COVID-19 pandemic in North Dakota: Significance, progression, and government response
Valquiria F. Quirino and Avram Slone
Valquiria Quirino has a PhD in forestry with focus on remote sensing and geospatial technology from Virginia Tech. Before working as a research specialist at North Dakota State University, she worked as a researcher at the University of Minnesota, as a data analysist for John Deere, and taught at Minnesota State University Moorhead and at Southern Oregon University. Dr. Quirino has experience in the application of statistical and geospatial technology as it applies to human interactions in and with the environment.
Avram Slone, M.A., is a research specialist with the Center for Social Research at North Dakota State University. He has previously worked as a research professional at the Alaska Justice Information Center in Anchorage, Alaska and as a statistical intern at the United States Census Bureau in Suitland, Maryland.The focus of his work at the Center for Social Research is on the disparate impacts of COVID-19 in North Dakota. He received his Master’s Degree in Sociology from the University of Kansas.
The overall health and economic impacts of the COVID-19 pandemic are numerous and global, affecting individuals, families, and communities around the world. And while illnesses and deaths have slowed, the long-term effects of COVID-19 are still evolving. To help guide North Dakota’s efforts in the event of future public health emergencies, the following article examines events that occurred before and during the COVID-19 pandemic in the state, its impact on COVID-19 cases, hospitalizations, and deaths, and how government officials responded at each step.
Viral outbreaks before COVID-19
The largest and most horrific viral outbreak affecting areas that include the present-day Dakotas was the 1837 smallpox epidemic which disparately affected indigenous populations, killing 17,000 American Indians . Approximately a century later, the 1918-1919 H1N1 influenza pandemic (commonly known as the Spanish flu) had a reported statewide death toll of 1,378 deaths; however, it is believed to have killed many more, likely between 3,000 and 5,000 people .
The 21st century brought other disease outbreaks. In 2002, North Dakota had its first reported case of the West Nile virus (WNV). By the end of the year, there were 17 reported cases of the virus. This number increased quickly, reaching 617 in 2003. This represented a 36-fold increase in cases . Fortunately, though, while the WNV caused extensive disease in the population, very few died. In fact, from 1999 to 2015, while 1,557 total cases of WNV were reported to the Centers for Disease Control and Prevention (CDC) for North Dakota, there were only 19 deaths . Hence, per year, the WNV infected 92 individuals and caused the death of one person.
COVID-19: A new and mysterious virus
At the end of 2019, a change occurred. There was an outbreak of a disease producing pneumonia-like symptoms which began in the Wuhan province of China . This new, highly transmissible coronavirus disease became known as COVID-19 and rapidly spread around the globe. On January 21st, 2020, the U.S. reported its first case of COVID-19 and on March 11th, 2020, “[t]he North Dakota Department of Health… confirmed the state’s first presumptive case of [the] novel coronavirus disease (COVID-19) in a Ward County resident” [9, 10]. On the same day, the Director-General of the World Health Organization (WHO) declared COVID-19 a pandemic . Two days later, on March 13th, 2020, the COVID-19 outbreak was declared a national emergency and Governor Doug Burgum declared a state of emergency in North Dakota [12, 13]. The declaration of a state of emergency empowered the Governor to enact executive orders in direct response to the COVID-19 pandemic.
In the days, weeks, and months that followed, the cascading impact of COVID-19 and the policies implemented to reduce harm caused by the disease led to major, previously unimaginable changes to the way people lived their lives in North Dakota, the United States, and around the world.
Tracking the new virus, early mitigation strategies, and community transmission
Little was known about COVID-19 in the early days of the pandemic, aside from that it was highly contagious and potentially deadly. To gauge the size and severity of the outbreak, on January 16th, 2020, the CDC began making available to the public the numbers of COVID-19 cases and deaths for the United States by state. In the first week, only two states – Delaware and Washington – had COVID-19 cases . In mid-March 2020, the North Dakota Department of Health (NDDoH) also began making the number of COVID-19 hospitalizations and cases for North Dakota available to the public .
Early mitigation strategies primarily focused on slowing the spread of the virus by limiting people’s exposure to each other. On March 15th, 2020, the Governor of North Dakota issued an order closing schools for one week . Four days later, on March 19th, 2020, the Governor issued an executive order closing on-site dining establishments and recreational facilities. In addition, all state agencies and offices were ordered to accelerate the transition of non-essential staff members to working remotely and, from this time on, appointments were required to access the North Dakota Capitol and all other state facilities . On March 22nd, schools were ordered to close indefinitely, and school districts were directed to prepare distance learning plans, and on March 27th, salons and tattoo and massage facilities were added to the list of businesses ordered to close in the wake of the pandemic [18, 19].
