The number of daily Covid-19 cases is continuing its steady climb as temperatures begin to dip across the US, students return to classrooms and more people stay indoors where the virus spreads easily.

While far fewer people are ending up hospitalised with the illness than during the pandemic’s surge in March and April, many more deaths are expected to be added to the almost 218,000 already reported nationally as cases spike, experts said.

“If you take a look from 30,000 feet, most states have rising case numbers, with no downward trends to be seen,” said William Schaffner, an infectious disease specialist at Vanderbilt University in Nashville, Tennessee. “That is troubling as winter approaches.”

Nationally, seven-day moving case averages have climbed to their highest in two months, while the number of currently hospitalised Covid-19 patients was the most since August 27, according to Johns Hopkins University and Covid Tracking Project data.

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“The seven-day average of deaths due to Covid-19 is still at about a third of peak levels in April, but a decline that took place over recent weeks appears to have stopped. Reported deaths often lag behind other numbers by several weeks,” said Schaffner, “so those numbers will likely follow the rising number of cases and hospitalisations.”

Rural surges

“All of us anticipate Covid-19 is going to increase this winter,” he said.

Hopes that warm summer weather might tamp down spread were frustrated by outbreaks in Sun Belt states. Since then, there’s been a surge of cases in the Upper Midwest and on college campuses across the country. The highest case rates per capita in the past seven days have been in North Dakota, South Dakota, Montana, Wisconsin and Utah. South Dakota leads the nation in Covid-19 hospitalisations per capita.

Those trends, and similar increases across Europe, are cause for alarm, said New York City Mayor Bill De Blasio.

“It’s absolutely troubling to see how far these places are falling backwards,” he said on Friday in an appearance on WNYC radio. “We can’t allow that to happen here.”

While the initial surge of the virus hit densely populated urban areas, it’s now overwhelming rural regions, suburbs and small cities. Based on the seven-day rolling average of new cases, New Mexico, Missouri, South Dakota, Michigan and Illinois have seen the biggest increases in the past week, by percentage.

“Overall, it’s looking grim to see the infections on the rise and the hospitalisations tracking with that,” said Eric Topol, director of the Scripps Translational Research Institute in La Jolla, California.

The growing number of daily cases is a key indicator of the virus’ nationwide spread. With holiday socialising, influenza and winter weather all on the horizon, the increased number of hospitalisations is also cause for concern that the health-care system may soon be overwhelmed once again in certain areas.

Indeed, hospitals in the Upper Midwest hot spots are reporting their resources stretched and having to send patients to hospitals hours away or even in other states. With the pathogen now more entrenched in the population, winter’s surge could be worse than the first.

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“We are arriving at the Covid-19 perfect storm,” said Michael Osterholm, director of the Centre for Infectious Disease Research and Policy at the University of Minnesota. “The current increases are only the start of a long winter ahead,” he said.

Improved treatment

One bright spot, Osterholm said, is that hospitals have become far more adept and have more tools available to treat the virus. Medicines like Gilead Sciences Inc’s remdesivir and generic steroid dexamethasone, both given to President Donald Trump after he was diagnosed, are helping people recover.

Increased testing is also catching more cases early. The Trump administration announced last month that it would distribute 150 million rapid tests made by Abbott Laboratories for use in nursing homes, schools, and hard-hit minority populations.

Diagnostics manufacturers are now shipping more than 1.4 million tests nationwide each day, up from 600,000 at the start of May, according to AdvaMed, a trade group for the medical-technology industry. Total shipments have surpassed 190 million tests.

But even states that not long ago appeared to be doing well have seen resurgences. In New York City, schools shuttered in several neighbourhoods shortly after reopening after a spike in cases in those areas.

“We’re just getting started,” said Osterholm, “And how bad it’s going to be is dependent on how the population responds. Right now, up to a third of the public doesn’t believe this is real; they believe it’s a hoax.”