# data[].attributes.body
This is an article from Wikipedia that summarizes how covid-19 reached the shores of USA.

# data[].attributes.attachment_link.readable_text
COVID-19 pandemic in the United States

Map of the outbreak in the United States by confirmed new infections per 100,000 people (14 days preceding July 24)

200-500 confirmed new cases

100-200 confirmed new cases

50-100 confirmed new cases

20-50 confirmed new cases

10-20 confirmed new cases

Map of the outbreak in the United States by total confirmed infections per 100,000 people (as of July 24)

1.00%+ confirmed infected

0.50%-1.00% confirmed infected

0.10%-0.50% confirmed infected

0.02%-0.10% confirmed infected

0.00%-0.02% confirmed infected

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]
(6 months, 1 week and 6 days ago)

Confirmed cases

4,099,310 (CDC, includes
probable cases)[5]

4,167,663 (JHU, includes
probable cases)[6]

4,158,341 (CTP)[7]

Recovered

1,279,414 ( JHU)[6]

145,013 (CDC, includes
probable deaths)[5]

146,317 (JHU, includes
probable deaths)[6]

138,692 (CTP)[7]

Government website

coronavirus.gov

The ongoing COVID-19 pandemic was confirmed to have reached the United States in January 2020. The first confirmed case of local transmission was recorded in January, while the first known deaths happened in February. By the end of March, cases had occurred in all 50 U.S. states, the District of Columbia, and all inhabited U.S. territories except American Samoa. As of June 24, 2020, the U.S. had the most confirmed active cases and deaths in the world. As of July 24, 2020, its death rate had reached 441 per million people, the eleventh-highest rate globally.

The Trump administration initially responded by declaring a public health emergency on January 31. On February2, it began to prevent the entry of most foreign nationals who had recently traveled to China; it did not ban entry of U.S. residents who had been there, and no virus testing was implemented to screen those seeking to enter the country. The initial U.S. response to the pandemic was otherwise slow, in terms of preparing the healthcare system, stopping other travel, or testing for the virus. Through March 10, the U.S. tested fewer than 10,000 people, in part because manufacturing defects rendered many government-developed test kits unusable and because commercial tests were disallowed by regulations. Meanwhile, President Donald Trump was downplaying the threat posed by the virus and claiming the outbreak was under control.

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. A national emergency was declared by President Trump on March13. In early March, the Food and Drug Administration (FDA) began allowing public health agencies and private companies to develop and administer tests, and loosened restrictions so anyone with a doctor's order could be tested. By the end of the month, more than a million people had been tested (1per 320 inhabitants). 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. Federal health inspectors who surveyed hospitals in late March found shortages of test supplies, personal protective equipment (PPE), and other resources due to extended patient stays while awaiting test results. By early May, the U.S. had processed around 6.5 million tests, and was conducting around 250,000 tests per day, but experts said this level of testing was still not enough to contain the outbreak.

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 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. Travel restrictions on most foreign nationals who had recently traveled to Iran or 28 European countries were implemented in March. By April 11, the federal government approved disaster declarations for all states and inhabited territories except American Samoa. 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 urban areas, nursing homes, long-term care facilities, group homes for the intellectually disabled, detention centers (including prisons), meatpacking plants, churches, and navy ships. Large gatherings that occurred before widespread shutdowns and social distancing measures were put in place, including Mardi Gras in New Orleans, accelerated transmission.

The second rise of infections began in June 2020, following relaxed restrictions in several states.

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 Secretary Alex Azar said the U.S. had offered to send a team of CDC health experts to China to help contain the outbreak. 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. The same day, the WHO declared the outbreak a Public Health Emergency of International Concern, warning that "all countries should be prepared for containment." The next day, January 31, the U.S. also 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

In response to the outbreak, the American federal government implemented a series of travel restrictions denying entry to foreign nationals who had traveled within the past 14 days in certain countries, with exceptions for the immediate family of American citizens or permanent residents. Americans returning home after traveling in these regions were required to undergo a health screening and submit to a 14-day quarantine. On February 2nd, the USA enacted travel restrictions to and from China.

