Covid cases in kids are soaring. In Tennessee, most remain unmasked and unvaccinated.

ALTAMONT, Tenn. - Sarah Rymer suspects her 11-year-old son was infected with the coronavirus, and she knows her husband was. He coaches Pee Wee football, and at least two other kids on his team also tested positive.

The Grundy County schools, which her three children attend, were forced to close for more than a week soon after the fall semester began. Her best friend's uncle recently died from covid-19, and a close friend's mother spent her 53rd birthday in the hospital at Vanderbilt University up in Nashville.

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The coronavirus pandemic feels more serious than ever to Rymer. But her children do not wear masks in school, and she is not considering vaccinating her 13-year-old daughter. Like most other people in the area, she remains unvaccinated herself. "It's one of those things. We don't get the flu shot so I don't know," she said. "It was developed so quick. I'm nervous."

A pandemic that first ravaged nursing homes is, today, more likely to rage through school lunchrooms. Children are still far less likely to become dangerously ill than older people, but with so many becoming infected, pediatric hospitalizations have spiked in the last few weeks.

Since the start of the pandemic, more than 5.7 million children have been infected, according to the American Academy of Pediatrics. More than 540 Americans up to the age of 18 have died, federal data show.

In August, for the first time in the pandemic, the rate of coronavirus infections among children topped those for adults ages 18 to 64 and seniors, driven by the highly contagious delta variant, according to a Washington Post analysis of Centers for Disease Control and Prevention data. In states like Tennessee, where vaccination rates are low, infections among children have skyrocketed. States with high vaccination rates are seeing far fewer pediatric infections.

In Tennessee, just 17% of those ages 12 to 17 across the state have been immunized, versus 52% nationwide. (Adult vaccinations here also lag, with 45% in Tennessee vaccinated, versus 56% nationwide.) Children now make up nearly one in four coronavirus cases in the state, close to the national average. Only one state, South Carolina, has a higher childhood infection rate, according to data as of Sept. 11, the most recent available.

In early September, the pediatric caseloads across Tennessee peaked, with 86 children hospitalized, including 21 in intensive care units and 12 on ventilators, state data show. So far, 20 children in the state have died of covid-19.

"It should be zero," said Diego Hijano, a pediatric infectious disease doctor at St. Jude Children's Research Hospital in Memphis. Hijano blames the lack of willingness to avoid large gatherings, wear masks and get vaccinated. "As a community, we're doing very poorly in taking care of each other," he said.

But there is scant leadership among top Tennessee officials to push for such health measures. Republican Gov. Bill Lee has blocked mask mandates for schools unless parents can opt out, and local school boards considering them have faced hostile crowds. The head of the state's immunization program said she was fired for promoting vaccinations among teens too vigorously. The state public health department is under orders to discuss vaccine availability without promoting the shots for teens, according to an agency official, speaking on the condition of anonymity as she was not authorized to comment publicly.

Across Grundy County and other areas, there are some complaints about the pandemic response. But most people seem to accept the virus will be part of their lives and don't feel the need to battle it with the tools most public health experts recommend. That means missed school days, with schools across the state forced to temporarily closed, and thousands of student cases reported. It's not that they don't know anyone who has had covid-19. Almost everybody here does. They just don't believe that masks and vaccines are the solution.

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The rise in coronavirus cases is most acute in rural parts of Tennessee like Grundy County, where federal data show 6% of those ages 12 to 17 have received the coronavirus vaccine. At least 190 students have been infected in Grundy County since schools reopened, and the district also has the highest infection rate in the state, according to a Washington Post analysis.

Grundy, less than an hour outside Chattanooga in Middle Tennessee, sits on the Cumberland Plateau on the western edge of the Appalachian Mountains. The county is home to vistas, forests, lakes and hikes which lead to majestic waterfalls. The locals brag that if someone is in trouble, neighbors will jump to help out and, at the one-room Annex diner in Tracy City on a recent day, a small crowd quickly formed to give a hand when an older woman fell.

Once reliant on coal mining, Grundy County struggles with about one in five people living in poverty, above the state average of 14%, 2019 Census Bureau estimates showed. The median household income hovers just above $40,000 a year, below the state average. Ninety-seven percent of residents are White, and three-fourths of the county voted to reelect President Donald Trump.

The CDC says masks and vaccines are the two most powerful tools to fight the pandemic. But masks are rare here, and few people in the schools wear them. Classes began in August, but as Labor Day approached, cases were climbing. Officials closed schools from Sept. 3 until Sept. 13 in hopes of curbing spread. A state policy set earlier this year bars districts from moving classes online, so students were given five days off, with the district forced to burn extra days worked into the calendar that typically are reserved for bad weather.

