers headed to hard-hit New York.

But the sustained and far-flung nature of the pandemic has made that approach unworkable. “The challenge right now,” Banda said, “is we are taxing the system all across the country.”

Theresa Q. Tran, an emergency medicine physician and assistant professor of emergency medicine at Houston’s Baylor College of Medicine, began to feel the crunch in June. Only a few weeks before, she had texted a friend to say how disheartening it was to see crowds of people reveling outdoors without masks on Memorial Day weekend.

Her fears were borne out when she found herself making call after call after call from her ER, unable to admit a critically ill patient because her hospital had run out of ICU space, but unable to find a hospital able to take them.

Under normal circumstances, the transfer of such patients — “where you’re afraid to look away, or to blink, because they may just crash on you,” as Tran describes them — happens quickly to ensure the close monitoring the ICU affords.

Those critical patients begin to stall in the ER, stretching the abilities of the nurses and doctors attending to them. “A lot of people, they come in, and they need attention immediately,” Tran said, noting that emergency physicians are constantly racing against time. “Time is brain, or time is heart.”

By mid-July, an influx of “surge” staff brought relief, Tran said. But that was short-lived as the crisis jumped from one locality to the next, with the emergency procedures to bring in more staff never quite keeping up with the rising infections.

An ER physician in the Rio Grande Valley said all three of the major trauma hospitals in the area have long since run out of the ability to absorb new ICU patients.

“We’ve been full for weeks,” said the physician, who spoke on the condition of anonymity because he feared retaliation for speaking out about the conditions.

“The truth is, the majority of our work now in the emergency department is ICU work,” he said. “Some of our patients down here, we’re now holding them for days.” And each one of those critically ill patients needs a nurse to stay with them.

When ICU space has opened up — maybe two, three, four beds — it never feels like relief, he said, because in the time it takes to move those patients out, 20 new ones arrive.

Even with help his hospital has received — masks and gowns were procured, and the staff more than doubled in the past few weeks with relief nurses and other health-care workers from outside — it still is not enough.

The local nurses are exhausted. Some quit. Even the relief nurses who helped out in New York in the spring seem horrified by the scale of the disaster in South Texas, he said.

“If no one comes and helps us out and gives us the ammo we need to fight this thing, we are not going to win,” the doctor said.

One of the root causes of the problem in the United States is that emergency departments and ICUs are often operating at or near capacity, Abir and Nelson said, putting them dangerously close to shortages before a crisis even hits.

Texas, along with 32 other states, has joined a licensure compact, allowing nurses to practice across state borders, but it is becoming increasingly difficult to recruit from other parts of the country.

Texas medical facilities can apply to the Department of State Health Services for staffers to fill a critical shortage, typically for a two-week period. But two weeks, which would allow time to respond to most disasters, hardly registers in a pandemic, so facilities have to ask for extensions or make new applications.

South Carolina last week issued an order that allows nursing graduates who have not yet completed their licensing exams to begin working under supervision. Prisma Health, the state’s biggest hospital system, said this week that the number of patients admitted to its hospitals has more than tripled in the past three weeks and is approaching 300 new patients a day.

“As the capacity increases, so does the need for additional staff,” Scott Sasser, the incident commander for Prisma Health’s covid-19 response said in a statement. Prisma has so far shifted nurses from one area to another, brought back furloughed nurses, hired more physicians and brought in temporary nurse hires, among other measures, Sasser said.

Bumpus has fielded calls from nurses all over the country — some as far afield as the United Kingdom — wanting to know how they can help. But Bumpus says she does not have an easy answer.

“I’ve had to kind of just do my own digging and use my connections,” she said. At first, she said, interested nurses were asked to register through the Texas Disaster Volunteer Registry; but then the system never seemed to be put to use.

Later she learned — “by happenstance … literally by social media” — that the state had contracted with private agencies to find nurses. So now she directs callers to those agencies.

Even rural parts of Texas that were spared initially are being ravaged by the virus, according to John Henderson, CEO of the Texas Organization of Rural and Community Hospitals.

“Unless things start getting better in short order, we don’t have enough staff,” he acknowledged. As for filling critical staffing gaps by moving people around, “even the state admits that they can’t continue to do that,” Henderson said.

The situation has become so dire in some rural parts of the state that Judge Eloy Vera implored people to stay home on the Starr County Facebook page, warning, “Unfortunately, Starr County Memorial Hospital has limited resources and our doctors are going to have to decide who receives treatment, and who is sent home to die.”

Steven Gularte, CEO of Chambers Health in Anahuac, Tex., 45 miles from Houston, said he had to bring in 10 nurses to help staff his 14-bed hospital after Houston facilities started appealing for help to care for patients who no longer needed intensive care but were not ready to go home.

“Normally, we are referring to them,” Gularte said. “Now, they are referring to us.”

