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Beware of RSV

Worrying.

Two common respiratory viruses continue to keep Houston pediatric hospitals unusually busy this time of year, with both the flu and RSV seeing a second surge following a rise in cases over the spring and summer, respectively.

Before the COVID-19 pandemic, children sickened with either illness flocked to hospitals later in the winter months, from November to January. But intense isolation, social distancing and masking appears to have changed when those viruses spread, experts say, with a swath of young children being exposed for the first time.

It’s also unusual to see both viruses surging twice in the same year, puzzling top pediatric doctors in Houston.

“I was not necessarily expecting a surge right now,” said Dr. Michael Chang, a pediatric infectious disease specialist at UTHealth and Children’s Memorial Hermann Hospital. “Having had a summer (RSV) surge, I was expecting that was it. It’s very unusual to have two surges in a single season. It happens, rarely, but it’s very uncommon.”

Both RSV, or respiratory syncytial virus, and the flu have similar symptoms with slight differences. Both illnesses produce cold-like symptoms. The flu is more associated with a higher fever, while a key indicator of RSV is wheezing, according to the Cleveland Clinic. Nearly all children catch RSV before age 2. Both illnesses often do not require hospitalization, but young infants and older adults with compromised immune systems are at higher risk of severe illness from RSV.

RSV saw a massive spike last summer, and Chang and other pediatric doctors had warned of another summer surge this year. But when cases initially started to rise in June, the numbers never dropped back to baseline levels. The statewide positivity rate for antigen tests hovered around 10 percent until September and early October, when the positivity rate jumped again to more than 25 percent, according to the Texas Department of State Health Services.  Last summer, the statewide positivity rate for antigen tests surpassed 30 percent.

[…]

Influenza A, one strain of the flu, also is on the rise after an increase in March and April. Houston Methodist’s respiratory pathogen data shows the hospital system is seeing year-long high in weekly cases with 656.

Despite the unusual pattern, parents of young children in the Houston area should not panic, doctors say. While national reports indicate record high patient volumes in some parts of the country, Houston is better equipped than other large cities to handle the surge, with two large pediatric hospitals in Texas Children’s and Children’s Memorial Hermann. The dual virus threat also is nothing new for pediatricians, as the flu and RSV season often overlapped before the pandemic.

“This is how every December and January used to be in children’s hospitals across the country,” Chang said.

COVID cases remain low in the Houston area. While some hospitals may hit capacity on busier days, and patients may encounter long wait times, the small percentage of RSV and flu patients who need hospitalization should be able to find beds, doctors say. Dr. James Versalovic, chief pathologist at Texas Children’s Hospital, said parents should consult with pediatricians if their children have persistent symptoms, including coughing, fever, poor feeding or rapid breathing. Virtual appointments are also available if area hospitals are strained.

It’s not just happening in Harris County, either. It’s having some negative effects.

With respiratory illnesses spreading among children more widely and earlier than in previous years, hospital leaders and medical experts say pediatric hospital beds across the state are in short supply.

After two years of mild flu seasons — a result of mitigation strategies to limit the spread of COVID-19 — medical experts say the number of children developing respiratory illnesses is already much higher this year, leading to more visits to health care centers and increasingly strained resources to treat those children.

Experts say the strain stems from overburdened hospital systems still reeling from the impact of the COVID-19 pandemic and a shortage of medical providers.

Dr. Gerald Stagg, a pediatrician working in Mount Pleasant, said cases of respiratory syncytial virus, known as RSV, and an earlier flu season have added pressure to hospital systems on top of other respiratory illnesses caused by COVID-19 and other viruses.

“I’ve been doing this for 42 years and I’ve never seen anything quite like it,” Stagg said of the number of children needing treatment for respiratory illnesses this year.

With the higher rates of respiratory illnesses, Stagg said not only are hospitals filling up, but clinics like his are having trouble keeping up with the huge uptick in visits from children with the flu.

Stagg said it’s become more difficult over the last two months to find beds in larger medical systems for sick children who require higher levels of care than what rural hospitals are able to provide.

“We’ve had to even send kids to Arkansas or Louisiana from our Texas facility because we couldn’t find a bed,” Stagg said.

He added that the shortage of hospital beds is a risk to children with serious illnesses that are not respiratory because there isn’t sufficient space in intensive care units for them.

Carrie Kroll, the vice president of advocacy, public policy and political strategy at the Texas Hospital Association, said the shortage of pediatric beds is a workforce issue. Hospital systems are still dealing with staffing shortages after droves of nurses and other hospital workers, suffering from pandemic-related burnout, retired or left the field.

“A bed is a bed. If it doesn’t have anyone to staff it, you can’t put a kid in it,” Kroll said.

[…]

Dr. Iván Meléndez, the Hidalgo County health authority, said his region has enough beds and resources to meet the needs of the community at the moment.

Meléndez did warn that this year could have significantly more cases of the flu than previous ones. Federal health data released Friday reported 880,000 cases of influenza and 360 flu-related deaths nationally. The last time the country saw similar rates of the flu was in 2009. And flu season has just started; it generally spans from October to May.

Earlier this month, Hidalgo County reported one of the first deaths of a child due to the flu this season.

“We’re thinking this may be the third since the turn of the century of being a ‘high-flu’ year,” Meléndez said.

He said the prevalence of the flu this year is an unintended consequence of masking and isolating during the COVID-19 pandemic.

“As a community, worldwide, we didn’t develop those antibodies that are usually present in the community at some level to protect people,” he said.

To address the surge of respiratory illnesses, Meléndez and other medical experts strongly recommended vaccinations against the flu and COVID-19.

Sure would be nice if we had a governor that was capable of delivering that message. There’s no vaccine for RSV, but the flu shot and the bivalent booster are easily available, so do what you can to protect yourself. Your Local Epidemiologist has more.

Is this just the calm before the next COVID wave?

Things look good now, at least in the Houston area, but COVID never sleeps.

As the U.S. heads into a third pandemic winter, the first hints are emerging that another possible surge of COVID-19 infections could be on its way.

So far, no national surge has started yet. The number of people getting infected, hospitalized and dying from COVID in the U.S. has been gently declining from a fairly high plateau.

But as the weather cools and people start spending more time inside, where the virus spreads more easily, the risks of a resurgence increase.

The first hint of what could be in store is what’s happening in Europe. Infections have been rising in many European countries, including the U.K., France, and Italy.

“In the past, what’s happened in Europe often has been a harbinger for what’s about to happen in the United States,” says Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “So I think the bottom line message for us in this country is: We have to be prepared for what they are beginning to see in Europe.”

Several computer models are projecting that COVID infections will continue to recede at least through the end of the year. But researchers stress there are many uncertainties that could change that, such as whether more infectious variants start to spread fast in the U.S.

In fact, scientists are watching a menagerie of new omicron subvariants that have emerged recently that appear to be even better at dodging immunity.

“We look around the world and see countries such as Germany and France are seeing increases as we speak,” says Lauren Ancel Meyers, director of the UT COVID-19 Modeling Consortium at the University of Texas at Austin. “That gives me pause. It adds uncertainty about what we can expect in the coming weeks and the coming months.”

However, it’s not certain the U.S. experience will echo Europe’s, says Justin Lessler, an epidemiologist at the University of North Carolina who helps run the COVID-19 Scenario Modeling Hub.

That’s because it’s not clear whether Europe’s rising cases are related to people’s greater susceptibility to new subvariants they’ve not yet been exposed to. In addition, different countries have different levels of immunity.

“If it is mostly just behavioral changes and climate, we might be able to avoid similar upticks if there is broad uptake of the bivalent vaccine,” Lessler says. “If it is immune escape across several variants with convergent evolution, the outlook for the U.S. may be more concerning.”

In fact, some researchers say the U.S. is already starting to see early signs of that. For example, the levels of virus being detected in wastewater are up in some parts of the country, such in Pennsylvania, Connecticut, Vermont and other parts of the Northeast. That could an early-warning sign of what’s coming, though overall the virus is declining nationally.

“It’s really too early to say something big is happening, but it’s something that we’re keeping an eye on,” says Amy Kirby, national wastewater surveillance program lead at the Centers for Disease Control and Prevention.

But infections and even hospitalizations have started rising in some of the same parts of New England, as well as some other northern areas, such as the Pacific Northwest, according to Dr. David Rubin, the director of the PolicyLab at Children’s Hospital of Philadelphia, which tracks the pandemic.

“We’re seeing the northern rim of the country beginning to show some evidence of increasing transmission,” Rubin says. “The winter resurgence is beginning.”

As the story notes, we’re overall in a much better place because there’s a lot more immunity thanks to vaccinations and our previous high rate of infections. The COVID levels in wastewater here is low now, and while we’re hardly a leader in vaccinations, we at least have warmer winters so there are still plenty of opportunities to be outside, and fewer times where you have to be congregated inside. But also, not nearly enough people have had their bivalent boosters yet, and there are concerns about the flu season. So, you know, remain appropriately cautious – masking in places where you used to have to mask is still an excellent idea – and get those shots.

The wastewater is looking good now

In terms of COVID levels, anyway.

The COVID-19 viral load in Houston’s wastewater has sunk to its lowest point in seven months as the city puts the latest wave, driven by the highly contagious omicron subvariant BA.5, in the rear view.

The wastewater levels are 71 percent of what the Houston Health Department detected during the July 2020 wave, which the city uses as a benchmark, according to Texas Medical Center data published Tuesday. The COVID hospitalization rate and positivity rate also continue to decline steadily.

Harris County last week dropped its COVID community level from “medium” to “low,” which recommends staying up to date on vaccinations and testing if you have symptoms. Scientists are looking to other countries for signs of what comes next.

“Our history has typically been a winter surge,” said Dr. Luis Ostrosky, chief of infectious diseases with McGovern Medical School at UTHealth Houston. “So let’s enjoy it while we can.”

Several new omicron off-shoots have been detected in the United Kingdom, India, Singapore, Denmark and Australia, according to the journal Nature. BA.5 continues to dominate cases in the United States, though one subvariant, BA.4.6, has gained some traction and now makes up roughly 12 percent of cases, according to the Centers for Disease Control and Prevention. Ostrosky urged people to get their updated booster shots, which better target omicron variants.

The dashboard is here, and you can see it as a graph here. COVID from the omicron wave peaked in the wastewater in July, but it was at almost ten times the level as it had been in July of 2020. It is now at 71% of the July 2020 levels, which is much better in so many respects. Get up to date on your boosters – I got my bivalent booster the other day – and get a flu shot (got one of those as well, at the same time), because there’s concern this could be a bad flu season. And even with these levels going down, hopefully for the foreseeable future, it’s still a good idea to wear a mask in crowded indoor spaces. Might help you avoid catching a winter cold, too.

The new county COVID risk assessment system

We’ll see how it works.

Harris County has revamped its method for assessing the public’s risk for contracting COVID-19, replacing the threat level system that has been in place since early in the pandemic with a community level system that places a greater emphasis on new cases.

The change was made due to a “decoupling” of the relationship between new cases and new hospitalizations during the most recent wave of COVID-19 fueled by the BA.5 subvariant of omicron, Judge Lina Hildalgo said during a news conference Thursday. Harris County did not see a spike in hospitalizations as COVID-19 cases surged this summer, she said.

The new system will allow the public to make their own decisions about the level of risk they are comfortable with taking, knowing that the chance of being hospitalized with a severe illness is relatively low if they have been vaccinated and boosted, Hidalgo said.

“We’re turning a page on a phase of this virus, and I’m very hopeful that we won’t have to go back to a time when surge hampered the entirety of the community,” Hidalgo said.

Hidalgo said the threat level system had been an important tool for gauging risk throughout the pandemic. It had been updated before, but this week’s changes represent a “wholesale redesign,” she said.

The new system uses a trio of color-coded community levels that indicate the risk for contracting COVID-19. Low is green, medium is yellow and high is orange. Harris County is currently yellow, but Hidalgo anticipated the community level could rise to orange with the risk for transmission increasing with children back in school.

[…]

The Harris County Public Health website offers guidance for each of the three threat levels, including recommendations for wearing a mask, traveling and social gatherings when the county is green, yellow or orange. The site will continue to offer other pertinent information, such as wastewater monitoring data and the percentage of county residents who have been vaccinated and boosted.

