Policy Analysis | November 2020

Spread of COVID-19 within Regions of the United States

Mikko Lindberg and Roger Moore

Last updated: November 19, 2020

A multitude of governmental, private and nonprofit research entities are closely monitoring the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) – the novel coronavirus that causes coronavirus disease 2019 (COVID-19)1,2 – across the United States on city, county, state and national levels. Originally, at the outset of the pandemic, a limited amount of research existed for how the virus circulated on a regional basis.3 Since the response of the federal government to the pandemic focused primarily on international travel restrictions, economic stimulus and distribution of medical supplies,4,5 public safety measures addressing social distancing, school closures, shelter-in-place orders and other precautions were established by state governors, city mayors and county executives. Across the nation, the timing and extent of these measures varied widely, particularly shelter-in-place orders and subsequent state reopenings (see Appendices I-III).6,7,8 Many experts and officials warned that a similarly uncoordinated approach to phasing out public safety measures would lead to the resurgence in positive cases and deaths that began in June and continued the following two months.9,10,11,12 Recently, a new surge, what many are calling the "third wave" of the pandemic, has led to a record number of cases and hospitalizations in the United States, with no clear indication that it will subside anytime soon.

This SLC Policy Analysis, updated on a weekly basis, tracks the movement of SARS-Cov-2 in four regions of the United States, in relation to the state and territorial membership of The Council of Governments (CSG).

Regions of The Council of State Governments
Region Member states and territories
East Connecticut, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Washington, D.C., Puerto Rico, U.S. Virgin Islands
Midwest Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin
South Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia
West Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, Wyoming, American Samoa, Guam, Northern Mariana Islands

Drawing on daily state-level data collected and published by The COVID Tracking Project – a volunteer organization launched from The Atlantic and referenced by Johns Hopkins,13 The White House and numerous national news syndicates – the following graphs portray seven-day moving averages14 for newly identified positive cases of COVID-19 and deaths attributed to COVID-19, along with three-day averages for the number of hospitalizations, within CSG's regions and the nation. These figures are presented in two ways: 1) seven-day moving averages for the daily change in absolute numbers and 2) seven-day moving averages for the daily change per capita (see Appendix IV for population calculations).15 For hospitalizations, three-day averages, both in absolute numbers and per capita, are included.

Of note, the sizable populations of certain states – such as California in the West; Florida and Texas in the South; New York and Pennsylvania in the East; and Illinois, Michigan and Ohio in the Midwest – have greater effect on the overall trend of their region. The state of New York, particularly, during the first peak of COVID-19 in the United States (April 2020), became the epicenter of the pandemic, accounting for more than 30 percent of the national total of confirmed positive cases and more than 40 percent of total deaths.16 Similarly, the summer surges in the South and West were driven primarily, though not entirely, by an increase in cases in Arizona, California, Florida and Texas beginning in the middle of June. The most recent surge is concentrated in the Midwest, but cases are rapidly increasing in every region, and the overall situation is expected to worsen before there is any improvement.


Figure 1: Seven-day moving average of daily change in positive cases of COVID-19 in the United States and CSG regions (March 15 – November 18, 2020)

(Clicking a region in the legend will show and hide its line)

Figure 1 shows three distinct trends for the average daily change in positive cases of COVID-19 in the CSG regions. In the East, the seven-day moving average peaked on April 11 at 18,601 new positive cases per day, then steadily fell through May and most of June. In the past month, new positive cases in the region have increased by nearly 250 percent, from an average of 6,000 per day in the middle of October to 20,800 in the middle of November. The data suggests additional increases during the remainder of November. In the Midwest, new positive cases peaked on May 5 and then declined until the middle of June, when there was a sharp uptick in cases that has continued through the first three weeks of November and shows no signs of abating. The seven-day moving average in the Midwest continues trending upward and, in the past month, has increased 256 percent, from 16,000 to 57,000. Meanwhile, the South and West followed similar paths, with moderate upward trajectories in the number of positive cases throughout the month of May, followed by more severe increases in June that continued through the first three weeks of July. It appeared both regions had reached their peaks in July; however, significant increases during the months of October and November have pushed the seven-day moving average of positive cases to record highs. During the past month, positive cases have increased approximately 100 percent in the South and 180 percent in the West. Like the other regions, the data indicates that neither the South nor West has reached a peak in cases, with additional increases expected in the weeks ahead. Nationally, the trajectory of positive cases surged in the second week of June and continued through most of July, with the seven-day moving average surpassing 60,000 in mid-July. Positive cases declined from the end of July until the second week of September. However, in the past month, new positive cases have increased approximately 175 percent, from an average of 54,000 per day in the middle of October to 150,000 in the middle of November. There is no indication that the numbers will decrease during the next couple of weeks, making the current surge the worst since the pandemic began.


