The Perfect Enemy | From plateau to pendulum: COVID hospitalizations down, wastewater levels fluctuate
December 1, 2022
Read Time:12 Minute

Last week’s rise in hospitalizations has proven to be a temporary blip, at least for now. Variants of concern remain in the headlines, and COVID continues to take the lives of an average of six Minnesotans per day, but so far there are no clear indications that a major surge has started in the state.

As people make plans for the holidays, many may be wondering whether it’s then safe to gather indoors with family and friends, especially those who are older or otherwise more vulnerable to the risk of severe COVID-19. While at this stage it appears risk is lower than the last two years, older people may still be at some risk, even if they are vaccinated. Since the current plateau-like wave began in May, people over age 65 in Minnesota have died at an average rate 20 times that of any other age group.

A panel of experts convened by Kaiser Health News last month discussed the continued impact of the pandemic on seniors, which you can watch here. They mention the importance of social interaction for everyone, and particularly for older people, and they offer some suggestions for staying safer while gathering. Strategies include:

  • Being extra cautious in the lead-up to a gathering (e.g., not attending crowded events, especially without a mask)

  • Testing with at-home rapid tests, even if you don’t have symptoms

  • HEPA filtration if you can afford it

  • Opening a window

On that open window, Dr. Sharon Brangman acknowledged that it could invite a rush of cold air, but it can also be a big help. “If you have some windows open, that keeps the virus moving around. If you can think of the virus like on a roller coaster, it gets harder for it to settle in if it’s rolling on all these little airwaves,” Dr. Brangman explained.

An epidemiologist on the panel, Dr. Céline Gounder, noted that for those who do get COVID Paxlovid continues to show effectiveness at preventing hospitalization and death among both vaccinated and unvaccinated people. While an unpleasant rebound effect is possible, “the key here is to say, is it keeping you out of the hospital? Is it preventing you from dying? And the resounding answer on this is yes,” Dr. Gounder said.

Avoiding coming down with COVID is of course the best strategy to stay out of the hospital. Below are the most recent trends to help you assess if cases are on the rise in your area. Plus, this week the APM Research Lab published a story using data to show how another virus of concern — monkeypox — has impacted the U.S. and particular communities, as well as its global impacts. Read on for a summarized version, or see the whole explainer here.

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Hospitalizations are back down after last week’s spike, cases and deaths relatively stable

In the Twin Cities Metro, official case counts declined steadily over the month, including another small drop in the last week of data. The same is true for northwestern Minnesota. Central areas of the state saw an increase of cases in the last week, along with southeastern Minnesota, though the numbers are still in the ballpark of where they’ve been in the last month.

Cases are up or down slightly depending on the area of the state, but no changes suggest a clear or dramatic trend.

David Montgomery

After a potentially alarming spike in COVID hospitalizations last week, the most recent week of data saw hospitalizations decline for both ICU and non-ICU admissions. For the most recent week of data, ending Oct. 27, there was a daily average of 58 new COVID hospitalizations statewide.

New ICU and non-ICU hospitalizations in MN

After an uptick last week, hospitalizations dropped in the most recent data.

David Montgomery

For the first half of October, an average of six people died each day from COVID in Minnesota. This is approximately what daily deaths have hovered around since this plateau-like wave began in early May.

MN covid deaths by year

Deaths have been relatively stable since early September, and there were fewer deaths than during October of the past two years.

David Montgomery

Wastewater: declines in the Metro and other parts of state, large increase in southwestern Minnesota

The most recent wastewater analysis in the state, from the Metropolitan Council and the University of Minnesota’s Genomic Center, show an 18 percent decrease in viral load entering the Twin Cities Metro Plant for the week ending Oct. 31 as compared with the previous week. According to the Metropolitan Council, “The weekly average load is now only one percent lower than it was two weeks ago, and essentially the same as it was six weeks ago.”  

COVID load in Twin Cities metro wastewater 11-4-22

COVID levels measured in wastewater at the Metro wastewater treatment plant were down last week.

