Feature

IDSA: COVID-19 in rural America will be a ‘long, sustained outbreak’

In mid-March, before schools in the state closed to help prevent the spread of COVID-19, more than 400 people gathered for a birthday party in a rural Nebraska town, one with a population of less than 1,000. Many people from neighboring towns and communities attended the party.

The day after the party, schools closed. Shortly after that, multiple cases of COVID-19 were traced back to that same party.

This event was recounted by Angela Hewlett, MD, MS, FIDSA, associate professor in the division of infectious diseases and associate medical director of infection control and epidemiology at the University of Nebraska Medical Center and medical director of the Nebraska Biocontainment Unit, during an IDSA press briefing on COVID-19 that was held on Tuesday, April 21.

According to Hewlett, these large gatherings are one of the attributes of rural America that make it “uniquely vulnerable” to outbreaks like COVID-19.

The industries associated with much of rural America contribute to this increased risk.

“The industry in these communities is different,” she said during the briefing. “These communities are often fed by large industries like the meat packing industry, or other food processing industries, and powerplants. These are not places where people can work from home or telecommute, so they have to go to work.”

This creates a situation where many people are working in very close contact, according to Hewlett, and a setup “for perpetuating a disease like COVID-19 to spread from person to person.”

In addition, once infections begin to spread, these smaller communities have smaller hospitals with less capacity to care for these patients, especially those with severe infections who would require an ICU. Moreover, they are often hindered by testing capabilities, which are very limited with a longer turn-around time.

This makes it “difficult to make decisions for patients,” Hewlett said.

According to Andrew T. Pavia, MD, FIDSA, chief of the division of pediatric infectious diseases for the University of Utah Health and adjunct professor of internal medicine and professor of pediatrics at the University of Utah, it may seem as though “rural communities have been relatively spared” by COVID-19, but that isn’t the case.

“What we’re seeing now is a lot of disease in small communities that don’t have the medical care that we have in the city,” he said during the briefing.

Pavia added that because many people in these areas are not receiving regular medical care, they may also have a higher prevalence of diabetes or other conditions, putting them at higher risk for severe infection. Further, in spite of these risk factors, Pavia says testing rates have varied a great deal in these regions, resulting in some areas where very few people have actually been tested.

This, however, “absolutely” does not mean that there is less disease in such an area, he continued: “It means we don’t have a good spotlight on what’s occurring in those communities and that we’re missing things.”

Pavia concluded by noting that the epidemiology of COVID-19 in rural America will look very different than it does in larger cities and heavily populated areas, where rapid, high peaks have been occurring.

“It will be a long, sustained outbreak and that means we will be fighting this for weeks and months to come,” he said. “It will also make reopening more challenging in these areas.” – by Caitlyn Stulpin

Disclosures: Healio could not confirm relevant financial disclosures for Hewlett and Pavia at the time of publication.

In mid-March, before schools in the state closed to help prevent the spread of COVID-19, more than 400 people gathered for a birthday party in a rural Nebraska town, one with a population of less than 1,000. Many people from neighboring towns and communities attended the party.

The day after the party, schools closed. Shortly after that, multiple cases of COVID-19 were traced back to that same party.

This event was recounted by Angela Hewlett, MD, MS, FIDSA, associate professor in the division of infectious diseases and associate medical director of infection control and epidemiology at the University of Nebraska Medical Center and medical director of the Nebraska Biocontainment Unit, during an IDSA press briefing on COVID-19 that was held on Tuesday, April 21.

According to Hewlett, these large gatherings are one of the attributes of rural America that make it “uniquely vulnerable” to outbreaks like COVID-19.

The industries associated with much of rural America contribute to this increased risk.

“The industry in these communities is different,” she said during the briefing. “These communities are often fed by large industries like the meat packing industry, or other food processing industries, and powerplants. These are not places where people can work from home or telecommute, so they have to go to work.”

This creates a situation where many people are working in very close contact, according to Hewlett, and a setup “for perpetuating a disease like COVID-19 to spread from person to person.”

In addition, once infections begin to spread, these smaller communities have smaller hospitals with less capacity to care for these patients, especially those with severe infections who would require an ICU. Moreover, they are often hindered by testing capabilities, which are very limited with a longer turn-around time.

This makes it “difficult to make decisions for patients,” Hewlett said.

According to Andrew T. Pavia, MD, FIDSA, chief of the division of pediatric infectious diseases for the University of Utah Health and adjunct professor of internal medicine and professor of pediatrics at the University of Utah, it may seem as though “rural communities have been relatively spared” by COVID-19, but that isn’t the case.

“What we’re seeing now is a lot of disease in small communities that don’t have the medical care that we have in the city,” he said during the briefing.

Pavia added that because many people in these areas are not receiving regular medical care, they may also have a higher prevalence of diabetes or other conditions, putting them at higher risk for severe infection. Further, in spite of these risk factors, Pavia says testing rates have varied a great deal in these regions, resulting in some areas where very few people have actually been tested.

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This, however, “absolutely” does not mean that there is less disease in such an area, he continued: “It means we don’t have a good spotlight on what’s occurring in those communities and that we’re missing things.”

Pavia concluded by noting that the epidemiology of COVID-19 in rural America will look very different than it does in larger cities and heavily populated areas, where rapid, high peaks have been occurring.

“It will be a long, sustained outbreak and that means we will be fighting this for weeks and months to come,” he said. “It will also make reopening more challenging in these areas.” – by Caitlyn Stulpin

Disclosures: Healio could not confirm relevant financial disclosures for Hewlett and Pavia at the time of publication.

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