June 12, 2020 -- Almost a month after many states began to roll back lockdowns and nearly 3 weeks after Memorial Day celebrations drew more Americans out of their homes to celebrate with friends and family, COVID-19 cases are rising in more than a dozen states across the southern and western regions of the U.S.

In some areas, those increases may be linked to increased testing, but in others, states are seeing spikes even though their testing numbers have been relatively flat, indicating true increases. Some states are also reporting growing numbers of COVID-19 patients needing time in a hospital and intensive care.

While many are calling this a second wave of COVID-19 infections, infectious disease experts say there’s no accepted definition for what a second wave would be. Instead, they say, since the U.S. never eliminated the virus to begin with, it’s probably better to think of the recent increases in some cities and states as a second peak in an ongoing epidemic.

Texas is seeing record numbers of COVID hospitalizations in some of its largest cities, including Dallas, Austin, and Houston.

“I’m growing increasingly concerned that we may be approaching the precipice of a disaster,” Harris County Judge Lina Hidalgo said in a news conference in Houston on Thursday. Since May 1, Texas has reopened in phases, lifting more restrictions every few weeks.

Harris County, with nearly 5 million residents, has a larger population than 24 states. On Thursday, the county raised its threat level in response to rising cases and hospitalizations. Public health officials are urging residents to lessen their contacts with others and once again work to flatten the curve.

From Carolinas to Arizona

Public health officials in other states echoed those fears in recent days.

“Today, I am more concerned about COVID-19 in South Carolina than I have ever been before,” Linda Bell, MD, the state’s chief epidemiologist, said in a June 10 news briefing. She noted that South Carolina had seen some of its highest daily numbers of COVID-19 cases over the past 2 weeks, and that the percentage of COVID-19 tests that came back positive was also increasing, meaning the virus was spreading through the community again.

Oregon Gov. Kate Brown late Thursday pushed pause on plans to loosen restrictions after state health officials said Oregon recorded the highest number of new cases since the pandemic began. 

In Arizona, which lifted its stay-at-home order in mid-May, testing has plateaued, but COVID-19 cases have nearly doubled over the last 2 weeks. Nearly 80% of the state’s ICU beds are now in use, an increase over the same time a month ago. In a letter sent on June 6 and obtained by the Arizona Republic newspaper, the Arizona Department of Health Services urged hospitals to fully use their emergency plans to handle the surge.

Banner Health, the largest hospital system in the state, said its ICU beds were rapidly filling and the number of COVID-19 patients needing ventilators had increased by nearly 500% since mid-May. Banner also said this week that with all nine of its ECMO machines in use by COVID-19 patients, it had run out of ECMO machines to support the most critically ill patients. ECMO machines take over for the work of the heart and lungs. They support the sickest patients through a crisis to give their bodies time to heal.

Other states that have seen cases increase by 10% or more over the last 2 weeks include Alabama, Alaska, Arkansas, California, Florida, Georgia, Idaho, Kentucky, Louisiana, Nevada, New Mexico, North Carolina, North Dakota, Oklahoma, Oregon, Tennessee, Utah, and Vermont. That’s according to data tracked by covidexitstrategy.org, a website run by a team of 10 public health experts and based on data collected by the COVID Tracking Project and the CDC.

“These places are starting to see a rebound,” says Cyrus Shahpar, MD, a medical epidemiologist and former CDC epidemic intelligence officer, who now works with the nonprofit organization Resolve to Save Lives.

“How high this rebound gets is really dependent on personal behaviors. We know people are going out more. How much can that be blunted by personal behaviors? That’s the question right now,” he says.

A Northeastern Recovery

Only a handful of states, including New York, New Jersey, and Massachusetts, have seen their cases drop.

“New York has truly had an up-and-down shape to its curve. It truly went up, and then it came down. They did what they needed to do,” says Carlos Del Rio, MD, an infectious disease specialist at Emory University School of Medicine and Grady Health System in Atlanta.

“Most other places, my own state included, said ‘Oh, the hell with it,’ and we have an ongoing epidemic, basically,” he says. “We had a highly disorganized response.”

While the increased transmission in some states may seem discouraging, infectious disease experts interviewed for this story say it isn’t necessarily surprising.

“I think we need to expect that there’s going to be increased transmission. We have to understand that’s going to happen,” says Sarah Fortune, MD, a professor of immunology and infectious diseases at the Harvard T.H. Chan School of Public Health.

She says the measure of success won’t be whether the U.S. sees an uptick in transmission, but whether we are able to keep COVID-19 infections from increasing exponentially so individual cities and states don’t lose control.

In response to rising cases, Nashville Mayor John Cooper delayed his city’s next phase of reopening, which would have allowed restaurants and retail stores to operate at full capacity.

North Carolina’s governor, Roy Cooper, warned that schools might not reopen in the fall if cases continue their upward trend there.

But other governors, including those in Texas, Arizona, and Arkansas, have said they have no plans to order future lockdowns, even as cases rise in their states.

With little government support on the horizon, experts emphasized personal responsibility will be key to staying safe for the foreseeable future.

“People really need to be thinking that it’s up to them what they do. It’s up to you. Don’t get infected,” Del Rio says.

CDC Offers Guidance

On Friday, in its first news briefing since March, the CDC issued new suggestions to help people decide whether to take part in certain activities.

“I know that people are eager to return to normal activities and ways of life. However, it’s important we remember that this situation is unprecedented and that the pandemic has not ended,” said CDC Director Robert Redfield, MD.

“It’s going to be critical to continue to embrace the principles of social distancing, hand-washing, and wearing a face covering when we’re in public,” he said.

Will it work? That depends, says Tom Ingelsby, MD, director of the Johns Hopkins Center for Health Security.

“It’s possible to do a great deal as individuals,” he says.

“We’ve seen historically that action taken by individuals has made a big difference in other parts of the world,” Ingelsby says.

“On the other hand, if the guidance isn’t clear from the top, from our political leaders and public health leaders, people will be confused.”

Confused about whether to wear a mask; confused about whether the virus is still a threat; and confused about whether they should still be staying at home, Ingelsby says. The messaging from the top matters, he says.

President Donald Trump, for example, has declined to wear a mask in public. He’s said he intends to hold political rallies as he campaigns for reelection, and he’s been searching for a state that will guarantee full attendance for the Republican National Convention this summer

Bell, the South Carolina state epidemiologist, says she’s seen some of that confusion playing out in her state.

She says many people across South Carolina were ignoring advice from public health experts to wear masks and avoid large gatherings.

Bell says the rising numbers underscored the reason it was so critical for “every one of us, every day, to wear a mask in public and to stay physically distanced from one another.”

“We’re all eager to return to our normal lives and what our new normal will be, but it will take us that much longer to get there if we don’t stop the virus today.”

Show Sources

Linda Bell, MD, state epidemiologist, South Carolina.

Cyrus Shahpar, MD, medical epidemiologist; director, Prevent Epidemics Team, Resolve to Save Lives, New York City.

Carlos Del Rio, MD, professor and chair, Department of Global Heath, Rollins School of Public Health, Emory University School of Medicine, Atlanta.

Sarah Fortune, MD, professor of immunology and infectious diseases, Harvard T.H. Chan School of Public Health, Cambridge, MA.

Robert Redfield, MD, director, CDC, Atlanta.

Tom Ingelsby, MD, director, Johns Hopkins Center for Health Security, Baltimore.

The COVID Tracking Project, accessed June 10, 2020.

COVIDexitstrategy.org, accessed June 10, 2020.

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