Figure 2: Seven-day moving average of daily change in positive cases of COVID-19 per one million people in the United States and CSG regions (March 15 – November 18, 2020)

(Clicking a region in the legend will show and hide its line)

Figure 2 underscores the distinct trajectories of new positive cases per capita in all four regions. The East and, to a less extent, the Midwest, were more affected by the virus during the first two months of the pandemic, while the South and West had a relatively small number of cases per capita. However, upward trajectories in the South and West resulted in both regions surpassing the East and Midwest during the first week of June, a discrepancy that widened significantly during June and most of July. In the South, the average daily change in new positive cases per capita initially peaked on July 21, at 316 new cases per one million people, while new positive cases in the West initially peaked on July 24, at 216 new cases per one million people. However, a surge in both regions that started gradually in the middle of September and then accelerated in October and November has pushed the number of cases to new highs. Meanwhile, a surge in positive cases in the Midwest that began in the middle of June and increased exponentially during the second week of September pushed its seven-day moving average for November 18 to almost 930 per cases one million people, making it the most affected region nationally by a significant margin. The region continues to set daily records in the number of cases per capita, with the data indicating more increases in the weeks ahead. The East continues to be less affected than the other three regions, but the trajectory has increased during the past two months, particularly in October and November. Nationally, the average daily change in new positive cases initially peaked at 200 per one million people during the third week of July. However, as of November 18, new positive cases averaged 471 per one million people, more than doubling the previous peak.


Figure 3: Three-day average of hospitalizations for COVID-19 in the United States and CSG regions (March 15 – November 18, 2020)

(Clicking a region in the legend will show and hide its line)

Hospitalizations (Figure 3) show how each region has been affected, to varying degrees, at different points in the year. The three-day moving average of hospitalizations in the East was more than three times higher than any of the other regions at the height of the first wave in April, before declining during the subsequent months. By the first week of July, hospitalizations in the East were lower than the other three regions, a pattern that has held steady through most of November. Meanwhile, hospitalizations surged in the South and West during the second half of July, with the South approaching hospitalization levels experienced in the East in April. By contrast, the Midwest currently is amid its worst outbreak, with hospitalizations increasing exponentially during the past month. Notably, as of November 18, the South continues to have more hospitalizations than any other region, although it is not as severe as the previous peak in July. Nationally, the three-day moving average of hospitalizations is breaking new records daily, with no clear sign of abating in the near future. As of November 18, the number of hospitalizations was higher than 79,000. The previous peak, in April, was 67,000.


Figure 4: Three-day average of hospitalizations for COVID-19 per one million people in the United States and CSG regions (March 15 – November 18, 2020)

(Clicking a region in the legend will show and hide its line)

Regional hospitalizations per capita (Figure 4) similarly have experienced various waves at different points in the year. In April, hospitalizations in the East were more than double the national average and three to four times higher than any of the other regions at that time. The Midwest also was impacted at the beginning of the pandemic, though to a much lesser degree. Hospitalizations in that region were at or below the national average for most of the year, until they begin rapidly increasing at the beginning of October. As of November 18, hospitalizations per capita are significantly higher in the Midwest than they are in any other region, and the data suggests the discrepancy could widen in the weeks ahead. Meanwhile, hospitalizations in the South and West initially peaked in July, though there are indications that both regions could surpass their previous peaks within the next few weeks. As of November 18, hospitalizations in the West were about 8 percent lower than they were in July, while hospitalizations in the South were about 19 percent lower. Nationally, hospitalizations per capita stand at nearly 240 per one million people, much higher than at any other point during the pandemic.


