Health Care

Experts say a Covid-19 holiday surge is likely. What happens next?

A Covid-19 testing site on Pine Street in Burlington on Aug. 24. Photo by Glenn Russell/VTDigger

Updated at 2:19 p.m.

For the second year in a row, Halloween proved to be a tipping point for Covid-19.

In 2020 — before the vaccine, before the Delta wave, with mask orders in place, when many towns canceled official celebrations — cases rose more than fivefold in the three weeks after Halloween. Covid-19 hospitalizations soon followed, rising from roughly three people at a time to more than 20.

Although state officials advised caution about large indoor parties this year, Vermont had no restrictions on Halloween. Gov. Phil Scott had already lifted them months earlier when the state hit its vaccination targets. 

Vermont also went into this Halloween with a higher baseline — higher than the highest peak of the surge last winter, driven by the Delta variant that one expert described as unbelievably contagious.

Since the start of November, cases have once again boomed. The seven-day case average is now close to double the pre-Halloween average. Hospitalizations, on the other hand, have not spiked so far, as they’re pushed upward by high infection rates but downward by high vaccination levels.

And there are several more major holidays left in the winter season. 

Now, what can be done?

For his part, Scott has declined to reimpose mask mandates and gathering bans. He has said a state of emergency, which would give him the ability to impose restrictions, would be overly broad and an abuse of power. 

Four experts interviewed by VTDigger offered a range of suggestions on where Vermont should go from here. All advocated for masking to different extents — either broad public measures or more targeted requirements — as well as clear and consistent messaging around vaccines and other measures to prevent spread of infections.

‘We knew’

No expert can claim to have a crystal ball to peek into the future of Covid-19, but Anne Sosin can say she saw this coming.

Sosin, a health policy researcher at Dartmouth College, has said for months that Vermont could expect a new wave of infections. 

“None of us want to be correct in projections like this, but I am dismayed to see us here at this point,” she said.

Several factors have pointed to increasing levels of infection since the summer, she said.

Anne Sosin, program director for the Center for Global Health Equity at Dartmouth College, seen at home in Thetford on April 8. Photo by Glenn Russell/VTDigger

“We knew” that a return to in-person schools, reopening offices and traveling this fall would increase people’s mobility and thus exposure, she said, and “we also knew that we're dealing with a more transmissible variant and waning immunity. And so all of these things would have led us to believe early on that we were not going to see an evaporating surge.”

Two factors are of major concern to Vermont’s ability to control the epidemic, she said. The first is the limited capacity in Vermont hospitals’ intensive care units. The number of open beds on a given day has been shrinking, mostly due to visits brought on by mental health crises and delayed care in the pandemic.

Scott himself has expressed concern about the tight capacity. Vermont has had days when there were only 10 open ICU beds in the entire state out of a stock of roughly 100. He recently suggested the real numbers to pay attention to are hospitalizations and ICU stays — as opposed to case counts — because the vaccine limits severe Covid-19 complications.

Sosin said she’s talked with providers across the state and heard concerns that the strained capacity is already having an effect on patients not getting care or not getting the care they need. Hospitals are getting backed up because they cannot discharge Covid-19 patients. 

“Patients (are) languishing in critical access hospitals or other places because they can't be transferred to an academic medical center,” she said. “While not all this was Covid-related, I am very concerned about what a looming surge will mean.”

In Colorado, that concern has become a reality. The state implemented crisis standards of care — meaning it must ration hospital resources to certain patients because of the strain. Sosin said Colorado’s example should “give us pause” here in Vermont.

[Looking for data on breakthrough cases? See our reporting on the latest available statistics.]

The second concern: Vermont has also pulled back on contact tracing. The Department of Health recently announced that it plans to interview only high-risk Vermonters, a measure that Sosin called a clear indicator that Vermont has lost control of the epidemic. 

“When we outstrip our contact tracing capacity, like we've done, we know that we're at a really dangerous point,” she said.

Despite the bad signs, Sosin believes it’s not too late to shift course. She doesn't advocate for lockdowns or closures, but her key recommendation is a data-driven mask policy for public places. She has pushed back on Scott’s assertion that mask mandates are ineffective, pointing to evidence that state policies have increased people’s masking in the real world.

Some researchers agree with her. 

Julia Raifman, an assistant professor at the Boston University School of Public Health, said Nevada is paving the way for a mask policy that fits the changing environment of the post-vaccine world. 

The state tracks county-level transmission, and when it hits the U.S. Centers for Disease Control and Prevention’s threshold for substantial transmission, it puts a mask order in place until the numbers come back down.

“I think that's a really nice approach because it lets everybody know that they don't need to mask forever,” Raifman said. “It sets out a very rational strategy for when people do and don't mask.”

One of the benefits of the policy is that Nevada has to implement it only one time, and then it “protects you against the unpredictable elements of the virus,” she said.

