COVID-19 pandemic in the United States

COVID-19 pandemic in the United States
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About this image
COVID-19 cases per 100,000 people by state, as of January 15
COVID-19 rolling 14day Prevalence in the United States by county.svg
Map of the outbreak in the United States by confirmed new infections per 100,000 people (14 days preceding January 17)
  1,000+
  500–1,000
  200–500
  100–200
  50–100
  20–50
  10–20
  0–10
  No confirmed new cases or no/bad data
Disease COVID-19
Virus strain SARS-CoV-2
Location United States
First outbreak Wuhan, Hubei, China[1]
Index case Chicago, Illinois (earliest known arrival)[2]
Everett, Washington (first case report)[3]
Arrival date January 13, 2020[4]
(1 year and 5 days ago)
Confirmed cases
Recovered
  • 10,121,103[8]
Deaths
Fatality rate
Government website
coronavirus.gov

The COVID-19 pandemic in the United States is part of the worldwide pandemic of coronavirus disease 2019 (COVID-19). More than 23,900,000 confirmed cases have been reported since January 2020, resulting in more than 397,000 deaths, the most of any country and the eleventh-highest on a per capita basis.[6][9] The U.S. has nearly a quarter of the world's cases and a fifth of all deaths. COVID-19 became the third leading cause of death in the U.S. in 2020, behind heart disease and cancer.[10]

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,[11][12] but the initial U.S. response to the pandemic was otherwise slow, in terms of preparing the healthcare system, stopping other travel, and testing.[13][14][15][a] Meanwhile, Trump downplayed the threat posed by the virus and claimed the outbreak was under control.[17]

The first known American deaths occurred in February.[18][b] On March 6, Trump signed the Coronavirus Preparedness and Response Supplemental Appropriations Act, which provided $8.3 billion in emergency funding for federal agencies to respond to the outbreak.[19] On March 13, President Trump declared a national emergency.[20] In mid-March, the Trump administration started to purchase large quantities of medical equipment,[21] and in late March, it invoked the Defense Production Act to direct industries to produce medical equipment.[22] By April 17, the federal government approved disaster declarations for all states and territories. By mid-April, cases had been confirmed in all fifty U.S. states, and by November in all inhabited U.S. territories. A second rise in infections began in June 2020, following relaxed restrictions in several states.[23]

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 school closures.[24] Disproportionate numbers of cases have been observed among Black and Latino populations,[25][26][27] and there were reported incidents of xenophobia and racism against Asian Americans.[28] Clusters of infections and deaths have occurred in many areas.[c]

Timeline

December 2019 to February 2020

In late November 2019, coronavirus infections had first broken out in Wuhan, China.[31][32] China publicly reported the cluster on December 31, 2019.[3] On January 6, U.S. Health and Human Services offered to send China a team of Centers for Disease Control and Prevention (CDC) health experts to help contain the outbreak, but China ignored the offer,[33] which the CDC said contributed to the U.S. and other countries getting a late start in identifying the danger and taking early action.[34][35]

After China confirmed that the cluster of infections was caused by a novel infectious coronavirus[3] on January 7, the CDC issued an official health advisory the following day.[36] The World Health Organization (WHO) warned on January 10 about the strong possibility of human-to-human transmission and urged precautions.[37] On January 20, the WHO and China both confirmed that human-to-human transmission had indeed occurred.[38] The CDC immediately activated its Emergency Operations Center (EOC) to respond to the outbreak in China.[39] Also, the first report of a COVID-19 case in the U.S. was reported.[3] After other cases were reported, on January 30, the WHO declared a Public Health Emergency of International Concern (PHEIC)—its highest level of alarm[40]—warning that "all countries should be prepared for containment."[41][42][e] The same day, the CDC confirmed the first person-to-person case in America.[44] The next day, the U.S. declared a public health emergency.[45] 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.[45]

