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Fears of coronavirus jump intensify in Thanksgiving’s aftermath (nationthailand.com)

Fears of coronavirus jump intensify in Thanksgiving’s aftermath

Health & BeautyNov 29. 2020

By The Washington Post · Sarah Kaplan · NATIONAL, HEALTH, SCIENCE-ENVIRONMENT, HEALTH-NEWS 
At a rural health system in Wisconsin, officials and medical experts began drawing up protocols for the once unthinkable practice of deciding which patients should get care.

The chief quality officer of a major New York hospital network double- and triple-checked his system’s stockpile of emergency equipment, grimly recalling the last time he had to count how many ventilators he had left. In Arizona, a battle-weary doctor watched in horror as people flooded airports and flocked to stores for Black Friday sales, knowing it was only a matter of time before some of them wound up in his emergency room. 

Days after millions of Americans ignored health guidance to avoid travel and large Thanksgiving gatherings, it’s still too soon to tell how many people became infected with the coronavirus over the course of the holiday weekend. But as travelers head home to communities already hit hard by the disease, hospitals and health officials across the country are bracing for what scientist Dave O’Connor called “a surge on top of a surge.”

“It is painful to watch,” said O’Connor, a virologist at the University of Wisconsin at Madison. “Like seeing two trains in the distance and knowing they’re about to crash, but you can’t do anything to stop it.”

“Because of the decisions and rationalizations people made to celebrate,” the scientist added, “we’re in for a very dark December.” 

The holiday, which is typically one of the busiest travel periods of the year, fell at a particularly dire time in the pandemic. Some 4 million Americans have been diagnosed with the coronavirus in November – twice the previous record, which was set last month. More than 2,000 people are dying every day. Despite that, over a million people passed through U.S. airports the day before Thanksgiving – the highest number of travelers seen since the start of the outbreak. 

Many states did not report new case counts over the holiday, and it typically takes about a week for official records to catch up after reporting delays, said Caitlin Rivers, an epidemiologist at the Johns Hopkins Center for Health Security. 

But in two to three weeks, she said, “I fully expect on a national level we will see those trends continue of new highs in case counts and hospitalizations and deaths.”

The nation has already notched several bleak milestones over the holiday weekend. On Thanksgiving Day, hospitalizations in the United States exceeded 90,000 people for the first time. The following day, the country hit 13 million cases. At least nine states have seen 1 in every 1,000 residents die from the coronavirus.

Mark Jarret, the chief quality officer for New York’s Northwell Health system, said he understood that many people are tiring of constant vigilance after nine months of isolation and Zoom gatherings and waving at people from six feet away.

“But we’re so close to getting some control,” he said, noting that federal officials are on the verge of authorizing one or more vaccines against the virus next month. “This is not the time to let up. This is the time to put on the best defense we can to prevent further spread, further death.”

Officials urged people who traveled or spent time with people outside their household to stay at home for 14 days to avoid further spread of the virus. And some jurisdictions are moving toward lockdown measures not seen since the spring. Los Angeles County on Friday issued a three-week “safer at home” order, limiting business capacity and prohibiting gatherings other than religious rervices and protests. 

Meanwhile, the December holidays are looming.

“Hopefully people will try to minimize their risks around Christmas, especially if there’s data that show Thanksgiving was really harmful,” O’Connor said. 

To Cleavon Gilman, a Navy veteran and emergency room doctor in Yuma, Ariz., the wave of holiday travel was “a slap in the face.”

“It’s as if there’s not a pandemic happening,” he said. “We’re in a war right now, and half the country isn’t on board.”

On Friday, members of the University of Arizona coronavirus modeling team issued an urgent warning to state health officials, projecting that the state will exceed ICU capacity by the beginning of December.

“If action is not immediately taken, then it risks a catastrophe on a scale of the worst natural disaster the state has ever experienced,” the team wrote in a letter to Steven Bailey, chief of the Bureau of Public Health Statistics. “It would be akin to facing a major forest fire without evacuation orders.”

Arizona has no statewide mask mandate, and businesses in many parts of the state, including indoor dining at restaurants, remain open.

