Physicians with the Carilion Clinic in Roanoke, Virginia wear enhanced personal protective equipment inside the health system's facilities (Photo courtesy of the Carilion Clinic).

Dr. Karen Shelton, director of the Mount Rogers Health District in the far corner of Southwest Virginia, was prepared for the holiday season to launch a potential surge of new COVID-19 cases from mid-December to late January.

But she didn’t expect the region’s current case burden, which began to rise precipitously in mid-October. After uniformly low case numbers in Southwest Virginia throughout much of the pandemic — with one county, Dickenson, that didn’t report its first infection until mid-June — the area is now driving the state’s increasing totals. 

As of Thursday, the Mount Rogers Health District, which includes Bland, Carroll, Grayson, Smyth, Washington, and Wythe counties, and the cities of Bristol and Galax, had approximately 459 active cases of COVID-19, Shelton said. In total, data from the Virginia Department of Health shows there have been 4,402 cases of the virus in the six counties and two independent cities that make up the district. 

Overall, the Southwest region has a seven-day average of nearly 412 daily new infections — almost 15 times the number of new cases it was seeing in early May. 

“It was hard to predict,” she added. “We thought maybe after September and Labor Day, people would kind of settle back into a routine. But unfortunately, settling back into a routine meant a lot of family gatherings, a lot of social gatherings, and so we’ve really had a lot of issues.”

Driving the spread are family dinners, meet-ups between coworkers, and other day-to-day gatherings — unlike the late-summer COVID surge in Eastern Virginia, which health officials largely linked to restaurants that weren’t complying with Gov. Ralph Northam’s indoor mask mandate. Shelton and other public health experts across the state worry that the ongoing spike in cases paints a troubling picture of what’s to come as the weather grows colder, a seemingly endless pandemic stretches into its eighth month, and the holidays offer more opportunities for separate households to mingle indoors.

But curbing transmission also presents new challenges. In July, Northam stepped up enforcement of the state’s mask order and introduced new restrictions in the Hampton Roads region in response to its surging case numbers, including a 50-person cap on gatherings and 10 p.m. cut-off for alcohol sales at restaurants. So far, though, he’s refrained from implementing similar measures in Southwest Virginia, instead urging residents in the region to “look at these numbers and step up your precautions.”

“In other states and other countries, they’re reimposing restrictions to get case numbers under better control,” Northam added at a news briefing in late October. “Nobody wants to do that, but this virus remains a very real threat.”

Gov. Ralph Northam at a press conference in October. (Ned Oliver/Virginia Mercury)

Northam’s spokeswoman, Alena Yarmosky, added in a Friday email that the governor was “working closely with the region’s local leaders and health department officials” and that discussions over potential new health measures “are continuing.” But Shelton and other regional leaders were skeptical that new restrictions would make a difference in the region’s rising case numbers.

One challenge is that few of the gatherings driving transmission are prohibited under the state’s current reopening guidelines, which allow for events with up to 250 people. Shelton said that most of the outbreaks in her districts have been linked to events with fewer than 50 people.

“No one is breaking any codes,” she added. “They’re not going against any of the governor’s guidance. It’s friends getting together, small parties — just people living their lives.”

The region’s proximity to neighboring states is another challenging factor. Tennessee — just a drive across town for many Southwestern localities — is “wide open,” Shelton said. 

“There’s no restrictions on events, on gatherings,” she added. “Their mask mandates aren’t statewide or permanent — they’re kind of month-to-month edicts. And they’re still having Friday night high school football with no masks. My husband turned on the TV and we could see the stands were just packed with people without masks, all yelling, cheering, screaming.”

The high crossover between the two states can delay or complicate case investigations. Shelton said some businesses have called and reported COVID-19 infections that the health district didn’t know about because the employee lived in Tennessee. She’s also had to notify Tennessee health authorities of residents who test positive in Virginia. 

Most workers are transparent with their employers when they test positive, Shelton said. But if they’re not, it can be difficult to track and isolate the case as quickly as possible to contain potential spread.

“It’s not been a huge issue, really, but it is working back and forth between the states to track cases,” she added. 

The factors driving the spread in Southwest Virginia make it more difficult to tailor specific restrictions. Shelton pointed out that some potential measures, such as a regionwide stay-at-home order or ban on gatherings with more than 10 people, would be as restrictive as the guidelines Northam implemented at the very beginning of the pandemic and make Southwest Virginia more regulated than any other part of the state.

Local leaders said that would be a particularly difficult pill to swallow in Southwest Virginia, where many local businesses were forced to shutter even before there was confirmed community spread.