Figure 5: Seven-day moving average of daily change in deaths caused by COVID-19 in the United States and CSG regions (March 15 – November 18, 2020)

(Clicking a region in the legend will show and hide its line)

Although new positive cases of COVID-19 in the United States have begun surging again, deaths attributed to COVID-19 (Figure 5) have not reached their previous peaks in the East, South or West. In the East, deaths peaked on April 16, after which they declined significantly and remain very low compared to earlier in the year. Meanwhile, average daily deaths in the South and West remained consistent through the month of June, before increasing significantly at the beginning of July. In the past month, the seven-day moving averages for daily deaths have increased by approximately 20 percent in the South and 56 percent in the West. The Midwest is experiencing a significantly worse outbreak during the current surge, with the number of deaths surpassing the previous peak by a wide margin. As of November 18, the seven-day moving average of deaths was 408, an 18 percent increase from the previous peak at the beginning of May. Nationally, the seven-day moving average of daily deaths was 1,209 on November 18. While it still is higher than the number of deaths recorded at the beginning of July, it remains much lower than the first peak in April.


Figure 6: Seven-day moving average of daily change in deaths caused by COVID-19 per one million people in the United States and CSG regions (March 15 – November 18, 2020)

(Clicking a region in the legend will show and hide its line)

The seven-day moving average for the daily change in deaths on a per capita basis (Figure 6) also displays a few notable regional comparisons. The East has borne the greatest number of deaths per capita from COVID-19, due to its devastating effect there in March and April. At its peak on April 16, daily deaths per capita in the East averaged 20 per one million people, more than three times the national average at the time. The Midwest similarly was affected, albeit at a much lower severity, at the beginning of the pandemic. Deaths declined at the beginning of May and continued falling through the middle of July; however, the recent surge has pushed the number of daily deaths to almost 7 per one million people, which is currently the highest nationally. Meanwhile, the daily death tolls of COVID-19 began climbing in the South and West at the beginning of July and continued through the first week of August. In the South, deaths began climbing again during the first week of November, while deaths in the West have been increasing since the middle of October.

Total positive cases of COVID-19 and deaths attributed to COVID-19 within CSG’s regions and the United States (last updated November 18, 2020)

Region Estimated 2019 population
Percent of total U.S. population
Total
positive
cases
Total positive cases per one million people Percent of total U.S. positive cases (adjusted for population) Total
deaths
Total deaths per one million people
Percent of total U.S. deaths (adjusted for population)
East 67,008,095 20.2% 1,779,138 26,551 19.6% 76,306 1139 38.2%
Midwest 62,191,576 18.7% 2,632,726 42,333 31.2% 42,411 682 22.9%
South 123,992,683 37.4% 4,693,309 37,851 27.9% 86,663 699 23.4%
West 78,616,055 23.7% 2,268,137 28,851 21.3% 36,324 462 15.5%
United States 331,808,409 100.0% 11,373,310 34,277 100.0% 241,704 728 100.0%

As illustrated by Figures 1-6, states in the East demonstrated success in curbing the spread of the novel coronavirus before experiencing a renewed increase in cases during the past two months. However, when factoring in the region's total population, Eastern states still account for 38 percent of total U.S. deaths, despite the recent surge in cases in the other regions. As of November 18, the Midwest accounted for 31 percent of total positive cases, when adjusted for population, followed by the South at 28 percent. The East and West accounted for 20 percent and 21 percent of cases, respectively, when adjusted for population. Although the speed and severity of how SARS-CoV-2 is transferred from person to person is affected by multiple factors, the regional trajectories provided in this analysis indicate that the novel coronavirus is still active and spreading in all four regions. Nationally, deaths began increasing the first week of July after steadily declining since the initial peak in the middle of April. The national increase was primarily attributed to the South and West, where a surge in positive cases in June precipitated a proportional increase in deaths at the beginning of July. Positive cases in all four regions are beginning to increase again, to varying degrees, and will continue to do so for at least the next few weeks. With the rise in cases, the number of deaths likely will increase during the last two weeks of November and, possibly, the remainder of the year.