I had to find the appropriate webpage for this on my own – click the embedded image to get there. The old threat level webpage now gives a 404 error. This new system seems fine and reasonable. The main concern is about what might come next.

Q: So how are we doing these days? The numbers certainly look better than they did.

A: They are falling, no doubt about it. But we have to keep in mind that we don’t have a lot of details about the real number of cases. Most of us are getting diagnosed at home using home testing kits. The numbers were always underestimating by a factor of four or five. Now it’s probably seven to 10. So you have to have to look trends.

Numbers are going down. But here are numbers I keep reminding people of: We’re still losing 400 or 500 Americans a day to COVID, which makes it the third or fourth leading cause of death on a daily basis in the United States. There’s still a lot of terrible messaging. People say we don’t have as many hospitalizations. Or that everybody has been infected or vaccinated or vaccinated with breakthrough. All of that is true. On a population level, it has had mitigating effects. But that doesn’t help you make an individual health decision.

People conflate that with individual health decisions. If you’re unvaccinated, there’s still a possibility you could lose your life to COVID. Even if you’re vaccinated and not boosted, there’s that possibility. And we’re seeing the boosters aren’t holding up as well as we’d hoped. That’s one of the reasons I’m strongly encouraging people to get this new booster, which has the mRNA for the original lineage and an added one against BA.5. After four or five months, there’s risk again for being hospitalized. The coverage declines from 80 percent to 50 percent protection against hospitalization.

Then this BA.5, even though it’s going down, it’s a long, slow tail. It’ll be around well into the fall. And the toughest thing to get people to understand is what’s going to happen in the winter. Obviously there’s no way to predict. But I think it’s still quite likely that we’re going to see a new variant just like we have the last two winters. Last winter it was omicron, BA.1. The winter before that we saw alpha. And new variants are arising because we’ve done such a poor job vaccinating low and middle-income countries.

We don’t know what a next variant could look like. More like the original lineage? Or something more like BA.5? The advantage of the new combined booster is that it gives you two shots on goal. It’s more likely to cross-protect against what’s coming down the pike. That’s no guarantee. But we’ve never done this before in terms of what the FDA does. We’ve never vaccinated against something that might be lurking out there. It’s a paradigm shift. What’s happening, and I don’t think the FDA will phrase it this way, but we’re creeping toward a universal coronavirus vaccine.

That’s from a Q&A with Dr. Peter Hotez, who knows better than I do. But I do know enough to say that you should get the omicron booster. And I also know enough to say that political stunts that endanger public health are bad. I think that about covers it.

“Safe haven” laws are also not a replacement for abortion

Continuing a theme.

What are safe haven laws?

flurry of Houston baby abandonments in the ’90s led Texas to become the first state to enact a safe haven law in 1999.

Created as an incentive for parents in crisis who are unable to care for their newborns, the law allow parents to drop off babies 60 days or younger at any hospital, fire station or EMS station in the state, no questions asked.

The baby will then be protected and given medical care until a permanent home is found. Provided the baby arrives unharmed and safe, the parents avoid prosecution for abandonment or neglect.

Do people actually use the laws?

Roughly 400,000 babies are born in Texas each year, but data shows that a small fraction of people actually utilize the option.

Just 172 infants have been relinquished under the state’s safe haven law since 2009, according to data from the Department of Family and Protective Services.

Why?

Most families have likely never heard of it, said Sheila M. Katz, a sociology professor at the University of Houston.

This is especially true for middle- and low-income families who may not have the “extra bandwidth” to explore something until they’re in the situation, Katz said.

[…]

Katz said safe haven laws are “very good” at doing what they’re designed to do, but weren’t created to be an option for people unwilling to continue pregnancies.

“It’s taking a law and trying to make it look like a band-aid for bigger issues,” she said.

“If a woman is in an unhealthy relationship and decides to get an abortion to sever ties,” Katz added, “a safe haven law will not help in this situation.”

Or, to put it another way, people who choose to get abortions do so because they don’t want to be pregnant. There’s a separate decision made about what to do after giving birth once that one has been made. The impression I get is that the kind of person who would dump a baby at a fire station is someone who felt truly desperate and trapped and without any other option. While it is very likely that the post-Dobbs criminalization of abortion in Texas will increase that population, the availability of abortion pills and the still-robust abortion access network may mitigate that. I could be wrong, of course – we may in fact see enough of an increase in that population to drive an equivalent increase in the number of babies getting deposited at these locations. If you think that’s something to cheer about, well, you know what I think of you.

A different EMTALA ruling in Idaho

As expected. You know where this goes from here.

A federal judge on Wednesday blocked Idaho from enforcing a ban on abortions when pregnant women require emergency care, a day after a judge in Texas ruled against President Joe Biden’s administration on the same issue.

The conflicting rulings came in two of the first lawsuits over Biden’s attempts to keep abortion legal after the conservative majority U.S. Supreme Court in June overturned the 1973 Roe v. Wade decision that legalized the procedure nationwide.

Legal experts said the dueling rulings in Idaho and Texas could, if upheld on appeal, force the Supreme Court to wade back into the debate.

[…]

In Idaho, U.S. District Judge B. Lynn Winmill agreed with the U.S. Department of Justice that the abortion ban taking effect Thursday conflicts with a federal law that ensures patients can receive emergency “stabilizing care.”

Winmill, who was appointed to the court by former Democratic President Bill Clinton, issued a preliminary injunction blocking Idaho from enforcing its ban to the extent it conflicts with federal law, citing the threat to patients.

“One cannot imagine the anxiety and fear (a pregnant woman) will experience if her doctors feel hobbled by an Idaho law that does not allow them to provide the medical care necessary to preserve her health and life,” Winmill wrote.

The Justice Department has said the federal Emergency Medical Treatment and Labor Act requires abortion care in emergency situations.

“Today’s decision by the District Court for the District of Idaho ensures that women in the State of Idaho can obtain the emergency medical treatment to which they are entitled under federal law,” U.S. Attorney General Merrick Garland said in a written statement.

“The Department of Justice will continue to use every tool at its disposal to defend the reproductive rights protected by federal law,” Garland said. The DOJ has said that it disagrees with the Texas ruling and is considering next legal steps.

See here for the background. TPM goes deeper into the two rulings and also provides copies of them, but the bottom line is that the Texas judge said that the federal guidance went too far, didn’t go through the formal rule-change process (even though it was guidance on an existing rule and not a change), didn’t take the rights of the fetus into account, and could only apply when the mother’s life was in danger, not just when her health was threatened. The Idaho judge didn’t do any of that.

Both rulings will be appealed, and as Idaho is in the more liberal Ninth Circuit, there’s a very good chance that this ruling will be upheld. The same is true for Texas, where the radical and lawless Fifth Circuit will get its paws on it. While it is usually the case that a split in the appellate courts means that SCOTUS will weigh in, it seems possible to me that they will duck the issue, perhaps on the grounds that this is really a dispute over state laws, and since the Texas case applies only to Texas, there’s no need for them to step in. I’m just guessing, I could easily be wrong. We’ll know soon enough. DAily Kos has more.

Restraining order granted in Paxton’s EMTALA lawsuit

Ugh.

Texas hospitals will not be required to provide emergency abortions after a federal judge ruled the Biden administration was unauthorized to enforce such a rule.

U.S. District Judge James Wesley Hendrix in Lubbock ruled that the guidance by the U.S. Department of Health and Human Services went beyond the text of a related federal law, Reuters reported. The judge’s ruling agreed with Republican Texas Attorney General Ken Paxton.

Hendrix, who was appointed by former President Donald Trump, only barred federal regulators from enforcing the guidance and its interpretation of the Emergency Medical Treatment and Active Labor Act in Texas, and against two anti-abortion groups of doctors. The judge declined to enjoin the guidance nationwide.

[…]

The Biden administration’s guidance was an attempted response to concerns about the health of pregnant patients being turned away or delayed care by hospitals worried about abortion bans. The Texas Medical Association wrote a letter asking state regulators to “prevent any wrongful intrusion into the practice of medicine.”

See here for the background. At least this time it’s just limited to the state and not nationwide, though of course it’s our effed-up state that needed this to be decided differently. As TPM notes, there’s a similar case in Idaho that may have a ruling by the time you read this, so we’re going to be fighting this out in the appeals courts and then very likely SCOTUS. Joy.

I often say that I Am Not A Lawyer in posts about legal things. I say that in part to make it clear that my analysis is that of a layperson, and one should be wary of accepting my acumen of the finer points of legal theory. But that also frees me to an extent of the concern about the technicalities and lets me just focus on the things that should matter, whether they actually will in a real courtroom or not. As a prime example of this, let’s look at a bit of the judge’s ruling. I’m quoting from that TPM story now:

“That Guidance goes well beyond EMTALA’s text, which protects both mothers and unborn children, is silent as to abortion, and preempts state law only when the two directly conflict,” Hendrix writes.

Siding with the two groups of anti-abortion physicians as well as the state of Texas, Hendrix writes that the HHS guidance requiring physicians to act when the woman’s health is at risk is too generous.

“The Guidance states that EMTALA may require an abortion when the health of the pregnant woman is in serious jeopardy,” he says. “Texas law, on the other hand, limits abortions to when the medical condition is life-threatening, and HLPA goes further to expressly limit the condition to a physical condition,” he adds, referring to Texas’ trigger law that outlaws abortions in most cases.

He argues that the guidance also does away with consideration for the embryo or fetus. The government contends that, when the wellbeing of the woman and embryo or fetus are in conflict, it should be the pregnant patient who decides whether or not to go forth with an abortion. Hendrix says that the decision should be taken out of the woman’s hands and put into the doctor’s — who has to then comply with state law.

He also dips into agency power arguments to hack back the guidance, claiming that Congress has not resolved the specific question at play.

“Specifically, the question at issue here is whether Congress has directly addressed whether physicians must perform abortions when they believe that it would resolve a pregnant woman’s emergency medical condition, irrespective of the unborn child’s health and state law,” he writes. “Congress has not.”

In other words, unless you the doctor who may get prosecuted for murder are sure the pregnant person is going to die, you have to let them suffer. I don’t care about the legal technicalities, I’m here to say that if you’re capable of committing these words to a document, you’re a goddamned sociopath and you have no business having power of any kind. That of course also applies to Ken Paxton and Greg Abbott and every single member of the Legislature who voted for these barbaric laws. It’s what this election is about. And I should note that Slate’s Mark Joseph Stern, who is an actual lawyer, sees this the same way I do. So there. Daily Kos and CNN have more.

At least you’re (probably) not giving birth in West Texas

This is a long story about the lack of prenatal and obstetric care in West Texas. It’s mostly set in Alpine, Presidio, and Big Bend, which are the “big cities” in the area that actually have doctors and medical facilities in them. The one hospital in the area is in Big Bend, and its labor and delivery unit is now closed much of the time, for a variety of reasons. This is a small taste of what it’s like to be pregnant in this part of the state.

Big Bend is the only hospital in a 12,000-square-mile area that delivers babies. If Billings’s patient goes into labor when the maternity ward is closed, she’ll have to make a difficult choice. She can drive to the next nearest hospital, in Fort Stockton, yet another hour away. Or, if her labor is too far along and she’s unlikely to make it, she can deliver in Big Bend’s emergency room. But the ER doesn’t have a fetal heart monitor or nurses who know how to use one. It also doesn’t keep patients overnight. When a woman gives birth there, she’s either transferred to Fort Stockton—enduring the long drive after having just had a baby—or discharged and sent home.

This situation is stressful and dangerous for pregnant women. Uterine hemorrhages, postpartum preeclampsia (a potentially deadly spike in blood pressure), and other life-threatening complications are most likely to occur in the first few days after childbirth. This is why hospitals usually keep new mothers under observation for 24 hours to 48 hours. “This is not the ‘standard of care’ that women should receive,” Billings says. “You’re not supposed to discharge patients and leave it up to chance.”

Big Bend doesn’t really have a choice. In the past two years, almost all its labor and delivery nurses quit. The hospital has tried to replace them, but the national nursing shortage caused by the pandemic has made that impossible. When Big Bend is too short-staffed to deliver a baby safely, its labor and delivery unit has to close.

