San Antonio Express-News (Sunday)
Experts fear virus will slam S.A. anew
Factors include holidays, travel, flu season, more
For months, San Antonio has experienced something of a reprieve from the coronavirus.
After cases spiked dramatically in June and July, new infections and hospitalizations steadily declined. By September, they had reached a plateau, with transmission of the virus and hospitalizations from COVID-19 steady but manageable.
But as winter approaches, San Antonio health experts warn that coronavirus transmission is likely to significantly worsen over the coming months. A confluence of factors — increased travel, a series of holidays, coolerweather that forces people indoors, the flu season, widespread misinformation and disinformation — could make the virus more difficult to contain and could strain hospital resources.
“The probability that we have a dark winter is much higher than the probability we remain in a plateau,” said Juan Gutiérrez, professor and chair of mathematics at the University of Texas at San Antonio, who has been leading an effort tomodel the trajectory of coronavirus transmission in the U.S.
“Everything’s stacked against us,” he added. Texas and the nation are experiencing rapid rises in cases and hospitalizations. Texas has been reporting record numbers of cases and last week became the first state to surpass 1 million infections. The severity of El Paso’s coronavirus crisis has grown so dire that hospitals are treating patients in tents and the city is utilizing 10 mobile morgues.
Last week, the U.S. reported more cases each day than it has during any other point in the pan
demic, logging more than 1 million cases just during the first 10 days of November. The virus is spreading uncontrolled in almost every state, at a time when partisanship has influenced how people respond to the pandemic. Major changes to the federal coronavirus response aren’t expected until late January, when the Biden administration takes office.
“We don’t live on an island. Infectious conditions don’t respect national or state or city orders,” said Dr. Junda Woo, medical director of the Metropolitan Health District. “That’s one of the reasons that I do think that eventually it’s going to seep back over to San Antonio.”
Resurgence of the virus has been slower in San Antonio than elsewhere in Texas, a trend experts attributed to consistent public health messaging that has encouraged residents to exercise precautions. Since March, Mayor Ron Nirenberg and Bexar County Judge Nelson Wolff have been holding daily televised briefings on the coronavirus’ impact, during which they have kept up a steady drumbeat of encouragement to wear masks and practice physical distancing.
But both officials have quarantined this month after exposure to individuals who later tested positive for the virus, and local transmission has steadily worsened over the past few weeks.
The positivity rate has climbed to 8.4 percent, the seven-day rolling average for new cases of the virus has risen to around 300 infections a day, and the number of people hospitalized with COVIDhas surpassed 350 for the first time since early September. More than 1,500 cases were reported over the past few days alone, and people in their 20s and 30s are being infected at higher rates, a trend thatwas a precursor to San Antonio’s summer surge.
With transmission on the rise heading into Thanksgiving, Woo said, the San Antonio area is “closer to a tipping point now than we were before Halloween.”
“I don’t think it’s possible to not have another surge,” said Woo, who has served as Bexar County’s health authority during the pandemic. “The question is howbig it will be, and how well we can manage it. I would be really surprised if something didn’t happen by, the latest, the end of January.”
A winter wave
For much of this year, Gutiérrez has been steeped in coronavirus data. During the spring and summer, he used information provided by local health and emergency officials to project cumulative case counts and hospitalizations. His model accurately projected San Antonio’s initial but relatively small peak in cases in May, and it estimated that more than 900,000 residents could eventually contract the virus if no containment measures were implemented.
From the start, the data has been imperfect. Laboratories processing tests have been plagued by delays and backlogs, and the numbers are frequently incomplete. To most accurately chart the pandemic’s course, Gutiérrez would need access to information about every coronavirus patient, including the date of their onset of symptoms and when they were tested, which is not always available.
The date on which results are reported to health officials does not reflect the true number of cases for that day, Gutiérrez said. Inconsistencies with reporting can obscure the start of a spike and affect the epidemiological curve of its trajectory over time. As a result, the modeling captures the health system’s cumulative surveillance of the virus, he said, rather than the actual spread of disease.
The models can help inform risk, Gutiérrez said, but they’re not meant to perfectly predict the future. And they can’t fully account for sudden changes in human behavior or government intervention, such as when Gov. Greg Abbott ordered bar closures and allowed localities to enforce mask mandates when cases soared over the summer.
Gutiérrez is nowworking with a team of researchers to project cumulative case counts for every county in the U.S., using data collected by Johns Hopkins University and the New York Times. On Oct. 1, the model accurately predicted that Texas would exceed 1 million cases by early November.
Recent modeling shows Bexar County has the potential to experience a 50percent increase in the cumulative number of cases by the end of December. However, there is substantial variability in the possible range of cases for the area because of inconsistencies with the data, likely related to reporting and data processing.
Thanksgiving and the December holidays introduce ahigh level of unpredictability, Gutiérrez said. But the bottom line, he said, is that the risk of a substantial increase in transmission is high.
“Don’t let the guard down. This is not the time,” he said. “We’re going to go into a very deadly season.”
