Annette Groves, public health nurse for Ramsey County, N.D., has a tough job nowadays. And as COVID case counts continue to climb, it’s not getting any easier.

In Ramsey County, there had been 25 coronavirus cases as of July 20 — and most of them had come since July 1. As the summer wears on, rural areas are seeing viral spread in a way they didn’t in the first months of the pandemic. It’s falling to public health investigators to keep up, often playing detective to figure out how and why cases are spreading through North Dakota communities.

“It's a challenge to maintain a positive relationship with many of the contacts that are identified by active cases. Communication has been an issue, compliance has been an issue,” Groves said. “We're very challenged with that task alone.”

That hard work is surely replaying itself throughout the upper Red River Valley. According to a Herald analysis of New York Times Data, the coronavirus appears to be entering a second stage, with community spread in rural areas on a level previously undetected.

In the early months of the pandemic, things were different. A big surge of cases sprung up in Grand Forks and Polk Counties, and by the end of April, the case count for both counties had reached 285. But in surrounding counties, there had been fewer than 30 cases — making the early months of the virus a distinctly urban trend.

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Michael Dulitz, a member of the COVID contact-tracing team at the Grand Forks Health Department, points out that much of that first stage could be traced to an outbreak at the L.M. Wind Power plant, which had been roundly discussed as a hot point for the virus at the time.

But now, Dulitz said, Grand Forks County is seeing a different kind of spread. Contact tracing shows a more decentralized spread of the virus, linked to workplaces and close family members.

"It just takes one person to be asymptomatic and not realize it and then be in close proximity with others and develop an outbreak,” Dulitz said. “Those outbreaks can extend to friend groups, they can extend to workplaces. That's where we can see a lot of (Grand Forks’) spread happening."

And now, cases in rural areas especially are rising. The list below shows the total number of cases in each county since the beginning of the pandemic, according to New York Times data through July 23. "Recent" cases are defined as those reported from July 3-23.

  • Cavalier: 26 total, 23 recent

  • Grand Forks: 560 total, 170 recent

  • Griggs: 4 total, 2 recent

  • Kittson: 3 total 1 recent

  • Marshall: 25 total, 13 recent

  • Nelson: 3 total, 2 recent

  • Norman: 26 total 6 recent

  • Pembina: 21 total, 12 recent

  • Pennington: 60 total, 9 recent

  • Polk: 104 total, 23 recent

  • Ramsey, 28 total, 18 recent

  • Red Lake: 5 total, 2 recent

  • Roseau: 34 total, 24 recent

  • Steele: 6 total, 4 recent

  • Traill: 33 total, 13 recent

  • Walsh: 86 total, 61 recent

And as of July 23, Grand Forks and Polk counties had seen about as many recent new cases as the rest of the region in recent weeks. That’s a huge change from the early stages of the virus, when most cases were clustered in Grand Forks.

Public health officials around the country continue to stress that masks and social distancing are crucial to fight the spread of the virus. In Minnesota, Gov. Tim Walz mandated public mask use beginning Saturday.

And for Groves, it’s important to work hard at keeping the virus contained.

"We're making efforts to get our children back in school safely,” Groves said. “It doesn't happen if we're on an upward trajectory."