Health officials in several parts of the United States are seeing worrisome signals in wastewater surveillance data that the coronavirus may be spreading more widely than recent tallies of new cases would indicate, and that a steeper wave may be coming.
Wastewater surveillance provides only a broad-brush picture of virus prevalence in a particular community, but the readings it gives are close to real-time and do not depend on people seeking tests and reporting results. So health officials are looking to wastewater data for early warning of trends. And in some places, those warnings are flashing red.
The data has been like a "canary in a coal mine" for New Orleans, said Dr. Jennifer Avegno, head of the city's health department.
Case counts are a "gross underrepresentation," because many people are opting to take at-home tests instead of going to hospitals or doctors' offices. Avegno said the rising prevalence of virus seen in wastewater testing has prompted the city to begin mobilizing resources to prepare for another spike.
Although the city is not considering reinstating mandates, it is preparing in other ways. City officials have begun planning mask giveaways and are stepping up their campaign to encourage residents to get vaccinated and boosted.
New-case counts in the city are averaging 155 a day, five times the rate of a month ago, and wastewater tests show increased coronavirus concentrations in residential and tourist areas.
"It looks like a surge in slow motion," Avegno said. "It's not the sharp increase we saw with delta and definitely not with omicron."
Houston is another city where wastewater data has been showing ominous signs of increasing infections.
"I don't know if it's going to be the magnitude that we saw in the previous surge, but I definitely think we're starting to see more community infections," Lauren Stadler, who manages wastewater collection and analysis at Rice University, said Thursday.
Harris County, where Houston is, has seen a 175% increase in cases in the last two weeks, according to a New York Times database.
Stadler said health officials in the city are trying to use the wastewater data to decide what a surge looks like these days.
"I definitely think the wastewater is telling us it's spreading in the community. But does that mean we're going to see a surge in hospitals? What does that mean in terms of, like, severity of disease," Stadler said. She added that wastewater collection also makes it hard to know who exactly is getting infected, since the data is less individualized.
Scott W. Long, medical director of diagnostic microbiology at Houston Methodist Hospital, said he hoped people would begin to take more precautions to lessen the severity of the surge in Houston.
"In my personal day-to-day, I know I'll be masking more outside of work and while traveling," he said.
In Maine, state health officials have been seeing a surge "for a while," Mike Abbott, a lead analyst on wastewater screening for the Maine Center for Disease Control and Prevention, said Thursday. He noted that the increase in cases began in mid-April, with the incline getting steeper in May.
A New York Times database shows that Maine recorded a sharp upward trend in cases the last week of April and into May that reached levels the state saw during the delta surge at the end of August.
"We've been riding that surge," Abbott said. "Now, as far as what's going to happen next and what we're worried about, I mean, certainly we're hoping this isn't the beginning of a surge similar to what we saw in January with the original variant."
Experts maintain that the best way to combat surges and protect yourself against the virus is to be vaccinated.
"My take-home advice for people is vaccines are still our best defense. Get boosted if you're due for one," Long said.
GET CHILDREN BOOSTED
Children ages 5 to 11 should get a booster dose of Pfizer's covid-19 vaccine, advisers to the U.S. government said Thursday.
The Center for Disease Control and Prevention quickly adopted the panel's recommendation, opening a third covid-19 shot to healthy elementary-age kids -- the same as what is already recommended for everyone 12 and older.
The hope is that an extra shot will shore up protection for kids ages 5 to 11 as infections once again are on the rise.
"Vaccination with a primary series among this age group has lagged behind other age groups leaving them vulnerable to serious illness," said CDC Director Dr. Rochelle Walensky, in a statement.
"We know that these vaccines are safe, and we must continue to increase the number of children who are protected," she said.
Earlier this week, the Food and Drug Administration authorized Pfizer's kid-sized booster, to be offered at least five months after the youngsters' last shot.
The CDC takes the next step of recommending who actually needs vaccinations. Its advisers debated if all otherwise healthy 5- to 11-year-olds need an extra dose, especially since so many children were infected during the huge winter surge of the omicron variant.
