With the arrival of December, it's now clear the winter surge of the pandemic is materializing in many of the ways that the country's top scientists and health care leaders feared.
On all fronts — cases, hospitalizations and deaths — the U.S. toppled records this week.
For the first time, new infections soared above 200,000 cases in a single day.
"What we're seeing now is less of a curve and more of a vertical climb," says Jennifer Nuzzo, an epidemiologist and senior scholar at the Johns Hopkins Center for Health Security. "It's really an extraordinary acceleration."
This week, the daily death toll eclipsed even the worst day of the spring, with nearly 2,900 lives lost on Thursday. And hospitals are teetering under the weight of so many critically ill patients.
"This is going to be the biggest stress test of American health care in history," says Dr. Bruce Siegel, president of , which represents more than 300 safety-net hospitals.
There continues to be very promising news on vaccines — what the National Institutes of Health's Dr. Anthony Fauci calls a "light at the end of the tunnel." Vaccination could truly be weeks away for some people.
But that will not come soon enough to prevent a staggering number of illnesses and deaths in the weeks ahead.
Here's where things stand.
1) U.S. hospitals are staggering under their patient load
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More than 100,000 people in the U.S. are now hospitalized for COVID-19. That is double what it was only a month ago. Harrowing stories of packed intensive care units and exhausted health care workers are emerging from all over. "Hospitals are on the brink of being overwhelmed," says Siegel. "It is across the country. It is not just one region."
The West hit an all-time record for hospitalizations this past week. The South is inching closer to its record from the summer. An encouraging sign is that the number of patients coming into hospitals in the Midwest has slowed down recently, after weeks of non-stop growth. Parts of the Northeast, especially Rhode Island and Connecticut, are under strain, but not nearly at the levels seen during the spring.
Some states are setting up field hospitals to care for the overflow of patients, a solution that Siegel calls "far from ideal." There are critical shortages of staff in hundreds of hospitals. By Christmas time, California Gov. Gavin Newsom warned, 112% of his state's ICU beds could soon be occupied. Hospitals are calling off medical procedures and sending COVID-19 patients who aren't seriously ill home.
It's hard to fathom the situation getting much worse, but that's exactly what is predicted. By the end of December, at least a dozen states are forecast to have more than 60% of their ICU beds filled with COVID-19 patients, a level that is astounding and could lead hospitals to ration care.
2) No more "hot spots." It's everywhere
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Forget hot spots. "We are way beyond that," says Siegel. The country is now averaging nearly 180,000 new cases per day. So many places have raging outbreaks that it's difficult to point to one region that is particularly bad. Rhode Island has now outpaced South Dakota with new cases per capita; New Mexico rivals Wisconsin, which previously had among the worst rates in the country
On the West Coast and in the Northeast, states that had successfully kept the virus in check are under siege. "The coasts are beginning to see the same kind of uptick as the Midwest," says Dr. William Miller, an epidemiologist at Ohio State University. Cases are growing in every region, with the South leading.
The fall surge arrived earlier in the Midwest than elsewhere, but there has been a notable decline since mid November. But Miller doesn't expect that trend to stick: "The Midwest is continuing at a pretty significant rate, with some variation state to state, so it's not good." In fact, Ohio, Illinois and Michigan have added more cases in the past week than any other states, save for Texas and California, which have much larger populations. And the region's rate of infections per capita is still much higher than anywhere else in the country,
Cases are falling in some states, but experts caution that the holiday has disrupted testing and the declines could soon change.
3) Thanksgiving surge? Time will tell
Will Thanksgiving propel another wave of infections across the country? Almost certainly, say health experts interviewed by NPR. While many Americans did travel and gather over the holiday, it's still too soon to see that in the data. "I think we will see a sharp increase," says Nuzzo, who anticipates the impact of the holiday will be more clear by mid December. And remember that the surging hospitalizations right now reflect people who were exposed two weeks ago. Deaths lag by three to four weeks.
"I don't think we've seen the consequences clinically yet," says Dr Thomas Tsai of the Harvard T.H. Chan School of Public Health. "We clearly saw a continued surge after Labor Day," he says, and there may be a surge "stacked on top of another surge."
Unlike previous holidays, there are reasons to think the wave of infections will be worse this time. The virus is more widespread than ever before and people are spending more time indoors this time of year. A worst case scenario, Siegel says, will be that the Thanksgiving surge will be mounting just as "millions of people are being exposed over the Christmas holidays."
4) Deaths are hitting new records, and it will get worse
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This week, the U.S. shattered its single-day record for deaths, which was set in April, logging nearly 2,900 deaths in one day. Nationwide, average daily deaths are pushing 2,000.
Over the summer, death rates fell, in large part because younger people were getting infected, "but eventually the virus finds its way into the groups that are statistically more likely to become hospitalized and to die," says Nuzzo. "Unfortunately, that's what we seem to be seeing right now." Just look at long-term care facilities, which house some of the most vulnerable.
In the final week of November, there was the largest single-week increase in deaths since the summer, according to the COVID Tracking Project. Forecasts offer a harrowing picture of the weeks ahead. Between 9,500 and 19,500 people could die by Christmas, according to an "ensemble" model used by the CDC.
Another model predicts the total U.S. death toll to be more than 435,000 by Feb. 1, with the caveat that the actual total will depend on how much people wear masks and physically distance. Advances in treating patients have contributed to lower death rates, but Nuzzo cautions that's "contingent on there actually being enough resources in the health system."
5) Are new pandemic restrictions working?
In November, states rolled out all kinds of new COVID-19 restrictions. In a few hard-hit places, there are signs that universal mask mandates could be paying off, in particular North Dakota and Iowa, where new infections have dropped. "There seems to be a clear effect in those states," says Siegel. In others, it's not so clear. New Mexico, Oregon and Washington put in place some of the most sweeping restrictions a few weeks ago, but cases are still rising quickly there.
Some states tried to find a middle ground, keeping businesses open to an extent and limiting capacity, including Connecticut and Massachusetts. Both are now seeing record-setting growth and doctors are pleading for tighter restrictions. California tried out curfews and lighter restrictions, but is now moving toward more stringent rules.
It may be too early to tell if the changes are making a big difference. Miller worries these public health interventions have materialized too "late on the upswing to have this dramatic effect." It's very hard to flatten exponential growth, which is why other countries have resorted to lockdowns. Plus no state is an island, says Nuzzo, and it's tough to "keep numbers lower when the rest of the country may be struggling."
6) Twindemic? Not yet
There is one glimmer of positive news: So far flu activity is lower than it has been in previous years. If this trend holds, it will be a godsend for overwhelmed hospitals, which had feared a "twindemic" of flu and the coronavirus.
This isn't entirely surprising because countries in the Southern Hemisphere had a lighter flu season, in part perhaps because face masks and physical distancing guard against influenza. A big push to get more people vaccinated this year may also be playing a role.
"The fact that it's flat so far is good news and I'm optimistic that it won't be terrible," says Miller of OSU. "But flu season can be quite unpredictable." Sometimes the flu doesn't really start to surge until January or even February.
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