On April 22, 40 people in Colorado died with coronavirus, marking the state's one-day record for deaths among people with COVID-19 in the spring.

After months of the daily death count falling and then staying steady, it jumped back up in the fall. Colorado matched its record on Nov. 11. A week later, the state posted a one-day total of 42 deaths.

On both Nov. 27 and Dec. 1, the state saw 60 deaths each day among those with coronavirus — Colorado's worst days on record, as of Dec. 11.

The rate of deaths — and new COVID-19 cases — now appear to be leveling off, but Colorado's new cases per day still dwarf the reported numbers from the spring and summer, making Colorado's previous “peaks” look like tiny blips. If the death rate only plateaus, Colorado could still see dozens dead each day.

And if public health officials decide that the Denver metro area — and other regions — need more coronavirus-related restrictions, they have few places left to go other than to impose the kind of stay-at-home orders that drastically recast life and business in the spring.

It's too early to say for sure, but at least as of Dec. 10, fears of Thanksgiving gatherings unleashing more severe virus spread in Colorado appear not to have come true. The rate of new cases appeared to have plateaued, or even slightly declined, according to the state's COVID-19 website data.

The head of Tri-County Health Department said it's “too early to tell” whether Denver metro counties will need new stay-at-home orders.

“I am pleasantly surprised that we haven't seen more of a post-Thanksgiving bounce,” said John Douglas, executive director of the health agency for Adams, Arapahoe and Douglas counties. “I suspect this is due to the red-level capacity limits and the publicity about the gravity of the pandemic that got many of us practicing safer behaviors.”

Douglas referred to the “red” restrictions on Colorado's COVID-19 dial, a level that bans private gatherings and indoor dining at restaurants, and tightens capacity limits at some types of businesses. It took effect Nov. 20 in Denver metro counties and other areas of the state. Now, just over half the state's 64 counties operate in level red.

State public health officials wouldn't say how likely new stay-at-home orders are for metro Denver and other regions. Officials are “pleased to see a plateau in cases, but our numbers still are significantly higher than they were in the spring,” said a statement from the Colorado State Joint Information Center, which takes questions for the state public-health department.

“It appears that the level red mitigation tactics are working. That said, we don't yet know if increases from Thanksgiving will create a spike or what cases will look like after the December holidays,” the statement said. “We need Coloradans to continue to avoid gatherings with other households, wear masks when interacting with people outside of their household and maintain at least 6 feet of distance from others.”

Getting to 'level purple'

Continuing its county-by-county approach to coronavirus restrictions, the state's new revision of the COVID-19 dial — the color-coded set of restrictions counties must follow based on local virus spread — added a “level purple” in November. That's the new term for a stay-at-home order.

While a county qualifying for lower dial levels depends on the local rates of new cases, how many COVID-19 tests come back positive and the trend in hospitalizations, a move into level purple depends more squarely on whether hospital capacity risks being breached. That scenario could be defined a few different ways, according to the public health order behind Colorado's dial, but the simplest is when hospitals approach 90% of their reported “surge capacity.”

Surge capacity means a hospital's ability to transition medical and surgical beds to intensive care unit (ICU) beds, create plans for additional staffing, and manage or delay elective surgeries, according to the State Joint Information Center. “Elective” means a surgery can be delayed without undue risk to health.

Estimates based on data from before Thanksgiving say that if Colorado kept up its levels of mask-wearing, physical distancing and moving activities outside, then hospital and ICU demand may stay within Colorado's estimated surge capacity, according to a Dec. 4 report by the Colorado School of Public Health.

But if Coloradans let their guard down enough over the holidays, demand on hospitals could break those estimates, the report says.

If that happens, the state could reach ICU surge capacity in early January or even late December depending on how closed-off Coloradans keep themselves from contacts.

What's more, local public health agencies, such as Tri-County Health in the metro area, could choose to issue their own stay-at-home orders whether the state's dial requires it or not. Back in March, three metro-area public health departments issued stay-at-home orders, covering Adams, Arapahoe, Douglas, Jefferson and Boulder counties, just before Gov. Jared Polis announced the statewide stay-at-home.

But Tri-County Health probably wouldn't issue its own order at this point in the pandemic, said Douglas, the health chief.

"I think this is unlikely since we now have a state framework (the dial) for all counties contributing to, or at risk from, a breach in hospital capacity to move together, which would be much more effective than movement of individual counties," Douglas said.

Program could loosen limits

Meanwhile, businesses' eyes are set on the state potentially going in the other direction: loosening rather than tightening restrictions, and possibly reopening indoor dining.

As of mid-December, the state public-health department was considering new rules that would let businesses operate at higher capacity than current restrictions normally allow — as long as the businesses stick to strict protocols designed to prevent the virus' spread in their buildings.

Colorado calls it the “business best practice certification” program, modeled after a system Mesa County has “pioneered and has successfully run since the summer,” according to the state public-health department. That's known as the “5-star rating program.”

If the state adopts a similar program, businesses could generally operate based on a level of the state's COVID-19 dial that is one notch less severe than the level the business would otherwise have to follow. For example, a business in a “level orange” county could operate at “level yellow” capacity restrictions.

It was still unclear as of Dec. 11 whether the state will allow businesses in level red counties to operate at level orange, though. That was to be determined depending on data from Mesa County on whether a 5-star program is compatible with the red level, according to the state public-health department.

Asked whether the program would allow indoor dining in level red counties, the State Joint Information Center seemed to indicate it would, saying: “In the draft proposal, if a county qualifies and chooses to develop the 5-star program, indoor dining could be allowed.”

It's also unclear whether the state will roll out the program on schedule.

“While the program might launch on Dec. 18, counties will likely need additional time to implement it,” the information center's statement said.

Vaccine not immediate fix

Even as word of vaccine rollouts spread across the nation, state officials are hoping Coloradans keep in mind that the general population won't have access to a vaccine until the summer — and that's if everything goes according to plan.

The highest-risk health care workers and individuals, and then moderate-risk health care workers and first responders, are expected to have access to the vaccine this winter, according to Colorado's COVID-19 website.

Up next are other high-risk individuals and essential workers in spring, and then comes the general public — anyone age 18-64 without high-risk health conditions — in the summer.

But a speedy timeline depends on “steady shipments of vaccines from the federal government and steady administration of the vaccine by providers around the state,” a governor's office news release said.

An estimated 1 in 40 Coloradans are infectious with COVID-19 — the highest prevalence to date, the School of Public Health's Dec. 4 report says.

And even accounting for the lack of testing early in the pandemic — a factor that makes Colorado's spring tally of COVID-19 cases appear artificially low — Coloradans are now likely becoming infected at more than twice the true rate experienced during spring, according to the report.

The estimated peak in the spring of all asymptomatic and symptomatic infections — not just the cases that are actually reported, generally, through testing — is estimated to have occurred around late March, with nearly 6,000 new infections in one day.

In mid-November, the one-day estimate of new infections had reached around 13,000. The reported number of new cases for Nov. 12 was 6,600.

Even by a conservative estimate, Colorado could see nearly 5,600 deaths associated with COVID-19 by the end of the year, the report says.

As of Dec. 10, Colorado had seen 3,012 deaths due to COVID-19. The total deaths among cases was 3,846 — the number who died with COVID-19 but not necessarily due to it.