Spatial distribution of COVID‐19 relative risk scores by quintiles. (Source: Rural Areas Face Higher and Distinct Risks of Serious COVID‐19 Outcomes than Urban Areas report)

The absence of widespread testing for the novel coronavirus may cause rural counties to appear “statistically invisible,” as the true numbers of cases remain unavailable, a new research report says. 

The missing data could put rural counties at risk of lowering their guard while the epidemic spreads across the country, according to the report issued by Iowa State University’s Extension and Outreach

Rural counties with towns of 5,000 to 10,000 residents may be especially at risk, the report says.

“An outbreak of five severe cases requiring ICU hospitalization in a rural county will far outstrip local resources, but not make national headlines,” the research report says. “There is a danger that needed resources will not flow to rural places if decisions are based on absolute counts instead of relative risk scores.” 

Iowa State researchers propose a different way of assessing the risk for rural areas using 10 indicators linked to Covid-19 complications, grouped in seven distinct components.

The seven components are: 

  • Population.
  • Density.
  • Group quarters (percent of the population living in institutional settings).
  • Percent of seniors and elders aged 65-84 and 85 and older.
  • Employment in elderly care facilities per 10,00 people.
  • Immunocompromised populations measured with mortality rates per 100,000 (from cancer, cardiovascular diseases, and chronic lower respiratory diseases).
  • The mortality rate from diabetes. 
  • And the mortality rate from influenza and pneumonia. 

These relative risk scores reveal that “non‐metropolitan counties are more at risk for Covid-19 than metro ones.”

“About 31 percent of rural counties fall into the high-risk group, as do 27 percent of semi‐rural and 21 percent of micropolitan places,” the report says. “Given their low overall relative risk, only 6.5 percent of the nation’s largest metropolitan counties are at high risk.” The concentration of high-risk communities are in the Great Plains, Midwest, lower Mississippi Delta, and several Great Lakes states.

The researchers found that while the primary risk for rural counties lies with senior and elder populations, including risks involved with diabetes, the outbreaks are unlikely to occur in elderly care facilities because of their low availability in remote counties, reducing the chances of spread. 

Covid-19 relative risk factor score estimates (Source:Rural Areas Face Higher and Distinct
Risks of Serious COVID‐19 Outcomes
than Urban Areas

It’s the semi-rural counties with larger towns (2,500-10,000) serving as trade and education hubs that face the combined risks, with severe cases of Covid-19 “driven by a mix of older residents, immunocompromised individuals, people living in institutional settings, and the prevalence of health issues like diabetes and flu/pneumonia.”

Meanwhile, metro areas, although younger and healthier on average and with a lower risk for complications and mortality, may suffer due to high population density, enabling rampant community spread. 

Using these risk factors may allow for a better design of mitigation practices, the report says. With populations spread across rural counties, shelter-in-place may not be as effective as in the case of densely populated metro areas. According to the research, for rural communities, the answer could be to quarantine, isolate or disperse vulnerable populations. 

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