On February6, the earliest confirmed American death occurred in Santa Clara County, California, when a 57-year-old woman died from cardiac complications caused by COVID-19. This case was only confirmed posthumously months later. The woman was likely infected between late December 2019 and early January 2020. She had not traveled recently, indicating she contracted the virus domestically. By May 5, Santa Clara County health officials had reclassified nine deaths which occurred before February6 as being due to COVID-19. According to forensic pathologist Judy Melinek, "it's likely" the virus had arrived and been circulating undetected in the U.S. before January, "maybe even as early as November".

On March 2, travel restrictions from Iran went into effect. On March11, 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 , and it held off calling the outbreak a pandemic because many countries at the time were reporting no spread or low spread.

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.

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.

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 cases 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 2020 to present

By May 27, less than four months after the pandemic reached the US, 100,000 Americans had died from COVID-19. By June 11, the number of cases in the USA had passed two million. By July 9, the number of cases had passed three million.

The CDC prepared detailed guidelines for businesses, public transit, restaurants, religious entities, schools and other public places who may wish to reopen. In early May, the guidelines were edited down however the original seven pages were provided to the Associated Press. Six flow charts were ultimately published on May 15, and a 60-page set of guidelines was released without comment on May 20, weeks after many states had already emerged from lockdowns.

Preparations made after previous outbreaks

Reports predicting global pandemics

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 one year.

The United States Intelligence Community, in its annual Worldwide Threat Assessment report of 2017 and 2018, said if a related coronavirus were "to acquire efficient human-to-human transmissibility", it would have "pandemic potential". The 2018 Worldwide Threat Assessment also said new types of microbes that are "easily transmissible between humans" remain "a major threat". Similarly, the 2019 Worldwide Threat Assessment warned that "the United States and the world will remain vulnerable to the next flu pandemic or large-scale outbreak of a contagious disease that could lead to massive rates of death and disability, severely affect the world economy, strain international resources, and increase calls on the United States for support."

Preparations

In 2005, President George W. Bush began preparing a national pandemic response plan. In 2006, the Department of Health and Human Services established a new division, the Biomedical Advanced Research and Development Authority (BARDA) to prepare for chemical, biological and nuclear attacks, as well as infectious diseases. In its first year of operation, BARDA "estimated that an additional 70,000 [ventilators] would be required in a moderate influenza pandemic"; a contract was let and work started, but no ventilators were ever delivered.

A vaccine for a related coronavirus, SARS, was developed in the U.S. by 2016, but never progressed human trials due to a lack of funding. In January 2017, the U.S. government had updated its estimate of resource gaps, including ventilators, face masks, and hospital beds. While some cities did take the risk of a pandemic seriously enough to prepare years ahead of time, there was often a failure to follow through due to financial constraints. New York City, for instance, took preparatory steps more than a decade ago, but then discontinued them in favor of other priorities.

In 2017, outgoing Obama administration officials briefed incoming Trump administration officials on how to respond to pandemics by using simulated scenarios. Obama's national security advisor Susan Rice met with her successor, General Michael Flynn, where she outlined the risk of a pandemic with a tabletop exercise and gave him a pandemic guidebook.

The Trump administration simulated a series of pandemic outbreaks from China in 2019 and found that the U.S. government response was "underfunded, underprepared, and uncoordinated" (see Crimson Contagion). Among the conclusions of the test was a shortage of certain medical supplies which are produced overseas, including N95 masks. President Trump responded to the simulation with an executive order to increase the availability and quality of flu vaccines, and the administration later increased funding for the pandemic threats program of the Department of Health and Human Services ( HHS). In September 2019, White House economists published a study that warned a pandemic could kill half a million Americans and devastate the economy.

Despite these reports, briefings, and exercises, President Trump commented in March 2020, "Nobody knew there would be a pandemic or epidemic of this proportion.... It's an unforeseen problem. What a problem. Came out of nowhere."

Reorganization and departures

In May 2018, National Security Advisor John Bolton reorganized the executive branch's United States National Security Council (NSC), largely merging the group responsible for global health security and biodefense-established by the Obama administration following the 2014 ebola epidemic-into a bigger group responsible for counter-proliferation and biodefense. Along with the reorganization, the leader of the global health security and biodefense group, Rear Admiral Timothy Ziemer, left to join another federal agency, while Tim Morrison became the leader of the combined group. Critics of this reorganization referred to it as "disbanding" a pandemic preparedness group.

