Younger. Unvaccinated. Sicker. That’s the new face of the COVID-19 patients coming to hospital doors.

Hospitals in low-vaccination states are preparing for yet another influx as the Delta variant continues to spread around the country. As of July 7, the seven-day moving average for new daily cases of coronavirus was at 14,885, down some 94% from the peak in January, according to the CDC. But cases have begun to rise, up 16% from where they were the previous week. Hospitals are anticipating a new wave, which they expect will be much smaller than those in the past but will include sicker patients.

“Virtually all COVID-19 hospitalizations and deaths in the United States are now occurring among unvaccinated individuals,” said Jeff Zients, White House COVID-19 response coordinator, in a press briefing on Thursday.

In Arkansas, one of the states with the lowest vaccination rates and highest incidence of the Delta variant, Steppe Mette and his colleagues at the University of Arkansas for Medical Sciences are seeing a 400% spike in COVID-19 patients already compared to the beginning of June.

“These patients are younger and much sicker,” says Mette, who is chief medical officer of the UAMS medical center. His hospital is seeing more patients in their twenties and thirties—and even some teenagers, he says. The majority of patients are under 50. They are also seeing more pregnant women needing intensive care than at any time before May.

Fifty to seventy percent of the COVID-19 cases they are now seeing at their small hospital have to be in the ICU and many are either put on a ventilator or treated with a complicated but less invasive blood oxygenation method known as ECMO, which was found in the latter part of 2020 to be an effective way of saving lives.

Fewer young people are getting vaccinated

The primary driver of this new spike is low vaccination among younger people, says Mette as well as the spread of the the Delta variant, which may be approximately 40-60% more contagious than the Alpha variant. 

Less than 35% of Arkansas’s total population is fully vaccinated against COVID-19. As in many other states, the vaccination rate among eligible people is lowest among those in the 12-17 age group. Four other states—Alabama, Mississippi, Wyoming and Louisiana—are all at or under that 35% threshold, and 31 states are under a 50% vaccination rate.

While children under 12 are ineligible to receive COVID-19 vaccines, experts interviewed for this story say it’s important to look at full vaccination numbers for the total state population when considering the potential impacts of the Delta variant. Children can catch and transmit COVID-19 of any variant, and some studies indicate that single doses of the two-dose COVID-19 vaccines provide less protection against the more transmissible Delta variant.

Twelve- to 17-year-olds were first recommended to receive a COVID-19 vaccination on May 12. In the time since, 36 percent of Americans in this demographic have received at least one dose.

Preparing for another wave

In states with low vaccination rates, hospitals are anticipating a late-summer surge in COVID-19 cases. “I expect our case counts to rise slowly over probably the next 4-6 weeks,” says Don Williamson, president of the Alabama Hospital Association. “I will not be surprised to see our hospitalizations rise.”

Low-vaccination states are fighting a battle on two fronts. As hospitals prepare for another surge in COVID-19 cases, made more severe by the Delta variant, everyone involved with COVID-19 prevention and care is trying to get more people vaccinated. “We have a long way to go,” Mississippi’s chief epidemiologist, Paul Byers, said in a June 30 press conference about vaccination and the variant.

Clinicians know a lot more about how to treat COVID-19 now, says Eric Boley, president of the Wyoming Hospital Association. “We’re better prepared. We understand the virus better,” he said. Beyond the level of preparation, supply shortages aren’t dogging hospitals. Access to everything from PPE to ventilators is at sustainable levels in Wyoming, he says. Alabama, Arkansas and Mississippi report the same.

But hospitals face other obstacles. “The potential of having another surge in the numbers means that we go back to doing what we were doing a year ago,” says Ijlal Babar, director of pulmonary and critical care at the Singing River Health System in Mississippi. For Babar and his colleagues, that means long hours and the constant stress of dealing with critically ill patients. Hospitals across the US are also facing significant shortages in nursing staff and technicians essential for COVID-19 care, which will also have a significant effect on future surges.

The Delta variant hasn’t yet been identified in large numbers in his region, Babar says, although it has become the dominant strain in Mississippi and across the country. He expects that to change as the highly transmissible variant continues to circulate.

Unlike earlier surges, the one that hospitals fear is coming could be prevented with vaccination. All of the three currently approved COVID-19 vaccines have proven highly effective, even against the Delta variant. Even if someone who is vaccinated does experience a breakthrough infection, they are far less likely to get extremely sick or to die.

“It seems like since the initial wave of people who were vaccinated,” said Mark Williams, Dean of UAMS Fay Boozman College of Public Health, it’s been a real uphill struggle to vaccinate the remainder.”