David Montgomery | MPR News

In terms of COVID variants, the Metropolitan Council reports that BA.5 makes up 92 percent of viral RNA. Separately, the Minnesota Department of Health continues to monitor variants and provided the following detail via e-mail:

  • BA.5 continues to be identified in the vast majority of cases, although slightly less than was reported last week (82 percent of sequenced clinical samples; the MDH has separated out some sublineages from the BA.5 category leading to the ten-point different with the Met Council’s report).

  • BA.4 accounts for 16 percent of sequenced cases, and BA.4.6 makes up the majority of those cases.

  • BA.2, mostly its BA.2.75 sublineage, makes up about two percent of sequenced cases.

  • BQ.1 (and sublineage BQ.1.1) has been identified in 19 cases.

  • BA.2.75 has been identified in 43 sequenced cases to date, no change from last week.

  • BF.7 has been identified in 53 sequenced cases, an increase from 46 cases last week and 29 cases the week before.

  • XBB cases remain at two, the same as last week, and BJ.1 has been identified in only one case so far.

The major takeaway: Compared to national data from the CDC, Minnesota’s levels of BQ.1, BF.7 and BA.2.75 so far remain slightly lower. The level of BA.4.6 in Minnesota now exceeds national and regional levels.   

The latest data out of the University of Minnesota’s Wastewater SARS-CoV2 Surveillance Study, tracking data from seven regions through Oct. 23, continues to show mixed results over the last month.  The South West saw a seemingly large increase of 98 percent (more on that below), and the North West and South East saw comparatively smaller increases. The COVID-19 levels in the Twin Cities Metro stayed mostly flat over the last month. However, there were double-digit decreases over the last month for the North East, Central and South Central regions of the state.

Data for the week ending on Oct. 23, shows modest decreases in COVID-19 levels in four of the study’s seven regions. This includes the Twin Cities Metro (the study’s largest region, including 13 plants serving 2.8 million Minnesotans), which saw a decline of 13% from the prior week. Increases were seen across the southern portion of the state, with the largest increase happening in the South West with a 106 percent increase in the COVID-19 load detected in the region’s wastewater compared to the prior week.

Such large increases in the South West are alarming, but it’s important to place those numbers in context. That big of a percentage increase is, in part, due to the very low starting point four weeks ago of five copies per liter, compared to 9.9 copies per liter for the most recent week of data. That most recent amount is also still well below the levels approaching 50 copies per liter seen in that region this summer.

CDC: only one high-risk county in Minnesota this week, and fewer counties meet or exceed threshold for COVID-19 transmission

The map of Minnesota continues to be less green than it was a few weeks ago according to the CDC’s latest “Community Level” ratings. The good news, however, is the CDC only rated one county in the state “high risk” this week—Rice County. Over the last month, including this week’s update, the number of high-risk counties has stayed relatively steady between zero and two. More concerning, 29 counties are now rated at medium-level risk, continuing the increasing trend from the 11 counties rated medium risk two weeks ago. The 58 remaining counties are all rated low risk, including much of the Twin Cities Metro.

In equally good news, only 13 of Minnesota’s 87 counties meet or exceed the CDC’s threshold for high COVID-19 transmission of at least 100 cases per 100,000 over the last week. This number is down significantly from last week, when 33 counties exceeded this threshold, and also down from the 47 counties that met the threshold for high COVID-19 transmission at the beginning of October. Only two counties this week exceeded a weekly case rate of 200 per 100,000: Yellow Medicine and Watonwan.  

The who, what, where and how of monkeypox

Note: This week our colleague Terrence Fraser at APM Research Lab published an explainer about monkeypox, including data on the outbreak itself and the response from U.S. officials. Below is an excerpted version.

The COVID-19 pandemic is not the only public health crisis this year; 2022 has also seen a global outbreak of monkeypox. Endemic to West Africa, the global outbreak initially occurred in Europe before spreading to the Americas. So far in 2022, the U.S. has reported over 28,000 confirmed monkeypox cases, a figure far surpassing all other countries and representing 37 percent of all cases documented globally this year—although the U.S. ranks fourth in terms of its rate of monkeypox infections behind Spain, Portugal and Peru.  

