High levels of community transmission indicate we are now solidly amid another substantial surge in cases, hospitalizations, and deaths. The surge will likely exceed rates last seen during the summer of 2020 (409 cases per 100K residents). If Louisiana, Mississippi, Florida, Arkansas, and Alabama are any guide, it is possible that we could approach rates seen during the winter of 2021 (915 cases per 100K residents). Currently these 5 states have rates of 848, 773, 697, 527, and 502 cases per 100K residents per week, respectively. Several have exceeded their prior peaks, and ominously, their rates continue to rise.

According to the CDC, 56% of Arizona adults have received 2-doses of vaccine while another 10% have received 1-dose. While vaccinations have plateaued at about 90 thousand doses per week, vaccine outreach is still important. At this point, only individual and community non-pharmacologic interventions like mask mandates, limiting gathering sizes, and targeted business mitigations can stave off another substantial surge.

Resumption of in-person instruction in the face of high community transmission, low vaccination rates, prohibition of universal masking, lack of surveillance testing, and minimal physical distancing is leading to frequent school-related outbreaks and accelerating community transmission (as predicted). On a positive note, several school systems are challenging the governor’s inane and constitutionally circumspect prohibition of mask mandates. The state universities have also wisely chosen to ignore the order. While mask mandates are necessary, they will not be sufficient to slow transmission without other layered protections throughout the community.

While difficult to appreciate, Figure 2a shows a new reversal of relative position between children (dotted) and older adults (solid). Historically, children 15 – 19 years of age have had rates approximating those of adults while prepubertal children have had meaningfully lower rates; however, rates among those age 5 – 9 years resemble those of their older counterparts in the presence of the Delta variant and the absence of effective non- pharmacologic measures (see CDC and the American Academy of Pediatrics recommendations; Figure 2b).

While considerable attention is being given to childhood cases, it is important to reaffirm that this outbreak, like past outbreaks, is being driven by transmission among adolescents and working-age adults in the community (Figure 2c). If our goal is to protect children, the most effective way to accomplish it is to slow transmission among adults. In certain respects, the current focus on K-12 re-opening is scapegoating children for adult misbehavior.

Vaccination has only modestly shifted the age distribution of cases with children “switching” relative position with older adults (Figure 2d). Children now represent about 18% of cases, up from 10% during the winter 2020 outbreak, while older adults now represent about 8% of cases, down from 15% during the winter 2020 outbreak.

To create a mental frame, it is helpful to compare our current circumstance to those we have previously experienced. Comparing school reopening this year (in-person) with last (virtual), levels of community transmission are much higher this year (Figure 2e). The availability of effective vaccines combined with an early summer reprieve provided a false sense of security that the Delta variant has now shattered. We relaxed our mitigation efforts too quickly and have been too slow to reinstitute them. Hundreds, if not thousands, of Arizonans will now pay the ultimate price for this hubris.

By comparing two different time periods with similar levels of transmission (August 8, 2021 and November 15, 2020), a shift towards younger age at time of diagnosis becomes apparent (Figure 2f). The most striking increases have occurred among those <15 years of age; the most striking declines have occurred among those >40 years of age. Even so, hospital occupancy is similar between the two time periods suggesting the Delta variant may be more likely to cause severe illness. Is sum, we should prepare for the worst while we hope for the best.

Test positivity among those undergoing traditional nasopharyngeal PCR testing held steady this week at 25% (Figure 3). This level indicates testing is inadequate for optimal public health practice and means many cases are going undiagnosed.

As of Aug 11th, 1527 (18%) of Arizona’s 8707 general ward beds were occupied by Covid-19 patients, a 21% increase from the previous week’s 1266 occupied beds (Figure 4 and Figure 5 Panel A). Another 797 (9%) beds remained available for use. The number of available beds is lower than the previous week’s 887 beds.

As of August 11th, 383 (22%) of Arizona’s 1722 ICU beds were occupied with Covid-19 patients, a 19% increase from the prior week’s count of 321 patients (Figure 4 and Figure 5 Panel B). An additional 174 (10%) ICU beds remained available for use, about the same as last week’s 175 beds.

Arizona hospital occupancy remains above seasonal levels and we are now seeing the first indications that our safety margin as measured by excess, available ward and ICU beds is eroding (Figure 6). Undoubtedly, some medically necessary procedures will likely be postponed and rescheduled over the coming weeks to make room for critically ill COVID-19 patients. Hospitals should be prepared for >20% COVID-19 ward occupancy and >25% ICU occupancy for the foreseeable future. Even if you are vaccinated, the COVID-19 surge can impact your health should you become ill and required hospital care. In the essence, care will become increasingly more rationed over the coming weeks with only the sickest of the sick being able to access critical care services.

While the week ending January 17, 2021 remains Arizona’s deadliest with 1093 deaths, we are once again seeing >100 COVID-19 deaths per week. The week ending August 1^st tallied 115 deaths so far with more likely to be recorded in the coming weeks. With a case fatality rate of about 1.5%, this week’s tally of 18340 cases will result in approximately 300 deaths per week by the end of August. There is nothing we can do about these deaths; they are already on the books we just don’t know it yet. Our work over the coming weeks is to prevent these 300 weekly deaths from becoming 500 or more.

Despite high vaccination rates among those >65 years of age, most deaths are still attributable to infections among this medically frail group (Figure 7b).

For the week ending August 8th, 1762 Pima County residents were diagnosed with Covid-19 (Figure 8). This is a 53% increase from the 1151 cases initially reported last week.

New cases are being diagnosed at a rate of 168 cases per 100K residents per week. This rate is increasing by 56 cases per 100K residents per week. Trends across the various age groups appear in Figure 9 (Note: cases among <15 years approximate adults).