“I think there’s a real element of COVID fatigue,” said Randy Eads, the city manager and attorney for Bristol, which straddles the Virginia-Tennessee border. When the neighboring state relaxed restrictions in April — nearly a month before Virginia entered the first phase of its reopening plan — Eads said he fielded calls from business owners who were upset that restaurants literally across the street could begin admitting customers. 

On Friday, he was planning another conference call to learn how local restaurants plan to handle an expected influx of indoor dining as the weather gets colder and outdoor seating becomes less and less desirable. The winter months worry him, and Eads said he’s not convinced the city’s COVID-19 numbers have reached their peak. But he’s also not sure that more restrictions are the best way to stop the disease from spreading.

“Once you lock a community down and then lift those restrictions, I think it’s very difficult to put a community on lockdown again,” Eads added. “I think there would be more frustration simply because shutting certain businesses down again would probably shutter those businesses for eternity.”

Right now, health officials are leaning on education to help reverse the trend. Eads said VDH has partnered with an outside communications team to launch a public health awareness campaign in Southwest Virginia, complete with print, radio, and TV ads, billboards, and direct mailers to residents. The rollout he reviewed also included targeted social media banners and even advertisements at gas pumps.

State Health Commissioner Dr. Norman Oliver has attributed the rise of cases in the region to a lack of awareness, largely driven by COVID-19’s trajectory across the state. In Northern Virginia, an area hit early — and hard — by the virus, residents adopted precautionary measures such as masks and social distancing early on, he said last month at the governor’s news briefing. But those same measures weren’t considered as important in Southwest Virginia until recently, when the impacts of the disease became more tangible.

State Health Commissioner Dr. Norman Oliver speaks at a press conference in August. (Ned Oliver/Virginia Mercury)

“We need to spread the message there that it’s important to take the same precautions we have throughout the commonwealth,” Oliver added. “Back when there were almost no cases, it was much harder to tell people they needed to stay at home.”

But Shelton said it can also feel like health officials are limited in their tools for enforcement. Northam’s mask mandate tasks local health departments with administering the order, and carries potential misdemeanor charges for violators. At the time, Northam said state code limited him from issuing emergency orders enforceable through civil penalties — a law that’s since been changed by the Virginia General Assembly, but won’t go into effect until next year.

Health departments can issue warnings and temporarily suspend business permits for repeat violators, but Shelton said it can be difficult to keep up with complaints. Most businesses in Southwest Virginia are compliant with the governor’s orders, but she added that a bigger issue is churches in the region ignoring the state’s mask mandate and current social distancing restrictions.

“We were told that religious services and protests are protected under the Constitution,” Shelton said. “So, if you’re not going to go in and break up a protest and tell people they have to wear masks, you’re not going into a church.” 

The governor’s mask order also includes an exemption for medical conditions, which residents can claim without providing any verification. The challenges with enforcement often pair with an overall reluctance by many officials to take a punitive approach to public health, Shelton said. 

“Nobody gave me a ticket book,” she added. “We have education at this time. And it’s tricky, at the health department. We’re about education and we’re about good health. We do have enforcement arms, but by and large, our goal is to educate the public and prevent the spread of communicable disease.”

While cases are rising faster in Southwest Virginia than in other areas of the state, officials there aren’t alone in their concern over the coming months. Dr. Danny Avula, director of Richmond and Henrico Health Districts, said last week that weddings, birthday parties and other small group gathering were spreading new outbreaks in central Virginia. One recent community testing event in Henrico County had a percent positivity rate of more than 30 percent — five times as high as the state’s current seven-day average.

In a recent letter to Virginia health care providers, Oliver pointed out that COVID-19 cases and hospitalizations are rising across the state, which recorded 70 confirmed outbreaks  — the highest number since the start of the pandemic — in late October. 

What makes Southwest Virginia particularly vulnerable is a more limited health care infrastructure. Some counties in the region have no local ICU beds, according to an analysis by Kaiser Health News. Richmond alone has 159. Last week, Ballad Health, the system that serves much of Southwest Virginia and Northeast Tennessee, reported that it only had 14 available ICU beds and 40 beds specifically for COVID-19 patients. Later that week, the number had dropped to 37, Eads said.

“As far as the health impact goes, the current situation is bleak,” he added Friday. “As of yesterday, we had a 16.1 percent positivity rate for the last seven days. Which is significant because as of Oct. 1, we had a 7.9 percent positivity rate. So, we’ve more than doubled in a little over a month.”

Rising hospitalizations in the Roanoke region have also led to concerns among local health leaders. Northam recently revised health guidelines to allow winter sports to begin in December. But like other officials, Shelton said she’s increasingly worried the relaxed guidelines will lead to another surge in cases.

“Basketball season will soon be upon us,” she added. “And that’s an indoor, close contact sport. So, I don’t expect that to go very well.”