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“We can’t handle much more”: Doctors sound alarm as COVID-19 surges in Alabama

Chip Brownlee | The Trace

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Some 7,283 cases of the coronavirus have been reported in Alabama since June 1, or about 29 percent of the state’s total confirmed case count, and while many of those who’ve tested positive may not be sick enough to be hospitalized, a doctor treating the sickest COVID-19 patients in Montgomery says he’s not sure how much more he and his colleagues can handle.

“Our seven-man group cannot handle much more at all,” said Dr. David Thrasher, the head of pulmonology at Jackson Hospital.

Thrasher and his six partners at Montgomery Pulmonary Consultants handle nearly every critically ill COVID-19 patient in the River Region who requires a ventilator or treatment in an ICU. That’s on top of their normal caseload of patients requiring critical pulmonary care.

“We’re twice our capacity, okay?” Thrasher said. “We’re working very, very long hours. Emotionally, it’s very, very stressful on everyone. We will do what it takes. We’re not going to give up. But there is a limit to what the human body can do.”

In an interview, Thrasher essentially begged the public to take the virus seriously and wear a mask when in public. And to not go out if you don’t have to.

“I’m a conservative guy,” Thrasher said. “I don’t like the government telling me what to do. But this is the only way we can control this until we have a vaccine. It needs to be done universally.”

Over the past week, as Alabama confirmed at least 5,000 cases of COVID-19, Montgomery reported about 15 percent of the state’s cases.

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At least 68 people have died in Montgomery County — at least 28 of them in the past two weeks. Neighboring Butler and Lowndes counties have the second- and third-highest per capita number of deaths in the state.

[For this data and more, check our COVID-19 data and mapping dashboard.]

“It’s bad,” Thrasher said. “The hospitals are darn near at capacity. We’ve got a lot of patients. It’s just steadily gone up the last week. The number of cases. People on ventilators. It’s bad. Unfortunately, it’s going to continue to get worse, I’m afraid.”

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At least 737 people have tested positive for COVID-19 in Montgomery County in the last seven days — the most of any county in the state. The percentage of tests that are positive in Montgomery County over the past week, on average, has been nearly 27 percent. Sunday saw the largest daily increase in new cases in Montgomery County.

Despite having a much smaller population than Jefferson County or Mobile County, which until now had the highest numbers of COVID-19 cases, Montgomery County now has the most cases of any county in Alabama. At least 2,791 people have tested positive since March.

What is most concerning about Montgomery, experts say, is how few of the cases have been linked through contact tracing to any particular facility, work place or business. Few of the cases in Montgomery have been in nursing homes or long-term care facilities.

State health officials say most of the transmission in Montgomery has not been epidemiologically linked, meaning most new infections are through community transmission as people go about their day-to-day lives and come into contact with someone who is infected.

“This is a bit like a forest fire, where if you have an isolated area, you can have the firefighters surround and isolate it off so it doesn’t spread any further,” said Dr. Michael Saag, a renowned infectious diseases expert at UAB. “When it’s very widespread, it’s an uncontrolled fire that we are really trying desperately to bring under control.”

It’s much easier to control isolated outbreaks through contact tracing and isolated quarantines. When new cases arise through community transmission, spread is much harder to contain.

Hospitals in Montgomery serve not just the state’s capital city and the county, but much of Central Alabama’s River and Black Belt regions. Neighboring Lowndes, Butler and Bullock counties have the high per capita rates of infection in Alabama.

While hospitals in Montgomery say they have more capacity to handle and treat more coronavirus patients, their capacity is already stretched.

The biggest hospitals in Montgomery — Baptist health and Jackson Hospital — have faced ICU bed shortages for weeks, and have managed, but how much more of a surge they can handle is a concern.

“I wish you could have a picture of these ICUs,” Thrasher said. “It’s like nothing I have ever seen. Normally, I cut up. I’m a funny guy. I keep everyone laughing. But these ICUs are like death chambers.”

