COVID-19 pandemic in the United States

The COVID-19 pandemic in the United States is part of the worldwide pandemic of coronavirus disease 2019 (COVID-19). As of November 2020, there were more than 11,400,000 confirmed cases and 249,000 COVID-19-related deaths in the U.S., representing nearly one-fifth of the world's known COVID-19 cases and deaths, and the most cases and deaths of any country. As of November 13, the U.S. death rate had reached 735 per million people, the thirteenth-highest rate globally. On December 31, 2019, China announced the discovery of a cluster of pneumonia cases in Wuhan. The first American case was reported on January 20, and President Donald Trump declared the U.S. outbreak a public health emergency on January 31. Restrictions were placed on flights arriving from China, but the initial U.S. response to the pandemic was otherwise slow, in terms of preparing the healthcare system, stopping other travel, and testing for the virus. Meanwhile, President Trump downplayed the threat posed by the virus and claimed the outbreak was under control. The first known American deaths occurred in February, but were not known to be caused by COVID-19 until April. By mid-April, cases had been confirmed in all fifty U.S. states, the District of Columbia, and all inhabited U.S. territories, except American Samoa. However, on November 9, American Samoa reported its first few cases, meaning that all inhabited U.S. jurisdictions now have confirmed cases of the virus. On March 13, President Trump declared a national emergency. The Trump administration largely waited until mid-March to start purchasing large quantities of medical equipment. In late March, the administration started to use the Defense Production Act to direct industries to produce medical equipment. By April 17, the federal government approved disaster declarations for all states and territories. A second rise in infections began in June 2020, following relaxed restrictions in several states. State and local responses to the outbreak have included prohibitions and cancellation of large-scale gatherings (including festivals and sporting events), stay-at-home orders, and the closure of schools. Disproportionate numbers of cases have been observed among Black and Latino populations, and there were reported incidents of xenophobia and racism against Asian Americans. Clusters of infections and deaths have occurred in many areas. Timeline: December 2019 to January 2020: On December 31, 2019, China reported a cluster of pneumonia cases in Wuhan. On January 6, Health and Human Services offered to send China a team of CDC health experts to help contain the outbreak, but they ignored the offer. According to Robert Redfield, the director of the CDC, the CDC was ready to send in a team of scientists within a week, but the Chinese government refused to let them in, which was a reason the U.S. had a later start in identifying the danger of virus outbreak there and taking early action. On January 7, 2020, the Chinese health authorities confirmed that this cluster was caused by a novel infectious coronavirus. On January 8, the CDC issued an official health advisory via its Health Alert Network (HAN) and established an Incident Management Structure to coordinate domestic and international public health actions. On January 10 and 11, the World Health Organization (WHO) issued technical briefings warning about a strong possibility of human-to-human transmission and urging precautions. On January 14, the WHO said "preliminary investigations conducted by the Chinese authorities have found no clear evidence of human-to-human transmission," although it recommended that countries still take precautions due to the human-to-human transmission during earlier SARS and MERS outbreaks. The CDC issued an update on January 17, noting that person-to-person spread was not confirmed, but was still a possibility. On January 20, it activated its Emergency Operations Center (EOC) to further respond to the outbreak in China. The same day, the WHO and China confirmed that human-to-human transmission had occurred. On January 20, the first report of a COVID-19 case in the U.S. came in a man who returned on January 15 from visiting family in Wuhan, China, to his home in Snohomish County, Washington. He sought medical attention on January 19. The second report came on January 24, in a woman who returned to Chicago, Illinois, on January 13 from visiting Wuhan. The woman passed the virus to her husband, and he was confirmed to have the virus on January 30; at the time it was the first reported case of local transmission in the United States. On January 30, the WHO declared a Public Health Emergency of International Concern (PHEIC)—its highest level of alarm—warning that "all countries should be prepared for containment." The same day, the CDC confirmed the first person-to-person case in America, and President Trump, during a speech about a trade agreement, said the virus outbreak in China was "under control and a very small problem in this country". The next day, January 31, the U.S. declared a public health emergency. Although by that date there were only seven known cases in the U.S., the HHS and CDC reported that there was a likelihood of further cases appearing in the country. February 2020: On February 2, the U.S. enacted travel restrictions to and from China. Additional travel restrictions were placed on foreign nationals who had traveled within the past 14 days in certain countries, with exceptions for families and residents. Americans returning from those regions underwent health screenings and a 14-day quarantine. On February 6, the earliest confirmed American death with COVID-19 occurred in Santa Clara County, California, of a 57-year-old woman. The confirmation was not reported by the CDC until April 21. It was also learned that nine other COVID-19 deaths had occurred in Santa Clara County since February 6. The virus had been circulating undetected at least since early January, and possibly as early as November. On February 25, the Centers for Disease Control and Prevention (CDC) warned the American public for the first time to prepare for a local outbreak. With no vaccine or treatment available, Americans were asked to prepare to take other precautions. Meanwhile, large gatherings that occurred before widespread shutdowns and social distancing measures were put in place, including Mardi Gras in New Orleans on February 25, accelerated transmission. On February 28, a 73-year old resident at a long-term care skilled nursing facility in King County, Washington tested positive for COVID-19. The total documented infections would include 81 residents, 34 staff members, and 14 visitors (129 cases in all), and 23 deaths. March 2020: On March 2, travel restrictions from Iran went into effect. On March 7, the CDC warned that widespread disease transmission may force large numbers of people to seek healthcare, which could overload healthcare systems and lead to otherwise preventable deaths. On March 