Since early July, Virginias COVID-19 case counts have remained relatively stable, with an average of around 3,000 new infections reported every day. But over the same time period, hospitalizations have risen, with more than 800 inpatients as of Wednesday, according to data from the Virginia Hospital and Healthcare Association.

The discrepancy, experts say, can be chalked up to data limitations. In a recent report, researchers with the University of Virginias Biocomplexity Institute wrote that the states current case rates are similar to those seen during last falls delta wave, which threatened to overwhelm local hospital systems. Detecting those cases, however, has become much more challenging.

In some ways, we might be revisiting early stages of the pandemic where all were observing is severe COVID, said Bryan Lewis, a computational epidemiologist on the Biocomplexity Institutes research team. People who end up going to the hospital are the only ones who end up getting confirmed.

Thats largely because testing, once in extremely limited supply, has become easily accessible to most Virginians. Rather than seeking out more sensitive PCR tests from pharmacies and local health department events, most patients with symptoms are relying on at-home antigen tests, whose results typically arent reported back to the Virginia Department of Health. And as pandemic fatigue sets in for more and more people, many arent testing at all, said Dr. Akira Shishido, an infectious disease specialist for VCU Health.

Like other public health experts, he said the lack of clarity around rising case rates has made it more challenging to offer guidance as the pandemic approaches its third year. Currently, the Biocomplexity Institute estimates that there are roughly 16 coronavirus infections for every reported case in Virginia, given the rise of highly infectious subvariants and the decline in test results reported to VDH. If thats true, it would put the states current infection rate closer to levels seen during the winter omicron surge.

Unlike this past winter, though, most Virginians arent taking the same health precautions. The states COVID-19 state of emergency expired last summer along with previous requirements for indoor masking and social distancing in public spaces. And after Gov. Glenn Youngkins successful push to repeal mandatory masking policies in schools, students and parents are expecting a mixed approach to face coverings at the start of the year. With community transmission already high in 55 of the states 133 localities and cases rising in most local health districts some providers say theyre worried about the coming fall and winter.

We still have circulating COVID, and I think well still see some people being admitted with severe COVID pneumonia, said Dr. Kyle Enfield, the medical director of UVA Healths medical intensive care unit. People are making the choice to not get vaccinated and not wear masks. And I think that will be compounded by a larger spread of other respiratory viruses that seemed to have decreased back when masks and social distancing were common.

Thats not to say there isnt a bright side to the current stage of the pandemic. Enfield emphasized that if hospitals do feel strained over the colder months, it will likely be due to a combination of cases that includes flu and possibly even monkeypox, an emerging virus thats spreading in Virginia and across the country. And theres evidence that omicron subvariants, while highly transmissible, are causing less severe disease, bolstered by growing population immunity.

Even as COVID-19 infections and hospitalizations rise across the state, Lewis pointed out that ICU admissions have remained relatively low, indicating that fewer people are developing severe illness from the virus. COVID-19 deaths have also sharply declined since mid-January, and theres evidence that vaccines and previous infections convey lasting protection against the worst outcomes.

At this point, so many Virginians have some degree of immunity against COVID-19 that its unlikely the state will experience the same rates of hospitalizations and deaths that occurred during last winters omicron surge, according to Lewis. Still, he said its unnerving to see hundreds of patients admitted for the virus every week.

Its pretty incredible were still generating a fair number of hospitalizations, Lewis added. Yeah, its not as horrible as the catastrophes that have happened a couple of times during this pandemic, but you just dont see that with other infectious agents, even during the worst flu seasons.

Thats why public health experts are still encouraging caution, especially in anticipation of cooler weather and more indoor gatherings. Shishido said the chance of reinfection is substantial even for those who have been vaccinated, boosted and previously infected with COVID, largely thanks to the antibody-evading capabilities of omicron subvariants.

Luckily, he said, vaccines still generate a type of protection known as cell-mediated immunity, which provides strong protection against hospitalization and death even in the case of breakthrough infections. But while severe outcomes are unlikely for immunized Virginians, Lewis cautioned theres limited information on the effect of repeated COVID-19 infections or long-lasting symptoms.

Long COVID is something we dont fully understand and is messing people up pretty badly, he said. Were finding a lot of studies out there where a fair portion of people were talking 20 or 30% of people, even young people were still reporting symptoms like shortness of breath, the loss of taste and smell, even six to nine months out.

Enfield said that unvaccinated and partially vaccinated Virginians are still driving hospital admissions at UVA, a trend borne out by national data (the Virginia Department of Health no longer reports cases and deaths by vaccination status). But he also warned that high community transmission increases the risk of spreading COVID-19 to more vulnerable populations including immunocompromised and elderly patients, who are still at risk of worse outcomes even if theyre fully vaccinated.

High infection rates also mean the virus will continue to mutate, and public health experts still worry an even more dangerous variant could emerge in the future. Thats unlikely, according to Shishido, given that the most successful viruses are typically highly infectious without killing their hosts. But like other doctors, he encouraged Virginians to avoid unnecessary risks.

The hard thing is, the public health measures we were pushing a year ago are the same things we want people to be doing now.

Dr. Kyle Enfield, medical director of UVA Healths medical intensive care unit

For Shishido, that means masking indoors and making use of COVID-19 therapies including Paxlovid, an antiviral pill for high-risk patients, and Evusheld, an experimental medication that can lower the risk of infection for immunocompromised patients. Enfield said people should continue to limit the size and number of social gatherings they attend, particularly if theyre regularly in contact with more vulnerable groups.

He also encouraged anyone with COVID-19 symptoms to seek confirmatory PCR testing if their antigen test results are negative given the lower sensitivity of most at-home tests. And like Shishido and Lewis, Enfield strongly encouraged Virginians to take advantage of upcoming COVID-19 boosters, which will be reformulated to offer better protection against omicron subvariants.

We know people can get reinfected with COVID even after a natural infection, and that immunity wanes over time and might not be as good as some of the vaccines, he said. So I would stress that vaccines are still in everyones best interest.

The hard thing is, the public health measures we were pushing a year ago are the same things we want people to be doing now, Enfield added. I know were at a point where people want to fully relax, but were really just not at a point where thats the right thing to do.

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Data limitations are making it harder to detect when COVID-19 is surging in Virginia - Virginia Mercury