Thrasher said he is increasingly concerned that nurses, doctors and respiratory therapists will face post-traumatic stress disorder. “It’s going to be bad,” he said. Dozens of health care workers have also tested positive. Statewide, nearly 3,000 have tested positive.

“It’s space,” Saag said. “Do we have enough room at the inn? But it’s also, at some point, going to be personnel burn out — the ability to keep pace with just the number of very sick people.”

Critically ill patients who otherwise would be treated in ICUs have been regularly placed in emergency room beds. While treating some patients in ERs instead of formal ICUs is not uncommon during bad flu seasons, the number of patients requiring ICU care and ventilators is unprecedented for the summer months.

“At one of the hospitals, three of their five ICUs are totally consumed with COVID patients on ventilators,” Thrasher said. “If you’re not on a ventilator, we put you on a COVID floor.”

The other ICUs, though, are not empty. People are still having other medical complications and accidents that require intensive care treatment.

“When I left, we had several of the COVID patients in the emergency room on ventilators, and two Saturdays ago, we had 30 patients in the emergency room waiting for COVID beds at one of the hospitals,” Thrasher said.

While the rise in cases and hospitalizations over the past two weeks has been particularly pronounced in and around Montgomery County, statewide, numbers are also on the rise. On Sunday, Alabama reported more than a thousand cases of the virus in a single day for the first time.

While testing has increased, so has the percentage of tests that are positive. By Sunday, the percentage of tests that are positive reached 13 percent for the first time since mid-April — a concerning sign that the state is not performing enough testing and that the virus is still spreading through community transmission.

“We’re in trouble,” Saag said. “It’s growing almost exponentially. It should be sounding alarms all the way from the city governments to the state.”

Tuscaloosa County, Mobile County, counties throughout the state’s Black Belt and in North Alabama are seeing rising case counties.

Madison County, home to Huntsville, which until this point had been spared from large case increases, is beginning to see rising daily case counts.

Fueled by outbreaks at several skilled nursing facilities and a state psychiatric hospital, Tuscaloosa County is also seeing a continuing surge of cases. But Tuscaloosa Mayor Walt Maddox said new cases recently have not just been limited to the most at-risk groups.

“We are beginning to see increased numbers of 18 to 23 [year-olds] contracting the virus,” he said on Twitter. “Please continue to exercise caution & common sense.”

Hospitalizations statewide remain at record-high levels, according to the department of health. At least 647 people were in hospitals with a positive case of COVID-19 on Thursday, the highest total to date.

Fewer hospitals report hospitalizations on Fridays and weekends, so the numbers are less reliable, but the total Friday was still at least 622.

Since reopening on April 30, the average daily increase in confirmed cases has risen 309 percent from 177 cases per day on April 30 to 724 cases per day by Sunday. Average tests per day, by contrast, have increased only 7 percent.

Earlier this week, the Alabama Department of Public Health issued a statement calling on Alabamians to heed advice from public health officials who say everyone should wear a face covering in public.

“COVID-19 spreads quickly, and your actions affect others. More than ever since the pandemic began, we need people to social distance, wear face coverings in public, and practice good respiratory hygiene,” State Health Officer Dr. Scott Harris said in a statement.

The Department of Public Health said some increases in cases have been connected to outbreaks as a result of large gatherings that occurred during the Memorial Holiday, and at other times.

“With ongoing community transmission, it is safer to be at home,” the department said in a statement.

But so far, no statewide requirement to wear a face covering has been put in place.

Thrasher said when he’s at the gas station or at a restaurant, he sees very few people wearing masks.

“It seems like nobody is doing the right thing,” Thrasher said. “Everybody is looking at me like I’m a freak in my mask. This epidemic is going to go on for a long time.”

On the ground, the doctors said they have been disillusioned and somewhat angry about how often they see people not wearing masks while out in public.

“I think it’s going to be one of those things where we’re going to see a fair amount of suffering before people wake up to the reality,” Saag said. “I’m concerned because it’s the combination of the number of cases, the rise in hospitalized cases and the relative lack of concern in the general population — at least from what I can see. And that doesn’t add up well to a happy outcome.”