11, the WHO declared the outbreak to be a pandemic. By this time, the virus had spread to 110 countries and all continents except Antarctica. The World Health Organization's definition of a pandemic "mixed severity and spread", reported Vox, and it held off calling the outbreak a pandemic because many countries at the time were reporting no spread or low spread. On March 11, in testimony to the US Congress House Oversight and Reform Committee, Anthony Fauci of the NIAID stated that mortality from seasonal influenza is 0.1% and that coronavirus has a mortality of 10 times that. By March 12, diagnosed cases of COVID-19 in the U.S. exceeded a thousand. On March 13, travel restriction for the 26 European countries that comprise the Schengen Area went into effect; restrictions for the United Kingdom and Ireland went into effect on March 16. Also on March 16, the White House advised against any gatherings of more than ten people. Since March 19, 2020, the State Department has advised U.S. citizens to avoid all international travel. By the middle of March, all fifty states were able to perform tests with a doctor's approval, either from the CDC or from commercial labs. However, the number of available test kits remained limited, which meant the true number of people infected had to be estimated. On March 19, administration officials warned that the number of cases would begin to rise sharply as the country's testing capacity substantially increased to 50,000-70,000 tests per day. As cases began spreading throughout the nation, federal and state agencies began taking urgent steps to prepare for a surge of hospital patients. Among the actions was establishing additional places for patients in case hospitals became overwhelmed. The Coachella Valley Music and Arts Festival, for instance, was postponed to October and the fairgrounds where it is normally held was turned into a medical center. Manpower from the military and volunteer armies were called up to help construct the emergency facilities. Throughout March and early April, several state, city, and county governments imposed "stay at home" quarantines on their populations to stem the spread of the virus. By March 27, the country had reported over 100,000 cases. April 2020: On April 2, at President Trump's direction, the Centers for Medicare & Medicaid Services (CMS) and CDC ordered additional preventive guidelines to the long-term care facility industry. They included requiring temperature checks for anyone in a nursing home, symptom screenings, and requiring all nursing home personnel to wear face masks. Trump also said COVID patients should have their own buildings or units and dedicated staffing teams. On April 11, the U.S. death toll became the highest in the world when the number of deaths reached 20,000, surpassing that of Italy. On April 19, the CMS added new regulations requiring nursing homes to inform residents, their families and representatives, of COVID-19 cases in their facilities. On April 28, the total number of confirmed cases across the country surpassed one million. On April 30, President Trump announced the administration was establishing a Coronavirus Commission for Safety and Quality in Nursing Homes. May to June 2020: On May 5, media reported COVID-19 "infections" discovered in meat-packing plants in Iowa as "cases". The CDC prepared detailed guidelines for the reopening of businesses, public transit, restaurants, religious organizations, schools, and other public places. The Trump administration shelved the guidelines, but an unauthorized copy was published by the Associated Press on May 7. Six flow charts were ultimately published on May 15, and a sixty-page set of guidelines was released without comment on May 20, weeks after many states had already emerged from lockdowns. By May 27, less than four months after the pandemic reached the U.S., 100,000 Americans had died with COVID-19. State economic reopenings and lack of widespread mask orders resulted in a sharp rise in cases across most of the continental U.S. outside of the Northeast. By June 11, the number of cases in the U.S. had passed two million. July to August 2020: By July 8, the number of cases had passed three million. President Trump was first seen wearing a face mask in public on July 11, months after it had been recommended by public health experts. On July 17, the U.S. recorded what was at the time the highest single-day rise in cases anywhere in the world, with 77,638 infections. By July 23, the number of cases had passed four million. On July 29, the U.S. passed 150,000 deaths. The U.S. passed five million and six million COVID-19 cases by August 8 and August 31, respectively.On July 10, the CDC adopted the Infection Fatality Ratio (IFR), "the number of individuals who die of the disease among all infected individuals (symptomatic and asymptomatic)," as a new metric for disease severity, replacing the Symptomatic Case Fatality Ratio and the Symptomatic Case Hospitalization Ratio. Per the CDC, the IFR "takes into account both symptomatic and asymptomatic cases, and may therefore be a more directly measurable parameter for disease severity for COVID-19." In July, U.S. PIRG and 150 health professionals sent a letter asking the federal government to "shut it down now, and start over". In July and early August, requests multiplied, with a number of experts asking for lockdowns of "six to eight weeks" that they believed would restore the country by October 1, in time to reopen schools and have an in-person election. In August, over 400,000 people attended the 80th Sturgis Motorcycle Rally in Sturgis, South Dakota, and from there, at least 300 people in more than 20 states were infected. September to October 2020: On September 22, the U.S. passed 200,000 deaths, according to data from Johns Hopkins University. By September 25, the number of cases had passed seven million. In early October, an unprecedented series of high-profile U.S. political figures and staffers announced they had tested positive for COVID-19. On October 1, it was announced that Hope Hicks, senior aide to President Trump, had tested positive and had worked closely and traveled with the president to multiple events the previous week. On October 2, Trump announced on Twitter that both he and the First Lady had tested positive for the coronavirus and would immediately quarantine, which also resulted in a number of White House staff and contacts announcing they tested positive. Trump was given an experimental Regeneron product with two monoclonal antibodies and taken to Walter Reed National Military Medical Center, where he was given remdesivir and dexamethasone. Other high-level figures who tested positive included former advisor Kellyanne Conway, Trump campaign manager Bill Stepien, White House press secretary Kayleigh McEnany, RNC Chairwoman Ronna McDaniel, North Carolina Senator Thom Tillis, Utah Senator Mike Lee, former New Jersey governor Chris Christie, and Wisconsin Senator Ron Johnson. On October 6, the vice commandant of