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Rural Health and COVID-19 - 1
By Todd Neeley
Monday, July 6, 2020 7:09AM CDT

OMAHA (DTN) -- A recent spike in new COVID-19 cases in rural America is hitting small-town hospitals that were already vulnerable.

Cash-strapped and underequipped since even before the pandemic hit, the new coronavirus forced them earlier this year to adjust their plans and resources to get through the past few months and survive in their communities -- as well as save and serve their patients.

However, as states and communities emerge from various restrictions and regulations that may have helped slow or contain the spread of COVID-19 for the past few months, the number of cases is growing and so is the rural health system's concern.

Rural Iowa shows how the numbers have jumped.

Carroll County, northwest of Des Moines, reported four new COVID-19 cases on June 1 -- this spiked to 48 new cases on June 24, then dropped to 32 on June 30, according to data from the state of Iowa.

Meanwhile, just to the northeast, Calhoun County saw a slight uptick in daily new cases from two on June 3, to 19 each on June 16 and June 17, to 18 new cases on June 30.

Webster County, to the west of Calhoun County, saw a dramatic jump in cases, from 15 on May 28, to 56 on June 30.

They were part of a national trend. Since mid-June, rural counties in the United States saw new cases surge from 2,481 on June 21, to 4,550 on June 26, according to data from non-profit organization USAFacts.

Yet the data still might not reflect the actual number of cases, since various health officials have cautioned the data could be outdated or not yet known.

"CDC has completed a series and will continue to do fairly extensive surveillance throughout the nation using antibody testing," explained Robert Redfield, director of the Centers for Disease Control and Prevention.

"And our best estimate right now is that for every case that was recorded, there actually are 10 other infections," he told a CDC telebriefing on June 25. He added that hospitalizations and deaths can sometimes lag three to four weeks.

In the first of a special two-story package on how COVID-19 is affecting the rural health system, DTN looks at how some rural hospitals are seeing a surge in COVID-19 cases and why.

WATCHING COVID-19 SPREAD

Officials at St. Anthony Regional Hospital in Carroll, Iowa, said that, back in January, they knew COVID-19 eventually would become a rural problem. They were observing what was happening in China and other places.

"Then, late February, Seattle had some nursing home deaths, and that really got us," Ed Smith, chief executive officer at St. Anthony, told DTN. He and others in Carroll thought about the 165 seniors housed in independent living, assisted living and nursing home residences on the St. Anthony campus.

The deadly virus continued to spread from Asia into Europe and into the United States. At first, it appeared more of an urban nightmare -- in Seattle, New York, Chicago, Denver and Detroit.

But, on March 12, Carroll County in Iowa reported its first case -- one of the first in the state.

HOTSPOTS IN MEATPACKING PLANTS

It continued to spread. Near the end of March into early April, a large number of cases began popping up in Midwest meatpacking plants, including in Iowa.

Smith said St. Anthony recognized the potential for COVID-19 spikes in communities with meatpacking plants, including in Dennison, where the Crawford County town of 8,400 residents to the west of Carroll has two such plants.

Meanwhile, north of Carroll County, Tyson Foods in Buena Vista County announced on June 2 that 591 workers at its plant tested positive for COVID-19. Since then, more than 1,000 people have tested positive, raising fears a new spike in cases is beginning as society begins to reopen.

So far, more than 3,300 workers at meatpacking plants in Iowa have tested positive for COVID-19, with seven fatalities reported by the state of Iowa, as of the end of June.

However, the number of positive daily new cases in Crawford County fell off from 321 on May 15, to 39 as of June 30. Crawford County's total number of cases, as of July 1, was 667 cases, including two deaths.

COMPARING REGIONS

Drilling more into the data shows how some of Iowa's health regions are comparing in number of cases and possible strain on resources.

Hospital Region 4 -- which has 10 counties and includes Council Bluffs -- as of July 1, four patients remain hospitalized and two are in an intensive care unit (ICU). The total number of cases for the region during the pandemic is 1,605, with 16 deaths.

As for Hospital Region 1 -- which has 22 counties including Carroll -- as of July 1, there are 51 people hospitalized throughout the region and eight in ICU. The total number of cases for the region since COVID-19 first hit: 10,417 positive cases and 297 deaths.

Dr. Kyle Ulveling, cardiologist and chief medical officer at St. Anthony, told DTN he expects to see the number of COVID-19 cases increase as Iowa continues to reopen.

"The reason for those temporary restrictions and shutting-down policies was to prevent the majority of the population getting infected at the same time and overwhelming the ability to provide health care," Ulveling said. "We expect people to have more cases of COVID as we increase our interaction."

Expanded testing through Test Iowa, he said, will help rural hospitals stay ahead of the fight by preventing new spread in places such as meatpacking plants.

Because of an increasing number of tests performed through Test Iowa, the number of positive cases has increased in Carroll County. On the first day, St. Anthony performed 50 tests but now does around 200 daily.

