North Dakota, Which Hasn't Mandated Mask-wearing, Now Has Country's Highest Infection Rate

As the coronavirus situation improves in some parts of the United States, the Midwest now appears to be bearing the brunt of the outbreak, with North Dakota, in particular—a state with no mask mandate—seeing a notable spike in new cases.

In the past seven days, the state has recorded more than 2,200 new cases of COVID-19. Given its relatively small population of around 760,000 it has the highest rate of infections of any state in the country over this period—299 per 100,000 people—as of Friday, according to The New York Times coronavirus map.

On Wednesday, North Dakota had a 14-day average of 295 cases per day—the highest level of the pandemic, according to the North Dakota Department of Health (NDDH). Two days prior on Monday, NDDH officials confirmed a total of 2,758 active cases—a new record for the state. And by Thursday, this figure stood at 2,713.

Since June and July, there have been steady increases in both the number of new daily cases and the test positivity rate—the percentage of tests that come back positive out of the total number conducted—a sign that prevalence of the disease is rising.

Jennifer Horney, an epidemiologist from the University of Delaware, told Newsweek that the rise in cases is fueling community transmission—the spread of a disease where the source of infection is unknown—in North Dakota. In fact, community spread accounts for just under half of all the state's active COVID-19 cases. The other main route of transmission has been via a known close contact.

The total number of confirmed cases in the state now exceeds 16,700, but this relatively low number—compared to the rest of the country—can be misleading. In total, the United States has confirmed more than 6.6 million coronavirus cases and recorded more than 197,000 deaths from the disease, according to the Johns Hopkins University Coronavirus Resource Center.

"It's the incidence rate—the rate of new cases per the population at risk—and not the total number that are of concern to public health officials," Horney told Newsweek. "Less populous states have lower total case counts, but also likely have fewer resources to respond—fewer hospital beds, ICU beds and ventilators and less testing and contact tracing capacity. Therefore there's no reason to be complacent in less populous states, even with lower total case counts."

North Dakota's test positivity rate is currently hovering around 5.5 percent—which is close to the threshold of five percent that the World Health Organization recommends a region should stay at or below for at least 14 days before restrictions can be relaxed. The number of positive cases per 100,000 people has increased to around 45 per 100,000 and is growing by the day.

According to Horney, case counts in the state are not rising due to increases in testing capacity—the number conducted has remained relatively stable since mid-August—but because the prevalence of the disease is higher than earlier in the pandemic. And the epidemiologist said it doesn't appear as if the recent rise in cases has reached its peak yet.

As cases rise, deaths will likely go up too. Horney said the latest rise in cases will likely lead to a noticeable spike in deaths, similar to other states that saw an increase in infections over the summer.

The number of COVID-related deaths in North Dakota stood at 182 on Friday, and the state's mortality rate has been among the lowest in the country. But there has been a steady rise in deaths from June, which saw 18 fatalities, to August, when 40 were recorded. If current trends continue, September looks set to break May's record for the highest number of deaths reported in a month. Forty-three people died in May, compared to 35 this month as of Friday, September 18.

Dr. Joshua Wynne, vice president for health affairs and dean of the School of Medicine and Health Sciences at the University of North Dakota (UND), told Newsweek that one of the most important factors in the current phase of the pandemic in North Dakota is the young age of recently infected individuals, with people aged 20-29 making up the largest proportion of new cases—many of whom are university students. Given the small population of the state, outbreaks linked to universities, such as one at UND, have had an outsized effect on the surge in cases.

The mortality rate in the 20-29 age bracket is relatively low, which may be suppressing the number of deaths for now. "But those same people can transmit the disease to older, sicker individuals, so we need to keep up our guard and our efforts," Wynne said.

North Dakota flag
Stock image: 3D rendering of the North Dakota state flag. iStock

According to Wynne, a number of factors have contributed to the spike in cases across the state. These include the return of students to universities, the popularity of the state for summer recreational activities and "likely, some degree of 'letting down our guard as initially our numbers were much better than almost anywhere else in the country," Wynne told Newsweek.

In addition, while Governor Doug Burgum (R) has emphasized the importance of appropriate mask use—appealing to residents' sense of personal responsibility—North Dakota does not require citizens to wear masks and the state has imposed less strict coronavirus restrictions than many others across the country. According to Horney this could be playing a role in the latest spike.

To mitigate the recent spread of the virus, Horney said the state has invested heavily in contact tracing, which is important given that most of the spread is community driven. But the epidemiologist said more needs to be done.

"Without mandates for masks or limitations on gatherings or business operations—even in areas where spread is increasing—isolation and contact tracing of those who are positive are needed to prevent spread. [Currently,] they are not preventing those initial infections that may have been avoided through universal masking and social distancing," Horney said.

Some areas of the state, such as the capital Bismark and the city of Dickinson, are currently reporting a higher proportion of cases in residents over 70 years of age, who are at much higher risk from the disease.

"It is important for us to not be lulled into a false sense of security. On the one hand, North Dakota's mortality rate all along has been among the lowest in the nation. On the other hand, we should not relax our efforts to limit the impact of the pandemic," Wynne said.

"We take the recent rise quite seriously, because we know from the experiences elsewhere that things can get out of hand quickly. But because we are responding aggressively to the rise, our hospital systems remain stable and our state university system has remained open."

The outlook for the coming weeks is mixed, according to the experts we spoke with. Wynne said the 14-day rolling average of positive cases appears to be flattening out, which "hopefully" means that the cases may be headed down soon.

"I wish I had a clearer crystal ball. But I am cautiously optimistic that the tide may be turning," he said.

But according to Horney, some characteristics of the current rise in cases are still a cause for concern. For example, coronavirus clusters in places where there are university students and greater population density have meant that active cases in some metropolitan areas are almost as high as they were in May. In addition, the high proportion of community spread in North Dakota and the surrounding region could pose a significant problem over the course of fall.

"Infectious diseases do not respect jurisdictional borders, and high rates of community spread in some areas of the state, as well as in nearby Iowa and Nebraska, do not bode well for rates in North Dakota over the coming weeks," she said.

North Dakota, Which Hasn't Mandated Mask-wearing, Now Has Country's Highest Infection Rate | U.S.