Maine hospitals are straining to care for record numbers of COVID-19 patients. Schools across the state are reporting outbreaks and sending kids home to quarantine. So many positive cases are being reported to the state that even an expanded public health staff can’t keep up.

And it’s not even October.

A year ago, when no one was vaccinated, Maine was reporting about 30 new cases a day. Then October arrived and people started moving indoors, where the virus spreads much more easily. Cases surged through November, December and January before falling again.

This September has been far different as the delta variant surged nationwide. Last week was among the darkest of the pandemic in Maine, when the state surpassed 1,000 deaths, broke hospitalization and ICU records and counted more than 70 school outbreaks in the first weeks of classes.

So what will happen this winter?

Will even larger numbers of Maine people become sickened and overflow hospitals when colder weather arrives and we spend more time indoors? Or is there reason to hope that we can avoid another winter like last year, when the virus killed more than 500 Maine people in three months?

Those who know the most about the virus say the one certainty is that it’s unpredictable.

“Anybody who projects out more than 30 to 60 days is basing those projections on pixie dust,” said Dr. Michael Osterholm, an epidemiologist who directs the Center for Infectious Disease Research and Policy at the University of Minnesota and who served on then President-elect Biden’s COVID-19 advisory board. Osterholm said you’d have better chances predicting the weather next September than what COVID-19 will do a few months from now.

“We don’t know, and that’s been a challenge,” he said. “We saw a number of people who were very public about their statements in May or June that we wouldn’t see a summer surge, … and look what happened.”

There are reasons for both pessimism and hope.

Maine is entering its indoor season, and the virus transmits to others more readily in indoor settings. And the more contagious delta variant has proven extremely efficient in finding and infecting unvaccinated populations. Also, while mask wearing and social distancing reduced the seasonal flu to near-record low levels last winter, no one knows how the flu season might complicate public health efforts this winter.

But some national experts say they see reasons for optimism, too.

Maine is a highly vaccinated state, and vaccination rates will continue to improve, especially as mandates kick in, such as the Biden administration’s directive that employers with more than 100 workers require them to vaccinate or test weekly. Also helping to improve vaccination is a likely approval of the vaccine for ages 5-11 around Halloween.

“I am looking for a bit better winter,” said Arthur Caplan, professor of bioethics at New York University’s Langone Medical Center who bases the cautious optimism on New England’s high vaccination rates and adherence to public health guidelines. Caplan is an expert on vaccination trends and is currently serving on the NCAA COVID-19 Medical Advisory Group.

“People in New England are smart and willing to take the three-pronged approach of vaccinate, test and mask,” he said.

Also, statistically speaking, the pandemic so far has been a series of peaks and valleys – not sustained surges that last many months.

Rachael Piltch-Loeb, a research associate in biostatistics at the Harvard T.H. Chan School of Public Health, said last week in a conference call with reporters that the pandemic has “waxed and waned” on roughly two-month cycles that scientists don’t completely understand. She also said vaccine rates will be an important factor this winter.

“The pandemic is going to look different (later this year) in different states,” Piltch-Loeb said. “We do expect differences regionally absolutely related to vaccination status.”

Dr. Nirav Shah, director of the Maine Center for Disease Control and Prevention, when asked during a media briefing last week about what the pandemic could look like in the next few months, said the answers are a combination of “too early to tell” and “can’t speculate.”

“We have started to see a little bit of easing in some states similar to what we saw in the U.K. ’round about four to five weeks ago,” Shah said.

While much of the country still has relatively high levels of virus prevalence, some states are starting to experience notable drops, including California, Oregon, South Dakota, Georgia and Texas, among others. Average weekly cases in the United States have declined from 1.1 million in early September to about 960,000 currently, according to the U.S. Centers for Disease Control and Prevention.

In Maine, on the other hand, the seven-day average of daily new cases continues to climb, up from 456 a week ago to 468.6 on Saturday. By comparison, the peak last January saw cases soar to more than 600 per day.

Even if Maine follows other states and sees a decline in daily cases in the coming weeks, that would not necessarily mean going back to 30 or fewer cases a day, however, Shah said.

“If this is the beginning of a decline, will it be a precipitous decline, so-called exponential decay, or will it be a reduction followed by a high plateau, which is what happened in the U.K.?”

In the United Kingdom, cases peaked in July, declined sharply for a few weeks and plateaued until early September, when they started descending again.

The U.K. experience may be especially instructive for Maine because it has high vaccination rates similar to New England with about 67 percent of the total population fully immunized.