But the U.S. now is averaging 100,000 new cases a day for the first time since February. And ultimately, the CDC's advisers pointed to growing evidence from older children and adults that two primary vaccinations plus a booster are providing the best protection against the newest coronavirus variants.
"This always perhaps should have been a three-dose vaccine," said Dr. Grace Lee of Stanford University, who chairs the CDC's advisory panel.
Parents still are anxiously awaiting a chance to vaccinate children under 5 -- the only group not yet eligible in the United States.
Dr. Doran Fink of the Food and Drug Administration said the agency is working "as rapidly as we can" to evaluate an application from vaccine maker Moderna, and is awaiting final data on the littlest children from rival Pfizer. The FDA's own advisers are expected to publicly debate data from one or both companies next month.
For the 5- to 11-year-olds, it's not clear how much booster demand there will be. Only about 30% of that age group have had the initial two Pfizer doses since vaccinations opened to them in November.
Thursday's decision also means that 5- to 11-year-olds with severely weakened immune systems, who are supposed to get three initial shots, would be eligible for a fourth dose.
Pfizer and its partner BioNTech currently make the only covid-19 vaccine available for children of any age in the U.S. Those ages 5 to 11 receive a dose that's one-third the amount given to everyone 12 and older.
In a small study, Pfizer found a booster revved up those kids' levels of virus-fighting antibodies -- including those able to fight the super-contagious omicron variant -- the same kind of jump adults get from an extra shot.
THERAPEUTICS AVAILABLE
As covid-19 again surges across the U.S., many people are going without time-sensitive therapeutics like Paxlovid because doctors worried about shortages are reluctant to prescribe the drugs. But the situation has changed and supplies are now abundant.
Paxlovid, a combination of pills taken for five days, cuts the risk of hospitalization by nearly 90%, according to the manufacturer, Pfizer. But to be effective, it must be taken within five days of the onset of symptoms -- which include everything from a scratchy throat, runny nose, cough and chills to fever, body aches, headache, nausea, vomiting, diarrhea, difficulty breathing and loss of taste or smell.
The Food and Drug Administration has issued an emergency-use authorization for the drug to treat mild to moderate covid-19 in people at high risk of severe disease. The Centers for Disease Control and Prevention defines those as individuals ages 50 years or older, unvaccinated, or with certain medical conditions like kidney, liver, lung and heart disease, diabetes, cancer and HIV. It also recommends the drug for people who are immunocompromised, pregnant, obese, cigarette smokers or suffering from mood disorders.
In March, the Biden administration launched a nationwide initiative to provide quick access to Paxlovid and other oral antivirals. Through this program, people can go to one site to get tested for covid-19 and a get a prescription filled the same day. These one-stop locations can be found by using the Department of Health and Human Services' Test to Treat Locator.
Some of the nation's largest pharmacy chains are participating, including CVS Health Corp., which has 1,200 MinuteClinics inside select stores in 35 states and Washington.
"The number of patients being prescribed oral antiviral medications at our MinuteClinic locations has increased steadily over the last three months," the company said in an email. Paxlovid, along with Merck & Co.'s Covid pill, molnupiravir, are available at almost all of CVS's pharmacies, the company said.
Critics of the program say these lifesaving drugs aren't getting to those who need them most. In March, NPR reported that a large percentage of the pills the government supplied to pharmacies for free were sitting on store shelves. CNN found that the government's site-locator tool was missing key locations like the Zuckerberg San Francisco General Hospital, which also offers test-to-treat services.
One limitation of the test to treat program is that pharmacists aren't approved to write prescriptions for Paxlovid, and allowing them to do so would increase access, Jason Gallagher, a clinical pharmacy specialist in infectious diseases at Temple University said Friday in a briefing held by the Infectious Disease Society of America. Paxlovid isn't for everyone, particularly those with certain kidney and liver diseases, and there needs to be greater education on interactions with common medications, herbal supplements and over-the-counter treatments, Melanie Thompson, an internist and HIV specialist affiliated with Piedmont Hospital Atlanta, said in the briefing.
Information for this article was contributed by Isabella Grullón Paz of The New York Times, Lauran Neergaard of The Associated Press and Martine Paris of Bloomberg News.