It was all smiles in North Las Vegas on Thursday as Gov. Steve Sisolak and other community leaders gathered to hand out the first of $5 million in prizes to vaccinated Nevadans.

The mostly maskless crowd chuckled at Sisolak’s jokes — “I feel like we’re at the Oscars here, or something” — and applauded enthusiastically when a North Las Vegas kindergarten teacher was awarded the biggest cash prize of the night, $250,000. The festive atmosphere made it almost easy to forget the reason they were there: To encourage as many Nevadans as possible to get vaccinated against a still-deadly and once again rapidly spreading virus.

“While we're in a much better place now than we were a year ago, the pandemic is not over,” Sisolak cautioned in his opening remarks.

Summer has ushered in a sense of normalcy to many people’s lives as they have resumed going to dinners with friends, gathering with family for holidays and taking long-delayed vacations. The last couple of weeks, however, have brought with them an unwelcome reminder that not only is COVID-19 still among us, but it is also better at infecting us than ever before.

“The variants that we're facing, which essentially dominate the field now, are your Olympian viruses,” Dr. Mark Pandori, head of the Nevada State Public Health Lab, said in an interview this week. “These are the ones that have competed and competed and competed and are now the most proficient at infecting people.”

As the highly transmissible Delta variant has taken hold across the United States, Nevada, and, in particular, Clark County, has quickly emerged as an epicenter of the latest surge of the virus. As of Friday, Nevada had the fourth highest case rate in the nation per capita over the last seven days; for many days last week, it was first.

The uptick in Clark County, in some ways, comes as no surprise. The county has a low vaccination rate, high population density and an economy built on bringing millions of domestic and international tourists together. While public health experts say vaccinated Nevadans remain fairly well protected against COVID-19, including the Delta variant, there is little protecting unvaccinated Nevadans from falling ill.

With no more social distancing, capacity restrictions or mask mandates and a highly transmissible variant, state officials are stressing that the risk to unvaccinated Nevadans now is greater than it has ever been during the pandemic. They have returned to full time pandemic response mode after starting to transition away from it earlier this summer, including dissolving a statewide COVID-19 task force, saying goodbye to its pandemic response director and ending routine press calls. 

In a marker of the increasing seriousness of the situation, those press calls started back up again this week on Thursday.

“This is one of those moments where we’re looking and saying, ‘It did feel so much better, and now we’re here, we’re seeing this increase, what do we do?’” said Michelle White, Sisolak’s chief of staff. “It is a renewed strategy. It's this renewed sense of urgency at the state level. It is a reexamination of how we're approaching vaccinations and the pandemic in general.”

The state is all-in on the vaccination effort and has requested assistance from federal surge teams to help with the rising COVID-19 cases. The first boots on the ground from FEMA, the Federal Emergency Management Agency, are expected to arrive this week in Southern Nevada, with more to follow. They’re expected to focus on targeted vaccine outreach to undervaccinated communities and boosting testing opportunities.

While some public health experts have renewed calls for the federal government and individual states to reinstate mask mandates and other mitigation measures in light of the latest surge, Sisolak told The Nevada Independent on Thursday that no new mask mandate is on the horizon.

“I'm confident that we can get the word out. We can get enough people vaccinated,” Sisolak said. “I don't want to take steps backwards.”

The rise of the Delta variant

Public health experts believed it was only a matter of time before the Delta variant became the dominant strain of COVID-19 in Nevada and the rest of the U.S. The Alpha variant, formerly known as the U.K. variant, is 50 percent more transmissible than the original strain of the virus, and the Delta variant is thought to be 40 to 60 percent more transmissible than that.

What has been interesting to those in the public health field, though, is how quickly the Delta variant has taken hold. Three weeks ago, the Delta variant was responsible for 16 percent of sequenced COVID-19 cases in Nevada in the previous 14 days. Two weeks ago, it was 46 percent. This week, it was 60 percent.

“The speed with which it did [increase] has been a surprise,” Pandori said.

Those who have been keeping an eye on statewide metrics expected that COVID-19 cases, test positivity and hospitalizations might once again increase after the state fully reopened on June 1, but they have been similarly surprised at how rapidly those metrics have climbed. The number of new cases being reported each day on average has doubled over the last three weeks, and test positivity and hospitalizations have doubled in just two weeks.

As of Friday, the state was seeing about 473 new cases reported on average each day over the last seven days, a number it hasn’t seen since mid-April. Hospitalizations, meanwhile, sit at 640, putting the state back to where it was in late February.

