Infectious Diseases Experts Look at the COVID-19 Challenges Facing Rural Healthcare
What are the prospects for rural healthcare providers and communities, as the COVID-19 pandemic spreads out from the large cities in which it has already had a devastating impact? That was the subject of the telephonic press briefing held by the Arlington, Va.-based Infectious Diseases Society of America (IDSA) on Tuesday, April 21. IDSA represents infectious diseases specialists, epidemiologists, and others whose work focuses on infectious diseases.
Christopher Busky, IDSA’s CEO, moderated a discussion on Tuesday, with two experts. Angela Hewlett, M.D., M.S., FIDSA, is an associate professor in the Division of Infectious Diseases at the University of Nebraska Medical center and medical director of the Nebraska Biocontainment Unit there, and an IDSA member. Andrew T. Pavia, M.D., FIDSA, also an IDSA member, is chief of the Division of Pediatric Infectious Diseases at the University of Utah School of Medicine and an adjunct professor in internal medicine and a professor in pediatrics at the University of Utah, in Salt Lake City.
Dr. Pavia began by stating that “I’m looking out over the sunrise on the Wasatch Mountains. This is an area of large cities separated by hundreds of miles, with rural communities. You might think those rural communities have been spared COVID-19, but they haven’t been. Resorts—Sun Valley, Park City, Utah, Vail, Colorado—have been hit. And it wasn’t just the tourists or people with second homes, who were affected, but many local residents, some of whom live far away and commute because they can’t afford to live in those towns. That’s how COVID-19 seeded small towns in the West, hospitals with fewer resources. People [in those communities] may have chronic illnesses, including diabetes.”
Further, he said, “We also have to look at the way in which the virus is hitting Native American communities. In the Four Corners area, the Navaho nation has been hit quite heavily by COVID-19, with death rates that have been quite high. Navaho Nation testing has been quite good. We’ve been lucky that we’ve been able to establish good levels of testing along the Wasatch Range. But the testing in the West is very uneven. And,” he said, “we’ve talked about disparities for poor people and people of color, but there’s another disparity, and that is in rural areas. We’re probably going to see long, sustained outbreaks for many weeks to come, though without high peaks. It’s also going to make it difficult to reopen. Also, the bigger cities have major medical centers, specialists, and ICU beds; but when you get hundreds of miles away from the big cities, the landscape is very different.”
“I think this is an incredibly important topic, as Dr. Pavia mentioned,” Dr. Hewlett said. “Living in rural America definitely has some definite advantages: people are naturally socially distanced, most live in single homes, and don’t have mass transit, as in urban centers. But it’s also a uniquely vulnerable population,” she hastened to add. “These are close-knit communities in small towns; whole towns may attend social gatherings. Also, the industries located in these communities are very different. These communities are often fed by meatpacking or other industries, or power plants; the jobs involved don’t allow people to work from home. And there are often people working in very close contact, so that’s a set up for infect. Also, the hospitals are small and are often ill-equipped for caring for patients with intensive needs. Also, limited testing capabilities. It’s difficult to obtain the tests, the turnaround on tests is very long, the tests have to be transported to labs far away, so it’s difficult to make decisions. Also, there may be one health department for many miles around, so it’s difficult to do good contact tracing.”
In that context, she asked, “So how are we doing in Nebraska? From far away, the numbers look small, but if you look at it by county, the results are alarming. It started in Omaha, with 500,000 people, but it’s since shifted to western Nebraska, including to one county with 61,000 people; that’s a very hard-hit area. There are several reasons for that,” she said. “One is the industry. Our smaller areas have a lot of food processing, including meatpacking. It’s very difficult to prevent the spread of disease. And in that one small town with a population of less than 1,000, with a meatpacking plant, they had a large birthday party the day before the schools were shut down, and more than 400 people attended, and there was an outbreak from that. And we’re seeing outbreaks in nursing homes in small towns as well. And the small hospitals with limited ICU capabilities are filling up fast, and are full, and are having to transfer people. And the virus is everywhere in these small communities. And other areas surrounding this one are seeing this.”
As a result, Hewlett said, “To summarize, our curve in Nebraska is moving upward. We have not reached our peak in any way yet. And although the vast majority of our state is very, very rural, we have not dodged this in any way. The vast majority of our state is very rural. And we need to approach this very seriously.” She added a further example: “Counties in southwest Georgia have seen huge outbreaks—rural, largely Black communities, with health disparities. Is this an indicator for other rural communities.”
“Yes, we’ve known for a long time that poverty is a big indicator for poor health,” Pavia agreed. “Poor people are more likely to have diabetes and heart disease, but also less able to access care. And poor communities often have less access to acute care, including ICU care. Is this an indicator to what’s going to happen around the country? Absolutely.” Analyses have been done of such areas, he said, “in which they look at poverty, access to care, the presence of chronic diseases, and older populations. It’s kind of a perfect storm.”
And, Hewlett added, “It’s also important to note that individuals living below the poverty line do not have the ability to self-isolate, in terms of their jobs.”
How realistic is the potential for contract tracing in rural areas?
A member of the press noted that, “In several western states, there are pretty low recorded infection rates. How realistic is it to do contact tracing, and effectively combat the disease more so than in places where contact rates are higher?”
“It’s a mixed picture,” Pavia noted. “You can have much greater impact in terms of contact tracing. But as Dr. Hewlett mentioned, you also have to have the public health infrastructure; it doesn’t do very well to do contact tracing 10 days after they’ve been transferred to the ICU. So you need to have a public health infrastructure, and that’s a real challenge in rural areas. We’ve lost workforce, lost expertise; there probably wasn’t a community in the US that had an adequate public health infrastructure.”
