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The Pandemic Will Likely End In One Of These Four Ways; Social Media and More About Vaccines.

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I am getting really frustrated having to try to convince friends and patients of the value of vaccinations for Covip-19. Vaccinations promise an end to the coronavirus pandemic in the US. What kind of ending, though, is up to us?

I “loved” the excuse that she knew that the GOVERNMENT was putting tracers in the vaccines to track our every move and racist thoughts.

And with the cases and deaths due to COVID increasing in such very high numbers, while Israel as a country is the only country that has reached herd immunity. Their vaccinations are over 80% of their population and their new cases are so very low.

Reporter Dan Vergano noted that if the White House’s vision goes according to plan, vaccinations will end the pandemic in the US in time for 4th of July fireworks. Or the pandemic won’t end, and these shots will be the first of many we’ll get for years. Or they’ll offer a brief summer respite — before a more severe version of the coronavirus catches fire.

A return to a life resembling normalcy looks closer than ever now that, as of Monday, vaccines are available to every adult in America. Around 80 million people are already fully vaccinated, and President Joe Biden said on Wednesday that the US has already reached his goal of 200 million shots in the first 100 days of his administration, eight days early.

But with half of the population still unvaccinated and COVID-19 cases once more rising, just how close are we to the pandemic ending, both in the US and across the world?

Whether the pandemic ends in the US by Independence Day — or much further in the future — will depend on the vaccines, the virus, and decisions people make, experts say. The big questions include how long the vaccines’ protection lasts, how well they fight off new coronavirus variants, and whether the entire globe can hold off these emerging threats. Then there’s the X factor of how many people will be willing to get shots.

The benchmark for a successful vaccination campaign has long been considered to be “herd immunity” — having enough people vaccinated to keep sick ones from sparking outbreaks. That might require 80% of US adults getting vaccinated, according to infectious disease researcher William Schaffner of the Vanderbilt University School of Medicine.

Other experts have urged Americans to not obsess over herd immunity. “I can’t say it’s going to be ‘this’ percent,” Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, said this month, although he has previously floated percentages ranging from 70% to 85%. “We’ll know it when we see it. It’ll be obvious.”

Getting to that turning point could take very different routes, experts told BuzzFeed News. Although the summer everyone hopes for is within reach, worse outcomes are also possible. At this pivotal moment in the crisis, a lot depends on how willing people are to help themselves by continuing to wear masks and isolating until they are fully vaccinated — and to help people around the world get vaccinated too.

“It depends on decisions we make,” Lauren Ancel Meyers, a University of Texas epidemiologist, said this month at a Stanford University symposium about herd immunity.

Here are four ways that the pandemic could end in the US.

1. The Better Ending: Vaccination Returns Life Close to “Normal”

By June, most US adults get vaccinated. The shots halt the spread of SARS-CoV-2, even the more transmissible variants. And people feel safe shopping, traveling, and visiting each other, almost like they did before the pandemic.

This is the best outcome — and it isn’t completely far-fetched. Half of US adults have received at least one shot. Even with Johnson & Johnson’s vaccine paused, more than 3 million shots are being administered a day; at that rate, every adult American could receive one by late June.

Israel offers a glimpse of this future. There, a fast-paced campaign had immunized more than half of the population by mid-April. The results have been striking in the country of 9 million, with new cases falling to around 200 a day, 2% of the January peak. Starting this weekend, an outdoor mask mandate will be lifted.

White House / Via whitehouse.gov

White House COVID-19 briefing slide, showing case drop with 62% vaccination

Similarly, in the US, new cases among nursing home residents dropped by 96% and deaths by 91% between December, when vaccinations started, and March. After a slow start, more than 4.8 million people in nursing facilities have received at least one shot.

Although case numbers have increased in recent weeks, Deepta Bhattacharya, an immunologist at the University of Arizona College of Medicine, predicts “a smaller bump over the next couple months that should by the summer settle down to a pretty low level of cases.”

That doesn’t mean that masking would stop. It’s worth noting that the declines in both Israel and nursing homes happened while restrictions were maintained. Under current US plans, young teens won’t start getting shots until the fall and elementary school–age children in the winter of 2022, meaning that their schools will likely keep face coverings, some virtual classes, and other restrictions for the foreseeable future.

But most partial or full closures of shops, restaurants, universities, and bars could end this summer if US cases fall like they did in Israel.

The bottom line is that the Pfizer and Moderna vaccines, which make up the great majority of US shots, have proven 90% effective in real-world studies against COVID-19. Although some people have gotten infected despite vaccination, their numbers are small: about 6,000 cases out of 84 million fully vaccinated people, or .007%, according to CDC data.

“It is not unexpected — the vaccine is not 100% protective,” Scott Lindquist, a Washington state health department official, said in a recent press briefing about “breakthrough” infections there. “But what we saw were mostly very mild symptoms, if any at all.”

And existing vaccines appear to protect against new coronavirus variants, such as the B.1.1.7 strain, according to CDC data. “If you lose a little bit of protection to a variant, but the vaccine still keeps you safe, that’s still a good result,” Bhattacharya said. Vaccines aside, he noted that a sizable chunk of the population — more than 1 in 5 Americans by one recent estimate — also has some natural immunity from past infections, though studies suggest that this protection likely isn’t as long-lasting or robust as vaccination.

“I do think we’ll be OK by the summer,” said the immunologist, who is personally planning to travel to see his family in cities across the country. “Tickets booked for early July!”

In this future, the coronavirus cools down enough to be managed like the measles: a virus tamed by a vaccine that is added to childhood shot regimens, with occasional outbreaks in unvaccinated communities.

2. A Mixed Ending: Defanging, Not Defeating, the Virus

Mass vaccination delivers yet another future: the death rate from COVID-19 drops drastically, because the shots prevent severe and fatal illness, but outbreaks continue, largely among pockets of unvaccinated people, including younger people who are less targeted for vaccines or less worried about getting sick in the first place.

“A more realistic scenario is that older, more vulnerable individuals will receive a disproportionate number of doses,” said infectious disease modeler Jack Buckner of the University of California, Davis, by email. “Under these conditions additional outbreaks are more likely but the case fatality rate would be lower.”

Last month, CDC Director Rochelle Walensky was asked whether a sharp decline in death rates, with case numbers remaining high over the summer, might lessen the public’s urgency to get vaccinated. She called it a concern, but noted that children are dying of COVID-19, albeit very rarely, and that long-term complications from infections, also known as “long COVID,” plague even people with mild cases. A recent study from Sweden, for example, found 1 in 10 healthcare workers who had mild cases have felt effects, like loss of smell and taste, fatigue, and breathing problems, for months after.

“We’re going to defang the virus rather than defeat it.”