Since then, Grundy County High School has struggled to cover for teachers absent due to illness, said Paul Conry, the principal. Conry said he and his secretary have had to work to pull teachers from other assignments and assign educational assistants to cover classes. "We simply don't have enough subs," Conry said. "They're sick or not able to come in because of fear."

Grundy does not require masks in school, and only a handful of people wear them, Conry said. Elaine Andrews, a retired teacher from the Grundy County Schools, said that she was so upset about the mask policy that she decided to contact a number of state and local officials to raise her concerns.

"I'm worried sick about our community and our schools with this virus," she wrote in a text message to a school board member. "I understand the hesitation to mandate [masks], but we mandate people stop at red lights, pay taxes, and have certain vaccinations in order to enter school. Lives are at stake."

She said he replied that the state barred mandates, suggesting the policy will need to change in order for the county to act. Andrews has been frustrated by the responses in the state. "You can't convince anyone," she said. "You have to be very careful who you have a conversation with. People get angry and you can't carry on a conversation. There's too much anger involved."

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Across the street from the county health department on Main Street sits a house painted in bright orange and white - inside and out - an homage to the University of Tennessee. The university flag flies on a tall flagpole, below the American flag and above one declaring "Trump 2024 Save America Again!"

Owner Randy Lee West, whose devotion to the Volunteers-inspired the decor, recently recovered from a punishing two-week bout of covid-19. His wife and two of his teenage sons were also sick, though the kids' symptoms were far milder. After that, West said the family discussed vaccination but decided against it for now. "To me, I don't think it's been tested long enough," he said. "It got rushed through." However, West hasn't ruled it out and says his support for Trump has nothing to do with his decision-making on vaccination.

Doubts about the safety and effectiveness of the vaccines are widespread in the county, according to interviews with more than three dozen people. Some were fully opposed, vowing to never support anything that President Joe Biden favors. Others were scared or skeptical, but open to considering vaccination.

Natasha King, 34, an assistant in a dental office, said she has no doubt the virus is real. A family friend died of covid-19, she said, and his family was "burying him as we speak." But she doesn't want the vaccine for herself, saying too many people have had bad reactions to it, and said she would not even consider it for her children, ages 16 and 13 or, if approved, for her 10-year-old twins. "My kids are not getting it," she said. "Nope. Nope, nope, nope, nope, nope." Her husband's employer may require vaccination for work, King said, and if so, then he will get the shot.

On a recent Friday evening, at the Grundy County High School football game, a nice size crowd showed up to cheer on the winless Yellowjackets. Almost no one on either side of the field wore masks, and teens and adults alike said they don't wear them inside either. There was scant interest in the vaccine.

"I consider myself healthy so if I get it, I'll be fine," said Tori Taylor, a junior at Grundy High. But she also admitted there is a lot she doesn't know. "I don't know all the facts. I don't feel I'm educated enough to make a decision."

There's not much of an organized effort locally to help educate her. The Grundy County Health Department administers coronavirus tests and vaccines under a tent behind the building, right next to the parking lot. But its own website does not mention the virus or the vaccine and there do not appear to be many, if any, signs about it in public places. On the local library door, there were fliers posted with information about unemployment benefits, domestic violence, free birth control and an Arts and Craft fair, but nothing about the pandemic.

Grundy County Mayor Michael Brady worries that his county has little health care infrastructure to handle the pandemic. If the health department is closed, Brady said, there is nowhere else in the county to get a coronavirus test.

He will not say whether he is vaccinated. ("I don't release any of my medical information to anyone," he says.) He said he struggles with what to tell people about the shot, having heard contradictory claims about its effectiveness. "So many people value your opinion but my opinion is just that," he said. "I don't have a medical background. I'm not an epidemiologist. I'm not a doctor."

Amy Evans, a pediatrician who practices just outside the county line, also worries. Most of her patients live in Grundy County, and she has seen more infections in the last two months than the rest of the pandemic combined. She said some of her patients would like to wear masks in school but fear they will be teased. She unsuccessfully lobbied one area school board for a mandate.

"They were more concerned about the backlash from parents who would be opposed to masks," she said. "The adults aren't making it easy for kids to do the right thing." On a recent Saturday morning, Evans walked into a Tracy City cafe for breakfast and saw nobody was wearing masks in the crowded dining room. She decided to look for somewhere with outdoor seating instead.

At the second spot, a waitress named Erin recognized Evans as her former pediatrician. Asked about the pandemic, Erin, who declined to give her last name, said she sees rising cases and has friends who were hospitalized. But she is not considering vaccination. She said she would like to research it when her baby daughter goes to sleep, but she's so tired herself. "I'm too busy. I work three jobs," she said. "I don't know what's in it. I've heard too many negative things." Evans asked Erin if she had a doctor who she trusted. She didn't.