the Coast Guard Charles W. Ray tested positive for COVID-19. Other military leaders were quarantined as a result. On October 15, Kamala Harris paused her in-person campaigning after one of her staffers, Elizabeth M. Allen, tested positive. The next day, Redfield said, "If every one of us embraced face coverings, social distancing, hand washing, crowd control, we all did that, we would really control this pandemic. We wouldn't eliminate it, but we would bring it back under control within six to 12 weeks." The U.S. passed eight million and nine million COVID-19 cases by October 16 and October 30, respectively. USA Today studied the aftermath of presidential election campaigning, often to large, unmasked, and often not socially distanced crowds. They concluded that Trump "left a trail of coronavirus cases in his wake." During the fall runup to the November election, Trump conducted several campaign events each week totaling 120,000 attendees over nine weeks. At least five of those locales experienced increases, including a 35% increase in coronavirus cases in the two weeks after Trump's rally in Beltrami County, Minnesota; two other locations showing no discernible change in case counts. One case was traced to a Biden rally in Duluth, Minnesota. November 2020: In November, Secretary Ben Carson, Mark Meadows, Trump's chief of staff, and a Trump campaign official tested positive. Following the election, 130 Secret Service officers or about 10% of the core security team were under quarantine or had tested positive. Corey Lewandowski, eight staffers at the Republican National Committee, and more than a dozen White House aides tested positive in early November. On November 9, President-elect Joe Biden's transition team announced his White House Coronavirus Task Force. This included David A. Kessler, Marcella Nunez-Smith, Vivek Murthy, Luciana Borio, among other names. On the same day, the total number of cases had surpassed 10 million, according to Johns Hopkins University. The total had risen by over 1 million cases in the ten days prior, averaging 102,300 new cases per day during that time span. Pfizer also announced that its COVID-19 vaccine may be up to 90% effective according to clinical trials, causing Pfizer's stock to soar 8% and the Dow Jones to briefly surpass its record high. On November 15, just six days after the U.S. crossed the threshold of 10 million cases, the total number of cases had surpassed 11 million. On November 12, the Trump administration reached an agreement with a number of pharmacies to make the COVID-19 vaccine free once available. The list of pharmacies joining the distribution partnership include retail chains like Rite Aid and Walgreens, supermarket drug stores like Albertsons and Publix, and big box stores like Costco and Walmart. Responses- Medical response: Initial response outside the U.S.: On January 6, a week after the U.S. was informed about the outbreak in China, both the Health and Human Services department and the CDC offered to send a team of U.S. health experts to China. According to CDC Director Robert Redfield, the Chinese government refused to let them in, which contributed to the U.S. getting a late start in identifying the danger of their outbreak and containing it before it reached other countries. U.S. Health Secretary Alex Azar said China did notify the world much sooner than it had after their SARS outbreak in 2003, but it was unexplainably turning away CDC help for this new one. On January 28, the CDC updated its China travel recommendations to level 3, its highest alert. Alex Azar submitted names of U.S. experts to the WHO and said the U.S. would provide $105 million in funding, adding that he had requested another $136 million from Congress. On February 8, the WHO's director-general announced that a team of international experts had been assembled to travel to China and he hoped officials from the CDC would also be part of that mission. The WHO team consisted of thirteen international researchers, including two Americans, and toured five cities in China with twelve local scientists to study the epidemic from February 16–23. The final report was released on February 28. In late January, Boeing announced a donation of 250,000 medical masks to help address China's supply shortages. On February 7, The State Department said it had facilitated the transportation of nearly eighteen tons of medical supplies to China, including masks, gowns, gauze, respirators, and other vital materials. On the same day, U.S. Secretary of State Pompeo announced a $100 million pledge to China and other countries to assist with their fights against the virus., however on March 21, China said it had not received epidemic funding from the U.S. and said so again on April 3. On February 28, the State Department offered to help Iran fight its own outbreak, as Iran's cases and deaths were dramatically increasing. Iran stated however that US sanctions were hampering its battle with the disease, which the US denied and said that Iran has mishandled the crisis. Testing: Testing for SARS-CoV-2 can allow healthcare workers to identify infected people. It is also an important component of tracking the pandemic. There are various types of tests currently on the market; some identify whether or not a patient is currently infected, while others give information about previous exposure to the virus. Contact tracing: Contact tracing is a tool to control transmission rates during the reopening process. Some states like Texas and Arizona opted to proceed with reopening without adequate contact tracing programs in place. Health experts have expressed concerns about training and hiring enough personnel to reduce transmission. Privacy concerns have prevented measures such as those imposed in South Korea where authorities used cellphone tracking and credit card details to locate and test thousands of nightclub patrons when new cases began emerging. Funding for contact tracing is thought to be insufficient, and even better-funded states have faced challenges getting in touch with contacts. Congress has allocated $631 million for state and local health surveillance programs, but the Johns Hopkins Center for Health Security estimates that $3.6 billion will be needed. The cost rises with the number of infections, and contact tracing is easier to implement when the infection count is lower. Health officials are also worried that low-income communities will fall further behind in contact tracing efforts which "may also be hobbled by long-standing distrust among minorities of public health officials". As of July 1, only four states are using contact tracing apps as part of their state-level strategies to control transmission. The apps document digital encounters between smartphones, so the users will automatically be notified if someone they had contact with has tested positive. Public health officials in California claim that most of the functionality could be duplicated by using text, chat, email and phone communications. Drug therapy