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The United States has surpassed yet another devastating milestone in the ongoing COVID-19 pandemic: 250,000 Americans have now died from the disease. That's more than twice the number of U.S. service members killed in World War I.

Coronavirus case numbers are exploding across the country at the beginning of what is shaping up to be a difficult winter of illness in America.

"Unfortunately, we are entering what I think will be the worst stretch that we have experienced so far," says 

, an epidemiologist at the Johns Hopkins Center for Health Security. "We're seeing hot spots all across the country and new highs for the number of cases and hospitalizations." 

In the past week, 36 states and one territory set records for daily new confirmed cases, and 12 states saw a day with the highest number of new deaths.

The virus is currently hitting the middle of the country especially hard, with the highest number of 

 in North and South Dakota, Minnesota, Wyoming, Wisconsin, Iowa, Nebraska and Montana. More than 76,000 people are currently hospitalized with the virus, 

With cases spiking, more deaths will follow — but advances in medicine in recent months have improved the odds of surviving COVID-19.

The infection fatality rate is declining by about 30%, says 

, professor and epidemiologist with the Institute for Health Metrics and Evaluation, and the chief strategy officer for Population Health at the University of Washington. 

That rate measures the fatality of those who are infected, not only those who are diagnosed, by using antibody testing data to understand 

the prevalence of the virus at a large scale

And the infection fatality rate is falling in all age groups, including among the elderly. Doctors and nurses now have more experience dealing with COVID-19 and anticipating its complications, and there have been advances in treatment and triage, Mokdad says. 

Unfortunately, that decline in the infection fatality rate comes as winter arrives, and more hospitalizations and deaths are expected. "The virus loves the cold," Mokdad says, and people are also moving more of their socializing indoors as temperatures drop. 

Now more infections are happening among family and friends in home settings. "These are the people you trust the most — you feel like they're not going to hurt you. And we see a lot of people not wearing a mask, not paying attention to safe distance," Mokdad says. "The virus is more likely to stay in the air, and more people are likely to get infected indoors."

So where are we in the trajectory of the coronavirus?

According to the Institute for Health Metrics and Evaluation's 

, by March 1, the U.S. may see nearly 439,000 total deaths from COVID-19. But Mokdad and his colleagues have calculated two alternative scenarios, depending on the path the country takes. If governmental mandates to limit the spread are eased, the model predicts more deaths: perhaps 587,000 by March 1. 

But if everyone in the U.S. would wear masks every time they are in public, the number of anticipated casualties by that date drops to about 371,000.

While the coronavirus continues to ravage communities across the country, much has been learned about the virus and how to treat it. Doctors have learned to put patients on their stomachs — known as "

 called dexamethasone has proved effective in treating seriously ill patients. 

"Every day that we learn about it, I think we're treating it more effectively," says Ryan Taube, an emergency medicine physician in Fort Lauderdale, Fla. 

"When patients were first coming in with any kind of respiratory symptoms, the recommendation was to have them be intubated and put on ventilators right at the get-go — and that was why there was such a fear of critical shortage of ICU beds and ventilators throughout the United States," Taube said.

"But I think we're finding now that if we can try to keep them off of the ventilator with other means of therapies, that the patients do better."

Taube remembers that at the beginning of the pandemic, people who were very ill were staying at home – out of fear of going to the hospital. 

"We had patients with delayed heart attacks who stayed at their home for three days with chest pain thinking, 'Oh, I would normally go get this checked out, but I'm not going to do because of I'm scared of COVID,' " he said. "People breaking legs and limbs and things like that ... scared to come in. Now I still see some of that, but it's much, much less now."

this month, with Pfizer and Moderna each announcing that their experimental vaccines are highly effective in preventing disease – 

Dr. Anthony Fauci, the country's foremost infectious disease expert, 

that hopefully by the end of the year, the two companies will have enough doses available for 20 million people. Health care workers are expected to receive the vaccine first.

Mokdad calls the vaccine progress welcome, life-changing news — but he warns that any vaccines won't come in time to help us this winter. "All that we have between now and March 1 is to wear a mask, watch our distance and wash our hands," he says.

Rivers concurs: "We are still going to be facing the holidays. We're still going to be facing the winter months using the nonpharmaceutical interventions: the hand-washing, the masks, the closures that we have all been using to slow transmission for the last number of months."

And she notes that the first emergency use authorization for the vaccines will likely not apply to children as more data need to be collected to ensure any vaccines are safe and effective for them as well. 

"That means that schools and other institutions that serve primarily children may be continue to need to follow the nonpharmaceutical interventions longer than older adult communities, for example, just because they will not be eligible for the vaccine right away," she says. 

 is plaguing hospitals as the beds fill with COVID-19 patients.

Unlike early in the pandemic, cases aren't clustered in a few big hot spots. The virus is everywhere.

"We are in a worse place than we were even in the spring, because in the spring it was primarily New York City and New Jersey and Connecticut that were experiencing a strain on their health care systems," Rivers says. "Right now we are seeing intense community transmission really all across the country. And that doesn't leave a lot of wiggle room to make sure that we are able to deploy extra resources to those places."

: As the pandemic stretches on, people get tired of being vigilant about masks and social distancing and not gathering with others indoors. Many people have suffered economic pain from the virus and the restrictions that have followed, and are eager for their lives to return to normal. 

"Unfortunately, because we are in such a bad spot right now, it's more important now than ever that we are vigilant about taking these protective measures," Rivers says. 

‘Thanksgiving could be a superspreader event’

Earlier case upticks in some places followed holiday weekends such as Memorial Day, Mother's Day and July Fourth — and those all took place in warmer months.

"Now we are concerned that potentially Thanksgiving could be a superspreader event," Mokdad says. Not only is Thanksgiving generally celebrated by bringing family and friends together, often over long distances, but the main event is a meal. It's hard to wear a mask while you're eating.

Public health officials are pleading with Americans not to celebrate Thanksgiving the way they usually do but instead use this occasion to invent new traditions.

 is to drop off food contactlessly to another household and then share the meal over video. 

 it will lift the 40-minute limit for its free accounts on Thanksgiving, to make it easier for loved ones to gather at a distance.

We can always hold Thanksgiving dinners on a future date, Mokdad, "but we can never get our loved ones back if they die because we didn't pay attention. So delay it, cancel it, isolate yourself. Make sure you behave extremely well before you join your family."

NPR's Audrey Carlsen contributed to this report.

Health

Politics and Government News

COVID-19

Laurel Wamsley

Author

Medical advances have reduced the infection fatality rate in the U.S. But experts warn that indoor gatherings, cold temperatures and pandemic fatigue augur dark months ahead.

As U.S. reaches 250,000 deaths from COVID-19, a long winter is coming

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