In this mixed scenario, we dodge a summer surge of deaths, but outbreaks occur in some counties or states. Herd immunity is also never quite reached in this future, because variants circle the globe every year like variations of the seasonal flu. Post–mass vaccination, the coronavirus would then enter a “mild endemic state,” where SARS-CoV-2 is reduced to a childhood cold, said Harvard epidemiologist Marc Lipsitch at the recent Stanford symposium about herd immunity. “We’re going to defang the virus rather than defeat it,” he said. “We’ll make it a nuisance that makes people a bit ill, rather than something that kills people in large numbers and causes the hospital system to groan under the weight.”

A related possibility is that vaccination only delivers immunity for a year or two and requires regular booster shots for older and younger people alike, which the heads of Pfizer and Moderna have told investors might be the case. (On Sunday, Fauci said on NBC’s Meet the Press that the FDA and CDC — not vaccine makers — will decide by fall about boosters.)

“Even if we reach the herd immunity threshold in the US or in rich countries, this virus is going to continue to circulate,” said Lipsitch.

Right now, doses are only promised on the order of hundreds of millions, and the planet is home to 7.8 billion people. The World Health Organization has warned that global under vaccination would be a catastrophic moral failure, prolonging coronavirus transmission around the world.

3. A Worse Ending: A Fourth Surge for the Summer

The better outcomes are far from inevitable. White House officials regularly say that the US is in a race between vaccination and more contagious coronavirus variants. In this scenario, we lose the race. The result: a fourth surge.

The reasons for worry are plain in case numbers that have stopped declining and are instead trending upward again, now averaging around 67,000 newly-reported infections a day. The more transmissible and dangerous B.1.1.7 coronavirus strain is quickly becoming the predominant one nationwide, now accounting for 26% of all new cases.

“We remain in a complicated stage,” the CDC’s Walensky said Monday. “On the one hand, more people in the United States are being vaccinated every single day and at an accelerated pace. On the other hand, cases and hospitalizations are increasing in some areas of the country, and cases among younger people who have not yet been vaccinated are also increasing.”

If the US falls behind on vaccinations, then a second lockdown period might result. Rising hospital admissions could lead governors and mayors to shutter bars, restaurants, and stores once again.

“We are in real risk of throwing away all the gains we have made, and losing another summer,” Debra Furr-Holden, a Michigan State University epidemiologist, told BuzzFeed News.

Her state, as well as the rest of the Upper Midwest and the Northeast, is in the thick of massive outbreaks right now. Some counties reopened bars, gyms, and restaurants too early, Furr-Holden believes, which in her view should serve as a warning to the rest of the country.

Although 74% of US adults say they want a shot, up from half in September, that’s still not enough to achieve herd immunity, some suggest. “We have to get about 80% of adults vaccinated,” said Schaffner, the infectious disease specialist at Vanderbilt. “We’ve never done that with any vaccine in the United States.”

Some areas of the country are also much more resistant to vaccination than others. In states like Tennessee, Kentucky, Alabama, and Mississippi, as many as 37% of people tell pollsters they don’t want a shot. Politics clearly plays a role. Older, rural conservatives express the most hesitation, and their fears are reinforced by misinformation and fearmongering on right-wing cable channels.

“We are running into people who have expressed some hesitancy, so we have to listen to them and address their concerns,” said Schaffner, who is based in Nashville. Walensky acknowledged this week that “the administration of vaccines across the country is not uniform.”

But Andy Slavitt, the senior White House COVID-19 adviser, said he was unwilling to entertain the idea of the federal vaccination campaign shifting doses to parts of the country clamoring for shots and sending less to ones in areas where they go unused. “We are not going to quote-unquote ‘punish’ less-ready areas,” Slavitt told BuzzFeed News during a briefing this week. The key, he said, is to convey to people that while vaccines were hard to get during the initial rollout, there are now more than 60,000 vaccination sites nationwide, and at least one of them is within 5 miles of where 95% of the population lives.

Whether enough Americans will take that message to heart remains to be seen. If not, we may only reach herd immunity after another painful surge.

4. The Bad Ending: After the Summer, Global Variants Revive the Pandemic

Then there’s the worst-case scenario. In a mostly unvaccinated world, a new and more deadly coronavirus variant — or variants — overpowers vaccines and restarts the global pandemic all over again. The US, along with everyone else, has to begin again with new vaccines.

“Coronavirus mutates a lot — they can do it in humans, they can do it in animals — and the question is how important are these mutants going to be,” Stanford University infectious disease expert Julie Parsonnet said at the herd immunity symposium held at her university. “We don’t live just in Palo Alto, or just in California, or just in the United States. We live in a world where there are a lot of unvaccinated people, and as long as we don’t focus on the world more globally, we’re going to have problems.”

For now, the available vaccines are effective against the variants circulating in the US. But experts are surprised at the speed at which more transmissible ones have arisen, said Bhattacharya of the University of Arizona. Their arrival reflects just how widely the coronavirus has spread from host to host, each acting as a lab for new mutations to emerge.

“The places where the variants are growing, they’re not growing because they are evading the immune system, they are going nuts because there aren’t enough people that are immune,” Bhattacharya said. “Obviously this isn’t the best situation, because the longer you let this go, the better the odds that you will get some weird thing that will eventually start to grow out because it can evade the immune system.”

Last week, the White House announced a $1.7 billion effort to detect such new strains. Pfizer, Moderna, and other vaccine makers are already testing prototype booster shots that are designed explicitly against variants, such as the B.1.1.7 strain.

In the face of this threat, a recent risk analysis led by George Ioannou, an expert on veteran care at the University of Washington, offers a framework for who should get prioritized for vaccines. To prevent deaths as much as possible, people with the most severe risk factors, such as diabetes, heart failure, or kidney failure, should be given shots first, this work suggests. At the same time, if there is enough supply, vaccines should be administered as quickly and widely as possible to combat the new variants.

“You really don’t want that threat just hanging around,” Bhattacharya said.

But even in this worst case, the silver lining is that the coronavirus has nevertheless proven amenable to vaccination, he and other experts noted, unlike HIV, which for decades has thwarted vaccines. A coronavirus strain that evades the current vaccines will almost certainly be susceptible to shots that have yet to be designed.

That means vaccines will at some point deliver an end to the pandemic, no matter how many changes in work, school, and daily life it leaves behind, said Yale sociologist Nicholas Christakis, author of Apollo’s Arrow: The Profound and Enduring Impact of Coronavirus on the Way We Live.

“Eventually it will return to normal,” Christakis told BuzzFeed News. “Plagues end — they just do.”

Social Media: A Parasite on Our Pandemic Mental Health

Doctor Vinay Prasad reported that recently, a physician colleague of mine, someone whom I’ve met in person and with whom I’ve shared a laugh, began to tweet increasingly hostile barbs about me. In a certain respect, it was a typical social media interaction — an uncharitable reading of one’s point of view and a scornful reply. But it was also unusual, as we have met in person, face to face.