After the coronavirus outbreak, reporters repeatedly asked Trump about this reorganization, and Trump provided conflicting responses. On March 6, 2020, when asked at a press briefing if he would "rethink" the 2018 choice not to have a pandemic preparation office, Trump implied the reorganization had been a reasonable choice at the time because "you can never really think [a pandemic] is going to happen... who would have thought we would even be having the subject?" On March 13, when PBS NewsHour White House correspondent Yamiche Alcindor asked if the reorganization had hampered the government response to the coronavirus outbreak, Trump berated her for asking a "nasty question", and he added: "I didn't do it... Disbanding, no, I don't know anything about it... It's the administration, perhaps they do that, let people go... things like that happen." On April 1, Fox News journalist John Roberts began a question by saying "you got rid of the pandemic office in the National Security Council," and Trump replied, "We didn't do that," describing the allegation four times as "false" but not elaborating further. As of July 2020, the administration planned to create a new pandemic preparedness office within the State Department.

Also in 2018, Homeland Security Advisor Tom Bossert left the administration, reportedly at Bolton's request. Bossert had helped to create the Trump administration's biodefense plans, and it was his responsibility to coordinate the government's response in the event of a biological crisis. Bossert's successor, Doug Fears, and Fears' successor Peter J. Brown, took over the biodefense responsibilities of the DHS. Bloomberg News reported in January 2020 that biodefense was by then a "less prominent" part of the Homeland Security Advisor's responsibilities. In another departure, Luciana Borio, the National Security Council director for medical and biodefense preparedness, left her post in March 2019. The Washington Post reported in March 2020 that the White House would not confirm the identity of Borio's replacement.

Reuters reported in March 2020 that the Trump administration had in the years before the coronavirus outbreak drastically reduced the number of staff working in the Beijing office of the U.S. CDC from 47 to 14. According to Reuters, one of the staff eliminated in July 2019 was training Chinese field epidemiologists to respond to disease outbreaks at their hotbeds. Trump claimed the report of the trainer's being cut was "100% wrong", but the U.S. CDC acknowledged that the report was true. The Trump administration also confirmed that it had closed the Beijing offices of the National Science Foundation (NSF) and the United States Agency for International Development (USAID); these offices had been each manned by a single U.S. official. In addition, the Trump administration acknowledged it had eliminated one managerial position from the Beijing office of the U.S. Department of Agriculture; Reuters reported that the position oversaw an animal disease monitoring program.

Unsuccessful efforts to improve mask and ventilator supply

Since 2015, the federal government has spent $9.8million on two projects to prevent a mask shortage in the event of a pandemic, but abandoned both projects before completion. A second BARDA contract was signed with Applied Research Associates of Albuquerque, to design an N95-rated mask that could be reused in emergencies without reduced effectiveness. Though federal reports had called for such a project since 2006, the ARA contract was not signed until 2017, and missed its 15-month completion deadline, resulting in the 2020 pandemic reaching the United States before the design was ready.

Previous respiratory epidemics and government planning indicated a need for a stockpile of ventilators that were easier for less-trained medical personnel to use. BARDA Project Aura issued a request for proposals in 2008, with a goal of FDA approval in 2010 or 2011. A contract for the production of up to 40,000 ventilators was awarded to Newport Medical Instruments, a small ventilator manufacturer, with a target price of $3,000, much lower than more complicated machines costing more than $10,000, and it produced prototypes with target FDA approval in 2013. Covidien purchased NMI and after requesting more money to complete the project (bringing the total cost to around $8million) asked the government to cancel the contract, saying it was not profitable. The government awarded a new $13.8million contract to Philips, in 2014. The design for the Trilogy Evo Universal gained FDA approval in July 2019. The government ordered 10,000 ventilators in September 2019, with a mid-2020 deadline for the first deliveries and a deadline of 2022 to complete all 10,000. Despite the start of the epidemic in December, the capacity of the company to have produced enough to fill the full order, and the ability of the government to force faster production, the government did not reach an agreement with Philips for accelerated delivery until March 10, 2020. By mid-March, the need for more ventilators had become immediate, and even in the absence of any government contracts, other manufacturers announced plans to make many tens of thousands. In the meantime, Philips had been selling a commercial version, the Trilogy Evo, at much higher prices, leaving only 12,700 in the Strategic National Stockpile as of March 15.

Compared to the small amount of money spent on recommended supplies for a pandemic, billions of dollars had been spent by the Strategic National Stockpile to create and store a vaccine for anthrax, and enough smallpox inoculations for the entire country.