Donald M. Yealy, chair of emergency medicine at the University of Pittsburgh Medical Center, said rather than sending staff to other states, his hospital has helped others virtually, particularly to support pulmonary and intensive care physicians.

“Covid has been catalytic in how we think about health care,” Yealy said, providing lessons that will outlast the pandemic.

But telehealth can do little to relieve the fatigue and fear that goes with front-line work in a prolonged pandemic. Donning and doffing masks, gowns and gloves is time consuming. Nurses worry about taking the virus home to their families.

“It is high energy work with a constant grind that is hard on people,” said Michael Sweat, director of the Center for Global Health at the Medical University of South Carolina.

Coronavirus has turned the regular staffing challenge at Harris Health in Houston into a daily life-or-death juggle for Pamela Russell, associate administrator of nursing operations, who helps provide supplemental workers for the system’s two public hospitals and 46 outpatient clinics.

Now, 162 staff members — including more than 50 nurses — are quarantined, either because they tested positive or are awaiting results. Many others need flexible schedules to accommodate child care, she said. Some cannot work in coronavirus units because of their own medical conditions. A few contract nurses left abruptly after learning their units would soon be taking covid-positive patients.

Russell has turned to the state and the international nonprofit Project Hope for resources, even as she acts as a morale booster, encouraging restaurants to send meals and supporting the hospital CEO in his cheerleading rounds.

“It’s hard to say how long we can do this. I just don’t know” said Russell, who praised the commitment of the nurses. “Like I said, it’s a calling. But I don’t see it being sustainable.”

 

 

 

 

Pinning hopes on vaccine is not the right coronavirus strategy, expert says

https://www.cnn.com/2020/07/22/health/us-coronavirus-wednesday/index.html

As cases continue to rise, Americans looking to a vaccine as the way out of the coronavirus pandemic should consider a more comprehensive approach, a leading medical expert told CNN on Wednesday.

“Pinning all our hopes on a vaccine that works immediately is not the right strategy,” Dr. William Haseltine, a former professor at Harvard University’s medical and public health schools, told CNN’s Wolf Blitzer.
Haseltine said a broad public health strategy is a better way to contain the spread of the virus along with the help of a vaccine and therapeutic drugs. Mandating masks will help but Haseltine said, “we need a lot more than masks to contain this epidemic that’s running through our country like a freight train.”
Haseltine recommended closing bars and other places where young people congregate at night and ban holding large meetings in the worst-hit regions. Life won’t get better until people make major changes to their behavior and public health services come forward with more resources, he said.
He said a vaccine is still six months away at the earliest and he warned not to underestimate a coronavirus. Haseltine, known for his work on fighting cancer and HIV/AIDS, said it won’t be easy to develop a vaccine.
“These are tricky viruses,” he said. “It’s not as simple as measles or mumps. It’s going to be a lot more complicated”.
Any Covid-19 vaccine that’s sponsored by the US government will be free or affordable for the American public, Health and Human Services Secretary Alex Azar told CNBC on Wednesday.
“For any vaccine that we have bought — so for instance the Pfizer vaccine — those hundred million doses would actually be acquired by the US government, then given for free to Americans,” Azar said.
He said the same would apply with the AstraZeneca and the Novovax vaccines.
“We will ensure that any vaccine that we’re involved in sponsoring is either free to the American people or is affordable,” Azar said.
And while some anti-mask protesters refuse to wear a piece of cloth to help save American lives, enormous signs of altruism have emerged.
More than 100,000 people have volunteered to participate in Covid-19 vaccine clinical trials, said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases.
“I think we’ll be fine with regards to getting enough people,” Fauci said during a webinar Wednesday with the TB Alliance.

1 million more cases in two weeks

The US is heading in the wrong direction with Covid-19 numbers, and it’s doing so with astonishing speed.
Just after 1,000 people died in a single day, the country is about to reach 4 million Covid-19 cases.
To put that in perspective, the first reported case came on January 21. After 99 days, 1 million Americans became infected.
It took just 43 days after that to reach 2 million cases.
And 28 days later, on July 8, the US reached 3 million cases. The 4 millionth case could come just two weeks after that.
As of Wednesday night, more than 3.96 million people had been infected across the US, and more than 143,000 have died, according to data from Johns Hopkins University.
Some states are reporting record-breaking numbers of new cases. Johns Hopkins reported at least 68,706 new cases and 1,152 deaths in the US on Wednesday.
More governors are requiring masks, and dozens of hospitals are out of intensive care unit beds.
President Donald Trump said the United States has now conducted more than 50 million coronavirus tests. He told reporters at a White House briefing that people should wear masks, pay attention to social distancing and wash their hands. While hot spots like Florida and Texas have popped up, it’s all going to work out, he said.
“We’re all in this together,” he said.