Gilman said the intensive care unit at his hospital is full, and there’s nowhere to transfer new patients. When he’s home, his mind echoes with the sound of people gasping for breath. He and his colleagues are exhausted, and with cases spiking across the country, he worries there is no way they can handle the surge that will likely follow Thanksgiving celebrations.

In La Crosse, Wis., Gundersen Health System chief executive Scott Rathgaber echoed that fear. “We’ve had to tell our hard-working staff, ‘There’s no one out there to come rescue us,'” he said.

Like many in his college town, Rathgaber is anxious about what will happen when students who spent the holiday with their families return to campus. Though the University of Wisconsin and other schools shifted classes online for the remainder of the semester, he anticipate students who have jobs and apartments in La Crosse will return to town.

“We had trouble the first time the students came back,” Rathgaber said, noting that the start of college classes in September preceded outbreaks in nursing homes and a spike in deaths in La Crosse County. “I will continue to implore, to beg people to take this seriously.”

Gundersen has already more than tripled the size of the covid-19 ward at its main hospital, and even before this week it was almost entirely full. Physicians from the system’s rural clinics have been reassigned to La Crosse to help in the ICU. Staff who were exposed to the virus are being called back before completing their 14-day quarantine. And Rathgaber now attends regular meetings with ethicists and end-of-life caregivers to figure out Gundersen’s triage protocol if the hospital becomes overwhelmed. 

“We’re not at a breaking point, but we are getting there,” Rathgaber said. “I’m concerned about what the next two weeks will bring.”

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Two-dose coronavirus vaccine regimens will make it harder to inoculate America (nationthailand.com)

Two-dose coronavirus vaccine regimens will make it harder to inoculate America

Health & BeautyNov 28. 2020On the road outside rural Wessington Springs, S.D., where 1 in 37 people had the virus this month. MUST CREDIT: Photo for The Washington Post by Jenn Ackerman 

By The Washington Post · Frances Stead Sellers · NATIONAL, HEALTH, SCIENCE-ENVIRONMENT, HEALTH-NEWS, HEALTH-FEATURES

When Molly Howell talks about the two-shot regimen needed to vaccinate residents of North Dakota’s 210 long-term-care facilities against the coronavirus, she sounds like a general mobilizing a massive air lift without knowing how many planes she will have.

As the state’s immunization program manager, Howell is on top of mass vaccinations for seasonal flu, essentially a one-stop shot. And she is well versed in serial immunizations, like the two-step shingles shots. But for the current coronavirus vaccines, which require two injections spaced either three or four weeks apart, she anticipates clinicians having to make many more than two visits to facilities. Will health-care workers be considered a high-priority group and thus scheduled for vaccination sooner than at-risk residents? How should shift workers be accommodated? And what about the many people who move in or out of facilities in the window between shots?

“It definitely will be an iterative process,” Howell said, as she multiplied those problems through jails, group homes and homeless shelters, wondering how not to waste precious doses if somebody doesn’t show up as expected for their second shot, leaving a precious vial in the refrigerator.

“Do you use second doses for first doses?” Howell speculated.

As the nation gears up to vaccinate tens of millions of Americans against the novel coronavirus, public health officials like her are facing novel dilemmas, driven by the urgency of the pandemic, the fact that only a small minority may have immunity from prior exposure and by the vaccine available at each site, with the differing intervals between shots depending on the manufacturer.

They will need to keep track of people who have received one dose in order to send a reminder about the need to return a few weeks later. They worry that the first vaccine may make people feel just sick enough that they won’t want to go through the ordeal again. And they foresee hitches if people get their first dose at, say, Walgreens and go to CVS for their second, or, worse still, if they cross state borders, moving from one health department’s registration system to another.

“Two doses more than doubles the logistical challenges of administering the vaccines,” said Jeffrey Duchin, health officer for public health in Seattle and King County, Wash. “The moving parts have to align.”

A two- or three-dose dose regimen is routine for building immunity against many illnesses, but it is unprecedented in a pandemic when the public health goal is to vaccinate 60 to 70% of the population within months to reach herd immunity and stop the virus’s spread.

“This is the only time we’ve faced a serious, immediate threat to the entire population that requires a two-dose vaccine,” said Kelly Moore of the Immunization Action Coalition, who was director of Tennessee’s program in 2009 during the H1N1 pandemic and recalls her relief when she learned everyone but young children would need only one shot.