In my experience, online anger like this is summoned only when the other person has been depersonalized — just a face dissociated from a person. I’d rarely experienced it from someone who I knew in real life. Just as I started to wonder what might be going on, a mutual friend called to say they had seen the out-of-character barbs. Apparently, this colleague has been suffering from a serious medical illness and was going through a hard time. By the end of the call, I was left feeling sympathetic.

Later that day, I noticed that a professor whose tweets I greatly enjoyed had shut down their account. Poof! They, and their astute comments, were gone entirely. I sent them a note, mostly to let them know that I had been affected by their sharp thinking over the years, and was sorry to see them go. The person wrote back that the growing hostility had driven them away. Every time they said anything, they felt mobbed by a sea of increasingly angry voices. They didn’t need the stress.

Finally, the same day, a colleague from another university called me to ask for some advice. She had been on Twitter, and was troubled by increasingly hostile and negative feedback. The specifics were ugly, and I could tell from the tone in her voice that my colleague was pained. I gave the few tips I know and went for a long run to think.

What Is Going On?

In the best of times, social media is a double-edged sword. It is a great way to get a message to many people, but it is de-personal, and driven by the economy of attention. Anger, disgust, and outrage are the emotions that engage and addict the users. People, good people, can become disinhibited and say things they don’t truly mean, or would never say in real life. Of course, this is during the best of times.

We are not in the best of times. People have been cut off from friends, family, and co-workers, and many are living in isolation. In fact, it is the loneliest year in human history. The largest number of people in history (billions) have deprived themselves of, at least some, social interactions. Mental health is suffering, and physicians, healthcare workers, researchers are suffering alongside everyone else. When we are tired and angry we are not our best selves, and paired with the algorithms of social media, it is a recipe for disaster.

Where Are We Now?

Every day people go online and the difficulties of the last year loom large in our minds — over 500,000 dead Americans, disjointed and often incoherent policy responses, the list goes on. Some are angry that we didn’t do more, sooner. Others are angry about interventions and restrictions that were broadly implemented that might not have helped, and even hurt. Both groups might be right: we were unwilling to do some things that might have helped, and simultaneously pursued other interventions that didn’t, and unfortunately hurt less-fortunate Americans. It will take years to tease these apart, as I have written. Regardless, we are angry. So, we go online looking to vent that anger. If we felt the bigger error was not enough restrictions, we get angry when someone is critical of restrictions. And if vice versa, we find a different scapegoat. A philosopher recently told me, we get most angry when other people don’t follow restrictions that we are able to follow.

The angry train goes off the rails when we invent motivations for others. Folks who share our point of view are always good people who want to save lives, and folks who disagree with us are people indifferent to human beings, grifters, ideologues, or attention-seekers. But, if one steps back, how can that possibly be? Surely people on all sides of an issue — whether that be school reopening or best vaccination practices — have varied reasons for holding their view. A tiny fraction may have some ulterior motive, but surely the vast majority hold their view for the same reason folks who disagree hold their view — an alternative interpretation of facts and values. I suspect a year from now the idea that the world is full of strictly good and bad people will look particularly ridiculous.

How Can We Make It Better?

I don’t know how we can improve the situation on social media, and more critically, reverse the anguish so many are facing in real life — but I do have some tips about how we might help ourselves.

1. Get offline. The professor who deleted their account had the right idea. Each of us has to decide if social media serves our purposes and makes us better informed or happier, but probably all of us should use it less. Read it less, and post less.

2. Mute all notifications. I did this a few years ago, and I quickly found more joy in my life. Say what you have to say, and let it go. No need to reply to anyone, and the easiest way is to set the accounts to never disturb you again.

3. Don’t reply to others. If you read a point of view you disagree with, what value is there in replying to the other person? Just state your point of view in your terms on your feed. No need to pick a fight. Just make your point on your terms.

4. If you are having a hard time at home or work, don’t use social media. It is hard enough to manage when you wake up in a good mood, but when you are feeling tired, scared, afraid or sick, it is too much. Corollary: If you love someone, and they are hurting, suggest they do the same.

5. Meet or call someone every day. Social media thrives from our loneliness — it’s a cheap way to feel less lonely in the loneliest year of human history. But it is a neon light to the sun. Call someone. Visit someone. Interact more in real life.

6. Tell someone you don’t know you appreciate their thoughts. Perhaps the best thing we can do to combat negative emotions is to give some positive feedback to folks we appreciate. I have sent some emails to people, but perhaps I am not thinking big enough. I plan to go on social media and talk openly about people whose thinking delighted me over this last year. It is the least I can do to combat the animosity.

Toward More Productive Dialogue

When we are feeling powerless, getting angry at someone is seductive. It is a way to channel and reorient your energy. Unfortunately, it leaves all involved worse off. Instead, consider using your energy to articulate or refine your perspective, to push for positive change. That doesn’t mean that there are not real errors — but jumping on a single tweet by a minor character in a drama is unlikely to be the change-maker. My tips are just suggestions, but all meant to re-orient the compass toward productive dialogue.

Scientists Reveal How the AstraZeneca Vaccine Causes Unusual Clots

Brenda Goodman reported that scientists in Germany say they’ve worked out the two-step mechanism by which the AstraZeneca vaccine causes rare but devastating blood clots that gobble up the body’s supply of platelets.

So far, European regulators have reported more than 220 cases of unusual blood clots and low levels of platelets in patients who received the vaccine, called Vaxzevria, which was developed with funding from Operation Warp Speed as part of the race to develop a suite of vaccines to protect people from COVID-19. Vaxzevria has not yet been authorized for use in the United States.

“This is, in my opinion, rock-solid evidence,” said Andreas Greinacher, MD, head of the Institute of Immunology and Transfusion Medicine, University Hospital Greifswald, Germany, who was among the first scientists in the world to link the rare clots to antibodies against the platelet factor 4 protein.

Greinacher said he found the same mechanism using three different technologies to gather evidence: dynamic light scattering, super-resolution microscopy, and electron microscopy.

“This is what scientists usually think is confirmatory evidence,” he said in a call with reporters hours after publishing his study as a preprint ahead of peer review on the Research Square server.

Greinacher said he felt an urgent need to get the information out as soon as possible. He said his team had worked around the clock for 5 weeks to get answers, “because we are in the middle of the vaccination campaign. This was the driving force for us and the big motivation to provide these data as fast as any other possible,” he told reporters on the call.

Greinacher said that he believes the mechanism linking the vaccine with the rare clotting reactions is likely to apply to other vaccines that also use adenoviruses to ferry instructions for making the virus’s spike protein into cells.