and vaccine development: There is currently no drug therapy or vaccine approved for treating COVID-19, nor is there any clear evidence that COVID-19 infection leads to immunity (although experts assume it does for some period). As of August 2020, there were over 500 potential therapies for COVID‑19 disease in various stages of preclinical or clinical research, and as of October, there were 321 vaccine candidates in development. Hydroxychloroquine and chloroquine: In early March, President Trump directed the FDA to test certain medications to discover if they had the potential to treat COVID-19 patients. Among those were chloroquine and hydroxychloroquine, which have been successfully used to treat malaria for over fifty years. A small test in France by researcher Didier Raoult had given positive results, although the study was criticized for design flaws, small sample size, and the fact that it was published before peer review. One of Didier's COVID-19 studies was later retracted by the International Journal of Antimicrobial Agents. On March 28, the FDA issued an Emergency Use Authorization (EUA) which allowed certain hospitalized COVID-19 patients to be treated with hydroxychloroquine or chloroquine. On June 15, the FDA revoked the EUA for hydroxychloroquine and chloroquine as potential treatments for COVID-19. The FDA said the available evidence showed "no benefit for decreasing the likelihood of death or speeding recovery". On July 1, the FDA published a review of safety issues associated with the drugs, including fatal cardiac arrhythmias among other side effects. In late July, President Trump continued to promote the use of hydroxychloroquine for COVID-19. This contrasted with the position of the NIH, which stated the drug was "very unlikely to be beneficial to hospitalized patients with COVID-19". Vaccine development: There is no vaccine for coronavirus as of July 2020, however, research is ongoing in a number of countries to create one. More than 70 companies and research teams are working on a vaccine, with five or six operating primarily in the U.S. As of October, 44 are in clinical trials on humans, and 91 preclinical vaccines are being tested on animals. Contributing funds to the research is Bill Gates, whose foundation is focusing entirely on the pandemic, and he anticipates a vaccine could be ready by April 2021. In preparation for large-scale production, Congress set aside more than $3.5 billion for this purpose as part of the CARES Act. Among the labs working on a vaccine is the Walter Reed Army Institute of Research, which has previously studied other infectious diseases, such as HIV/AIDS, ebola, and MERS. By March 18, tests had begun with dozens of volunteers in Seattle, which was sponsored by the U.S. government. Similar safety trials of other coronavirus vaccines will begin soon in the U.S. This search for a vaccine has taken on aspects of national security and global competition. On August 5, 2020, the United States agreed to pay Johnson and Johnson more than $1 billion to create 100 million doses of COVID-19 vaccine. The deal gave the US an option to order an additional 200 million doses. The doses were supposed to be provided for free to Americans if they are used in a COVID-19 vaccination campaign. BIO, a trade group including all makers of coronavirus vaccines except AstraZeneca, tried to persuade HHS Secretary Alex Azar to publish strict FDA guidelines that could help ensure the safety and public uptake of the vaccine. However, politics entered scientific practice, when chief of staff Mark Meadows blocked the FDA when the timing of the provisions would make it impossible for a vaccine to be authorized before the November election. Ultimately, the guidelines emerged from the Office of Management and Budget and were published on the FDA website. Medical supply shortages: The first known case of COVID-19 in the U.S. was confirmed by the CDC on January 21, 2020. The next day, the owner of the medical supply company Prestige Ameritech wrote to HHS officials to say he could produce millions of N95 masks per month, but the government was not interested. In a follow-up letter on January 23, the business owner informed the government that "We are the last major domestic mask company," without success. On February 5, Trump administration officials declined an offer for congressional coronavirus funding. Senator Chris Murphy recalled that the officials, including HHS Secretary Alex Azar, "didn't need emergency funding, that they would be able to handle it within existing appropriations." On February 7 Mike Pompeo announced the administration donated more than 35,000 pounds of "masks, gowns, gauze, respirators, and other vital materials" to China the same day the WHO warned about "the limited stock of PPE (personal protective equipment)". In February, the Department of Commerce published guidance advising U.S. firms on compliance with Beijing's fast-track process for the sale of "critical medical products", which required the masks shipped overseas meet U.S. regulatory standards. According to Chinese customs disclosures, more than 600 tons of face masks were shipped to China in February. In early March, the country had about twelve million N95 masks and thirty million surgical masks in the Strategic National Stockpile (SNS), but the DHS estimated the stockpile had only 1.2% of the roughly 3.5 billion masks that would be needed if COVID-19 were to become a "full-blown" pandemic. A previous 2015 CDC study found that seven billion N95 respirators might be necessary to handle a "severe respiratory outbreak". As of March, the SNS had more than 19,000 ventilators (16,660 immediately available and 2,425 in maintenance), all of which dated from previous administrations. Vessel manifests maintained by U.S. Customs and Border Protection showed a steady flow of the medical equipment needed to treat the coronavirus being shipped abroad as recently as March 17. Meanwhile FEMA said the agency "has not actively encouraged or discouraged U.S. companies from exporting overseas" and asked USAID to send back its reserves of protective gear for use in the U.S. President Trump evoked the Defense Production Act to prohibit some medical exports. Some analysts warned that export restrictions could cause retaliation from countries that have medical supplies the United States needs to import. By the end of March, states were in a bidding war against each other and the federal government for scarce medical supplies such as N95 masks, surgical masks, and ventilators. Meanwhile, as states scrambled to purchase supplies at inflated prices from third party distributors (some of which later turned out to be defective), hundreds of tons of medical-grade face masks were shipped by air freight to foreign buyers in China and other countries. Medical organizations such as the American Medical Association and American Nurses Association implored Trump to obtain medical supplies, because they were "urgently needed". That led President Trump to sign