Potential response strategies

Medical responses

Attempts to assist China

By late January, Health and Human Services Secretary Alex Azar had already offered to send a team of U.S. health experts to China multiple times but had not received their approval. Nor had the WHO yet been to China to perform its own investigation despite weeks of requests. Meanwhile, 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 $105million in funding, adding that he had requested another $136million 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 13 international researchers, including two Americans, and toured five cities in China with 12 local scientists to study the epidemic from February 16-23. The final report was released on February 28.

At that time, a number of U.S. organizations began sending personal protective equipment to China in late January. Boeing announced a donation of 250,000 medical masks to help address China's supply shortages, while the United Church of Christ (UCC) and American Baptist Churches USA joined an ecumenical effort of American churches to provide much-needed medical supplies to China.

The U.S. State Department also took steps to help China. Deputy Secretary of State Steve Biegun offered America's "deepest compassion" to the Chinese as the State Department organized a "robust effort to help the Chinese people get their arms around this outbreak". The State Department said on February7 that it has facilitated the transportation of nearly 17.8 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. On March 21, China said it had not received epidemic funding from the U.S. government and said so again on April 3. A few weeks later the State Department offered to help Iran fight its own outbreak, as their cases and deaths were dramatically increasing.

Beyond identifying whether a person is currently infected, coronavirus testing helps health professionals ascertain how bad the epidemic is and where it is worst. However, the accuracy of national statistics on the number of cases and deaths from the outbreak depend on knowing how many people are being tested every day, and how the available tests are being allocated.

Meanwhile, from the start of the outbreak to early March 2020, the CDC gave restrictive guidelines on who should be eligible for COVID-19 testing. The initial criteria were (a) people who had recently traveled to certain countries, or (b) people with respiratory illness serious enough to require hospitalization, or (c) people who have been in contact with a person confirmed to have coronavirus. Only on March5 did the CDC relax the criteria to allow doctors discretion to decide who would be eligible for tests.

The United States had a slow start in widespread coronavirus testing. Fewer than 4,000 tests were conducted in the U.S. by February 27. The first U.S. case of a person having coronavirus of unknown origin (a possible indication of community transmission) saw the patient's test being delayed for four days after being hospitalized on February 19, because he had not qualified for a test under the initial federal testing criteria. In Washington state, a group of researchers from the Seattle Flu Study defied federal and state officials to conduct their own tests from February 25, using samples already collected from flu study subjects who had not given permission for coronavirus testing. They quickly found a teenager infected with coronavirus of unknown origin, newly indicating that an outbreak had already been occurring in Washington for the past six weeks. State regulators stopped these researchers' testing on March 2, although the testing later resumed through the creation of the Seattle Coronavirus Assessment Network.

On March 5, Vice President Mike Pence, the leader of the coronavirus response team, acknowledged that "we don't have enough tests" to meet the predicted future demand; this announcement came only three days after FDA commissioner Stephen Hahn committed to producing nearly a million tests by that week. Senator Chris Murphy of Connecticut and Representative Stephen Lynch of Massachusetts both noted that as of March8 their states had not yet received the new test kits. Doctor Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, acknowledged on March 12 it was "a failing" of the U.S. system that the demand for coronavirus tests was not being met; Fauci later clarified that he believed the private sector should have been brought in sooner to address the shortfall. By March 11, the U.S had tested fewer than 10,000 people.

By mid-March, the U.S. had tested 125 people per million of their population, which was lower than several other countries. The first COVID-19 cases in the U.S. and South Korea were identified at around the same time. Critics say the U.S. government has botched the approval and distribution of test kits, losing crucial time during the early weeks of the outbreak, with the result that the true number of cases in the United States was impossible to estimate with any reasonable accuracy.

By March 12, all 50 states were able to perform tests, with a doctor's approval, either from the CDC or local commercial lab. This was followed by the government announcing a series of measures intended to speed up testing. These measures included the appointment of Admiral Brett Giroir of the U.S. Public Health Service to oversee testing, funding for two companies developing rapid tests, and a hotline to help labs find needed supplies. The FDA also gave emergency authorization for New York to obtain an automated coronavirus testing machine.

