Less than a week ago, West Virginia held the distinction of being the only US state without a confirmed case of the novel coronavirus. Since then, 20 people have tested positive for the virus, according to Johns Hopkins University.

With just 1.8 million residents, the Appalachian state is one of the least populated in the United States. But with the coronavirus now inside state lines, it faces a potentially significant health crisis, with West Virginians possibly finding themselves more affected than any other US state.

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A string of health concerns means the state's residents may be more susceptible to coronavirus than others: The coronavirus that causes COVID-19 hits the elderly and those with underlying conditions particularly hard. Only Maine (20.6 percent of its population is 65 years old or older) and Florida (20.5 percent) have populations older than West Virginia's, where 19.9 percent of the population fits that age profile. In 2018, it was home to around 360,000 people aged 65 or older.

By a host of measures, however, West Virginia lags behind those states: Maine is known for its high quality of nursing homes and Medicare, the national health insurance programme. Florida, for its part, has a robust, multi-faceted economy.

On the other hand, while nearly 14 percent of adult Americans reported smoking every day in 2018, that jumps to 25 percent in West Virginia. The state also ranks first nationally in adults reporting poor health and has the second-highest lung cancer mortality rate, as well as high levels of heart attacks and strokes.

Members of the West Virginia National Guard's Chemical, Biological, Radiological, Nuclear and High Yield Explosive (CBRNE) Battalion and 35th Civil Support Team (CST) provide assistance for COVID-19 swabbing for the staff of a nursing facility in Morgantown, West Virginia [Handout/US Army National Guard/Davis Rohrer/Reuters]

None of those numbers is lost on Tina Coleman, who runs a flower and gift store outside the town of Welch in McDowell County in the south of the state. Once a mining powerhouse, the county is West Virginia's poorest and one of the most impoverished counties in the US.

Coleman's 74-year-old mother lives with her and suffers from chronic obstructive pulmonary disease (COPD), a serious lung ailment.

"Normally, I would bring her with me [to the store], but now I leave her at home," she told Al Jazeera. "I strip my clothes off as soon as I walk in the door and go straight to the shower."

Coleman's husband is a diabetic and she said she was told by a local doctor's wife on Thursday morning that insulin supplies in the area are almost out, although that could not be independently confirmed. Luckily, Coleman's husband has a month's supply on hand.

Healthcase system in decline

Many West Virginians live in rural hollows and small, former mining communities that suffer more from underlying health conditions than most other US states as a result of the coal industry, which has employed tens of thousands of workers over decades. Black lung disease or progressive massive fibrosis caused by chronic inhalation of coal dust is thought to afflict one in five former miners across the Appalachia region.

Last year, West Virginia ranked 48th out of 50 states for quality of healthcare, according to the US News & World Report, in an assessment of access, quality, affordability and healthcare outcomes.

Additionally, the state has been hammered by the opioid epidemic that, in recent months, has created a spike in cases of HIV centred on Cabell County in the north of the state.

Local health departments in West Virginia have experienced a 20 percent decrease in funding from the state government in the last decade.

Homes sit in front of the Consol Coal Shoemaker Mine facility along the Ohio River in Benwood, West Virginia [File: Brian Snyder/Reuters]

"That makes it harder to respond to an event [such as the coronavirus pandemic], when you have no surge capacity because you are full out to start with," said Diane Gross, regional epidemiologist with the Monongalia County Health Department and an adjunct professor at West Virginia University in Morgantown. "As a state, we may be particularly hard hit by this crisis because we are having a number of [existing] public health and medical crises, including the opioid crisis."

She suggested the reason West Virginia was the last US state to identify a positive coronavirus case could have been due to lower travel activity, less access to healthcare and low levels of testing.

Early last week, President Donald Trump caused angst among some West Virginians by claiming it would not need federal help as it had not, at that time, reported any cases of the virus.

State officials, however, have attempted to mobilise quickly. Testing centres have been set up in several towns, including Morgantown. Children dependent on now-closed schools for food have been able to collect meals from their local bus stops. Some elderly centres that have closed in McDowell County are offering "grab and go" food packages that can be picked up at noon each day.

Members of the West Virginia National Guard's special response teams provide hands-on personal protective equipment instruction to the staff of Cabell Huntington Hospital to help prepare the facility for potential future cases of novel coronavirus in Huntington, West Virginia [Handout/US Army National Guard/Edwin L Wriston/Reuters]

On Thursday, West Virginia Governor Jim Justice announced the state bought 100,000 surgical masks, some to be used by medical workers. "The one advantage that we might have is that it's given us some time to prepare a little more and potentially learn of the lessons other states and countries have had," Gross said.

As of Monday, however, just 448 tests had been conducted and Tina Coleman believes the state authorities are "absolutely not" prepared to deal with the unfolding crisis.

"There should be a plan in place for this. You can't just shut the whole state down," she said.

She's worried by the fact that McDowell County is home to a high number of elderly residents.

"Are they going to have what they need to ride this out?"