[…]

Medicaid pays for 42 percent of all hospital births, but it doesn’t reimburse hospitals for the full cost of care. (In most states it pays between 50 cents and 70 cents on the dollar, which means a hospital loses money when it cares for someone on the program.) To offset its losses, a hospital often charges its privately insured patients significantly higher fees. But if it’s in a poor neighborhood and doesn’t have enough privately insured patients, it can’t recoup the money. So most pre-pandemic maternity ward closures were in low-income areas and disproportionately affected pregnant women of color. Pandemic-related nursing shortages have only made the situation worse. Nowhere is this problem more evident than in Texas.

The state is the national leader in maternity ward closures. In the past decade, more than twenty rural hospitals have stopped delivering babies. More than half the state’s rural counties don’t even have a gynecologist. Texas has some of the lowest income eligibility limits for Medicaid and has declined to expand them, as allowed by the Affordable Care Act. (Childless adults don’t qualify for the program unless they’re disabled.) As a result, more than 18 percent of Texans don’t have health insurance, the highest percentage of uninsured residents in the U.S. Income eligibility limits jump for pregnant women—$36,200 for single mothers, $45,600 for married ones—but the application process takes at least a month. According to the March of Dimes, a fifth of all pregnant women in Texas don’t get prenatal care until they’re five months along. In other words, when a poor woman gets pregnant in Texas, it’s hard for her to find a doctor or even a hospital.

“What we’re seeing in terms of health outcomes, it’s not good,” says John Henderson, chief executive officer and president of the Texas Organization of Rural & Community Hospitals. “We have lower birth weights, more preterm births. When it comes to caring for pregnant women and their babies, Texas does not compare favorably to other states.”

Like I said, this is a long story and it’s worth your time to read. I’m old enough to remember when tort “reform”, in particular putting a cap on damage awards that can be given in medical malpractice lawsuits, was supposed to usher in a new era of doctor abundance in Texas. I don’t think that has worked out in the way we were promised. Towards the end, one of the doctors the author spoke to for the story notes that since abortion was already impossible to get in their region, the new state ban on abortion likely won’t result in more babies being born there. These docs will still deal with miscarriages and ectopic pregnancies and other life-threatening situations – they tell some amazing stories – despite the threat to their own safety. Click over and read on for more.

The latest COVID wave may be peaking in Houston

Hopefully

Texas Medical Center data released Tuesday suggests the latest wave of COVID-19 might have reached its peak in the Houston area, though several key metrics used to track the virus remain high.

The medical center’s weekly data report shows that COVID-19 hospitalizations, the positivity rate of coronaviruus tests and the amount of virus detected at the city of Houston’s wastewater treatment plants all trended downward for the second straight week. Those trends indicate the Houston area has likely crested the peak of a recent surge caused by the extremely contagious BA.5 subvariant, said Dr. James McDeavitt, executive vice president and dean of clinical affairs at Baylor College of Medicine.

“All the numbers are pointing to the fact that we’ve peaked maybe a week, a week and a half ago,” McDeavitt said. “I fully expect we will continue to trend down over the next several weeks.”

The line graphs from the TMC show a mountain range of peaks from prior waves of COVID-19, such as those caused by the delta and omicron variants. The latest BA.5 wave shows that after several weeks of steady climbing, the line is finally on the descent.

During previous waves, the virus did not pick up steam again after the numbers started to trend downward, McDeavitt said. He expects the same trajectory from BA.5.

It appears the current wave has at least reached a plateau, said Dr. Ashley Drews, an infectious disease specialist at Houston Methodist. The fact that the key metrics have stabilized is an encouraging sign, she said.

“We’re cautiously optimistic that things are turning in the right direction, and we’re going down,” Drews said.

[…]

During the week of July 25, TMC hospitals admitted an average of 219 patients with COVID-19 per day. That’s down from an average of 226 during the week of July 18, and 240 during the week of July 11.

However, the numbers remain much higher than they were before the emergence of BA.5. Three months ago, TMC hospitals admitted an average of 80 patients per day.

The good news is that the percentage of patients who need to be treated in an ICU remains lower than prior surges of COVID-19.

Last week, less than 14 percent of the 912 patients admitted with COVID-19 were treated in an ICU, according to TMC data. That’s lower than the percentage of patients treated in an ICU at the peaks of the omicron wave (17 percent) and the delta wave (22 percent).

[…]

The amount of virus detected at the city of Houston’s wastewater treatment plants, which has been a reliable indicator of community spread, also fell for the second straight week.

Wastewater loads reached an all-time high during the week of July 11, at 927 percent higher than a baseline established in June 2020. That fell to 774 percent during the week of July 18, and to 725 percent over the past week.

The amount of virus in the wastewater is still much higher than before the recent surge. Three months ago, it was less than 100 percent higher than the June 2020 baseline.

So, the data is starting to go in the right direction, which is good. But there’s still a lot of COVID out there, and all of the levels are still a lot higher than they were before the wave began, even if they never approached the heights of the previous peaks, and that’s bad. You should still be exercising caution, which is to say wearing your mask and avoiding indoor crowds if you can. And of course, get vaxxed and boosted as needed. We may be back on the downswing, but there’s no reason to believe we won’t trend up again at some point, and we’ve still got a ways to go to get to the lower levels we want.

We need more monkeypox vaccines

We have a chance to get on top of this. Let’s try to take it.

Houston-area leaders on Monday evening called for more vaccines to combat the small but growing number of local monkeypox infections.

There are 57 reported cases in the Houston area, including 10 in unincorporated Harris County. The Houston area recently received just over 5,000 doses of the JYNNEOS monkeypox vaccine from the state, but demand still far exceeds supply, health officials say. A two-dose series, administered four weeks apart, is required for full vaccination.

“What we learned from COVID is when the demand is high and supply is limited, people are very, very frustrated,” Mayor Sylvester Turner said during a news conference at Houston TranStar headquarters. “Now with monkeypox, with all the attention that’s been brought to it, the demand is very high.”

The World Health Organization over the weekend declared monkeypox a global health emergency. Monkeypox for years has been endemic in certain parts of Africa but has spread worldwide in recent weeks, with most cases among men who have sex with men.

[…]

The risk to the general public is low, health officials say. There have been no reported deaths among the roughly 2,800 cases in the U.S., and hospitalizations are mostly for pain management. There is at least one hospitalized monkeypox patient in Houston.

Even so, cases continue to rise around the world, and Turner and Harris County Judge Lina Hidalgo suggested at the press conference that a more preventative approach is needed in Houston.

“We have an opportunity to leap frog ahead of this virus to try to mitigate it in a way we couldn’t do with covid,” Hidalgo said.

Before the latest shipment, Houston and Harris County health departments have been making due with a few hundred monkeypox vaccines, prioritizing those suspected of coming into contact with a confirmed case.

There was a similar story from Dallas the day before this one came out. The monkeypox vaccine has been around for years, the issue was that it wasn’t readily available around the country. That is starting to change, and a broader group of people are eligible to receive it now, so as I said in the title, maybe we can get ahead of this before it gets to be too big. The good news is that this isn’t an easily transmitted virus, but it is very much out there now and the number of people who are infected with it will grow in the absence of action. Mayor Turner and Judge Hidalgo are on the right page here. They just need some support from the feds.

UPDATE: Followup story, Harris County has received more vaccines, a few hours after having to suspend vaccination appointments.

The current state of the hospitals

Worse than before, but not nearly as bad as before that.

A small but growing share of Houston healthcare workers are calling in sick with COVID, exacerbating long-running staffing issues at some hospitals amid the virus’s resurgence.

But despite spreading infections, medical leaders say the Houston-area healthcare system is managing this wave better than previous bouts with the virus, pointing to better therapeutics and fewer COVID patients requiring critical care.

Anecdotally, doctors say at least half of all COVID patients were admitted for reasons unrelated to the virus. While wastewater data reflects a soaring infection rate, daily new hospitalizations are climbing at a slower pace compared to the record-breaking omicron wave in January and February, according to Texas Medical Center data.

“I don’t anticipate we’re going to have major operational problems” among medical center hospitals, said Dr. James McDeavitt, executive vice president and dean of clinical affairs at Baylor College of Medicine.

The latest Texas Medical Center data, published Tuesday, show hospitalizations have nearly doubled over the last five weeks, from 121 in early June to 240 last week. In January, it took only five weeks for omicron to spark a nearly 600 percent increase in daily COVID hospitalizations, as admissions jumped from 74 to a record 515, according to TMC data.

Meanwhile, the increasing viral load detected in the city’s wastewater — 927 percent higher last week than July 2020 — appears to be as high as ever. Two weeks ago, the viral load was 843 percent of the July 2020 baseline. The citywide positivity rate also saw a slight increase from 29 percent two weeks ago to 31 percent last week, while the positivity rate in the medical center dropped slightly from 16.1 percent to 15.9 percent.

[…]

The number of sick hospital staff members reflects a small portion of the overall workforce at Houston hospitals. On Monday, Houston Methodist reported 402 staff members — 1.4 percent of all employees — had tested positive for COVID. Harris Health System said 245 staff members, or 2.4 percent of its workforce, had tested positive for COVID so far this July, compared to roughly 90 staff members throughout most of June.

Additionally, spokespeople for Memorial Hermann Health System, Texas Children’s Hospital and HCA Houston Healthcare say they are not experiencing major staffing issues or operational interruptions amid the current surge.

“Because of our vaccination and booster requirements, our staffing across hospitals is robust and fully intact,” said Dr. James Versalovic, chief pathologist at Texas Children’s Hospital. “I’m happy to say, we have prepared ourselves for this moment.”

More than two years into the pandemic, medical leaders now greet surges with more nuanced messaging, showing concern over rising infections and staffing struggles while assuring the public that hospitals are now better equipped to withstand rising infections.

Versalovic noted that Texas Children’s has seen its COVID population double over the last month. The 7-day rolling average of pediatric COVID patients is now more than 50 in the hospital system. He urged parents to seek out vaccinations as the start of school closes in.

On the one hand, this is basically good news. The hospitals are able to function without being overburdened, our overall vaccination level (and the good luck that this variant, however more contagious it is, isn’t particularly devastating) is helping keep levels in check, and while we’re worse off than we were a couple of months ago we’re much better off than we were in previous waves. One could argue that this is more or less what “endemic” looks like.

On the other hand, Stace is right. We’ve basically given up on trying to keep a lid on this thing – to be sure, there’s far less that governments can do now, thanks to a bunch of wingnut court rulings and Greg Abbott executive orders, but there are plenty of things we could be doing that we aren’t. A lot of leaders who should know better aren’t setting good examples. Even a milder form of COVID is potentially deadly to people with various comorbidities and risk factors, or who are immunocompromised in some way. Just having people mask up again as a matter of course would make all of their lives better, but we’re not doing that.

I’m definitely masking in indoor spaces again, but I’m also willing to be in indoor spaces, and to be among groups of people. I’ve mitigated some of my risk, but I’m engaging in riskier behavior than I had been before. It’s one part denial, one part pandemic fatigue, one part the perhaps naive hope that there will be another booster coming soon, and one part hoping that I’m being cautious enough. I don’t know what happens next if things do get worse from here. I very much hope I don’t have to find out.

When abortion is outlawed, pregnant people will be denied health care

It’s already happening.

The Texas Medical Association is asking state regulators to step in after it says several hospitals afraid of violating the state’s abortion ban have turned away pregnant patients or delayed care leading to complications, The Dallas Morning News reported.

In a letter to the Texas Medical Board — the state agency that regulates the practice of medicine — TMA officials on Wednesday said they have received complaints that hospital administrators and their legal teams are stopping doctors from providing medically appropriate care to patients with some pregnancy complications. They ask the board to “swiftly act to prevent any wrongful intrusion into the practice of medicine.”

TMA is a professional nonprofit that represents over 55,000 medical professionals in the state.

The request comes as confusion and concerns abound among Texas medical professionals over what they can and cannot do under Texas’ abortion ban.

Beyond elective abortions, there are several situations in which a doctor might advise an abortion for the safety of the patient — including ectopic pregnancies, in which a fertilized egg grows outside of the uterus, making it unviable — or provide other stabilizing treatments during hypertension and preeclampsia. Delays in treatment can cause serious health complications.

But in a post-Roe world, physicians in states where abortion has been banned have to weigh the legal implications of their actions, instead of making decisions based on what prevailing medical literature recommends. In Texas, doctors can face six-figure fines and be put in jail for any disallowed abortions.

