One year of COVID-19 in Colorado: What we’ve learned

After a year of living with COVID-19, we’ve amassed an astounding body of knowledge about the novel coronavirus that sparked a pandemic, but we still allowed a third wave to claim more lives than were lost when we knew almost nothing about the virus.

Colorado, and much of the country, successfully kept the virus in check for months, only to watch cases explode again in the fall. Nearly twice as many people died in Colorado in the worst weeks of the fall as did during the virus’s early peak in the spring.

One year and nearly 6,000 deaths after Colorado’s first confirmed cases, it remains to be seen whether we’ve finally gotten the upper hand on the coronavirus. What we’ve learned — and whether we remember it — will help decide how many more people get sick and die, whether from new variants of the current coronavirus or from some disease still biding its time in bats or birds.

ONE YEAR OF COVID

If Americans can keep up precautions like social distancing for a few months more, the vaccine gives us a way out of the crisis, said Dr. Hana Akselrod, assistant professor of medicine at George Washington University’s School of Medicine and Health Sciences.

Viruses aren’t like most living things — they need a host to reproduce, and every time they colonize a new person, there’s a chance they’ll stumble upon some lucky mutation that makes it easier to keep spreading from one host to another, or to get around the immune system’s defenses.

The more the virus circulates, the more chances it has to mutate in a way that allows it to evade the vaccine — delaying a return to normal while drugmakers adjust the vaccine for the new variants, Akselrod said. To prevent that, we need to keep up precautions until enough people are vaccinated that the virus has few possible hosts left.

“We have a window of opportunity in the U.S.,” she said.

The question is whether we’ll take that opportunity.

State took a less-restrictive approach

On March 5, 2020, when Colorado confirmed its first COVID-19 cases, we didn’t yet know that people without symptoms could spread it. The evidence about whether masks would be a useful tool to slow transmission was still in dispute. No one had a clear sense of what the odds were that an infected person would die, because no one knew how many people carried the virus — only those who were seriously ill or had traveled to China could get a test.

By November, it was clear that everyone needed to wear masks and keep their distance in public, because of the risk that asymptomatic people could infect others. While we knew that only about 1% of infected people would die, we’d also seen how a small percentage could add up: 200,000 Americans already had died as the third wave was beginning.

Despite everything we’d learned, the death toll nationwide more than doubled — the U.S. passed 500,000 deaths on Feb. 21. Twice as many Coloradans died in the worst week of the fall wave as in the spring peak. Hospitalizations also were higher, with nearly 2,000 people receiving treatment for confirmed or suspected COVID-19 statewide at the peak in early December, compared to fewer than 1,300 during the worst days of April.

No one’s entirely sure why the fall wave approached tsunami levels in much of the country at the same time. Weather could be one factor, because coronaviruses spread more easily in cold, dry air, and people generally start spending more time indoors in the fall, state epidemiologist Dr. Rachel Herlihy said.

It’s not clear how much of an effect weather had in this case, though. Denver International Airport recorded more days with highs above 70 than below 40 in November, according to Weather Underground — though temperatures were significantly lower in the mountains.

“We also know there’s this real and sustained concern with pandemic fatigue,” Herlihy said. “It’s hard to sustain those (precautions) over time.”

Cell-phone tracking data doesn’t show that people threw caution to the wind in the fall, but it does suggest more returned to work, said Jude Bayham, an assistant professor at Colorado State University who has studied mobility during the pandemic. It’s likely that the virus spread through workplaces, but people also may have returned to more of their pre-pandemic routines, giving it even more openings, he said.

“I think about it as a giant network of interactions that is being rebuilt,” he said.

For the virus to spread, infected and susceptible people have to be close enough for it to make the jump. Cell-phone tracking data can measure if the population is mixing in a way that would give the virus an opportunity, but can’t tell you if it’s blocked by other factors like masks, Bayham said. So if people stop mixing, transmission will drop, but we don’t know with certainty that it will pick up once they get together again, he said.

The state took a different approach in the fall than it had in the spring. In March, there was no option other than ordering a statewide lockdown, because each infected person was passing the virus to as many as five others, said Jill Hunsaker Ryan, executive director of the Colorado Department of Public Health and Environment. By fall, however, the state’s dial framework allowed for more targeted responses, based on how widely the virus was spreading in each county, she said.

Yet under the original dial framework, much of the state had enough cases to trigger another stay-at-home order. Instead, Gov. Jared Polis announced a new level of restrictions that closed indoor dining and forbade personal gatherings, but allowed most businesses to stay open. The fact that cases and hospitalizations decreased in December suggests it worked, while reducing economic damage, Ryan said.

“It’s been this tricky balance,” she said.

The state had incredibly high rates of COVID-19 spread heading into Thanksgiving, and things weren’t much better when Christmas arrived a month later. If large numbers of people had gone ahead with their normal holiday plans, cases would have exploded. Instead, the state saw two small bumps, and cases and hospitalizations started falling again within a few weeks of the holidays.

It’s not completely clear how much state orders influenced the virus’s trajectory, Bayham said. Phone tracking data suggests people already had begun isolating to some degree before Polis issued the spring stay-at-home order, but people weren’t as quick to change their behavior as the pandemic went on, he said.

“As people sort of acclimate to the risk… policy becomes more important,” he said.

It has been hard for people to sustain the highest level of precautions, but Coloradans should get credit for what they did to beat back the virus, said Dr. Jon Samet, dean of the Colorado School of Public Health.

“We’ve never, in the lifetime of the generations alive now, had to live the way we have in the past year,” he said.

The world had warnings

That may reflect how lucky the world has been.

