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A message of encouragement is painted on the fence of a home in Grand Island, which got some better news on Thursday.

The vast swaths of open space beyond the Omaha and Lincoln metros in Nebraska would seem an unlikely place for a coronavirus epidemic.

People spread out over rural towns, small cities and farmland. The large majority living in single-family homes. No mass transit systems. Social distancing? It’s part of the natural landscape.

But the reality in this pandemic is proving radically different than that expectation in some areas outside Nebraska’s biggest cities, said Dr. Angela Hewlett, an infectious disease expert at the University of Nebraska Medical Center.

Many in rural Nebraska work side by side in large food processing and meatpacking centers. Their work is seen as part of an essential industry, and it’s not a job that lends itself to telecommuting.

And it only takes one infection in a small, close-knit community to send COVID-19 cases spiking through the roof.

It all combines to help explain why Hall, Dawson and Dakota Counties have emerged as the epicenter of Nebraska’s COVID-19 pandemic.

“People think individuals out there in rural America are always living socially distant, and it’s simply not true,” said Hewlett, the medical director for the Nebraska Biocontainment Unit. “It’s a completely different picture that emerges, and it’s alarming, actually, what we’re seeing.”

Indeed, Hall, Dawson and Dakota Counties are seeing rates of COVID-19 more than 16 times that of the rest of the state and almost six times the national average, according to a World-Herald analysis of the latest per-capita coronavirus rates in Nebraska’s 93 counties.

And now the deaths are beginning to add up, particularly in Hall County. Home to just 3% of the state’s residents, as of Thursday morning Hall County — which includes Grand Island — accounted for about a third of the state’s 45 coronavirus deaths.

The analysis shows how powerfully the spread of the virus in those three meatpacking communities is driving Nebraska’s recent massive increases in COVID-19 cases. No matter how you slice up the state, those three meatpacking counties stand out.

In contrast, in Nebraska’s most populous areas, the state’s efforts to slow the spread of the virus through social distancing appears to be working. In the five Nebraska counties that are part of the Omaha metro area, the rate of 4.8 cases per 10,000 population is about half the statewide average of 9.3 and well below the national average of 14.

The Lincoln metro is even lower, with a rate of only 3 cases per 10,000.

“It’s excellent that we have not overwhelmed our health care system in Douglas County, which is what people were afraid of,” Hewlett said. “Those social distancing methods have helped.”

The coronavirus rate is also only about 4 cases per 10,000 in the most rural parts of the state — that is, counties without a city having a population of 10,000 or more.

Even in major meatpacking centers outside Hall, Dawson and Dakota, the average rate is half the state average. Colfax, where meatpacking makes up the highest percentage of jobs of any county in Nebraska, to date has seen few cases. Rates in Madison County are also low, though they appear to now be on the rise.

But rates as of Thursday morning were nearly 100 per 10,000 in Hall, nearly 84 in Dawson and over 43 in Dakota, towering above the rest of the state.

What’s happening in those rural Nebraska counties is in some ways not a complete surprise, Hewlett said. A similar pattern was seen when the virus swept through Italy earlier this year, with many smaller communities hard hit. And it’s playing out in many counties across the Great Plains, particularly those that are hubs of meatpacking.

With thousands of people working in close quarters in an industry that’s considered essential to the nation’s food supply, “it really is a setup for perpetuating a disease like this that’s spread from person to person,” Hewlett said.

Other attributes of American rural life also come into play in the coronavirus spread. Rural communities are often close-knit, with the whole town coming together for events and gatherings.

“And it doesn’t matter whether you’re in a small town or a larger city, if you have people together and someone is infected, it’s going to spread,” Hewlett said.

That can create big problems for health care systems in small counties that aren’t equipped to handle big influxes of patients. The intensive care unit in Grand Island’s hospital for the past week has been running near capacity.

Getting test results is difficult because samples must be sent off to labs across the state. And small communities lack the public health personnel needed to track contacts with the sick and help prevent further spread.

Hewlett said the worst days in those hard-hit counties are likely still ahead.

“We have not reached our peak in any way here,” she said.

Hewlett said she’s hopeful the small number of cases in some meatpacking communities aren’t a matter of luck. A team of her UNMC colleagues are among the experts working with plants around the state on finding best practices that can help protect workers from infection.

Hewlett said certainly not all the people being sickened in hard-hit counties are associated with meatpacking. Social distancing is important for everyone, and she said it’s possible a more formal stay-at-home order from Gov. Pete Ricketts would slow the spread of the virus in those communities. But the issue is more complicated than that, she said.

A stay-at-home order would not stop the essential food plants from operating. And while Ricketts has not issued a formal order, his consistent message has been that people across the state should just stay at home.

Whether a formal stay-at-home order is now needed would depend on how well people are heeding that message, Hewlett said. She said she doesn’t know if people are staying home in those most troubled counties, but they certainly need to do so.

“To me it really doesn’t matter if we have a formal order or not if people are doing the right thing,” she said. “It’s really a community effort. In Grand Island, people should be staying home.”