Covid-19 a leading cause of death in L.A. County

California, the most populous state and the first to shut down months ago, appeared to have Covid-19 under control — only to suffer a massive resurgence and surpass New York with the most coronavirus cases in the nation.
This month, state Gov. Gavin Newsom shut down bars and indoor restaurant services again due to an influx of cases after reopening.
Covid-19 is set to become one of the leading causes of death in Los Angeles County, according to Barbara Ferrer, the county’s health director.
“It’s killing more people than Alzheimer’s disease, other kinds of heart disease, stroke and COPD,” Ferrer said, referring to chronic obstructive pulmonary disease, which causes airflow blockage and breathing issues.
Comparing Covid-19 to the flu, Ferrer said data shows Covid-19 killed twice as many people in six months as the flu did in eight months.

Where cases are surging

Some politicians, including the President, have insisted that much of the soaring case numbers are a reflection of increased testing.
But the surge is new cases has greatly outpaced the increase in testing, with troubling rates of transmission and test positivity in many states.
A CNN analysis of testing data from the Covid Tracking Project reveals the positive test rate — or the average number of positive test results out of 1,000 tests performed — has increased significantly in many of the current hotspots, including Florida, Arizona, Texas and Georgia.
Florida saw an average rate of 35 positive results per 1,000 tests during the month of May. But in June, that number nearly tripled to 105. So far in July, the average rate of test positivity has been 187 out of 1,000.
But Florida Gov. Ron DeSantis said the state is on the “right course” in the fight against the virus.
“I think we will continue to see improvements,” the governor said Tuesday. “We just have to, particularly Floridians, have to continue doing the basic things.”
Over the weekend, nearly 50 Florida hospitals said they were out of ICU beds. Statewide, the ICU bed availability had dwindled to 15.98% on Tuesday, down from about 18.1% on Monday.
And new data from the CDC also show infections could be more than 10 times higher than the number of reported cases in some parts of the US.

More mask mandates lead to decreased death projections

Researchers estimate the US will have 219,864 total Covid-19 deaths by November 1, according to the Institute for Health Metrics at the University of Washington.
That’s actually a decrease of about 5,000 deaths from the IHME’s previous forecast of 224,546 by that date.
The reasons for the slightly better forecast include more face masks mandates, more people wearing masks, and more people practicing social distancing, the researchers said.
“So a mandate is very important and helping, and a national mandate, of course, would do much better,” said Ali Mokdad, a professor of health metrics sciences at the IHME.
If Americans wore masks nationwide, the number of total deaths by November 1 would drop to 185,887, the researchers project. But if the mandates ease more, the US could have 231,012 deaths by November 1.
At least 41 states have some kind of mask requirement in place or planned. Starting Saturday, Minnesota will require people to wear masks inside businesses or indoor public settings. People who have conditions that make “it unreasonable for the individual to maintain a face covering are exempt from the order,” Gov. Tim Walz said.
Trump said Wednesday he would make a decision over the next day on whether to mandate masks on federal property.

Major testing delays make tracing almost useless

With the high transmission levels of the virus, traditional contact tracing has now become “impractical and difficult to do,” said California Health Secretary Dr. Mark Ghaly.
The state is working to refine strategies and continue to work with counties to build up their “tracing army,” but Ghaly warns that “even a very robust contact tracing program will have a hard time reaching out to every single case.”
Contact tracing is now harder all over the nation while testing results take days, Fauci said.
Quest Diagnostics, a leading commercial testing lab, said in a news release Monday that for some patients, testing results can take up to two weeks.
“The time frame from when you get a test to the time you get the results back is sometimes measured in a few days,” Fauci said Tuesday.
“If that’s the case, it kind of negates the purpose of the contract tracing because if you don’t know if that person gets the results back at a period of time that’s reasonable, 24 hours, 48 hours at the most … that kind of really mitigates against getting a good tracing and a good isolation.”

 

 

 

Doctors have gotten better at treating coronavirus patients

https://www.axios.com/coronavirus-treatment-better-drugs-hospitals-6f92cf31-4fa1-4181-ba21-a5a8c778ec9e.html

Doctors and hospitals have gotten better at treating coronavirus ...

Doctors and hospitals have learned a lot about how best to treat people infected with the coronavirus in the months since the pandemic began.

Why it matters: Better treatment means fewer deaths and less pain for people who are infected, and research into pharmaceutical treatments is advancing at the same time as hospital care.

The big picture: Some of the simplest changes have been the most effective. For example, doctors have learned that flipping patients onto their stomachs instead of their backs can help increase airflow to the lungs.

  • Providers also now prefer high-flow oxygen over ventilators, despite the early focus on ventilator supply.
  • “If you can avoid ventilation, it is preferred if someone is able to breathe on their own and you just help them out by giving them more oxygenated air to breathe,” said Janis Orlowski, chief health care officer of the Association of American Medical Colleges.