According to the Morning News, the TMA included in its letter examples of some cases in which treatment was denied or delayed but did not name specific hospitals. In Central Texas, a physician was allegedly instructed to not treat an ectopic pregnancy until a rupture occurred, which puts patient health at serious risk, the letter says.

“Delayed or prevented care in this scenario creates a substantial risk for the patient’s future reproductive ability and poses serious risk to the patient’s immediate physical wellbeing,” the letter says.

The TMA letter also accused two other hospitals of telling doctors to turn away pregnant patients and send them home to “expel the fetus” if their water broke too soon, which can put them at risk of infection.

Not only are patients being put at risk of serious injury, but doctors could face lawsuits or the loss of their medical licenses for not providing adequate care, the TMA letter says. Failing to do so might violate the state’s prohibition on the corporate practice of medicine, which generally prohibits corporations or nonphysicians from practicing medicine.

The TMA’s plea comes one day after Texas sued the Biden administration to block new federal guidance reiterating to the nation’s doctors that they’re protected by federal law to terminate a pregnancy as part of emergency treatment.

Yeah, that. Look, I’m sure that was a splendid and appropriately stern letter that the TMA sent to those hospitals and pharmacies. I can’t find a copy of it online, but I believe it said all the right things. You know what would be even better than those words? Some action in the form of supporting candidates that will not sue to stop hospitals and doctors from giving needed treatment to their patients, and will not support the surely forthcoming legislation that will aim to put doctors and nurses and other healthcare workers in jail for providing needed health care to patients. I can think of a few, and I’m sure you can, too. What do you say, Texas Medical Association?

Paxton sues over emergency guidance to doctors

This is what “leaving it to the states” looks like.

Best mugshot ever

Texas is suing the Biden administration over guidance released Monday telling the nation’s doctors they’re protected by federal law to terminate a pregnancy as part of emergency treatment — and threatening to defund hospitals that don’t perform these procedures.

The Biden administration’s guidance states that federal law requires doctors to perform abortions for pregnant people in emergency rooms when it is “the stabilizing treatment necessary” to resolve a medical emergency, including treatments for ectopic pregnancy, hypertension and preeclampsia.

On Wednesday, the Biden administration also warned retail pharmacies that they must fill prescriptions for pills that can induce abortion or risk violating federal civil rights law.

These two recent actions pit the federal executive branch against state governments after the U.S. Supreme Court undid a nearly half-century-old precedent that had affirmed access to abortion as a constitutional right.

Texas Attorney General Ken Paxton’s office filed the suit challenging the guidance in federal court on Thursday, saying the Biden administration’s guidance violates the state’s “sovereign interest in the power to create and enforce a legal code.”

[…]

The Biden administration reassured the nation’s doctors that they don’t need to wait until a patient’s health deteriorates before acting and that they can act in cases where nontreatment would result in serious impairment, guidance that comes as medical professionals in Texas and other states where abortion is banned are trying to figure out what kind of women’s health care is allowed under new restrictions. The guidance isn’t seeking to update existing law but is said to clarify a hospital’s duties under the Emergency Medical Treatment and Active Labor Act.

I thought it was federal law that was sovereign, but what do I know? I know that if Paxton gets his way women are going to die because doctors won’t be able to treat them properly and in a timely fashion. That’s what’s really at stake here. And I expect Paxton to get his way, at least at first. The Chron points out the obvious:

The case underscores the dominant position that conservative Republicans hold in the federal judicial system: Paxton filed the case in Lubbock, in the U.S. Northern District of Texas, where there are 12 judges, 10 of whom were appointed by Republican presidents and six of whom were named by former President Donald J. Trump.

If Paxton were to lose, the case would go to the Fifth Circuit Court in New Orleans, widely recognized as one of the most conservative federal appellate courts in the country, and the final step would be the Supreme Court, which ruled last month to overturn Roe v Wade in the first place.

I guarantee you, whatever the district court judge does, the Fifth Circuit will give Ken Paxton what he wants because that’s what they do. And then SCOTUS gets to make another abortion ruling. Great system we have here, isn’t it?

I had drafted a post about the imminent threat to EMTALA that the Biden administration’s guidance had queued up, and then made the mistake of not publishing it in time to keep up with the news cycle. My bad. The original post is beneath the fold. I stand by what I said in this post. Now let’s bring the fight that this requires. Daily Kos and Mother Jones have more.

(more…)

COVID hospitalizations up in Houston

Welp.

COVID-19 hospitalizations have nearly doubled in the Houston area over the last month, according to re-published Texas Medical Center data, which paints a clearer picture of the risk associated with newer, increasingly transmissible versions of the virus.

The medical center discontinued its weekly reports in May, when the omicron wave had officially receded, and COVID drifted out of the public’s mind. But a new COVID surge prompted the medical center to post a revamped dashboard Tuesday, showing that the virus remains a persistent part of life.

Among the more urgent revelations: The average number of daily new hospitalizations rose from 121 in early June to 224 last week. That number is nearly half of the record-breaking hospitalization peak in early January, when an average of 515 COVID patients were admitted per day, according to the updated TMC data.

“Hopefully it’s peaking,” Dr. Paul Klotman, president and CEO of Baylor College of Medicine, said during a Tuesday news briefing. “It’s still a dangerous virus.”

[…]

The increase coincides with the rise of BA.5, a latest subvariant in the omicron lineage, which in a matter of weeks took over as the dominant strain in the U.S. First detected in South Africa, the subvariant made its way to the U.S. in early May and now makes up 65 percent of cases nationwide. In the Houston Methodist system, BA.5 comprises 57 percent of cases, while BA.4, another highly transmissible strain, makes up 19 percent.

BA.5 is concerning, experts say, because it appears to be more capable of re-infecting people and more resistant to vaccine-induced immunity. Even those who battled a COVID infection a few weeks ago could be susceptible to BA.5, said Dr. Wesley Long, a clinical pathologist and medical director of diagnostic microbiology at Houston Methodist.

“In previous waves, there was a thought that if you were infected, you had natural immunity for a couple of months,” he said. “With this shift from BA.2 to BA.5, that rule isn’t holding true.”

A recent study published in Nature found that BA.4 and 5 — which share similar mutations — are more likely to cause vaccine breakthrough infections compared to BA.2.12, the previously dominant strain. Waning vaccine immunity also compounds the risk.

Even so, vaccines are still effective at preventing severe disease, hospitalization and death, Long said.

“People shouldn’t get the wrong idea and think ‘I don’t need to get my vaccine’ or ‘I don’t need to get my booster,’” he said.

It’s still too early to say whether BA.5 is causing more severe illness than its predecessors. Early research shows it contains mutations found in the delta variant, which was linked to more acute sickness. But the rise in hospitalizations could simply be attributed to the volume of infections in the community, said Klotman.

Yeah, it could be worse. We’ve definitely seen worse. You know what you need to do to keep it from getting worse. All together now: You may be done with COVID, but COVID isn’t done with you. Stace and the Texas Signal have more.

The empty “mental health” promise

What’s going on in Uvalde these days.

Days after the May 24 shooting, Texas Gov. Greg Abbott promised an “abundance of mental health services” to help “anyone in the community who needs it … the totality of anyone who lives in this community.” He said the services would be free. “We just want you to ask for them,” he said, before giving out the 24/7 hotline number — 888-690-0799.

That’s a tall order for a community in an area with a shortage of mental health resources, in a state that ranks last for overall access to mental health care, according to a 2022 State of Mental Health in America report.

Mental health organizations are assembling a collection of services to assist those who seek help in Uvalde. But there have been hiccups and hitches along the way.

There is worry that what’s being offered is not coming together as fast or efficiently as it could be, and that it’s being assembled without keeping in mind the community it serves: Many residents are lower income, and some may have difficulties with transportation, or are mainly Hispanic. Many are not accustomed to seeking out therapy, or are distrustful of who is providing it.

Quintanilla-Taylor didn’t believe many would use the mental health services and had doubts about their long term availability.

“It’s not going be prevalent. … I don’t trust the resources, and that’s coming from an educated person,” said Quintanilla-Taylor, who’s pursuing a doctorate in philosophy and specializing in organizational leadership at the University of Texas at San Antonio.

[…]

Uvalde County Commissioners, the countywide government body, voted Thursday to purchase a building to create the Uvalde Together Resiliency Center to serve as a hub for long-term services, such as crisis counseling and behavioral health care for survivors.

Abbott set aside $5 million in funding for the center, which has been operating at the county fairgrounds.

Texas Sen. Roland Gutierrez, whose vast district includes Uvalde, said the community needs continuity of care and rather than create a new building the state could invest in the existing local community health clinic, in operation for 40 years and already serving 11,000 uninsured Uvalde residents.

“These are people who have behavioral health on the ground. They actually have the one psychiatrist in Uvalde right here,” Gutierrez said Friday referring to the clinic. “We needed to have the budget so that we can bring in therapists, which we would have been able to do with that money. Instead, they’re starting from whole cloth this promised center you’re going to have the district attorney run?”

Gutierrez, who has shifted a district office from Eagle Pass to Uvalde, said he met with 11 families whose children survived the shootings and were either wounded or sent to the hospital.

“What the families have been telling me is they don’t want to see one therapist one week, a different one the following and another one yet maybe the next week,” he said. “So, they are having trouble with appointments, with continuity and that’s very, very important, especially when we are talking about young children.”

Gutierrez said he sent a letter to Abbott asking for $2 million for the existing free community clinic to provide crisis care but has not heard back.

I’ve discussed this before, and this is another illustration of the problem. We can count on hearing two things whenever there’s a mass shooting in Texas. One is the usual blather about guns and why restricting access to guns isn’t the answer. The other is a rush to talk about mental health, both as a means of explaining the shooter’s actions and now more regularly as an alternate mitigation for gun violence that doesn’t restrict access to guns. It was a big component of the Cornyn bill, and may have been a key to its passage since there’s no question that more mental health services and funding for those services are badly needed. I’m happy to see that happen, it’s just that we all know this is only one piece of a much larger puzzle.

From the state perspective, any and all talk of mental health and services for mental health that comes from our state leaders is guaranteed to be little more than hot air. We have the longstanding issue of healthcare in general being out of reach for too many people because of lack of insurance, and the continued resistance to expanding Medicaid, which would be the single biggest step forward in that regard. We have the also longstanding issue of healthcare in rural areas, from hospitals closing for lack of funds to scarcity of doctors in rural areas, a problem that was supposed to have been solved by the passage of the tort “reform” constitutional amendment nearly 20 years ago. More recently there was Abbott’s redirection of over $200 million in funds from the Department of Health and Human Services to his never-ending border boondoggle. At every opportunity, the Republican leadership has made it clear that they don’t care about funding healthcare in general, and mental health services in particular. But they are willing to use the promise of mental health services as a distraction when the next crisis hits. That’s where we are now, and where we will be again if nothing changes.

Are we going to raise the COVID threat level again?

Maybe, but not yet.

Coronavirus infections are on the rise across Houston, wastewater tracking shows, even as fewer people seek testing two years into the pandemic.

Four months after the city saw record infection rates caused by the highly contagious omicron variant, new COVID-19 cases are once again climbing, according to data collected by Rice University and the Houston Health Department. The most recent sewage samples show increased viral loads at all but a few of the city’s three dozen wastewater treatment plants.

Citywide, the amount of virus particles detected in wastewater is up 242 percent above baseline, with an overall positivity rate of 14 percent. Both metrics increased by about a third over the previous samples, taken in early May. At the 69th street plant, serving much of the Inner Loop, officials said virus levels are 123 percent above baseline, with a 22 percent positivity rate.

Despite the uptick, health officials do not anticipate raising Harris County’s threat level to the highest level. The county’s threat level is currently set at moderate, signally a controlled level of COVID spread.

“Even though we see positivity rates going up, our hospital rates continue to remain low, said Dr. Erika Brown of the Harris County Health Department.

[…]

New of the rise in viral levels in the wastewater comes days after researchers at Houston Methodist reported new insight into how the omicron variant is mutating in Houston and across Texas.

Researchers demonstrated that two dominant sublineages of omicron have developed “unprecedented numbers” of spike protein mutations, leading to increased transmissibility. The mutations also enhance its ability to evade vaccines and the immune system.