On February 2, the U.S. enacted travel restrictions to and from China.[12] On February 6, the earliest confirmed American death with COVID-19 (that of a 57-year-old woman) occurred in Santa Clara County, California. The CDC did not report its confirmation until April 21,[18] by which point nine other COVID-19 deaths had occurred in Santa Clara County.[46] The virus had been circulating undetected at least since early January and possibly as early as November.[47] On February 25, the CDC warned the American public for the first time to prepare for a local outbreak.[48] However, large gatherings that occurred before then accelerated transmission.[49]

In February, Vice President Mike Pence took over for Secretary Alex Azar as chair of the White House Coronavirus Task Force.[50]

March to April 2020

March 6: President Trump and Alex Azar at the signing of Coronavirus Preparedness and Response Supplemental Appropriations Act into law

By March 11, the virus had spread to 110 countries, and the WHO officially declared a pandemic.[24] The CDC had already warned that large numbers of people needing hospital care could overload the healthcare system, which would lead to otherwise preventable deaths.[51][52] Dr. Anthony Fauci said the mortality from the coronavirus was 10 times higher than the common flu.[53]

By March 12, diagnosed cases of COVID-19 in the U.S. exceeded a thousand.[54] On March 16, the White House advised against any gatherings of more than ten people.[55] Since March 19, the State Department has advised U.S. citizens to avoid all international travel.[56]

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.[57] 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.[58] Manpower from the military and volunteer armies were called up to help construct the emergency facilities.[59][60]

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.[61] By March 27, the country had reported over 100,000 cases.[62] 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.[63] 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.[64] 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.[65] On April 28, the total number of confirmed cases across the country surpassed one million.[66]

May to August 2020

By May 27, less than four months after the pandemic reached the U.S., 100,000 Americans had died with COVID-19.[67] 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.[68]

On July 6, the United States Department of State announced U.S. withdrawal from the World Health Organization effective July 6, 2021.[69] The U.S. passed five million COVID-19 cases by August 8.[70]

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."[71]

In July, U.S. PIRG and 150 health professionals sent a letter asking the federal government to "shut it down now, and start over".[72] In July and early August, requests multiplied, with a number of experts asking for lockdowns of "six to eight weeks"[73] that they believed would restore the country by October 1, in time to reopen schools and have an in-person election.[74]

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.[75] The CDC followed up with a report on the associated 51 confirmed primary event-associated cases, 21 secondary cases, and five tertiary cases in the neighboring state of Minnesota, where one attendee died of COVID-19.[76]

September to December 2020

On September 22, the U.S. passed 200,000 deaths, according to data from Johns Hopkins University.[77] In early October, an unprecedented series of high-profile U.S. political figures and staffers announced they had tested positive for COVID-19.[78][79] On October 2, Trump announced on Twitter that both he and the First Lady had tested positive for the coronavirus and would immediately quarantine.[80][79] Trump was given an experimental Regeneron product with two monoclonal antibodies[81][f] and taken to Walter Reed National Military Medical Center,[83] where he was given remdesivir and dexamethasone.[84]

USA Today studied the aftermath of presidential election campaigning, recognizing that causation was impossible to determine. Among their findings, cases increased 35% compared to 14% for the state after a Trump rally in Beltrami County, Minnesota. One case was traced to a Biden rally in Duluth.[85]

On November 9, President-elect Joe Biden's transition team announced his COVID-19 Advisory Board.[86] On the same day, the total number of cases had surpassed 10 million[87] while the total had risen by over 1 million cases in the ten days prior, averaging 102,300 new cases per day.[88] Pfizer also announced that its COVID-19 vaccine may be up to 90% effective.[89][90] In November, the Trump administration reached an agreement with a number of retail outlets, including pharmacies and supermarkets, to make the COVID-19 vaccine free once available.[91]