On March 17th, 2020, the first North Dakotan was hospitalized due to COVID-19, and on March 18th, 2020, North Dakota recorded its first confirmed case of community transmission of the disease, meaning that for the first-time authorities were unable to trace the source of the infection [15, 20]. On March 27th, 2020, the first death related to COVID-19 was reported in North Dakota . Two days later, on March 29th, 2020, North Dakota registered 100 cases of COVID-19 .
Additional mitigation strategies: Self-isolation and quarantine
To further mitigate the spread of COVID-19, on April 6th, 2020, Governor Burgum signed an executive order that required COVID-19 positive individuals and their households to self-quarantine . Also in April, the NDDoH State Health Officer signed orders that mandated, with some exceptions, that anyone entering the state of North Dakota from another state or country be subject to a 14-day quarantine ; and that persons in North Dakota who tested positive for COVID-19 self-isolate for at least seven days after the onset of symptoms and 72 hours after the end of fever and the improvement of other symptoms . The order provided workforce exemptions to the disease control measures for some essential critical infrastructure workers who had or could have had household exposure to COVID-19 but were asymptomatic and took necessary precautions .
U.S. and North Dakota reopen but COVID-19 cases and deaths continue to increase
Although mitigation strategies continued, there were efforts, to the extent possible, to reduce the degree to which North Dakota, and the country, were shut down. On April 16th, 2020, about five weeks after the beginning of the pandemic, President Trump announced Opening Up America Again , a shift in policy that spearheaded efforts to reopen the American public square and economy. Two weeks later, on April 29th, 2020, Governor Burgum issued an executive order allowing many of the businesses that had been shut down under previous orders to reopen on May 1st, 2020 . Although these policies indicated a return to some form of normalcy, COVID-19 continued to have overwhelming public health impacts in the state of North Dakota.
On April 28th, 2020, the day before Governor Burgum announced the reopening of North Dakota businesses, 1,000 cases of COVID-19 had been reported in North Dakota . During the week beginning with July 16th, 2020, four months after the first COVID-19 related death was reported in North Dakota, 100 COVID-19 related deaths were reported in the state . By August 24th, 2020, 10,000 COVID-19 cases had been reported and by August 26th, 2020, there were 142 COVID-19 related deaths in the state [15, 14].
Early treatments, COVID-19’s peaks, and mask mandates
In October 2020, the Food and Drug Administration (FDA) approved the drug Veklury (remdesivir) for the treatment of COVID-19 requiring hospitalization, the first COVID-19 treatment approved by the agency . While this drug represented a positive step towards reducing the impact of COVID-19 on the population, COVID-19 cases, hospitalization, and deaths continued to rise in North Dakota. Between November 5th, 2020, and November 11th, 2020, 128 North Dakotans died from COVID-19, the most deaths due to the virus in a single week . By mid-November the number of hospitalizations peaked at 527 . By late November, the 1,000th COVID-19 related death was reported in North Dakota .
Because of the novelty of the virus and the unavailability of effective medication and treatments, the increase in COVID-19 cases and deaths in the state led to measures such as mask mandates and social distancing. From mid-October through early November, Fargo, Minot, West Fargo, New Town, Bismarck, Grand Forks, Jamestown, Rugby, New Rockford, Valley City, Williston, and Mandan either strongly encouraged or mandated the use of masks in public indoor settings [29-40]. In response to mounting hospitalization and deaths, on November 13th, 2020, the State Health Officer of the NDDoH signed an order requiring face coverings in indoor businesses and public areas, as well as outdoor businesses and public areas in locations where it was not possible to maintain social distancing .
Vaccine roll-out and the rescission of COVID-19 executive orders
On May 15th, 2020, the federal government announced Operation Warp Speed, a program intended to accelerate the development, manufacturing, and distribution of medical countermeasures to COVID-19 including but not limited to vaccinations . Operation Warp Speed came to fruition on December 11th, 2020, when the FDA issued emergency use authorization of the Pfizer-BioNTech COVID-19 vaccine for persons ages 16 and older . Three days later, on December 14th, 2020, the first COVID-19 vaccines were distributed to the state of North Dakota . Initial distribution of vaccines was rolled out in phases. Phase 1A vaccines went to frontline health care workers, first responders, and long-term care residents and staff .
