COVID-19 is spreading fastest in smaller and more rural Arizona counties

The spread of COVID-19 in Arizona is behaving differently than it did in the summer, with spikes happening in rural areas such as Graham and Gila counties that had far fewer cases during the state's first surge.

Arizona's COVID-19 case increases at the onset of the pandemic began with an outbreak in Navajo County that was traced to a religious rally, followed by a gradual rise in the metropolitan areas of Phoenix and Tucson, and hot spot activity in the border areas of Yuma and Santa Cruz counties.

Although the large and urban Maricopa and Pima counties, home to metro Phoenix and Tucson, have seen the highest case counts and most deaths, COVID-19 is spreading the fastest in smaller and more rural counties.

Some of Arizona’s less densely populated regions are seeing the highest rates of COVID-19 cases.

Rural counties such as Gila, Graham, Greenlee and Coconino are leading the statewide resurgence in terms of new case rates, according to Joe Gerald, an associate professor at University of Arizona's Mel and Enid Zuckerman College of Public Health who has been tracking the pandemic’s spread in Arizona for months.

Counties such as Navajo and Yuma, which struggled in the summer, remain among the worst statewide in the second surge while Maricopa and Pima counties are doing slightly better this time around, he said.

“When you mix it all together you get this state average, but that average hides places that are struggling and places that are being successful," Gerald said.

"So that complicates any type of message that’s trying to describe Arizona as a whole because we have such different communities."

Graham County cases have increased 377% since July

In late July, as COVID-19 cases in Arizona surpassed 150,000, Graham County in southeastern Arizona had just 314 cases, and hospitalized patients maxed out at six.

This week, the county's case count was at more than 1,500 — a 377% jump. Deaths, which stood at five in late July during Arizona's COVID-19 summer peak, are now at 31.

Nine patients were hospitalized at Mt. Graham Regional Medical Center in Safford as of Tuesday, higher than any point during the summer surge, said Ky Sanders, who is the hospital's director of quality.

Neither Graham County nor the city of Safford have mask mandates.

"We're seeing people locally who are just not wearing masks, or are not limiting gatherings," Sanders said. "It's really frustrating on the public health side to see these things being ignored, and now we are paying the price for it. ... Any kind of thing we can do to reduce that transmission of flu and RSV and COVID would be extremely helpful."

All employees in the Graham County town of Pima were in quarantine last week because of COVID-19, resulting in closure of the town hall and cancellation of the Town Council meeting, the Eastern Arizona Courier reported Nov. 2.

Sanders said the hospital has been using the Arizona state surge line on a weekly basis lately to place patients who can't be treated locally.

"The percent of positive cases, the number of tests we've performed and visits to the ER have increased over the past three or four weeks. So really the things we are seeing now are from exposures of up to two weeks ago," Sanders said. "Who even knows what it's going to be like in another couple of weeks."

Graham County's numbers are small compared to the rest of the state. Its entire population is about 38,000, and while its percent of positive tests was running high last week at 25%, that statistic is based on only 78 tests that were electronically reported to the state.

"Percent positivity has a lot to do with the capacity and enthusiasm for testing, so the rural areas could be suffering from a lack of testing — whether it's because there isn't easy testing or because rural people aren't seeking tests as much as us urban and suburban people," said Will Humble, executive director of the Arizona Public Health Association.

To gauge hot spots, it's important to look at case rates per 100,000 and percent positivity together, Humble said. Graham County's percent positivity is well above the common benchmark level of 5%.

"The president kept saying we're finding more cases because we're testing more. That's true. If you test more, you will find more cases. But you also will drive down your percent positivity," Humble said.

"The more people you test, the better, because you are finding them and you are driving down your percent positivity. But when you have a case like Graham County or Gila County, where you have a high case rate and a high positivity, that means not only are you not testing enough because you know the percent positivity is high, you are also finding lots of cases.

"That means you have a lot of community spread and probably a lot of asymptomatic or mildly symptomatic spread that you are not catching. ...Your percent positivity helps put your case count and your case rate in context."

Other rural counties are hot spots, too

Yuma and Navajo counties continue to lead in terms of case rates since the pandemic began, followed by Santa Cruz and Apache counties, as they did during the summer peak.

Behind Apache County in terms of cases per 100,000 people as of Wednesday was Coconino County, with 4,098 cases per 100,000 people; Gila County with 4,068 cases per 100,000 people; and Graham County with 3,984 cases per 100,000 people, which are higher than the rates in Maricopa and Pima counties, according to state data.

The national average case rate since the onset of the pandemic is 3,033 cases per 100,000 people, the Centers for Disease Control and Prevention's COVID Data Tracker said Tuesday.

As for more recent numbers, case rates in some of the rural areas are 50% to 100% higher than the statewide average, Gerald said. He’s not sure what’s driving the changes as it’s hard for him in Pima County to understand situations on the ground in counties across the state.

