FARGO — The number of active COVID-19 cases in North Dakota is on par with infections one year ago — a prelude to a fall outbreak that threatened to overrun hospitals and produced death rates that for a time were the worst in the world.

North Dakota reported 1,688 active COVID-19 cases on Tuesday, Aug. 24. A year earlier, on Aug. 24, 2020, the state reported 1,541 cases.

But testing for COVID-19 is way down from last year, and the rate of positive tests is up to 5.9% over the last two weeks — much higher than the 3.3% rate on the same date a year earlier. Finding more infection on fewer tests indicates the coronavirus is spreading at a more rapid pace than it did last year, said North Dakota Department of Health Disease Control Director Kirby Kruger.

“We’re heading into an absolute disaster this fall,” said Dr. Stephen McDonough, a retired Bismarck pediatrician and former senior state health official.

One big difference between now and a year ago: 49.2% of those 12 and older have been fully vaccinated against COVID-19, according to the Centers for Disease Control and Prevention. Also, doctors are more experienced in treating COVID-19 and treatments like monoclonal antibodies are more available.

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But vaccination rates are much lower for children and young adults than for older adults, and children younger than 12 are not eligible for vaccination, making those age groups more vulnerable to infection.

“This time it will be younger people and children,” McDonough said, compared to the elderly, who accounted for most hospitalizations and deaths before vaccines became available.

State immunization coordinator Molly Howell notes that around 2% of children who test positive for COVID-19 require hospitalization, and epidemiologists assume that most unvaccinated or previously uninfected children will come down with the illness by the end of the year.

“If you take 2% of that number, that’s a lot of kids,” Howell said. “The risk is hospitals getting overwhelmed.”

‘This virus is going to have its way’

McDonough has a weary sense of deja vu.

“Here we are again,” he said. “It’s just mind-numbing. It’s just massive COVID denial again.”

Kirby Kruger, infectious disease division director for the North Dakota Department of Health, said more than half of new COVID-19 cases are among those younger than age 50, including more than 60% of new cases reported on Monday, Aug. 23.

Young people are not immune to COVID-19, and should be mindful that they can develop chronic, “long COVID” symptoms including fatigue, memory problems and “brain fog” and difficulty breathing, he said.

“I am worried,” said Dr. Avish Nagpal, the chief infectious disease specialist at Sanford Health in Fargo. “I think we’re in worse shape this year despite having a pretty good vaccine.”

Given current trends and the highly transmissible delta variant of the coronavirus that now prevails, North Dakota is likely to experience another major wave of cases similar to what the state sustained last year — and possibly worse, though with fewer hospitalizations and deaths, Nagpal and McDonough said.

“The delta variant changed everything,” McDonough said. “It’s as contagious as chicken pox.”

Kruger said he doesn’t have a crystal ball, but he’s “very concerned cases could grow very rapidly” as they did over the last two months in the similarly undervaccinated southern United States.

“I look at Louisiana, I look at Florida and I know I don’t want to be there, but I don’t think we can dismiss that,” Kruger said.

“Last summer what happened in the southern states came right up to us,” McDonough said.

Because most older adults are vaccinated, however, there likely will be fewer hospital admissions and deaths during this wave than last year, Kruger, McDonough and Nagpal agreed.

Schools can expect to have to deal with infection outbreaks, Nagpal and McDonough said.

The fact that COVID-19 cases are on par with those a year ago — and trending higher — reflects the low adherence to precautions including wearing masks and maintaining social distancing, Nagpal and McDonough said.

“This virus is going to have its way,” McDonough said. “If you don’t act now, you’re going to have kids in the hospital, some will be on ventilators and some will die.”

Ideal conditions to spread

Mike Nowatzki, a spokesman for Gov. Doug Burgum, said the state’s top officeholder is not actively considering issuing a new COVID-19 state of emergency, which would allow him to make far-reaching executive orders and suspend state law. The Republican-held Legislature, which has favored a hands-off approach from government during the pandemic, created a new law earlier this year that would give lawmakers a greater ability to cancel a state of emergency declared by Burgum.

Nowatzki said the governor sees widespread vaccination as the single best answer to the state’s COVID-19 woes.

“We’re seeing a similar spike to last year, and we know where that ended,” Nowatzki said. “There’s a way to avoid that through the vaccine.”

North Dakota legislators also passed a law barring statewide mask mandates imposed by the executive branch, but allows lawmakers to do so.

Fargo was the first city to implement a mask mandate last October, quickly followed by other cities. More than half of the state’s population lived in cities with mandates by the time North Dakota imposed a state mandate last November.

“What saved us was the mask mandate,” McDonough said, but added that no such requirements are widely in place now.

“People are sick and tired of it,” Nagpal said, referring to resistance to mask usage and other precautions. “I get all of that. I’m not blaming anyone.”

But with about half of the population unvaccinated and few wearing masks, the virus has ideal conditions to spread.

To try to keep the pressure off of hospitals, health providers can treat high-risk patients with monoclonal antibodies, a treatment Sanford is working to make available in nursing homes, Nagpal said.

Pediatricians are worried that a spike in hospital admissions of children with COVID-19 could mean children will be treated in non-pediatric units, McDonough said.

Hospitals already are pushing their capacity. As of Tuesday, North Dakota hospitals were treating 58 patients with COVID-19, but staffed available beds were scarce. In Fargo, Sanford had nine staffed beds available on Tuesday and Essentia had seven, according to figures compiled for the state.

The real challenge will start in the fall, when students return to school and the colder weather keeps people indoors more, Nagpal and McDonough said.

“What’s going to happen when we get indoors and schools open back and universities come back?” McDonough asked.