COVID may increase in the US and we may not know

The rise of Covid cases in some regions of the US, just as testing efforts are waning, has raised the specter that the next big wave of the virus may be hard to detect. In fact, the country may be in the middle of a wave right now and we may not even know it.

Testing and viral sequencing are critical to responding quickly to new outbreaks of Covid. And yet, as the country tries to put the pandemic behind it, demand for lab testing has declined and federal funding priorities have shifted. The change has forced some testing centers to close, while others have raised prices in response to the end of government-funded testing programs. People are increasingly relying on at-home rapid tests if they decide to test at all. But those results are rarely reported, leaving public health officials with little insight into how widespread the virus really is.

“There is always more spread than we can detect,” said Abraar Karan, an infectious disease physician at Stanford University. “That’s even more true now than before in the pandemic.”

Despite groundbreaking scientific advances such as vaccines and antivirals, public health experts say US Covid defenses appear to be getting weaker, not stronger, over time.

“We’re in a worse position,” said Julia Raifman, an assistant professor of health law, policy, and management at Boston University School of Public Health. “We learned more about the virus and how to deal with it, and then we didn’t do what we needed to do to deal with it.”

In late February, the Centers for Disease Control and Prevention began relying on hospital admissions and ICU capacity to determine risk at a community level. That was a change from reliance on the number of Covid cases and the percentage of positive tests, which are widely regarded as a better snapshot of how much virus is circulating in a given community. Several states, including Arizona, Hawaii, Nevada and Ohio, have now completely stopped reporting daily Covid data to the CDC, making it more difficult to measure the progress of the pandemic in those states.

According to the CDC, most of the country is still considered low risk. However, public health experts argue that this is misleading, as hospitalization and death typically occur days to weeks after the initial infection. Without widespread testing, it would be impossible to detect a spike until it’s too late to do anything about it.

“CDC underestimates and downplays cases,” said Gregg Gonsalves, an infectious disease expert at Yale’s School of Public Health. “Their alarm bells won’t go off until we see an increase in hospitalizations and deaths, which are lagging indicators.”

Transferable variant

While omicron tends to cause milder symptoms in healthy, vaccinated people, its transmissibility led to such a massive spike in cases that it broke previous pandemic records in hospital admissions. The variant also ensured that a record number of children went to hospital. During the New York Gulf, black people were hospitalized twice as often as whites. Vaccines are extraordinarily effective at preventing serious illness, if not always preventing cases, one of the reasons the statistics have shifted to hospitalizations to assess the condition of the virus. But not following cases creates a blind spot. Experts say it is critical to continue monitoring them to protect vulnerable communities and respond to new waves of the virus before the health system becomes overwhelmed.

In recent weeks, cases have started to mount in places like New York, Massachusetts and Chicago, but conflicting public reports have caused confusion. National leaders have largely declared victory over the virus, but some local governments are once again urging caution. New York City postponed lifting a mask mandate for children under 5 due to rising cases, and the city’s health commissioner advised New Yorkers to return to indoor masks.

Still, even in New York, things look very different from the onset of previous peaks. Gone are the days of long test lines and sold-out antigen tests. And all over the country, pop-up test centers, once a pandemic mainstay, are beginning to disappear. Although state-run testing facilities have continued to operate in some regions, people without health insurance face high prices. And as of March 22, the U.S. Health Resources and Services Administration will also no longer accept reimbursement claims from health care providers for Covid testing.

At the same time, rapid testing at home has increased. The problem is, the CDC doesn’t require people to report positive home test results, so it’s rare for home test results to feed into public health data.

“We probably underestimate the number of infections we have now because a lot of the infections are either symptom-free or minimally symptomatic and you’re going to miss people doing it at home,” Anthony Fauci, President Joe Biden’s top medical adviser, told Bloomberg TV on Wednesday.

In New Jersey, for example, Stacy Flanagan, the director of health and human services for Jersey City, said she’s called only two people in the past three months to report positive tests at home. According to data from the health department, cases in the city are continuing rapidly with an average of 64 new cases per day. That’s almost double the number of daily cases reported a month ago.

“We’ve heard of only a handful of conscientious people calling us and saying, ‘I took a home test and it’s positive,’” said Dave Henry, the health officer for more than a dozen cities in New York’s Monmouth County. Jersey.

Public health experts must compile data from a variety of sources. For Rick Bright, a virologist and CEO of the Rockefeller Foundation’s Pandemic Prevention Institute, that means using the CDC data and a number of other resources to understand the spread of Covid. “Unfortunately, we still have to go to a handful of sites to try and bring together what’s really happening across the country.”

Other metrics such as wastewater monitoring and even air sampling could eventually become useful alternatives for understanding how much virus is circulating in a community. For weeks, sewage data shows that cases are on the rise in some regions of the US — heralding the surge in the positives places like New York and Massachusetts are now seeing.

In the nation’s capital, more than 50 people who attended the elite Gridiron Club dinner on April 2 tested positive for the coronavirus, the Washington Post reported — at least 8 percent of those who attended. The list of infected persons includes the US Attorney General, Secretary of Commerce, aides to Vice President Kamala Harris and First Lady Jill Biden, and the president’s sister.

Speaker of the House Nancy Pelosi, who did not attend the dinner, also tested positive, raising concerns about the time she spent with President Biden prior to her diagnosis.

Test at home

The White House insists there is enough data on Covid in circulation to accommodate the next wave. Tom Inglesby, senior policy advisor for Biden’s Covid-19 response team, said the CDC receives 850,000 lab test results each day, which he believes is enough to detect trends in positivity rate and variant prevalence.

“It’s true that there’s now a bigger shift to switch to over-the-counter testing, that’s definitely happening,” Inglesby said during a panel discussion. “Several efforts are underway to try and assess whether people are willing to volunteer some of the tests performed at home.” A biotech company, Ellume, has rolled out a home test and app that automatically reports positive tests to the CDC over a secure, HIPAA-compliant connection.

Meanwhile, the CDC has pledged to step up its wastewater monitoring efforts. The agency doesn’t yet have data from locations in every state, so it may even be helpful to access some of the sampling already underway. Environmental surveillance, like many other tools to detect Covid, could be at risk without additional funding from Congress. On Tuesday, lawmakers reached an agreement to reallocate $10 billion to pandemic preparedness, which press secretary Jen Psaki said would fund “the most immediate needs” such as antivirals and testing. That bill has yet to be approved by the Senate.

“The information we get from the CDC will be less reliable, spotty and losing power,” Bright said. “There are really big concerns about the lack of sustainable funding to keep the momentum going and get the job done for the surveillance we’re building for pandemic prevention.”

A lesson could be learned from the 1918 flu pandemic. After the number of cases began to decline after the first two waves of the flu virus, public sentiment shifted and many health measures were lifted. But in 1919, at the end of the pandemic, a fourth wave hit New York City, causing deaths to rise higher than during previous waves, according to a government-funded study.

“These late waves of pandemics are sometimes the deadliest because people have given up,” Yale’s Gonsalves said.

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