The first wave of COVID-19 swept through the Northeast this spring and the second wave, over the summer, was concentrated in the Southeast. Now, as temperatures drop, the Midwest has become the latest frontier for the coronavirus, with five states among the top 10 nationally for new infections. 

Wisconsin’s recent numbers have turned the state into one of the nation’s hottest COVID-19 hotspots. Cases more than doubled in the past month and a half, hospitals are filling up, and deaths are setting new record highs. 

Ohio smashed its daily COVID-19 case record Thursday with 3,590 new cases. Kentucky’s positivity rate is over 6% after a week of record cases, and the state announced new guidelines this week to slow the spread of the virus. In Chicago, officials have shut down indoor dining. 

As the weather turns, scientists say the virus is more transmissible. Aerosol particles that transmit coronavirus SARS-CoV-2 fare better out of direct sunlight and linger in cold, dry air. But officials say Midwesterners can mitigate transmission even during the colder seasons by avoiding risky behaviors. 

Political and legal developments blocking health orders have curtailed the tools available for officials to respond to virus; the onset of fatigue eight months into the pandemic has led to residents letting their guard down; and the restart of academic calendars resulted in new environments for transmission in younger populations. 

The behavioral causes of the fall COVID-19 surge in the Midwest may offer clues into what it will take to turn the region’s numbers around. 

In the midst of Wisconsin’s surge, the state’s public health tools have been limited by political and legal battles, according to Wisconsin Gov. Tony Evers.

“Part of the problem that has put us in this position, of having trouble preventing deaths in the state of Wisconsin, is that we haven’t had a consistent message,” Evers said at a Tuesday media briefing.

Since the spring, measures from the governor and the state Department of Health Services have faced frequent challenges. 

A “Safer at Home” order issued in March was struck down by the state Supreme Court in May. The governor’s mask mandate, which has been in place since July, has also faced legal challenge — the state Supreme Court agreed this week to hear a lawsuit against the rule. And a recent order limiting indoor venues to 25% capacity has been blocked, reinstated, and blocked again by the courts, all within the past month.

Other states in the Midwest have also struggled to impose widespread health restrictions or keep them in place, with some continuing to reopen even as cases surge.

The lack of a unified state approach and the mixed messaging from ever-changing guidance have become important roadblocks in the pandemic response, said Amanda Simanek, an associate professor of epidemiology at UW-Milwaukee’s Zilber School of Public Health.

“In no other state are government officials and public health officials so disempowered to just take control of a public health crisis,” Simanek said. “It’s really stunning what’s happening here.”

Measures like masking and staying home only work well if they’re employed across the board, she said. When rules are inconsistent and it becomes “every local health department for themselves,” the virus finds ways to slip through the cracks and keep spreading.

She likens pandemic restrictions to traffic laws: If one person runs a red light, they may “escape scot-free” and not face any major consequences. In the same way, if one person goes to a store without a mask, they may not infect other shoppers. 

But they could also cause a serious crash, or spread a serious virus — and if everyone starts throwing caution to the wind, these tragic outcomes will become much more common. 

It can already be difficult to get people to care about health measures when they don’t personally feel at risk, Simanek said. When you add polarized politics, mixed messages, and even misinformation, that disconnect becomes even harder to bridge. And it all adds up to a less successful public health response.

“Measures or mitigation strategies that shouldn’t be politically embroiled — they should be just based on science — become polarizing. They become symbolic of your political affiliation,” Simanek said. “And, you know, this virus does not care what your political affiliation is.”

On Monday, when Gov. Andy Beshear announced new recommendations to slow the spread of the coronavirus across Kentucky, he directed his pleas not at restaurants packing in diners or churches filling pews, but at the individuals failing to take precautions needed to stem community spread.

“If we could get back to wearing masks at all times when we’re supposed to, we wouldn't have the level of cases we have right now,” Beshear said. “But fatigue, and I guess a cultural war that has somehow sprang up around what keeps you alive and keeps people around you alive, have led to less compliance.”

Health officials have reached the same conclusion as Beshear: Lax adherence to social distancing and masking rules, brought on by a combination of fatigue and pandemic politicization, is fueling the spread. 