In spite of recommendations by the government not to travel, over two million people ended up flying on airlines during the Thanksgiving period.[92] On December 8, the U.S. passed 15 million cases, with about one out of every 22 Americans having tested positive since the pandemic began.[93] By December 12, TSA employees across U.S. airports had a 38% increase in COVID-19 infections.[94] On December 14, the U.S. passed 300,000 deaths, representing an average of more than 961 deaths per day since the first known death on February 6. More than 50,000 deaths were reported in the past month, with an average of 2,403 daily deaths occurring in the past week.[95] On December 20, a 52-year-old female Black woman, Dr Susan Moore died of complications from COVID-19, after she was sent home from the hospital following her treatment. Moore had raised a complaint against the biased medical treatment of Black patients, where a white doctor at a hospital in suburban Indianapolis downplayed her complaints of pain.[96]

On December 24, following concerns over a probably more easily transmissible new SARS-CoV-2 variant from the United Kingdom (B.1.1.7), the CDC announced testing requirements for American passengers traveling from the UK, to be administered within 72 hours, starting on December 28.[97][98] On December 29, the U.S. reported the first case of this variant in Colorado. The patient had no travel history, leading the CDC to state, "Given the small fraction of US infections that have been sequenced, the variant could already be in the United States without having been detected."[99] On December 30 and 31, the country's second and third confirmed cases of the variant were reported in California and Florida.[100][101]

January 2021

On January 1, 2021, the U.S. passed 20 million cases, representing an increase of more than one million over the past week and 10 million in less than two months.[102][103] On January 6, the CDC announced that it had found at least 52 confirmed cases of the more contagious SARS-CoV-2 variant in California, Florida, Colorado, Georgia, and New York; and it also stressed that there could already be more cases in the country.[104] In the following days, more cases of the variant were reported in other states, leading former CDC director Tom Frieden to express his concerns that the U.S. will soon face "close to a worst-case scenario".[105]

Also on January 6, supporters of President Trump stormed the United States Capitol building, leading to public health experts saying the event could be a potential COVID-19 superspreader event in the days after.[106] At least one activist participated in the riot despite a recent positive COVID-19 diagnosis,[107] and few members of the crowd wore face coverings, with many coming from out of town.[106] A group of maskless Republicans sheltering in place were recorded refusing masks offered by Representative Lisa Blunt Rochester (D–DE),[108] and as many as 200 congressional staffers reportedly sheltered in various rooms inside the Capitol, further increasing the risk of transmission.[106][109] Brian P. Monahan, the attending physician of Congress, later reported that members of Congress may have been exposed to others with COVID-19 while sheltering in place.[108][110] Four members of Congress have since tested positive due to the exposure.[111]

Responses

Medical response

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.[33][112] According to CDC Director Robert R. 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.[34] 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.[113]

On January 28, the CDC updated its China travel recommendations to level 3, its highest alert.[33] 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.[114][113] 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.[115][113] 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.[116] The final report was released on February 28.[117]

In late January, Boeing announced a donation of 250,000 medical masks to help address China's supply shortages.[118] 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.[119] 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.,[120] however on March 21, China said it had not received epidemic funding from the U.S. and said so again on April 3.[citation needed]

On February 28, the State Department offered to help Iran fight its own outbreak, as Iran's cases and deaths were dramatically increasing.[121][122] Iran said, however, that U.S. sanctions were hampering its battle with the disease, which the U.S. denied, saying that Iran had mishandled the crisis.[123]

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 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.[124] 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".[125]

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.[126]

March 3: President Trump and Anthony Fauci visit the Vaccine Research Center and the Viral Pathogenesis Laboratory at the National Institutes of Health.

In the United States, remdesivir is indicated for use in adults and adolescents (aged twelve years and older with body weight at least 40 kilograms (88 lb)) for the treatment of COVID‑19 requiring hospitalization.[127] In November 2020, the FDA issued an emergency use authorization (EUA) for the combination of baricitinib with remdesivir, for the treatment of suspected or laboratory confirmed COVID-19 in hospitalized people two years of age or older requiring supplemental oxygen, invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO).[128] As of August 2020, there were over 500 potential therapies for COVID‑19 disease in various stages of preclinical or clinical research.

