Even as rules have loosened and COVID-19 cases rise in Colorado, deaths have stayed relatively low. But, health experts warn, there’s no guarantee that will last if the virus continues to spread widely.
Following five weeks of increasing cases across the state, Colorado reported 2,217 new coronavirus infections between Monday and Thursday of this week, or 554 a day — a higher daily rate than the state reached during the peak of the epidemic in late April.
Hospitalizations and deaths have remained well below the April peak, though they have increased since mid-June.
In the past two weeks, Gov. Jared Polis issued a statewide mask mandate and ordered restaurants to stop serving alcohol at 10 p.m., rather than 2 a.m., to try to cut down on behavior that could spread the virus by people who’ve had too much to drink. He’d ordered bars that don’t serve food to close at the end of June, after two weeks of rising cases.
Changing behavior now, while the increase is still manageable, is the best way for Colorado to avoid a situation like what’s happening in Houston, where intensive care units have been overwhelmed, said Jeffrey Morris, a professor of biostatistics at the University of Pennsylvania.
In Houston, “people were arguing about whether it was real as it continued to grow, and that’s how it got out of control,” he said.
So what happened in Colorado?
State officials cautioned there could be an increase in the virus’ spread after Polis lifted the state’s stay-at-home order in late April, but the number of new cases continued to fall, hitting a low of 162 cases per day in the second week of June. At the peak in April, Colorado had about 537 cases per day.
New cases started to rise slowly in the second half of June, a few weeks after the Colorado Department of Public Health and Environment issued guidance allowing churches, gyms, bars and other businesses to open at reduced capacity. Some people don’t experience symptoms for two weeks after infection, though the average is closer to five days.
It’s difficult to know what role those reopenings played, since the increase also came within a few weeks of Memorial Day travel, parties and protests, said Beth Carlton, an assistant professor of environmental and occupational health at the Colorado School of Public Health.
“I would love to know the answer to that,” she said.
The increase in cases accelerated in the weeks following the Fourth of July weekend, with cases hitting levels not seen since April.
Models of social distancing in Colorado vary, but most show a general trend of people leaving home more than they did this spring — increasing the chances that infected and susceptible people will cross paths. Getting out more isn’t inherently bad, but some people didn’t understand that the virus is still circulating and they need to stay away from crowds and wear masks, Carlton said.
Curve had been flattened
Colorado “flattened the curve” in March and April, keeping infections from skyrocketing beyond what the health care system could handle, Carlton said. That means a large segment of the population is still vulnerable to getting the virus, though, and spread could take off again if people return to their normal behavior, she said.
Higher levels of testing explain some of the increase in cases in Colorado, but the percentage of tests coming back positive is starting to grow again, so that’s not the full story, Morris said.
The state’s positivity rate has risen since early June, according to the Colorado Department of Public Health and Environment, though it’s nowhere near what it was in March and April, when testing was much more limited, largely reserved for people with multiple symptoms or who already were hospitalized.
“I think it’s easy for people to let their guard down a bit,” Morris said. “People are trying to do the right thing, but they get stir-crazy.”
Most states made a mistake in allowing high-risk settings, like bars, to reopen relatively early, said Dr. Cyrus Shahpar, director of the Prevent Epidemics team under public health nonprofit Vital Strategies. Contagion in those settings spread out until community circulation got so high that schools might not be able to have in-person learning this fall in some parts of the country, he said.
Increases in travel and younger people socializing without distancing have helped drive up cases again in Denver, though they aren’t rising as fast as they were in the spring, said Dr. Seth Foldy, director of epidemiology, preparedness and informatics at Denver Health and Hospital Authority. Denver has added more than 2,600 cases since June 13.
Cases also increased significantly in Adams, Arapahoe, Boulder, Douglas, El Paso, Jefferson, Larimer and Weld counties.
In Boulder County’s case, it’s difficult to point to one factor, said Chana Goussetis, spokeswoman for the county health department. Large gatherings in June contributed, but more travelers are visiting Colorado, sports training has resumed, and some people have gotten lax about following health guidelines, she said.
Ashley Richter, communicable disease epidemiology manager for Tri-County Health Department, said Colorado drove cases down to “manageable levels” in June, but some people either got tired of following restrictions, or misunderstood businesses reopening as a sign that all was well. Tri-County serves Adams, Arapahoe and Douglas counties.