This is a press release about the study in question; it’s from late April, which I’d classify as more than “days” ago, but whatever. The COVID levels in our wastewater continue to rise, but if the hospitals are still not seeing an increase in patients, then the threat level will stay where it is. I don’t know how long we can maintain this balance, but I sure hope it continues.

That press release is worth a read:

“One of the surprising findings in this study was that many mutations with critical roles in immune escape in previous variants of SARS-CoV-2 do not play the same roles in immune escape in omicron, and, in some cases, the effects of these mutations are completely reversed,” said Gollihar, who is the head of antibody discovery and accelerated protein therapeutics in Houston Methodist’s Center for Infectious Diseases. “The virus also appears to be stabilizing itself to allow for more mutations to evade our immune systems.”

He said this study is the first to systematically dissect each of the omicron mutations across the entirety of the spike protein. Previous studies miss contextual and long-range interactions across the protein.

“We developed a comprehensive map showing various mechanisms of immune escape by omicron that allows us to identify which antibodies retain neutralization activity against the virus,” Gollihar said. “This and future work will enable clinicians to make informed decisions about the use of monoclonal antibody therapy and aid in the development of next-generation vaccines.”

Having this new information about key features of omicron’s spike protein mutations and how they synergize, Gollihar and his team say it’s possible that the continuing accumulation of mutations may set the stage for greatly altering the equilibrium and stability of the spike protein in a way that allows for new, more virulent strains to develop. Understanding this evolution is critical, they say, to better inform future therapeutic targets and vaccine formulations, as the SARS-CoV-2 virus will continue to evolve with new variants inevitably arising and spreading.

Looking forward, they add, the strategy used in this study also will be applicable to future zoonotic outbreaks and other microbial pathogens, providing a powerful platform for investigating evolutionary trajectories of infectious agents and engineering appropriate and adaptable vaccines.

“We will continue to monitor the virus for changes in the spike protein and add new antibodies to test as they are discovered. Continuing to do so will allow us to design better probes for antibody discovery in hopes of engineering new therapeutics by finding potent neutralizing antibodies across all variants,” Gollihar said. “We have also recently expanded the platform to other pathogens where we hope to stay ahead of other potential outbreaks.”

I’m in awe of the work these folks have done and continue to do – I’m speaking of the researchers worldwide, not just these specific ones. We’re in a constant race with this virus, and so far we’ve been able to keep up. As above, I sure hope that continues, too. Stace has more.

Checking in again on the wastewater

COVID levels keep creeping up.

After the U.S. death toll from COVID-19 hit 1 million deaths on Monday, new data shows numbers on the rise again.

The latest Houston Health Department wastewater results from May 9 show levels are now higher than they were in July of 2020.

The viral load on May 9 was 127 percent higher in comparison to July 6, 2020.

The July 2020 readings serve as a baseline for wastewater testing, since that was during the summer surge of cases.

The positivity rate in Houston is also now at 8 percent. At the end of March, Houston’s wastewater positivity rate was 2 percent.

Since the results are delayed, levels are likely higher now.

Houston Methodist is also reporting a rise in cases over the last two weeks.

[…]

“We have also seen our first cases of BA.4 and BA.5, which we will continue to monitor, since literature suggests these variants escape immunity from previous Omicron infection,” [Dr. Wesley Long of Houston Methodist] tweeted. “Vaccines are still our best defense against COVID-19 along with masking and distancing.”

Long also says while the wastewater levels are nearly 30 percent higher than the July 2020 surge, that the public shouldn’t be fearful, but shouldn’t ignore the trend either.

“The bottom line is, the amount of virus in the community is going up,” Long said. “That’s one thing we know for sure. I wouldn’t be worried, but I would be paying attention.”

There was a story in the Sunday print edition of the Chron about the Houston wastewater tracking, with a byline from the NY Times, but I could not find it online. Note that this KHOU story reports on the May 9 virus level in two different ways, saying that the viral load is “127 percent higher” and also that it is “nearly 30 percent higher”. The latter is correct – the Houston COVID dashboard says that the COVID load is “127% in comparison to the July 2020 level”, which is to say up 27%. Pay attention in those math classes, people.

At this point, until there is a new type of vaccine, we have what we’re going to get. I heard on the CityCast Houston podcast that the vax level in Harris County is about 67%, which is better than it used to be but still too low to really slow things down. What we can do is whatever we can to get the unvaxxed people in our lives to get the shots, and we can get boosted – one if we’re under 50, two if we’re over. Get your kids boosted, which also very much means getting them vaxxed in the first place – only about 30% of kids in this range have had two shots, which is just madness to me. Wear your masks when in indoor public places again, and avoid needless indoor public gatherings. You have to take care of yourself now, so do it. Until it gets worse – and I still hope it won’t – this is the best you can do.

UPDATE: The May 16 numbers are now on the dashboard, and they show that we are at 170% of the July 6, 2020 level. Not great!

Time once again for Texas hospitals to struggle financially

I feel their pain, but…

More than $3 billion in federal money has flowed to Texas health care providers in recent months to help pay for COVID-19 treatments, tests and vaccines for patients without health insurance, according to national health officials.

Of that, a tiny fraction — some $2.2 million — went to the local independent hospital in rural Titus County for treating patients during wave after overwhelming wave of the devastating virus in an area where 1 in 3 residents are uninsured.

But the 174-bed Titus Regional Medical Center in northeast Texas needed every penny it could get as it struggled to cover the sudden, skyrocketing expenses of the pandemic: paying staff competitive wages to keep them on the job, keeping up with federal safety rules and managing record-breaking numbers of patients pouring into in the intensive care unit from a 150-mile radius, said CEO Terry Scoggin.

Now, after sending some $19 billion to hospitals and other health care providers nationwide, the fund known as the Health Resources and Services Administration COVID-19 Uninsured Program — created to help hospitals like Titus Regional pay for the care of uninsured COVID patients — has dried up.

While the halting of funds comes as Texas has seen infection numbers fall dramatically, the virus is still largely uncontrolled, causing surges and lockdowns in other countries. In the past, those surges abroad have always occurred before new cases rise again here in the United States, including Texas, which has more uninsured residents than any other state.

The failure to renew the program in time to continue reimbursing providers means that hospitals, clinics, private practices and others that don’t get public health funding from the state will have to “eat the cost” if they don’t charge for COVID-related services, Scoggin said.

“It’s a huge issue for us because we have so many adults who are uninsured,” Scoggin said. “And so it was kind of a kick in the gut for us when they shut that program off because I thought it was a good use of funds for the COVID piece.”

Refusing care to those patients who can’t pay is not an option, legally or morally, he said.

“We can’t turn people away, so we’re still going to pay for it,” Scoggin said. “It just shifted the expense of the uninsured from federal funds to individual hospitals.”

We’ve discussed the financial straits of rural hospitals in Texas before. I am once again pointing out that the locale in which this story is sited, Titus County, is yet another place that votes heavily Republican – Trump and Cornyn in 2020 and Abbott and Cruz in 2018 all topped 70% of the vote. I continue to have empathy for the employees of these hospitals, who for all I know may be habitually voting for politicians whose stated policy preferences are to help them. But I’m also saying it would be nice for these stories to include that easy-to-look-up data, because the simple fact is that if the likes of Greg Abbott or John Cornyn wanted to help the Titus Regional Medical Center, by expanding Medicaid or helping to push through more federal funds for the care of uninsured COVID payments, they could absolutely do so. The dots are just sitting there, waiting to be connected. We should do that.

Are we about to get more COVID in Houston?

We could be.

New data from the Texas Medical Center shows COVID-19 cases have leveled off over the past week, but some trends suggest the Greater Houston area could be on the verge of seeing higher virus spread.

TMC hospitals reported an average of 351 new cases per day during the week of April 18, the same number it reported during the previous seven-day period. The number of new cases does not include anyone who used an at-home test and did not report a positive result.

Those numbers represent a significant decline from last month, when the hospitals were reporting an average of 2,592 new cases per day.

However, the effective reproduction rate – or the average number of people who will be infected by someone with COVID – increased to 1.0 last week, up from 0.82 one week earlier. The rate essentially measures how well collective behaviors like wearing masks and social distancing are slowing the spread of the virus, with any rate higher than 1.0 meaning that spread is increasing.

The amount of virus being detected at the city of Houston’s wastewater treatment plants has also increased to the highest rate since Feb. 7, according to data from the Houston Health Department. Twenty-one of the city’s 39 wastewater treatment plants saw an increase in viral load in samples that were collected and analyzed April 18. By comparison, 16 plants saw in increase in samples collected and analyzed one week earlier.

The TMC’s weekly update also shows new hospitalizations have increased to an average of 59 admissions per day during the week of April 18, up from 42 the week before. TMC hospitals admitted an average of 89 new patients per day last month.

The data isn’t strongly conclusive, but it’s also early in what could be a trend, and as we know with this virus once you really start to see an uptick, it’s already too late. On the other hand, lots of people have COVID antibodies now, and that plus the number of vaxxed people who haven’t had COVID is probably enough to mitigate any crazy spread, or at least to make it less harmful, at this time. But of course there are still plenty of high-risk people out there, and lots of kids haven’t been vaxxed, and no one wants to get even a mild case of COVID. So, you know, stay cautious. You can still wear a mask even if you don’t have to, and you can get that second booster if you’re eligible. It’s never a bad idea to minimize your exposure to this thing. Stace has more.

COVID hospitalizations at a low in the state

Good news (say it with me) for now.

Texas hospitals are treating fewer than 1,000 patients with COVID-19 for the first time in two years. According to the Texas Department of State Health Services, hospitalizations totaled 993 on Sunday. The last time COVID-19 patients in Texas numbered less than a thousand was April 4, 2020, before the state’s initial surge in hospitalizations, which rose to nearly 11,000 by late July that year.

“Less than a thousand [hospitalizations] is a good place to be and this is what we’ve kind of been waiting for and watching really closely,” said Chief State Epidemiologist Dr. Jennifer Shuford.

Fewer people are getting severely ill and needing medical care, said Dr. Shuford, because nearly the entire Texas population has now developed at least some immune response to SARS-CoV-2, the virus that causes COVID-19.

“We expect, based on some antibody studies that we’ve done, that about 99% of our population has some antibodies to COVID-19, either from vaccination or from prior infection.”

Other infectious disease experts are also cautiously optimistic that vaccinations, combined with four waves of widespread infections – the most recent of which was driven by the omicron variant – will help minimize future surges in cases and hospitalizations.

“I do think that the antibody seroprevalence does have something to do with the declining severity of the illness that we’re seeing in terms of decreased hospitalizations,” said Dr. Robert Atmar, an infectious disease expert who teaches at Baylor College of Medicine.

Dr. Atmar said while he was not aware of how DSHS estimated Texas’ overall immune response, the high rate is possible, especially if infection rates for the virus have been under reported.

“It wouldn’t be surprising if a large percentage of the population had been infected and/or vaccinated. 99% just seems high, but it’s certainly not unreasonable that that might be the case,” he said.

I’m just some guy on the Internet, and I also think 99% is a little high. I do agree that between our mediocre vaccination rate and our undoubtedly high infection rate that a lot of people have at least some immunity at this point, and that is keeping the rate low for now. To some extent, as I understand it, this is how a pandemic becomes endemic – there’s enough residual immunity out there to keep infection rates modest and generally tamp down on larger outbreaks. But that surely comes with no guarantees, and the next bad mutation could happen at any time. If we’re lucky, that will either be relatively mild or be mostly stopped by vaccinations, but at this point who knows what could happen. I’ll be getting booster #2 in the near future, and you should be getting whichever booster you can if you haven’t already. It’s still your best bet.

And we’re back to yellow again

Let’s hope it lasts.

Harris County Judge Lina Hidalgo on Thursday lowered the county’s COVID threat level to yellow, signaling a controlled level of cases following the decline of the omicron wave.

The yellow level means COVID poses a “moderate threat” to the public and urges residents to continue to stay vigilant unless fully vaccinated.

Under the yellow or moderate level, unvaccinated residents are encouraged to continue masking and social distancing, while vaccinated residents are encouraged to do the same where required by law.

