Epidemiology Inpatient Practice

The Next Surge In COVID-19 Hospitalizations

Just when we thought it was safe to go back to the movie theater, to church, and to the grocery store… it looks like we are in for COVID, the sequel. The CDC reported that an outbreak of COVID infections in a town on Cape Cod earlier this month resulted in 469 people becoming infected, of whom 74% had previously been vaccinated. Of these vaccinated persons who developed infection, 79% had symptoms and 4 of them required hospitalization. Disturbingly, vaccinated people who developed COVID-19 had the same viral load detected in their noses as unvaccinated people who developed COVID-19.

This change in the epidemiology of the pandemic is attributed to the Delta variant, a much more contagious strain of the coronavirus that causes COVID-19. Coupling Delta with recent evidence that the SARS-CoV-2 virus is not simply transmitted by droplet spread as originally believed but can also be spread by aerosolization is a warning that we will likely see a resurgence in COVID hospitalizations in the near future. In anticipation of this, the CDC yesterday published recommendations to resume indoor masking for all people (regardless of vaccination status) in areas of the country where there is “substantial or high transmission” of COVID-19. In July 2021, there was a dramatic increase in U.S. counties with high transmission. The three figures below show the change in transmission rates over the past 4 weeks (red is high transmission and orange is substantial transmission):

This data indicates that most U.S. counties are now experiencing high transmission rates. To determine what these trends will mean in the upcoming weeks for U.S. hospitals, we can look at COVID-19 hospitalization trends. The figure below shows the number of new hospitalizations for the entire United States from August 1, 2020 through July 28, 2021. This indicates that the hospitalizations are going up but are not as high as the nationwide peak in January 2021.

Florida was one of the first states to convert from moderate to high transmission over the past month. As such, Florida may be a bellwether for the rest of the country. The figure below shows the same hospitalization data but just for Florida. Hospitalizations in Florida now exceed those of January 2021, when the rest of the country was at peak numbers.

So, if hospitalizations are about to go up, what demographic of patients are likely to be hospitalized? Intuitively, one might think that hospitalizations will be mainly younger people since older Americans are considerably more likely to be vaccinated. The figure below is data from the CDC that shows that in Florida (graph on the right), more younger people are being hospitalized now than in January (yellow line). However, older people still comprise the majority of hospitalizations.

So, what should hospitals do now?

From the Massachusetts outbreak and the Florida data, we can draw several conclusions: (1) the Delta variant is more contagious than earlier variants, (2) vaccinated persons can still get infected and when they do, they have just as high of a viral load as unvaccinated persons, (3) the Delta variant is more likely to be spread by aerosolization rather than simply by droplets, (4) adult hospitalizations are increasing. With those conclusions in mind, here are some tactics that hospitals can take now:

  1. Ensure that all front-line healthcare workers are vaccinated. During the January 2021 surge, many hospitals found that healthcare workers were more likely to get infected by another healthcare worker than by an infected patient. Furthermore, if a hospitalized patient becomes infected from an unvaccinated infected healthcare worker, the hospital could face litigation vulnerability in the future.
  2. Re-institute routine admission SARS-Co-2 testing. Given that more Americans are vaccinated, it is likely that we will begin to see more asymptomatic infections in patients being admitted to the hospital for non-COVID-19 related medical/surgical conditions. These asymptomatic patients can serve as vectors to infect other patients and hospital staff.
  3. Re-institute universal masking. Last winter, nearly all hospitals in the U.S. required patients, visitors, and healthcare workers to wear face masks while in patient care areas and public areas of the hospital. Because of “anti-masking” political pressure, some hospitals have loosened masking requirements in the past few months. These hospitals need to resume universal masking.
  4. Buy more N-95 masks. Given that the Delta variant is so contagious and given that it appears to be more likely to be spread by aerosols than simply by droplets, N-95 masks are likely to be more protective than simple face masks to prevent acquisition of Delta. It is likely that frontline healthcare workers will increasingly demand access to N-95 masks.
  5. Update the surge plan. Last December, hospitals made plans for expanding ICU bed capacity and for increasing the number of non-ICU beds for the January COVID surge of inpatients. It is time to revisit those plans, both for intra-hospital care as well as inter-hospital care.

17 years ago, my family was stuck on an island in the outer banks when Hurricane Alex hit. The night before, the main road became covered by a shifting sand dune and the bridge to Hatteras Island had to be closed. A few hours before impact, the local radio announcer said “Hope for the best but prepare for the worst“. That was sound advice in 2004 and it is sound advice again in 2021.

July 31, 2021

By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital