The University of Tennessee, Knoxville.

Understanding Comparisons:

COVID-19 in Tennessee and Kentucky

A Policy Brief by the Howard H. Baker Jr. Center for Public Policy

in Partnership with the Coronavirus-19 Outbreak Response Experts (CORE-19)

March 26, 2020
Tennessee State Capitol and Flag
Using publicly available data from emerging research on COVID-19, this brief was written and reviewed by the Coronavirus-19 Outbreak Response Experts (CORE-19) at the University of Tennessee, Knoxville. It provides insights into comparisons between COVID-19 case rates and spread in Tennessee versus Kentucky.  

COVID-19 Cases: Tennessee vs. Kentucky

Policy analysts often compare states with similar characteristics and demographics in order to evaluate the robustness and effectiveness of state-level policy interventions. Comparing Tennessee and Kentucky and their respective responses to the COVID-19 outbreak can shed light on which polices are proving effective and which are not. 
As of Wednesday, March 25, 2020, Tennessee has reported:
  • 784 confirmed cases of COVID-19, including 53 hospitalizations and 3 deaths, AND 
  • administered an estimated 11,796 tests for COVID-19 to date, when accounting for both state and non-state laboratories,
For the same time period, Kentucky has reported:
  • 198 confirmed cases of COVID-19, including 4 deaths according to news reports complied by The COVID Tracking Project, AND
  • administered an estimated 3,300 tests for COVID-19 to date.
Note: The Kentucky Department for Public Health (DPH) does not currently provide official statistics on the number of hospitalizations or deaths due to COVID-19.
There are several possible reasons for the disparity in cases between Kentucky and Tennessee, including differences in the distribution of the population, testing capability and strategy, and state-level responses and government action. 

Population Distribution

Based on 2019 population estimates, Tennessee is nearly 33% larger than neighboring Kentucky with population of 6.8 million compared to Kentucky’s 4.5 million. Likewise, according to 2010 estimates, Tennessee also has a greater population density and urban population:
Such differences in population distribution can impact the geographic spread of disease and the ease with which it can be contained. For example, denser population distributions can lead to greater likelihood of effective contact and therefore disease transmission, as disease spreads more quickly when individuals live in closer proximity to each other.

Testing Capability and Strategy

There are also differences in the volume of COVID-19 tests being administered, and possibly variation in the respective states’ strategies for testing its population.
As of Wednesday, March 25, 2020, Tennessee has conducted an estimated 11,796 tests (including tests administered by both state and non-state laboratories), yielding an approximate positivity rate of 7% (total of 784 positive cases) with the majority of positive cases (61%) occurring among individuals between the ages of 21 to 50 years old.  
As of Wednesday, March 25, 2020, Kentucky has conducted an estimated 3,300 tests (KDPH does not specify whether tested administered by non-state laboratories are included in this figure), yielding an approximate positivity rate of 6% (total of 198 positive cases). According to news reports, the majority of positive cases thus far have occurred among individuals between the ages of 50 and 69 years old.  
There is a significant difference in the rate of testing among the two states:
  • Tennessee: 164 tests per 100,000 residents
  • Kentucky: 67 tests per 100,000 residents
The rate at which a state is testing its population is important to consider when comparing cumulative case counts between states, as low testing rates could indicate under-detection of cases.
Likewise, daily case counts can also reflect changes in a state’s testing infrastructure, such as laboratory processing capacity or lag-times in state-level reporting.
Another factor to consider is that individuals living in border counties in each state may travel across state-lines for diagnosis and/or treatment. This would delay reporting to state/county of residence and reduce the number of positives being reported in these areas.
These compounding factors are why state-to-state comparisons should rely on a multitude of metrics, including hospitalizations and deaths, which do not vary according to testing rate and present a direct reflection of the strain COVID-19 is placing on a state’s healthcare system. These additional metrics also provide more insight related to the severity of cases.  

