The United States has set a one-day record for new coronavirus cases with at least 102,591 infections and with hospitals in several states reporting a rising tide of patients.
Nine states reported record one-day increases in cases on Wednesday: Colorado, Idaho, Indiana, Maine, Michigan, Minnesota, Rhode Island, Washington and Wisconsin.
The pandemic has affected nearly every aspect of American life, including a record number of voters mailing in their ballots in Tuesday's presidential election.
In addition to rising cases, on Tuesday hospitalisations topped 50,000 for the first time in three months.
North Dakota reported only six free intensive care unit beds in the entire state on Wednesday, when it was one of 14 states that reported record levels of hospitalised COVID-19 patients.
Hospitalisations are a key metric because they are not impacted by the amount of testing done.
The proportion of tests coming back positive is greater than 50 per cent in South Dakota and over 40 per cent in Iowa and Wyoming.
The World Health Organization says rates of more than 5 per cent are concerning because they indicate undetected community transmission.
Coronavirus deaths are trending higher but not at the same rate as cases.
The United States is averaging 850 deaths a day, up from 700 a month ago.
The outbreak is hitting the Midwest the hardest, based on new cases per capita in recent weeks.
Illinois has reported 48,579 cases in the past seven days, more than any other state.
Texas, which has twice as many residents, reported 47,932 cases and both California and Florida reported about 30,000 new cases each.
The previous US record for new cases in a day was 100,233 on October 30, the highest ever reported by any country in the world.