Outside of the continent of Africa, the monkeypox outbreak is primarily impacting gay, bisexual and other men who have sex with men, with 80 to 100 percent of cases being reported within this group throughout the global outbreak, according to data compiled by the World Health Organization.

But epidemiologists stress that this group is not inherently predisposed to contracting the virus. “I get the sense that people may think that monkeypox is just a gay disease. Which of course it’s not,” said Dr. Dustin Duncan, associate professor of epidemiology at Columbia Mailman School of Public Health. Duncan added, however, that once an infectious disease has spread within a particular group, it can be easier for it to stay within that group rather than spread to new populations.

Monkeypox has spread primarily throughout cities in the U.S. “We are seeing the density of monkeypox cases in the U.S. in cities because that’s where sexual networks of men who have sex with men are the densest,” explained Dan Royles, associate professor of history at Florida International University.

Among U.S. cities, New York has the highest number of cases, with over 3,700 total monkeypox cases citywide (13 percent of the national total). But Miami, Florida has the highest monkeypox infection rate—195 cases per 100,000 persons—followed by Atlanta, Georgia—155 cases per 100,000 persons.

On a statewide level, California—the most populous state in the country—has the greatest number of cases, while New York has the highest percentage of population infected with monkeypox. In Minnesota, there have been 199 confirmed cases of monkeypox, placing the state 23rd highest for number of cases and 24th highest for rate of infections.

Much as we have seen with COVID-19 there are racial and ethnic disparities largely due to systemic racism and inequitable access to healthcare and, in the case of monkeypox, vaccines.

 This inequitable access to vaccines has likely had an impact on the racial disparities we now see in the outbreak. During the first weeks of the U.S. outbreak (May 15 to May 29), Black men represented only 7 percent to 12 percent of all monkeypox cases in the U.S.—a percentage similar to or less than Black people’s share of the U.S. population. As the outbreak continued, Black men began representing a significantly higher proportion of cases. By the end of August, Black men represented over 35 percent of all new monkeypox cases. And by September’s end, that figure was 50 percent.

There are several other possible explanations for these higher rates of infection in Black and Hispanic men. “One explanation for this shift is that it’s a pathogen moving through the population based on contact patterns,” said Dr. Keletso Makofane, health and human rights fellow at the FXB Center for Health & Human Rights at Harvard University.

Makofane explained that the outbreak started among an affluent, whiter group of men in Western Europe before coming over to large North American cities. Because richer, white gay men tend to be more closely connected to one another sexually than they are to other groups, the outbreak could have started there and then filtered into other populations, Makofane hypothesized.

“Another explanation could be that testing was so hard to get that the people who had access to testing were richer, whiter people. As testing has expanded, different kinds of people are now accessing tests, and so it would appear that the number of cases among Black people has increased sharply whereas it’s really a matter of detected cases increasing sharply,” Makofane said. “But the one mechanism for understanding the epidemic, which is testing, is an intervention that has not been rolled out effectively or equitably from the beginning.” 

The good news for the U.S. and Europe is that monkeypox cases are declining—although the reason why this is happening is still not clearly understood. Unfortunately, new monkeypox infections have sharply increased in the continent of Africa.

“Even if cases are declining in the global north, monkeypox is still a challenge and this problem has not been addressed in Africa,” said Dr. Dimie Ogoina, professor of medicine and infectious diseases at Niger Delta University.

Ogoina made comparisons to the start of major HIV/AIDS outbreaks, which initially spread in communities of gay and bisexual men in the U.S., but now impact sub-Saharan Africa the most. Ogoina said the same could be true of the trajectory of this outbreak.

“Even the global north is not safe,” said Ogoina. But, he added, “It’s still not too late for us to invest and resolve the problem for all countries.”