an order setting motion parts of the Defense Production Act, first used during the Korean War, to allow the federal government a wide range of powers, including telling industries on what to produce, allocating supplies, giving incentives to industries, and allowing companies to cooperate. Trump then ordered auto manufacturer General Motors to make ventilators. During this period, hospitals in the U.S. and other countries were reporting shortages of test kits, test swabs, masks, gowns and gloves, referred to as PPE. The Office of Inspector General, U.S. Department of Health and Human Services released a report regarding their March 23–27 survey of 323 hospitals. The hospitals reported "severe shortages of testing supplies", "frequently waiting 7 days or longer for test results", which extended the length of patient stays, and as a result, "strained bed availability, personal protective equipment (PPE) supplies, and staffing". The hospitals also reported, "widespread shortages of PPE" and "changing and sometimes inconsistent guidance from federal, state and local authorities". At a press briefing following the release of the report President Trump called the report "wrong" and questioned the motives of the author. Later he called the report "another fake dossier". In early April, there was a widespread shortage of PPE, including masks, gloves, gowns, and sanitizing products. The difficulties in acquiring PPE for local hospitals led to orders for gowns and other safety items being confiscated by FEMA and diverted to other locations, which meant that in some cases states had to compete for the same PPE. The shortages led in one instance of a governor asking the New England Patriots of the NFL to use their private plane to fly approximately 1.2 million masks from China to Boston. At that time, Veterans Affairs (VA) employees said nurses were having to use surgical masks and face shields instead of more protective N95 masks. In May, Rick Bright, a federal immunologist and whistleblower, testified that the federal government had not taken proper action to acquire the needed supplies. An unexpectedly high percentage of COVID-19 patients in the ICU required dialysis as a result of kidney failure, about 20%. In mid-April, employees at some hospitals in New York City reported not having enough dialysis machines, were running low on fluids to operate the machines, and reported a shortage of dialysis nurses as many were out sick with COVID-19 due to lack of sufficient PPE. On May 14, a Trump administration official told reporters "we do anticipate having 300 million” N95 masks by autumn; however, at the end of September, there were only 87.6 million N95 masks in the government stockpile. Supply problems persisted in August 2020, when a survey reported 42% of nurses were experiencing widespread or intermittent shortages of personal protective equipment, with 60% using single-use equipment for five or more days. A September report by National Public Radio found some items were in short supply but others widely available, depending on the difficulty of manufacturing. The DPA was effective in producing ventilators but less so in producing N95s. As of September, the DPA had stimulated N95 production mainly by existing major manufacturers and less so by smaller companies. Additionally, the DPA's provision that exempts manufacturers from antitrust laws had not yet been used to encourage collaboration in N95 production. In response to demand, a number of domestic businesses retooled and due to lack of federal coordination ended up producing a glut of hand sanitizer and face shields, some losing money due to the oversupply. The federal government used the Defense Production Act to get a small number of large manufacturers such as 3M and Honeywell to increase production of the more difficult to manufacture N95 masks, but supply was still falling hundreds of millions of units short of demand. NPR found the shortage could be resolved by providing government guarantees to small and medium-sized manufacturers so they could increase production of N95 masks without the risk of losing money or going out of business due to oversupply or drop in demand when the pandemic ends. Instead, President Trump has denied the PPE shortages exist, calling them "fake news" in April and in September saying "we've opened up factories, we've had tremendous success with face masks and with shields". Demand has also increased since the early weeks of the pandemic as various industries reopened, including medical and dental offices, construction, and trucking. The 2020 California wildfires also increased demand for N95 masks for agricultural and other outdoor workers, due to state regulations requiring protection during poor air quality conditions. Exceeding hospital capacity: Uncontrolled community spread led some medical facilities to refuse new patients or start transferring patients out. In March and April, this happened in the Detroit, Michigan area and New York City area; Yakima, Washington in June; and in July it happened in Houston, the Boise, Idaho area, Lake Charles and Lafayette, Louisiana, and at dozens of hospitals across Florida. By August, some hospitals in Mississippi were transferring patients out of state. Arizona declared crisis standards of care in July 2020, allowing hospitals to legally provide treatment normally considered substandard to some patients in order to save others. Federal, state, and local governments: The federal government of the United States responded to the pandemic with various declarations of emergency, which resulted in travel and entry restrictions. They also imposed guidelines and recommendations regarding the closure of schools and public meeting places, lockdowns, and other restrictions intended to slow the progression of the virus, which state, territorial, tribal, and local governments have followed. Effective July 15, 2020, the default data centralization point for COVID-19 data in the U.S. is switching from the Centers for Disease Control and Prevention to Department of Health and Human Services. However, "hospitals may be relieved from reporting directly to the Federal Government if they receive a written release from the State stating the State will collect the data from the hospitals and take over Federal reporting." Military: On February 3, an unclassified Army briefing document on the coronavirus projected that in an unlikely "black swan" scenario, "between 80,000 and 150,000 could die." The theory correctly stated that asymptomatic people could "easily" transmit the virus, a belief that was presented as outside medical consensus at the time of the briefing. The briefing also stated that military forces could be tasked with providing logistics and medical support to civilians, including "providing PPE (N-95 Face Mask, Eye Protection, and Gloves) to evacuees, staff, and DoD personnel". In mid-March, the government began having the military add its health care capacity to impacted areas. The United States Army Corps of