On March 13, drive-through testing in the U.S. began in New Rochelle, Westchester County, as New Rochelle was the U.S. town with the most diagnosed cases at that time. By March 22, drive-through testing had started in more than thirty states, although the Associated Press reported that "the system has been marked by inconsistencies, delays, and shortages", leading to many people waiting hours or days even though they showed symptoms and were recommended by a doctor to get a test. A lack of supplies had already forced the closure of drive-through testing in seven states.

In a March 13 press conference, the Trump administration announced a campaign to conduct tests in retail store parking lots across the country, but this was not widely implemented.

During the weeks of April 6 and 13, the U.S. conducted about 150,000 tests per day, while experts recommended at least 500,000 per day prior to ending social distancing, with some recommending several times that level. Building up both testing and surveillance capacity are important to re-opening the economy; the purpose of social distancing is to buy time for such capacity-building.

The New York Times reported on April 26 that the U.S. still had yet to reach an adequate level of testing capacity needed to monitor and contain outbreaks. The capacity has been hampered by shortages of reagents, shortages of test kits components like nasal swabs, shortages of protective gear for health workers, limited laboratory workers and equipment, and the federal government's limited interventions to solve shortages, instead of leaving the issue to the free market, causing states and hospitals to compete with each other for supplies.

By early May, the U.S. was testing around 240,000 to 260,000 people per day, but this was still an inadequate level to contain the outbreak, reported The Washington Post, The Atlantic, NPR, and FactCheck.org.

By June 26, 2020, Dr. Fauci was publicizing pooled testing as a way to speed up testing by a factor of ten -from half a million to five million-in a single day. Of the 41 federally funded "community-based testing" sites originally established on March, 13 were set to lose federal funding by the end of June. They will remain under state and local control. The sites that will lose funding are in Texas, Illinois, New Jersey, Colorado, and Pennsylvania. Admiral Giroir described the original community-based testing program as having become "antiquated".

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 contract tracing is thought to be insufficient, and even better-funded states have faced challenges getting in touch with contacts. Congress has allocated $631million for state and local health surveillance programs, but the Johns Hopkins Center for Health Security estimates that $3.6billion will be needed. The cost rises with the number of infections, and contract 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 contract tracing efforts which "may also be hobbled by long-standing distrust among minorities or public health officials."

Drug therapy and vaccine development

There is currently no drug approved for treating COVID-19 either as a therapy or a vaccine, nor is there any clear evidence COVID-19 infection leads to immunity (although experts assume it does for some period). As of late March 2020, more than a hundred drugs were in testing.

In April 2020, the CDC began testing blood samples to determine if a person has been exposed to the virus, even without showing symptoms, which could provide information about immunity. Learning who is protected is a primary factor in deciding when people can fully return to society. Until then, physical distancing is recommended as it has been shown to slow the spread of the disease. Due to the emergency nature of the pandemic, former FDA commissioners Drs. Scott Gottlieb and Mark McClellan have called for the FDA to develop therapeutics and vaccines that would be exempt from some regulatory requirements. The FDA has also sent warning letters to at least seven retailers selling essential oils, nasal sprays, herbal remedies, and other products claiming to test for, treat, or prevent COVID-19.

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 50 years. A small test in France had apparently given good results and they were being tested in a European Union-wide clinical trial. Some U.S. physicians, under the compassionate use and Emergency Use Authorization exceptions by the FDA, have prescribed them while trials and analysis are still ongoing.

While there is evidence that the drug has been effective in preventing or treating coronavirus infections, Australian experts advised before June 4, 2020 against its use outside of a clinical trial. On July 1, 2020, the FDA updated its advice and cautioned against the use of hydroxychloroquine for COVID-19 outside of a hospital or clinical trial due to heart risk, but maintained its approved use for malaria, lupus, and rheumatoid arthritis. In a study of 1446 patients hospitalized for COVID-19 published June 18, 2020, hydroxychloroquine was found to not have a significant beneficial or adverse effect. However, in a study of 2,541 patients admitted to hospitals for COVID-19, published July 1, 2020, the use of hydroxychloroquine with and without azithromycin resulted in a significant reduction of deaths.

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. Contributing funds to the research is Bill Gates, whose foundation will be focusing entirely on the pandemic, and he anticipates having a vaccine ready in 12 months. Scott Gottlieb, former commissioner of the FDA, when a vaccine is ready for testing, about 25,000 people, in different groups, would be given the vaccine, two weeks apart, until 100,000 people have been inoculated over about six weeks. Researchers would then have a large enough sampling to see if the vaccine works. If successful, the next massive challenge would be making enough vaccines. In preparation for large-scale production, Congress set aside more than $3.5billion 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, Washington, 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.

