Tim Henderson, Stateline
January 23, 2024
Although it’s spotty and inconsistent in many places, wastewater testing is pointing to a new wave of COVID-19 infections, with as many as one-third of Americans expected to contract the disease by late February.
With pandemic fatigue also in full force, and deaths and hospitalizations well down from peaks in 2021 because of high vaccination and immunity rates, many people are inclined to shrug off the new wave, fueled by the JN.1 variant. But COVID-19 continues to take thousands of lives a month. Older, sicker people need to take particular precautions, experts point out, and everybody should think about the debilitating condition known as long COVID that can strike even young, healthy people and last years.
Wastewater testing indicates the current wave of COVID-19 peaked in late December with 1.9 million daily infections, the highest since the omicron wave of 2021. Some experts want to maintain and expand wastewater surveillance to stay on top of future waves at state and local levels, even as the public has wearied of COVID-19 mitigation efforts.
“If you know you are one of the first communities where it’s surging, that could be very helpful,” said Michael Hoerger, a Tulane University School of Medicine assistant professor who made the national estimate about peak infection rates and future infection forecasts.
Like many experts, Hoerger said everybody should be more aware of the high risk and try to avoid getting infected or reinfected with COVID-19, since every new infection increases the chance of long COVID. He said Americans might be experiencing “descent neglect,” the phenomenon that makes people more careless when things are getting better.
“Everyone is vulnerable in some way. The best way to avoid getting long COVID is to avoid getting COVID,” Hoerger said.
Deaths have declined more slowly in states with older populations such as Vermont, Hawaii and Maine, according to a Stateline analysis of preliminary data from the federal Centers for Disease Control and Prevention. Vermont hospital employees started masking again earlier this month amid the new surge.
Alarm bells are going off in other states as well: Indiana’s most populous county asked residents with mild symptoms to avoid crowded emergency rooms to prioritize care for patients seriously ill with COVID-19 and other respiratory illnesses. Michigan reported its highest weekly COVID-19 death toll since late 2022, around 156, in mid-January. Illinois saw a 17% jump in COVID-19 hospitalizations in one week earlier this month.
It can be hard to get a read on local trends, however, when testing is inconsistent and methods of analysis vary.
The CDC publishes a “current conditions” map based on wastewater analysis that shows “high” or “very high” COVID-19 levels in wastewater for every state with sufficient data. The categories are not specific but indicate virus levels that are high compared with the past.
But at the same time, public patience with masking and other precautions is at a low, making it more likely that infection will spread and claim new victims among the vulnerable.
In South Carolina, Clemson University got high marks in 2020 for its wastewater surveillance program, earning a congratulatory visit from the White House coronavirus task force. But today the university has lost interest, said David Freedman, an environmental engineering professor who ran surveillance for three sewer plants, including the university’s.
Today he monitors only one community plant, though he can see that its level of COVID-19 is higher than at any time since 2021 by looking at virus copies detected in tests. Even the university’s plant itself has dropped out of testing, he said.
“The testing is free, but there’s some labor involved in collecting the sample and sending it off, and I haven’t been able to convince the university to keep doing it,” Freedman said. “Interest in this has really fallen off.
“To me it’s almost unethical that we’re not warning people that this highly transmissible virus is still with us and some people should really be taking precautions,” he added. “Some people with higher health risks should really be putting on a mask again.”
A Clemson spokesperson, Joe Galbraith, said the university considers wastewater testing to be a “valuable tool” but decided recently to rely on individual COVID-19 testing instead to monitor the disease within the university. Clemson is, however, partnering with the state and other South Carolina universities to create a statewide wastewater testing program, Galbraith said.
Older people and cancer patients make up an increasing proportion of COVID-19 deaths, according to Stateline’s analysis. People 65 or older made up 88% of those deaths last year, compared with 69% in the peak year for deaths, 2021. Cancer patients made up 12% of COVID-19 deaths last year, up from 5% in 2021.
In some states with older populations, COVID-19 deaths remain stubbornly high compared with other states. Vermont had the lowest COVID-19 death rate in the country in 2021 but now ranks fourth in the number of deaths per capita, behind Kentucky, West Virginia and Mississippi.
Last year Vermont had 220 deaths related to COVID-19, according to the analysis. That was almost two-thirds of the 2021 total of 331 such deaths.
No other state had nearly as high a proportion: Hawaii was next with 35% of its peak-level 2021 COVID-19 death toll happening in 2023. That was followed by Maine (32%), Massachusetts (31%) and New Hampshire (29%), all states with relatively old populations.
Texas, which is relatively young, last year had 10% of the COVID-19 deaths that it did in 2021, about 4,700 compared with 48,000.
Vermont has seen increased hospitalizations for COVID-19 this year and has been suggesting that people wear masks if they think they were exposed or have a high risk of serious illness, said Ben Truman, a spokesperson for the state health department. The guidance also applies to the flu and RSV, which are peaking in winter months, he said.
Residents in Vermont reacted calmly and cooperatively in the early days of the pandemic, saving lives early on compared to other states, said John Davy, an epidemiologist for the state health department.
“It wasn’t divisive. It wasn’t an identity issue here,” Davy said.
In some areas the latest wave of infections may even be higher than the 2021 omicron wave, which crested at around 6.5 million infections per day, according to Hoerger’s analysis. In Santa Clara County, home of California’s Silicon Valley, wastewater shows some areas reached their highest infection counts ever earlier this month.
Hospitalizations and deaths in the area remain low, said Sarah Rudman, a deputy health officer at the county health department, but the county is advising vulnerable people to consult with doctors and consider masking. “It’s an individual decision,” she said.
The county’s wastewater monitoring covers 90% of county residents and has benefited from strong support from local universities. The county uses an advanced form of measurement that can estimate the number of cases in the community without individual testing, Rudman said. It helps that the county started gathering data early and can compare levels from the start of the pandemic, she added.
Even those without underlying risk factors can get debilitating long COVID.
Jay Breneman was 39 and athletic, cycling and training for marathons, when he got COVID-19 in the summer of 2022 — too young to qualify for medication such as Paxlovid at the time. He ended up bedridden or in a wheelchair for more than a year.
Now the president of the Erie, Pennsylvania, school board, Breneman said he masks in public despite heckling, including from a man who told him at the county Democratic Party headquarters on election night that COVID-19 was “a hoax.”
“This has been hell. There’s no other word that describes it,” Breneman said. “I wouldn’t wish it on anybody. And every single person I know is sick with something right now. The last thing I want now is to get sick again.”
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