The outcome measure was mortality rate attributed to COVID-19 for each county death count included confirmed and probable COVID-19 deaths by day. Our objective was to further inform current and future state health policy decisions and provide data for public health planning, resource allocation, equitable vaccine distribution, and future response efforts. We compared differences in COVID-19 mortality rates for the study period with influenza and pneumonia mortality and all-cause mortality rates from 2015 to 2019 by county type, respectively, for additional insight into understanding rural community vulnerability. To better characterize the effects of the COVID-19 pandemic on communities in Tennessee and address rural health concerns, we investigated differences in urban and rural mortality rates attributed to COVID-19 prior to widespread COVID-19 vaccine availability. 17 While rural-urban inequalities in COVID-19 mortality rates might reflect disparities across multiple factors, we expect some of these factors to be similar when comparing differences in rural-urban mortality rates for COVID-19 with influenza and pneumonia. 16 Previous studies have identified rural-urban disparities in influenza and pneumonia mortality rates these have widened over time, with rural areas showing increased mortality from influenza and pneumonia. 15 In addition, there are also similarities in the modes of transmission and populations at highest risk. Commonly observed clinical signs in COVID-19 (eg, fever, cough, shortness of breath) are similar to those of other respiratory viral diseases including influenza.
To provide additional insight into rural communities' vulnerability to COVID-19, influenza and pneumonia death rates can serve as a historical comparator in rural regions. 7 Due in part to geographic and socioeconomic challenges, many rural communities experience higher rates of health disparities (including COVID-19 mortality differences) attributed to socioeconomic status, 8 racial disparities, 9, 10 social determinants of health, 11, 12 age differences, 13 and urbanization patterns. Like other southern US states, Tennessee has seen a large effect from rural hospital closures, losing 9 hospitals over the last 5 years alone. Health care access also varies rural hospital access has declined over recent years, including throughout the COVID-19 pandemic. 6 Tennessee has notable differences between urban and rural communities in population size, demographics, culture, infrastructure, and population health. This includes Tennessee, with a majority of the land area and approximately 22% of the resident population in rural areas in 2019.
Rural communities make up a sizeable proportion in many states. As the course of the pandemic progressed, however, cumulative incidence increased steadily in rural areas, 4 followed closely by rising mortality rates. 4 Early in the pandemic, from mid-March to mid-May 2020, cumulative incidence was highest among residents of large urban areas where the virus was initially introduced. 1– 3 Since the first documented case of COVID-19 in the United States in January 2020, weekly incidence has differed between urban and rural areas. Reduction of health inequities, including those between rural and urban counties, remains an important public health policy goal and an emphasis of the Centers for Disease Control and Prevention's (CDC) health equity strategy. The United States faces geographical disparities in health and disease.
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