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Causes of COVID-19 burden in urban, suburban, and rural counties are unclear, as early studies provide mixed results implicating high prevalence of pre-existing health risks and chronic diseases. However, poor sleep health that has been linked to infection-based pandemics may provide additional insight for place-based burden. To address this gap, we investigated the relationship between habitual insufficient sleep (sleep &amp;lt;7 hrs./24 hr. period) and COVID-19 cases and deaths across urban, suburban, and rural counties in the US. Methods County-level variables were obtained from the 2014–2018 American community survey five-year estimates and the Center for Disease Control and Prevention. These included percent with insufficient sleep, percent uninsured, percent obese, and social vulnerability index. County level COVID-19 infection and death data through September 12, 2020 were obtained from USA Facts. Cumulative COVID-19 infections and deaths for urban (n=68), suburban (n=740), and rural (n=2331) counties were modeled using separate negative binomial mixed effects regression models with logarithmic link and random state-level intercepts. Zero-inflated models were considered for deaths among suburban and rural counties to account for excess zeros. Results Multivariate regression models indicated positive associations between cumulative COVID-19 infection rates and insufficient sleep in urban, suburban and rural counties. The incidence rate ratio (IRR) for urban counties was 1.03 (95% CI: 1.01 – 1.05), 1.04 (95% CI: 1.02 – 1.05) for suburban, and 1.02 (95% CI: 1.00 – 1.03) rural counties.. Similar positive associations were observed with county-level COVID-19 death rates, IRR = 1.11 (95% CI: 1.07 – 1.16) for urban counties, IRR = 1.04 (95% CI: 1.01 – 1.06) for suburban counties, and IRR = 1.03 (95% CI: 1.01 – 1.05) for rural counties. Level of urbanicity moderated the association between insufficient sleep and COVID deaths, but not for the association between insufficient sleep and COVID infection rates. Conclusion Insufficient sleep was associated with COVID-19 infection cases and mortality rates in urban, suburban and rural counties. Level of urbanicity only moderated the relationship between insufficient sleep and COVID death rates. Future studies should investigate individual-level analysis to understand the role of sleep mitigating COVID-19 infection and death rates. Support (if any) NIH (K07AG052685, R01MD007716, R01HL142066, K01HL135452, R01HL152453

694 Insufficient sleep linked with higher COVID-19 infection cases and deaths in the United States