Southeast U.S. poised for a firestorm of omicron cases, with few safeguards in place

The United States is heading into the third year of the coronavirus pandemic with the extremely contagious omicron variant poised to ignite a firestorm of infection across the Southeast after exploding through the Northeast and Mid-Atlantic regions.

Lower vaccination rates and fewer mask and vaccine mandates have created a much different environment for the omicron variant to spread in the South, leaving experts unsure whether outbreaks will end up deadlier than in the North.

Florida, Georgia, Louisiana and Mississippi are among the states experiencing the sharpest increases in COVID-19 hospitalizations since Christmas, according to data tracked by the Washington Post. And the situation may only get worse, as initial outbreaks in metropolitan areas spread to more poorly vaccinated rural regions.

Georgia has shattered records, with nearly 1 in 3 tests coming back positive in the last week of December — and in metro Atlanta, nearly half of tests were positive. New daily infections in Florida have hit an average of about 43,000 — far above the peak of 23,000 reached during the delta variant surge in the summer. Louisiana also has eclipsed daily infection records set during its summer surge, with 12,500 cases reported Thursday, which state officials said was nearly twice the record, established in August.

David Rubin, who monitors coronavirus trends nationally for PolicyLab at Children's Hospital of Philadelphia, said he expects the Southeast to be a major driver of the nation's cases this month. But he said he expects a fast decline, mirroring patterns observed during omicron variant surges in South Africa and Britain.

"The [South's] bigger test is probably going to be in the summertime, when they usually have their big surges," Rubin said. "We are going to continue to have waves in the new year that I think will become lesser in amplitude over time and will lead to fewer hospitalizations over time."

Maryland Republican Gov. Larry Hogan cautioned Sunday that the next month could mark the "worst part" of the pandemic in his state, with residents who are unvaccinated against the virus placing a strain on hospitals. Hogan appeared on CNN's "State of the Union," days after Maryland hospitals eclipsed a record set a year ago of more than 2,000 people hospitalized with COVID-19.

In New York, Democratic Gov. Kathy Hochul has held regular briefings since cases started exploding and has required businesses to mandate proof of vaccination for entry or that customers wear masks. But Republican governors in Southern states with outbreaks have remained comparatively muted and have resisted measures to contain the spread, as they did during the delta variant surge.

Texas Republican Gov. Greg Abbott said he would not reconsider his ban on local mask mandates and told a radio station that "we're moving forward with life as we know it" when asked recently about his response to the omicron variant.

As infections in Georgia surge to record highs and hospital beds fill up faster than in any state besides New Jersey, Republican Gov. Brian Kemp announced that his administration would expand testing sites, deploy 200 National Guard troops to hospitals and testing sites, and spend up to $100 million to add as many as 1,000 health care workers. But he pointedly rejected measures to contain the virus and criticized Atlanta for recently reimposing a mask mandate.

"It is time to trust our citizens to do what's right for themselves and their families," Kemp said in a statement Wednesday. "That is why I will absolutely not be implementing any measures that shutter businesses or divide the vaccinated from the unvaccinated, or the masked from the unmasked."

Harry Heiman, a public health professor at Georgia State University, said such an approach is more about managing the consequences of a virus surge rather than trying to quell it.

"Unfortunately, the deja vu we are experiencing in Georgia also includes state-level public health leadership that in the face of a predictably severe surge of the pandemic is really doing very little to proactively respond," Heiman said.

"We will see more people hospitalized and more people dying, especially as it moves into the more rural parts of our state, where there's a higher number of people who are unvaccinated and less health care infrastructure to take care of people when they are sick," he said.

Monty Veazey, president of the Georgia Alliance of Community Hospitals, said the small, largely rural hospitals he represents are bracing for the coming weeks, especially with the potential of hospital staff members calling out sick.

"People need to know if they come to a hospital during a surge, they are going to have to be patient," Veazey said. "This issue is not going away. We must live with it just like the flu, and the only way to really curb that is to be fully vaccinated."

But the South remains the most poorly vaccinated region of the United States, with about half the population vaccinated in most Southern states, unlike in New Jersey, New York and the District of Columbia, where about 7 in 10 residents are fully vaccinated as omicron variant cases surge. Alabama, Georgia, Mississippi and Texas also have some of the nation's lowest booster rates, as does D.C.

