The New York Times - USA (2020-10-25)

6 N THE NEW YORK TIMES, SUNDAY, OCTOBER 25, 2020

Tracking an OutbreakU.S. Fallout

The coronavirus was slow to

come to Foster County, N.D., a

community of just over 3,

people in the eastern part of the

state. When virus cases surged

in the Northeast in the spring,

the county recorded just one

positive case. When national

case counts peaked in mid-July,

it had recorded just two more.

But by Tuesday, about one in

every 20 residents had tested

positive for the virus. More than

half of those cases were reported

in the past two weeks.

Most of the worst outbreaks in

the United States right now are

in rural places like Foster

County. Where earlier peaks saw

virus cases concentrated mainly

in cities and suburbs, the current

surge is the most geographically

dispersed yet, and it is hitting

hard remote counties that often

lack a hospital or other critical

health care resources.

Since late summer, per capita

case and death rates in rural

areas have outpaced those in

metropolitan areas.

The total number of coronavi-

rus cases and deaths in rural

places remains smaller than

those in cities because of the

comparatively low population in

rural areas. But the rural share

of the virus burden has grown

over time.

Now, about one in four deaths

from the virus is recorded in a

rural county. That stands in

contrast to March and April,

when almost every death was in

a metropolitan area, as the virus

tore through the Northeast, after

early clusters in the Seattle area

and populous parts of California.

During the summer surge,

rural outbreaks occurred more

often than they had in the

spring, but reported cases per

million remained higher in cities

and their suburbs than in rural

counties.

It was not until August, when

the outbreak was receding from

Sun Belt cities like Houston,

Miami and Phoenix that per

capita rates of cases and deaths

in rural areas surpassed those in

metropolitan areas.

Now, with the national case

count and hospitalization rates

approaching a third peak, none

of the country’s biggest hotspots

are in a large city. Almost all the

counties with the largest out-

breaks have populations under

50,000, and most have popula-

tions under 10,000. Nearly all are

in the Midwest or the Mountain

West.

Though the outbreak’s geo-

graphic spread is expanding,

many of the same kinds of places

remain at risk for clusters of

infections. In Norton County,

Kan., the hardest-hit county in

the country relative to its popu-

lation, all 62 residents of one

nursing home have been in-

fected with the virus, and 10

have died. A state prison in the

county also has an outbreak.

Hospitals across the Upper

Midwest and the Mountain West

are also feeling the surge. Facili-

ties are struggling with capacity,

and in some cases residents are

finding that the nearest hospital

with available beds is hours

away, or in another state.

Earlier this month, hospitals

in North Dakota had to turn

patients away. Bismarck, the

state’s capital, had one staffed

I.C.U. bed available as of Mon-

day.

Overwhelmed by the record

case numbers, North Dakota

suspended its contact tracing

program this week. New Mexi-

co’s governor, also seeing hospi-

tal beds fill up in her state, plans

to put in effect new restrictions

on restaurants, bars and retail

stores.

And Alaska, which is experi-

encing record numbers, provides

a cautionary tale: Even with

extensive testing and robust

contact tracing, the virus is

poised to thrive as temperatures

drop and people move activities

indoors.