“My hope is that we are at a permanent turning point of this pandemic,” Hidalgo said in a statement. “But we’ve yet to have a wave where our hospitals don’t get overwhelmed, so we need to tread with caution before we declare victory over this virus.”

As noted, we dropped to the orange level two weeks ago. We were last in yellow in November, for less than a month before omicron moved in. I’m still wearing a mask for the grocery store and other indoor places with lots of people – I mean, I haven’t had a cold in over two years now, so why wouldn’t I? You do you, as long as that means getting vaxxed and/or boosted if you haven’t yet.

The Rodeo is back

Gonna be interesting to see how different it is, if it’s different at all.

And this year, after a one-year hiatus, the rodeo again will be focused on preventing the spread of COVID-19, the virus that abruptly brought the rodeo to a halt nearly two years ago. Masks will be required on public transit to the rodeo’s grounds, where an abundance of hand-washing and sanitizing stations will be positioned throughout. Many concession stands will only accept credit or debit cards instead of cash, and air-filtration systems have been updated to maximize the fresh air flowing inside NRG Stadium and NRG Center.

As the record-breaking omicron surge subsides, rodeo organizers encourage people to follow health and safety guidelines issued by the Centers for Disease Control and Prevention, which recommends that people stay up-to-date on vaccinations and take precaution such as wearing masks in areas of high transmission. People who are feeling ill are encouraged to stay home. More than 100 people a day continue to die of COVID-19 in Texas, with most of those fatalities among the unvaccinated, figures show.

Still, with the pandemic approaching the two-year mark and nearly 64 percent of Texans age 5 and older vaccinated, health experts agree that it’s time for people to return to large events such as the rodeo.

“We are going to have to live with COVID for a while, and I believe that people should be able to establish a new ‘normal’ and enjoy their lives,” said Dr. M. Kristen Peek, interim dean of the school of public and population health at the University of Texas Medical Branch in Galveston. “The Houston Livestock and Rodeo Show is an important part of Houston that people go and enjoy — just do it safely.”

After reviewing the rodeo’s eight-page document containing its COVID health protocols, Peek said the added precautions “look appropriate.” She said she is looking forward to attending the rodeo with her family.

“We will definitely be masked,” she said.

[…]

Now, 66 percent of Harris County is vaccinated with at least the primary series of Pfizer, Moderna and Johnson & Johnson, according to Harris County Public Health. The recent wave likely boosted natural immunity, and the community is equipped to handle the event without a major risk, said Dr. Paul Klotman, president and CEO of Baylor College of Medicine.

“The rodeo is in a big venue, so there’s a lot of ventilation and a big space,” he said. “Relative to other gatherings, this one ought to be safer than others. And if you look at some of the (recent) football games, there haven’t been a lot of big outbreaks.”

Klotman and other experts added a word of caution: the pandemic is not over. Vulnerable populations, such as immunocompromised people, still face a heightened risk of severe illness if infected.

“I wouldn’t be going if I lived with somebody who is going through cancer chemotherapy,” stressed Dr. James McDeavitt, executive vice president and dean of clinical affairs at Baylor.

See here for some background. I’m mostly okay with this, especially for the outdoor parts of the rodeo. We don’t currently have any plans to go to the fairgrounds, but we’re all vaxxed and boosted, we don’t have any immunocompromised people in our daily lives, and the risk being outdoors is fairly low. Honestly, taking the train to and from the event, which is the only way to go for me, feels a lot more risky just because the trains are always super full during Rodeo times. I’d feel more apprehensive about attending indoor events and the concerts, but if we did we’d be wearing our KN-95s, so it’s no more risky than some other things we’ve been doing. I don’t expect this to become a vector for infection, but by all means exercise as much caution as you want. Don’t go if you don’t feel good about it.

Orange is the new threat level

New again, anyway.

Harris County Judge Lina Hidalgo lowered Harris County’s COVID-19 threat level to “significant” Thursday, signaling the city is emerging from the worst of the omicron wave as infection rates plummet.

Harris County has met all four metrics needed to lower its threat level from red, its highest level indicating “severe risk,” to orange, the second-highest possible threat level. Under orange, officials still recommend that residents minimize all unnecessary contact and avoid large gatherings to stem the spread of the virus.

“The omicron wave hit Harris County very, very hard,” Hidalgo said in a statement. “In fact, only now have our hospitalization rates dropped to levels that don’t immediately threaten the capacity of our healthcare system.”

[…]

The two other metrics that were keeping the county in red — ICU capacity and new cases per 100,000 — have improved in recent days, leading to the downgrade Thursday. The overall percentage of COVID patients in the ICU fell to the county’s threshold of 15 percent, and the seven-day rate of new cases per 100,000 people declined to 83, well below the county’s goal of 100.

Hidalgo encouraged residents to get vaccinated to avoid another “dangerous” COVID spike.

“While we’re moving in the right direction, there are no guarantees we won’t see another wave in the future,” Hidalgo said.

We were last at orange in December, on the way to red a couple of weeks later. At this rate, we’ll likely be back to yellow soon, and after that who knows. The good news is that between our vaccination level and the sheer number of people who contracted omicron, our overall immunity level for the short term is as good as it’s ever been. The bad news is that our vax level is still way too low, far too few kids have been vaxxed, and the waning omicron wave is causing fewer people to get vaxxed now because the threat is receding. It really is just a matter of time before we’re back in a crisis situation again. If we’re lucky, and we make a strong effort to get a lot more people vaccinated in countries that have not had nearly enough vaccine supply, then maybe that next wave is farther off. If not, well, I probably don’t have to tell you what that means. Stace has more.

The wastewater is once again in our favor

But there’s still a lot of room for improvement.

The latest samples of Houston’s flushed wastewater show diminishing traces of COVID-19 across the region — a promising sign that the highly contagious omicron variant is in retreat.

Hospital admissions are down. Fewer people are testing positive for the virus. And now, the amount of coronavirus in the sewage is falling at all but two Houston wastewater treatment plants. Samples taken from across the city show the virus is no longer proliferating as quickly as it was earlier in the omicron outbreak.

After rising to “unbelievable” heights with omicron’s arrival just weeks ago, the city’s viral load is now falling rapidly, said Loren Hopkins, chief environmental officer at the Houston Health Department.

The level of COVID present in the city’s sewage is now about one-third of that measured at the onset of the omicron peak in late December and early January.

“We had this huge rise to levels we had never seen before,” Hopkins said Wednesday afternoon. “It went up very fast and has been dropping very fast.”

But while the variant may be loosening its grip, levels of the virus remains high. According to sewage testing, there is about as much COVID circulating citywide now as there was during the post-holiday surge a year ago that sickened Houston residents by the thousands and overwhelmed area hospitals.

See here for more on the wastewater tracking project. This metric is in line with other data, but please note what that last paragraph says. I expect this trend to continue, but it’s not far enough down yet that if it were to hit a floor we’d be content with it. Please do continue taking all reasonable precautions. You can see that lovely COVID-in-the-wastewater dashboard here.

Omicron on the decline in Houston

Some good news.

Omicron is receding in the Houston area, new data show, even as hospitals continue to feel the strain of January’s post-holiday bump in COVID-19 cases.

The region’s rate of transmission — a key metric used to gauge how likely an infected person is to spread the virus to others — fell for the third week in a row, health officials reported Monday, fueling hopes that omicron may be on its way out.

The COVID transmission rate across the Houston area was 0.74 last week, meaning the average person who had the virus gave it to one person or less, according to the Texas Medical Center. Spread has remained below 1.0 for two weeks, reflecting omicron’s loosening grip.

New hospital admissions also fell, an encouraging sign after an explosive surge that pushed Texas emergency rooms and intensive care units closer to capacity than at any time during the pandemic. About 2,300 people were hospitalized for COVID in the nine-county region around Houston on Sunday, down 20 percent from two weeks ago.

Houston averaged fewer positive COVID tests last week relative to the mid-January peak. Around 5,400 people tested positive for the virus each day in the greater Houston area, 60 percent as many as the previous week, when the region averaged 9,000 new cases daily, according to TMC data.

That’s good, and it’s consistent with other reporting. We could sure use a bit of a breather. That said, and as the story notes, hospital ICUs are near capacity, and there’s no reason to believe this wave will be the last wave. We still need to get a lot more people vaccinated and boosted. At least on that note, there’s a little more good news.

Earlier this month, Ipsos conducted surveys in Italy and France to gauge the support levels among the populations there for the tough new vaccination mandates that were just introduced. The polling firm shared the data exclusively with Fortune, and the findings surprised not only the pollsters, but also Fortune readers.

As a result, Fortune asked Ipsos to expand the survey to include four new countries: the United States, the United Kingdom, Germany, and Australia.

The findings were remarkably similar across all six countries. Among the general population, there’s wide support for compulsory vaccination rules. And even more startling, the ranks of unvaccinated see some merit in selective vaccination mandates. For example, there is overwhelming support for requiring teachers and health care workers to get vaccinated across all those polled. Requiring that private sector workers be vaccinated draws less support, but there’s still a majority in all but the U.K.

Even in the United States, where mandate battles have raged from state to state since the early days of the vaccination campaign, a majority of poll respondents are seemingly okay with rules requiring vaccination to enter workplaces, shops, and attend public events. This finding comes as courts across the country, and even the U.S. Supreme Court, strike down a variety of enforcement orders that would have required employees at large businesses get vaccinated, undergo weekly testing, or simply wear a mask.

But what continues to surprise pollsters the most is that the most strident blocs in each country—the unvaccinated—are showing signs that they, too, will go along with tougher measures in certain circumstances.

Call it a case of Omicron fatigue: This highly infectious variant is testing the resolve of even the most dogged anti-vaxxers, the pollsters find.

“They are definitely not a group of people that are hard-core sure they are right,” says Andrei Postoaca, CEO of Ipsos Digital. The data from these surveys tell him that there is probably one-quarter of the remaining unvaccinated who don’t fall into the strident “true believer” category. “More and more are willing to take a jab, are willing to accept a mandatory vaccination. So the question is: Step by step, will you get people to cross the line” and drop their opposition to vaccines and vaccine mandates?

“What I would say is clearly the vaccinated support a decision of mandatory vaccination. And a decent chunk of the unvaccinated in most countries also support it,” Postoaca adds.

The poll suggests that about 13% of unvaccinated Americans are planning to get their first COVID shot. That’s not a lot, but if it’s accurate it would raise the overall vaccination rate in the US by about four points, and that’s not nothing. Here’s hoping.

“Maternity deserts”

I have three things to say about this.

A few weeks ago, a woman gave birth at Hereford Regional Medical Center, a critical access hospital in the Texas Panhandle.

Or, rather, the woman gave birth in the parking lot at Hereford Regional Medical Center after driving over an hour to get there, according to Jeff Barnhart, the hospital’s chief executive.

Barnhart said he’s heard it all over the years: patients giving birth at rest stops and in ambulances and in the car on the side of the road. The hospital’s patients come from a 1,600-square-mile area in the Texas Panhandle, and some of them just don’t make it in time.

But now, even patients who do make it to the hospital have another variable to contend with: critical staffing shortages and exploding COVID-19 case counts. There are days when Hereford Regional doesn’t have enough nurses to operate the labor and delivery unit, forcing it to divert patients 50 miles northeast, to Amarillo.

“We give them a medical exam and see if there’s time to get them in an ambulance to another hospital that can take them,” he said. “But sometimes, that baby’s coming and there’s just not time.”

Those patients give birth in the emergency room, an increasingly common occurrence as rural hospitals limit or cease labor and delivery services due to insufficient staffing.

Nationally, the health care system is facing an unprecedented labor shortage as nurses retire, resign, burn out or leave staff positions for more lucrative travel nursing contracts. Rural hospitals, many of which already operate with a shoestring staff, are especially hard hit.

Declining populations and cuts to Medicaid and Medicare funding have made Texas the national leader in rural hospital closings, with some 26 closures — permanent or temporary — of rural facilities in the last decade. Two-thirds of the state’s 157 rural hospitals are public, which means less flexibility in salary negotiations. Administrators also say it’s often difficult to recruit medical personnel to smaller towns in remote counties.

Struggling to survive, the remaining hospitals in Texas’ rural communities have had to cut back services. And when that happens, labor and delivery is often the first to go.

Only 40% of Texas’ rural hospitals still have a labor and delivery unit, according to the Texas Organization of Rural and Community Hospitals, leaving whole swaths of the state without access to nearby obstetrics care.