So far, 768 Alabamians have died from COVID-19, according to the Alabama Department of Public Health. Nearly 2,300 have been hospitalized since March.

“I’m afraid that by the time the numbers get to a point where it’s becoming almost catastrophic, it might be the time when people change, but in some ways it’s too late,” Saag said. “Because whatever change we make for the better, we won’t see the effect on numbers for two to three weeks after that.”

Chip Brownlee is a former political reporter, online content manager and webmaster at the Alabama Political Reporter. He is now a reporter at The Trace, a non-profit newsroom covering guns in America.

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CDC confirmed expanded “close contact” definition to Alabama officials in August

It is unclear why the CDC waited until late October to update or clarify its public-facing guidance on its website.

Eddie Burkhalter

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New federal guidance on how a person is determined to have been in close contact with someone infected by COVID-19 won’t impact how Alabama works to mitigate the disease, said the state’s top health official. That’s because the state was already aware of the expanded definition in August before the change was made public last week.

It is unclear why the CDC waited until late October to update or clarify its public-facing guidance on its website when it was giving more precise definitions to at least one state health department and receiving questions from public health officials about the definition.

The delay in announcing the change is raising questions about how state health officials nationwide have been determining the public’s possible exposure to the deadly disease and if contact tracing and mitigation efforts will be made more time- and resource-intensive with the more inclusive definition in place.

The CDC on Wednesday expanded the definition of “close contact” to mean a person can be at risk of contracting COVID-19 if that person is within six feet of an infected person for a period of at least 15 minutes over a 24-hour period.

The previous definition stated a person should quarantine if they were within six feet of an infected person for at least 15 minutes. Alternately, in other areas of the CDC’s website, the language stated “a total of 15 minutes” in the definition of close contact.

“What they changed their definition to is something they had verbally confirmed to us months ago, and we have always been using that definition,” said Alabama State Health Officer Dr. Scott Harris, speaking to APR on Friday.

Harris said a support team from the CDC was in Alabama in July as the Alabama Department of Public Health was preparing plans to reopen schools. Harris said the question was asked of CDC staff because his department was getting questions on the definition of close contact from school officials.

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APDH staff took the definition then of “a total of 15 minutes” to mean that there could be several exposures over a period of time equaling that 15 minute threshold, so they asked CDC to clarify that assertion.

“When those folks were here we asked the CDC people directly. Can you confirm for us what that means, and they said, it adds up to a total of 15 minutes in a 24-hour period,” Harris said. “And we even got somebody to commit to that in an email somewhere.”

Melissa Morrison, CDC’s career epidemiology field officer working at the ADPH in Montgomery, in an Aug. 13 email to ADPH’s director of the office of governmental affairs, quotes a statement Morrison attributes to her CDC colleague, CDC public health advisor Kelly Bishop. Harris shared the email with APR.

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“Yes, I did get a response from the contact tracing team. The 15 minutes for a close contact is cumulative, and they said ‘The time period for the cumulative exposure should start from 2 days before the cases’ illness onset (or, for asymptomatic patients, 2 days prior to positive specimen collection date) until the time the patient is isolated,” Morrison quotes Bishop in the email.

In the August email, Bishop goes on to say, as attributed by Morrison, that “as of now there is no established upper limit on the time period (i.e. 48, 72 hours etc).”

The CDC’s expanded definition was reflected in an Aug. 20 statement from the Alabama Department of Public Health.

“The 15-minute time is a cumulative period of time. For example, a close contact might be within 6 feet of a COVID-19 positive person for 5 minutes each at 8 a.m., noon and 5 p.m. This is a standard based on guidance from the CDC,” the statement reads.

In an email to APR on Friday, Harris said he’d discussed the matter with Morrison on Friday who “emphasized that the guidance this week from CDC was NOT a change but rather a clarification. They simply used the MMWR corrections story as a convenient time to make the point.”

Harris was referring to a CDC’s Morbidity and Mortality Weekly Report released Wednesday that detailed findings by Vermont health officials showing that a prison worker contracted COVID-19 during an eight-hour shift in which the worker had 22 close contacts with an infected inmate totaling 17 minutes.

