(Reuters) – Arizona again told hospitals to activate the coronavirus emergency plans after cases spiked following reopening, turning it into a U.S. virus hotspot along with neighboring Southwest states.

The state’s stay-at-home order ended on May 15, and its cases have increased 115 percent since then, leading a former state health chief to warn Arizona may need new social distancing measures or field hospitals.

State health director Cara Christ on Saturday told hospitals to “fully activate” emergency plans – a message she last sent on March 25 – after Arizona’s largest medical network Banner Health warned it was reaching its capacity in intensive care unit beds.

“Since May 15, ventilated COVID-19 patients have quadrupled,” Banner Health tweeted on Monday, adding it had hit capacity for some patients needing cardiac and respiratory care.

The alert came after Arizona, New Mexico and Utah each posted rises of 40% or higher in new cases for the week ended June 7 compared with the prior seven days, joining hotpots in the South like Florida and Arkansas, according to a Reuters analysis.

University of Washington researchers estimated on Monday 145,728 people could die of COVID-19 in the United States by August, raising their forecast by over 5,000 fatalities in a matter of days.

In Arizona, a “cavalier” exit from the state’s successful stay-at-home program caused the sudden case surge, said former state health chief Will Humble.

Humble said Governor Doug Ducey let Arizonans voluntarily follow Centers for Disease Control guidance but must now impose measures like mandatory face mask use inside public spaces. A failure to do so will leave Ducey with two drastic choices, he added.

“He’s going to have to either A) implement a field hospital plan, B) do another stay-at-home order, or C) both,” said Humble, head of health professionals organization the Arizona Public Health Association.

Ducey last week told a press briefing that the increase in cases was to be expected due to a rise in testing.