Engineers (USACE), under the authority of Federal Emergency Management Agency (FEMA), leased private buildings nationwide. They included hotels, college dormitories, and larger open buildings, which were converted into temporary hospitals. The Jacob K. Javits Convention Center in New York City was quickly transformed into a 2,000-bed care facility on March 23, 2020. The Army also set up field hospitals in various affected cities. Some of these facilities had ICUs for COVID-19 patients, while others served non-coronavirus patients to allow established hospitals to concentrate on the pandemic. At the height of this effort, U.S. Northern Command had deployed nine thousand military medical personnel. On March 18, in addition to the many popup hospitals nationwide, the Navy deployed two hospital ships, USNS Mercy and USNS Comfort, which were planned to accept non-coronavirus patients transferred from land-based hospitals, so those hospitals could concentrate on virus cases. On March 29, citing reduction in on-shore medical capabilities and the closure of facilities at the Port of Miami to new patients, the U.S. Coast Guard required ships carrying more than fifty people to prepare to care for sick people on board. On April 6, the Army announced that basic training would be postponed for new recruits. Recruits already in training would continue what the Army is calling "social-distanced-enabled training". However, the military, in general, remained ready for any contingency in a COVID-19 environment. By April 9, nearly 2,000 service members had confirmed cases of COVID-19. In April, the Army made plans to resume collective training. Social distancing of soldiers is in place during training, assemblies, and transport between locations. Temperatures of the soldiers are taken at identified intervals, and measures are taken to immediately remediate affected soldiers. On June 26, 2020, the VA reported 20,509 cases of COVID-19 and 1,573 deaths among patients (plus more than two thousand cases and 38 deaths among its own employees). As of July 2020, additional Reserve personnel are on 'prepare-to-deploy orders' to Texas and California. Private sector: Many janitors and other cleaners throughout the United States reported that they were not given adequate time, resources or training to clean and to disinfect institutions for COVID-19. One pilot reported that less than 10 minutes was allotted to clean entire airplanes between arrival and departure, which did not allow cleaners to disinfect the tray tables and bathrooms, for which the practice was to wipe down only those that "looks dirty." Cleaning cloths and wipes were reused, and disinfecting agents, such as bleach, were not provided. Employees also complained that they were not informed if coworkers tested positive for the virus. The Occupational Safety and Health Administration (OSHA), the federal agency that regulates workplace safety and health, investigated a small fraction of these complaints. Mary Kay Henry, president of Service Employees International Union, which represents 375,000 American custodians, explained that "reopenings happened across the country without much thoughtfulness for cleaning standards." She urged better government standards and a certification system. Public response- Partisan divide: Polling showed a significant partisan divide regarding the outbreak. In February, similar numbers of Democrats and Republicans believed COVID-19 was "a real threat": 70% and 72%, respectively. By mid-March, 76% of Democrats viewed COVID-19 as "a real threat", while only 40% of Republicans agreed. In mid-March, various polls found Democrats were more likely than Republicans to believe "the worst was yet to come" (79% to 40%), to believe their lives would change in a major way due to the outbreak (56% to 26%), and to take certain precautions against the virus (83% to 53%). The CDC was the most trusted source of information about the outbreak (85%), followed by the WHO (77%), state and local government officials (70-71%), the news media (47%), and President Trump (46%). Political analysts anticipated that the pandemic may negatively affect Trump's chances of re-election. In March 2020, when social distancing practices began, the governors of many states experienced sharp gains in approval ratings. Trump's approval rating increased from 44% to 49% in Gallup polls, but fell to 43% by mid-April. At that time, Pew Research polls indicated that 65% of Americans felt Trump was too slow in taking major steps to respond to the coronavirus outbreak. On April 16, Pew Research polls indicated that 32% of Americans worried state governments would take too long to re-allow public activities, while 66% feared the state restrictions would be lifted too quickly. An April 21 poll found a 44% approval rate for the president's handling of the pandemic, compared to 72% approval for state governors. A mid-April poll estimated that President Trump was a source of information on the pandemic for 28% of Americans, while state or local governments were a source for 50% of Americans. 60% of Americans felt Trump was not listening enough to health experts in dealing with the outbreak. A May 2020 poll concluded that 54% of people in the U.S. felt the federal government was doing a poor job in stopping the spread of COVID-19 in the country. 57% felt the federal government was not doing enough to address the limited availability of COVID-19 testing. 58% felt the federal government was not doing enough to prevent a second wave of COVID-19 cases later in 2020. A poll conducted from May 20 and 21 found that 56% of the American public were "very" concerned about "false or misleading information being communicated about coronavirus", while 30% were "somewhat" concerned. 56% of Democrats said the top source of false or misleading information about the coronavirus was the Trump administration, while 54% of Republicans felt the media was the top source of false or misleading information. The same poll found that 44% of Republicans and 19% of Democrats believed a debunked conspiracy theory that Bill Gates was plotting to use a COVID-19 vaccine to inject microchips into the population. Studies using GPS location data and surveys found that Republicans engaged in less social distancing than Democrats during the pandemic. Controlling for relevant factors, Republican governors were slower to implement social distance policies than Democratic governors. Protests: Beginning in mid-April 2020, there were protests in several U.S. states against government-imposed lockdowns in response to the COVID-19 pandemic in the United States. The protests, mostly organized by conservative groups and individuals, decried the economic and social impact of stay-at-home orders, business closures, and restricted personal movement and association, and demanded that their respective states be "re-opened" for normal business and personal activity. The protests made international news and were widely condemned as unsafe and ill-advised. They ranged