OMAHA, Neb. (AP) — A new monthly survey of business leaders in nine Midwest and Plains states suggests faltering confidence in the region’s economy as a new surge of the coronavirus outbreak sweeps the country.

After climbing every month since bottoming out in April, the overall index of the Creighton University Mid-America Business Conditions survey fell to 69.0 in November from October’s 70.2.

Any score above 50 on the survey’s indexes suggests growth, while a score below 50 suggests recession.

The monthly survey results have mirrored national manufacturing survey results, which indicate the sector has been expanding at a steady pace since sinking to a post-2008 recession low in April, according to Creighton University economist Ernie Goss, who oversees the survey.

“Even so, current output in the regional and U.S. manufacturing sectors remains below pre-COVID-19 levels,” Goss said.