Complicating matters is human behavior, such as what happened in the U.K. when schools reopened this summer with few pandemic restrictions and the Euro Cup soccer tournament brought thousands together for watch parties, Dr. William Hanage, an epidemiology professor at Harvard University, told the Harvard Gazette in an interview in late August. Cases stopped falling, but when schools went on another summer break and the tournament ended, cases went down, Hanage said.

Adding to confusion about what the future holds in the United States are forecasting models that paint very different pictures of the next year.

The COVID-19 Scenario Modeling Hub, which combines forecasts from several models for the U.S. CDC, shows a steady decline in cases across the nation from now through March 2022, when the model projects less than 10,000 cases per day nationally. That’s about 15 times less than case counts being reported now. The modeling hub does not currently do long-range projections by state.

But according to another model – the IHME forecasting model produced by the University of Washington – cases are projected to decline slightly this fall before picking back up again in December and January. The IHME model shows more of a plateau than a huge winter spike, however.

Caplan, the bioethicist, said there could be big regional differences this winter, with high-vaccination states such as Maine clamping down on the virus and states in the South and interior West with lower vaccination rates remaining susceptible to COVID-19 spikes.

Maine and most of New England have the best vaccination rates in the nation, approaching 70 percent of the population fully immunized, while states such as North Dakota, Mississippi, Alabama, Idaho and West Virginia have vaccination rates of less than 45 percent, according to federal data.

In fact, despite the record hospitalizations, Maine’s vaccination rate appears to have prevented the state from experiencing the same intensity of the delta variant surge as other states with lower vaccination rates. The state has remained below the national infection rate throughout August and September.

When vaccinations are combined with people who have natural immunity from contracting COVID-19, there are even fewer people that the virus can successfully transmit to. And, Caplan said, the expectation that school-age children – about 100,000 of Maine’s 1.3 million population – will become eligible for vaccination later this fall “really helps a lot.” Currently, only people 12 and older can get their shots.

“Schoolchildren are a big group of people and they are spreaders. They go to common areas, schools, and go home and bring the virus back home,” Caplan said.

The rollout of booster shots this fall could provide some help, too. Boosters have been approved for those who received the Pfizer vaccine and are either 65 and older or younger with high risk factors.

However, Piltch-Loeb said it’s unclear how much the booster shots will prevent transmission of the virus, although they will definitely help reduce severe cases of COVID-19.

Another unknown is the potential for the emergence of a new variant that is more contagious and deadly than the delta, Caplan said.

It’s difficult to determine how likely it is that a new variant will come along and drive a surge of cases, experts say, because delta is so transmissible that it keeps others from taking hold. Another variant would likely have to be more contagious to overtake delta.

For instance, the mu variant is the cause for some concern because of the potential to evade vaccines, but there’s no evidence that it is more transmissible than delta and so is unlikely to take off in the United States, several infectious disease experts told The Wall Street Journal.

Caplan said his relative optimism for New England is based partly on a belief that safety protocols are going to increase in the coming weeks.

He envisions more restrictions will be put in place this winter for unvaccinated people, including more indoor venues demanding proof of vaccination to attend entertainment or sporting events, as more people come to accept the measures. Employers will impose the vaccine mandates without waiting for the courts to sort out whether Biden’s vaccine rules for workers can be enforced, he said.

Although the Biden administration has not yet required vaccination proof for domestic air travel, like Canada has done, Caplan said he also expects the federal government will eventually mandate vaccination for air travel.

“I think that (more vaccine mandates) are going to be more popular and more important,” he said.

Caplan said overall he does not see a “doom and gloom” scenario playing out this winter, especially in New England.

“I’m optimistic about New England. There’s less ideological opposition to vaccines and masks,” Caplan said. “There’s more respect for science and doctors in New England.”

Osterholm, the University of Minnesota epidemiologist, is less optimistic about the national outlook.

Because of the rapid changes and unpredictability of the coronavirus, “there are days that I know less about this virus than I did six months ago,” he said. For example, while delta-driven surges were likely predictable in areas with low vaccination rates, places such as the New England states as well as the United Kingdom have experienced large surges despite high vaccination rates.

The author of the best-selling 2017 book “Deadliest Enemy: Our War Against Killer Germs,” Osterholm has been involved in infectious disease research for decades and has held numerous positions at the state and federal levels. He has also been a consultant to the World Health Organization, the Food and Drug Administration, and the National Institutes of Health.

And he steered clear of any predictions.

“We could have another surge after this one and it could be sizable or we may not,” Osterholm said. “We’ll just have to see how these things occur.”

And, he said, the low acceptance of vaccines in the United States that is driving the current surge is also making predictions about the fall and winter much more difficult.

“We have the vaccines – we just have to use them,” he said. “This virus is beating us up badly but we’re sure helping it.”

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