in size from a few hundred people to a few thousand, and spread on social media with encouragement from U.S. President Donald Trump. By May 1, there had been demonstrations in more than half of the states; many governors began to take steps to lift the restrictions as daily new infections began decreasing due to social distancing measures. Starting in late May, large-scale protests against police brutality in at least 200 U.S. cities in response to the killing of George Floyd raised concerns of a resurgence of the virus due to the close proximity of protesters. Fauci said it could be a "perfect set-up for the spread of the virus", and that "masks can help, but it's masks plus physical separation." International views of the United States: In September 2020, Pew Research Center found that the global image of the United States had suffered in many foreign nations. In some nations, the United States' favorability rating had reached a record low since Pew began collecting this data nearly 20 years ago. Across 13 different nations, a median of 15% of respondents rated the US response to the COVID-19 pandemic positively. Other: The outbreak prompted calls for the United States to adopt social policies common in other wealthy countries, including universal health care, universal child care, paid sick leave, and higher levels of funding for public health. It has also generated support in the U.S. House of Representatives for the Local Journalism Sustainability Act, presumably because more people are recognizing the need for local journalism while their funding continues to shrink. Impacts- Economic: The pandemic, along with the resultant stock market crash and other impacts, has led a recession in the United States following the economic cycle peak in February 2020. The economy contracted 4.8 percent from January through March 2020, and the unemployment rate rose to 14.7 percent in April. The total healthcare costs of treating the epidemic could be anywhere from $34 billion to $251 billion according to analysis presented by The New York Times. A study by economists Austan Goolsbee and Chad Syverson indicated that most economic impact due to consumer behavior changes was prior to mandated lockdowns. During the second quarter of 2020, the U.S. economy suffered its largest drop on record, with GDP falling at an annualized rate of 32.9%. As of June 2020, the U.S. economy was over 10% smaller than it was in December 2019. In September, Bain & Company reported on the tumultuous changes in consumer behavior before and during the COVID-19 pandemic. Potentially permanently, they found acceleration towards e-commerce, online primary healthcare, livestreamed gym workouts, and moviegoing via subscription television. Concurrent searches for both low-cost and premium products, and a shift to safety over sustainability, occurred alongside rescinded bans and taxes on single-use plastics, and losses of three to seven years of gains in out-of-home foodservice. OpenTable estimated in May that 25% of American restaurants would close their doors permanently. The economic impact and mass unemployment caused by the COVID-19 pandemic has raised fears of a mass eviction crisis, with an analysis by the Aspen Institute indicating 30–40 million are at risk for eviction by the end of 2020. According to a report by the Yelp, about 60% of U.S. businesses that have closed since the start of the pandemic will stay shut permanently. Rural communities: In May daily infection and death rates were still higher per capita in densely populated cities and suburbs, but were increasing faster in rural counties. Of the 25 counties with the highest per capita case rates in May, 20 had a meatpacking plant or prison where the virus was able to spread unchecked. By July rural communities with populations less than 50,000 had some of the highest rates of new daily cases per capita. Factors contributing to the spread of COVID-19 in these communities are high rates of obesity, the relatively high numbers of elderly residents, immigrant laborers with shared living conditions and meat-processing plants. Social: The pandemic has had far-reaching consequences beyond the disease itself and efforts to contain it, including political, cultural, and social implications. Disproportionate numbers of cases have been observed among Black and Latino populations, and there were reported incidents of xenophobia and racism against Asian Americans. Of four studies published in September, three found clear disparities due to race and the fourth found slightly better survival rates for Hispanics and Blacks. As of September 15, Blacks had COVID-19 mortality rates more than twice as high as the rate for Whites and Asians, who have the lowest rates. CNN reported in May that the Navajo Nation had the highest rate of infection in the United States. Additionally, a study published by the New England Journal of Medicine in July revealed that the effect of stress and weathering on minority groups decreases their stamina against COVID. In September, NPR reviewed its previously reported data from the COVID Tracking Project finding again that COVID-19 infected and killed people of color at higher rates than Whites and more than their share of the population. Blacks died 1.5 times and in some states 2.5 times their share of the population. Hispanics and Latinos died more often in 19 states, and were infected more frequently in 45 states. Native American and Alaskan Native deaths and cases were disproportionally high in 21 states and 5 times more in some states, with insufficient data in some states. White non-Hispanics died at a lower rate than their share of the population in 36 states and D.C. By April, closed schools affected more than 55 million students. Elections: The pandemic prompted calls from voting rights groups and some Democratic Party leaders to expand mail-in voting. Republican leaders generally opposed the change, though Republican governors in Nebraska and New Hampshire adopted it. Some states were unable to agree on changes, and a lawsuit in Texas resulted in a ruling (which is under appeal) that would allow any voter to mail in a ballot. Responding to Democratic proposals for nation-wide mail-in voting as part of a coronavirus relief law, President Trump said "you'd never have a Republican elected in this country again" despite evidence the change would not favor any particular group. Trump called mail-in voting "corrupt" and said voters should be required to show up in person, even though, as reporters pointed out, he had himself voted by mail in the last Florida primary. Though vote fraud is slightly higher than in-person voter fraud, both instances are rare, and mail-in voting can be made more secure by disallowing third parties to collect ballots and providing free drop-off locations or prepaid postage. April 7 elections in Wisconsin were impacted by the pandemic. Many polling locations were consolidated, resulting in hours-long lines. County clerks were overwhelmed by a shift from 20 to 