As the coronavirus outbreak recedes in many parts of the U.S., the Pacific Northwest has emerged as an outlier — gripped by a late spring surge that has filled hospitals in the metro areas around Seattle and Portland.

In recent weeks, the governors of both states have hit the brakes on reopening plans in hopes of countering the rapid spread of the more contagious B.1.1.7. variant of the coronavirus, first identified in the U.K.

In Washington state, new hospital admissions for COVID-19 have been higher during this current surge than at any other time, except for this past winter.

"We have seen a clear fourth wave of hospitalizations," says Dr. Michael Anderson, chief medical officer for Virginia Mason Franciscan Health, which has hospitals throughout Washington state. "The rise of the curves for admissions has been scary in that it has taken off so quickly."

"Very, very" busy hospitals, restrictions remain

Similar to the national trends, the patients being hospitalized in Washington are now overwhelmingly young and middle-aged adults — not older Americans who are mostly vaccinated at this point.

"It's keeping our system very, very busy," says Dr. Michael Myint, infectious disease epidemiologist who leads the COVID-19 response at MultiCare, a hospital system based in Tacoma, Wash.

The average age of COVID-19 patients at MultiCare has fallen about a decade, which has made this latest surge more manageable because younger patients tend to have shorter hospital stays than the elderly do, he says.

Washington Gov. Jay Inslee has enacted a statewide pause on loosening any pandemic restrictions and put in place more stringent rules on several regions last month, including the state's second most populous county just south of Seattle.

"We would be dealing with a very severe wave that would probably be worse than the third wave if not for this background of vaccination," says Dr. Joshua Schiffer, an infectious disease expert at the Fred Hutchinson Cancer Research Center.

There are several likely explanations for why Oregon and Washington are being hit with a late spring surge: how quickly the B.1.1.7 strain took off, cooler weather still keeping people indoors and the region's relative success at fending off the virus earlier in the pandemic, which now leaves the population more vulnerable — at least until more people are fully vaccinated.

"It's notable the states that have had lower degrees of infection have had fourth waves, so having some degree of preexisting immunity based on infection has helped certain states with this fourth wave," Schiffer says.

Washington health officials say there are early signs that new cases may have peaked, but the outlook remains uncertain, especially given the unknowns about which other variants — not just the B.1.1.7 — may be spreading undetected.

"We may be plateauing now and the big outstanding question is how do the variants interface with each other?" asks Myint of MultiCare. "The one way that we're going to blunt and then get over this fourth wave is really the vaccines."

Vaccine demand slows, a renewed push in rural Wash.

Washington is firmly in the top half of states for how many people are fully vaccinated and for its rate of new vaccinations. More than half of adults in the state have had at least one dose, and in the Seattle metro area that number rises to about 70%.

But, as with much of the country, the pace of vaccination appears to be slowing down.

"Now when we post new appointments, they're still available a week later. We're not filling them. We are not able to deliver the vaccine that we have," says Dr. Anderson of Virginia Mason Franciscan Health.

Public health leaders are trying to be more creative with how they get shots into arms, enlisting companies such as Uber and Lyft to provide free and discounted rides to vaccination clinics.

The challenge of bringing vaccines to people — and convincing them to get it — are only amplified in rural parts of the state.

In White Salmon, Wash., the vaccine tent outside NorthShore Medical Group is not attracting crowds of people, even though state data show that a majority of the adult population in the region has not received at least one shot.

Scott Kotlarz, who just received his second shot there, says he personally knows of two people in the state who have died during this latest surge of COVID-19, including one who was a distant relative.

"She chose not to get the vaccine," Kotlarz says. "So now it has actually touched the family — that was my first experience of that."

NorthShore has two clinics in the stretch of southern Washington that hugs the Columbia River Gorge, about four hours from Seattle.

"We've gone from the arms looking for vaccines to the vaccines looking for arms phase," says Dr. Chris Faison, a family physician there. "We're all realizing this is going to be a less mass vaccination, superefficient process, and it's really going to come down to one on one conversations and actually approaching patients out in the community."

This an expensive proposition for a rural primary care practice — one that the Biden administration hopes to encourage through a nearly $1 billion investment in rural America's COVID-19 response.

Without extra funding, many rural practices would have to scale down their vaccination efforts because the time and manpower to do a piecemeal vaccine campaign isn't financially feasible.

Faison cites a recent vaccine clinic NorthShore held at a nearby Catholic church, which serves the Hispanic community.

It's an example of how providers should be reaching out to people that may not have access or information about the vaccine, he says, but ultimately only a handful people ended up getting a shot over the course of several hours.

"It's worth paying for," Faison says, "and it even helps the people that don't get their shot because they see and hear that you're part of the community, you're there and you care."

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