The coronavirus first entered Pennsylvania with a vengeance in the Philadelphia region. Much of the rest of the state was spared as hospitalizations and deaths mounted here and farther north.

During the summer, the virus concentrated on Pittsburgh and Southwestern Pennsylvania, said Rachel Levine, Pennsylvania’s secretary of health.

Now, maps of infections show a new pattern. “It’s everywhere,” Levine said. Just as the virus has taken off in Midwestern and Western states that had previously seen little infection, it is spreading in Pennsylvania’s rural counties, along with smaller cities and the big metropolitan areas. Only a few sparsely populated counties have still seen little of the virus, she said.

Some of the places with the highest incidence rates — cases per 100,000 in population — are counties that usually don’t make much news: Huntingdon, Bradford, Montour, and Lackawanna. Some smaller Southeastern Pennsylvania counties — Lebanon, Schuylkill, and Berks — also have rates well above the state average. Philadelphia and Delaware Counties are also above the state average incidence rate, while nearby Bucks, Chester and Montgomery are below it.

It is possible that people in more rural areas have less access to testing, but the fact that test positivity rates are low in the least populous counties suggests there may be little undetected community spread. Huntingdon and Bradford, however, have 12% and 11.2% rates, respectively, well above the 5% threshold experts consider a sign of considerable spread.

Levine said 57 of the state’s 67 counties now have increasing case counts and 43 are on the state’s watch list.

As researchers at Children’s Hospital of Philadelphia warned last week, the trend in new cases sets the stage for “exponential spread.” Hospitalizations and deaths tend to rise a few weeks after new cases do.

“I know things are going to get worse before they get better, and that has me worried on a number of levels,” said Stanley Martin, director of infectious diseases for the Geisinger Health System, which serves much of central and northeastern Pennsylvania. He said some of the system’s hospitals are feeling the strain of rising COVID-19 cases but can handle the influx.

Levine, along with other public health officials, said the numbers mean Pennsylvanians need to double down on behaviors known to reduce spread: wearing masks, distancing, and hand-washing. She says it’s not safe to have anyone who doesn’t already live with you in your house for dinner.

So far, Levine said, Pennsylvania is “not even close to” reaching hospital capacity. As of Friday, 1,229 COVID-19 patients were hospitalized, compared with 3,000 in the spring. Ventilator use is lower now.

Leaders at Geisinger and UPMC, the state’s largest health system, agreed that they are coping well now, even in rural areas that have fewer hospitals than urban centers. They are still seeing patients with other health problems and are not currently considering reimposing such measures as halting elective surgeries. Hospitals usually get busier in the fall and winter because infectious diseases spread more readily after lower temperatures drive people inside. (A reminder for everyone: Get a flu shot.)

UPMC, which has a total of 5,500 beds, had 243 coronavirus patients in hospitals across its system on Thursday. The previous peak was 190 in July. Geisinger had as many as 145 COVID-19 patients in its hospitals in the spring. That figure fell to 15 in the summer and is now back in the low 80s, said J. Edward Hartle, executive vice president and chief medical officer. Some hospitals, he said, start feeling stressed when the numbers reach 100. Debra Powell, chief of infectious diseases at Reading Hospital, Tower Health, said her hospital had 50 COVID-19 cases last week, up from 15 to 20 two weeks earlier. It peaked at about 90 in midspring.

Mary Wetherall, a nurse, is CEO of three federally qualified health centers in the northeastern corner of Susquehanna County. While the numbers are still small, cases are rising. After seeing very few positives over the summer, four of 50 people tested at an event the weekend before Halloween had COVID-19 and another four tested positive through the centers. She’s worried about what could come next. Her county is the kind of place where people taunt mask wearers in the convenience store.

“There’s a segment of the population … they’re not taking it seriously. They never did. It’s not like they have COVID exhaustion,” she said.

George Garrow, chief medical officer of Primary Health Network, which operates 50 health centers from Western Pennsylvania to Schuylkill County, said his centers are now seeing the most patients with COVID-19 symptoms or who need testing. The number of positive tests, while still small, rose from three in September to 35 in October. Some have said they attended gatherings.

“People are tired of this,” he said. “I hear that more than anything else.” He thinks health officials need to change their messaging about how long we’ll have to be careful.

A fall surge was expected

Health system leaders said a fall surge was long predicted, so the current rise in cases is not a surprise. While the weather deserves some blame, they said human behavior has contributed throughout the state. Lapses in mask-wearing and social distancing due to COVID-19 fatigue exposed some to the virus.

It’s hard to know how big a role the state’s highly polarized politics has played. President Donald Trump has downplayed the importance of wearing masks, and many attending his rallies — what his critics call “super-spreader events” — don’t wear them. An Inquirer analysis did not find a clear pattern of infections after four Trump campaign events in Pennsylvania earlier this year, but, because outsiders travel to the rallies, resulting infections could occur far from the rally site. It’s too soon to evaluate the impact of larger, more recent rallies.

Pennsylvania Gov. Tom Wolf asked Trump not to host the rallies because of the potential to spread the virus. Levine said many people who test positive have not cooperated with state contact tracers when asked where they had been before they got sick.

A USA Today analysis did find evidence of increasing coronavirus cases after five Trump rallies around the nation, including one in Lackawanna. CNN found increases in coronavirus cases in 14 of 17 counties that hosted Trump rallies. A Vanderbilt University study found that Tennessee counties with mask mandates had lower hospitalization rates for COVID-19 than counties without mandates. Pennsylvania has a statewide mandate that has faced some vocal opposition.

Levine said the state does not track compliance with mask rules. Lisa Davis, director and outreach associate professor of health policy and administration for the Pennsylvania Office of Rural Health, said that once she goes outside her community in Centre County, she sees a decline in mask-wearing. “There is a dramatic drop-off in really giving the pandemic the level of caution and respect that it deserves,” she said.

Like the hospital leaders, Levine kept politics out of it and said only that “people who are not following our mitigation advice” are a factor in rising infection rates.

Martin said he preferred to talk about coming together to fight the virus. “I’ve never known any situation where people have a belief where, if you tell them they’re wrong, it helps. That’s just not how the human brain works,” he said.

Earlier in the pandemic, large outbreaks in congregate living settings such as nursing homes often fueled case increases and deaths. Those outbreaks are still happening, but facilities are better at containing them, Levine and others said. Huntingdon County has had 186 cases associated with long-term care in the last month, and Bradford has had 151, said Nate Wardle, a spokesperson for the state Health Department. He added that cases in the community have also been high.

Infections in colleges, schools, and prisons can also raise rates in particular counties.

Levine said people have gotten sick after attending both large and small gatherings.

David Lopatofsky, chief medical officer for UPMC in the Susquehanna region, said he’s seen many cases traced to funerals, weddings, and birthday parties.

Powell has also seen cases stemming from coworkers eating lunch together. People should try to eat alone, she said. If coworkers want to sit together and talk, they should wear masks and stay at least six feet apart. Eight to 10 is better.

On the plus side, doctors said the patients they’re seeing now are not as sick as those earlier in the pandemic, possibly because there have been fewer nursing home patients, and people at high risk for serious disease have been extra careful. Also, so far, there hasn’t been much flu, which could stress providers even more.

Martin said it’s hard for health-care workers to watch the coronavirus numbers rising again. “The whole thing has been very sad, and certainly we’ve all had our moments of frustration,” he said. “I think we’re acutely aware that, as a country, we could have done much, much better.”