The United States passed nine million reported coronavirus cases on Friday, according to a tally from Johns Hopkins University, as infections spike days before the nation chooses its next president.
With the virus spreading most rampantly in the Midwest and the South, hospitals are also filling up again, stretching the health care system just as the nation heads in to flu season.
"We are not ready for this wave," Ashish Jha, dean of the Brown University school of public health, warned on ABC's Good Morning America on Thursday.
Authorities in El Paso, Texas, imposed a curfew this week to protect "overwhelmed" health care workers and began setting up field hospitals.
But a judge's attempt to shut down non-essential businesses in the city has been challenged by the mayor and the state's attorney general, the Washington Post reported.
Midwestern state Wisconsin has also set up a field hospital in recent weeks, and hospital workers in Missouri were sounding warning bells as cases there rise.
Hospitals in the western state of Utah were preparing to ration care by as early as next week as patients flood their ICUs, according to local media.
The US, which has seen a resurgence of its Covid-19 outbreak since mid-October, has now notched up 9,007,298 cases, according to a real-time count by the Baltimore-based school.
On Thursday the country set a record for new daily infections of more than 91,000 in 24 hours.
The pattern of the pandemic so far shows that hospitalisations usually begin to rise several weeks after infections, and deaths a few weeks after that.
More than 229,000 people have died of the virus in the US since the pandemic began, the Hopkins tally showed as of Friday afternoon, with the daily number of deaths creeping steadily upwards in recent weeks also - though at present it remains below peak levels.
For months public health officials have been warning of a surge in cases as cooler fall weather settles over the US, driving more people indoors.
As the weather changes, New York and other parts of the northeast, which were the epicenter of the US outbreak in the spring but largely controlled the virus over the summer, were reporting a worrying rise.
Some epidemiologists believe that Covid-19 spreads more easily in drier, cool air.
Rural areas, which in the spring appeared to be getting off lightly compared to crowded cities, were also facing spikes with states like North Dakota charting one of the steepest rises in recent weeks.
The state is so overwhelmed that earlier this month it told residents they have to do their own contact tracing, local media reported.
With four days to go until the election, Donald Trump was battling to hold on to the White House against challenger Joe Biden, who has slammed the president's virus response.
"It is as severe an indictment of a president's record as one can possibly imagine, and it is utterly disqualifying," Biden said Friday as the toll passed nine million.
Trump downplays the virus even as the toll has been accelerating once more, holding a slew of rallies with little social distancing or mask use.
He has repeatedly told supporters that the country is "rounding the curve" on Covid infections.
But Americans, wary of crowded polling booths on Election Day as the virus spreads, are voting early in record numbers.