High-risk holidays
Earlier this year, Memorial Day became a benchmark for Texas’ first major wave of coronavirus infections.
The holiday weekend, which came amid Texas’ reopening, ushered in a surge of cases across the state, including in its largest cities. Over the course of June and July, San Antonio’s cumulative coronavirus cases exploded from about 2,800 to more than 40,000. The city’s hospitals were able to manage the flood of COVID patients only with the help of hundreds of critical care staff sent from the
military, state health departments and contract agencies.
Heading into Thanksgiving, the coronavirus is circulating at higher levels in San Antonio than it was before Memorial Day. Perhaps more than any other holiday, Thanksgiving encourages behavior that raises the risk of transmission: traveling, gathering for extended periods with people from other households, eating and drinking indoors.
And it will be closely followed by a series of other holidays where people gather with friends and family — Hanukkah, Christmas, the New Year — as well as the slated reopening of more nonessential businesses at the beginning of 2021, Woo said.
“All of those together, bam bam bam, we’ve got four different reasons that things could heat up again by the end of January,” Woo said.
For many people, months of working from home and rarely seeing friends and family have taken a toll. Many people are experiencing fatigue froma lack of social contact and the monotony of life during the pandemic, making gatherings for the holidays even more appealing.
“It’s just a difficult situation,” said Jack Tsai, a clinical psychologist and dean of the San Antonio campus of the UT Health School of Public Health. “There’s a lot of mental health concerns with social isolation.”
Tsai, who has been overseeing coronavirus case investigations for the city in partnership with Metro Health, said increased travel over the next fewmonths could complicate his team’s efforts to break chains of transmission.
There are currently 130 to 140
case investigators, he said, but their efforts become much more difficult during a major surge of cases. There were multiple days over the summerwhen thousands of new cases were reported in Bexar County, creating tremendous caseloads for contact tracers and case investigators.
“We need to err on the side of caution,” Tsai said. “It could get really bad, and I think we should be prepared.”
Mitigating the spread
While another spike is likely, it’s possible that the next surge will not be as dramatic as the one that occurred over the summer, said Dr. Jan Patterson, an infectious disease professor at UT Health San Antonio.
Tens of thousands of people, including a large number of younger people, have already recovered from COVID, she said, so there is presumably some level of immunity among those most likely to spread the virus.
Face masks, temperature screenings and symptom questionnaires have become a routine part of visiting businesses and workplaces. Public coronavirus testing sites have been opened to those without symptoms, enabling more people to get tested in preparation for a trip or after exposure to someone with the virus.
The mortality rate has also dropped as physicians and health care workers have learned more about how to treat the disease.
However, the flu season typically sends more people to the hospital, leaving less capacity for a major influx of coronavirus patients over the next few months. It’s also possible that fewer out-ofstate health care workers will be available to respond to a coronavirus crisis again in San Antonio if infections are spiking in many areas across the country at the same time, as they are now.
“We have a limited number of hospital beds and a limited number of ventilators. That is still in play, and that’s going to be a very key thing,” Patterson said. “If the hospital’s full of COVID patients, it may make it difficult for you to get in for your heart attack or your stroke.”
The holiday celebration that poses the least risk of spreading the virus is staying at home and connecting only virtually with family and friends outside of the household, according to recommendations released by Metro Health.
Hosting a small dinner with immediate family and people within a social bubble would be moderately risky, the department said. Such a gathering would be safer if theme al was moved outdoors and food was served on plates, rather than buffet style. If it’s not possible to eat outdoors, it’s safer to gather in well-ventilated rooms or to open windows.
The highest-risk activities include attending large gatherings, visiting someone in a nursing home or other congregant facility, and traveling. Sharing food and beverages, hugging and kissing, and eating at a buffet also could raise the risk of contracting the virus.
MetroHealth recommends self-quarantining for 14 days before traveling or visiting a nursing home.
“Think about the case rate not only where we are but where your destination is,” Woo said. “Because you could be bringing COVID to your destination or you could be bringing COVID from your destination.”
‘It’s widespread’
Even with strong local precautions, Patterson said, some of the damage has already been done. The virus is widely seeded as the country heads into a critical period for the pandemic.
“Our nation is in this situation where it’s widespread, every state and every community. Unfortunately, the precautions that we needed to take in the spring that we didn’t take early enough, we’re going to have to continue,” Patterson said. “That’s where we are right now. We’re going to have to accept it.”
Patterson said it has been difficult to walk the halls of University Hospital, where rooms have housed COVID patients of all ages, including some who are quite young.
Over and over, she’s seen the scenes that have come to define this public health crisis.
The panic written on the faces of patients struggling for breath, even as they breathe in pure oxygen from high-flow masks. The patients proned on their stomachs to relieve pressure on their lungs. The motionless forms of the sickest patients who have had breathing tubes inserted down their throats.
Like all health care workers, Patterson sees sick patients all the time. But this crisis is harder to swallow.
“It’s just very difficult to see this because it’s preventable,” she said.
“You just don’t forget what it looks like to see people struggling to breathe.”