Medical supplies

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. "We are the last major domestic mask company," the business owner informed the government in a follow-up letter on January 23, without success.

An unclassified Army briefing document, prepared February 3, on the coronavirus projected that "between 80,000 and 150,000 could die". The estimates also correctly said asymptomatic people could "easily" transmit the virus, 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". Trump administration officials declined an offer for congressional coronavirus funding on February 5. The officials, including HHS Secretary Alex Azar, "didn't need emergency funding, that they would be able to handle it within existing appropriations," Senator Chris Murphy recalled. On February7 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 early March, the country had about 12 million N95 masks and 30 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. As of March, the SNS had over 19,000 ventilators (16,660 immediately available and 2,425 in maintenance), all of which dated from previous administrations. A previous 2015 CDC study found that seven billion N95 respirators might be necessary to handle a "severe respiratory outbreak". 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.

Some states had immediate needs for ventilators; hospitals in New York City, for example, ran out. 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. In February, the Department of Commerce published a 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, over 600 tons of face masks were shipped to China in February. Rick Bright, a federal immunologist and whistleblower testified in May that the federal government had not taken proper action to acquire the needed supplies.

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 7days 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 employees said nurses were having to use surgical masks and face shields instead of more protective N95 masks.

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.

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. On a per capita basis, the U.S. had the 11th most cases of any country. By April 25, The United States ranked 10th in deaths per million people with 158, compared to Italy (423), Spain (474), and France (326). By April 25, the U.S. had over 905,000 confirmed coronavirus cases and nearly 52,000 deaths, giving it a mortality rate around 5.7 percent. Comparatively, Spain's mortality rate was 10.2 percent and Italy at 13.5 percent; Dr. Deborah Birx pointed out the nation's low mortality rate during a White House coronavirus briefing. Of those, more than 10,000 deaths 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 20 to 50 percent.

According to an excess mortality analysis of seven of the worst-affected states, there are an additional 9,000 deaths than expected from prior years which are not explained by official reported coronavirus mortality statistics. In these states, the death rate was nearly 50% higher than baseline between March8 and April 11. (Excess mortality is higher than these figures because some death certificates have yet to be processed and reported).

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.

The response to the pandemic has resulted in an unprecedented expansion of government power. Advocates of small government worry that the state will be reluctant to give up that power once the crisis is over, as has often been the case historically.

Effective 15 July 2020, the default US data centralization point for COVID-19 data in the US 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 that the State will collect the data from the hospitals and take over Federal reporting."

Private sector

Many janitors and other cleaners throughout the United States have reported that they are afforded completely inadequate time and resources to clean and to disinfect for COVID-19. Many office cleaners reported that they are given insufficient time for cleaning and no training on how to disinfect COVID-19. Airlines often allot 10 minutes to clean an entire airplane between arrival and departure, and cleaners are unable to disinfect even close to all the tray tables and bathrooms. Often, cleaners are not told where workers who test positive for COVID-19 are working; cleaning cloths and wipes are re-used, and disinfecting agents, such as bleach, are not provided. The Occupational Safety and Health Administration (OSHA), the federal agency that regulates workplace safety and health, investigates but a small fraction of COVID-19 complaints. Mary Kay Henry, president of Service Employees International Union (a trade union which represents 375,000 American custodians), explained that "reopenings happened across the country without much thoughtfulness for cleaning standards." She urges better government standards and a certification system.