Researchers have also discovered new utility in old drugs.

  • Dexamethasone, a cheap steroid used to treat inflammation, has been found to reduce deaths by one-third among patients on ventilators and one-fifth among those on oxygen.
  • Preliminary data has shown that remdesivir, an antiviral, probably doesn’t save seriously ill patients’ lives, but can help others get out of the hospital a few days earlier. “Anyone who has evidence of lung injury or needing oxygen, we give it,” said Armond Esmaili, a hospitalist at the University of California San Francisco Medical Center.
  • Doctors have also learned to put all COVID patients on drugs to prevent blood clots, Esmaili said.

What they’re saying: There’s still a lot doctors and scientists don’t know about the virus, but they say they’ve come along way since February and March, when they were essentially flying blind.

  • “It was very scary, just to give you the subjective feeling, of caring for patients and talking with patients and their families and a lot of the time saying, ‘We don’t know a lot about this disease. We don’t know how you’re going to do,’” Esmaili said.

Between the lines: Hospitals are also able to provide better care when they’re not overwhelmed with patients.

  • New York’s hospitals were so overwhelmed in the spring that they brought in employees to work well outside of their specialties. In some hospitals’ emergency rooms, patient-to-nurse ratios rose to more than 20 to 1the NYT reports — five times the recommended ratio.
  • “Really attentive-level care is important,” Esmaili said.“It’s not that hard to imagine that when you have the resources and you’re not overburdened with a massive amount of patients that patients are going to get better care.”

What we’re watching: These advances in treatment protocols will only go so far, especially if hospitals in states like Florida, Arizona and Texas become too full to put them into practice.

  • In states with rising case counts, “I think you’re going to see mortality rates increase there because of that phenomenon of hospitals being unable to deliver optimal care, because they don’t have the staffing,” said James Lawler, an infectious disease specialist at the University of Nebraska Medical Center.
  • “You don’t want your ICU nurse to have to take care of five or six patients at the same time,” he said.

 

 

 

 

What happens if Covid-19 symptoms don’t go away? Doctors are trying to figure it out.

https://www.vox.com/2020/7/14/21324201/covid-19-long-term-effects-symptoms-treatment

Covid-19 long-term effects: People with persistent symptoms ...

People with long-term Covid-19 complications are meanwhile struggling to get care.

In late March, when Covid-19 was first surging, Jake Suett, a doctor of anesthesiology and intensive care medicine with the National Health Service in Norfolk, England, had seen plenty of patients with the disease — and intubated a few of them.

Then one day, he started to feel unwell, tired, with a sore throat. He pushed through it, continuing to work for five days until he developed a dry cough and fever. “Eventually, I got to the point where I was gasping for air literally doing nothing, lying on my bed.”

At the hospital, his chest X-rays and oxygen levels were normal — except he was gasping for air. After he was sent home, he continued to experience trouble breathing and developed severe cardiac-type chest pain.

Because of a shortage of Covid-19 tests, Suett wasn’t immediately tested; when he was able to get a test, 24 days after he got sick, it came back negative. PCR tests, which are most commonly used, can only detect acute infections, and because of testing shortages, not everyone has been able to get a test when they need one.

It’s now been 14 weeks since Suett’s presumed infection and he still has symptoms, including trouble concentrating, known as brain fog. (One recent study in Spain found that a majority of 841 hospitalized Covid-19 patients had neurological symptoms, including headaches and seizures.) “I don’t know what my future holds anymore,” Suett says.

Some doctors have dismissed some of his ongoing symptoms. One doctor suggested his intense breathing difficulties might be related to anxiety. “I found that really surprising,” Suett says. “As a doctor, I wanted to tell people, ‘Maybe we’re missing something here.’” He’s concerned not just for himself, but that many Covid-19 survivors with long-term symptoms aren’t being acknowledged or treated.

Suett says that even if the proportion of people who don’t eventually fully recover is small, there’s still a significant population who will need long-term care — and they’re having trouble getting it. “It’s a huge, unreported problem, and it’s crazy no one is shouting this from rooftops.”

In the US, a number of specialized centers are popping up at hospitals to help treat — and study — ongoing Covid-19 symptoms. The most successful draw on existing post-ICU protocols and a wide range of experts, from pulmonologists to psychiatrists. Yet even as care improves, patients are also running into familiar challenges in finding treatment: accessing and being able to pay for it.

What’s causing these long-term symptoms?

Scientists are still learning about the many ways the virus that causes Covid-19 impacts the body — both during initial infection and as symptoms persist.

One of the researchers studying them is Michael Peluso, a clinical fellow in infectious diseases at the University of California San Francisco, who is currently enrolling Covid-19 patients in San Francisco in a two-year study to study the disease’s long-term effects. The goal is to better understand what symptoms people are developing, how long they last, and eventually, the mechanisms that cause them. This could help scientists answer questions like how antibodies and immune cells called T-cells respond to the virus, and how different individuals might have different immune responses, leading to longer or shorter recovery times.

