BISMARCK — Much of North Dakota is considered rural, with people spread out in small towns and few venues to gather in large groups. But, these less-populated areas have now exceeded metropolitan regions in the number of COVID-19 cases they have per capita, according to the North Dakota Department of Health.

More than half of North Dakota's 53 counties have reported more confirmed positive COVID-19 cases per 10,000 people in the last 14 days, than Cass County — which includes Fargo and West Fargo and is by far the state's most populous county. Multiple rural counties, including Foster, Towner and Eddy counties, have even reported the among most cases per capita in the United States.

In the beginning stages of the pandemic, North Dakota's densely populated cities reported the most cases, and Gov. Doug Burgum ordered schools and businesses statewide to shut down in order to curb the virus' spread. Now, as a result of community spread and in part driven by people attending large gatherings, the cities with the fewest North Dakotans are reporting the most positive tests per capita.

Foster County, which has a population of just over 3,200 people, reported the most cases per 10,000 people as of Wednesday, Oct. 21, with 258 positive cases in the last 14 days. In contrast, Cass County had 117 cases and Burleigh County, which encompasses Bismarck, had 176.

The New York Times reported that about one in four COVID-19 deaths have been recorded in rural areas, and since the summer, the number of per capita cases and deaths rates in rural areas have surpassed those in metropolitan areas.

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Some of North Dakota's rural counties do not have hospitals, and many that do are transferring patients out of state as demand for hospital resources has increased and North Dakota's hospital capacity remains startlingly low.

Of the state's 46 hospitals, only 14 staffed intensive care beds and 232 staffed in-patient beds were available statewide as of Thursday, Oct. 22, according to the state.

The number of COVID-19 cases in North Dakota continues to break records as the state's Department of Health on Thursday, announced another 1,038 positive cases and the number of North Dakotans known to be infected with the illness is now 6,350.

An additional nine deaths were reported on Thursday, including two residents of Grand Forks County, two residents of LaMoure County and one each from Cass, Grant, Morton, Richland and Ward counties. All were in their 50s to 90s and had underlying health conditions.

The U.S. Centers for Disease Control and Prevention says older adults and people with HIV, diabetes, asthma, liver disease or other conditions that compromise one's immune system are at a greater risk of serious illness or death from COVID-19.

The state's total COVID-19 death toll is now 431, of which 161 deaths have occurred in October alone, according to the state.

At least 258 of the state's deaths have come in nursing homes and other long-term care facilities, many of which have seen skyrocketing cases among residents and employees in the last month.

The state announced Tuesday, Oct. 20, that it is now asking residents to conduct their own contact tracing as the state's operation is overwhelmed by the number of cases. The state said Thursday that it had resolved a backlog of notifications for over 800 North Dakotans who tested positive for the virus.

North Dakota reported the most COVID-19 cases and deaths per capita in the nation over the last week, according to The New York Times, and according to one analysis, if North Dakota was its own country it would have the worst COVID-19 outbreak in the world.

Cass County now has 1,429 residents known to be infected with the illness — the most of the state's 53 counties. It announced an additional 280 cases Thursday.

Burleigh County reported the second-greatest number of new cases with 209 additional positives. The county now has 1,054 positive cases.

About 13% of the 7,931 residents tested as part of the latest batch received a positive result, but almost 23% of residents tested for the first time got a positive result.

North Dakota does not report a seven-day rolling average for positivity rate, but Forum News Service calculated the rate to be 11% for all residents tested and about 19% for tests taken on previously untested residents.

Readers can reach reporter Michelle Griffith, a Report for America corps member, at mgriffith@forumcomm.com.

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