After mid-March, the federal government made a major move to use the U.S. military to add health care capacity to impacted areas. The United States Army Corps of Engineers (USACE), under existing statutory authority that comes from authorizations and powers of the Federal Emergency Management Agency (FEMA), is leasing many buildings nationwide such as hotels, college dormitories, and larger open buildings to immediately convert them into hospital facilities. To assist USACE and FEMA efforts, the United States Army is setting up field hospitals in cities widely affected by the pandemic. Some of these facilities will have ICU capability for patients of the pandemic, while others will serve non-coronavirus patients to allow established hospitals to concentrate on the pandemic. A public briefing of the plan was given by Army General Todd Semonite on March 20. USACE will handle leasing and engineering, with contracts for rapid facility modification and setup issued to local contractors. The plan envisions that operation of the facilities and the provision of medical staff would be entirely handled by the various U.S. states rather than the Federal government. One of the early and largest buildings to be converted is the Jacob K. Javits Convention Center in New York City, which was quickly being transformed into a 2,000-bed care facility on March 23, 2020. Beginning in mid-March, fifteen Urban Augmentation Medical Task Forces (UAMTFs) from the Army Reserve were deployed to 15 regions, including UAMTF 332-1 (from 332nd Medical Brigade out of Nashville, Tennessee) which was deployed to Newark, New Jersey for six weeks. Other UAMTFs were sent to New York City, Baton Rouge, Louisiana, and Seattle. At the height of this effort, U.S. Northern Command had deployed 9000 military medical personnel. As of July 2020 additional Reserve personnel are on 'prepare-to-deploy orders' to Texas and California.

According to a mid-April report, the Joint Force Headquarters National Capital Region's Joint Task Force National Capital Region was activated on March 16, operating under multiple contingency plans, from specific pandemic response operations to White House-directed continuity plans, in support of COVID-19 response efforts in the Washington, D.C., Maryland, and Virginia region.

In addition to the many popup hospitals nationwide, the Navy on March 18 prepared to deploy two hospital ships, USNS Mercy and USNS Comfort. The ships will take in non-coronavirus patients transferred from land-based hospitals, so those hospitals can concentrate on virus cases. Mercy arrived in Los Angeles on March 27, and Comfort arrived in New York City on March 30. On April 1, it was reported that the United States Department of Defense was working to provide 100,000 military-style nylon body bags to fulfill a request from FEMA. Only half this number was already kept in stock by the military.

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 in the Seventh District (southeast and Atlantic territories) carrying more than fifty people to prepare to care for sick people onboard indefinitely, for vessels requesting medical evacuation to make arrangements with an on-shore hospital, and for foreign vessels to seek medical assistance from their country of registration. Despite earlier opposition from the governor of Florida, arrangements were made allowing MS Zaandam and MS Rotterdam to dock at Port Everglades on April2 after nearly two hundred people became ill with COVID-19 and four passengers died.

In regards to the status of U.S. military readiness during the pandemic, Chairman of the Joint Chiefs of Staff General Mark Milley said on April9 that the military was ready for any contingency and was adapting to "operating in a COVID-19 environment", further warning that it would be a "terrible, tragic mistake" for anyone attempting to take advantage of the crisis to harm the U.S. or its interests. By April 9, 1,898 service members had confirmed cases of COVID-19-1,389 Army soldiers, 367 Air Force personnel, 164 Marines, 597 Navy sailors, and 381 National Guard members, less than 0.09% of military forces. 64 service members had been hospitalized.

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 $34billion to $251billion 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.

The pandemic has had far-reaching consequences in the country that go beyond the spread of the disease itself and efforts to quarantine it, including political, cultural, and social implications.

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. April7 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.

Public response

Polling showed a significant partisan divide regarding the outbreak. NPR, PBS NewsHour, and Marist found in their mid-March survey that 76% of Democrats viewed COVID-19 as "a real threat", while only 40% of Republicans agreed; the previous month's figures for Democrats and Republicans were 70% and 72%, respectively. A mid-March poll conducted by NBC News and The Wall Street Journal found that 60% of Democrats were concerned someone in their family might contract the virus, while 40% of Republicans expressed concern. Nearly 80% of Democrats believed the worst was yet to come, whereas 40% of Republicans thought so. About 56% of Democrats believed their lives would change in a major way due to the outbreak, compared to 26% for Republicans. A mid-March poll by the Kaiser Family Foundation found that 83% of Democrats had taken certain precautions against the virus, compared to 53% of Republicans. The poll found that President Trump was the least-trusted source of information about the outbreak, at 46% overall, after the news media (47%), state and local government officials (70%), WHO (77%), and CDC (85%). 88% of Republicans expressed trust in the President; 69% of Democrats expressed trust in the media. A CNBC/Change Research Poll conducted in early May-in six states where the November election was expected to be close-found that 97% of Democrats but only 39% of Republicans were "seriously concerned" about the outbreak, and similarly that Democrats were far more likely to report taking health precautions.

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.

