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8 states that experts worry are the new Covid-19 hot spots

Have these states seen a spike because of their economic reopenings?

Arizona has seen some of the most worrisome trends in Covid-19 cases and hospitalizations since its economic reopening began.
Mark Ralston/AFP via Getty Images
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

If reopening the economy were going to lead to more coronavirus spread, states would likely just now be starting to feel the effects, with rising case counts, higher positive-test rates, and increasingly strained hospitals. Unfortunately, there is a good amount of evidence that is exactly what is happening.

A couple of things to be mindful of as we track Covid-19 after reopening: First, states certainly expected some additional spread once people began going back to restaurants and resuming other normal activities. It is a question of trade-offs: How much new coronavirus spread is “worth” alleviating the costs of the economic shutdown?

What’s most important is whether a state health system maintains enough hospital capacity that it can treat all the coronavirus patients — and other patients — it has. Exponential spread that risks overwhelming the hospitals in the state, and requires the reinstitution of strict social distancing measures, is the worst-case scenario.

One other consideration: Raw case counts alone might not tell you much about a state’s Covid-19 situation. We would expect cases to increase along with testing. But if a state’s rate of positive tests is rising, or if the number of hospitalizations is going up, that is better evidence of increased spread.

And looking ahead, the continued easing of social distancing could serve to exacerbate these trends.

“The thing about all of these places is not that these increases are definitely tied to reopening or partying over Memorial Day weekend, though they might be, but that in the face of increasing numbers of case counts, the continued relaxation will only provide more opportunity for community transmission,” William Hanage, a Harvard epidemiologist, said. “The virus is getting highways along which to transmit.”

With that in mind, I asked public health experts across the country which coronavirus hot spots they are watching and worrying about. Here’s the list. (Eric Topol, a top medical scientist, came up with a very similar list on Twitter.) All data pulled on Wednesday, June 10.


Relaxed/ended stay-at-home order: May 16

Hospitalizations on May 16: 791

Hospitalizations on June 8: 1,252

Test positivity rate: 12.7 percent (increased from 7.7 percent two weeks ago)

Arizona has quickly become the most closely watched state in the country. The state’s largest health system has warned that its intensive care unit is filling up. The state’s top health official asked hospitals to activate their emergency plans for increasing their bed capacity.

Public health experts in the state have blamed the relaxing of social distancing for the spread, as the Arizona Republic reported. Arizona began to reopen gyms, restaurants, and other businesses in mid-May. The state has not required all individuals to wear masks in public, but workers who interact with the public are expected to have a mask.

Gov. Doug Ducey’s administration points to increased testing capacity to explain the state’s numbers. But while it’s true that the number of daily tests has increased from 4,200 to 7,900 over the past two weeks, the rate at which those tests are coming back positive is also increasing. Experts say such a trend suggests the virus is actually spreading, not just that more tests happen to be finding more cases.

Arizona’s former state health director warned this week that the state may be forced to issue a new stay-at-home order. With the state’s hospitals reporting a relatively low amount of bed availability as well, Arizona is at the foreground of the fears about reopening and renewed spread.

North Carolina

Relaxed/ended stay-at-home order: May 22

Hospitalizations on May 22: 568

Hospitalizations on June 9: 774

Test positivity rate: 7.2 percent (increased from 5.2 percent two weeks ago)

North Carolina repeats many of the same trends as Arizona, though to a slightly less severe degree. Hospitalizations are up, and the positive test rate is rising. The hospital system’s bed availability is considered low, according to the Covid Exit Strategy dashboard, though it is not dangerously so yet.

The Raleigh News & Observer reported the state saw a record number of hospitalizations on Tuesday. Democratic Gov. Roy Cooper has sought to restore some social distancing in problematic places, such as ordering a racetrack that had been the site of an informal, maskless protest to close again.

At the same time, certain activities — like high school sports — have been allowed to resume in recent days. The state is also not currently requiring masks to be worn in public places. Its trendlines are being watched closely for now; the top state health official recently said she was concerned about the specific benchmarks being monitored to determine whether schools will be reopened.

South Carolina

Relaxed/ended stay-at-home order: May 4

Hospitalizations on June 9: 541 (up from 482 on June 7)

Test positivity rate: 9.6 percent (increased from 3.9 percent two weeks ago)

South Carolina saw a dramatic one-day spike in Covid-19 hospitalizations, which has put it on the national radar. Its bed capacity is also beginning to dwindle, down to about 30 percent statewide, with some areas seeing even less availability, according to the Washington Post.

The state is an anomaly on testing: Its daily average in tests has actually trailed off in the last two weeks, from 5,400 to 4,200. But its positive test rate has more than doubled over the same period, suggesting increased spread since South Carolina was on the leading edge of allowing some businesses to reopen starting on April 20.