The hope is more testing will help isolate more illnesses.

"I would much rather us be patient and continue opening up methodically than try to open everything up, have the numbers go too much and having to go back to shutting things down," Ulveling said. "I'd much rather us find a few positives in a certain factory, have them isolated rather than shut down shifts."

COVID-19 CASES INCREASING

On June 25, Iowa Gov. Kim Reynolds proclaimed an extension of public health mitigation measures currently in place until at least July 25. While the state has reopened more businesses and services than some states, social distancing and other health measures to reduce the risk of transmission are still urged.

As of July 1, there were 29,451 COVID-19 cases in all of Iowa, with a total of 717 deaths. A total of 23,607 people have recovered, according to Iowa government data.

Though rural hospitals responded to the COVID-19 challenge, Ulveling said overall health may have worsened as health providers focused on the virus.

"I can easily say the patients I'm seeing in clinic are sicker than they were six months ago," he said.

He said he's seeing much fewer wellness checks and much more sick visits than he was six months ago.

PRESSURE ON RURAL HEALTH CARE

There continues to be growing concerns COVID-19 could overrun the rural health care system. The main reasons are that rural America is older, less healthy and has far fewer health care resources.

A March 24, 2020, analysis by Lerner Center for Public Health Promotion at Syracuse University pointed to the biggest underlying COVID-19 concern in rural America.

Thirty-one percent of COVID-19 cases, 45% of hospitalizations, 53% of intensive care admissions and 80% of deaths had been among adults aged 65 and older with the, "highest percentage of severe outcomes among those 85 years and older. This is bad news for rural America."

In addition, 19% of the rural population is 65 years or older, compared to 15% in urban areas.

CDC UPDATES LIST OF INCREASED RISKS

"Part of the reason why risk increases with age is because, as people get older, they are more likely to have other health issues that may place them at higher risk," Dr. Jay Butler, COVID-19 incident manager, said at a briefing by the Centers for Disease Control and Prevention on June 25.

"We reviewed the evidence related to each of these conditions and determined whether there was strong, mixed or limited evidence whether they were associated with increased risk of more severe illness, which may be measured by hospitalization, ICU admission or death."

Butler said the underlying conditions for which there is the strongest evidence of higher risk are cardiovascular disease; chronic kidney disease; chronic obstructive pulmonary disease, such as emphysema; obesity; any immunosuppressing condition or treatment; Sickle Cell Disease; history of organ transplants and type 2 diabetes.

In addition, the CDC compiled an updated list of conditions that might increase risk of severe illness.

Some of those include: chronic lung diseases, including moderate to severe asthma and cystic fibrosis; high blood pressure; a weakened immune system -- as may occur among persons after blood or bone marrow transplant -- immune deficiencies, poorly controlled HIV or use of other immune-weakening medicines; neurologic conditions, such as dementia or history of stroke; liver disease and pregnancy.

NOT JUST ELDERLY AFFECTED

CDC also said children who are "medically complex" who have neurologic, genetic, metabolic conditions, or who have congenital heart disease are at higher risk for severe illness from COVID-19 than other children.

CDC said there's a difference between now and earlier when the coronavirus first hit the U.S.

"I'm asking people to recognize that we're in a different situation today than we were in March, in April, where the virus was disproportionately being recognized in older individuals with significant co-morbidities that was causing significant hospitalizations and deaths," CDC's Redfield said in late June. "Today we're seeing more virus. It's in younger individuals. Fewer of those individuals are requiring the hospitalizations and having a fatal outcome, but that is not to minimize it."

Iowa's statistics show the coronavirus can strike all ages. Since it first hit Iowa's Carroll county in mid-March, for example, the cases now break down to the following (as of June 30): aged under 18 (11%); 18-40 (38%), 41-60 (31%), 61-above 80 (20%). There was one fatality in the county since the beginning.

WHAT IS BACK TO NORMAL?

"Everyone keeps talking about getting back to normal," said St. Anthony's Smith.

"I don't know when that's going to be. But, in the short run, I think we're all going to be wearing masks. In the short run, we're all going to be doing temperature checks and answering entry-point questions to enter into the health care facilities. I think testing is going to be an important part of anything we do until a vaccine is thoroughly tested."

Redfield said more than 90% of the American public has yet to experience the virus.

"And so, for the Fourth of July, which is a family event, we want to re-emphasize that it's really important that we get back to being vigilant to our collective commitment to do these social mitigation steps to protect the vulnerable friends, family, community and those individuals that we don't know that we're interacting with, from potentially getting infected and having a poor, negative outcome because of the co-morbidities," Redfield said.

**

Editor's Note:

Next in this two-story package: How did rural hospitals prepare to handle COVID-19, and what is the possible impact of COVID-19 on their bottom line.

Todd Neeley can be reached at todd.neeley@dtn.com

Follow him on Twitter @toddneeleyDTN


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