That was possible because unlike covid-19, which is caused by a novel virus, an influenza similar to H1N1 had previously circulated in humans giving many people partial immunity. Clinical trials showed that protection was afforded with only one injection.

With Ebola, Moore said, both single- and two-dose vaccines exist and experts have been figuring out how best to deploy them both in and around outbreaks, depending on the availability of supplies.

It’s not unusual for a vaccine to require re-upping in order to provoke the immune system to respond more effectively. The classic schedule for vaccines that target proteins like the spike protein on the surface of this coronavirus, Moore said, is three shots – “prime, prime, boost” – with the second and third shots coming one and six months after the first injection. Each of the first two shots primes the immune system and is typically followed by a modest drop-off in antibodies. The third shot, usually at least six months after the first one, can give long-term protection by boosting the immune system’s memory cells, which by that point have matured and are ready to respond.

It’s not yet clear whether any of the new coronavirus vaccines in the pipeline will ultimately work best with a third shot capable of boosting long-term protection.

“Memory cells increase stepwise during at least six months,” said Claire-Anne Siegrist, a professor of vaccinology at the University of Geneva and head of the World Health Organization’s Collaborating Center for Vaccine Immunology. The urgency of the increasing infection rates and death tolls has led to the promotion of an immediate two-shot solution.

“In a ramping pandemic, where efficacy should be elicited as rapidly as possible, giving two primary vaccine doses and following to see whether and when a booster might be needed is a most reasonable choice,” she said.

It’s also possible that fewer doses may prove sufficient.

“For all we know, all these two-dose vaccines may work in one dose,” Duchin said.

Data will be gathered as populations are immunized, providing further information about how best to vanquish this particular disease.

“I think we have to learn what is needed to keep immunity,” said Bruce Gellin, president of global immunization at the Sabin Vaccine Institute, fine-tuning strategies and policies based on the evolving science, with the potential for revaccination in the future, as with the annual flu vaccine.

“There are a lot of missing data points,” said John Brownstein, chief innovation officer at Boston Children’s Hospital, who runs Vaccine Finder, a system developed by Google a decade ago to help deploy the H1N1 vaccine.

The Vaccine Finder is designed to help people find providers of vaccines, from flu to shingles, close to where they live. The system doesn’t collect personal data, however, which would be necessary to send out reminders to individuals about a second coronavirus shot, for example.

“Right now, it’s a one-way push,” said Brownstein, who described his ambitions to rebuild the infrastructure so people could receive updates and information about scheduled vaccines.

The challenges of registering individuals and reminding them electronically about their second shots are daunting, said Sacramento County Health Director Peter Beilenson, who like Howell is concerned about the potential inefficiency of staggered staff and residents’ immunizations in long-term-care and other residential facilities.

The two-shot emergency schedule will upend the way many health departments have organized mass vaccination programs in recent years. For a decade, the Vanderbilt University School of Medicine has developed a program to immunize students, faculty, staff and volunteers against the flu – a one-shot-and-you’re-done deal that has succeeded in immunizing as many as 15,000 people in a single day.

Many of those efficiencies won’t be possible with the two-shot regime.

“It does impact staffing resources” at a time when health-care workers are already stretched thin, said Vanderbilt infectious-disease chief Thomas Talbot.

The coronavirus vaccines may give headaches, fevers and other unpleasant symptoms – all good signs of the body’s immune system getting to work – but Talbot is concerned they may prevent people from returning for their second dose.

Moore, who has studied another painful vaccine – two-dose shingles shots – says she is heartened by the way a vast majority of people who are educated about what to expect come back for their second doses despite the discomfort.

“I am very encouraged that our experience with Shingrix is that motivated people will come back as long as they are properly prepared to do so,” Moore said.

And while the challenges ahead are daunting, Howell said she is glad to be able to think them through with other experts.

“It’s comforting that we are all in same position,” she said. “All of us are going to figure this out.”

