More than half of Tennessee's newly reported cases of COVID-19 and hospitalizations are now in areas outside of the state's two largest metro areas of Nashville and Memphis, according to a new Vanderbilt University analysis released Monday.

The shift represents a stark change from early in the pandemic, when outbreaks were concentrated in large urban areas. Since mid-July, COVID-19 cases and hospitalizations are increasing in areas outside of Tennessee's largest metro areas, yet appear stable in Nashville and Memphis, according to researchers at Vanderbilt's School of Medicine and University Medical Center who authored the report.

In May, more than three-quarters of cases and hospitalizations were located in the Nashville and Memphis metropolitan areas, and many of the state's regions were on similar rising trajectories, the analysis states. At that time, smaller metro areas of the state with less than 1 million people — Chattanooga, Knoxville, Clarksville, Jackson and the Tri-Cities area — accounted for 11% of the state's coronavirus patients.

By late July, 44% of the state's COVID-19 patients were hospitalized in smaller metro areas. Researchers note that Chattanooga's coronavirus hospitalizations have stabilized around 100 in recent days, but hospitalizations continue to climb in the Knoxville, Johnson City and Jackson areas.

"Of course, stability over a period of a month or less does not imply that cases and hospitalizations will not go up — or down — in the coming months," Melinda Buntin, health policy professor and department chairwoman at Vanderbilt, said in a news release.

On Monday, the Hamilton County Health Department reported 94 COVID-19 patients hospitalized in the county, which includes nine unconfirmed patients. Of those patients in Hamilton County hospitals, 35 were in intensive care, marking the most critically ill patients in local hospitals to date.

The county also reported the fewest number of new cases — 44 — since cases began to rise in early July. At the same time, only 384 negative tests were reported Monday — significantly less than the previous seven-day average of 1,096 negative tests per day.

The number of COVID-19 deaths in Hamilton County remains at 48.

John Graves, associate professor of health policy and director of Vanderbilt's Center for Health Economic Modeling, said in a news release that understanding the changing face of the pandemic is critical for targeting resources and preparing to address increasing needs for services and effects on rural health care systems.

"It could even be that hospitalization estimates are understating the burden the smaller and more rural areas of the state are facing, because some patients from these areas are being treated in facilities in larger metro areas," Graves said. "That makes it even more important for health care leaders and public officials to closely monitor these trends to best deploy ... resources and mitigation strategies."

As of Monday, 40 of the patients in Hamilton County hospitals were from Hamilton County and the remaining 54 patients were from outside counties.

The report states, "If smaller metro areas have fewer resources for contact tracing, or if individuals and policymakers in those communities are less likely to adopt mitigation strategies (e.g., mask ordinances and limitations on large group gatherings), there is the potential for the disease to spread further. There is also the potential that as numbers increase in those areas, depleted health care resources may result in transfers of patients back to facilities in metro areas."

As a largely rural state, Tennessee stands to be among the states most affected by this change, researchers said in the release.

Contact Elizabeth Fite at or follow her on Twitter @ecfite.