For now, countries are betting they can suppress hospital admissions and deaths without imposing more lockdowns, even as case numbers approach peak levels from last spring.
In Munich, Germany, normally brimming with boisterous crowds for Oktoberfest this month, authorities just banned gatherings of more than five people. In Marseille, France, all bars and restaurants will be closed Monday. And in London, where the government spent weeks urging workers to return to the city's empty skyscrapers, it is now asking them to work from home.
Summer ended in Europe this week with a heavy thud amid ominous signs that a spike in coronavirus cases may send another wave of patients into hospitals. Officials across the Continent fear a repeat of the harrowing scenes from spring, when the virus swamped intensive care units in Italy and Spain. Already in Spain, some hospitals are struggling with an influx of virus patients.
"I'm sorry to say that, as in Spain and France and many other countries, we've reached a perilous turning point," Prime Minister Boris Johnson said Tuesday, as he imposed new restrictions — including shutting pubs and restaurants at 10pm — to prevent Britain's National Health Service from becoming overwhelmed.
But just how imminent is the peril?
As they weigh actions to curb a second wave of the virus, Johnson and other European leaders are dealing with a confusing, fast-changing situation, with conflicting evidence on how quickly new cases are translating into hospital admissions — and how severe those cases will end up being.
In Spain, where new cases have surged to more than 10,000 a day, hospitals in Madrid are close to capacity and the government said it was preparing to reopen field hospitals in hotels and in the city's largest exhibition center. Yet in France, which reported 66,000 new cases over the past seven days, hospital admissions and deaths, while also rising, are going up more slowly.
There is a similar divergence between infection rates and hospitalisations in Germany and Austria. And in Britain, which reported 6,178 new coronavirus cases Wednesday — the highest figure since May 1 — just 134 patients were admitted to hospitals Monday, barely a tenth of those admitted in early May.
Some experts argue that this shows the virus has lost potency since it first arrived in Europe, or that it is now infecting mostly younger people, who are less likely to experience severe symptoms. Others say it is a testament to social distancing, the widespread use of face masks, greater precautions for more vulnerable people and better medical treatment.
"It's not going to be like the first time when we needed to stop everything," said Dr. Karol Sikora, an oncologist and professor of medicine at the University of Buckingham Medical School. "It's going to be a slow burn."
He and 31 other doctors and scientists sent a letter to Johnson urging him to take a more targeted response to the spike in cases.
Other experts, however, warn against being lulled into complacency. The gap between case numbers and hospital admissions, they say, is mainly a reflection of the fact that more people are being tested, and more quickly.
"Deaths and hospitalisations are a lagging indicator," said Devi Sridhar, director of the global health governance program at the University of Edinburgh. "There was no lag back in March because we only tested people who were already in the hospital. At a certain point, your ICUs are going to fill up."
The uncertainty about hospitalisations and deaths is another example of how mysterious the virus remains, even after 10 months of intense study. And that uncertainty complicates the task for political leaders who are balancing the need to protect their citizens with a desire avoid imposing more lockdowns.
In France, where the government has adopted a philosophy of learning to live with the virus, President Emmanuel Macron has bucked pressure to impose new national restrictions and left it to cities to impose tighter curbs on public gatherings.
"Many people told me, 'Stop everything,'" he said Tuesday. "On the contrary, I believe that we must continue."
France currently has more than 5,700 people hospitalised with Covid-19. Roughly 900 of them are in intensive care. That is more than during the summer, when hospitalisations dropped to about 4,500 people, but it is far less than during the peak in April, when more than 32,000 were hospitalised.
And the rate of spread is slower this time around, which helps cushion the impact on hospitals, according to Dr. Yazdan Yazdanpanah, head of the infectious disease department at Bichat-Claude Bernard Hospital in Paris. In March, he said, the number of hospitalised patients doubled every three days. Now the rate is 15 days in Ile-de-France, the region that includes Paris.
Yazdanpanah attributed that difference to more people wearing masks and the fact that many, especially seniors, are more careful about social distancing. And while the patients arriving in hospitals fit the same profile as last spring — mainly older or high-risk — doctors have learned how to treat them more effectively, with techniques like high-flow oxygen, which makes intubating less necessary.
"All of this has decreased the number of patients who have to go into intensive care by 60 per cent, and the mortality rate by 50 per cent," he said.
There are worrying signs: Hospitals in Paris will postpone 20 per cent of surgeries, starting this weekend, because of the increase in virus patients, who now account for 20 per cent of all patients in intensive care.
The problems are even greater in Spain, where more than 11,000 people are hospitalised with the virus, nearly 4,000 of them in Madrid. Coronavirus patients fill 25 per cent of the available beds in Madrid and hospitals still have spare ICU capacity — a far cry from last spring, when they were so overcrowded that patients were forced to sleep in corridors.
But doctors said the influx of patients was crippling primary-care services because the hospitals have had to divert so many of their resources to deal with the virus. After months of strain, Spanish health workers are exhausted and demoralised.
"We're definitely not yet in the March-April situation, but there are reasons to fear that we could get there again," said Manuel Franco, a researcher and professor of epidemiology at the University of Alcalá de Henares.
On Monday, authorities in Madrid put parts of the capital region back in a lockdown that affects about 850,000 residents. That, as well as the resurgence of the virus, has provoked bitter recrimination, with critics saying the government squandered the hard-won achievements of its first lockdown by throwing open the country's borders to revive its battered tourism industry.
"We didn't do our homework," Dr. Alberto Garcia-Basteiro, a prominent epidemiologist, told the Spanish newspaper El País. He and other doctors have called for an independent investigation of the country's response to the pandemic.
In Germany, which handled the virus better than many of its neighbours, there is concern about the spike in infections but less about hospitalisations. Of the 9,396 people infected with the virus in recent weeks, only 267 have required intensive care treatment, with slightly more than half of them on respirators.
"We know so much more than we did six months ago," Jens Spahn, the German health minister, told ARD public television, pointing to Germany's increased testing capacity, protective gear and intensive care beds.
Britain, like Germany, has made progress in fortifying its National Health Service for another round of battle, but it lags far behind Germany in building a nationwide test-and-trace system. On Thursday, it finally launched its trouble-plagued smartphone app in England and Wales, which it hopes will allow it to track the virus better.
The chief medical officer, Chris Whitty, said the number of people hospitalised with the virus in Britain was doubling every seven to eight days, and that deaths would multiply, "potentially on an exponential curve." If the virus spreads unchecked, that could lead to 50,000 new cases a day by October and 200 deaths a day by November, according to Patrick Vallance, the chief scientific adviser.
Whitty disputed two of the most common arguments of those who say a second wave will be less deadly. While many of those infected in recent weeks have been young, he said there was evidence that infections "are moving up the age bands, from younger people to older people." He also said there was no evidence that the virus had become any less lethal.
Britain is not the only country that has struggled to find a clear metric to track the spread of the virus.
In Belgium, officials recently announced that nearly 2,000 people had tested positive in a single day. That was nearly as many as tested positive each day during the peak of the epidemic. Back then, though, the country could conduct only a few thousand tests a day. Now, that number is around 30,000.
On Wednesday, Belgian Prime Minister Sophie Wilmès announced that her government would use hospital admissions, rather than the number of positive tests, as its key barometer.
"Contrary to other criticized indicators, the number of hospital admissions cannot be interpreted in various ways," Wilmès said. "It is an indisputable indicator that allows us to measure the severity of the situation."
Written by: Mark Landler
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