Dr. Lynne Saddler, district director for Northern Kentucky Health Department, told Spectrum News 1 the region’s rise of COVID-19 cases is attributable in part to the “fatigue of dealing with COVID every day, having to worry about social distancing, and having the mask.” All four counties the department serves are in the accelerated, or "orange zone" of community spread.

Laurel County, in southeastern Kentucky, is in the “red zone,” meaning there are more than 25 cases per day per 100,000 residents. Health Department Director Mark Hensley told WKYT that schools and senior living facilities in the county have done a good job controlling spread. But residents are “fatigued with COVID-19.”

“People are letting their guards down,” he said. “Not practicing social distancing. Not wearing their mask.”

In the Midwest, the surge is hitting rural areas harder than it did in the spring or over the summer. According to the Centers for Disease Control and Prevention, the seven-day case average in rural America is higher than in small cities, big cities, and suburbs. Throughout March and April, rural areas were at the bottom of the list. “Living in a rural area, or being part of a rural area right now, doesn’t protect you from this virus,” Dr. Deborah Birx, of the White House COVID-19 Response Task Force, said this week.

Restlessness after eight months of a pandemic is not confined to rural areas though. As the weather cools and schools open, Americans are taking fewer precautions than they did earlier in the pandemic. Polling by Gallup, conducted in the second half of September, showed 53% of Americans are avoiding public spaces and 45% are avoiding small gatherings, the lowest levels for both since March. 

Frustrated with staying at home and avoiding social situations, people are gathering in small groups for house parties and family get-togethers. This week, the White House identified that as one of the primary drivers for the new surge, writing in a report that “current transmissions are linked to home gatherings.”

"They are spreading this virus with a large number of cases linked to them,” Beshear said of these gatherings. He cautioned not to let this weekend make things worse. “With Halloween coming up, if you're having a Halloween party, the state believes you're spreading the virus. The federal government believes you're spreading the virus. Don’t spread the virus. We need your help.”

Coronavirus outbreaks in the Midwest worsened in September and October, a few weeks after college and K-12 students started their school years. But did going back to school drive the Midwest COVID-19 surge? 

By the end of the summer, people under 30 represented more than a third of U.S. COVID-19 cases, double the share of cases they accounted for in the spring, according to the CDC.

According to public health officials, only a small fraction of the tens of thousands of Midwest students who have contracted the virus became infected in a classroom. Behavior off-campus is much more commonly identified by contact tracers as the source of infections. 

“What is known and what is proven by research is that kids have been far more likely to contract the infection outside of school than they are inside of school,” said Adam Mezoff, chief medical officer at Dayton Children’s Hospital. 

Officials say slowing the spread of the virus will require younger populations to take the same precautions outside of the classroom that are required in school. 

At colleges where the virus has raged, officials say their outbreaks are a result of parties, crowded campus bars, and transmission in congregate living environments.  

At the K-12 level, officials say gatherings like pool parties, birthday celebrations, and sleepovers are responsible for outbreaks. 

Some Midwest states report case numbers for their K-12 schools. Ohio has recorded 5,058 school cases with 1,232 in the last week and Kentucky: 4,042, with 1,096 in the last two weeks. 

“When done right, kids can be in school,” Mezoff said. 

But he said schools have to consider whether they have the resources to ensure students are always masked in the classroom, the quality of the building ventilation, and the amount of available space in the classroom for distancing.

At the college level, Big Ten universities have reported 26,416 COVID-19 cases as of Thursday, according to school dashboards. 

College student populations see fewer undetected cases due to requirements for mass surveillance testing at many universities, whereas K-12 cases are generally reported to schools by families and by students who pursue testing after potential exposure. Only some K-12 schools require surveillance testing. 

For schools reopening, Mezoff says districts have to take into account the risk-level for older populations more likely to become hospitalized if they become secondary infections. 

“It's rare for kids to get sick enough to be in the hospital, or to get into our Intensive Care Unit,” Mezoff said. “Although there are certainly kids who've gotten very sick.”

Student cases directly contribute more to the Midwest’s COVID-19 case surge than to the uptick in hospitalization rates, given younger people are more likely to be either asymptomatic or sick with minor symptoms when they contract the virus.

Mezoff said it is hard to know the full extent to which students are contributing to the Midwest COVID-19 case surge, as it is often unknown whether school outbreaks seep into adult populations in surrounding communities.