“My assumption is, and that’s a hypothesis, that this is a class effect of vaccines using adenovirus,” he said. He added that he could not be certain because he only studied reactions to the Vaxzevria vaccine. But previous studies have shown that adenoviruses can cause the type of platelet activation he saw in the reactions he studied.

Greinacher said that he had worked out an agreement with Johnson & Johnson about an hour before the call to collaborate on studying its COVID-19 vaccine. The company had previously been unwilling to share information, he said.

At least seven cases of the same pattern of unusual clots have been documented in people who received the one-dose Johnson & Johnson vaccine, which also uses an adenovirus as its delivery vehicle. Over 7 million Johnson & Johnson vaccines have been given in the United States so far.

While the reactions are extremely rare, they can be serious. One person, a 45-year-old woman in Virginia, has died. That led the US Centers for Disease Control and Prevention and the US Food and Drug Administration to call for a pause on administering the Johnson & Johnson vaccine last week. The company also announced that it would hold clinical trials to get more answers about the reactions.

In his new study, Greinacher and colleagues describe a cascade of events that has to happen in the body before the vaccines broker these large clots. He explained that while everyone has the basic immune machinery that leads to the unusual clots, it is almost always kept in balance. The body uses a series of checks to prevent any step in the process from getting out of control.

In some cases, however, there’s a perfect storm where each stage progresses to the next and the end result is very hard to control. That autoimmune attack, which causes the body to go into a hyper-clotting state, typically burns itself out after a few weeks. So if patients can get rapid treatment, the condition nearly always goes away.

He said he only knew of one case of an autoimmune syndrome like this lasting 10 years, but that was in a patient who had taken the blood thinner heparin, which can cause a nearly identical syndrome.

Two-Step Process Leads to Clots

In the first step, the adenovirus shell in the vaccine, along with proteins from the cells where the vaccine is grown, come into contact with platelets from the blood.

Platelets are best known as colorless cell fragments that rush to the site of an infection or injury, helping the blood congeal to stop bleeding; they also play a key role in the body’s immune response.

When activated, they surround invaders like bacteria and change shape to release chemical signals they store in granules.

When platelets are activated en masse, as can happen rarely after a person takes the blood thinner heparin or gets the Vaxzevria vaccine, they release a flood of these signals, Greinacher explained. These blaring signals recruit an ancient and hard-to-control branch of the immune response.

“Imagine this is like a dragon in the cave who was sleeping for a long time [but] which now got alerted by someone’s throwing a stone on it,” he said. The chemical signals awaken B-cells that then produce massive amounts of antibodies against the platelet factor 4 protein, which helps coordinate blood clotting.

The body erroneously thinks it is reacting to massive amounts of pathogens in the body, so the immune system overshoots. The antibodies bind the platelets, the platelets recruit white blood cells, and “then the whole thing is exploding,” he said.

The second key step in these reactions is caused by EDTA, a calcium-binding agent and stabilizer that is added to the Vaxzevria vaccine.

EDTA is not listed as an ingredient in the Johnson & Johnson vaccine.

EDTA opens junctions between cells that form the walls of blood vessels, causing them to become leaky. This allows the giant complexes formed by proteins and platelets to enter the blood circulation, where they — on very rare occasions — trigger that bodywide alarm.

Asked if he thought there was anything that could be done to make the vaccine safer, Greinacher said his first thought would be to try to get rid of the EDTA, which causes the second step in the process. But he said he was not a vaccine developer and didn’t know how important it might be to its formulation.

Why might the Johnson & Johnson vaccine lead to similar types of clots, even though it doesn’t contain EDTA? Greinacher speculated that size might play a role.

When this reaction occurs in patients who have taken heparin, the size of the heparin molecule matters. With unfractionated heparin, the longest kind of molecule, the reaction is 10 times more common than when patients take smaller low-molecular weight heparins.

Other vaccines might form smaller antibody-protein complexes that generate smaller warning signals, making the reaction less likely.

As for why the reaction appeared to be more common in women, Greinacher said he was growing skeptical that there is a large gender bias. He pointed out that most of the first vaccine recipients in Europe had been healthcare workers, who are disproportionately women.

He noted that women might be slightly more susceptible because of hormones and because women are more likely to develop autoimmune diseases, but that the risk was probably more balanced between men and women than it first seemed.

“It’s not a disease of young women,” he said.

Several European countries have changed or abandoned their use of the AstraZeneca vaccine.

Last week, Denmark said it would no longer include Vaxzevria as part of its vaccination program. Italy has recommended that AstraZeneca vaccine only be used in people over age 60. UK officials said people under age 30 should be offered an alternative.

Meanwhile, the European Medicines Agency said a warning about the risk of blood clots and low platelets should be added to product information for the Johnson & Johnson vaccine.

ACIP Green-Lights J&J Vax for All Adults

Finally, Molly Walker reported that the pause is lifted, and Johnson & Johnson’s COVID-19 vaccine is once again recommended for adults, according to the CDC’s Advisory Committee on Immunization Practices (ACIP).

In a 10-4 vote, with one abstention, ACIP said in updated interim guidance that the Johnson & Johnson vaccine is recommended under FDA emergency use authorization (EUA) for all adults.

They ultimately decided that including a separate warning on the vaccine, as well as in an FDA EUA fact sheet and materials on the CDC website, was sufficient. One choice the committee chose not to vote on would have added language that women under age 50 should be aware of the increased risks of rare clotting events, and may opt for a different authorized COVID-19 vaccine. The committee agreed that any further qualifiers would be too cumbersome for local jurisdictions to implement and might contribute to vaccine hesitancy.

Johnson & Johnson researchers unveiled a proposed warning that the FDA agreed to add to the vaccine’s current EUA. It warns about the risks of thrombosis with thrombocytopenia syndrome (TTS), and recommends that clinicians consult with the published American Society of Hematology guidance for diagnosis and treatment of the condition.

ACIP member Grace Lee, MD, of Stanford University School of Medicine, said that putting a qualifier for any demographic group would be “extremely confusing,” because every ACIP recommendation “is a benefit/risk balance.”

The committee believed that the benefits of one-dose vaccination outweighed the risks, as it makes this vaccine available for vulnerable populations, including people experiencing homelessness, incarcerated populations, and home-bound populations.

The “no” votes came from members who felt that younger women would not be adequately informed about the risks of this rare adverse event by a warning label and EUA fact sheet.

“I did not object to the recommendation. I objected to the absence of any kind of guidance from us,” said ACIP member, Sarah Long, MD, of Drexel University College of Medicine in Philadelphia. “This is an age group that is most at risk and is getting the vaccine predominantly to save other people’s lives. I’m very sorry we haven’t chosen to put up front the knowledge we have that … there are options.”

ACIP chair, José Romero, MD, ultimately voted yes, but added that he thought there was a bit of a “selective interpretation” in terms of how much younger women would be informed. He urged vaccination sites to have a second vaccine available so that younger women are not forced to shop for vaccines.