If you’re at least 19, you’ve lived through four novel diseases appearing in humans: the original Severe Acute Respiratory Syndrome, or SARS, caused by a coronavirus that didn’t spread nearly as easily as the one we’re facing now; H1N1, a new flu strain; Middle East Respiratory Syndrome, or MERS, caused by yet another less-contagious coronavirus; and now, COVID-19.

Public health Cassandras sounded the alarm about new viruses for decades, Samet said. Still, we didn’t have adequate stockpiles of protective equipment, and some of the country didn’t have enough hospital beds as rural facilities closed and some urban ones shifted their focus to more-expensive specialty care, he said.

“I think, collectively, we’ve all flunked preparedness,” he said.

State and federal plans for a potential pandemic didn’t focus on a disease that could spread as easily as COVID-19 ultimately did, and the Centers for Disease Control and Prevention left an information “vacuum” at times, Herlihy said.

Colorado’s plan was focused on the possibility of a new form of flu, and didn’t account for people without symptoms spreading the virus, Ryan said.

“People who get influenza are sick and they naturally isolate. They go to bed,” she said.

Nearly all states, including Colorado, hadn’t funded public health to keep up with inflation, let alone to build up capacity to respond to new threats. At the beginning of the pandemic, local health departments were faxing their test results to the state, though they’ve since upgraded the information technology system to send reports automatically, Herlihy said.

The health care system also didn’t have a plan for a threat like COVID-19. Federal and state regulators require hospitals to prepare for disasters like wildfires and power outages, but they never had a drill involving a year-long pandemic, said Amber Burkhart, director of public policy at the Colorado Hospital Association.

“Historically, hospitals have focused their preparedness on short-term events,” she said.

Unlike some parts of Asia and Europe, the United States had time to set up testing and stockpile protective equipment — it just didn’t use that time well, said Dr. Connie Price, chief medical officer at Denver Health. In the spring, the supply chain problems seemed like a short-term issue that hospitals and others would have to work through until manufacturing ramped up. For whatever reason, that didn’t happen, and they still deal with periodic shortages, she said.

“Even with that lead time, we failed to get the infrastructure to contain COVID-19, somehow,” she said.

The health care system isn’t set up for a pandemic, Price said. Theoretically, hospitals could have an extra wing equipped and ready to go, but it’s not feasible to have more skilled staff than you anticipate needing, indefinitely, she said.

“We’re designed to run at capacity, like any business,” she said. “We don’t have a lot of physicians laying around.”

Hospitals found a way to get through, by cross-training staff, setting up a way to transfer patients to facilities with more capacity and sharing what they were learning in ways that they hadn’t under normal circumstances, said Darlene Tad-y, vice president of clinical affairs at the Colorado Hospital Association. Some of those practices may outlast the pandemic.

Nikki Clowers, managing director of the U.S. Government Accountability Office’s health care team, said watchdogs had flagged some of the problems that would bedevil the COVID-19 response in the aftermath of 2009’s H1N1 pandemic, and in responses to more common disasters like hurricanes.

For example, GAO staff told Congress in February 2020 that agencies that weren’t clear on their roles could leave gaps or inadvertently work against each other, Clowers said. It had happened before, when the Department of Health and Human Services thought it would get extensive help responding to a hurricane in Puerto Rico from the Department of Veterans Affairs, but the VA thought it was only responsible for affected veterans’ care, she said.

“People thought one agency was going to do something, and they thought they were doing something else,” she said.

Doug Farmer, president and CEO of the Colorado Health Care Association, said one of the biggest lessons of the pandemic was the need for a “clear, consistent plan,” and for guidance about what to do when the plan fell apart. For example, many nursing homes couldn’t get personal protective equipment in the spring, and needed information about the safest way to stretch what they had, he said.

“It was very well known by everyone — CDC, OSHA, CDPHE — that there was a worldwide shortage of” personal protective equipment, he said. “It wasn’t taking into consideration the reality.”

An exercise in which federal agencies simulated how they might respond to a pandemic didn’t specifically look at a virus like COVID-19, but still identified that confusion and supply chain problems would be likely with a new disease, Clowers said.

“It almost predicted perfectly what we saw,” she said.

Preparing for the next pandemic

We’ll likely live through another pandemic, though we have no way of knowing when. As the growing human population pushes into previously wild areas, it increases the chances a bat or some other animal will cross paths with a person, starting a chain of infections that could spread around the world.

It’s a scenario that scientists and writers have been warning about since at least the mid-’90s, Samet said. SARS-CoV-2, the virus that causes COVID-19, just happened to have a few traits that let it get out of control in humans, like the ability to spread when the infected person still feels fine, he said.

“We had pandemics before we had airplanes, but certainly a globalized world has complicated things,” he said.

If there’s a positive aspect of COVID-19, it could be renewed attention to neglected areas of health research, such as the exact mechanics of how respiratory viruses infect susceptible people, Samet said. The pandemic also could mean a new emphasis on developing antiviral drugs, and has already taught us a great deal about developing vaccines, he said.

There’s also new public interest in infectious disease concepts that only specialists recognized a year ago, George Washington University’s Akselrod said.

“Before this year, I couldn’t pay my students to care about test sensitivity or specificity,” she said, referring to whether a test may miss cases or inaccurately label negative results as positive.

Time will tell whether the lessons of COVID-19 last. We’ve kept making the same mistakes that contribute to devastation from wildfires and other disasters, and visions of a possible future may be less compelling than immediate needs when politicians are deciding where to invest resources.

Still, Samet thinks the pandemic could define current generations the way the Great Depression shaped his parents’ view of the world for the rest of their lives. So far, COVID-19 has killed more than 518,000 Americans and 2.5 million people worldwide.

“Let’s hope we’ve learned from this one,” he said.

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