“We knew that hospitalizations were going to go up when we reopened,” said Chris Lake, executive director of community resilience for the Nevada Hospital Association. “But what we didn't necessarily anticipate was the new Delta variant, which is very highly contagious. That increased transmission, along with the plateau in vaccinations, is really what is driving this rapid increase in hospitalizations.”

While the surge in Clark, as the state’s largest county, dominates the statewide numbers, some rural counties have seen upticks as well. As of Friday, the state had flagged Clark, Elko and Lander counties for high COVID-19 case rates.

The Delta variant, however, has been identified in at least seven counties statewide. Among the state’s most populous counties, the Delta variant was responsible for 54 percent of sequenced cases in June in Clark County, 46 percent in Washoe County and 56 percent in Carson City.

While Washoe and Carson have less population density than Clark County and slightly cooler weather that allows for more outdoor activities, public health experts point to one key difference as to why the virus has rapidly spread in Clark County while numbers have remained low in its two northern counterparts: vaccination rates.

Nearly 50 percent of Carson City residents and 47 percent of Washoe County residents are fully vaccinated against COVID-19, compared to only 38 percent in Clark County. That, coupled with Southern Nevada’s face-to-face service economy, have made the county ripe for a surge, public health experts say.

“When you talk about an environment that’s hostile or less hostile for the virus, you’ve got one that’s less hostile to the virus in Southern Nevada because it’s easier to find a host and when you find a host, the probability of that host being unvaccinated is higher,” Pandori said. “It’s a more forgiving environment for this virus.”

Southern Nevada Health District officials said they haven’t identified specific locations responsible for the uptick in COVID-19 cases so much as unvaccinated people generally being out and about in the community.

“One factor that is driving the positivity rate is the amount of individuals in our community and statewide who are not vaccinated,” said Victoria Hughes, contact tracer supervisor for the Southern Nevada Health District.

Complicating things, the ones who are most likely to be out and about — younger adults — are also the ones who are least likely to be vaccinated. More than three-quarters of Nevadans aged 60 and up have received at least one dose of the vaccine, while only half of those 20 to 59 have received their first shot.

While younger adults may believe their generally stronger immune systems will protect them against COVID-19 and that they don’t need the shot, the numbers say otherwise. 

Data provided to the Independent by the Nevada Hospital Association show that adults aged 20 to 59 were responsible for 57 percent of new hospitalizations between June 27 and July 7, compared to only 36 percent between Nov. 27 and Dec. 7 during the prior surge. By comparison, those 70 and up only made up 22 percent of new hospitalizations, compared to 41 percent during the previous surge.

“You can see it’s really a younger population going to the hospital,” Lake said. “It really is a flip flop.”

Brian Labus, an assistant professor of public health at UNLV, said there’s a degree of variability in a disease outbreak. Over the course of this pandemic, for instance, the U.S. has seen hotspots crop up in New York, Michigan and California at different times.

“We've seen this over the course of the entire pandemic. There have been cities that have always been hotspots for a couple of weeks, and then some new city takes over as things flare up,” Labus said. “Kind of like when a fire is raging, like a forest fire, you're going to find places that have hotspots and places where it slows down.”

But Ali Mokdad, an epidemiologist at the Institute for Health Metrics and Evaluation at the University of Washington, said Las Vegas will likely always be in a particularly vulnerable position when it comes to the virus because of its tourism industry.

“When you compare states to another state, you have to look at it basically like playing cards. You play your deck of cards, you can’t play somebody else’s cards,” Mokdad said. “Basically, the culture and people coming in, that's allowing the virus to arrive faster, allowing the virus to spread faster.”

What public health experts aren’t yet sure about is where the current surge is heading. Research on the Delta variant is ongoing, but data out of Israel have shown that the Pfizer vaccine is 64 percent effective at preventing symptomatic and asymptomatic infections and 93 percent effective at preventing hospitalizations and deaths, which public health experts consider good news for vaccinated individuals.

The picture is less rosy for the unvaccinated, though. Early research out of Scotland suggests the risk of hospital admission related to the Delta variant is twice what it was for the Alpha variant, and about 95 percent of hospital admissions in Clark County over the last three months have been among unvaccinated individuals, Dr. Fermin Leguen, chief health officer for the Southern Nevada Health District said last week.