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Hospitals race to set vaccine priorities for health-care workers (nationthailand.com)

Hospitals race to set vaccine priorities for health-care workers

Health & BeautyNov 28. 2020

By Syndication Washington Post, Bloomberg · Angelica LaVito · NATIONAL, HEALTH, HEALTH-NEWS

Large hospital systems are grappling with how best to decide which health-care workers will be vaccinated first for covid-19, a daunting task when it’s unclear which shots they’ll get, how many and when they’ll arrive.

The first covid-19 vaccine could be cleared for U.S. use as soon as next month, with Pfizer Inc. and BioNTech SE’s candidate already under review and Moderna Inc.’s shot not far behind. Federal officials, meanwhile, have signaled that health-care workers and older Americans at high risk should be vaccinated as step one in what could set off months of fraught decisions involving other key priority groups.

But following those initial guidelines could prove difficult. With 21 million health-care workers in the U.S., there almost certainly won’t be enough doses to reach them all at once. That’s forcing hospitals to categorize their workers based on best-guess distribution estimates, a task made even more complex for some systems by a patchwork state-by-state approach.

Minnesota’s Allina Health system, which employs 15,600 workers who have direct contact with patients in Minnesota and Wisconsin, is estimating it could get 3,000 to 4,000 doses initially. The plan: Prioritize those that interact directly with coronavirus patients by listing each worker by their job type and the units they work in.

“We’re looking at all employees, where they work, what their roles are and what their exposure risk is,” said Ryan Else, a doctor who is overseeing the coronavirus response in Allina Health’s hospitals.

Health systems that operate across state lines face an even bigger challenge. While states are taking cues from federal guidelines, they are developing their own priority lists, creating a situation where some employees in one state might get vaccinated before their peers in another.

“How fair does that feel to people in the same system?” said Amy Compton-Phillips, a doctor and chief clinical officer at Providence, which operates 51 hospitals, as well clinics and medical offices across seven states.

Like Allina, Providence also plans to vaccinate workers based on their roles in an attempt at fairness. The health system will notify workers when it’s their turn to get vaccinated. It is also creating an appeal process if people think groups were misclassified. “When things are in short supply, you make really hard decisions. They don’t feel good,” Compton-Phillips said.

Federal officials plan to initially send 6.4 million doses across the country, according to Gus Perna, Operation Warp Speed’s chief operating officer. More doses will then be sent out on a weekly basis with the goal of distributing 40 million doses by the end of the year, Perna said on a call with reporters Tuesday.

Shipments will be divvied up across states based on the size of their adult populations, and not in response to any virus surges, U.S. Department of Health and Human Services Secretary Alex Azar said on the call.

“We wanted to keep this simple, first because we’re seeing nationwide spread and susceptibility to the disease,” Azar said. “But also, once we pass through these initial tranches where we’re in much more of a scarcity situation, we’re eventually going to get to the point where it would need to be per capita. So instead of having multiple methodologies, we thought it best to keep it simple.”

Some health systems are taking a more granular approach in preparing for use of the shots.

Advocate Aurora Health Inc., with 26 hospitals and even more clinics and doctors across Illinois and Wisconsin, is identifying workers at greatest risk of severe illness, anticipating it will not receive enough doses to cover employees evenly. That means factoring in details like how prevalent the coronavirus is in a particular community, as well as employees’ risk factors, said Robert Citronberg, a doctor and executive medical director of infectious disease and prevention.

“We want to target as best as possible the people who are most likely to get severely ill from covid, and we know those are older people, people with underlying medical conditions,” Citronberg said.

New York’s Northwell Health, with 23 hospitals, has already compiled a spreadsheet of its 74,000 workers that categorizes them by their risk of catching the novel coronavirus on the job, according to Mark Jarrett, who is a doctor and the system’s chief quality officer.

Northwell’s calculation weighs how much employees interact with infected patients and, like Advocate Aurora, how prevalent the virus is in the community. That second data point could change at times, resulting in people working in areas with more spread being vaccinated first.

And Jarrett brings another issue to the table. He’s worried less about people clamoring for a vaccine and more about workers not wanting one, a fear other hospital executives across the country echoed.

Health systems already had to contend with anti-vaccination movements when concerns about the quick speed of covid-19 vaccine development further spooked workers, Providence’s Compton-Phillips said.