Appendix I – Start date of statewide shelter-in-place orders (as of April 9, 2020)

Source: Jennifer Kates, Josh Michaud and Jennifer Tolbert, "Stay-At-Home Orders to Fight COVID-19 in the United States: The Risks of a Scattershot Approach," Kaiser Family Foundation, April 5, 2020, updated April 9, 2020, https://www.kff.org/coronavirus-policy-watch/stay-at-home-orders-to-fight-covid19/.


Appendix II – Shelter-in-place orders for COVID-19 (as of April 30, 2020)

Source: “Shutdown, Shelter in Place, and Back to Work Orders in the U.S.: Current Status,” Bryan Cave Leighton Paisner LLP, May 1, 2020, https://www.bclplaw.com/en-US/insights/shutdown-shelter-in-place-and-back-to-work-orders-in-the-us-current-status.html.


Appendix III – Status of State Reopenings (as of July 29, 2020)

Source: Jasmine C. Lee et al., “See How All 50 States Are Reopening (and Closing Again),” The New York Times, updated July 29, 2020, https://www.nytimes.com/interactive/2020/us/states-reopen-map-coronavirus.html.


Appendix IV – Populations of CSG Regions
State/Territory/Region Population
Connecticut 3,565,287
Delaware 973,764
Maine 1,344,212
Maryland 6,045,680
Massachusetts 6,892,503
New Jersey 8,882,190
New Hampshire 1,359,711
New York 19,453,561
Pennsylvania 12,801,989
Rhode Island 1,059,361
Vermont 623,989
District of Columbia 705,749
Puerto Rico 3,193,694
U.S. Virgin Islands * 106,405
East 67,008,095
Illinois 12,671,821
Indiana 6,732,219
Iowa 3,155,070
Kansas 2,913,314
Michigan 9,986,857
Minnesota 5,639,632
Nebraska 1,934,408
Ohio 11,689,100
North Dakota 762,062
South Dakota 884,659
Wisconsin 5,822,434
Midwest 62,191,576
Alabama 4,903,185
Arkansas 3,017,804
Florida 21,477,737
Georgia 10,617,423
Mississippi 2,976,149
Missouri 6,137,428
Kentucky 4,467,673
Louisiana 4,648,794
North Carolina 10,488,084
Oklahoma 3,956,971
South Carolina 5,148,714
Tennessee 6,829,174
Texas 28,995,881
Virginia 8,535,519
West Virginia 1,792,147
South 123,992,683
Alaska 731,545
Arizona 7,278,717
California 39,512,223
Colorado 5,758,736
Hawaii 1,415,872
Idaho 1,787,065
Montana 1,068,778
Nevada 3,080,156
New Mexico 2,096,829
Oregon 4,217,737
Utah 3,205,958
Washington 7,614,893
Wyoming 578,759
American Samoa * 55,519
Northern Mariana Islands * 53,883
Guam * 159,385
West 78,616,055

Sources: “Annual Estimates of the Resident Population for the United States, Regions, States, and Puerto Rico: April 1, 2010 to July 1, 2019 (NST-EST2019-01),” U.S. Census Bureau, accessed May 6, 2020, https://www.census.gov/data/tables/time-series/demo/popest/2010s-state-total.html and “The U.S. Census Bureau Begins to Count U.S. Island Areas Populations,” Press Release, U.S. Census Bureau, March 2, 2020, https://www.census.gov/newsroom/press-releases/2020/2020-island-areas-populations.html.

* The U.S. Census Bureau does not estimate the populations of American Samoa, Guam, Northern Mariana Islands, and United States Virgin Islands between the decennial censuses. Their populations in 2010 are included and used in per capita calculations.


Notes:

1 “Human Coronavirus Types,” National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, U.S. Department of Health & Human Services, accessed May 7, 2020, https://www.cdc.gov/coronavirus/types.html.

2 “Naming the coronavirus disease (COVID-19) and the virus that causes it,” World Health Organization, accessed May 7, 2020, https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it.

3 As of May 7, 2020, the authors of this analysis were able to identify only one report that included regional COVID-19 statistics: “COVID-19 Updates,” Center for Health Metrics and Evaluation, American Heart Association, May 5, 2020, https://healthmetrics.heart.org/wp-content/uploads/2020/03/COVID-19-Updates_5-5-2020.pdf.