Ajay Sethi, an associate professor at the University of Wisconsin-Madison who focuses on population health, is more doubtful about whether people will comply with a mask order. 

Scott argued earlier this month that Vermonters would be unlikely to follow a statewide mask order. 

“You can put all the restrictions in place, but if they’re not adhered to, it’s all for naught. And then you do create areas of confrontation,” he said.

Sethi said that just going around in his daily life, “you see a lot of people not wearing masks when maybe they ought to. And we're definitely in a different world today than we were a year ago, where the desire to do any kind of mitigation is not great.”

It’s become difficult to do that in many places because of the lingering association between mask orders and assaults on personal freedom, he said. 

“It's almost a knee-jerk reflex, and it just makes it very hard to even have people adopt almost anything related to mitigation,” Sethi said.

Sethi said having buy-in from all levels of government — and a comprehensive approach — is what’s needed, but he believes we don’t really have it anywhere in the United States at this point.

A better example, he said, would be Bangladesh, where local health workers and researchers collaborated to promote mask-wearing, provide free masks, and educate the public on how and when to wear masks. Mask-wearing tripled, and the study has become the largest-ever trial demonstrating the effectiveness of masks for preventing symptomatic cases of the disease.  

“There is something to be said for leadership at all levels — not just the governor but from the governor down — for having unanimity in how to handle a pandemic. And having one message, one voice,” he said.

Sosin agrees. She said one thing the state’s response has been missing is consistent, clear messaging and guidance to help Vermonters make informed decisions. 

“Many have done all of those right things, everything that's been asked of them, and simply don't understand that it is possible (that) in a setting of widespread community transmission (you can) become infected and transmit to others,” she said. 

Much of the guidance the Department of Health provides is tailored to individual risk, neglecting the fact that each individual is part of family and social networks.

“You may be in your 20s, but if you're going to visit family for Thanksgiving, then what you do (can) have potential impacts on them,” she said.

‘A more dangerous world’

Pam Berenbaum advocates for a more targeted approach to mask-wearing. The director of the Global Health Program at Middlebury College, Berenbaum said mask mandates are best suited to schools and workplaces where “people whose social circles are really different (are) stuck together for eight hours a day.”

But she doesn’t believe in a broad mask mandate for all public settings, and she’s concerned about the potential that indefinite restrictions will wear people down.

“We do know some things about how people feel about the pandemic. People are sick of it,” she said. “People really appreciated the relaxation of the restrictions in the summer.”

Now that Vermonters have vaccines, people need to be able to reclaim their lives, she said — even though people are going to keep getting Covid-19. 

“The vaccines work really well at minimizing severe illness and death, which is all they were ever designed to do,” she said. “They were not designed to make Covid go away or to keep people from getting sick. They were designed to keep people out of the ICU.”

Vaccinations are the critical component to curbing the spread of the virus, Berenbaum said, although she believes the effort needs to be national and global since unvaccinated people are “petri dishes” for new variants that put everyone at risk.

On the other hand, if people are getting together with other vaccinated friends, for example, Berenbaum does not think there’s any reason to wear masks. 

“If we're going to wear masks in that situation, we need to wear masks for the rest of our lives,” she said.

She also does not think mask mandates are necessary in most public spaces that people pass through, such as restaurant takeout or grocery stores, because the length of time spent there limits the possibility of transmission.

As for the holidays, she said Vermont’s rigid lockdown and great compliance early in the pandemic delayed a gigantic surge, but it could very well be on its way. 

“Every place seems to have a big surge at some point, and I feel like this is the surge that we've just been kind of putting off,” she said. “It's like doing your taxes. You can do (them) sooner or you can do (them) later, but you’ve got to do them eventually.”

What about high-risk people, who are vulnerable even after vaccination? Berenbaum is sympathetic — she’s in that category herself. 

“The bottom line is we now live in a more dangerous world,” she said.

“It's kind of like when Los Alamos detonated the first atomic bomb,” she said. “The old world where we didn't have nuclear weapons was gone in an instant. And we can never go back to that world.”

Better treatments — like a Covid-19 pill that is up for authorization — and boosters may make life more normal for high-risk people in the far future. She pointed to the example of HIV, which was once a death sentence but now functions more like a chronic disease for Americans who have it.

Still, people in high-risk categories may have to just live their lives a little differently from now on — “which sucks,” she said.

“(Like) every other risk that we face, really high-risk people are going to have to take matters into their own hands to a large extent and be very selective about who they socialize with. And maybe limit eating in restaurants to when they can do it outdoors in the summer,” she said.

But the actions that Vermonters have taken, including a long lockdown, were not meaningless. She said they bought time for the scientific community to understand the virus and develop treatments and the vaccine that will doubtless limit deaths and hospitalizations even when cases surge.

“Hundreds of Vermonters are alive today because (we) were locked down,” she said. “We'll never know how many people, but I'm sure it was a lot, and I think that it was worth it from that standpoint.”

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Erin Petenko

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