The tip of the coronavirus spear is piercing the United States' long-term care facilities again in a surge that underscores the country's repeated failure to protect its most vulnerable.
States reported over 29,000 new infections the previous week in places such as nursing homes and assisted-living facilities, the steepest uptick since at least May, according to Covid Tracking Project data.
They come as national daily case counts were higher than ever this month, with a record of over 170,000 new cases on Nov 13.
On Wednesday, Pfizer said its experimental vaccine was 95 per cent effective, but developments elsewhere mean months of suffering until the shots are widely available.
The US passed 250,000 deaths, New York City stopped in-person schooling, Wisconsin will extend a mask mandate into next year and news emerged that more than 900 workers at Minnesota's Mayo Clinic have been infected in the past two weeks.
Minnesota Governor Tim Walz said in an evening address that he would shut down much of its economy for a month.
State leaders, public health experts and owners are sounding the loudest alarms over the infection spike in nursing homes and long-term care, where cases were falling until September.
Meanwhile, visits from families travelling for the holidays threaten to exacerbate the outbreak.
"Our worst fears have come true as Covid-19 runs rampant among the general population," Mr Mark Parkinson, chief executive officer of the American Health Care Association and National Centre for Assisted Living, said. "Long-term care facilities are powerless to fully prevent it from entering."
More than half of the country's nursing homes have staff reporting infections, and about 20 per cent have more than 10 cases.
Mr Parkinson's group, which represents more than 14,000 nursing homes and assisted-living communities, said that community spread in the broader population is linked to cases in nursing homes.
In the week leading up to Nov 12, Ohio reported the largest weekly increase in long-term care cases, accounting for 10 per cent of the national total.
Illinois saw cases double to nearly 2,000 in a week, and Kansas shattered its record. In New Hampshire, four of five deaths have occurred in a long-term facility.
The data likely underestimates the toll. States vary in reporting: Some combine resident and staff cases, while others do not report active outbreaks in facilities at all.
Several states have set harsher lockdowns, particularly in the Midwest, where the spread has been sustained and severe.
In Kaukauna, Wisconsin, St Paul Elder Services has experienced two distinct outbreaks at its nursing home since August, said chief executive Sondra Norder. Both times, employees who caught the virus in the community brought it into the facility and spread it among patients and colleagues.
In total, 75 residents of about 120 have tested positive, of whom 12 died during treatment and eight died after discharge. About 80 employees have also been infected.
The situation is frustratingly cyclical for experts.
"It really has a feeling of deja vu," said Professor David Grabowski from Harvard Medical School, adding that lessons from the first two spikes in nursing homes should have made a third preventable.
But missteps, mainly by the federal government, such as failure to nationalise the equipment supply chain and ensure testing capabilities, have left the elderly and the public at risk again.
The American Health Care Association is asking for a litany of assistance measures, ranging from a US$5 billion (S$6.73 billion) testing fund to vaccine priority for residents and staff and enshrined Medicaid protection.
The federal government has made available US$333 million for incentives granted to high-performing homes, and supplied about 12 million tests as well as personal protective equipment.
Mr Michael Bars, a White House spokesman, said on Wednesday that the administration would prioritise vaccine distribution "to protect the health and safety of elderly Americans in nursing homes and senior living centres".
Colorado state epidemiologist Rachel Herlihy was optimistic concerning the trajectory of the pandemic in homes. "We're finding those outbreaks sooner, and that's largely through the testing strategies that are in place," she said at a Wednesday news briefing.
BLOOMBERG