It also didn’t help that the disease can have a long incubation period, Richter said, because some people figured they could take more risks when they didn’t feel sick within a few days after going out.
“I think we all got a little relaxed about the recommendations,” she said. “If we continue to have relaxed expectations of ourselves… what we’re seeing will be small compared to what we could see.”
Hospitalizations, deaths rise more slowly
So far, hospitalizations and deaths remain well below their April peak, when nearly 900 people were in the hospital and 32 died on an average day. As of Friday afternoon, 247 people were hospitalized statewide, and about three people have died each day in July, though there was a slight uptick in the second half of the month.
Part of the reason hospitalizations and deaths have remained low compared to cases is that testing is finding more relatively mild cases, which the state didn’t have the infrastructure to look for in March and April, Carlton said.
Another factor is that the recent increase has mostly fallen on younger people.
In late April, people younger than 40 and those older than 60 each accounted for about one-third of all cases. By late July, older people accounted for only about one-fifth of all cases, while younger made up almost half of the total. People younger than 40 aren’t immune to getting seriously sick from the virus — 1,075 of them have been hospitalized and 28 have died in Colorado — but they’re at a lower risk than older people.
Hospitals have enough space and staff for the foreseeable future, but the supply chain for protective equipment and certain medications is still “rocky,” said Julie Lonborg, vice president of communications and media relations at the Colorado Hospital Association. Hospitals never stopped conserving masks by having employees wear one all day or cleaning N95 respirators, but some are still struggling to get pain medications and sedatives for patients who need ventilator care, she said.
“Even though we’re using fewer ventilators in our patients … we know those medications are in high demand,” she said.
“A tricky dance”
Models have predicted vastly different possible futures for Colorado.
A report released by the Colorado School of Public Health last week warned that hospitals could run out of intensive-care beds by September, though the slowdown in new hospitalizations over the last few days makes that scenario appear less likely, Carlton said. In contrast, the Children’s Hospital of Philadelphia’s PolicyLab predicted cases would either stabilize or fall over the next month in Colorado’s larger counties.
One major question is whether steps meant to protect people living in nursing homes, like frequent testing of employees, will keep the virus out if it starts to spread more widely. In the early weeks of the epidemic in Colorado, outbreaks in long-term care facilities accounted for more than half of all deaths.
Doug Farmer, president and CEO of the Colorado Health Care Association, said so far his member nursing homes aren’t seeing the virus return, but they’re keeping a close eye on it. The supply of protective equipment is a little better than it was this spring, and testing is more available, but residents will still be at risk if COVID-19 is roaring back in the surrounding area, he said.
“Any time the general community transmission starts to increase, that’s a concern,” he said.
Dr. David Rubin, director of PolicyLab, said Denver and the surrounding counties could be in a difficult position in the coming weeks. Relatively high adherence with mask-wearing in the city itself is helping keep cases down, but it won’t cancel out the effects of people practicing less social distancing, he said.
The trajectory also is worrisome in El Paso County, Rubin said. Cases there have more than doubled since June 13.
“They’re barely distancing at this point, and they have a major outbreak,” he said.
The state health department notified 15 counties, including El Paso and much of the Denver metro area, that they could lose their existing variances from state anti-virus rules if they don’t get cases under control. Eight elected to return to following all state rules. Statewide, all new variances are temporarily on hold.
Jill Hunsaker Ryan, executive director of the state health department, likened the situation to an experiment playing out in all states, to determine how much life could return to normal without an unsustainable increase in cases.
“It’s a tricky dance,” she said at a news conference earlier this week.
Colorado is doing better than many states, but that doesn’t mean it can sit back and relax, Morris said. By the time hospitalizations and deaths start to rise, it’s too late to avoid the worst because so many people have already been infected. Colorado residents need to keep wearing masks and practicing distancing even if it doesn’t feel immediately necessary, he said.
“If everybody cooperates and does that, there’s a good chance to keep it under control,” he said.
Foldy said he’s seen “encouraging signs” of more people in Denver getting tested and wearing masks in public, and that restrictions on bars could help reduce spread.
“Whether it’s enough, I can’t say with certainty,” he said.
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