Some public health experts are holding out hope that the recent surge in hospitalizations won’t translate to as many deaths as the state has seen during previous waves, owing to the comparatively younger ages of the current hospitalized population, the experience doctors now have in treating COVID-19 and the effectiveness of the vaccines in preventing serious hospitalizations and deaths. For the unvaccinated, though, they stress that the situation is even worse than it was last year.

“As we see people getting infected, we see more hospitalizations, and we naturally see more deaths from that,” Labus said. “Our vaccination rates are preventing some people from being hospitalized and dying, but we still have a major proportion of our population completely unprotected. So if they get infected, their risk of death is going to be the same as before.”

The vaccination campaign

When Craig Barnes tested positive for COVID-19 before a trip to Hawaii, he was in shock. He received his second shot of the Pfizer vaccine in late March and had started easing back to normal life, including going out to eat and playing video poker at casinos. Even in big crowds, he didn’t even think to put his mask on, he said.

Barnes, 51, started to feel sick in late June, but a trip to the doctor’s office left him with a diagnosis of sinusitis. It wasn’t until a couple of days later when he went to get tested before his trip that he found out he had the virus.

At first, he was angry at having to cancel a family vacation. But that anger quickly turned to relief, particularly when he thought about the fact that his brother had been hospitalized with COVID-19 back in October for three months. His worst symptoms, by contrast, included fever, fatigue and a loss of taste and smell.

“Now that I’m looking back, if I didn’t have the vaccine, how sick would I have been? I really believe if I had not had the vaccine I would have been in the hospital or either sick for four or five days,” Barnes, who lives in Las Vegas, said. “I truly believe that.”

There has been some understandable angst and frustration among vaccinated individuals who have contracted the virus, though. Vaccination gave them a sense of freedom, invincibility even. While reports of breakthrough cases — those among fully vaccinated individuals — are concerning, public health officials statewide have continued to underscore that breakthrough infections represent just a fraction of the overall cases and hospitalizations they are seeing.

According to Department of Health and Human Services data requested by the Independent, there have been 136 breakthrough cases identified statewide that have resulted in hospitalization or death out of more than 1.2 million fully vaccinated Nevadans. (Less serious breakthrough cases are not tracked by the state.) 

Those aged 60 and older make up 78 percent of those breakthrough cases, while men, who have generally been hit harder by the virus throughout the pandemic, were responsible for 61 percent.

As the COVID-19 situation continues to worsen in Nevada, state officials have been doubling down on the vaccination effort. A vaccination may not protect someone from catching COVID-19, but it may turn a serious hospital stay into something resembling no more than sinusitis, as it was for Barnes.

“When you have a variant like the Delta variant that spreads more easily, it's going to be possible that some people who are vaccinated will get sick. But typically, when they do get sick, the disease is more mild, so they won't don't wind up being hospitalized. They don’t wind up dying from it,” Labus said. “It's kind of like wearing a seatbelt. It's not going to stop all people from dying in car accidents, but it really reduces the numbers and just because some people still die in car accidents doesn't mean everybody should stop wearing their seatbelts.”

The problem, public health experts say, is that many unvaccinated individuals are behaving as if they are vaccinated, going out frequently in crowded places, not social distancing and not wearing masks.

“Ninety percent of our new cases in the past three months are from the unvaccinated population, so vaccines do provide considerable protection,” said Dr. Nancy Diao, division director of epidemiology and public health preparedness for the Washoe County Health District. “I think when the mask mandate was removed by CDC, it was to provide a reward for those who are vaccinated and an incentive for those who aren't. But a portion of the population who are unvaccinated, they saw this as a sign that, ‘We’re good,’ and nothing more needs to be done.”

Even for those unvaccinated individuals who are still trying to be careful, there is a risk. Yvonne Culliver-Holland, a 55-year-old from Pahrump, said she fell ill with COVID-19 after her sister and her sister’s friend recently came to visit. Culliver and her husband had been vigilant since the beginning of the pandemic, staying home as much as possible, hand sanitizing frequently and continuing to wear masks out in public. Her sister and the friend were the first two guests they had invited to their home.

As it turns out, the friend had a sore throat but didn’t tell anyone before they came, Culliver said. They chalked it up to the dry air.

Culliver, who is vegan and considers herself very healthy, fell very sick with the virus, as did her husband. Her symptoms included fever, headache, body aches, cough, fatigue, dizziness and lack of appetite.