As vaccine distribution began, Governor Burgum began rescinding previous COVID-19 related executive orders. On December 18th, 2020, he terminated 31 previously issued COVID-19 related executive orders and, on December 21st, 2020, he issued an order allowing restaurants and bars to resume normal business hours [46, 47]. By mid-January 2021, Governor Burgum issued an executive order rescinding capacity limits for bars, restaurants, and event venues .
By the end of March 2021 vaccines were available to the general public and on April 30th, 2021, Governor Burgum rescinded the public health emergency declaration [49; 50]. On May 10th, 2021, the FDA issued emergency use authorization for the Pfizer-BioNTech COVID-19 vaccine to be administered to adolescents ages 12 to 15 . While the availability of vaccines represented a crucial turning point in the timeline of the COVID-19 pandemic, the virus had exacted a devastating toll on the state and its residents. By March 4th, 2021, there had been 100,000 confirmed cases of COVID-19 and by May 12th, 2021, 1,500 North Dakotans had succumbed to COVID-19 [15, 14].
The Delta variant, vaccine boosters for individuals ages 16 and older, and vaccines for children
On June 24th, 2021, the NDDoH confirmed the presence of the Delta variant of the COVID-19 virus in North Dakota . Delta brought a new wave of uncertainty. According to NDDoH Disease Control and Forensic Pathology Section Chief Kirby Kruger, the new variant was more easily transmissible and could cause serious disease, especially among the unvaccinated . A little over a week later, on July 3rd, 2021, the CDC reported that the Delta variant had become the dominant variant in the United States . By July 7, 2021, COVID-19 cases in North Dakota had increased to 110,775 and the number of total COVID-19 deaths had reached 1,533 .
In response to waning immunity caused by both the increased transmissibility of the Delta variant and the natural reduction of the efficacy of vaccination over time, on October 20th, 2021, the state of North Dakota began administering booster doses of the COVID-19 vaccine to individuals ages 18 and older . On November 3rd, 2021, the state began vaccinating children ages 5 and up, and on December 9th, 2021, the FDA authorized booster doses of the COVID-19 vaccine for individuals ages 16 and 17 [44, 54]. By December 11th, 2021, slightly over half of North Dakotans – 51.5 percent — were fully vaccinated .
The Omicron variant and the peak of new weekly positive COVID-19 cases
On December 20th, 2021, roughly six months after the first confirmed case of the Delta variant of COVID-19 appeared in North Dakota, the NDDoH confirmed the presence of the Omicron variant of COVID-19 in the state . The Omicron variant rapidly infected large swaths of the population, and by January 15th,2022, had emerged as the dominant variant of COVID-19 in North Dakota . Less than a week later, on January 20th, 2022, North Dakota registered the single highest number of new weekly positive COVID-19 cases since the pandemic started: 15,851 . Fortunately, while the Omicron variant was more transmissible than the Delta variant, it was also less lethal.While there were 65 percent more confirmed cases at the peak of the Omicron wave than the peak of the Delta wave, there were 37 percent fewer hospitalizations .
The new normal: From pandemic to endemic
By March 9th, 2022, COVID-19 had had a significant human toll in terms of illness and death in North Dakota. The virus had caused 238,884 infections and 2,230 deaths in the state . A day later, on March 10th, 2022, two years after COVID-19 first emerged in North Dakota, Governor Burgum declared that the COVID-19 pandemic had shifted status to endemic . While the declaration by the Governor signified the official end of the COVID-19 pandemic in the state of North Dakota, the CDC and WHO still classified COVID-19 as either a public health emergency or a global health emergency until May 2023 [58, 59].
The virus, however, was and is still present in the world and in North Dakota. New variants continue to emerge and cause individuals to fall ill from COVID-19. Recent strains have been less lethal, though. This has allowed for changes that occurred during the pandemic, or modified versions from them, to become permanent and a part of a ‘new normal’. Many employees who began working remotely during the pandemic continue to do so or have switched to a hybrid model. Teleconferencing, rare before the pandemic, has been widely adopted. Schools that used virtual learning during the pandemic have retained a virtual learning option in case of inclement weather. These are only a few changes that have become permanent. However, the full and long-term effects of the pandemic are ongoing and likely not yet fully understood. That is why the examination of events that occurred in those two years are of such importance. They can not only help guide efforts in the event of future public health emergencies but record details for future generations about how the pandemic has fundamentally changed many aspects of day-to-day life in North Dakota and in the world. Scholars from many disciplines will be studying the impact of COVID-19 for years to come.
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