South Dakota is one of the nation’s hot spots for COVID-19 infections. That didn’t stop another large-scale event from kicking off Thursday.

The rural South Dakota State Fair, which reported an attendance of 205,000 people last year, is set to run through Labor Day with more hand-washing stations, social distancing reminders and an encouragement — but not a requirement — for attendees to wear masks. It comes on the heels of the state’s two largest events: The Sturgis Motorcycle Rally and the The Sioux Empire Fair.

In the weeks following those events, South Dakota has emerged as a virus hotbed, according to data analysis. State and national health experts say the rise in cases is likely fueled by a combination of factors, including school reopenings, small gatherings and major events.

Inside the numbers:The coronavirus spread is slowing in some states. It’s getting worse in others.

Those larger events have been made possible by South Dakota Gov. Kristi Noem’s steadfast resistance to restrictive measures aimed at slowing the spread of the virus. She has discouraged schools from requiring masks, instead promoting hand-washing as the best way to prevent infections, and railed against an “elite class of so-called experts” whose opinions impact individuals’ liberties.

But as cases surge in the state, public health officials are grappling with the impact of the Sturgis rally, which gained national attention as one of the largest events to be held since the onset of the pandemic.

People watch a concert at the Full Throttle Saloon during the 80th Annual Sturgis Motorcycle Rally in Sturgis, S.D., on Aug. 9.

The event has so far been linked to one death. In South Dakota, 118 residents who attended the rally subsequently tested positive for COVID-19. Nationally, about 300 cases have been linked to the rally.

While that’s less than 1% of the more than 460,000 people who converged on Sturgis, Dr. Robert J. Kim-Farley said it’s likely “the tip of the iceberg.”

Kim-Farley, a professor of epidemiology and community health sciences at the UCLA Fielding School of Public Health, told USA TODAY on Thursday that COVID-19 is a particularly difficult virus to trace to its infection point. Symptoms might not show up for weeks, if at all, in an infected person. Meanwhile, that person could be spreading the virus.

Cellphone location data analyzed by the nonprofit COVID Alliance has found evidence that rally participants came from each of the 48 continental United States and more than half of the nation’s counties.

The data also suggests participants were less likely to practice social distancing — they stayed at home less and traveled more compared to their neighbors. This behavior continued before and after the August rally, COVID Alliance data shows.

Gov. Kristi Noem ‘remains focused on our hospitalization rate,’ not state’s case count

While the rally’s impact ripples across the nation, a spike in cases in South Dakota is also gaining national attention.

The Mount Rushmore State has recorded the nation’s third-highest rate of coronavirus cases per capita over the last two weeks, according to The Associated Press, and the highest per-capita rate in the nation for the past seven days, according to New York Times data.

A statement from Noem’s office emailed to USA TODAY on Thursday says the Republican governor “remains focused on our hospitalization rate, and we are encouraged by the fact that only 6% of our ICU beds are currently occupied by COVID patients.”

Mapping coronavirus:Tracking the U.S. outbreak

While hospitalizations are a more accurate metric for studying COVID-19 spread than cases, there’s a lag time from days to weeks, Kim-Farley said.

It’s “a little bit early to say that hospitalizations haven’t been affected,” Kim-Farley said.

State epidemiologist Josh Clayton acknowledged there is typically a two-week lag between increases in cases and hospitalizations. Currently, less than 100 COVID-19 patients are hospitalized, well within the state’s capacity.

The pandemic and the surge of cases is impacting the state fair, Candi Briley, the event’s assistant manager, told USA TODAY.

While organizers are “ready to welcome fairgoers” to Huron, about 125 miles northwest of Sioux Falls, they “understand some people might not feel comfortable coming out and we respect (their decision),” Briley said.

For those who do, they’ll be encouraged to keep their distance. Among the reminders, according to Briley, are signs featuring pigs that read, “Have a squeal of a time at the fair. Stay 6 feet apart.”