The coronavirus pandemic that has hammered some of America's largest cities is now spreading to smaller rural areas, a progression that will bring a virus President Trump Donald John TrumpBubba Wallace to be driver of Michael Jordan, Denny Hamlin NASCAR team Graham: GOP will confirm Trump's Supreme Court nominee before the election Southwest Airlines, unions call for six-month extension of government aid MORE once downplayed to the doorsteps of voters who sent him to the White House.

Early epicenters of the disease in the United States have concentrated in urban settings. The first major outbreaks struck Seattle and San Francisco, followed by the greater New York City area that has suffered hundreds of thousands of confirmed cases.

But in recent weeks, the coronavirus has spread to rural areas, especially southern states like Mississippi, Alabama and Georgia and the Midwest, hitting Indiana, Iowa, Nebraska and Oklahoma.

ADVERTISEMENT

Up until late March, 80 percent of the counties with high prevalence of the coronavirus were home to large urban cores, according to a new analysis by William Frey, a senior demographer at the Brookings Institution. But over the last three weeks, the share of suburban, small metropolitan and non-metropolitan areas experiencing coronavirus prevalence has grown.

Now, more than half the counties showing signs of rapid growth are outside metro areas.

While the confirmed case counts remain highest in states like New York, New Jersey and Massachusetts, confirmed cases are growing at faster rates in smaller, more rural states. In just the last three days, Arkansas, Iowa, Kansas, Nebraska, New Mexico and Wisconsin have all recorded their highest daily case counts.

Epidemiologists said the spread from urban cores to rural regions is typical of an infectious disease like influenza, which usually lands in big cities with busy hub airports. Viruses tend to fan out across cities, but expand more slowly — though no less dangerously — in rural areas.

The early cases in Seattle and San Francisco were imported by travelers from China, while genetic sequencing of the first cases in New York shows they were most likely brought over from Italy or other European countries.

"When there are viral infections, it's often certain cities where there are high population density, high connectivity, presence of an international airport, those cities tend to be the first hit," said Amesh Adalja, a senior scholar at Johns Hopkins University's Center for Health Security. "Then you see diffusion to other parts of the country."

ADVERTISEMENT

The spread of the coronavirus to rural areas will be slower, experts said, because of some built-in defenses those communities can use to their advantage: Lower population density means more natural social distancing. Public transit, which has spread the virus in places like New York City, is not a factor in many rural communities. And those areas have fewer connections to big cities.

But those connections exist, meaning the virus will spread eventually.

"The places with the most movement for human connectivity are the largest cities, and then you go down in size and population density from there," said Nita Bharti, a biologist at the Center for Infectious Disease Dynamics at Penn State University. "The less populated places tend to be less connected than the big cities, but they're still connected."

The virus can take any number of routes from big cities to small towns. Prisons and jails have become epicenters of coronavirus outbreaks in rural parts of Indiana and Ohio in recent weeks. So too have meat processing plants in South Dakota and Iowa.

There are signs that city residents might be importing the virus when they visit their second homes. An analysis by University of New Hampshire Carsey School of Public Policy researcher Jessica Carson found much higher rates of coronavirus in rural areas with high proportions of vacation homes.

Epidemiologists are worried that the slow spread of the virus into rural America means it is only now arriving in communities that have been on lockdown for weeks. In conservative enclaves, many may see the virus's slow spread in their areas as evidence that Trump was right, and that the virus poses little risk to them or their community.

Put another way: The coronavirus landed among voters who favored former Secretary of State Hillary Clinton Hillary Diane Rodham ClintonJoe Biden looks to expand election battleground into Trump country Biden leads Trump by 12 points among Catholic voters: poll The Hill's Campaign Report: Biden goes on offense MORE in 2016. It is now spreading to voters who backed Trump.

Clinton beat Trump in counties that experienced the earliest outbreaks by a 62 percent to 34 percent margin, according to Frey's calculations; in counties that have been hit harder in recent weeks, Clinton's lead is down to 52 percent to 42 percent, a sign that the virus is moving into more conservative territory.

Some worry that Trump’s early attempts to downplay the virus, amplified by Fox News hosts for months, coupled with the coronavirus’s slow arrival, have made conservative rural voters skeptical that it poses a real threat. Trump’s own remarks may have lulled his base voters into a false and dangerous sense of security.

"The early messaging out of the White House was extremely dangerous. And I think a lot of people heard early on that this did not have to be taken seriously, and I think that sentiment was hard to unseat in people's minds," Bharti said. "Part of the feedback loop is that they heard that this pandemic was no big deal, they didn't see that many first hand cases. A lot of rural residents didn't really see a lot of preparation and planning in their towns."

Though Trump is taking the coronavirus much more seriously now than he did in January, February and even early March, he has still voiced hope, without evidence and contrary to the medical experts often standing beside him, that the virus will be gone by the fall. He has blamed the media for repeating his words verbatim, setting up another opportunity for his base to choose between a president they love and the elites they loath — a matchup that Trump wins every time.

"This certainly is a politicized pandemic. There are a lot of areas of the country that are seeing the effects of that," Bharti said.

ADVERTISEMENT

Once the virus arrives in rural areas, the demographics of America's smaller towns mean it will likely put millions of lives in jeopardy. Rural Americans are older, more prone to underlying conditions like diabetes, heart disease and hypertension, and more likely to smoke — all risk factors that heighten one's vulnerability to the worst symptoms of COVID-19.

Their communities are also less likely to have hospitals with the capacity needed to handle a potential surge in cases. An epidemic of rural hospital closures in recent years has robbed hundreds of communities of their local providers, and the pandemic itself has put tremendous budget pressure on those that remain, as states order freezes on elective surgeries and patients cancel scheduled doctor visits.

"Some of those places may be medically underserved, there may be more chronic conditions," Adalja said. "Those rural areas may end up having disproportionate numbers of people who need to be hospitalized."