At the beginning of the Covid-19 pandemic, “the assumption was that people would get better, and then it was over,” Peluso says. “But we know from lots of other viral infections that there is almost always a subset of people who experience longer-term consequences.” He explains these can be due to damage to the body during the initial illness, the result of lingering viral infection, or because of complex immunological responses that occur after the initial disease.

“People sick enough to be hospitalized are likely to experience prolonged recovery, but with Covid-19, we’re seeing tremendous variability,” he says. It’s not necessarily just the sickest patients who experience long-term symptoms, but often people who weren’t even initially hospitalized.

That’s why long-term studies of large numbers of Covid-19 patients are so important, Peluso says. Once researchers can find what might be causing long-term symptoms, they can start targeting treatments to help people feel better. “I hope that a few months from now, we’ll have a sense if there is a biological target for managing some of these long-term symptoms.”

Lekshmi Santhosh, a physician lead and founder of the new post-Covid OPTIMAL Clinic at UCSF, says many of her patients are reporting the same kinds of problems. “The majority of patients have either persistent shortness of breath and/or fatigue for weeks to months,” she says.

Additionally, Timothy Henrich, a virologist and viral immunologist at UCSF who is also a principal investigator in the study, says that getting better at managing the initial illness may also help. “More effective acute treatments may also help reduce severity and duration of post-infectious symptoms.”

In the meantime, doctors can already help patients by treating some of their lingering symptoms. But the first step, Peluso explains, is not dismissing them. “It is important that patients know — and that doctors send the message — that they can help manage these symptoms, even if they are incompletely understood,” he says. “It sounds like many people may not be being told that.”

Long-term symptoms, long-term consequences

Even though we have a lot to learn about the specific damage Covid-19 can cause, doctors already know quite a bit about recovery from other viruses: namely, how complex and challenging a task long-term recovery from any serious infection can be for many patients.

Generally, it’s common for patients who have been hospitalized, intubated, or ventilated — as is common with severe Covid-19 — to have a long recovery. Being bed-bound can cause muscle weakness, known as deconditioning, which can result in prolonged shortness of breath. After a severe illness, many people also experience anxiety, depression, and PTSD.

A stay in the ICU not uncommonly leads to delirium, a serious mental disorder sometimes resulting in confused thinking, hallucinations, and reduced awareness of surroundings. But Covid-19 has created a “delirium factory,” says Santhosh at UCSF. This is because the illness has meant long hospital stays, interactions only with staff in full PPE, and the absence of family or other visitors.

Theodore Iwashyna, an ICU physician-scientist at the University of Michigan and VA Ann Arbor, is involved with the CAIRO Network, a group of 40 post-intensive care clinics on four continents. In general, after patients are discharged from ICUs, he says, “about half of people have some substantial new disability, and half will never get back to work. Maybe a third of people will have some degree of cognitive impairment. And a third have emotional problems.” And it’s common for them to have difficulty getting care for their ongoing symptoms after being discharged.

In working with Covid-19 patients, says Santhosh, she tells patients, “We believe you … and we are going to work on the mind and body together.”

Yet it’s currently impossible to predict who will have long-lasting symptoms from Covid-19. “People who are older and frailer with more comorbidities are more likely to have longer physical recovery. However, I’ve seen a lot of young people be really, really sick,” Santhosh says. “They will have a long tail of recovery too.”

Who can access care?

At the new OPTIMAL Clinic at UCSF, doctors are seeing patients who were hospitalized for Covid-19 at the UCSF health system, as well as taking referrals of other patients with persistent pulmonary symptoms. For ongoing cough and chest tightness, the clinic is providing inhalers, as well as pulmonary rehabilitation, including gradual aerobic exercise with oxygen monitoring. They’re also connecting patients with mental health resources.

“Normalizing those symptoms, as well as plugging people into mental health care, is really critical,” says Santhosh, who is also the physician lead and founder of the clinic. “I want people to know this is real. It’s not ‘in their heads.’”

Neeta Thakur, a pulmonary specialist at Zuckerberg San Francisco General Hospital and Trauma Center who has been providing care for Covid-19 patients in the ICU, just opened a similar outpatient clinic for post-Covid care. Thakur has also arranged a multidisciplinary approach, including occupational and physical therapy, as well as expedited referrals to neurology colleagues for rehabilitation for the muscles and nerves that can often be compressed when patients are prone for long periods in the ICU. But she’s most concerned by the cognitive impairments she’s seeing, especially as she’s dealing with a lot of younger patients.