Allison Suttle, a doctor and chief medical officer of Sioux Falls, South Dakota-based Sanford Health, hopes clinical trial data will reassure the system’s workers. Internal surveys found more people said they would take a covid-19 vaccine after Pfizer and Moderna released early results showing their candidates were each around 95% effective.

“I’m optimistic, cautiously optimistic, and proud of our health-care workers that they’re willing to jump up, stick out their shoulder and get the vaccine,” Suttle said.

If and when the Food and Drug Administration authorizes vaccine candidates, the Centers for Disease Control and Prevention will make its final recommendations for whom to vaccinate. Members of the CDC’s immunization committee will review the data for clues on whether the formulas work better in some groups than others.

In the meantime, health systems will continue preparing as best they can. When asked whether Northwell knows how many doses it will receive, Jarrett laughed.

“Nope,” he answered. Any estimates are likely to change, Jarrett said, and even the smallest of fluctuations could make a big difference.

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AstraZeneca eyes extra global vaccine trial as questions mount (nationthailand.com)

AstraZeneca eyes extra global vaccine trial as questions mount

Health & BeautyNov 28. 2020

By Syndication Washington Post, Bloomberg · Suzi Ring, James Paton · NATIONAL, BUSINESS, HEALTH, HEALTH-NEWS

AstraZeneca’s covid-19 vaccine looks as if it’s headed for an additional global trial as the drugmaker tries to clear up uncertainty and confusion surrounding favorable results in its current study.

The company wants the new test to confirm the 90% efficacy rate that the shot showed in a portion of an existing trial, Chief Executive Officer Pascal Soriot said. It’s favoring that option rather than adding an arm to a separate study that’s already underway in the U.S.

Questions are mounting over one of the fastest-moving shots after the company acknowledged that a lower dosage level that appeared more effective resulted from a manufacturing discrepancy. The company and its partner, the University of Oxford, didn’t initially disclose the error and other key details, leading to concern over their transparency.

“Now that we’ve found what looks like a better efficacy we have to validate this, so we need to do an additional study,” Soriot said in his first interview since the data were released. It will probably be another “international study, but this one could be faster because we know the efficacy is high so we need a smaller number of patients.”

Soriot said he didn’t expect the additional trial to hold up regulatory approvals in the U.K. and European Union.

U.K. Health Secretary Matt Hancock asked the nation’s medical regulator to potentially bypass its E.U. counterpart and approve the supply of AstraZeneca’s vaccine to speed its deployment. Until the end of the year, when the U.K. exits a post-Brexit transition period, vaccines must be authorized by the European Medicines Agency. But on Friday, Hancock said he invoked a special rule allowing Britain’s regulator to authorize a temporary supply of the vaccine if the data is robust enough.

Clearance from the U.S. Food and Drug Administration may take longer because the regulator is unlikely to approve the vaccine on the basis of studies conducted elsewhere, especially given the questions over the results, Soriot said. Authorization in some countries is still expected before the end of the year, he said.

“The question for us was, will we need the U.S. data to get approval in the U.S. or can we get approval in the U.S. with international data, and it was never clear,” said Soriot, who is in quarantine after arriving in Australia. “Now with those results it’s more likely that we will need the U.S. data.”

Astra and its CEO are facing scrutiny as the drugmaker responds to growing confusion over the vaccine. The company’s late-stage data initially increased confidence that the world would soon have multiple shots to combat the pathogen, following positive reports from front-runners Pfizer Inc. and Moderna Inc. But scant disclosures and the manufacturing discrepancy have sparked doubts among scientists and investors.

Astra shares fell 0.8% by 8:57 a.m. in London trading Friday, bringing the decline this week to about 8% amid questions about the trial results.

Astra and Oxford reported Monday that a lower initial dose of the vaccine, followed by a full dose, produced a 90% efficacy rate in a smaller set of participants, compared with 62% for two full doses.

A day after the data were unveiled the head of Operation Warp Speed, the U.S. vaccine program, said that the regimen showing the higher level of effectiveness was tested in a younger population. He also said the half-dose was given to some people because of an error in the quantity of vaccine put into some vials. None of those details were disclosed in Astra or Oxford’s original statements.