Josh Beck, deputy director of public health for Gila County, said after coming down from its peak in mid-to-late June, the county for several weeks averaged just four or five new cases a week. But for the past two weeks, it’s averaged nearly 60 new cases a week, he said, back to the level from the summer surge. He said it’s largely due to a combination of more community spread and cases from in-person school.

In addition to a case rate above the statewide average, Gila County’s death rate is significantly higher than the statewide average. Beck said this likely is because of the county’s average age and socioeconomic status.

In Navajo County, public health director Jeffrey Lee said case counts and hospitalizations have been steadily rising again as they did before the summer surge. Navajo County has among the highest cumulative number of cases and deaths per 100,000 residents of Arizona’s 15 counties.

Lee said he believes the high death rate in Navajo County is a reflection of the lack of resources in tribal areas of the county as well as outbreaks at long-term care facilities.

Native Americans are at higher risk

Gerald said counties with higher proportions of Native American residents, such as Navajo, Apache and Coconino counties, may have higher numbers of deaths per 100,000 residents.

“Native Americans are particularly at risk because of socioeconomic factors, structural racism, historical disparities in rates of diabetes, obesity, hypertension, difficulty accessing medical care,” he said.

“So the differences in mortality are going to be attributable to both differences in the absolute case rates and the vulnerabilities of the groups of people, the populations of people, that are in those areas.”

Native Americans are dying in disproportionate numbers in Arizona from COVID-19, according to state data. Native Americans make up 11% of those who have died from COVID-19 in Arizona, among the cases for which race and ethnicity are known (race is unknown for 11% of deaths). But the American Community Survey's five-year estimates show that just 4.6% of Arizonans are American Indian or Alaska Native.

Lee thought Navajo County would benefit from being a rural area, but it has not.

“One of the things that we thought would play in our favor is our population density — it’s very low up here, our population is spread out, it’s rural, and we thought that would play in our favor," he said. "But one factor that didn’t is the multigenerational homes that we have throughout the county and seeing how that alone is a congregate setting and how quickly it spreads within the household and then into the community was really, really surprising to all of us.”

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Lee said case rates have climbed in part because the county does not have a mask mandate and in part due to COVID fatigue being felt everywhere. He thinks people have gotten more lackadaisical about following public health recommendations for the past few weeks, contributing to the resurgence. Spread is primarily coming from people going to work when they’re sick and from small family gatherings, Lee said.

Beck in Gila County said masks have presented a similar challenge.

“Mask-wearing can be complicated. It can be a political thing, and it’s a more conservative county, so we push the message out, but much like everywhere, the conservative parts of the county don’t wear masks as much as the more liberal parts of the county,” he said.

Not everyone is wearing a mask

Masks and mitigation strategies likely are contributing to the different outcomes seen across counties, said Joshua LaBaer, director of the Arizona State University Biodesign Institute and leader of the university's COVID-19 research efforts.

“I think if you get out of the cities, you will find a little bit less adherence to mitigation factors, and I think that’s probably contributing to a lot of spread in those places,” he said.

“There is a healthy population out there that is following the mitigation factors and they’re adhering to it, and that is helping prevent it from really skyrocketing. But nonetheless, there’s clearly a population out there that is not, and that’s what is contributing to the rise in numbers. If we could just get that under control, we could get our numbers back down low where we want them and get back to more normal life.”

While most major population areas of the state, including Phoenix, Maricopa County, Mesa, Tucson and Pima County have mask ordinances in place, several rural areas do not. Others have repealed mask requirements.

Payson rescinded mask requirements Sept. 21. The Kingman City Council voted in favor of ending its mask requirement on Oct. 21 and the city councils of Bullhead City and Lake Havasu City rescinded their mask orders in September, the Mohave Valley Daily News reported.

Some local jurisdictions such as the eastern Arizona town of Eagar have chosen not to adopt any mask requirements.

Nogales, in Santa Cruz County, has a mask requirement, but has also seen a spike. Mayor Arturo Garino said the city reported between zero and six cases a day for a month and a half, but recently reported 49 cases in a day, although that's still below summer levels.

Garino said he’s not sure what’s causing the case growth locally. In the summer, he said spikes were clearly identified in relation to Cinco de Mayo, Mother’s Day, Father’s Day and graduation parties. Now it may be linked to more travel back and forth to Mexico and more people relaxing on social distancing and mask-wearing, he said.

The fact that Nogales is a border city with lots of cross-border traffic certainly contributes to its high case rates, Garino said.

“We can’t let this happen again,” he said of COVID’s spread and impacts on business and the community.

Yuma Regional Medical Center had 55 COVID-19 patients hospitalized as of Wednesday morning. That number is far below the total number of coronavirus patients the hospital had in the summer peak when it was at 165 to 170, said Dr. Robert Trenschel, the hospital's president and CEO, but certainly a recent increase.