4 Caitlin Oprysko, Anita Kumar and Nahal Toosi, “Trump administration expands travel ban,” Politico, January 31, 2020, https://www.politico.com/news/2020/01/31/trump-administration-expands-travel-ban-110005.

5 Sharon Parrott et al., “CARES Act Includes Essential Measures to Respond to Public Health, Economic Crises, But More Will Be Needed,” Center on Budget and Policy Priorities, March 27, 2020, https://www.cbpp.org/research/economy/cares-act-includes-essential-measures-to-respond-to-public-health-economic-crises.

6 Jennifer Kates, Josh Michaud and Jennifer Tolbert, "Stay-At-Home Orders to Fight COVID-19 in the United States: The Risks of a Scattershot Approach," Kaiser Family Foundation, April 5, 2020, updated April 9, 2020, https://www.kff.org/coronavirus-policy-watch/stay-at-home-orders-to-fight-covid19/.

7 “Shutdown, Shelter in Place, and Back to Work Orders in the U.S.: Current Status,” Bryan Cave Leighton Paisner LLP, May 1, 2020, https://www.bclplaw.com/en-US/insights/shutdown-shelter-in-place-and-back-to-work-orders-in-the-us-current-status.html.

8 Jasmine C. Lee et al., “See How All 50 States Are Reopening (and Closing Again),” The New York Times, updated July 29, 2020, https://www.nytimes.com/interactive/2020/us/states-reopen-map-coronavirus.html.

9 Jennifer Kates et al., "Stay-At-Home Orders to Fight COVID-19." (See reference 6.)

10 Teresa Yamana, Sen Pei and Jeffrey Shaman, “Projection of COVID-19 Cases and Deaths in the US as Individual States Re-open,” May 4, 2020, Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, https://behcolumbia.files.wordpress.com/2020/05/yamana_etal_reopening_projections.pdf.

11 “Dr. Anthony Fauci & CDC Director Senate Testimony Transcript,” Rev.com, May 12, 2020, https://www.rev.com/blog/transcripts/dr-anthony-fauci-cdc-director-senate-testimony-transcript-may-12.

12 Teo Armus et al., “Live updates: Vaccine expert to warn of ‘darkest winter in modern history’ without coordinated U.S. response,” The Washington Post, accessed May 14, 2020, https://www.washingtonpost.com/nation/2020/05/14/coronavirus-update-us/.

13 The Coronavirus Resource Center of Johns Hopkins utilizes The Covid Tracking Project figures for testing and hospitalizations as one of multiple data sources to track COVID-19 globally and nationally.

14 Due to considerable daily fluctuations in the numbers of new positive cases and deaths, the historical data for these figures have been normalized through averaging of daily counts. For instances where new positive cases or deaths experience an artificial spike due to changes in how an individual state calculates and reports its daily figures, but does not update historical data, the exaggerated increase is distributed through averaging into counts for the previous weeks or months, depending on the estimated length of the data anomaly. Although data on current hospitalizations is presently collected for all 50 states and U.S. territories, the start date of this data collection for individual states varies widely. In these instances, the number of hospitalizations on the first day the number was reported has been evenly distributed among the days the data is missing. For further information about the normalization of data anomalies, you may contact SLC Senior Communications and Research Specialist Mikko Lindberg, at mlindberg@csg.org.

15 The total populations of CSG’s regions derive from the most recent state population (2019) and territorial (2010) estimates by the U.S. Census Bureau: “Annual Estimates of the Resident Population for the United States, Regions, States, and Puerto Rico: April 1, 2010 to July 1, 2019 (NST-EST2019-01),” U.S. Census Bureau, accessed May 6, 2020, https://www.census.gov/data/tables/time-series/demo/popest/2010s-state-total.html and “The U.S. Census Bureau Begins to Count U.S. Island Areas Populations,” Press Release, U.S. Census Bureau, March 2, 2020, https://www.census.gov/newsroom/press-releases/2020/2020-island-areas-populations.html.

16 "Our Data," The Covid Tracking Project at The Atlantic, accessed May 19, 2020, https://covidtracking.com/data.