Most of Iowa’s counties now have at least one confirmed case of COVID-19, and in many of the state’s rural counties, there’s just a handful of cases. But this has given some a false sense of security that rural areas could be more protected against the virus.

Shelly Bickel has long been worried about COVID-19 coming to Wayne County.

"Because as you know, most critical access hospitals don't have more than two ventilators and probably not enough PPE," she said.

Bickel, the administrator for the county health department, said she’s been sending out information to residents for weeks. But she's concerned it will take at least one confirmed local case in the county to really get people’s attention.

I don't want to say people aren’t taking it seriously. The elderly for sure are, and I don't see many young people out. So I'm thinking they do," she said. "But it's different when you don't have a case or you have hundreds of cases."

In neighboring Appanoose County, there has been a confirmed COVID-19 case, but lifelong resident Terry Tuttle says that hasn’t worried him.

"I'm not overly concerned because I believe that person has since passed away and from what I've been told they were elderly in a nursing home facility," Tuttle said.

Tuttle, the owner of Captain’s Landing Restaurant in Moravia, said a lot of people are following social distancing recommendations there. But he said he also feels safer living in a sparsely-populated area.

"The thing I'm very thankful for -- as well as my family -- is that we live in southern Iowa as compared to living in Des Moines or even a larger city," he said.

But experts say rural areas are much more vulnerable to COVID-19 than many realize.

People have this false sense of security. That's only going to enable the virus to be able to penetrate our populations more. - Megan Srinivas, an Infectious Disease Specialist in Fort Dodge.

"We are a much older population, where a population that has a lot more comorbidities, and both of those things places as at high risk for having severely ill patients," said Megan Srinivas, an Infectious Disease Specialist in Fort Dodge.

Srinivas said the problem is testing is still limited so it’s unclear how many cases are out there and many rural areas don't have any ICU beds.

Also, she said rural areas lag behind their urban counterparts when it comes to the spread of the virus.

"People have this false sense of security. That's only going to enable the virus to be able to penetrate our populations more," Srinivas said.

A University of Texas at Austin study released earlier this month predicted if there’s just one confirmed COVID-19 case in a rural county, the chances of an undetected outbreak increases from 9 percent to 51 percent.

And at a press conference this week, Gov. Kim Reynolds said Iowans should just assume the virus is everywhere.

"You should just assume that it’s in your community no matter where you live because we crossed that level a long, long time ago," Reynolds said.

But this message can be hard to spread to some rural areas -- even those with significant cases.

Louisa County has had more than 150 cases, mostly linked to a huge outbreak at a Columbus Junction food processing plant.

"We were a little surprised that it took off as quickly as it did," said Shawn Mayne, the mayor of Wapello, which is 14 miles from the pork plant.

But Mayne says he’s not worried about an outbreak in his town. He says Wapello does have some cases, but residents are following precautions.

"Louisa County is so rural, there is not one streetlight in the entire county. So we're already kind of spread out a little bit," he said.

In Allamakee County, which has had more than two dozen cases, Robin Harmon, the owner of a bar and grill in New Albin said she’s had to worry more about her restaurant -- which has lost two-thirds of its business.

"I guess I don't think about it because I just think about coming to work. But for people that have underlying health issues, they're nervous about it, because you know, they don't want to catch it," she said.

But some rural areas said they’re worried about visitors bringing the virus to their area.

In Dickinson County, Emergency Management Coordinator Mike Ehret said they’ve seen a lot of people coming from urban areas like Des Moines or Omaha to their vacation homes. They’ve asked anyone coming from outside the county to self-isolate for 14 days.

"We don't want a bunch of people out here in our county to end up with COVID because, you know, somebody came in for the summer [from] somewhere else and then brought it with them," Ehret said.

Earlier this month, Wayne County got a lot of attention when a local man hosted a horse auction that drew 600 people from eight states.

County Health Administrator Shelly Bickel said her department and many of the county’s residents strongly opposed it.

"The problem was it came down to one man who we went out and talked to. Everybody talked to him. He didn't listen," she said.

Right after that auction, Gov. Reynolds imposed stricter restrictions that would stop similar events from happening.

Natalie Krebs is IPR's health reporter. Support for her work comes from the Mid-Iowa Health Foundation.