In the fourth year of the pandemic, Covid-19 is once again spreading across America and being driven by the recent holidays, fewer precautions and the continuing evolution of Omicron subvariants of the virus.

New sub-variants are causing concern for their increased transmissibility and ability to evade some antibodies, but the same tools continue to curtail the spread of Covid, especially bivalent boosters, masks, ventilation, antivirals and other precautions, experts said.

Yet booster uptake has been “pitiful”, said Neil Sehgal, an assistant professor of health policy and management at the University of Maryland School of Public Health. Antiviral uptake has been low, and few mandates on masking, vaccination and testing have resumed in the face of the winter surge, which is once again putting pressure on health systems.

New Covid hospital admissions are now at the fourth-highest rate of the pandemic, according to the US Centers for Disease Control and Prevention (CDC). Covid hospitalizations declined somewhat after the summer wave, but never dropped to the low levels seen after previous spikes, persisting through the fall and rising again with the winter holidays.

“Hospitals are at maximum capacity,” said Brendan Williams, president and CEO of the New Hampshire Health Care Association, of his region’s current rates. “I’m not sure what the trajectory of this thing’s going to be, but I am worried.”

The majority of Covid hospitalizations are among those 65 and older, although the share for children under four roughly doubled in 2022.

In the past week, Covid deaths rose by 44%, from 2,705 in the week ending 4 January to 3,907 in the week ending 11 January.

This is one of the greatest surges of Covid cases in the entire pandemic, according to wastewater analyses of the virus. It’s much lower than the peak in January 2022, but similar to the summer 2022 surge, which was the second biggest.

And it’s not done yet. “Certainly it does not appear that we are peaking yet,” Sehgal said.

The Omicron subvariants BQ.1.1 and BQ.1 as well as the quickly expanding XBB.1.5 make up the majority of cases, according to CDC estimates. The north-east, where more than 80% of cases are estimated to be from the XBB.1.5 subvariant, has the highest proportion of cases, according to wastewater data.

“With XBB, there’s such a significant transmission advantage that exposure is really risky – it’s riskier now than it’s ever been” in terms of transmissibility, Sehgal said.

Official case counts have been slower to rise, because of the prevalence of at-home tests and because of a general reluctance to test at all, experts say. Of the tests that are reported, however, positivity rates have been very high, with about one in six tests (16%) turning positive.

Despite the high rates of Covid spread, hospitalizations have not yet reached previous peaks seen earlier in the pandemic, probably due to immunity from vaccinations and prior cases, said Stuart Ray, a professor of medicine and infectious diseases at the Johns Hopkins University School of Medicine.

But that protection should not be taken for granted, he said, particularly because immunity wanes.

“Boosters really do make a difference,” he said. “The severe cases we are seeing are probably at least somewhat avoidable, if folks make sure that they stay updated on vaccination, because that’s still the safest way to gain immunity.”

Boosters, especially the updated bivalent boosters, are highly effective at reducing the risk of severe disease and death. Yet only 15.4% of Americans over the age of five have received the new boosters.

“You’re just fighting a lot of misinformation and also some political missteps when it comes to the vaccines,” Williams said. When Joe Biden declared the pandemic was “over” in September, he said, it probably stalled public enthusiasm for the new booster and spurred further inaction from Congress on more funding to address the pandemic.

“It’s challenging to strike that parallel narrative that you shouldn’t worry about Covid but also go get a shot,” said Sehgal, calling the declaration “another unforced error”.

While vaccines are very important, other precautions also help prevent infection, disease, and death, Sehgal said – particularly important during a surge like this. Yet because of poor messaging from officials, many people may not even realize the US is experiencing a surge and precautions are still necessary, he added.

“I think the majority of people who aren’t masking today, just don’t know that they should.”

Even if the US reaches the point where surges do not cause a corresponding increase in hospitalizations and death, they will still increase the number of people sickened and disabled by long Covid, experts said.

“There’s accumulating data that repeated Covid accumulates risk for short- and long-term complications, including cardiovascular, mental health and other problems,” Ray said. “We will only know in retrospect exactly how big this cost is. But evolving data suggests that there is a cost that’s incremental as we accumulate infections.”

Williams is worried that hospitals are reaching maximum capacity even as long-term care facilities see outbreaks among residents and staff, after years of worker shortages.

“In New Hampshire, nursing homes will not admit those that they feel that they cannot staff to care for, which I think is admirable, but the consequence of that is that the hospitals are jammed up,” he said. Hospitals that might release patients to care facilities for transitional or long-term care will see beds filled for longer, putting even more pressure on the hospitals, patients and health workers.

“It’s a continuum, but right now the continuum is broken,” Williams said.

Health workers have experienced three years of burnout, disability and death, and some have needed to exit the workforce. Others have been alarmed by unsafe working conditions and the continued crises caused by the pandemic. Nurses in New York reached a tentative agreement this week after striking for safer working conditions.

Nursing homes and residential care facilities have roughly 300,000 fewer workers today than there were in March 2020, Williams said. “It’s hard to see how it’s going to get better,” he said.

In the meantime, Covid continues circulating, with nursing home residents and staff seeing one of the biggest rises in cases of the pandemic.

“The first key to keeping people healthy in a nursing home is to keep people in the community healthy,” Williams said. But “it just doesn’t seem like people are wearing masks and getting boosted – people aren’t taking any of this seriously. We just seemed to declare that when it comes to Covid mortality, we’re number one, and that’s a title that we’re not going to relinquish to any other country.”

Sehgal calls it a “collective forgetting” about how and why we need to protect ourselves and one another. “There are people for whom a mild infection actually isn’t so mild, either because of their underlying health, or because of social factors in their life,” he said. “It’s just a tremendous self-inflicted wound.”

And the more the virus spreads, the more opportunities it has to evolve, potentially picking up mutations that make it easier to overcome immunity.

Yet the same measures that helped curb previous surges still work today. And they don’t just prevent illness and death – they also minimize social disruption, like lost hours at work and school. “Those steps that we can take to protect ourselves and protect other people – they don’t seem onerous in the face of a Covid infection,” Sehgal said.

As Ray put it: “When we could be wearing a mask, why aren’t we?”

Melody Schreiber

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