“These events are rare, but they are serious,” Romero said.

The American Medical Association (AMA) reiterated their support for the Johnson & Johnson vaccine and pledged to help inform patients about the rare adverse events.

“The AMA will continue to work with the FDA and the [CDC] to ensure physicians and patients are aware of the rare, but increased risk of [TTS] in women under the age of 50, as well as the appropriate treatment, so they can act quickly,” said AMA president Susan Bailey, MD, in a statement.

On April 13, CDC and FDA agreed to a “pause” on use of Johnson & Johnson’s COVID-19 vaccine out of an abundance of caution. At that point, there were six cases of cerebral venous sinus thrombosis (CVST) with thrombocytopenia, one fatal. ACIP met on April 14, but agreed to wait to vote until more data accrued on the available cases, including potential risk factors.

As of April 21, the number of cases rose to 15, with three deaths. Seven patients remain hospitalized, including four in the ICU, while five were discharged home.

Thirteen of these cases were in women ages 18-49, with two in women older than 50. Based on these data, Tom Shimabukuro, MD, of the CDC, estimated that the rate of TTS was 7.0 per million doses in younger women, and 0.9 per million in older women. Seven cases of 15 were among women ages 30-39.

While all cases were in women, Shimabukuro noted that some data were still under review, “including potentially male cases,” although as of now, there were no cases reported in men.

Median patient age was 37, with a median time to onset of 8 days following vaccination. While 12 cases were CVST, three were other forms of thrombosis. Seven patients had obesity, while two patients apiece reported oral contraceptive use, hypothyroidism, or hypertension. No patients had established coagulation disorders.

All patients had thrombocytopenia, with 10 patients having severe thrombocytopenia, or platelet levels under 50,000. Of the 11 patients where a platelet factor 4 heparin-induced thrombocytopenia ELISA antibody test was performed, all were positive. Four patients did not have available results. Seven patients with CVST experienced intracerebral hemorrhage.

Non-heparin anticoagulants were used to treat 12 patients and intravenous immunoglobulin to treat eight patients, while platelet transfusion was used for seven patients and heparin for six patients. Shimabukuro noted that the six patients received heparin prior to the CDC Health Alert about treating this condition.

Shimabukuro said that cases under investigation may increase, as researchers plan to broaden their case definition to harmonize with the draft Brighton Collaboration case definition for TTS. This could include other thrombotic events, including venous thromboembolism, deep vein thrombosis, pulmonary embolism, ischemic stroke, and acute myocardial infarction.

As I try to conquer my depression in my interaction with some of my patients who refuse to get vaccinated, I wonder if we, our country will ever reach herd immunity as Israel has accomplished. I am trying to figure out whether it is worth keeping these patients in my practice due to my concern for my staff, my other patients and our families.

Please get vaccinated!!

Mood darkens in Sweden as high death rate raises tough questions over lack of lockdown, and Now A Second Wave and a Possible Kids’ Epidemic!

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Richard Orange noted that Sweden, in deference to the rest of the countries believing in the strategy to lockdown their populace, decided not to use stay-at-home or lockdowns except for the elderly.  Sweden’s opposition has attacked the government for its handling of the coronavirus pandemic, with the stubbornly high death rate fueling questions over the decision not to impose a lockdown. 

Jimmie Akesson, the leader of the populist Sweden Democrats, first called for Anders Tegnell, the architect of Sweden’s less restrictive coronavirus strategy, to resign. The attacks continued in heated televised leaders’ debate on Sunday night.  

“The strategy in Sweden was not to try to hold back the infection, but instead to try to limit it at the same time as protecting risk groups,” Mr Akesson wrote in a debate article in the Dagens Nyheter newspaper.

“By that measure, it has failed miserably. Anders Tegnell should therefore resign. Only then will he show the Swedish people that he takes responsibility for the mistakes FHM [Public Health Agency of Sweden] has made.”

During a party leaders’ debate on Sunday evening, Ebba Busch-Thor, leader of the Christian Democrat party, blamed Sweden’s strategy – and by extension the government that allowed it – for some of the 4,659 deaths due to the virus. 

“What we can say about Sweden is that many of those who are mourning over those they have lost this spring are doing so because Sweden knowingly and deliberately allowed a large spread of the infection,” she said.  

Ulf Kristersson, the leader of the Moderate Party, the biggest party on the Centre-Right, held back from joining Mrs. Busch-Thor’s attack on the strategy, instead attacking the implementation of it.

“I had no problem with the strategy. It was a bit slow but, when it was in place, I had nothing against it,” he said. “But the government didn’t put any power behind the words.”

The Prime Minister, Stefan Lofven, continued to back Sweden’s strategic decision not to impose a lockdown, instead laying the blame for the death rate on failures within elderly care. 

“I think the strategy is the right one,” he said. “But it has transpired that that very many people, in certain areas, have died in elderly care. There’s no doubt that elderly care needs to be improved.” 

Mr Akesson faced an immediate counter-attack from Johan Carlsson, the director of FHM, who dismissed his call as “almost pathetic”. 

Dagens Nyheter’s political commentator Ewa Stenberg wrote on Sunday that the debate marked an end to the “borgsfred”, or “castle truce”, in Sweden.

“The tone was harsh and quite contrary to how it was when the virus hit the country. Then all the parties backed the government’s decision to let the Public Health Authority take the lead,” she wrote.

However, the return of political opposition does not yet seem to reflect a loss of support for the government among the public.

Kids During Lockdown: Is Another Epidemic About to be Revealed?

Ingrid Walker-Descartes noted that even in non-pandemic years, the summertime “back-to-school” rush of appointments in many pediatric practices can be a logistical challenge. This year could be even more hectic after many families delayed routine appointments during quarantine. Hoping to return to their routines, children and teens will need vaccines, physical exams for sports clearances and school forms, and all the regular developmental and emotional surveillance that is so important to keep them healthy.

As pediatricians, we should be adding another layer to our checklists in these visits this year. For many children, this visit may be the first time in weeks or months that someone outside their immediate family has had eyes on them.

We must be careful to listen, very carefully, to what the children and parents tell us, both in their words and in other signs. How has the family coped with the stress of being stuck at home? Are there financial struggles? Food insecurity? Other stresses? As a child abuse pediatrician, I know all of these things can put tremendous stress on a family, and ultimately can lead to a child being maltreated or abused. We have a real opportunity right now to intervene and provide critical support to families, and to protect children.

Sadly, we know from previous disasters that during these times of intense emotional and economic stress, rates of child abuse and neglect increase. Injuries and deaths among infants due to abusive head trauma increase during times of economic stress, and scattered reports among physicians at children’s hospitals in various states are reporting that is happening now, too. For example, a hospital in Fort Worth, Texas, and a hospital in Philadelphia, are reporting an increase in the number of severe physical abuse cases. Many times, this abuse occurs when a parent or caregiver is frustrated or at the “end of their rope,” and in a moment of anger, makes a devastating choice that injures a child.

