Policy Analysis | March 2021

Spread of COVID-19 within Regions of the United States

Mikko Lindberg and Roger Moore

Over the course of a year, this SLC Policy Analysis tracked the proliferation of COVID-19 amongst The Council of State Government's four regions, using data collected and published by The COVID Tracking Project. On March 7, 2021, updates to the data hosted by the project were discontinued and, consequently, this analysis of the data on a regional basis was concluded.

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 initial 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 A new surge, which began in the final months of 2020, led to a record number of cases, hospitalizations and deaths across the nation. However, positive cases and hospitalizations both have declined significantly in recent weeks, suggesting the most recent surge has subsided.

This SLC Policy Analysis examines the movement of SARS-Cov-2 in four regions of the United Statesfrom March 2020 to March 2021 in relation to the state and territorial membership of The Council of Governments (CSG), as provided below.

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 the number of current hospitalizations for a given day, 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 Current hospitalizations are examined in both absolute numbers and on a per capita basis.

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 initially was concentrated in the Midwest, before cases subsequently increased in the other regions.


Figure 1: Seven-day moving average of daily change in positive cases of COVID-19 in the United States and CSG regions (March 15, 2020 – March 7, 2021)

(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 approximately 18,600 new positive cases per day, then steadily fell through May and most of June, before marginally increasing through most of September. However, beginning in October, positive cases began increasing rapidly and continued rising until the middle of January. The growth rate has slowed since then, and the data suggest further declines are probable. In the Midwest, new positive cases remained relatively low until October, when the region experienced a sharp uptick in cases through the first three weeks of November. From the beginning of October through the third week of November, cases increased by more than 400 percent. Since then, however, cases in the Midwest have begun decreasing and are now below the number of cases recorded in the other regions. Meanwhile, the South and West have followed similar paths since the outset of the pandemic, 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 from the beginning of October through the end of December pushed the seven-day moving average of positive cases to record highs. The number of cases in both regions began declining in January and it appears the worst of the surge has passed. 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, at which point they began rapidly increasing through the beginning of January. However, during the past two months, the overall situation has improved considerably, with the number of cases declining more than 75 percent between January 12 and March 7.


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, 2020 – March 7, 2021)

(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 both the South and West, the average daily change in new positive cases per capita first peaked on July 21, at 318 and 213 cases per one million people, respectively, before declining the following two months. However, a surge in both regions that started gradually in the middle of September and continued through the middle of January 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 to a peak of 930 cases per one million people on November 19. Since then, the number of cases per capita has fallen in the Midwest by 86 percent. Nationally, the average daily change in new positive cases peaked at 723 per one million people on January 12 following months of increases before beginning to decline.


Figure 3: Current hospitalizations for COVID-19 in the United States and CSG regions (March 15, 2020 – March 7, 2021)

(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 held steady through the first week of December. 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. The recent surge that began at the end of September pushed hospitalizations in both the South and West to record highs at the beginning of 2021. The Midwest experienced significant increases in hospitalizations during October and November, before declining the following month. Nationally, the three-day moving average of hospitalizations was breaking new records daily during the last three months of 2020, eventually peaking at more than 132,000 on January 7.


Figure 4: Current hospitalizations for COVID-19 per one million people in the United States and CSG regions (March 15, 2020 – March 7, 2021)

(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 and November. The situation in the Midwest improved considerably in December and, as of March 7, the number of hospitalizations per capita is the lowest among the four regions. Meanwhile, hospitalizations in the South and West initially peaked in July, but the recent surge pushed both regions beyond their previous peaks. However, during the past two months, hospitalizations per capita in the South and West have declined 68 percent and 79 percent, respectively, signaling that the worst may have passed. As of March 7, the East and South have more hospitalizations per capita than the other two regions. Nationally, hospitalizations per capita peaked at nearly 399 per one million people on January 7.


Figure 5: Seven-day moving average of daily change in deaths caused by COVID-19 in the United States and CSG regions (March 15, 2020 – March 7, 2021)

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

As the number of new positive cases of COVID-19 continued to increase during the most recent surge in the final months of 2020 and the beginning of 2021, the number of deaths subsequently spiked (Figure 5). In the East, deaths steadily climbed between the beginning of November and middle of January; however, they remained 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. Between the beginning of December and beginning of February, deaths climbed by 156 percent in the South and 228 percent in the West. However, the situation has improved since then, with deaths declining more than 45 percent in both regions since the beginning of February. The Midwest also experienced a severe outbreak during the most recent surge, with the number of deaths rapidly increasing from the middle of October through the middle of December. Nationally, the seven-day moving average of daily deaths was 1,629 on March 7, more than 50 percent lower than the peak of 3,371 recorded on January 15.


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, 2020 – March 7, 2021)

(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 24 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, between the end of October and the end of the year, the Midwest experienced more daily deaths per capita than any other CSG region. 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 began increasing in the middle of October, trajectories that continued until the beginning of February.

Total positive cases of COVID-19 and deaths attributed to COVID-19 within CSG’s regions and the United States (last updated March 7, 2021)

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% 5,207,759 77,718 22.7% 137,088 2046 31.8%
Midwest 62,191,576 18.7% 5,607,056 90,158 26.3% 99,582 1601 24.9%
South 123,992,683 37.4% 11,395,258 91,903 26.8% 187,880 1515 23.6%
West 78,616,055 23.7% 6,546,111 83,267 24.3% 99,426 1265 19.7%
United States 331,808,409 100.0% 28,756,184 86,665 100.0% 523,976 1579 100.0%

As illustrated by Figures 1-6, all four regions have experienced a combination of successes and setbacks in curbing the spread of the novel coronavirus since it first emerged in the early months of 2020. When factoring in the regions' populations, Eastern states account for 32 percent of total U.S. deaths, followed by the Midwest, South, and West at 25 percent, 24 percent, and 20 percent, respectively. Adjusted for population, the number of positive cases is similar across the four regions, led by the South at 27 percent. The regional trajectories provided in this analysis indicate that the novel coronavirus is still active in all four regions, albeit spreading at a significantly slower rate. With the administration of vaccinations accelerating across the country, it is likely the worst of the pandemic in the United States has passed, as long as new and highly transmissible variants of the virus do not stymie the progress the nation has made.


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.