“If we’ve got nurses to cover a day, of course, we’re going to try to take care of everything that we can here,” Barnhart said. “But it’s just a scheduling crisis, and whenever we can’t make it work, we just let the hospitals in Amarillo know so they can expect it.”

Before I get to my points I want to say this is a good story and you should read the rest. Now…

1. There have been a lot of stories in recent years about the serious problems that rural communities have in accessing emergency health care because so many rural hospitals have closed down. This is a corollary of that problem, and I have a lot of sympathy for everyone involved. But as is my wont, I can’t help but see these stories through a political lens. These areas are overwhelmingly Republican. Republican politicians like Greg Abbott have done everything in their power to continue that cycle, with the fanatical refusal to expand Medicaid at the top of the list. To be sure, there are problems beyond that, and the overall demographic trends are a big factor as well, but however you look at it their representatives and the state leaders that they keep voting for have done nothing to help them. Just once, in one of these stories, I’d like to see that question explored.

2. I should note that while Abbott and state leadership and Republicans in Congress and the Lege are the main actors in this drama, sometimes it’s these same rural communities that bring the damage on themselves. I say I have sympathy and I really do, but boy does it get tested sometimes.

3. I’m old enough to remember that one of the arguments made by the defense (i.e., the state of Texas) in the Whole Women’s Health v Hellerstedt case, in which a very different SCOTUS decided that the 2013 version of Texas’ radical anti-abortion law was unconstitutional, was that forcing women to travel up to 250 miles to get an abortion because all of the clinics closer to her had been closed down as a result of that law represented an “undue burden”. I wonder what those folks think about forcing women who are actively in labor to drive a hundred miles or more to give birth because your healthcare policies have resulted in the closure of hospitals and maternity wards closer to them. Haha, I’m kidding, I don’t wonder that at all. I know for a fact that they don’t care. But still. You, a normal person, might think that’s not such a great thing. Yet here we are.

You don’t want to go to the ICU right now

And even if for some reason you did want to go to the intensive care unit, there probably wouldn’t be room for you.

The number of Texas intensive care unit beds available for adult patients is at an all-time low for the pandemic, with only 259 staffed beds open across the state as of Wednesday, as hospitals fight a historic staffing crisis and more unvaccinated people infected by the omicron variant pour into hospitals.

That’s 11 fewer beds than the previous record set in September during the deadly surge of the delta variant of COVID-19, according to the Texas Department of State Health Services. An average of 295 available beds has been reported in the last week, which is also lower than previous record averages.

The crunch on the state’s intensive care units comes as patient cases skyrocket and as hospitals themselves work to fill shifts left open by more workers home sick from COVID-19.

As of Wednesday, more than 13,300 hospitalized Texans have tested positive for the virus.

“Because of the high level of transmission and infectivity of the omicron variant, so many of our staff are getting positive,” said Bryan Alsip, chief medical officer for University Health in San Antonio. “We’ve been doing this a long time now — close to two years. We’re now experiencing our fourth large surge of those patients. It can get tiring.”

Alsip said University Health — the public hospital system for the San Antonio and the third largest of its kind in the state — is approaching numbers of hospitalized COVID-19 patients that the system has not seen since the last deadly surges in the early months of 2021 or the fall and summer of 2020.

[…]

But while omicron is putting fewer patients into the ICU than in previous surges, there are also fewer ICU beds that are able to be staffed due to a nursing shortage, officials say — and the sheer number of omicron cases is pushing patient counts higher.

The bottom line, they say, is that there are fewer beds for any Texas patient who may be suffering a serious medical event and need intensive care — whether they were put there by omicron or not.

So yeah, now when people tell you to drive safely, it’s more than just a bit of politeness. We might be reaching peak omicron, but as noted before hospitalization is a lagging indicator. There’s still a few weeks to go before we start seeing declines in those numbers.

While it would be nice to think that once this omicron wave recedes we’ll be in for a longer period of calm, but Dr. Peter Hotez says don’t count on it.

Q: There’s a lot of talk about omicron creating herd immunity and the transition from pandemic to endemic. Your thoughts?

A: The big picture, I’m still concerned about. There’s a lot of happy talk about omicron somehow acting as a weakened virus, herd immunity and the end of the pandemic. I do not think so yet. I think we’re in for another wave this summer across Texas and it could be just like 2020 and 2021. Here are the reasons why.

One: I’m not convinced the durability of the protection from omicron is going to be adequate. It may resemble the short-lived immunity you get from the upper respiratory virus. The population could still be vulnerable in the spring.

And vaccination rates are still not great in lower- and middle-income countries where these variants arose. I think we’re still very vulnerable to another variant arising in Africa or Asia.

Q: As you pointed out, that runs contrary to a lot of the hopeful buzz about omicron that I’m coming across.

A: Yeah, you hear that coming from the White House. And I’m hearing it from a lot of my talking head colleagues. But to me, right now, that rings hollow. I don’t think it’s wise. I think what we need most urgently right now is a national strategy for how we’re going to prevent another big variant in the summer from hitting Texas and the southern United States. Here’s what I think that strategy requires.

One: a strategy for global immunization against COVID-19, which just doesn’t exist now. The White House announced another 400 million doses, which is slightly more than what our Texas Children’s vaccine has done. We need 9 billion doses.

Second: We need a greater understanding about the durability and protection from the mRNA boosters. We’re getting conflicting results about the durability. That needs to be clarified. We need to understand that for a strategy for moving forward. Whether we keep the singular focus on the mRNA vaccine or broaden our COVID stockpiles to include additional technology.

And let me say, third: What’s our plan for global surveillance? So far we’ve been surprised by every major variant of concern. We need predictable surveillance models, but we don’t have them. That’s a need. What I’d like to see coming out of the White House is a national strategic task force to really dive into those three components. We need a realistic plan for the country. And I just don’t get the sense we have that right now. Nationally, we’re still in reactive mode every time.

As noted, Dr. Hotez and his colleague Dr. Maria Elena Bottazzi have done what they can to help with global vaccine supply. But we still need to get more shots in arms here – ESPECIALLY KIDS – and I don’t know what we can do to make that happen. Rewards and gimmicks might help a little around the margins, but not enough to really make a difference. The various federal mandates would have made a real difference, but well, you know. Your safety is officially in your hands. Don’t screw around with it.

The Rodeo will (probably) happen

Assuming it all doesn’t go south from here.

Harris County Judge Lina Hidalgo said Tuesday the Houston Livestock Show & Rodeo should proceed as planned, citing a decline in COVID-19 cases and hospitalizations.

“It’s difficult to predict what things are going to look like in a month, but I’m very hopeful,” Hidalgo said. “I hesitate to say A-OK, because I know what our hospitals are facing.”

She did not rule out, however, shuttering the event for the third straight year if trends reverse.

Hidalgo returned the county to its highest virus threat level on Jan. 10, which urges the more than 1 million unvaccinated residents here to stay home and avoid unnecessary contact with others.

There is growing evidence that the omicron wave is waning in the Houston region. Virus hospitalizations have declined 8 percent since peaking on Jan. 18. Unlike previous surges, the Texas Medical Center has never exceeded its base ICU capacity while dealing with omicron.

Last year’s Rodeo was cancelled, and the 2020 Rodeo, which began just before COVID became a known threat here, ended early, though some argued at the time that decision took too long. Our current numbers are headed in the right direction and should be better in a couple more weeks. I doubt I’d be ready to attend actual Rodeo events or one of the concerts, as those are all indoors, but I expect that going to the fairgrounds for a day of outdoor activity ought to be fine. Especially, you know, if you’re vaxxed and boostered. Wearing a mask, at least when you’re in line and definitely when you’re getting food, would also be a good idea. Do what you think makes sense for your risk profile.

I repeat: We need to get more kids vaccinated

Come on, Houston.

In spite of the spread of the omicron variant, national COVID-19 vaccination rates for children ages 5-11 remain low. The same is true for children in Harris County, according to a Kaiser Health News analysis of CDC data.

Of Harris County’s children aged 5-11, only 18.2% of them are fully vaccinated; 22.2% have received one dose. Pharmaceutical company Pfizer announced the FDA authorization of their COVID-19 vaccine on October 29, 2021.

In Texas, most counties have low vaccination rates. Only 34 of Texas’ 254 counties have child vaccination rates above 10%.

When compared to other counties in the U.S. with child populations over 100,000 Harris County comes near the bottom of the list when ranked by vaccination rate.

At 13% fully vaccinated, Harris County’s child vaccination rate is barely higher than Dallas County’s (11%), lower than Bexar County’s (14%) and is about half of Travis County’s (26%).

That 18.2% cited appears to be a typo – according to both the embedded image in the story and the Kaiser Health News story, the actual figure is 12.8% for Harris. Half of what Travis County has done to this point, in other words. We have to do better than that.

And as a reminder why, there’s this.

Vaccines continued to provide strong protection against death from COVID-19 in December, even against the new omicron variant, according to state data released Friday.

Unvaccinated Texans were 16 times as likely to die from the virus in December, and were two times as likely to test positive for it. That gap has shrunk from the fall, likely due to omicron’s increased transmissibility.

The divide was most evident for Texans between 65 and 75 years old, who were 19 times more likely to die from COVID if they were unvaccinated. Nearly 80,000 COVID deaths have been reported in Texas since the pandemic began, the majority of them in 2021, when vaccines became available. Just under 1,600 deaths were reported to the state in December.

Yes, not being vaccinated is not the same risk for a 5-year-old as it is for a 75-year-old. But still, there are a lot more kids in the hospitals these days, and the little ones can certainly spread COVID to their elders. Get them their shots already.

Spare a thought for the nurses

And do everything you can to avoid getting COVID.

[Kristen McLaury, a nurse and unit manager at Methodist Hospital The Woodlands] treated one of the hospital’s first COVID patients and hasn’t stopped since. She now runs the respiratory unit, where she and her nurses have watched otherwise healthy young people gasping for breath. They’ve put countless people on oxygen, or taken them off life-support. They’ve had to comfort grieving families, and facilitate video calls so no one had to die alone.

She’s risked her own life on the frontlines for nearly two years, and now, watching these hospital beds fill up again, she just feels defeated. In Montgomery County, a conservative, wealthy suburban county northwest of Houston, only 53 percent of its more than 600,000 residents are vaccinated, which is among the lowest rates for Texas counties with populations exceeding 500,000. Less than 16 percent of residents have received a booster shot.

“I work 60 hours a week and I don’t see my child, I don’t see my husband, so that I can come and care for you while you yell at me because you’re upset that you have a disease that I told you how to prevent in the first place,” McLaury said.

As the unit manager, it’s McLaury’s job to keep morale up among the other nurses, a herculean task right now. Like every hospital across the country, they’re facing a nursing shortage, an increase in employee infections and a potentially terminal case of staff burnout.

As the omicron variant surges, Texas is on track to soon surpass its previous COVID hospitalization record, set in January 2021. Then, at least, there was the hope of vaccines on the horizon. Now, nurses like McLaury don’t see much hope at all.

From behind her Houston Astros mask and face shield, she begins to cry.

“It’s real, and maybe it might not be you [in the hospital], but it might be somebody else,” she said. “That compassion, I think, is just gone. The world has become so selfish.”

[…]

“Patients stay in the lobby for my entire shift,” said Meredith Moore, an emergency room nurse. “12 hours. It’s frustrating. It’s hard for them…and they get angry. It’s justified. But who receives that anger? Me.”

Moore has been a nurse for nine years and joined the emergency department here since soon after the hospital opened in 2017. She’s young and energetic, with expressive eyes that communicate exactly what she’s thinking — even behind a mask.

Before the pandemic, Moore loved the fast-paced environment and the feeling of helping people who really needed it. She was especially good at controlling her emotions, a requisite for this job.

“In the ER, you have a patient die on you and you have to go into your next room, and you have to act like nothing is wrong,” she said. “That has gotten more difficult as this has gone on.”

Last week, for the first time, she broke down and cried in the emergency room.

“I had five ambulances that had to have a bed…I had a patient that was circling the drain…I don’t have a nurse to take care of that patient,” she said. “That was the first time in two years I really felt helpless, because if one thing falls, if one person starts coding, it’s all over. It all goes up in flames.”