For the past few months, during sheltering in place, children have lacked many of the people who often step forward as protectors — the aunt they may confide in, a teacher who sees a bruise, or a physician who notices an injury where there reasonably should be none. Reports to child abuse hotlines and child protective services have declined during the pandemic, but this is not necessarily because fewer children are being injured. We know that teachers and school counselors are the most frequent reporters of suspected abuse, and for months children have not had access to these trusted protectors. Many of them have not seen their pediatrician, either. These combined realities have left some of our most vulnerable children without several much-needed layers of protection.

As a pediatrician who specializes in diagnosing abuse and protecting children from further abuse, I am well versed in talking with children to understand what happened to cause their injuries. Some may convey lessons learned from their choices made due to curiosity or naivete. Others struggle to elaborate on marks or scars made in anger by a caregiver. Post COVID-19, it will be important for all pediatricians to have a careful approach as they are talking with families, listening and observing to understand what children experienced during the pandemic, and how we can help them and their families be safe and healthy.

Some families may benefit from a referral to a nutrition program, caregiver support program, parental counseling, or other resources. In other cases, a pediatrician may notice a sign of potential abuse that should be reported to the relevant child protection agencies. This is always difficult, but it can be the first step to making sure a child is safe and protected while a family gets the support they need.

The American Academy of Pediatrics (AAP) recently provided a webinar guide on how to identify child abuse during the pandemic, and additional resources are provided on the AAP website, including a list of child abuse programs across the country to help support you in this difficult role.

The stress on families and children will not end when the stay-at-home orders lift. Let’s be prepared to help all our children emerge healthy and strong, and ready to learn.

CDC wants states to count ‘probable’ coronavirus cases and deaths, but most aren’t doing it

Reinhard, Emma Brown Reis Thebault and Lena H. Sun reported that fewer than half the states are following federal recommendations to report probable novel coronavirus cases and deaths, marking what experts say is an unusual break with public health practices that leads to inconsistent data collection and undercounts of the disease’s impact.

A Washington Post review found that the states not disclosing probable cases and deaths include some of the largest: California, Florida, North Carolina and New York. That is one reason government officials and public health experts say the virus’s true toll is above the U.S. tally as of Sunday of about 1.9 million coronavirus cases and 109,000 deaths — benchmarks that shape policymaking and public opinion on the pandemic.

The U.S. Centers for Disease Control and Prevention works closely with a group of health officials called the Council of State and Territorial Epidemiologists to issue guidelines for tracking certain illnesses. The guidelines are voluntary, though states generally comply. The goal: solid comparisons between states and accurate national statistics that inform public health decision-making.

In April, as coronavirus infections multiplied and laboratory testing was limited, the CSTE and the CDC advised states to count both probable cases and deaths — where symptoms and exposure pointed to infection — along with those confirmed by tests.

Yet weeks after the guidance was handed down to standardize coronavirus reporting, a Post review found states as of early June counting cases and deaths in all sorts of ways.

At least 24 states are not heeding the national guidelines on reporting probable cases and deaths, despite previously identifying probable cases in other national outbreaks, including H1N1 flu during the country’s last pandemic in 2009.

The failure of many states to document probable coronavirus cases and deaths is “historic in many ways because there are lots of probable case classifications and probables are regularly and normally reported on,” said Janet Hamilton, the CSTE executive director. “We are definitely concerned about the undercounting of covid-19 deaths and cases.”

New Jersey says it began reporting probable cases and deaths to the CDC on May 15 but does not disclose them publicly on its website. Georgia says it tracks the information internally but is not reporting those numbers on its website or to the CDC.

“We do have intentions of sharing them but not yet,” said Nancy Nydam, a spokeswoman for the Georgia Department of Public Health, who said as of late May the department had tracked 1,658 probable cases and potentially dozens of probable deaths.

Officials in Montana, Rhode Island and the District of Columbia say they haven’t reported any probable cases or deaths because they have not had any, citing low numbers or the wide availability of testing.

Seven states did not respond to The Post’s requests for a breakdown of cases and death counts. Five of those are not reporting probable cases or deaths, according to data the CDC began publishing June 2. South Dakota reports probable deaths but not cases.

Officials in the remaining 17 states say they are reporting probable and confirmed coronavirus cases and deaths on their websites and to the CDC. Some states distinguish between probable and confirmed while others group them.

In some states not reporting probable cases, officials cite the demands of an unprecedented crisis in which Americans press for daily updates from public health data systems that are chronically underfunded and outdated.

In Washington state, where many of the nation’s first deaths occurred, health department spokeswoman Lisa Stromme Warren said documenting probable cases and deaths “is one of many urgent priorities.” The state has identified about 100 people whose death certificates list covid-19 but were never tested, so they are not included in the public death count or reported to the CDC.

“We suspect that we are actually more likely to be undercounting deaths than overcounting them,” Katie Hutchinson, the health department’s health statistics manager, said during a recent briefing.

CDC spokeswoman Kristen Nordlund said that the agency is working with health departments to improve the flow of data. “In pandemic circumstances, such as with covid-19, collecting complete information on each case is challenging,” Nordlund said. “The current case and deaths counts reported to CDC are likely an undercount.”

During the H1N1 flu pandemic, states initially counted probable and confirmed cases individually. But about three months into the outbreak, the CDC said those individual counts represented “only a fraction of the true burden” of the disease. The agency stopped collecting individual case reports and instead began publishing estimates based on hospitalizations, symptoms and other data.

The CDC is planning to come up with similar estimates for the coronavirus but has no immediate plans to stop counting individual cases. “CDC is actively working on a model to address and assess the true burden of covid-19 in the U.S.,” Nordlund said.

All eyes on numbers

For government officials assessing how quickly to reopen the economy and individuals deciding what risks to take, their daily judgment calls are based, in part, on the case and death counts publicized on television and computer screens.

That has propelled the pandemic counts into the contentious political arena, where some allies of President Trump and conservative voices on social media have claimed that the covid-19 death toll is inflated. The debate over whether counts of probables are crucial or misleading extends beyond the nation’s capital.

In Illinois, two Republican lawmakers and three businesses have sued the Democratic governor over coronavirus disaster orders. A spokeswoman for the health department, Melaney Arnold, said the state is not divulging probable deaths on its website “because there is concern from the public that the number of deaths is being inflated. . . . We need the public to have confidence in the data and therefore are reporting only those deaths that are laboratory confirmed.”

The state website lists about 5,700 deaths as of June 5, excluding the approximately 185 probable deaths tracked internally as of that day and reported to the CDC.