“I finally felt like we were kind of breathing, if you may, just like, ‘We made it, we're okay,’ and then this happens,” Culliver said. “Literally, COVID. Like, I can't believe it. We really are sitting here with COVID. Today makes two weeks that we're sick. We’re not well.”

Culliver still isn’t interested in getting vaccinated and says she hasn’t received a vaccine since she was an adult and was able to make her own decisions. But she says she plans on being even more cautious now.

“You hear everyone, you see the news and everything and everyone saying, ‘Oh, finally the restrictions are being let up.’ Although I've always heard that, I’ve said, ‘Yeah, well I'm going to continue my same routine. I'm not going to change,’” Culliver said. “Now, it's just confirmation for me, like, ‘Oh my goodness, it is still out there. I knew it was out there, but this is just confirmation like, good Lord, nobody’s safe.”

State officials know they won’t be able to convince everyone to get vaccinated, but they are hopeful that through targeted outreach and their vaccination awards campaign, known as Vax Nevada Days, they will at least be able to keep the pace of vaccinations up. 

As of Friday, Nevada ranked 33rd in the nation for percentage of total residents fully vaccinated, with about 5,800 shots being put into arms on average each day over the prior seven days.

“Even when we don't see a huge jump, just the fact that we are able to level off and maintain the number of vaccinations that we've been seeing and maintain that rate, it's actually a really good sign,” Dr. Ellie Graeden, founder and CEO of Talus Analytics and an adjunct faculty member at Georgetown University’s Center for Global Health Science and Security who has been consulting with the state on its COVID-19 response, said of the state’s vaccination awards program during a press call this week. “We may not need to see a big spike for it to still be really indicative of a successful program.”

Looking forward

Messaging around the vaccine has often focused on individuals: how the vaccine will protect them, how it will protect their families and how it will let them get back to the activities they enjoy. That may not be much of an incentive, though, for unvaccinated individuals who don’t see the virus as a threat.

Public health experts say there’s another, more global reason to get vaccinated, though. Each time the virus spreads, it has a chance to mutate. Those mutations, over time, add up to become new variants that can evade vaccines, better infect people and possibly make them sicker. Without a critical mass of vaccinated individuals to halt the spread of the virus for good, the virus will only continue to evolve.

“It's a very difficult situation because as long as you're not vaccinated and you're getting infected, or even if you are vaccinated and you just somehow get infected, it's just going to perpetuate this virus and perpetuating it leads to its further evolution,” Pandori said. “So, while these current lineages may not be much of an issue for us if you're vaccinated, we could be creating a variant eventually that would be a more serious issue for us.”

Pandori described it as “genetic warfare.”

“[The vaccine] is another weapon in an arms race, literally, with this virus,” Pandori said. “I think that's a much more kind of wonkier message to sell, but now that people are so mad and crazy about variants, it has opened the door to teach that about the vaccine.”

Even as they continue to push the vaccination message, local health departments are once again making preparations for a surge of cases. The Washoe County Health District is in the process of upping its contact tracing capabilities in preparation for a possible fall surge, while the Southern Nevada Health District has the capacity to pull health district members off of other assignments to help contact trace, though it hasn’t yet had to do so.

Hospitals, meanwhile, are keeping an eye on the rising numbers but aren’t yet thinking about surge capacity or crisis standards of care, Lake said.

“The hospitals are watching it very closely. I don't think we're at a level of concern that we were with the previous waves of this virus, but we're definitely watching it,” Lake said.

State officials have been hesitant in recent days to even answer questions about whether reimposing mitigation measures is on the table, instead emphasizing the importance of the vaccination effort.

“We're constantly looking at a whole number of things we can do but, again ... the top of that list is vaccinations,” White said. “But it's also our responsibility and our obligation to remind folks that if you are not vaccinated, the same risks that were there a year ago, over a year ago, are still here today. In fact, it’s increased.”

But nationally, some public health experts, including the University of Washington’s Mokdad, have been pushing either for the federal government or states to reimpose mask mandates. Mokdad said states should also consider setting benchmarks and reimposing restrictions if their residents don’t meet them.

It would be a hard political pill to swallow, Mokdad acknowledges, but he also worries about the danger of not doing so.

“There are so many ongoing experiments — and I hate to use that word — all over the world. I mean, we don't live by ourselves on this planet,” Mokdad said. “We see what's happening around us. In many countries that didn't rush to do the right things, they paid dearly for it.”