That has raised acute concerns about Southern hospitals that may not be able to bank on a largely vaccinated community ending up with mostly mild symptoms. Hospitals have warned they can be overwhelmed by even smaller surges in cases if infected staff members are sidelined, or if even a small fraction of those sickened in a huge outbreak are admitted.

"So, you are going to have a lot more people who are going to get sick because they don't have any immunity," said Marcus Plescia, chief medical officer for the Association of State and Territorial Health Officials. "Now, the South has had pretty substantial outbreaks already, and it may be that people have some natural immunity. That could be the one thing that perhaps is a saving grace."

Louisiana has urged vigilance among residents who were infected during a massive summer spike that prompted the governor to impose a statewide indoor mask mandate and the mayor of New Orleans to mandate proof of vaccination to enter the city's music venues and restaurants. State officials reported that about 1,200 people had experienced reinfections in addition to about 9,500 people infected for the first time at the end of the year.

Experts say this is not surprising, especially given evidence from South Africa that the omicron variant is reinfecting people in droves. But it remains unclear whether disease-fighting antibodies from previous bouts of the virus can stave off the worst complications, keeping unvaccinated people infected with omicron out of the hospital. Experts believe immunity induced from vaccines has that effect.

"It's so hard in the midst of this process to understand whether previous natural infection might also provide some benefits in terms of severe illness. That's far more difficult to understand," said Susan Hassig, an epidemiologist at Tulane University in New Orleans. In the meantime, those who have previously gotten the delta variant "shouldn't count on that protecting them — certainly not from infection, which means they could spread it to a whole host of people with their family and workplace."

As in the summer wave, about 80% of those now hospitalized in Louisiana with COVID-19 are unvaccinated. Catherine O'Neal, chief medical officer at Our Lady of the Lake medical center in Baton Rouge, said vaccinated patients are generally coming in for precautionary visits because of other medical conditions that could be aggravated by the virus, while unvaccinated patients are coming in as sick as they were during the delta variant wave.

"We see this idea a lot: Surely everybody has had this. Surely enough people have been infected [that] the pandemic is going to go away. And it just has not played out," O'Neal said.

"All we can say is people who have been previously vaccinated are faring better," O'Neal said. "That's the only trend I can take from all of these surges."

Louisiana Democratic Gov. John Bel Edwards urged residents to celebrate New Year's Eve only with other members of their household to control the spread of the virus, citing explosive omicron variant numbers. He recommended masking but did not reimpose a mandate as he did during the summer, when hospitals warned they were at risk of being overwhelmed.

While the threat of the omicron variant has led to the return of mask mandates or new vaccine rules in blue parts of the country such as D.C. and the San Francisco Bay area and in communities across the Northeast, mandates are unlikely to return in large numbers in conservative swaths of the country.

That's by design in many places such as Florida, where Republican Gov. Ron DeSantis has repeatedly taken steps to limit public health powers. Most recently, DeSantis called a special session of the state legislature to pass bills restricting the ability of businesses and local governments to mandate masks and vaccines.

Experts say such measures, which have proliferated across the country, will make it harder to stop surges of the omicron variant.

"The best way to prevent infection right now is to have everyone wearing a mask, and we know without a mandate that's not going to happen," said Cindy Prins, a University of Florida epidemiologist.

Orange County Democratic Mayor Jerry Demings has drawn fire from DeSantis for attempting to enforce social distancing rules and for imposing a vaccine mandate on county workers.

Central Florida hospitals have not raised alarms about being overwhelmed as they did during the summer surge. Still, Demings said he wants the option to impose temporary mask mandates in the event a massive omicron variant spike leads to widespread worker shortages in a region dependent on winter tourism. He also criticized DeSantis for not holding news briefings or regularly addressing the omicron surge in the state.

"Those tools are all controlled by the state of Florida, but where is the state, where is the governor right now? He is missing in action," Demings, who is married to Democratic U.S. Senate candidate Val Demings, said in an interview.

"What we are seeing here is this sleight of hand going on," the Orange County mayor said. "On the one hand, our governor says we want to empower local governments but effectively took all the power away from local governments. They are not filling the void. They are not stepping up."

Christina Pushaw, a spokeswoman for DeSantis, referred questions to state health officials, who did not respond. But she questioned the value of aggressive measures to contain the omicron variant, contending that regions with "strict mask mandates and vaccine passports are experiencing the same or worse surges than the open areas of the country."