Soriot disputed the idea that the half-dose regimen was an error, saying that after researchers realized the dosing discrepancy they formally changed the trial protocol with the blessing of regulators.

“I won’t tell you we expected the efficacy to be higher,” said Soriot. But “people call it a mistake — it’s not a mistake.”

The company has previously said it might add a new arm to its U.S. trial to test the lower dosage.

Astra and researchers have declined to provide more data ahead of a peer-reviewed analysis that is expected to be published in the coming weeks. Results have been submitted to an undisclosed journal, Astra said in a statement.

Astra’s is one of three vaccines that could be approved before the end of the year. Pfizer and Moderna, which have both created shots using messenger RNA, published data earlier this month that showed their vaccines were about 95% effective, and Pfizer has applied to U.S. regulators for emergency approval.

There’s added pressure on the Astra shot to succeed because it’s easier to store and the company is selling it at cost during the pandemic, which means many low- and middle-income countries are relying on it.

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Wyoming’s governor, who resisted calls for a mask mandate, now has the coronavirus (nationthailand.com)

Wyoming’s governor, who resisted calls for a mask mandate, now has the coronavirus

Health & BeautyNov 26. 2020

By The Washington Post · Tim Elfrink · NATIONAL, HEALTH, HEALTH-NEWS 

Earlier this month, with coronavirus cases rising dramatically across Wyoming, a coalition of medical experts and nearly every county health officer in the state wrote to Republican Gov. Mark Gordon with an urgent demand: to issue a statewide mask mandate.

Gordon declined. While he has stressed the importance of wearing masks, he has also argued that it’s an individual choice to do so.

“It is incredibly important that we take personal responsibility for our actions and understand how those actions can implicate others,” Gordon said last month.

Now Gordon, 63, has tested positive for the virus, his office announced Wednesday. “He only has minor symptoms at this time and plans to continue working on behalf of Wyoming remotely,” Gordon’s office said in a news release.

Throughout the pandemic, a number of Republican governors have resisted mandating face coverings, with some questioning their effect – an echo of President Donald Trump’s dismissive attitude toward masks – and others, like Gordon, calling for personal responsibility. But in recent weeks, with the pandemic dramatically worsening and evidence mounting that mask mandates can reduce transmission, several have reversed course.

GOP-led states including Utah, West Virginia and North Dakota all recently tightened mask rules, and Iowa Gov. Kim Reynolds, a Republican who had previously called such rules “feel-good” measures, put a limited mandate into effect earlier this month.

Gordon, though, has held firm against any statewide mask rules even as Wyoming, like other states in the West and Midwest, has seen coronavirus cases increase significantly this fall. The state has now topped 30,000 cases and recorded at least 215 deaths, according to The Washington Post’s coronavirus tracker.

While some counties in Wyoming have issued local mask requirements, health experts say they’re often ignored – and enacting new rules on the county level hasn’t been easy.

When commissioners in Natrona County, which includes Casper, the state’s second-largest city, invited health officials to discuss a possible mask mandate this month, the meeting had to be adjourned early because of incessant heckling. Anti-mask protesters have repeatedly gathered at the state Capitol in Cheyenne as well.

On Nov. 12, Wyoming public health experts urged Gordon to reconsider a statewide mask rule. A letter signed by 21 county health officers and the heads of the state’s medical society and hospital association noted that recommendations alone weren’t driving enough people to mask up.

“Education and encouragement alone have not achieved desired outcomes. Our health care resources are becoming critically strained with hospitalizations and deaths increasing,” the letter said.

Last week, Gordon responded to the record case numbers by issuing new restrictions, including reducing the size of indoor and outdoor gatherings. And he urged residents to wear masks.

“The Governor reminded residents to practice the three Ws – wash your hands, watch your distance and wear a face covering,” his office said Nov. 19.

But Gordon again stopped short of issuing a mask mandate.

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Coronavirus cases are skyrocketing again in cities (nationthailand.com)

Coronavirus cases are skyrocketing again in cities

Health & BeautyNov 26. 2020

By The Washington Post · Brittany Shammas, Mark Guarino, Jacqueline Dupree · NATIONAL, HEALTH, HEALTH-NEWS 
For a few months, coronavirus-weary Chicago residents got a reprieve from the strict regulations that shuttered the nation’s third-largest city during the spring.

