In year three of the pandemic, public health shifts its focus to COVID’s burden on hospitals

From her perch at the Minnesota Department of Health, Commissioner Jan Malcolm says the COVID-19 pandemic isn’t over — but it’s better.

“There's a lot of virus still circulating out there,” she said. Medically vulnerable people are still at high risk of getting very sick from the virus.

“But the cases are fairly low as well as stable, and cause less disruption in our communities and less risk to health,” said Malcolm.

Going forward, people will base risk on a variety of factors including community spread, but also on factors like vaccination status, previous infections, willingness to wear masks and hospital capacity in their area, she said.

“Folks are going to be in different risk situations for themselves and their families,” she said. “And so we're in a phase now where there's a much more individualized picture of risk.”  

And with this new phase of the pandemic, Malcolm said daily COVID case counts — a metric so many have been conditioned to pay close attention to — don’t mean as much as they used to; the numbers are muddied by the use of at-home COVID tests and changes in how COVID test results are reported. 

It signals a shift in how public health will track, and potentially respond to, future COVID waves, she said. 

“The big thing to watch now is really the impact on the health care system,” said Malcolm. 

An incomplete view

Earlier this month, the Centers for Disease Control and Prevention announced that negative test results no longer need to be reported. This week, the state health department stopped reporting testing volume, too, a decision tied to the new federal guidance.

That’s made the positivity rate less meaningful. Those rates have been used as a key COVID metric that teases out how many new tests resulted in positive cases.

At the same time, over-the-counter rapid tests are easier to get at retailers; free tests are available through federal and state programs. Many of those results, positive or negative, are never reported to the Health Department, giving public health experts an incomplete view of how many new cases are being detected through testing. 

While new COVID cases are still being taken into account, federal, state and local public health departments are relying more on how the virus is showing up in hospitals — people who are coming in with the virus, being hospitalized for the virus and dying from it.

All these data points are layered into a new tool from the Centers for Disease Control and Prevention that help people assess COVID’s seriousness in their communities and how they should react to those levels of risk. 

“It’s kind of a more refined measure of how concerned we should be,” said Malcolm.

Layers of detection

While case counts and positivity rates may be a less useful COVID measurement now, state epidemiologist Dr. Ruth Lynfield said there are a lot of other tools to track the virus in the Health Department’s toolkit — many refined in the state’s ongoing efforts to track other respiratory viruses. 

“There are a number of surveillance systems that we stood up during the pandemic and some that predated it,” said Lynfield. 

For instance, the state will track COVID emergency department visits and hospital admissions; they’re gleaning information from electronic medical records around the state; and they’re monitoring how many hospital beds are being used for COVID patients.

“There’s a lot of eyes looking in through different windows to the house to give us a sense of what is going on,” she said. 

At the University of Minnesota Medical School, Dr. Tim Schacker is involved in an ongoing effort to better detect new COVID surges and variants by measuring the virus in wastewater.

Tracking COVID by relying on indicators that take a while to emerge — like hospitalization — isn’t enough, he said. 

“[Wastewater detection] has turned out to be an extremely useful sort of early warning system that something was going on in the community,” he said. 

“The folks in the hospital represent a small proportion of people who got infected. So it's a skewed population. If you look at wastewater, everybody contributes, and you really get a population-based analysis of what's going on with that particular pathogen,” he said.

Wastewater samples are being collected regularly from 40 sites around the state, Schacker said. Right now, cases continue to be low.

“We may see wastewater levels rise, but we won't see the same dramatic rise in hospitalizations,” he said. “And if that's true, we've got to determine what is a rise that is going to predict some level of increased hospitalization? And what’s the proper response?”

‘A difficult dance’

Wider use of unreported at-home COVID tests and new reporting requirements can make communicating the relative risk of the virus to the public challenging right now, said Carlton County public health nurse Jenny Barta. 

“It’s a difficult dance for us at public health,” Barta said. “We want people to be able to live their lives and to do it safely and responsibly, but also, how can we communicate those necessary protections that they need to take?”

In Olmsted County, cases have been fluctuating in recent weeks, but hospitalizations remain low.

Epidemiology program manager Meaghan Sherden said with masking and some vaccine requirements disappearing, her community is starting to get a sense of what it may be like to live with COVID-19 in the long run without major disruptions.

“As much as I would love to know every positive test in Olmsted County, the fact that people can do at-home testing and get those results so much faster, that's a huge mitigation and prevention strategy for us,” she said.

Sherden said those tests are critical in helping people make real-time decisions about their individual behavior and susceptibility to risk, which she said is critical in continuing to prevent transmission of the virus. 

The tests tell us “how can we see our loved ones who maybe have underlying health conditions. And what are the potential risks that I may be exposing [to] others,” Sherden said. 

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