But a resident looking at a state chart and then turning to the CDC might not find the same numbers. The newly posted CDC table does not reflect the probables that officials in some states said they have reported. Officials say that’s because the reports sent to the CDC include those with confirmed cases in one figure and because the national update can run slightly behind state websites.

Since the 1950s, CSTE has recommended which diseases states should track and what those reports to the federal government should look like. The CDC works closely with the epidemiologists’ council and adopts its guidelines to “enable public health officials to classify and count cases consistently across reporting jurisdictions,” according to the CDC website.

States usually follow these recommendations and report the incidence of dozens of different diseases to the CDC, with some exceptions. A state may not report cases of a disease that does not occur within its borders, yet may track another illness found only in its part of the country.

Hawaii, for example, does not report Lyme disease, as every other state does, but it does report hallucinogenic fish poisoning.

“It’s more of a handshake agreement between the states and CDC that we will send you the data in this way so that you can then aggregate it,” said Kathy Turner, Idaho’s deputy epidemiologist. “In general, there’s no argument. We all do it because we realize the importance of being able to look at a disease on a national level.”

Some reportable diseases rarely result in deaths, so CSTE directives have typically focused on how to count cases, not fatalities. Then came the coronavirus and a mushrooming death toll. The CDC acknowledged in early April that the death count was an “underestimation” because it included only fatalities in which the virus was laboratory confirmed. Testing shortages, people dying at home or in nursing homes, and spotty postmortem testing meant victims were overlooked.

“When the outbreak first started and we were all just counting lab-confirmed cases by default, it became clear that we were not going to be able to describe the burden of the pandemic because so many people were not being tested,” said Turner, lead author of the CSTE statement on covid-19.

“We usually don’t approach a death separately from a case, but in this situation, we decided it was needed,” she said.

The CSTE recommended reporting probable and confirmed cases and deaths on April 5. The CDC’s written response to the recommendations, which was shared with The Post, said the agency “concurs” and that adoption by states is “very important” for covid-19 record-keeping. On April 14, the CDC noted on its website that the national tally includes probables, although the agency did not at that time provide a state-by state breakdown. The CDC also modified the form states use for coronavirus reports, adding boxes that can be checked to indicate a “lab-confirmed” case or “probable” case.

Probable cases were defined as showing symptoms and having contact with an infected person, or meeting one of those criteria and testing positive for coronavirus antibodies, rather than for the virus itself. Probable deaths meant those who were never tested for the virus but whose death certificates listed covid-19 as the cause of death or a significant condition contributing to death.

The CSTE statement also says that confirmed and probable counts should be included in the tallies “released outside the public health agency,” which could mean a state website or written report, according to the organization.

“When states are using different approaches, it always begs the question: ‘Why does one state choose one over another? Why a more conservative approach over a more sensitive one?’’’ asked Lorna Thorpe, director of the division of epidemiology at NYU Grossman School of Medicine. “That’s the reason we have standards and guidance that are technically sound.”

Information varies

The erratic reporting of coronavirus cases and deaths means that what residents can learn about the extent of the pandemic in their community varies widely.

Ohio was one the first states to begin disclosing probable cases and deaths in early April. “It usually is a given when CSTE makes a recommendation like that,” said Brian Fowler, chief data officer for the Ohio Department of Health. “When they made that recommendation, we looked at it and said, okay, well this is what we need to use.”

As of June 5, Ohio’s website showed 2,117 confirmed deaths and 222 probables. By breaking out the numbers separately, Fowler said, “you can’t be accused of hiding information and you can’t be accused of inflating numbers — it’s all out there.”

The transition to counting probables was not “a huge lift,” Fowler said. Epidemiologists at the health department were already reviewing all suspected coronavirus cases.

Some health officials were candid about how adding probable deaths would boost the overall tally. “I want to make sure that everyone understands that these are not new deaths,” Indiana Health Commissioner Kristina Box said at an April 20 news conference. “Rather, we are capturing the deaths that have occurred really since this pandemic began.” Box suggested other states would do the same: “Indiana — like every other state — will include these deaths in our reporting in order to better capture the toll that covid-19 has truly taken.”

One week earlier, Michigan officials had said they intended to begin disclosing probable cases and deaths. When the state finally began doing that on June 5, more than 5,000 cases and 200 deaths were added to coronavirus totals.

California’s state health department is reviewing the process to track probable deaths and “working to provide as much data as possible about COVID 19 while ensuring that the data are valid and useful for understanding the pandemic,” according to a May 20 email to The Post.

Hilda Solis, a supervisor in Los Angeles County who represents a heavily Hispanic and impoverished district, said she was surprised that the state is not following national recommendations on counting coronavirus deaths. She has called for more post-mortem testing by the medical examiner. “A lot of people are dying at home. Poor people are dying at home. Homeless people are dying,” said Solis, a former U.S. labor secretary under President Barack Obama. “I do believe covid-19 is being underreported and that we need to take more responsibility.”

The scale of undercounting that results from reporting only confirmed cases became clear when New York City on April 14 added more than 3,700 probable deaths to its numbers, sending the city’s tally over 10,000.

The city that sits at the epicenter of the pandemic in the United States still is not counting probable cases, however. New York Gov. Andrew M. Cuomo, a Democrat praised for his command of daily news briefings during the pandemic, has indicated skepticism about recording probable cases. “Probable is different than confirmed,” he said at a news conference in late May. “Probable is ‘probable, but I have to check, I don’t know, I have to do further testing.’ We’ve had many cases that were probable coronavirus and turned out not to be coronavirus and that’s why they call them probable.” Covid-19 websites for New York and New Jersey include probable deaths at nursing homes, but those numbers are not included in the states’ overall death totals. A spokesperson for North Carolina’s health department said the state is not reporting probables because of wariness about the reliability of antibody tests, and because of concerns that the CSTE’s definition of a probable case is overly broad. Officials in Florida did not respond to repeated requests for comment about why the state isn’t following federal guidelines.

People behind ‘probables’

Behind each probable death is a person. Barnes O’Neal, 83, checked into the Brightmoor Nursing Center in Georgia in March to recover from a 10-day hospitalization. Less than a month into his stay at the facility about 40 miles south of Atlanta, a coronavirus outbreak forced a lockdown. O’Neal developed a fever and pneumonia. His daughter, Natalie Turner, pleaded with her father’s caretakers and the state health department for a coronavirus test. She said she wanted his illness on the record.

On April 20, just hours after Turner had spoken with him by phone, O’Neal died. He was never tested, but Turner said his doctor told her there was “zero doubt” it was covid-19 and wrote it on her father’s death certificate.

Still, her father, a frequent volunteer at the local soup kitchen, would not be included in the death toll on the state website because he was never tested. “It’s just important to me because my dad’s life counted,” Turner said. “I feel like there’s a face behind every statistic, and that’s forgotten many times.”