Testing, again, does not seem sufficient to explain the trends, and health officials are clearly worried about people not taking proper precautions. No state mandate for mask-wearing is in effect, though people are being urged to wear one.

“Other factors, including gatherings at which people fail to practice safety measures, could be in play as well,” state officials said this week, according to WCSC. “There is still a significant risk of being exposed to the COVID-19 virus in a public setting in any community.”


Relaxed social distancing policies: May 1

Hospitalizations on May 4: 102

Hospitalizations on June 9: 126

Test positivity rate: 9.4 percent (increased from 4.8 percent two weeks ago)

Utah has not seen a dramatic surge in hospitalizations to date, but its positive test rate is soaring to concerning heights. Tests are coming back positive with twice the frequency they were two weeks ago, even though the state slightly increased its number of daily tests over the same period.

An outbreak in a meat-packing plant is at least partially to blame for the spike in cases. Some cities have started closing their public facilities again in response to the apparent surge. Utah never actually instituted a stay-at-home order, and businesses were allowed to start reopening on May 1.

State officials acknowledge that transmission is worrisomely persistent, and masks have been required or strongly recommended in public places since April. There does not appear to be any serious consideration of renewed social distancing policies for the time being.


Relaxed social distancing policies: May 4

Hospitalizations on May 4: 91

Hospitalizations on June 8: 171

Test positivity rate: 8.1 percent (increased from 6.6 percent two weeks ago)

Arkansas has seen its level of Covid-19 hospitalizations nearly double in the past month, though hospitals in the state do not yet appear to be at risk of exceeding capacity. But what’s concerning is the combination of increased hospitalizations and a higher positive test rate, even while its testing capacity is nearly twice what it was two weeks ago.

This is one of the states that never had a statewide stay-at-home order, and some business activities resumed in early May. The general public is not being required to wear masks, but employees at public-facing companies are.

Gov. Asa Hutchinson and state health officials have insisted they do not believe the increase in cases is related to reopening, citing instead clusters in nursing homes and correctional facilities. In fact, the governor is expected to announce the next phase of reopening on Wednesday.


Relaxed social distancing policies: May 1

Hospitalizations on May 1: 1,778

Hospitalizations on June 8: 1,935

Test positivity rate: 6.6 percent (increased from 4.9 percent two weeks ago)

Texas is experiencing the same trends — hospitalizations up, positive test rates up — just at a much larger scale because it is a much larger state. It started reopening businesses and restaurants at the beginning of May. The Houston Chronicle reported hospitalizations are up 36 percent since the Memorial Day weekend. For now, the state’s hospitals have a little more than 30 percent of their general and ICU beds available.

Gov. Greg Abbott has equivocated on whether reopening or the anti-police violence protests are to blame for the worrisome trendlines, but public health experts point to the relaxing of social distancing and the holiday, according to the Chronicle.

Nevertheless, reopening continues unabated for now. Restaurants will be allowed to fill their dining rooms to 75 percent capacity starting this week, and amusement parks will be permitted to let in 50 percent of their usual capacity next week.


Relaxed/ended stay-at-home order: May 18

Test positivity rate: 4.1 percent (increased from 3.2 percent two weeks ago)

It’s not clear if Florida is experiencing a spike in hospitalizations right now because the state only reports cumulative totals, not current capacity. But its positive test rate grew in the past two weeks, even though testing capacity is stable, suggesting an increase in spread.

Florida was a little later in reopening than other states on this list, so it is difficult to be sure why spread seems to be picking up. Gov. Ron DeSantis pointed to groups of agriculture workers who live in close quarters as one possible explanation. He also blamed people for failing to wear masks as has been advised — but not mandated, except for workers — by the state.

(Here, as elsewhere, officials are also citing increased testing to explain the trends. But, again, that does not explain the rise in tests returning as positive.)


Relaxed social distancing policies: May 1

Daily average of new hospitalizations as of May 20: 18

Daily average of new hospitalizations as of June 9: 26

Test positivity rate: 5.4 percent (increased from 5 percent two weeks ago)

Tennessee does not disclose its total current hospitalizations, but it does report new hospitalizations each day, and those have jumped since late May. Its positive test rate is also up slightly. Restaurants have been open since late April, and the stay-at-home order was rolled back on May 1.

“COVID is still with us. It’s not going on a summer vacation, and our opening up clearly opened the door for more transmission,” William Schaffner, an infectious disease professor at Vanderbilt University, told the Tennessean.

Nashville in particular is delaying its next stage of reopening — which would have allowed restaurants, retail stores, and small music venues to operate at their full capacity again — because of the rise in new cases there, according to the newspaper.

This story appears in VoxCare, a newsletter from Vox on the latest twists and turns in America’s health care debate. Sign up to get VoxCare in your inbox along with more health care stats and news.

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