Virginia data suggests that children and younger adults are contributing in a major way to the continued spread of COVID-19 — a trend that’s worrying health officials as the state continues a vaccination campaign described by many experts as “a race between variants and the vaccine.”
“The overall number of cases in Virginia has really decreased,” said Deputy State Epidemiologist Caroline Holsinger. “But what we are seeing is that the percentage of cases among 0 to 19 year-olds has increased.”
In January, infections among that age group made up roughly 15 percent of the state’s total cases. Last week, they made up 22 percent, Holsinger said. Adults aged 20 through 39 make up the largest share of Virginia’s cases, but that number has remained relatively stable. During the same time period, 20 through 39-year-olds accounted for around 34 to 38 percent of the state’s total cases — even as infections among senior Virginians have dropped significantly.
Overall, Virginia isn’t experiencing the surge of new cases that’s been seen in other areas of the country — including parts of Texas and Michigan, which is struggling to contain variant spread. But after a dramatic drop in late January, infections are plateauing rather than declining, state vaccine coordinator Dr. Danny Avula said in a telebriefing last week.
That’s a concern for health officials as the state races to vaccinate a larger share of its population. As of Friday, Virginia had administered more than 4.5 million doses and nearly 20 percent of residents were fully vaccinated. But the shifting age demographics of new infections suggests the virus is still spreading among younger Virginians who aren’t yet eligible for the vaccine — or who weren’t prioritized in the initial phases of the state’s rollout.
COVID-19 variants are contributing to a growing number of cases. By the end of March, the state had identified more than 100 cases of the B.1.1.7 variant — also known as the UK variant — and 25 cases of B.1.351, a variant first discovered in South Africa. There’s a significant lag in identifying those strains, so real numbers are likely far higher, according to Bryan Lewis, a computational epidemiologist at the University of Virginia’s Biocomplexity Institute.
In Virginia, approximately 30 percent of infections from the B.1.1.7 variant are found in patients under the age of 20, Holsinger said. There’s still no definitive evidence that it or other recently discovered strains are more likely to infect children and data also suggests that available vaccines are still highly protective against them. But B.1.1.7, especially, is both more infectious and can potentially cause more severe illness — even among younger patients.
“We can’t necessarily look at our data in Virginia and draw any absolute conclusions,” she said. But recent hospital numbers are also causing some concern. According to Holsinger, the majority of hospitalizations nationwide are occurring among 18 through 49 year-olds and 50 through 64-year-olds.
“So, we’re seeing this shift away from those 65 and older, who were driving a lot of hospitalizations earlier in the pandemic,” she said. In Virginia, there’s been a slight increase in hospitalizations among young adults, but only in certain regions of the state.
In some ways, the recent trends are a testament to the power of vaccines, which appear to be significantly reducing severe illness and deaths among older Virginians who were immunized earlier stages in the rollout. But they also present several worries for state and local health officials as they fight to curb new transmission.
In Southwest Virginia, for example, COVID-19 hospitalizations are rising again at Ballad Health, one of the state’s hardest-hit hospital systems during the winter holiday surge. Jamie Swift, the system’s chief infection prevention officer, said the average age of those cases has decreased from 70 years old to 60. And the system is also seeing an increase in hospitalized teenagers, college students, and working adults — people who are “out and about and living their everyday lives.”
“We’re seeing 30-year-olds in our hospitals every day,” she said. Multiple health districts also say there’s anecdotal evidence that variant cases are creating greater spread — more infections originating from a single case — as well as more notable symptoms among those who contract the disease.
Experts emphasize that the information is still very preliminary. In Richmond, for example — where there’s been a slight increase in cases among 20 to 29-year-olds — early outbreak data has indicated that cases resulting from the B.1.1.7 variant may cause more symptoms among younger patients who previously had more asymptomatic infections.
“That’s very observational and I’m actively looking for that to be proven or disproven based on the literature and further outbreaks,” said epidemiologist Rebekah Butterfield. But across the state, one concern is that variants could cause more serious disease among younger residents who haven’t had the opportunity to be vaccinated.
On a more systemic level, the worry is that older children and young adults are drivers of transmission. Epidemiologically, they’re more mobile and more likely to participate in risky behavior, Avula said — part of why the state has been focused on vaccinating college students before they break for summer vacation (those plans may be pushed back after a significant decline in next week’s shipments of Johnson & Johnson vaccine).
Cases driven by young adults aren’t a new phenomenon. In July of last year, Gov. Ralph Northam implemented new restrictions in the Hampton Roads region, scolding residents for congregating, often unmasked, in bars and restaurants. Ryan McKay, director of policy and planning for the Blue Ridge Health District, said local cases rose dramatically in February when UVA students returned from winter break — with almost as many new infections among college students as there were when they first arrived on campus in the fall.
And while it’s still uncertain whether variants can (or will) worsen symptoms among children and young adults, there’s ample evidence that the risk of severe infection increases with age. With roughly 80 percent of Virginians still not fully vaccinated, the big worry is that continued spread will lead to a new surge of hospitalizations.
“From the public perspective, the real issue is that each one of us does have control and responsibility over how we address the pandemic and prevent further transmission,” Holsinger said. “Because every single transmission event has the ability to lead to a death or hospitalization of someone, or someone’s parent or someone’s child.”
State outbreak data also suggests a shift in how and where the virus is being spread. Through much of the pandemic, outbreaks in long-term care facilities often drove case surges in many health districts. But recently, Holsinger said the number of outbreaks in educational settings — defined by state epidemiologists as colleges and universities as well as K-12 schools — has almost doubled.
In December, educational outbreaks accounted for 15 percent of the state’s totals. By March, that had risen to 34 percent. While state data suggests there are more outbreaks in K-12 schools than colleges and universities — 229 versus 85 — they account for fewer total cases. McKay said outbreaks at schools in his district generally resulted in five or fewer infections.
But there’s also been a rise of outbreaks in “congregate settings,” a broad category that includes recreational sports outside of schools. In December, they accounted for 28 percent of the state’s total outbreaks, according to Holsinger. By March, that had risen to 48 percent.
Within schools, sports also play a disproportionate role in spread — accounting for 43 percent of school-related outbreaks in the same month.
Holsinger said that makes curbing transmission harder as the state gradually lifts restrictions on gatherings, entertainment venues and events like graduations and commencements — as well as recreational sporting events. Virginia has taken a much more cautious approach to reopening than some neighboring states, and Northam’s spokeswoman, Alena Yarmosky, said the administration regularly considers age data in its decision-making.
“The governor has paid particular attention to this demographic data as cases remain steady even as vaccinations increase,” she wrote in a Friday email. It’s left health officials emphasizing distancing, mask wearing and other mitigation measures. But Avula said case numbers could grow less important as more Virginians are vaccinated.
“Depending on what happens with these variants, the really important question might become, ‘Are people getting hospitalized or continuing to die at similar rates from COVID?’” he said. “Because we could get to a point where young people are getting the disease and still having asymptomatic or mild disease. But everyone who’s really at risk is still protected.”