And now the pandemic’s overall death toll in U.S. has exceeded 100,000, but what are the real numbers?

Second U.S. Virus Wave Emerges as Cases Top 2 Million

Emma Court and David Baker noted that a second wave of coronavirus cases is emerging in the U.S., raising alarms as new infections push the overall count past 2 million Americans. Texas on Wednesday reported 2,504 new coronavirus cases, the highest one-day total since the pandemic emerged. A month into its reopening, Florida this week reported 8,553 new cases — the most of any seven-day period. California’s hospitalizations are at their highest since May 13 and have risen in nine of the past 10 days.

A fresh onslaught of the novel coronavirus is bringing challenges for residents and the economy in pockets across the U.S. The localized surges have raised concerns among experts even as the nation’s overall case count early this week rose just under 1%, the smallest increase since March.

“There is a new wave coming in parts of the country,” said Eric Toner, a senior scholar at the Johns Hopkins Center for Health Security. “It’s small and it’s distant so far, but it’s coming.”

Though the outbreaks come weeks into state reopenings, it’s not clear that they’re linked to increased economic activity. And health experts say it’s still too soon to tell whether the massive protests against police brutality that have erupted in the past two weeks have led to more infections.

In Georgia, where hair salons, tattoo parlors and gyms have been operating for a month and a half, case numbers have plateaued, flummoxing experts.

Puzzling differences show up even within states. In California, which imposed a stay-at-home order in late March, San Francisco saw zero cases for three consecutive days this week, while Los Angeles County reported well over half of the state’s new cases. The White House Coronavirus Task Force has yet to see any relationship between reopening and increased cases of Covid-19, Food and Drug Administration Commissioner Stephen Hahn said on a podcast.

But in some states, rising numbers outpace increases in testing, raising concerns about whether the virus can be controlled. It will take a couple of weeks to know, Toner said, but by then “it’s going to be pretty late” to respond.

Since the pandemic initially swept the U.S. starting early this year, 2 million people have been infected and more than 112,000 have died.

After a national shutdown that arrested the spread, rising illness had been expected as restrictions loosened. The trend has been observed across 22 states in recent weeks, though many increases are steady but slow.

In New York, the state hardest hit by Covid-19, Governor Andrew Cuomo only recently started reopening by region. New York City, the epicenter, began the first of four phases Monday.

“We know as a fact that reopening other states, we’re seeing significant problems,” Cuomo said Tuesday. “Just because you reopen does not mean you will have a spike, but if you are not smart, you can have a spike.”

Experts see evidence of a second wave building in Arizona, Texas, Florida and California. Arizona “sticks out like a sore thumb in terms of a major problem,” said Jeffrey Morris, director of the division of biostatistics at University of Pennsylvania’s Perelman School of Medicine.

Arizona Spike

Arizona’s daily tally of new cases has abruptly spiked in the last two weeks, hitting an all-time high of 1,187 on June 2.

This week, its Department of Health Services urged hospitals to activate emergency plans. Director Cara Christ, told a Phoenix television station that she was concerned about the rising case count and percentage of people tested who are found to be positive.

Valleywise Health, the public hospital system in Phoenix, has seen an increase in Covid-19 cases during the past two weeks. It’s expanded its intensive-care capacity and those beds are 87% full, about half with Covid patients, according to Michael White, the chief medical officer.

White said Valleywise has adequate protective gear for staff, but hospitals aren’t getting their entire orders. A surge in Covid cases could put that supply under stress, he said.

The increase in transmission follows steps to resume business and public life as well as the riots and protests.

“Within Phoenix, we’ve been more relaxed than I’ve seen in some of the other parts of the country,” White said, with some people disregarding advice to wear masks and maintain six feet of distance from others. “People are coming together in environments where social distancing is challenging.”

Texas on Wednesday reported a 4.7% jump in hospitalizations to 2,153, the fourth consecutive daily increase. The latest figures showing an escalation came as Governor Greg Abbott tweeted a public service announcement featuring baseball legend Nolan Ryan urging Texans to wash their hands and to not be “a knucklehead.”

Abbott was criticized for an aggressive reopening last month. Mobile-phone data show activity by residents is rebounding toward pre-Covid levels, according to the Children’s Hospital of Philadelphia’s PolicyLab.

That could reflect a perception that the virus wasn’t “ever a big threat,” said Morris, who recently moved to Philadelphia after 20 years in Houston.

Florida’s health department said in a statement that it attributes the increase in cases to “greatly expanded efforts in testing,” and noted that overall positivity rates remain low, at about 5.5%.

Bucking the trend is Georgia, which was the first U.S. state to reopen. Covid cases there have plateaued. Despite local outbreaks in the state, “their sea levels did not rise,” said David Rubin, director of the PolicyLab, which has been modeling the virus’ spread. “They’ve kind of held this fragile equilibrium.”

Creeping In

California was the earliest state to shut down its economy over the coronavirus, after one of the nation’s first outbreaks in the San Francisco Bay Area. It has been slower than most to reopen.

Even so, the state has also seen the number of people hospitalized with Covid-19 rebound in the past two weeks, as commerce accelerates. Case counts are climbing too, although officials attribute that to increased testing and say it’s a sign of preparation.

In part, rising numbers represent the virus spreading into places that largely avoided the first round of infections, including rural Imperial County in California’s southeastern desert. Yet the contagion remains present in places that bore the brunt of the first wave, including Los Angeles County. Hospitalizations there are lower than at the start of May, but deaths remain stubbornly high, with 500 in the past week alone.

Barbara Ferrer, Los Angeles County public health director, said the region has likely not seen the end of the first wave. And despite concerns about infections coming out of mass demonstrations in the sprawling city, she thinks the reopening of the economy will have a bigger impact.

“We’re not at the tail end of anything,” Ferrer said. “We never had a huge peak. We’ve kind of been within this band. We’re not in decline, we’re kind of holding our own in ways that protect the health-care system.” But, she added, “go to Venice and see the crowds, and you’ll understand why I have concerns.”

Another Onslaught

The U.S. has long been bracing for another wave, but future outbreaks are likely to take a different shape. Social distancing and mask-wearing, as well as careful behavior by individuals, are likely to have staying power even as economies reopen.

Experts are steeling for autumn, when changes in weather and back-to-school plans could have damaging repercussions.

“The second wave isn’t going to mirror the first wave exactly,” said Lance Waller, a professor at Emory University’s Rollins School of Public Health in Atlanta. “It’s not snapping back to exactly the same thing as before, because we’re not exactly the way we were before.”

Daniel Lucey, a fellow at the Infectious Diseases Society of America, compared the virus’ new paradigm with a day at the beach: The U.S. has been bracing for another “high tide” like the one that engulfed New York City. Today is a low tide, but “the waves are always coming in.”