California, the U.S. coronavirus hot spot early this year, in recent weeks has recorded some of the lowest case rates in the country.
How did that happen? And why does it appear to have reversed positions with states that fared better through the winter surge?
One clear example is the New England states of Vermont and Maine. Relatively shielded from the worst of the nation's previous surges, they have struggled against the delta variant, which has sent their case rates soaring.
The two states have higher vaccination rates than California's, experts say — but lower natural immunity.
As horrific as the winter surge was, with hospitals overwhelmed and death rates hitting pandemic peaks, experts say California emerged from it with a relatively significant amount of natural immunity. And that, combined with vaccination levels that are above the national average, is now playing a major role in keeping case rates so low.
Experts stress that case rates are just one data point — and that a more telling metrics at this point in the pandemic are hospitalizations and death rates, which are low across the board in both California and New England due to the power of vaccines.
However, "There is a lot of naturally acquired immunity from last January," said George Rutherford, an infectious disease expert at UCSF. "Maybe it's not the end-all be-all, but it sure as hell works for the short term."
Comparing data: Maine, Vermont struggling
Adding to the success in California, Rutherford said, are relatively strict health policies, particularly in the Bay Area but also other more populated regions including Los Angeles County. Vaccine mandates and mask rules have proliferated in Bay Area counties and across the state, which is even the first in the nation to require schoolchildren to be vaccinated, when full federal approval is given for the shots.
All these factors are reflected in California's coronavirus numbers: This week, state data — reflecting single-day daily averages, unlike the Centers for Disease Control and Prevention's full-week averages — showed the average daily rate of new cases was 18 per 100,000 people, the second lowest rate in the nation behind Connecticut. The case rate for just the Bay Area was even lower at 10 per 100,000.
Like California, many New England states have also been known for their pandemic rigor. Five of New England's six states have the highest vaccination rates in the country, with Vermont topping the list at 70% of its total population fully vaccinated. California's rate is lower at 59%.
And yet in states like Maine and Vermont, which had long staved off the worst of the pandemic, the delta variant has latched onto unvaccinated pockets. Maine, with a vaccination rate just under Vermont's at 69%, has been struggling the hardest in the region, breaking its single-day record in daily new cases last week. Its most recent case rate was 44 per 100,000 residents.
Maine and Vermont, like California, recommend universal indoor masking, and have instituted some COVID-19 vaccination requirements for state and health workers.
But they lack a higher level of natural immunity like California's, experts said.
"Maine is paying the price of not having had big numbers of cases," said Dr. Shira Doron, an infectious disease physician and hospital epidemiologist at Tufts Medical Center in Boston. "They don't have natural immunity to help."
While Maine CDC Director Nirav Shah said Monday that cases are trending downward, he expressed concern that they may settle at a "very high plateau," according to Maine Public .
Vermont has also seen a higher spike during the delta surge, reaching a pandemic peak of 35 cases per 100,000 per day on Sept. 21. While cases there are also starting to decline, the rate is still relatively high at 30.
Comparing data: Connecticut
New England's southernmost state, Connecticut, has charted a different coronavirus curve from the rest of the region — one more similar to California's, owing to some of the same factors, including natural immunity, experts say.
Connecticut was hit hard early in the pandemic as cases exploded in neighboring New York, Doron said. The pandemic curve then followed a trajectory roughly similar to California's. Connecticut this week had the lowest seven-day daily average of new cases among U.S. states at 12 per 100,000, according to state data.
The state also has a high vaccination rate, with 69% of the population fully vaccinated, and like California has a universal indoor masking recommendation.
Connecticut also requires all state employees, child care workers and employees of K-12 schools to be fully vaccinated or undergo weekly testing. Health care workers are required to be vaccinated, with no exceptions.
But another key difference for Connecticut, as in California, is its natural immunity from previous surges, experts say. The state was hard-hit both in the spring 2020 and winter surges, and Doron said "that likely makes the difference."
Hospitalizations, deaths lower for all
While California's low case rates have received much attention in recent weeks, experts point to other numbers that they say should guide the future course of pandemic policy — namely, hospitalization and death rates.
Those numbers are low across the board in California and New England — a sign that while cases may spike in areas within highly vaccinated states, vaccines provide strong protection against severe illness and deaths, experts say.
According to the New York Times COVID tracker , all the New England states except Maine top the list for lowest hospitalization rates in the U.S., ranging from 7 per 100,000 in Massachusetts to 10 per 100,000 in New Hampshire and Rhode Island. California's is No. 7 lowest in the nation at 13 per 100,000. Maine is not far behind at No. 11 in the nation, with 16 hospitalizations per 100,000.
Death rates in the New England states and California are also among the lowest dozen in the nation: New Hampshire's deaths per day per 100,000 are the lowest at 0.14, with Maine following closely at 0.15. California is No. 12 in the nation with a rate of 0.24, but is half the national average of 0.54.
Doron stressed that in the delta era, case rates are no longer the most important metric.
"We're still trained to be focused on cases," she said. "We are going to have to shift our focus from cases to hospitalizations. With vaccinations there will come a time when cases don't matter. They're not the yardstick to which policy should be made."
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