These California centers join new post-Covid-19 clinics in major cities across the country, including Mount Sinai in New York and National Jewish Health Hospital in Denver. As more and more hospitals begin to focus on post-Covid care, Iwashyna suggests patients try to seek treatment where they were hospitalized, if possible, because of the difficulty in transferring sufficient medical records.

Santosh recommends that patients with persistent symptoms call their closest hospital, or nearest academic medical center’s pulmonary division, and ask if they can participate in any clinical trials. Many of the new clinics are enrolling patients in studies to try to better understand the long-term consequences of the disease. Fortunately, treatment associated with research is often free, and sometimes also offers financial incentives to participants.

But otherwise, one of the biggest challenges in post-Covid-19 treatment is — like so much of American health care — being able to pay for it.

Outside of clinical trials, cost can be a barrier to treatment. It can be tricky to get insurance to cover long-term care, Iwashyna notes. After being discharged from an ICU, he says, “Recovery depends on [patients’] social support, and how broke they are afterward.” Many struggle to cover the costs of treatment. “Our patient population is all underinsured,” says Thakur, noting that her hospital works with patients to try to help cover costs.

Lasting health impacts can also affect a person’s ability to go back to work. In Iwashyna’s experience, many patients quickly run through their guaranteed 12 weeks of leave under the Family Medical and Leave Act, which isn’t required to be paid. Eve Leckie, a 39-year-old ICU nurse in New Hampshire, came down with Covid-19 on March 15. Since then, Leckie has experienced symptom relapses and still can’t even get a drink of water without help.

“I’m typing this to you from my bed, because I’m too short of breath today to get out,” they say. “This could disable me for the rest of my life, and I have no idea how much that would cost, or at what point I will lose my insurance, since it’s dependent on my employment, and I’m incapable of working.” Leckie was the sole wage earner for their five children, and was facing eviction when their partner “essentially rescued us,” allowing them to move in.

These long-term burdens are not being felt equally. At Thakur’s hospital in San Francisco, “The population [admitted] here is younger and Latinx, a disparity which reflects who gets exposed,” she says. She worries that during the pandemic, “social and structural determinants of health will just widen disparities across the board.” People of color have been disproportionately affected by the virus, in part because they are less likely to be able to work from home.

Black people are also more likely to be hospitalized if they get Covid-19, both because of higher rates of preexisting conditions — which are the result of structural inequality — and because of lack of access to health care.

“If you are more likely to be exposed because of your job, and likely to seek care later because of fear of cost, or needing to work, you’re more likely to have severe disease,” Thakur says. “As a result, you’re more likely to have long-term consequences. Depending on what that looks like, your ability to work and economic opportunities will be hindered. It’s a very striking example of how social determinants of health can really impact someone over their lifetime.”

If policies don’t support people with persistent symptoms in getting the care they need, ongoing Covid-19 challenges will deepen what’s already a clear crisis of inequality.

Iwashyna explains that a lot of extended treatment for Covid-19 patients is “going to be about interactions with health care systems that are not well-designed. The correctable problems often involve helping people navigate a horribly fragmented health care system.

“We can fix that, but we’re not going to fix that tomorrow. These patients need help now.”

 

 

 

Does Delirium Cause Long-Term Cognitive Decline?

https://www.medpagetoday.com/neurology/dementia/87543?xid=nl_popmed_2020-07-14&eun=g885344d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=DailyUpdate_071420&utm_term=NL_Daily_Breaking_News_Active

Does Delirium Cause Long-Term Cognitive Decline? | MedPage Today

 Analysis has “great implications in the COVID era”

Delirium was linked to long-term cognitive decline in both surgical and nonsurgical patients, a meta-analysis showed.

Patients who experienced an episode of delirium were more than twice as likely to show long-term cognitive decline than patients without delirium (OR 2.30, 95% CI 1.85-2.86), reported Terry Goldberg, PhD, of Columbia University in New York City, and co-authors.

Delirium was associated with long-term cognitive decline with a Hedges g effect size of 0.45 (95% CI 0.34-0.57, P<0.001) in a meta-analysis of 23 observational studies (after one outlier study with an exceptionally high OR was excluded), they wrote in JAMA Neurology. Effect sizes were similar between surgical and nonsurgical groups.

“The connection between delirium and cognitive decline that we observed was highly significant and remarkably consistent,” Goldberg said.

“What we propose is that delirium is not simply a marker for those patients already on a downward trajectory, but may be causative in and of itself,” he told MedPage Today. “This may be especially relevant to COVID patients, many of whom experience delirium in the ICU.”

Delirium is “ubiquitous and spares no age groups or populations, occurring in 20% to 70% of hospitalized patients, with the higher numbers seen in critically ill patients on mechanical ventilation,” said Pratik Pandharipande, MD, co-director of the Critical Illness, Brain Dysfunction and Survivorship Center at Vanderbilt University in Nashville, who wasn’t involved with the meta-analysis.

