Rurality and Covid-19 in Tennessee: Assessing and Communicating Pandemic Emergence and Transmission

The first reported case of COVID-19 in Tennessee (TN) occurred on March 5, 2020, growing to 580,809 cases state-wide by the end of 2020. A GIS dashboard was developed using data from the TN Department of Health to communicate state-wide COVID-19 spread, and a relationship between pandemic development and rurality was observed during the first wave (through September 2020), noted in other US and global research. Because > 90% of TN counties are designated rural or mixed-rural, we examined metrics to describe development as it relates to rurality. Metrics included days to the first case/hospitalization/fatality, days between state and county peak, and days to an incidence rate of ten per 100,000. Metrics were compared within different classes of rurality, using seven rurality classification schemes. Significant differences were noted in four of the five metrics between classes of rurality. Rural counties in TN experienced significant lags to the first case, hospitalization, and fatality, and the peak cases in rural counties were delayed relative to urban counties when outlier counties with early state prison outbreaks were excluded. In rural TN counties, regardless of rurality definition, cases, hospitalizations, and fatalities were slower to appear. However, once community spread was established, rurality no longer had a protective effect.