In early March, President Trump directed the FDA to test certain medications to discover if they had the potential to treat COVID-19 patients.[129] 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.[130] One of Didier's COVID-19 studies was later retracted by the International Journal of Antimicrobial Agents.[131]

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.[132][129][133][134] 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.[135]

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".[136]


Research is ongoing in several countries to create vaccines.[139] More than 70 companies and research teams are working on a vaccine, with five or six operating primarily in the U.S.[140] As of October, 44 are in clinical trials on humans, and 91 pre-clinical vaccines are being tested on animals.[141] Bill Gates, whose foundation shifted its focus nearly entirely to the pandemic, anticipated in early 2020 that a vaccine could be ready by early 2021.[142] In preparation for large-scale production, Congress set aside more than $3.5 billion for this purpose as part of the CARES Act.[143][140] 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, sponsored by the U.S. government, and similar safety trials of other potential vaccines were to begin soon in the U.S.[144] This search for a vaccine has taken on aspects of national security and global competition.[145]

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 U.S. 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.[146]

BIO, a trade group including all makers of coronavirus vaccines except AstraZeneca, tried to persuade Secretary Azar to publish strict FDA guidelines that could help ensure the safety and public uptake of the vaccine. Politics impacted scientific practice, however, when chief of staff Mark Meadows blocked the FDA when it was realized that the timing of the provisions would make it impossible for a vaccine to be authorized before the November election.[147][148] Ultimately, the guidelines emerged[149] from the Office of Management and Budget and were published on the FDA website.[150]

On November 20, 2020, the Pfizer-BioNTech partnership submitted a request for emergency use authorization to the FDA,[151][152] and the FDA announced that its Vaccines and Related Biological Products Advisory Committee (VRBPAC) will review the EUA request on December 10.[153][154]

On November 30, 2020, Moderna submitted a request for an EUA to the FDA.[155][156]

On December 11, 2020, the Food and Drug Administration (FDA) granted emergency use authorization for the Pfizer-BioNTech vaccine.[157][158] An initial shipment of 2.9 million doses are scheduled to be distributed rapidly and Pfizer has promised to continue supplying the rest of the 100 million doses through March 2021.[159][160] Pfizer began distribution of its vaccine on December 17, 2020, but the federal government inexplicably substantially reduced the amounts anticipated, and that it was allowed to distribute, despite adequate stocks having been made available.[161][162]

On December 18, 2020, the FDA granted the Moderna vaccine emergency use authorization.[163][164] The U.S. plans to rapidly distribute 5.9 million doses with more to come later.[165][166]

The first known case of COVID-19 in the U.S. was confirmed by the CDC on January 21, 2020.[167] 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.[168]

On February 5, Trump administration officials declined an offer for congressional coronavirus funding. Senator Chris Murphy recalled that the officials, including Secretary Azar, "didn't need emergency funding, that they would be able to handle it within existing appropriations."[169] 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)".[167]

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.[170][171] According to Chinese customs disclosures, more than 600 tons of face masks were shipped to China in February.[172]

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.[173] A previous 2015 CDC study found that seven billion N95 respirators might be necessary to handle a "severe respiratory outbreak".[174]

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.[175] 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.[176][177] President Trump evoked the Defense Production Act to prohibit some medical exports.[178] Some analysts warned that export restrictions could cause retaliation from countries that have medical supplies the United States needs to import.[179]

May 21: President Trump traveled to the Ford Rawsonville Components Plant in Ypsilanti, Michigan to tour the factory where ventilators were being produced.

