What Went Wrong With the Coronavirus Pandemic in Florida

MIAMI — The unexpected and unwelcome coronavirus surge now unfolding in the United States has hit hardest in states that were slow to embrace vaccines. And then there is Florida.

While leaders in that state also refused lockdowns and mask orders, they made it a priority to vaccinate vulnerable older people. Gov. Ron DeSantis, a Republican, opened mass vaccination sites and sent teams to retirement communities and nursing homes. Younger people also lined up for shots.

Mr. DeSantis and public health experts expected a rise in cases this summer as people gathered indoors in the air-conditioning. But what happened was much worse: Cases spiraled out of control, reaching peaks higher than Florida had seen before. Hospitalizations followed. So did deaths, which are considerably higher than the numbers currently reached anywhere else in the country.

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The Florida story is a cautionary tale for dealing with the current incarnation of the coronavirus. The United States has used the vaccines as its primary pandemic weapon. But Florida shows that even a state that made a major push for vaccinations — Florida ranks 21st among states and Washington, D.C., in giving people of all ages at least one shot — can be crushed by the Delta variant, reaching frightening levels of hospitalizations and deaths.

“Clearly the vaccines are keeping most of these people out of the hospital, but we’re not building the herd immunity that people hoped,” Mr. DeSantis said at a news conference this past week. “You’ve got a huge percentage of people — adults — that have gotten shots, and yet you’ve still seen a wave.”

Morgues and crematories are full or getting there. Public utilities in Orlando and Tampa have asked residents to cut back on water usage so liquid oxygen, which is used in water treatment, can be conserved for hospitals. As of Friday, Florida was recording an average of 242 virus deaths a day, nearly as many as California and Texas combined, though a few states still had a higher per capita rate, according to public health data tracked by The New York Times.

Florida’s pandemic data, more scant since the state ended its declared Covid-19 state of emergency in June, reveals only limited information about who is dying. Hospitals have said upward of 90 percent of their patients have been unvaccinated. Exactly why the state has been so hard-hit remains an elusive question. Other states with comparable vaccine coverage have a small fraction of Florida’s hospitalization rate.

The best explanation of what has happened is that Florida’s vaccination rates were good, but not good enough for its demographics. It has so many older people that even vaccinating a vast majority of them left more than 800,000 unprotected. Vaccination rates among younger people were uneven, so clusters of people remained at risk. Previous virus waves, which were milder than in some other states, conferred only some natural immunity.

And Florida is Florida: People have enjoyed many months of barhopping, party-going and traveling, all activities conducive to swift virus spread.

Unlike in places like Oregon, which is clamping down again, adopting even outdoor mask mandates, Mr. DeSantis continues to stay the course, hoping to power through despite the devastating human toll. A Quinnipiac University poll released this past week found that Mr. DeSantis’s approval rating was 47 percent.

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He and other state officials have sought to steer away from measures that could curtail infections, banning strict mask mandates in public schools. The biggest school districts imposed them anyway, and on Friday, a state judge ruled that Florida could not prevent those mandates, a decision the Department of Education plans to appeal.

Florida has experienced more deaths than normal — from all causes, not just Covid-19 — throughout the pandemic. In the early weeks of 2021, with cases surging and the vaccine rollout kicking off, the state averaged 5,600 deaths each week, about a third more than typical for that time of year, according to mortality figures from the Centers for Disease Control and Prevention. The deaths dropped and then went back up.

These excess deaths are important, both because a number of Covid-19 deaths occur outside hospitals, and because the virus may contribute to deaths from other causes as a result of the strain on the health system.

In the first week of August, the state recorded another 5,600 deaths. But because mortality rates normally drop during summer months, the figure was more than 50 percent above what’s typical.

“We’re seeing a ton of people calling us to report the Covid deaths,” said Dr. Stephen J. Nelson, the Polk County medical examiner. “They’re typically young people that have been sick for a while.”

The picture of who is dying, however, is complicated.

About 82 percent of people 65 and older in the state are fully vaccinated, about average for the nation. That has still left a relatively large number of older people — about 819,000 — unvaccinated or only partially vaccinated, said Jason L. Salemi, an epidemiologist at the University of South Florida. If the unvaccinated also take fewer other precautions, he added, that would put them directly in the virus’s path.