After infections plummeted in early June, restaurants welcomed diners back inside. Movie theaters, fitness centers and bowling alleys reopened their doors. And the barriers came down on the bike pathway along the city’s cherished lakefront.

But with new coronavirus cases surging beyond the springtime peak, Chicago is now hunkering down. Statewide measures have closed some businesses and limited the capacity at others, while officials are urging residents to stay home. Again.

“We’ve been through a heck of a lot this year,” Lori Lightfoot, the city’s Democratic mayor, said during a recent news conference. “And it’s not over.”

Across much of America, the picture is similar. Major metropolitan areas were the face of the pandemic before being overtaken by spikes in less populated parts of the country in September. Since then, the nation’s worst outbreaks have been concentrated in rural parts of the Upper Midwest.

Yet dramatic increases have been reported in many major American cities in recent weeks, with some being hit harder than they were during their previous peaks. Testing has greatly ramped up since the start of the pandemic, but that alone does not explain the growing caseloads.

“The dreaded fall wave, in many places, is upon us,” said Josh Michaud, an epidemiologist and associate director for global health policy at the nonprofit Kaiser Family Foundation. “And that includes in metropolitan areas.”

In Cook County, where Chicago is located, the seven-day average of new cases hit a record high of 4,654 on Nov. 17 – far outpacing the peak of 1,690 during the spring surge. Deaths are lower than the numbers seen in the spring but have climbed in recent weeks.

With winter approaching, business owners who stayed afloat by turning to outdoor service have been investing in heating lamps, hoping to keep customers coming even in temperatures that can drop below freezing.

Michelle Foik, co-owner of Eris Brewery & Cider House, said she saw the shutdown of indoor dining as inevitable. The facility’s patio has been “our saving grace,” she said, but she worries about what will happen this winter. She’s torn between relief that the rise in cases was met with more restrictions and concerned over the impact on her business.

“Believe me, we need the money,” Foik said. “We’re a start-up. We are investing in our future, but if this become a longtime shutdown, it just hurts everything.”

At NorthShore University HealthSystem, infectious-disease specialist Kamaljit Sandhu Singh said he and other health-care workers were “exhausted physically and mentally” as hospitalizations and intensive care unit admissions increased.

He said the pandemic reminded him of growing up during the Vietnam War: “I could never wrap my name around the number of soldiers’ lives lost, but the pictures were compelling.”

Cases are surging on Chicago’s West and Southwest sides, where the virus spread at a disproportionate rate in the spring and the majority of residents are Black or Latino. Kiran Joshi, senior medical officer at the Cook County Department of Public Health, said “a myriad of factors” play into why those areas are surging highest, but that a common attribute is that people there “experienced structural racism over decades.”

The second peak in Chicago mirrors those in metropolitan areas across the country. In recent weeks, counties home to cities including Philadelphia, Los Angeles, Detroit, Las Vegas and Minneapolis have seen new cases surpass their past highs. Miami-Dade County has been trending up again, while Salt Lake County is experiencing its first major peak of the pandemic, with cases and hospitalizations rising since early October.

In Maricopa County, which includes Phoenix, Valleywise Health “had a little breather” after the summer’s surge in Sun Belt states, said Michael White, the health system’s chief clinical officer. But the seven-day average of new cases, which hovered around 500 a day in late October, exceeded 2,000 on Monday.

“We’re hanging in there is how I would describe it,” White said. “Our biggest concern always is, as we continue to see this case count rise, that that certainly can lead to more folks needing hospitalization down the road, on top of a time where we usually see a higher rate of hospitalizations for non-covid-related illnesses.”

Phoenix-based Banner Health is projecting that 125 percent of the system’s licensed hospital beds will be full by the first week of December. Hospital administrators believe they have stocked up on enough personal protective equipment, ventilators and beds to weather the surge, Chief Clinical Officer Marjorie Bessel said during a news conference Tuesday. They worry most about staffing – they’ve hired nearly 1,000 health-care workers from out of state and are recruiting 900 more.

The health system always beefs up its staff for the winter months, Bessel said, but the coming weeks are expected to be markedly different from previous years and even the Sun Belt’s summer surge.