Asked when they expect to see peaks of infection in the areas in which they work, Hewlett said, “We have seen this gradual uptick in cases here in Nebraska; we don’t really know when our peak will be; we anticipate the end of this month or the beginning of May, but that also depends on what happens in our community. I’m afraid we’ll see a peak, a downslope, and if we go back to business-as-usual, another uptick. But we’re at least a week or two away.”
“I think we’ve oversimplified this idea of peaks, because we’re actually seeing thousands of different outbreaks across the country,” Pavia stated. “Here in Utah, we’ve done a reasonably good job of tamping down the rate of rise; but in the past week, we’ve seen a rise again. And I think it’s been because of some of these micro-outbreaks. And everyone’s become an ‘expert’ in curves, but it’s actually very complex.”
Medical transport issues cited
Asked about the complexities around medical transport to and from rural areas, Hewlett said, “Air transport is definitely a way to transport sick patients from one place to another, particularly individuals critically ill who need ICU care. In Nebraska, you can drive eight hours and still be in Nebraska. Ground transport is very difficult. So we have had air transport, but that being said, this is very different. There are a lot of sick patients out there, and when those beds are full, which is occurring as of today, they’re needing to ship those patients out. And that’s very difficult.”
“Another challenge has been protecting the air crews; these folks take risks every day,” Pavia noted. “They fly in snowstorms. But it’s a different challenge to protect them when transporting very sick people with respiratory diseases in close quarters. Sometimes, it’s a three-hour flight. It’s been a real challenge. We’ve heard stories of a few who have refused to fly because of the risk.”
What impact will the opening up of businesses have, in states like Georgia and South Carolina? “It’s hard for me to speak to the economics of that,” Pavia said. “But in terms of risk, it depends on the kinds of industries that open back up again. There are certain jobs that can carefully be opened up, with masking, etc. But many types of jobs, that’s not possible, you’re working in crowded spaces, and it’s too hot to wear a mask. Will it be worse in rural communities than in cities? I think it will depend on the community. If it’s in a manufacturing plant with tight quarters and poor infection control, that will be very difficult. Ranching, you can probably do pretty safely.”
“It really depends on how we do this,” Hewlett chimed in. “If we open up and don’t take this very seriously and don’t think about the actions, we’ll definitely see a lot more cases.”
Asked about the planned opening up of many types of businesses and activities in Georgia on Friday (April 24), Hewlett said, “As I mentioned before, we just really have to be careful about this. And from what I’ve seen with the numbers out of Georgia, we haven’t seen decreases for weeks. That hasn’t been occurring. I don’t think we’re ready yet to do that. I do feel it should be a local and state decision, because this is a local phenomenon, even by county. But we just have to be very careful in terms of how we do this. We don’t want to shoot ourselves in the foot and open up too early.”
What’s more, Pavia added, “You have to have enough healthcare capacity; you have to have a sustained drop in cases; you have to have a sufficient public health infrastructure.”
Capacity and resource challenges in rural hospitals
With regard to resource availability, Hewlett noted that, “You have to look at the types of facilities involved; in a rural area, you may have a critical-access hospital, with maybe 28 beds and maybe one ventilator, if that. Even our regional hospitals that are a bit larger still have ICUs that are 10-15 beds. And our facilities like that, their ICUs are full of patients on ventilators. And that’s the physical facility, much less the staffing. They don’t have a lot of reserve as far as their staffing goes. So it’s very difficult to care for a patient on a ventilator in any ICU, much less in a small community. The supply chain is also different. If they have 100 beds and a 10-bed ICU, but maybe only one ventilator—it’s very difficult to care for these numbers of patients we’re seeing.”
“Some of these frontier hospitals may only have 20 beds, and may only have one or a few ICU beds,” Pavia added. “The staff are pretty quickly overwhelmed; they have to staff 24/7 for weeks at a time, and many of these communities barely have enough staff to care for normal conditions.”
What about the lack of specialized medical skills needed to treat COVID-19 patients, such as from infectious diseases specialists and intensivists, and the specialized nursing skills needed to manage these situations? “Your question is definitely valid,” Hewlett told a reporter. “I can speak for Nebraska, and can say if you’re outside of Omaha or Lincoln, once you start going west, you have essentially two infectious diseases specialists in the entire state. And that goes for critical care specialists as well, there are very few. And what we’re seeing with this disease is patients who are very sick and requiring extended ICU care for weeks, often requiring several weeks’ worth of ICU-level and ventilator-level support. And in these small communities, that’s just not sustainable. They’re very well known for stepping up. But that having been said, this is a very different scenario than we’ve ever seen. And I agree, there just aren’t a lot of specialists.”
“There’s a really critical shortage of infectious disease specialists throughout the country,” Pavia noted. “Here in Utah, we’ve been working for a number of years on using telehealth to support infectious diseases and intensivist needs; but it’s been quickly overwhelmed by the need. That said, we’ve been better positioned here in Utah to do outreach. But we need to do a lot more. And also because of the fragmentation, you can do well in one integrated health system, but a smaller health system or independent hospital might not be able to do that.”
So, a reporter asked, what can be done to help and support hospitals and healthcare organizations in rural areas? “I’ll start by mentioning something that Dr. Pavia said earlier: supporting local health departments is incredibly important, in terms of contact tracing and outbreak investigation,” Hewlett said. “The problem is that in these small areas, they just don’t have the staffing or capabilities. So that would help. And enhancing tracing capabilities would be huge here. So if we could get some assistance with testing in rural areas, as well as everywhere else in the United States, that would go a long way.”
“There are no easy fixes,” Pavia emphasized. “We can’t send physicians to every community in the country. One of the things that would be helpful would be to provide assistance in how to reopen industries safely. We’ve talked about meatpacking. We don’t really know what needs to be done to safely open manufacturing plants. That’s an area where the federal government could provide help.”