The CDC in statements to numerous news outlets, and to APR, cite that Vermont study in connection to Wednesday’s definition change.

“That’s kind of why they said it out loud,” Harris said of the study and the Wednesday announcement. “But I have to say, when I saw that updated guidance I thought, ‘I can’t believe anybody ever thought otherwise.’”

Different pages on the CDC’s website on Saturday defined close contact as both being “a total of 15 minutes or more” and “a total of 15 minutes or more over a 24-hour period,” confusing the matter further, and numerous other state health departments had not yet updated their websites Saturday to reflect the CDC’s expanded definition.

A CDC spokesman in an email to APR on Wednesday noted the Vermont study on the prison worker and said “CDC clarified the amount of time it would take for someone to be considered a close contact exposed to a person with COVID-19.”

“The CDC website now defines a close contact as someone who was within 6 feet of an infected person for a total of 15 minutes or more over a 24-hour period. Previous language defined a close contact as someone who spent at least 15 minutes within 6 feet of a confirmed case,” CDC spokesman Scott Pauley told APR by email Wednesday.

Pauley didn’t respond to APR’s question on Friday asking why the CDC waited until Wednesday to update its guidance online, given that ADPH had confirmed the definition of close contact in August. He also didn’t respond to a request to verify the statement Morrison attributed to her CDC colleague in the August email.

“To us, we thought if it says a total, that means you must be adding up smaller amounts to get to 15 minutes, or you wouldn’t use the word total,” Harris said. “When they changed it this week, I don’t know the details of why that happened, but I think, obviously, everybody didn’t have the same message everywhere.”

Dr. Bertha Hidalgo, an epidemiologist and assistant professor at UAB’s Department of Epidemiology, told APR on Friday that her understanding prior to Wednesday’s expanded definition was that a contact was defined as someone who was exposed to the COVID-19 positive individual for at least 15 min or more at a time and explained that the updated guidance complicates how public health officials will engage in contact tracing.

“This means significant efforts for contact tracing moving forward, in effect needing to identify every person that person came into contact with during the possible exposure timeframe,” she said.

It was unclear Monday how the definition change impacts Alabama’s Guidesafe COVID-19 exposure notification app, which notifies a user if they come into close contact with an infected person. The app was developed by ADPH and University of Alabama at Birmingham, thanks to a partnership between Apple and Google’s combined development of the technology, and alerts users to possible exposure while keeping all users’ identities anonymous.

Sue Feldman, professor of health informatics, UAB School of Health Professions, in a message to APR on Friday said that due to the anonymity of the app, it would be difficult, but not impossible, to update the app to take into consideration the CDC’s expanded guidance.

“We are taking this into consideration for our next update,” Feldman said in the message.

Also unclear is how many other states that have similar exposure notification apps, also using Google and Apple’s technology, aren’t yet using the expanded definition of a “close contact.” Colorado is to roll out that state’s app on Sunday, and according to Colorado Public Radio News the app will notify a user that they’ve been exposed if they come “within six feet of the phone of someone who tested positive for at least ten minutes.”

New York’s exposure notification app also appears to use the old CDC guidance, and will alert users if they come “within 6 feet of your phone for longer than 10 minutes,” according to the state’s website.

The updated definition, which health departments refer to when conducting contact tracing, is likely to have a serious impact on schools, workplaces and other group settings where personal contact may stretch over longer periods of time including multiple interactions.

It greatly expands the pool of people considered at risk of transmission. “It’s easy to accumulate 15 minutes in small increments when you spend all day together — a few minutes at the water cooler, a few minutes in the elevator, and so on,” Johns Hopkins Center for Health Security epidemiologist Caitlin Rivers told The Washington Post. “I expect this will result in many more people being identified as close contacts.”

The clarification comes as cases and hospitalizations are rising both in Alabama and nationwide. Alabama’s 14-day average of cases has increased 41.2 percent over the past two weeks. The percentage of tests that are positive has increased from roughly 13 percent to more than 20 percent over the past 14 days. The U.S. average of new daily infections is now at its highest point of the pandemic, with 481,372 cases reported in a week, according to CNN and Johns Hopkins University.