“This study has great implications in the COVID era,” Pandharipande told MedPage Today. “Mechanically ventilated patients with COVID are at a much higher risk of developing delirium because they are subject to all the major risk factors — deeper levels of sedation, high severity of illness, often older age, and additionally, social isolation due to limited visitation rules in the hospital and the fact that the virus can directly affect the brain and lead to neuroinflammation.”

“The meta-analysis reported here shows a consistent message; all selected studies showed that delirium and longer duration of delirium were associated with cognitive impairment,” Pandharipande continued.

“While it is unclear if delirium causes dementia, there is mounting evidence — and the meta-analysis adds to this — that there are structural brain changes with delirium and this puts you at a worse cognitive trajectory,” he said.

“Incorporating strategies such as the ABCDEF bundle from the Society of Critical Care Medicine into the care of your patients — including mechanically ventilated COVID patients — is likely to reduce delirium and possibly its long-term consequences,” he added.

The meta-analysis included a systematic search of articles from 1965 through 2018. The researchers looked for studies that contrasted patients with and without delirium, had objective continuous or binary measures of cognitive outcome, and had a final time point of 3 months or later after the delirium episode.

Data from 24 observational studies, including 3,562 patients who experienced delirium and 6,987 controls who did not, were used. One study with an OR greater than 41 — an order of magnitude greater than any other study — was excluded from some analyses.

Mean study age was about 75 and mean follow-up after a delirium episode was 2.4 years. On average, men made up about 47% of the study populations. The Confusion Assessment Method (CAM) or CAM–intensive care unit was the most frequent delirium measure used, and the Mini-Mental State Examination was used most frequently as a cognitive outcome.

“In all studies, the group that experienced delirium had worse cognition at the final time point,” Goldberg and co-authors wrote.

Meta-regression did not show differences in cognitive outcomes between surgical and nonsurgical studies, suggesting “the underlying pathophysiological events associated with delirium may be similar and speculatively may be associated with inflammatory processes common to both contexts,” they added.

The researchers also did not find significant differences between cognition treated as a continuous variable based on neurocognitive test scores or as a binary variable based on the presence or absence of dementia.

The I2 measure of between-study variability in g was 0.81. Studies of longer duration yielded greater differences, while those with more covariates, and those without baseline cognitive matching, yielded smaller differences.

The observational studies used in this meta-analysis cannot show that delirium is a causative factor in subsequent cognitive decline, the researchers noted. Differences in cognitive outcome measures and the way dementia was diagnosed may be sources of variability, but meta-regressions did not find significant differences among them in terms of their effect on g, they added.

Importantly, the study could not evaluate delirium in the context of other factors, such as frailty, and unmeasured confounders may have influenced results.

 

 

 

 

As cases and deaths rise, Americans ponder a return to school

https://mailchi.mp/86e2f0f0290d/the-weekly-gist-july-10-2020?e=d1e747d2d8

Top 10 List of Must Do's for Back to School 2019 ...

The US spent another week headed in the wrong direction, with daily new COVID-19 cases reaching nearly 60,000 on Thursday, the sixth record-setting total in the past ten days.

The spike continued to be most pronounced in states that reopened early, with Texas, South Carolina, Arizona, and Florida hit particularly hard. More worryingly, several states saw daily deaths from COVID rise, with Alabama, Florida, Mississippi, South Dakota and Tennessee hitting one-day death records.

Like the light from some malign star, death numbers are a lagging indicator—a reflection of new case totals from weeks earlier—leading health experts to warn of dark days ahead for the rest of the summer. In his customary understated manner, top White House health advisor Dr. Anthony Fauci said this week, “I don’t think you could say we’re doing great. I mean, we’re just not.”

Responding to concerns about the availability of hospital capacity, Texas Gov. Greg Abbott expanded a ban on elective surgeries to more than 100 counties across the state, and HCA Healthcare delayed inpatient surgeries at more than a dozen of its hospitals in Florida, as did other health systems there.

School reopening emerged as a political flashpoint this week, with President Trump hosting a summit meeting on “Safely Reopening America’s Schools” on Tuesday at the White House. The President criticized reopening guidelines from the Centers for Disease Control (CDC) as being “very tough & expensive”, but on Thursday CDC director Dr. Robert Redfield told CNN that the guidelines, first published in May, would not be revised.

With schools and colleges set to restart in many places next month, the influential American Academy of Pediatrics modified its earlier support for reopening schools, pushing back on the administration’s threatened funding cuts for school districts that do not reopen on time, with in-person classes.

The debate over how to handle school reopening underscores how much time was lost between March and May, when a national reopening plan should have been developed. As the virus surges, with students and teachers set to return in just a few short weeks, and further economic recovery hinging on parents’ ability to send their kids safely to school, the window is rapidly closing on our ability to navigate this critical transition.