“I don’t think that people [know] unless you’re on this side,” she said. “I tell my family all the time. I’m glad you don’t know. But that’s a heavy burden to carry.”

The article started with a focus on one of the patients at Methodist Hospital The Woodlands, some unvaccinated dude who didn’t believe in the science of vaccines but was more than happy to trust the science of hospitals. I think we’ve heard enough from people like that. The rest is about the nurses and their experiences, and we need to be more aware of what they’re going through. Go read it.

Have we reached peak omicron?

I sure hope so (fingers crossed).

Omicron’s swift and sudden surge may have peaked, experts said Monday, but hospitals are likely to remain full in the coming weeks, with the highly contagious COVID-19 strain not expected to recede until March.

Two key metrics — transmission rate and wastewater tracking — indicate the variant may be loosening its grip on the Houston area.

Texas Medical Center records show positive case rates are declining. Around 9,000 people tested positive for COVID each day last week in the greater Houston area, down about 40 percent from the previous week, when the region averaged about 13,400 new cases daily, according to TMC data.

But hospitalizations and deaths lag behind new infections, so health care workers still have a challenging couple of weeks ahead, said Dr. David Persse, Houston’s chief medical officer. Intensive care units around Texas are at 92 percent capacity, among the highest levels recorded since the pandemic began.

“It appears that we may have hit a peak,” Persse said. “However, our numbers are still really really high. I hesitate for anyone hearing that we may have peaked to think that its over. It is far from over.”

[…]

Houston’s declining rate of transmission — a statistic used to gauge how likely an infected person is to spread their illness to others — offers some clues. The rate of transmission fell below 1.0 last week for the first time since mid-December, according to new TMC data. That means each infected Houstonian is spreading the virus to less than one other person.

The city’s wastewater offers another optimistic sign of omicron’s decline. The wastewater virus load last week was about half what it was in December, and appears to be falling precipitously from its all-time high recorded on Jan. 7, officials said.

As a reminder, the wastewater dashboard is here. It’s still high, but compare to January 3, and you’ll see how much better things look now. As noted, hospitalizations lag cases, and deaths lag hospitalizations, so while the number of people getting COVID may now be trending down, we’ll still see high levels of hospital bed usage, and a higher death rate for the time being. But at least there we can begin to see the end as well. Hang in there, and stay safe.

Have I mentioned that we need to get more kids vaccinated?

Seriously, y’all.

Since November, 693,345 Texas elementary-age children have received at least one dose of the vaccine, accounting for about 24% of the state’s 2.9 million children ages 5-11 — and a figure in line with the national rate. Nearly 390,000 of the 5-11 group are fully vaccinated, while more than half of Texans ages 12-15 are fully vaccinated.

Texas’ child vaccination rate is higher than in many other Southern states, where rates as low as 10% are being recorded. In the first two weeks after the shot was approved for emergency use in the younger age group, some 100,000 children showed up to Texas school clinics, pharmacies and pediatricians’ offices to get inoculated.

[…]

At Texas Children’s Hospital in Houston, positive cases among patients went from zero in early December to some 70 patients with COVID-19 a month later, mostly among unvaccinated children, said Dr. Jim Versalovic, pathologist-in-chief for the hospital. Their hospitalizations of children with COVID-19 broke all previous pandemic records, and at breakneck speed, he said. Just weeks after omicron was first detected in Texas, it was causing more than 90% of new cases showing up at his hospital — less than a month after the vaccine was approved for young kids.

“We have staggering numbers here during this omicron surge,” Versalovic said in a news conference in early January.

That same day, the state broke its own record of children hospitalized with COVID-19, reporting 350 — five more than the previous peak a few months before.

On Friday, the state health department released data on 3.8 million confirmed cases of COVID-19 in Texas in the first two years of the pandemic. Almost 19% of them — 722,393 — were diagnosed in residents under age 20. The demographics do not include cases reported in 2022.

During the first week of January, the Texas Department of State Health Services and the Texas Education Agency reported that about 26,500 students and 11,800 staff members had been infected with COVID, according to data released Friday.

While the numbers of student cases are nearing levels not seen since the start of school last fall, there are more cases of COVID-19 among staffers than at any other time in the pandemic. The numbers are likely to increase as more districts report their numbers to the state. The current numbers include only about half of all of the state’s 1,200 districts, and the number of districts reporting any numbers is inconsistent from week to week.

Meanwhile, on Wednesday, the state reported 471 children in Texas hospitals with COVID-19. Most of them are unvaccinated, hospital officials have said. But there is no state data detailing how many COVID-19 child patients are in Texas pediatric intensive care units.

Yes, I’ve said this before. The numbers have climbed a bit since then, but there’s so much farther to go. As was the case with previous iterations of the vaccine, there was a large initial burst of activity, as the folks who had been eagerly awaiting the day that it became available for that group rushed out to get it, then it leveled off. The difference is that this time that initial burst was much smaller. Gotta say, I have no idea why. Get your kids vaccinated. What are you waiting for?

Back to Code Red

Hopefully not for too long.

Harris County Judge Lina Hidalgo on Monday moved the county again to its highest COVID-19 threat level, her office said.

The announcement should be old hat for Hidalgo, who has moved to Level Red each of the past three calendar years.

“Unfortunately, today we find ourselves crossing a threshold we don’t want to cross,” Hidalgo said at Booker Elementary School in Spring ISD. “We are in the midst of another COVID-10 tsunami.”

She cited an explosion of new COVID-19 cases. She expounded on the dangers of the new Omicron variant. She pointed out that virus hospitalizations are increasing at a higher rate than ever.

Twenty-one months into the pandemic, a question looms: How many people are still listening?

Schools are back in session. Restaurants, bars, theatres and sports arenas are open to capacity. There are no county- or state-wide mask rules. Moving to Level Red does not change any of that; instead, it urges unvaccinated residents to stay home and avoid unnecessary contact with others. The decree is not enforceable.

[…]

Hidalgo has made warning the public about COVID-19 central to her messaging since the pandemic reached Texas in March 2020. For more than a year, she and county public health officials have cajoled, implored, exhorted, implored, advised, recommended, begged and even bribed residents to get vaccinated.

Hidalgo tried to remain optimistic, reasoning that getting more residents inoculated is the way to retreat from Level Red and never return.

“We can break that habit,” Hidalgo said. “I don’t want this always to be bad news.”

Growth of the county’s rate of vaccinated residents has slowed significantly. It now stands at 59.8 percent, up just 3.3 percent since before Thanksgiving. At this rate, 70 percent county of county residents would not be vaccinated until July.

See here for the previous time the threat level was raised. It’s a fair question whether anyone is still listening. I never really stopped wearing masks for indoor things like grocery shopping and ordering at restaurants – I eat outside if at all possible – but now I’m wearing KN95s instead of cloth masks. In my observation, we’re nowhere close to the levels of mask wearing we had a year ago, and few places are doing much about it. I guess we’re going to got for a low-rent version of herd immunity, at least for the short term. Better hope that the “milder” part of this strain holds up. More here from the Chron.

The hospitals are getting slammed again

Take precautions, y’all.

Pandemic forecasters in Texas say the state’s current surge of omicron infections and hospitalizations is likely to get much worse before it gets better, with hospitalizations expected to continue climbing for at least three weeks if social behaviors don’t change and slow the trend.

Across the nation, hospitalizations are already on the verge of breaking new pandemic records. In Texas on Thursday, according to state data, about 9,200 people were hospitalized with COVID-19 — far short of the record 14,218 hospitalizations from Jan. 11, 2021.

But with current numbers climbing exponentially each week, hospitalizations of Texans with COVID are likely to follow national trends and surpass previous levels in the state before they start to decline, said Anass Bouchnita, a researcher at the University of Texas COVID-19 Modeling Consortium, which uses data and research to project the path of the pandemic nationally.

The number of Texans testing positive for the virus every day is already at an all-time high, reaching a seven-day average of almost 44,000 confirmed cases on Friday. The seven-day average of new confirmed cases during the peak of the delta surge back in September was over 15,000.

That trend is likely to continue for at least another week, Bouchnita said.

“The situation in Texas is that it probably won’t reach the peak [for cases] until the second half of January,” he said.

Experts say the extremely high case count is why so many people are showing up in the hospital even as medical evidence suggests that the omicron variant — responsible for most new and active cases in Texas — is less severe than the previously dominant delta variant.

Bouchnita talked to The Texas Tribune on Friday, the same day the UT consortium released a report with the research team’s latest calculations about omicron’s projected path nationally. The report, which looked at eight scenarios in which omicron had varying degrees of severity, infectiousness and resistance to immunity, suggests the nation could see its new cases of this more contagious but less severe strain peak by mid-January before decreasing by half in early February.

The report called the current surge the largest COVID-19 wave in the United States to date.

[…]

Intensive care units at more than 50 hospitals are at 100% capacity, according to state reports, and some regions of the state, including El Paso, are reporting no ICU beds available in the area.

Already, the state’s children’s hospitals have more patients with COVID-19 in their beds than at any other time in the pandemic — 351 statewide on Thursday, which is higher than the last peak during the delta variant surge of 345 in early September.

“It’s pretty crazy,” said Frisco pediatrician Dr. Seth Kaplan, immediate past president of the Texas Pediatrics Society. “Our volume is way up.”

It’s mostly omicron now, very little delta in Texas, though there’s still a fair amount of delta in other parts of the US. It is true that omicron is less severe than delta, but it’s also true that it’s far more transmissible, and it’s affecting far more vaccinated people. Even with less severity, the sheer number of people being infected is driving the higher number of hospitalizations.

And while more vaccinated people are being infected by COVID, there’s still a big difference in outcomes between the vaxxed and the unvaxxed.

Omicron is sending a larger share of vaccinated people to the hospital that any previous COVID-19 variant, but unvaccinated people are still more likely to need critical care, according to Houston-area hospital officials.

Twenty-two of the 27 COVID patients in Harris Health System’s intensive care units are unvaccinated. At Houston Methodist, roughly 60 percent of the 80 COVID patients in the ICU are unvaccinated, and a high percentage of the remaining patients have underlying health conditions, said Dr. Faisal Masud, the hospital’s medical director of critical care.

It’s a similar story at St. Luke’s Health and Memorial Hermann Health System, both of which say 70 percent of ICU patients are unvaccinated.

“The vast majority of the people who are critically ill are either unvaccinated or have significant comorbidities,” said Dr. James McCarthy, chief physician executive at Memorial Hermann. “We are not seeing middle-aged, healthy, vaccinated individuals in the ICU like we did in the previous wave.”

[…]

Statewide, the number of patients in the ICU has been steadily rising since Christmas Eve, from 1,030 to 1,711 on Wednesday, according to the Texas Department of State Health Services. That’s about half of the patients in the ICU at the peak of the delta wave, but some Houston hospitals are already seeing ICU rates double over the last week.

The number of incoming ICU patients could exceed all previous peaks, said Dr. Esmaeil Porsa, president and CEO of Harris Health System. While the vaccines may not be as effective as they were initially, the current ICU population indicates that “they are still extremely effective against severe disease,” he said.

“More and more breakthrough infections are going to happen,” Porsa said. “We’re going to get a higher percentage of people who are vaccinated, but that number is never going to be a big number. It’s always going to be minority of people.”

Overall, doctors say omicron is not damaging the lungs as much as earlier strains. Fewer COVID patients in the Harris Health ICU require mechanical ventilation compared to delta, said Porsa, but other health issues like kidney and heart failure are becoming more common.

At Methodist, Masud has observed a similar pattern. A large portion of ICU patients Masud has treated ended up in the unit because the virus exacerbated an existing disease. The risk of facing such complications is higher for unvaccinated people, he said.

“This is eliciting an immune response, which is not only limited to lungs but which makes the patients sicker, with existing disease becoming much worse,” he said.

Masud said that now is a critical time to wear a well-fitted mask in public, especially for people who are not vaccinated.

It’s the same as before, in that the things you can do to mitigate your risk haven’t changed. Get vaxxed, and get your booster. Wear an N95 or KN95 mask when out with people. Avoid large indoor events and gatherings. Stay home if you’re not feeling well. This will pass, but how bad it gets before it passes is still up in the air. For more on the national picture, see TPM, Mother Jones, and Daily Kos.