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Study: COVID-19 infection rates more than double without lockdowns

Infection and fatality rates would have been higher without stay-at-home orders, a new UAB study found.

Micah Danney

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New research from the University of Alabama at Birmingham says that if there had been no stay-at-home orders issued in the U.S. in response to the coronavirus pandemic, the country would have experienced a 220 percent higher rate of infection and a 22 percent higher fatality rate than if such orders were implemented nationwide.

Seven states never imposed stay-at-home orders, or SAHOs. The study analyzed daily positive case rates by state against the presence or absence of statewide SAHOs between March 1 and May 4, the period when such orders began to be implemented. Twelve states lifted their SAHOs before May 4.

The researchers defined SAHOs as being in effect when a state’s governor issued an order for residents of the entire state to leave home only for essential activities and when schools and nonessential businesses were closed.

“During March and April, most states in the United States imposed shutdowns and enacted SAHOs in an effort to control the disease,” said Bisakha Sen, the study’s senior author. “However, mixed messages from political authorities on the usefulness of SAHOs, popular pressure and concerns about the economic fallout led some states to lift the restrictions before public health experts considered it advisable.”

The research also sought to determine if the proportion of a state’s Black residents was associated with its number of positive cases. It found that there was.

“This finding adds to evidence from existing studies using county-level data on racial disparities in COVID-19 infection rates and underlines the urgency of better understanding and addressing these disparities,” said study co-author Vidya Sagar Hanumanthu. 

The research can help advance a greater understanding of racial disparities in the health care system as a whole, and help leaders make future decisions about shutdowns as the virus continues to spread, Sen said.

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“While the high economic cost makes SAHOs unsustainable as a long-term policy, our findings could help inform federal, state and local policymakers in weighing the costs and benefits of different short-term options to combat the pandemic,” she said.

The study was published Friday in JAMA Network Open.

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122,000 Alabamians could lose health coverage if ACA is overturned, study finds

President Donald Trump’s administration and 18 states, including Alabama, are asking the country’s highest court to strike down the law. 

Eddie Burkhalter

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At least 122,000 Alabamians and 21.1 million in the U.S. overall would lose health coverage if the U.S. Supreme Court strikes down the Affordable Care Act, according to a recent study. 

The Washington D.C.-based think tank Urban Institute’s analysis found that Alabama’s uninsured rate would increase by 25 percent if the court strikes down the Affordable Care Act. Oral arguments in a case against the landmark health care law are to begin on Nov. 10.  

President Donald Trump’s administration and 18 states, including Alabama, are asking the country’s highest court to strike down the entire ACA. 

Trump, speaking to CBS News’s Lesley Stahl in a recent interview, said he would like the Supreme Court to end the ACA. There’s concern among many that Trump’s pick to replace the late Justice Ruth Bader Ginsburg on the court, conservative Judge Amy Coney Barrett, could be a deciding factor in the repeal of the ACA when the Supreme Court hears the case just after the Nov. 3 election.

“I hope that they end it. It’ll be so good if they end it,” Trump told Stahl.

“Repealing the ACA would throw our health care system into chaos in the middle of a pandemic and a deep recession,” Alabama Arise executive director Robyn Hyden said in a statement. “Tens of thousands of Alabamians would lose health coverage when they need it most. And hundreds of thousands would pay more for coverage or lose protections for their preexisting conditions.”

Health care coverage losses could be even larger next year, as the COVID-19 pandemic and recession likely still will be ongoing, according to the study. 

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“The ACA has been a health lifeline for many Alabamians during the pandemic,” Hyden said. “It provides coverage options for people who have lost their jobs or seen sharp reductions in their income. And it ensures people aren’t denied insurance just because they got sick.”

Ending the ACA would also reverse gains made in reducing racial disparities in health care coverage, researchers in the study found, noting that overturning the ACA would strip health coverage from nearly one in 10 Black and Latino Americans under age 65, and more than one in 10 Native Americans nationwide would lose health insurance. 