US coronavirus update: 3.2M cases; 135K deaths; 38.0M tests conducted.

 

 

 

 

COVID-19 surge pushes US toward deadly cliff

https://thehill.com/policy/healthcare/public-global-health/506852-covid-19-surge-pushes-us-toward-deadly-cliff

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The coronavirus is spreading at ever-faster rates in a broad array of states, putting the U.S. on the precipice of an explosion of illness that threatens to overwhelm the nation’s health care system.

The painful economic lockdowns imposed in March gave the country time to flatten the epidemiological curve and contain the virus. But that window of opportunity, which came at great economic cost, is quickly slamming shut. Health experts say all signs point to a deadly summer and fall unless government leaders implement a much more robust national strategy.

The breadth of the spread is staggering. Forty-three states have seen the number of cases confirmed on an average day increase in the last two weeks. The number of patients in hospitals has risen over the same period in 29 states. More than 80 percent of intensive care beds are occupied in Alabama, Arizona and Georgia.

The same models that predicted surges in Phoenix, Houston and Miami now show a new and broader round of cities as the likely next epicenters. The number of confirmed cases is likely to rise substantially in places like Atlanta, Kansas City, Mo., Tulsa, Okla., and Greenville, S.C.

The virus also appears to be traveling north along the I-95 corridor. Cities like Philadelphia and Baltimore, which struggled through earlier peaks of viral transmission, are now seeing early signs of a second wave. Transmissions even appear to be rising in New York City.

On the other side of the country, outbreaks in California have grown to unprecedented proportions. The Golden State is now averaging more than 7,900 new cases a day, substantially more than its seven-day average just two weeks ago.

Public health experts warn that the U.S. has only a fleeting window in which to wrestle the virus back under some form of control. Without a stronger national response, including restrictions on large gatherings and requirements that people wear masks in public, the risk of a second peak could bring new lockdowns and more economic harm, derail the beginning of the new school year and even overwhelm local health systems.

“Our projections show that without immediate actions to significantly reduce travel and social distancing nationwide, this virus will not only threaten our ability to reopen schools in the coming weeks, but our capacity to care for the sickest individuals,” said David Rubin, director of PolicyLab at the Children’s Hospital of Philadelphia whose models forecast higher case counts.

More than 3.1 million Americans have tested positive for the virus, though the Centers for Disease Control and Prevention estimate that as many as 25 million people in the U.S. may have contracted it. More than 133,000 people have died, almost twice as many victims as in Brazil, the second-hardest hit country.

Cities that successfully avoided early explosions of cases are now in the crosshairs after the loosening of restrictions in some states and regions that helped avoid what studies have suggested would have been tens of millions of infections.

“I would be lying if I didn’t say I was concerned,” Kansas City, Mo., Mayor Quintin Lucas said in an interview. “We have looked at the trends out of Texas, Arizona and Florida. Those states kind of reflect the political choices that were made statewide in Missouri, and that does give us concern.”

The Kansas City metropolitan area has confirmed more than 10,000 coronavirus cases. The PolicyLab model shows Jackson County, Mo., is likely to experience more than 200 new cases every day by the beginning of August.

Rubin warned that smaller cities are likely to experience significant outbreaks in the coming weeks, potentially straining health systems that are not as prepared to handle a high volume of patients in need of intensive care. College towns like South Bend, Ind., and Tuscaloosa, Ala., are beginning to see case counts rise even with most students gone.

“We’re starting to see a mild uptick,” said James Mueller, South Bend’s mayor. “We’re in a much better position now than we were for the first increase or the first peak.”

At other levels of government, some who have sought to downplay the severity of the American outbreak have pointed to an increasing number of tests being conducted across the country, which they say will naturally lead to identification of those who have only minor symptoms or asymptomatic cases. But the number of cases is rising faster than would be accounted for by the increase in testing; the share of tests coming back positive is rising in 38 states.

More than a quarter of tests conducted in Arizona are coming back positive, according to state data. More than 15 percent of tests are coming back positive in Alabama, Florida, Mississippi, South Carolina and Texas.

Governors in 23 states have ordered residents to wear masks in public, though President Trump has refused to order a nationwide mask mandate. Trump has instead focused on reopening the economy, insisting that schools operate as normal in the months before he faces voters in November.

But public health experts argue action is needed now to avoid a second peak of tsunami-like proportions.

“We never gave communities a real chance at success as we lacked a national strategy around masking and limiting gathering sizes to act as a buffer as places reopened,” Rubin and his colleagues Gregory Tasian and Jing Huang wrote.

“So, do we admit that we’ve failed and try to salvage the reopening of our schools in fall by quickly enacting a national approach to pause all reopenings and try to get our country back onto stable footing?” he asked. “It may not be what people want to hear, but the situation is that dire that we need to consider this.”