Few or

no cases

Avg. daily cases per million in the past week

100 300 500 700

How Cases Looked in Rural Areas

At Different Points of the National Outbreak

Cases in rural areas when cases first peaked

April 10

Cases in rural areas when cases peaked over the summer

July 25

Oct. 22

Cases in rural areas now

LAUREN LEATHERBY/THE NEW YORK TIMES

Metro areas

are not shown

Rural counties

Most Counties With the Worst Per Capita Outbreaks

Now Have Fewer Than 10,000 People

THE NEW YORK TIMES

COUNTY POPULATION

AVG. DAILY CASES,

PAST 7 DAYS

AVG. DAILY CASES

PER 100,

1 Norton, Kan. 5,486 39 72

2 Bon Homme, S.D. 6,969 23 33

3 Faulk, S.D. 2,322 6 27

4 Sheridan, Kan. 2,506 6 26

5 Harding, S.D. 1,311 3 25

6 Miner, S.D. 2,229 5 24

7 Buffalo, S.D. 2,053 5 22

8 Oglala Lakota, S.D. 14,335 32 22

9 Carter, Mont. 1,318 3 22

10 Roosevelt, Mont. 11,228 24 21

11 Hayes, Neb. 943 2 20

12 Menominee, Wis. 4,579 9 20

13 Blaine, Mont. 6,727 13 19

14 McCone, Mont. 1,630 3 19

15 Decatur, Kan. 2,881 5 18

16 Foster, N.D. 3,290 6 18

17 Madison, Idaho 38,705 66 17

18 Florence, Wis. 4,337 7 17

19 Izard, Ark. 13,559 23 17

20 Hill, Mont. 16,439 27 17

21 Webster, Neb. 3,571 6 16

22 Sully, S.D. 1,331 2 16

23 McLean, N.D. 9,608 15 16

24 Logan, N.D. 1,927 3 16

25 Langlade, Wis. 19,164 30 16

26 Eddy, N.D. 2,313 4 15

27 Perry, Tenn. 7,912 12 15

28 Campbell, S.D. 1,435 2 15

29 Brule, S.D. 5,256 8 15

30 Deer Lodge, Mont. 9,100 13 14

31 Big Horn, Mont. 13,376 19 14

32 Valley, Mont. 7,532 11 14

33 Gove, Kan. 2,619 4 14

34 Burleigh, N.D. 93,737 131 14

35 Golden Valley, Mont. 724 1 14

36 Turner, S.D. 8,264 11 13

37 Jackson, S.D. 3,287 4 13

38 Sedgwick, Colo. 2,350 3 13

39 Lincoln, Ark. 13,695 18 13

40 Todd, S.D. 10,146 13 13

41 Sheridan, N.D. 1,405 2 13

42 Shawano, Wis. 41,009 53 13

43 Morton, N.D. 30,544 39 13

44 Hettinger, N.D. 2,576 3 13

45 Towner, N.D. 2,246 3 13

46 Kusilvak Census

Area, Alaska

8,198 10 13

47 Powell, Mont. 6,861 9 13

48 Wichita, Kan. 2,143 3 13

49 Garfield, Mont. 1,141 1 13

50 McIntosh, N.D. 2,654 3 12

NEW CLUSTERS

The Worst Virus Outbreaks in the U.S. Are Now in Rural Areas

Amy Schoenfeld Walker contrib-

uted reporting.

10 per million

Rural areas

Metro areas

March 1 Oct. 22

200 per million

Rural areas

Metro areas

March 1 Oct. 22

New reported cases by day in the United States, 7-day average New reported cases by day in the United States, 7-day average

Rural areas are those counties located outside of metropolitan areas, as defined by

the U.S.D.A.’s Economic Research Service. They may include small cities and towns. LAUREN LEATHERBY/THE NEW YORK TIMES

Counties of fewer than

10,000 people have

more cases than ever.

By LAUREN LEATHERBY

Source: Coronavirus case data is

from a New York Times database

of reports from state and local

health agencies and hospitals.

Data is as of Oct. 22.

With Covid-19 hospitalizations
spiking again in many parts of the
country, public health officials
have expressed concerns about a
perennial source of strain on the
health care system: seasonal flu.
As threats of a “twindemic” loom,
health care workers have stressed
the need for vaccination and other
preventive measures to slow the
spread of flu.
One insurance company is go-
ing further to try to mitigate the
effects of flu season: United-
Healthcare, the country’s largest
health insurance company, plans
to provide at-risk patients with
200,000 kits that include Tamiflu,
the prescription antiviral treat-
ment; a digital thermometer; and
a coronavirus P.C.R. diagnostic
test. People can take the test at
home and then mail it in for lab-
oratory analysis, helping patients
and doctors determine the cause
of their symptoms, which is par-
ticularly important because the
coronavirus and flu have similar
symptoms but differ in treatment.
“These viruses have proven
themselves highly capable of
putting strain on our health care
system alone,” said Dr. Kelly
Moore, an associate director of the
Immunization Action Coalition.
“Their combined impact is really
worrisome.”
In late September, United-
Healthcare began inviting its
Medicare Advantage members to
sign up for the kits either online or
by phone, starting with a focus on
those at highest risk of complica-
tions from Covid-19 and the flu
based on their age and health sta-
tus. Since then, 120,000 people
have enrolled, and the company
has begun shipping the kits. The
company has more than 5 million
Medicare Advantage members.
The company said supplying
people with Tamiflu in advance
could help to mitigate the severity
of flu infections because the an-
tiviral medication gets less effec-
tive with every hour that passes
from onset of symptoms and is
virtually ineffective after 48
hours. Tamiflu on average short-
ens the duration of illness by one
to two days if taken rapidly, ac-
cording to Dr. Moore. It can also
help prevent illness in someone at
high risk of complications who has
been exposed to the flu, but is not
routinely recommended for pre-
ventive use in most populations.
All members signing up for the
flu kits had to confirm the state
where they live so the Tamiflu pre-
scription could be dispensed by a
physician in their state. They had
to say they would wait to take the
prescription drug or the coronavi-
rus test until after receiving direc-
tion from a physician through a
telemedicine appointment. Mem-
bers also had to agree not to give
the medication to others.
“We thought, ‘Imagine if you
start getting sick and already had
a mini pharmacy at home,’ ” said
Dr. Deneen Vojta, executive vice
president for research and devel-
opment at UnitedHealthcare. The
goal, she added, is to decrease the
number of emergency room visits,
hospitalizations and deaths re-
sulting from seasonal flu.
There is no charge for the Tami-
flu or the coronavirus test, as long
as people receive advice from a
doctor via telemedicine. A com-
pany spokesman said that the kits
could produce savings by reduc-
ing hospitalizations through pre-
ventive care.
Flu kit recipients will be di-
rected to schedule virtual doctor’s
appointments if they experience
viral symptoms. The initiative has
become possible largely because
of the public’s increased accept-
ance of telemedicine amid the
pandemic. A national survey from
Deloitte released in August found
that the proportion of health care
consumers using virtual doctor’s
visits rose to 28 percent in April
2020 from 15 percent in 2019, as
patients have avoided in-person
visits to clinics where they are at
risk of coronavirus exposure.
UnitedHealthcare’s initiative
targeted Medicare patients be-
cause the elderly are more at risk
of severe infection from the co-
ronavirus and the flu. Covid-19 pa-
tients who are over 80 are hun-
dreds of times more likely to die
from the disease than those under

40. They are also more likely to die
    from the flu — between 70 and 85
    percent of flu-related deaths occur
    in people 65 or older, according to
    data from the Centers for Disease
    Control and Prevention.
    While no other insurance com-
    pany has said it plans to send out
    prescription antiviral drugs,
    Aetna announced it would send its
    2.7 million Medicare members kits
    containing a thermometer, hand
    sanitizer and face masks. Anthem
    has partnered with community or-
    ganizations to create 500 local
    pop-up clinics administering free
    flu vaccines.

PREVENTION

Insurer Takes

Steps to Curb

Flu in Patients

With Risks

By EMMA GOLDBERG

.