30% mail-in ballots to about 70%, and some voters had problems receiving and returning ballots in time. Despite the problems, turnout was 34%, comparable to similar previous primaries. According to a study published in Science Advances, areas with higher levels of COVID-19 fatalities were less likely to support Trump and Republican candidates for Congress. Preparations made after previous outbreaks: The United States has been subjected to pandemics and epidemics throughout its history, including the 1918 Spanish flu, the 1957 Asian flu, and the 1968 Hong Kong flu pandemics. In the most recent pandemic prior to COVID-19, the 2009 swine flu pandemic took the lives of more than 12,000 Americans and hospitalized another 270,000 over the course of approximately a year. According to the Global Health Security Index, an American-British assessment which ranks the health security capabilities in 195 countries, the U.S. in 2020 was the "most prepared" nation. Statistics: The CDC publishes official numbers, originally every Monday, Wednesday, and Friday and reporting several categories of cases: individual travelers, people who contracted the disease from other people within the U.S., and repatriated citizens who returned to the U.S. from crisis locations, such as Wuhan, where the disease originated, and the cruise ship Diamond Princess. However, multiple sources noted early in the pandemic that statistics on confirmed coronavirus cases were misleading, since the shortage of tests meant the actual number of cases was much higher than the number of cases confirmed. The number of deaths confirmed to be due to coronavirus was likely to be an undercount for the same reason. Excess mortality comparing deaths for all causes versus the seasonal average is more reliable. It counts additional deaths which are not explained by official reported coronavirus mortality statistics. The CDC says it will issue an official estimate of coronavirus deaths in 2021—current estimates may not be reliable. The following numbers are based on CDC data, which is incomplete. In most U.S. locations, testing for some time was performed only on symptomatic people with a history of travel to Wuhan or with close contact to such people. CDC testing protocols did not include non-travelling patients with no known contact with China until February 28. Measuring case and mortality rates: By March 26, the United States, with the world's third-largest population, surpassed China and Italy as the country with the highest number of confirmed cases in the world. By April 25, the U.S. had more than 905,000 confirmed coronavirus cases and nearly 52,000 deaths, giving it a mortality rate around 5.7 percent. (In comparison, Spain's mortality rate was 10.2 percent and Italy's was 13.5 percent.) In April, more than 10,000 American deaths had occurred in nursing homes. Most nursing homes did not have easy access to testing, making the actual number unknown. Subsequently, a number of states including Maryland and New Jersey reported their own estimates of deaths at nursing homes, ranging from twenty to fifty percent of the states' total deaths. A PNAS report in September confirmed that the virus is much more dangerous for the elderly than the young, noting that about 70% of all U.S. COVID-19 deaths had occurred to those over the age of 70. In April, President Trump had established a Coronavirus Commission for Safety and Quality in Nursing Homes. As of early August 2020, among the 45 countries that had over 50,000 cases, the U.S. had the eighth highest number of deaths per-capita. Its case fatality ratio, however, was significantly better where it ranked 24th in the world, with 3.3% of its cases resulting in death. Several studies suggest both that the number of infections is far higher than officially reported, and thus that the infection fatality rate is far lower than the case fatality rate. The CDC estimates that 40 percent of people infected will never show symptoms (asymptomatic), although there is a 75% chance they can still spread the disease. And while children have a lower risk of becoming ill or dying, the CDC warns that they can still function as asymptomatic carriers and transmit the virus to adults. The American Academy of Pediatrics's weekly report from when states started reporting to September 17 tracked 587,948 child COVID-19 cases, 5,016 child hospitalizations, and 109 child deaths. In counting actual confirmed cases, some have questioned the reliability of totals reported by different countries. Measuring rates reported by countries such as China or Iran have been questioned as potentially inaccurate. In mid-April 2020, China revised its case totals much higher and its death toll up by 50% for Wuhan, partly as a result of a number of countries having questioned China's official numbers. Iran's rates have also been disputed, as when the WHO's reports about their case counts were contradicted by top Iranian health officials. Within the U.S., there are also discrepancies in rates between different states. After a group of epidemiologists requested revisions in how the CDC counts cases and deaths, the CDC in mid-April updated its guidance for counting COVID-19 cases and deaths to include both confirmed and probable ones, although each state can still determine what to report. Without accurate reporting of cases and deaths, however, epidemiologists have difficulty in guiding government response. Death projections: On March 31, 2020, the CDC projected that, even under the best-case scenario, eventually at least 100,000 Americans would die of coronavirus. This death toll was reached within two months after the CDC made its projection. Then, at the end of May, the CDC correctly projected the death toll would surpass 115,000 by June 20, by which point it had reached ~112,000. The CDC ensemble forecast on July 31 also correctly predicted at least 168,000 total deaths by August 22, by which point it had reached ~165,000. As of October 17, 2020, the CDC projected the cumulative number of deaths to reach 230,000-250,000 by November 14, four weeks from the estimate. For comparison, the CDC estimated deaths in the U.S. from the 1918 Spanish Flu, the 1957–1958 influenza pandemic, and the 1968 Hong Kong flu were 675,000; 116,000; and 100,000 respectively. Impact of face coverings: The Institute for Health Metrics and Evaluation (IHME) predicted that universal wearing of face masks could prevent 17,000–28,000 deaths between June 26 and October 1, 2020. An IHME model in late August 2020 projected that nationwide deaths would exceed 317,000 by December 1 if people did not wear masks, but 67,000 lives could be saved if at least 95% of people wear masks in public. Similarly, an IHME model in late October 2020 projected 1 million deaths by the end of February 2021 if only half of Americans wear masks and if states do not mandate social distancing, while hundreds of thousands of lives could be saved with universal mask-wearing and with state lockdowns when outbreaks reach certain thresholds.