Political analysts anticipated it 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, and Trump's approval rating increased from 44% to 49% in Gallup polls, although it then 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. An April 21 Washington Post-University of Maryland 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 by the Associated Press and NORC at the University of Chicago 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.

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.

A poll conducted from May 7 to 10 by SRSS, for CNN, 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% feel the federal government is not doing enough to address the limited availability of COVID-19 testing. 58% feel the federal government is not doing enough to prevent a second wave of COVID-19 cases later in 2020. A poll conducted from May 20 and 21 by Yahoo News and YouGov 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. Regarding a debunked conspiracy theory that philanthropist Bill Gates was planning to use mass COVID-19 vaccinations to implant microchips into people to track them, 44% of Republicans believed the conspiracy theory, as did 19% of Democrats.

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. Doctor Fauci said it could be a "perfect set-up for the spread of the virus". Fauci also said, "Masks can help, but it's masks plus physical separation".

Statistics

The CDC publishes official numbers every Monday, Wednesday, and Friday, 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 note that statistics on confirmed coronavirus cases are misleading, since the shortage of tests means the actual number of cases is much higher than the number of cases confirmed. The number of deaths confirmed to be due to coronavirus is likely to be an undercount for the same reason. Conversely, deaths of people who had underlying conditions may lead to overcounting. Excess mortality comparing deaths for all causes versus the seasonal average is more reliable, but it may include deaths due to strained healthcare systems, bans on elective surgery, or by policies aimed at curtailing the epidemic. 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.

The original CDC-developed tests sent out on February5 turned out to be faulty. The faulty test produced a false positive from ordinary running water; a newer version is accurate and reliable. On February 29, the FDA announced that labs would be allowed to do their own in-house testing immediately, independently of CDC testing, as long as they complete an emergency use authorization (EUA) within 15 days.

Map of states and territories in the U.S. with number of confirmed cases as of July 25, 2020

Map of states and territories in the U.S. with number of confirmed deaths (as of July 21, 2020)

Confirmed COVID-19 cases by county (as of July 23, 2020)

Confirmed cases per 100,000 residents by state as of July 24, 2020

> 100,000 cases

50,000-100,000 cases

Progression charts

No. of new daily cases (also in covidtracking.com and Worldometers):

No. of new daily recoveries:

No. of new daily deaths (also in covidtracking.com and Worldometers):

The plots above are charts showing the number of COVID-19 cases, deaths, and recoveries in the U.S. since February 26, 2020. The plot below uses a log scale for all four y axes on one plot to show relationships between the trends. On a log scale, data that shows exponential growth will plot as a more-or-less straight line. Each major division is a factor of 10. This makes the slope of the plot the relative rate of change anywhere in the timeline, which allows comparison of one plot with the others throughout the pandemic.

Daily new tests from Our World in Data, from owid-covid-data.csv [2] ( chart, pop-adjusted chart), smoothed via 7-day moving average:

Test positivity rate for US, calculated from Our World in Data (OWID), from owid-covid-data.csv [3] ( chart), smoothed via 7-day moving average:

Test positivity rate is the ratio of positive tests to all tests made on the day.

As of July 19, 2020, maximum test positivity rates on state level (7-day average) are 23.6% for Arizona, 19.1% for Nevada and 18.7% for Florida [4].

Weekly covid-positive hospitalizations from cdc.gov, from COVID19Phase5Data.zip, from Weekly_Data_Counts.csv [5]:

A more up-to-date hospitalization chart is available at covidtracking.com.

Demographics

No. of deaths by age

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 projected the death toll would reach 115,000-135,000 by June 20. The CDC eventually counted 119,000 deaths by this date.

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. Adjusted for growth in population, these would be per-capita equivalents of 2,147,000, 218,000, and 164,000, respectively, in 2020.

Impact of face coverings

IHME predicted that universal wearing of face masks could prevent between 17,000 and 28,000 deaths between June 26 and October 1, 2020. An IHME model in early July 2020 projected that nationwide deaths would exceed 200,000 by November 1 if people did not wear masks.

References

# data[].attributes.attachment_link.description
COVID-19 pandemic in the United States Map of the outbreak in the United States by confirmed new infections per 100,000 people (14 days preceding July 24) 200-500 confirmed new cases 100-200 confirmed new cases 50-100 confirmed new cases 20-50 confirmed new cases 10-20 confirmed new cases Map of the outbreak