People with pre-existing conditions would be charged higher insurance rates, or have their coverage dropped altogether, if the ACA is struck down, according to the study, which also found that the law’s repeal would harm people who have health insurance through their jobs. 

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Those who have health insurance from an employer could see their plans reintroduce annual and lifetime coverage limits, and requirements for plans to cover essential benefits and provide free preventive services would disappear, according to the study, as would the requirement for insurers to allow young adults to be covered through their parents’ plans.

While millions would lose health care if the law is repealed, the country’s top earners would receive tax cuts, according to a study by the Center on Budget and Policy Priorities, which found that the highest-income 0.1 percent of households, which earn more than $3 million annually, would receive tax cuts averaging about $198,000 per year. 

“A portion of these tax cuts — about $10 billion per year — would come at the direct expense of the Medicare Trust Fund, since the additional Medicare tax the ACA instituted for couples with earnings over $250,000 flows to the fund,” the Center of Budget and Policy Priority study reads. 

Pharmaceutical companies would pay $2.8 billion less in taxes each year, according to the study, while millions of seniors would pay billions more for prescription drugs due to the gap in Medicare’s prescription drug benefit if the ACA is repealed. 

“The ACA has left Alabama better equipped to fight COVID-19 and rebuild our economy after the recession,” Hyden said. “And those benefits would be even greater if Alabama would adopt Medicaid expansion.

“Striking down the ACA would harm the Alabamians who have suffered the most during the pandemic and the recession. It would deprive our state of the opportunity to save lives and strengthen our health care system by expanding Medicaid,” Hyden continued. “And it would shower huge tax cuts on rich people while making life harder for everyone else. Alabama officials should stop seeking to undermine the ACA and start investing in a healthier future for our entire state.”

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Alabama’s hospitalized COVID-19 patients Sunday at highest number since Sept. 2.

It’s a trend that has public health officials and hospital staff concerned that the state may be headed for another surge.

Eddie Burkhalter

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Alabama hospitals on Sunday were caring for 920 COVID-19 inpatients, the highest number of patients since Sept. 2 and a 23 percent increase from a month ago. 

It’s a trend that has public health officials and hospital staff concerned that the state may be headed for another  surge just as the regular flu season begins to fill up hospital beds. 

Alabama state health officer Dr. Scott Harris by phone Friday called the rising new cases and hospitalizations “worrisome.”

Alabama’s seven-day average of daily hospitalized COVID-19 patients was 864 on Sunday, the highest it’s been since Sept. 8. State hospitals saw a peak of COVID-19 inpatients on Aug. 6, when 1,613 patients were being cared for. 

The state added 1,079 new confirmed and probable cases on Sunday, and Alabama’s 14-day average of new daily cases hit 1,358 Sunday, the highest it’s been since Aug. 13. Two “data dumps” to the Alabama Department of Public Health of older confirmed cases Thursday and Friday elevated the daily counts on those days, but after weeks of daily cases hovering around 700 and 800, the state now regularly sees more than 1,000 cases a day. 

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The older test results skew the state’s percent positivity, but Alabama’s 14-day average of percent positivity on Sunday was 20 percent. Just prior to the addition of those older cases, the 14-day average was 15 percent. Public health officials say it should be at or below five percent or cases are going undetected.

As cases continue to rise, the number of tests being performed statewide continue to decline, which is increasing Alabama’s percent positivity rate. The 14-day average of daily tests was 6,619 on Sunday — a 5 percent decrease from two weeks ago. 

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There have been 2,866 confirmed and probable COVID-19 deaths statewide. The state’s 14-day average of daily confirmed deaths was 14 on Sunday, up from 12 two weeks ago. 

The United States on Saturday recorded its second highest day of new cases since the start of the pandemic, with 83,718 new cases, according to Johns Hopkins University. Saturday’s peak was just 39 cases fewer than the country’s all-time daily high, set on Friday. As of Sunday, 225,061 people have died from COVID-19 in the U.S.

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