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.[180][181][21] 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.[172]

Medical organizations such as the American Medical Association and American Nurses Association implored Trump to obtain medical supplies, because they were "urgently needed".[182][183] 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.[184][185] Trump then ordered auto manufacturer General Motors to make ventilators.[22]

During this period, hospitals in the U.S. and other countries were reporting shortages of test kits, test swabs, masks, gowns, and gloves (collectively referred to as PPE.)[186][187][188] 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".[189] 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".[190]

In early April, there was a widespread shortage of PPE, including masks, gloves, gowns, and sanitizing products.[191] 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.[192] 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.[193] At that time, Veterans Affairs (VA) employees said nurses were having to use surgical masks and face shields instead of more protective N95 masks.[194] In May, Rick Bright, a federal immunologist and whistleblower, testified that the federal government had not taken proper action to acquire the needed supplies.[172]

An unexpectedly high percentage of COVID-19 patients in the ICU required dialysis as a result of kidney failure, about 20%.[195] 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.[195][196][197]

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.[198]

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.[199] A September report by National Public Radio found some items were in short supply but others widely available, depending on the difficulty of manufacturing.[200] 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.[201]

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[202] and in September saying "we've opened up factories, we've had tremendous success with face masks and with shields".[200] Demand has also increased since the early weeks of the pandemic as various industries reopened, including medical and dental offices, construction, and trucking.[203] 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.[204]

The San Diego-based hospital ship Mercy arrived in Los Angeles in late March to help treat non-coronavirus patients

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[205] and New York City area;[206] Yakima, Washington in June;[207] and in July it happened in Houston,[208] the Boise, Idaho area,[209] Lake Charles and Lafayette, Louisiana,[210] and at dozens of hospitals across Florida.[211] By August, some hospitals in Mississippi were transferring patients out of state.[212]

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.[213]

In January 2021, Southern California hospitals began to be overwhelmed with patients. Officials in Los Angeles County, where some ambulances had to wait up to eight hours to discharge patients at emergency rooms, ordered EMTs to stop bringing patients to the hospital who had little chance of survival. They also directed crews to take measures to conserve medical oxygen.[214]

A testing team responds to a confirmed case in a nursing home in Charleston, West Virginia

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.[215][216][217] 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."[215]

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 "provid[ing] PPE (N-95 Face Mask, Eye Protection, and Gloves) to evacuees, staff, and DoD personnel".[218][219]

USNS Comfort, docked in Manhattan
The members of the Florida National Guard support Feed Tampa Bay in their efforts to distribute food to the local community

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.[220] The Army also set up field hospitals in various affected cities.[221]

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.[222][221] At the height of this effort, U.S. Northern Command had deployed nine thousand military medical personnel.[221]

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.[223] 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.[224][225]

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".[226] 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.[227]

In April, the Army made plans to resume collective training.[228] Social distancing of soldiers is in place during training, assemblies,[229] and transport between locations.[230] Temperatures of the soldiers are taken at identified intervals, and measures are taken to immediately remediate affected soldiers.[231][232][233][234]

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.[235] As of July 2020, additional Reserve personnel are on 'prepare-to-deploy orders' to Texas and California.[221]

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 ten 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 "[look] 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.[236]

Public response

Passengers wearing facemasks at Hartsfield–Jackson Atlanta International Airport

Polling showed a significant partisan divide regarding the outbreak.[237] 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.[238] 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%),[239] and to take certain precautions against the virus (83% to 53%).[240] 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%).[240]

Political analysts anticipated that the pandemic would negatively affect Trump's chances of re-election.[241][242] In March 2020, when social distancing practices began, the governors of many states experienced sharp gains in approval ratings.[243] Trump's approval rating increased from 44% to 49% in Gallup polls,[244] but it 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 pandemic.[245]

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.[246] An April 21 poll found a 44% approval rate for the president's handling of the pandemic, compared to 72% approval for state governors.[247] 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.[248][249]

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.[250] 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.[251]

Studies using GPS location data and surveys found that Republicans engaged in less social distancing than Democrats during the pandemic.[252][253] Controlling for relevant factors, Republican governors were slower to implement social distance policies than Democratic governors.[254]

An anti-lockdown protester wearing a face mask at the Ohio Statehouse in April 2020 [265]

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.[266] Fauci said it could be a "perfect set-up for the spread of the virus",[267] and that "masks can help, but it's masks plus physical separation."[268] One study found an increase in cases,[269] while the Associated Press reported that there is little evidence for such an assertion.[270]