In September, the hospital's count of COVID-19 inpatients was in the single digits, he said. While he's hoping 55 is as high as the hospital gets, the staff is ready in case the numbers continue to rise, he said.

"We are certainly increasing from where we were before but we are not peaking obviously," he said. "The information from the state is they are expecting the peak to be between Thanksgiving and Christmas, we're projecting probably more toward Christmastime here, maybe a little after."

Trenschel said he doesn't know precisely why cases have been so high in Yuma County throughout the pandemic. From his perspective mask compliance is good and the county has a mask ordinance.

"I don't know what's driving it, but obviously something is," he said. "We knew the second peak would happen, we just didn't know when. We're not seeing a lot of flu, so that's good news."

Southeastern Arizona patients testing positive for COVID and flu

Right now, influenza is a concern at the Graham County hospital, Sanders said. Two to three outpatients have tested positive for both influenza and COVID-19, though none of the patients now hospitalized for COVID-19 has both, Sanders said.

"Historically, we start seeing influenza in late October, peaking around February or March," he said.

"We're already starting to see influenza cases. ... The big concerning thing is that we're a small hospital and we fill up quite a bit with influenza and RSV already. So as we're seeing this sort of second wave coming through, we're concerned about that."

Testing is an issue at the hospital, he said.

"We have testing. All the clinics have testing supplies and our hospital has testing supplies," he said. "The hard part is getting the tests run. We do have the availability to do in-house testing in our hospital lab. What we're running up against is we have a very limited number of test kits for that in-house system."

Each test kit box has 30 tests and two need to be used for quality control checks, which leaves 28 tests per box. The hospital is getting just one box per week from the manufacturer, he said. The results come back in about four hours, but not all patients can get one of those because the amounts are limited, he explained.

"We're extremely limited to perform in-house tests," he said. "We're saving those for patients who are really critical, who are being admitted, or who we know are going to be admitted, things like that," he said.

The other tests are sent out to a lab, which  can be upwards of 48 hours before results come back, Sanders said.

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The biggest worry at the hospital is getting overrun this winter, Sanders said.

"We've held okay in the past and we've had really good outcomes with the patients we've treated. It's just the amount," he said. "We're okay on equipment, the problem is the staff and the physical space to put those patients in. Right now we are running up against staff members coming down with COVID, so that is becoming a challenge."

COVID-19 testing more broadly is an added challenge in rural areas and smaller communities where setting up a drive-thru test site won't have the output it would see in an urban area, for example.

Asked whether the state was doing enough testing in rural parts of the state, Dr. Cara Christ, the Arizona Department of Health Services director, said it's a work in progress.

The state has been working with ASU to expand its saliva-based testing in rural counties and outlying areas in Graham, Gila, Yuma and Pima counties, and is working to add drive-thru test sites in rural areas, she said.

"There’s always the opportunity to get more testing as we continue to expand access to testing in Arizona,” Christ said. “I don’t know that we’ll ever stop trying to expand the access to testing.”

COVID-19 in rural areas is a problem across the U.S.

Arizona isn't the only state that is being hit in rural areas.

Cases are soaring in some parts of the country, among them North Dakota, South Dakota, Wyoming and Utah — areas where "we hadn't seen quite these levels before," said Dr. Andrew  Pavia, a fellow with the Infectious Diseases Society of America and chief of the division of pediatric infectious diseases at the University of Utah School of Medicine.

"It's hard epidemiologically to point at any causes, and there are different causes for the epidemics in different places. But there are some things they have in common that we can speculate," he said.

"These are all states that were not impacted as heavily in March and April and so there was perhaps less fear of the virus, less actions have been taken early on. There was a political climate in which there's general distrust in government and a lot of reluctance to take harsh measures."

Arizona is not one of those states where cases are surging exponentially, but the trajectory here is moving in the wrong direction. And experts are concerned cases could overwhelm the hospital system here when combined with flu and other respiratory viruses during the winter months.

One problem in Western states is a shortage of staff, including ICU nurses, respiratory therapists and infectious disease physicians with the expertise to provide care for COVID-19 patients, Pavia said.

"Throughout the region people are facing a crisis in staffing. ...There's no one point at which things become overwhelmed. But, for example, here in Utah we have to prioritize admitting patients from Utah to our ICUs and those we would normally serve from surrounding states have had to wait for beds to open up," he said.

"So the situation really has to be described as dire."

Reach the reporter at Alison.Steinbach@arizonarepublic.com or at 602-444-4282. Follow her on Twitter @alisteinbach.

Reach health care reporter Stephanie Innes at Stephanie.Innes@gannett.com or at 602-444-8369. Follow her on Twitter @stephanieinnes.

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