“The entire country is surging at the same time,” she said.

Health officials attribute the virus’s resurgence in cities to several factors, including eased restrictions, increased gatherings and what’s being called “covid fatigue.” Eight months into the pandemic, “there is no longer that sense of urgency,” said Mouhanad Hammami, chief health strategist in Wayne County, home to Detroit. “When you live with something, it is no longer urgent, and you tend to get desensitized to it.”

Some authorities in Chicago blamed rock-bottom hotel prices and the state-imposed indoor dining ban, suggesting it may have caused parties to relocate to hotel rooms or other spaces, such as Airbnb rentals. On Nov. 12, Lightfoot told reporters that current restrictions apply to both.

“I know the hotel industry was hit hard and is in many instances is on life support, but that cannot include parties,” she said. “I urge the hotel industry to be much more diligent about who is coming in. … People think it’s party time. It’s not.”

Officials in many hard-hit cities also point to increasingly widespread transmission across the United States, which has been reporting record-setting numbers of infections. Over the past week, the country had well over 150,000 new cases each day. Ahead of Thanksgiving, traditionally a time of significant travel and extended family get-togethers, health experts feared the number would only continue to climb.

“We would love to be that shining city on the hill where we’re avoiding all this,” said Philadelphia Department of Public Health spokesman James Garrow. “But I don’t know that anybody’s going to be able to avoid this.”

Mortality rates have improved from earlier in the pandemic – a change attributed to improved therapeutics and knowledge of how to handle covid-19, the disease caused by the virus. Still, authorities in areas that are seeing spiking infections have reacted with alarm, noting that the explosion in cases will inevitably drive up the death toll.

In Los Angeles County, where hospitalizations are up and deaths increased slightly last week, Public Health Director Barbara Ferrer on Friday described the data as looking “really bad right now” and added that the county had experienced “three terrible days in terms of case rates and increases in hospitalizations.” She said health officials were hoping deaths “don’t go up … as much as earlier in the pandemic.”

With rapidly rising case numbers has come a return to some of the restrictions of the spring. In Los Angeles, health officials suspended outdoor dining for the first time since May. They warned that a stay-at-home order could follow if the situation worsens. 

Wayne County’s health department on Friday strongly recommended that schools shift to virtual instruction through mid-January, noting that the current wave “is at a level higher than the first peak in April 2020.”

Philadelphia on Nov. 20 imposed new “Safer at Home” restrictions, which required schools to shift to online learning, restaurants to suspend indoor dining, and gyms and indoor fitness classes to close. Movie theaters, casinos and bowling alleys were also shuttered and indoor gatherings of more than one household prohibited.

“The hope is that by implementing these restrictions as soon as we could – and we’re doing it ahead of at least a lot of surrounding counties and states – that we’ll be able to head off getting to a point where we outstrip our capacity and get to a point worse than we were in April,” Garrow said.

Months after the first shutdowns in the United States, a better understanding of how the coronavirus spreads means that this latest wave of restrictions can be more targeted, Michaud said. Authorities can focus on what is believed to carry the greatest risk of transmission: venues where people are crowded together indoors for extended periods of time.

“In the spring, we didn’t know a whole lot about the virus and exactly what were the activities that were the riskiest,” he said. “We know a whole lot more now. And that means that we don’t have to put in a Chinese-style lockdown to have an effect on transmission. You can be much more surgical in your approach.”

But among some already battered by earlier shutdowns, the new restrictions drew frustration.

The Illinois Restaurant Association released a statement objecting to the state’s ban on indoor dining, arguing that it “will force people into less controlled, private gatherings with no safety precautions – resulting in the exact opposite of slowing the spread” of the virus. The organization said that without being allowed to serve indoors in some capacity, “our state’s largest private sector employer will be pushed to the brink of permanent devastation.”

Mark Domitrovich, co-owner of Chicago restaurants Ina Mae Tavern and Frontier, said he was trying to “string together as much as an outdoor dining situation as we can get” because takeout and delivery alone weren’t enough to get by.

“At this point we’re trying to grind it out. To try to drive as much business as possible,” he said. “It’ll run out at some point and it doesn’t seem like the cavalry is on the way either, so we’re just praying right now.”