State-Level Response and Government Action

There have also been differences in the timeline of the outbreak and the substance of each state’s response to the pandemic. For example, Kentucky issued a state of emergency immediately following their first confirmed case and implemented social distancing policies by closing restaurants and bars to in-person dining more quickly than Tennessee. 
Government action has also differed across state-lines. In Kentucky, there seems to be a more unified, statewide response; whereas, in Tennessee, some counties are taking stricter actions than others (e.g., Knox County ‘safer at home’ order announced on March 23).
Here is a brief timeline of the outbreaks:
  • March 5: First case reported in Tennessee
  • March 6: First case reported in Kentucky; Kentucky declares state-of-emergency
  • March 12: Tennessee declares state-of-emergency; Recommendation to close schools in Kentucky
  • March 16: Recommendation to close schools in Tennessee; Recommendation to close childcare centers in Kentucky
  • March 22: Kentucky announces executive order to close in-person dining; Kentucky announces executive order to close non-essential businesses (otherwise known as shelter-in-place); Tennessee announces executive order to close in-person dining
As of Wednesday, March 25, 2020, Tennessee has not issued a statewide recommendation to close childcare center or issued an executive order to close non-essential businesses.
This brief is part of a series that will be produced by the CORE-19 team over the next few weeks answering questions and forecasting the health and economic impact of the virus. The Department of Health for the State of Tennessee is also providing ongoing updates. As this is an emerging issue dealing with a novel virus, information included here is potentially subject to revision as new research and data emerge. 

For more information on COVID-19 read our other policy briefs:

Disclaimer: the information in this policy brief was produced by researchers, not medical or public health professionals, and is based on their best assessment of the existing knowledge and data available on the topic. It does not constitute medical advice and is subject to change as additional information becomes available. 

Coronavirus-19 Outbreak Response Experts (CORE-19) 

Dr. Kristina Kintziger

Dr. Kristina W. Kintziger, PhD, MPH

Kintziger is an Assistant Professor in the Department of Public Health and the co-Director of the Doctoral Program. She has worked in academia and public health practice, and comes to Tennessee from the Florida Department of Health, where she worked as an epidemiologist and biostatistician. She is an environmental and infectious disease epidemiologist.
Dr. Kathleen Brown

Dr. Kathleen C. Brown, PhD, MPH

Brown is an Associate Professor of Practice in the Department of Public Health and the Program Director for the Master's in Public Health (MPH) degree. Her research focuses on the health and well-being of individuals and communities. She has experience in local public health in epidemiology, risk reduction and health promotion.
Dr. Katie Cahill

Dr. Katie A. Cahill, PhD

Cahill is the Associate Director of the Howard H. Baker Jr. Center for Public Policy. She also is the Director of the Center's Leadership & Governance program and holds a courtesy faculty position in the Department of Political Science. Her area of expertise is public health policy. She leads the Healthy Appalachia project. 
Dr. Matthew Murray

Dr. Matthew N. Murray, PhD

Murray is the Director of the Howard H. Baker Jr. Center for Public Policy. He also is the Associate Director of the Boyd Center for Business and Economic Research and is a professor in the Department of Economics in the Haslam College of Business. He has led the team producing Tennessee's annual economic report to the governor since 1995. 
Dr. Agricola Odoi

Dr. Agricola Odoi, BVM, MSc, PhD

Odoi is a professor of epidemiology at the University of Tennessee College of Veterinary Medicine. He teaches quantitative and geographical epidemiology and his research interests are in population health and impact of place on health and access to health services. He was a public health epidemiologist before joining academia.
Dr. Marcy Souza

Dr. Marcy J. Souza, DVM, MPH

Souza is an associate professor and Director of Veterinary Public Health in the UT College of Veterinary Medicine.  Her teaching and research focuses on zoonotic diseases and food safety issues. 

Research Support for CORE-19

Hancen Sale

Hancen Sale

Sale is an undergraduate student researcher with the Center. He is a senior majoring in economics with a minor from the Center's public policy analytics program. He has worked on an NSF-funded project regarding rebel group grievances, as well as in supporting The White House's American Workforce Policy Advisory Board
Howard H. Baker Jr Center for Public Policy
1640 Cumberland Avenue
Knoxville, TN 37996
Phone: 865-974-0931
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