“The Delta variant is exceptional at finding vulnerable populations,” he said.

The situation in nursing homes, where infections can spread swiftly, has also been problematic. While vaccination rates among older Floridians as a whole have been good, the rate of nursing home residents who are fully vaccinated — an average of 73.1 percent in each home — is lower than every state but Nevada, according to the C.D.C. About 47.5 percent of nursing home staff members were fully vaccinated as of Aug. 15, the lowest of any state but Louisiana.

Older people are also more likely to have immune deficiencies and comorbidities, making them more susceptible to breakthrough infections and hospitalizations, noted Dr. Peter Chin-Hong, an infectious-disease specialist at the University of California, San Francisco. And some, though not all, data have suggested that immunity against infection has waned in older, vaccinated adults; the Biden administration has indicated that those people will be among the first in line for booster shots.

Then there are the younger people, who now make up a larger share of Florida virus deaths. Before June 25, people under 65 made up 22 percent of deaths. Since then, that proportion has risen to 28 percent.

Fifty-six percent of people between the ages of 12 and 64 in Florida’s 10 largest counties are fully vaccinated, which is consistent with national figures. But in the rest of the state, that figure is only 43 percent, and in 27 counties, less than 1 in 3 residents in the age group is fully vaccinated.

The heart-wrenching deaths of children remain rare. The deaths of young and middle-aged adults have become routine.

“My mom had no prior illnesses — she was strong as an ox,” said Tré Burrows, whose 50-year-old mother, Cindy Dawkins, died from Covid-19 on Aug. 7. “There was literally nothing wrong with her. This just came out of nowhere.”

Ms. Dawkins, a mother of four who worked in a restaurant in Boynton Beach, began to feel ill shortly before her birthday, as the family was en route to celebrate in Orlando. Ms. Dawkins developed a cough and shortness of breath. Four days later, she went to a hospital. Doctors placed her on a ventilator. Thirty-two hours later, she was dead.

Her son said she had not gotten vaccinated because she feared possible side effects.

Those who did not get vaccinated are only part of the explanation behind the surge. Many states slammed by the virus earlier developed deep reservoirs of natural immunity from prior infections, affording them higher levels of protection than would be evident from vaccination rates alone.

Not so in Florida. Compared to other states, Florida was spared as devastating a wintertime wave of cases as ravaged other parts of the country — in part because warm weather made it possible for people to gather outdoors. That was a boon to Florida’s economy and its political leaders but a liability come summertime, when the state was unable to rely on the same wall of natural immunity that is now helping to shield places walloped by the virus this winter.

“People have underestimated the role of natural immunity,” Dr. Chin-Hong said. “Wherever you get hit hard, you kind of get a reprieve from the virus.”

There is some question as to whether Florida’s vaccination rates, especially in places like Miami and Orlando, might have been inflated by tourists getting shots. Regardless, vaccinations appear to be making Covid-19 cases less severe in Miami-Dade County, which had one of the state’s highest vaccination rates, according to research by Dr. Jeffrey Harris, a physician and emeritus professor of economics at the Massachusetts Institute of Technology.

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Beyond that, the hot weather has driven people indoors and attracted hordes of vacationers, creating the conditions for Delta to spread. For all of the focus on vaccines, scientists said, the virus’s path remains highly dependent on how closely people are packed together, where people are congregating and what precautions they are taking.

For other states whose residents will head indoors as temperatures drop in the fall and winter, Florida offers an important lesson, Dr. Dean said: As in the beginning of the pandemic, hospitalizations need to be kept in check.

“The minimum thing we should be achieving is to keep those hospitalization numbers low so it’s not straining the health care system, because that doesn’t just affect Covid patients — it affects everyone,” she said.

And policymakers, she said, must realize that vaccination rates need to be higher than previously thought to control a more contagious virus variant.

“Things can get out of hand,” she said. “I do believe that this could happen in other states, too.”

Lisa Waananen contributed reporting. Kitty Bennett contributed research.