It's hard to overstate how much the U.S. coronavirus outbreak has deteriorated this past week, with each day ushering in new, disturbing records.
On Thursday, there were more than 150,000 new infections. It was only last week that the U.S. reached a record of more than 100,000 infections in a single day for the first time ever.
"This is the worst the pandemic has been," says Dr. Preeti Malani, Chief Health Officer in the Divisions of Infectious Diseases and Geriatric Medicine at the University of Michigan.
Daily cases have gone up more than 70% nationwide, since the beginning of November. Another way to put it: one in every 378 people in the U.S. tested positive for COVID-19 over the past week.
"You have the entire country seeing surges and you're seeing it in rural areas and in urban areas. It's a reflection of the fact that COVID is so widespread."
While the week brought some promising news about a potential vaccine, there are dark months ahead of the country, as people spend more time indoors and travel for the holidays.
"This is a really dangerous time," says Malani, who is also a fellow with the Infectious Diseases Society of America. "It's not too late. We can still turn things around, but it's going to require a big effort."
Here are some of the big takeaways from the week in COVID-19:
1. Hospitals have never been so full
Across the country, more than 67,000 COVID-19 patients are now hospitalized. Compare that to the spring and summer peaks, when hospitalizations leveled off at close to 60,000 patients. Experts say there is no indication that the current trend will slow down. In fact, quite the opposite. Given the record-setting growth of cases, it's likely that hospitalizations will pick up speed in the coming weeks, as some patients end up seriously ill.
The Midwest and the South (including Texas) account for more than two-thirds of all COVID-19 hospitalizations. Earlier surges were concentrated in a few places, but this fall spike is hitting lots of states all at once. From Utah to Wisconsin to Iowa, hospitals are warning that the situation is not sustainable if the volume of new patients doesn't slow down. An NPR analysis found at least 18 states have crossed into a dangerous zone where their hospitals could be at risk of reaching capacity, which could eventually require extreme measures like rationing care.
2. Parts of Midwest and the West are 'at the breaking point'
For months, the virus has pummeled the Midwest. There are no signs that is subsiding. In fact, new daily cases have more than doubled over the past two weeks in that region, which is made up of 12 states. Illinois has added far more cases over the past week than any other state — 80,000, which is almost twice as many as California.
The Dakotas, Wisconsin, Iowa and Nebraska have the highest rate of infections per capita in the U.S. Wisconsin is now averaging more cases a day than New York City did at the height of its outbreak.
In the West, Utah is setting new records in cases as the state's governor says, "We're at the breaking point." Parts of Texas, in particular El Paso, are in crisis and carting in mobile morgues because of rising deaths. Montana is reeling after months of rising case counts, and doctors are warning the region is on the "brink of disaster."
3. States tiptoe toward new restrictions, but gaping holes remain
From Iowa to Connecticut, state leaders have started tightening restrictions and rolling back their reopening plans. Parts of California have stopped all indoor dining, including San Francisco. Minnesota has told restaurants to stop in-person service at 10 pm, saying that infections spread the most quickly later in the evening.
Indiana is putting caps on gathering sizes, limiting them to 25 people in the hardest hit counties (though religious services are exempted). Meanwhile, New York has put in place a nightly curfew for indoor dining, gyms and bars. In Illinois, state leaders have warned a shutdown could be on the way; Chicago has issued a stay-at-home advisory, although it's unclear how that will be enforced.
Some states are taking things further: On Friday, New Mexico announced a stay-at-home order that will take effect next week and non-essential businesses will close in person service. Oregon's governor made a similar decision.
Public health experts caution that states need consistent policies, instead of a patchwork of restrictions that only chip away at certain high-risk settings. As Anne Rimoin of UCLA told NPR recently: "This is a hard moment where we don't necessarily get to have our cake and eat it too. You want to have bars open, then you might not be able to have schools open. You want to not wear a mask, you're going to see more COVID."
4. New mask mandates — kinda?
Some state leaders that resisted mandating mask use are starting to bend, but experts say these new measures don't go far enough.
Utah's Republican governor issued a statewide mask mandate. Iowa's Governor Kim Reynolds has implemented a limited mask requirement, mostly aimed at large gatherings. Nebraska's new mandate also only requires people to wear a mask when they spend an average of 15 minutes together and are within six feet of each other.
And there are quite a few states that don't have a sweeping statewide mask mandate. And even those that do, compliance and enforcement are issues.
"We need to make mask-wearing obligatory and put a lot of stress once again on not having group assemblies of any kind," says Dr. William Schaffner, medical director of the National Foundation for Infectious Diseases.
5. After a long plateau, deaths are now going up
Since the summer, one of the few hopeful developments has been that fewer people are dying. That trend is shifting now. After averaging below 900 since Sept. 1, average daily deaths broke above 1,000 this week. Daily deaths have increased about 23% over the past week. The current average is still about half of what the U.S recorded during the spring peak, but public health experts caution that deaths lag behind hospitalizations by a few weeks.
The latest prediction from the modeling group at the University of Washington predicts that more than 2,000 people will die each day from COVID-19 by mid January, and that the total U.S death toll will reach about 440,000 by March. The modelers say that changes in behavior could still prevent that from happening.
6. Even East and West coast states, that had kept cases low, are heading into trouble
Parts of the country that kept the virus in check for months are starting to see growth. Look at the Northeast, where daily cases have close to doubled over the past two weeks. New Jersey and Massachusetts are still averaging about half as many cases a day as hard-hit states like Minnesota and Michigan.
On the opposite side of the country, in Washington state, cases have more than doubled since the beginning of November. Oregon is not far behind. California is a bit more mixed. The per-capita rate remains lower than almost any other state, but there are pockets of alarming growth, particularly in the San Francisco Bay area and around San Diego.
7. Rural and suburban counties outpace metro counties in per capita infections
The pandemic was slow in reaching rural America, but it's hold hasn't loosened since getting to those communities. The rate of infections in the most rural counties remains higher than anywhere else and well-above the large urban areas. Much of the stress on hospitals in parts of the Midwest like Michigan, Kansas and Utah comes from rural areas, which rely on transferring patients in need of care to the metro areas. "In Michigan, a lot of the new cases are coming from the west side of the state and from less populated areas,"says Dr. Malani.
In the Dakotas, the numbers are nothing short of staggering. One in 1,629 residents of South Dakota is hospitalized for COVID-19, the highest per capita rates in the country. The mortality rate in rural communities is also higher than urban areas. Public health experts say there are similar patterns with other public health crises, like HIV. It can take longer to reach rural America, but once there it's harder to root out the problem.
8. Long-term care facilities are getting hammered again
More than 40% of all COVID-19 deaths are linked to long-term care facilities. These populations are exceptionally vulnerable because of their age and how easily an outbreak can balloon in congregate living situations. There were horrifying examples of the coronavirus tearing through nursing homes earlier in the pandemic. Now, the COVID Tracking Project finds that cases are again surging in these facilities, with more than 24,000 cases in these facilities last week. Indiana, Ohio, Pennsylvania and Texas account for about one third of all nursing home deaths this week.