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 U.S. response to the COVID-19 pandemic positively.[271]

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.[272][273][274]

Challenges

The American cultural values of individualism and skepticism of government have created difficulties in getting the population to abide by public health directives.[275] The prevalence of pandemic fatigue has resulted in further noncompliance.[276][277]

Conspiracy theories and misinformation reached millions of Americans through social media and television commentary.[278] As a result, many people believe falsehoods, for example, that wearing masks is dangerous, that a global syndicate planned the virus, or that COVID-19 is a hoax.[278][279] Facebook announced that it had labeled or deleted 179 million user posts containing COVID-19 misinformation during the first three quarters of 2020.[280] President Trump has repeatedly broadcast misinformation to downplay the threat of the virus and to deflect criticism of the administration's response.[281] Trump has asserted that he does this to "show calm", stating "I don't want to create a panic" [282]

Impacts

Economic

Sign reading "we'll get thru this"
Marquee at a closed music venue in Washington, D.C.

The pandemic, along with the resultant stock market crash and other impacts, led a recession in the United States following the economic cycle peak in February 2020.[283] The economy contracted 4.8 percent from January through March 2020,[284] and the unemployment rate rose to 14.7 percent in April.[285] 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.[286] A study by economists Austan Goolsbee and Chad Syverson indicated that most economic impact due to consumer behavior changes was prior to mandated lockdowns.[287] 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.[288]

President Trump and Airline CEOs discuss COVID-19's impact on the travel industry on March 4, 2020

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.[289] OpenTable estimated in May that 25% of American restaurants would close their doors permanently.[290]

The economic impact and mass unemployment caused by the COVID-19 pandemic has raised fears of a mass eviction crisis,[291][292][293][294] with an analysis by the Aspen Institute indicating 30–40 million are at risk for eviction by the end of 2020.[295][296] According to a report by Yelp, about 60% of U.S. businesses that have closed since the start of the pandemic will stay shut permanently.[297]

Impact of the pandemic on various economic variables
Variable Feb Mar Apr May June July Aug Sep Oct Nov
Jobs, level (000s)[298] 152,463 151,090 130,303 133,002 137,802 139,582 140,914 141,720 142,373 142,629
Jobs, monthly change (000s)[298] 251 −1,373 −20,787 2,699 4,800 1,780 1,371 661 653 256
Unemployment rate %[299] 3.5% 4.4% 14.7% 13.3% 11.1% 10.2% 8.4% 7.9% 6.9% 6.7%
Number unemployed (millions)[300] 5.8 7.1 23.1 21.0 17.8 16.3 13.6 12.6 11.1 10.7
Employment to population ratio %, age 25-54[301] 80.5% 79.6% 69.7% 71.4% 73.5% 73.8% 75.3% 75.0% 76.0% 76.0%
Inflation rate % (CPI-All)[302] 2.3% 1.5% 0.4% 0.2% 0.7% 1.0% TBD TBD TBD TBD
Stock market S&P 500 (avg. level)[303] 3,277 2,652 2,762 2,920 3,105 3,230 3,392 3,380 3,270 3,694
Debt held by public ($ trillion)[304] 17.4 17.7 19.1 19.9 20.5 20.6 20.8 21.0 21.2 21.3

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.[305] 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[306][dubious ], the relatively high numbers of elderly residents, immigrant laborers with shared living conditions and meat-processing plants.[307]

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,[25][26][27] and there were reported incidents of xenophobia and racism against Asian Americans.[28] 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.[308] 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.[309] CNN reported in May that the Navajo Nation had the highest rate of infection in the United States.[310] 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.[311]

In September, NPR reviewed its previously reported data from the COVID Tracking Project[312] 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.[313]

By April, closed schools affected more than 55 million students.[314]

Elections

A masked voter casts a ballot at Roosevelt High School in Des Moines, Iowa

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.[315] 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.[316] 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.[317] Though mail-in 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.[318] 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.[319]

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.[320]

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.[321][322][323] 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.[321]

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.[324][325]

Statistics

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