Spatially refined time-varying reproduction numbers of SARS-CoV-2 in Arkansas and Kentucky and their relationship to population size and public health policy, March - November 2020.

Purpose: To examine the time-varying reproduction number, R, for COVID-19 in Arkansas and Kentucky and investigate the impact of policies and preventative measures on the variability in R.

Methods: Arkansas and Kentucky county-level COVID-19 cumulative case count data (March 6-November 7, 2020) were obtained. R was estimated using the R package 'EpiEstim', by county, region (Delta, non-Delta, Appalachian, non-Appalachian), and policy measures.

Results: The R was initially high, falling below 1 in May or June depending on the region, before stabilizing around 1 in the later months. The median R for Arkansas and Kentucky at the end of the study were 1.15 (95% credible interval [CrI], 1.13, 1.18) and 1.10 (95% CrI, 1.08, 1.12), respectively, and remained above 1 for the non-Appalachian region. R decreased when facial coverings were mandated, changing by -10.64% (95% CrI, -10.60%, -10.70%) in Arkansas and -5.93% (95% CrI, -4.31%, -7.65%) in Kentucky. The trends in R estimates were mostly associated with the implementation and relaxation of social distancing measures.

Conclusions: Arkansas and Kentucky maintained a median R above 1 during the entire study period. Changes in R estimates allow quantitative estimates of potential impact of policies such as facemask mandate.