The Association of Stay-at-Home Orders and the Spread of COVID-19 in Rural and Urban United States

Jiang, D. H.; Roy, D. J.; Pollock, B. D.; Shah, N. D.; McCoy, R. G.

Background: Throughout the spring of 2020, stay-at-home orders were imposed to curb the spread of COVID-19. There is limited data on the effectiveness of stay-at-home orders, particularly in rural as compared to urban areas. Objective: To examine the association between stay-at-home order implementation and the incidence of COVID-19 in rural vs. urban counties. Design: Interrupted time series analysis using a mixed effects zero-inflated Poisson model. Participants: 3,142 U.S. counties. Interventions: Stay-at-home orders. Main Measures: COVID-19 daily incidence (primary) and mobility (secondary and intermediate measure of stay-at-home effectiveness) Key Results: Stay-at-home orders were implemented later (median March 30 vs. March 28) and were shorter (median 35 vs. 54 days) in rural than urban counties. Indoor mobility was, on average, 2.6-6.9% higher in rural than urban counties both during and after stay-at-home orders. Compared to the baseline (pre-stay-at-home) period, the number of new COVID-19 cases increased under stay-at-home by IRR 1.60 (95% CI, 1.57-1.64) in rural and 1.36 (95% CI, 1.30-1.42) in urban counties. For each day under stay-at-home orders, the number of new cases changed by a factor of 0.982 (95% CI 0.981-0.982) in rural and 0.952 (95% CI, 0.951-0.953) in urban counties compared to prior to stay-at-home. Each day after stay-at-home orders expired, the number of new cases changed by a factor of 0.995 (95% CI, 0.994-0.995) in rural and 0.997 (95% CI, 0.995-0.999) in urban counties compared to prior to stay-at-home. Conclusion: Stay-at-home orders decreased mobility and slowed the spread of COVID-19, but less effectively in rural than in urban counties. This necessitates a critical reevaluation of how stay-at-home orders are designed, communicated, and implemented in rural areas.