The doctor then offered a low-key pitch, acknowledging that it's right to be skeptical about something new but saying the vaccine has been delivered to millions of people across the country and had proven itself. "The vaccine is very safe, very effective," she told Erin, who replied, "I will eventually, more than likely, get it. It will just take time for me to see how things go." Evans ended the conversation by telling Erin that she could call anytime with questions.

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In Tennessee, there is almost no concerted government effort to persuade people like Erin to overcome their concerns. The governor says he supports vaccines as the best tool available to fight the pandemic but opposes mandates. Lee has renewed his executive order to let parents to opt out of mask mandates in schools, despite the court rulings in several counties invalidating it.

In August, when he first announced the order, the governor said, "Requiring parents to make their children wear masks to solve an adult problem is in my view the wrong approach." That day, he also said he had received the vaccine but stopped short of encouraging other citizens to do the same. "I encourage Tennesseans who have not been vaccinated to talk to their doctor to consider getting vaccinated and to make an informed decision," the governor said.

Critics say Lee's office has resisted promoting even voluntary vaccination. One state health department official said senior officials from his office instructed agency officials to promote access to the vaccine to teens but to not overtly encourage it. "The message to us from the governor's office was our job is to provide access. People can choose what to do," the official said. She said after the delta variant spiked, no strategy was developed to promote vaccination.

Anna Morad, president of the Tennessee chapter of the American Academy of Pediatrics, said she met with the governor about requiring masks in schools and presented data showing their effectiveness in blocking transmission of the coronavirus. "He was very receptive," Morad said, but told her he could not rescind his executive order. "We need a plan that everybody can agree upon," Lee said, according to Morad. Lee declined an interview request, while a spokeswoman from his office declined to comment on private meetings.

In July, Michelle Fiscus, the head of the immunization program in Tennessee, says she was fired under pressure after she told local doctors in a memo that state law called the "Mature Minor Doctrine" allows young people age 14 and up to be vaccinated without parental permission. "Unfortunately, we have a growing contingent of legislators here who are quite anti-science and as a result anti-vaccine," Fiscus said in a recent interview with The Post.

At a legislative hearing in June, state Sen. Janice Bowling, a Republican, said the state was overstepping and "misjudging" its legal authority, and she urged the agency to "back off" the "misapplication" of the doctrine and take action to "remove the fear, the concerns and the anger that has gone across the state" as a result of the letter from Fiscus. After she was fired, the Tennessean reported, the agency had temporarily stopped promoting all vaccinations for children.

Bill Christian, a spokesman for the Tennessee Health Department, declined to comment on the allegations from Fiscus about her dismissal. He said the state has developed outreach based on market research about why Tennesseans are hesitant to receive the vaccine, and plans additional research soon. Christian added that vaccine rates are increasing each week across the state.

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Grundy County is hardly alone in dealing with surging coronavirus cases this fall. In Marion County to the south, cases have spiked and masks are officially required, though parents can opt out under the governor's executive order. At Marion County High Schools, about half the students have mandate opt-outs on file, said principal Sherry Prince.

It makes it hard to run the school, she said, not remembering off the top of her head who is and who is not required to mask. On a recent Friday, students gathered in the gymnasium to hear about the risks of texting and driving. The guest speaker pumped up the crowd with loud music and dance contests. The students, seated close together in the rafters, danced and shouted. Almost no one was wearing a mask over their mouths. Many had pulled them down.

A teacher paced in front of the rafters, pointing to her chin to signal students with masks that they needed to pull them up. The whole scene was stressful for Prince. "Last year was easier because there were clear-cut rules," she said.

Nearby, the Hamilton County Schools, which serve Chattanooga, has also seen a surge in coronavirus cases. In the last academic year, the district recorded its highest monthly student case total in December, when it hit 570 cases. During the first two weeks of school this August, there were about 1,600 students who tested positive, said Nakia Towns, who serves as interim superintendent.

Case counts declined in September, however, they still remain higher than at any point last school year. Unlike in Grundy County, though, the district has hosted vaccine clinics and requires masks with the parental opt-out option.

It's been difficult trying to identify close contacts of students, and the district had to hire more contract tracers, Towns said. At one point, around 5,000 students were in quarantine. "We really thought in many ways covid would be in our rearview mirrors," she said. "We thought we were really turning the corner. We weren't mentally or emotionally prepared for the onslaught."

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The Washington Post's John D. Harden contributed to this report.

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