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story.lead_photo.caption FILE - This July 2021 file photo shows a sign on the door of a hair salon informing patrons that masks are required to be in the business in Kansas City, Mo. St. Louis County's top elected official insisted Wednesday, July 28, 2021 that a mask mandate remained in place even though the county commission voted to overturn it. Across the state, meanwhile, Kansas City issued its own order in an effort to stem a rise in COVID-19 cases that is straining hospitals, leading to an immediate threat of a lawsuit.(Jill Toyoshiba/The Kansas City Star via AP, File)

KANSAS CITY (AP) — More than a dozen high-risk Missouri residents who were vaccinated against COVID-19 were among those who died amid a surge of cases that has led the University of Missouri to reinstate a mask mandate and some St. Louis restaurants to permit only the immunized to eat indoors.

"High risk, immune compromised and sadly couldn't muster an immune response," tweeted Steve Edwards, president and CEO of CoxHealth, in announcing Thursday there had been six COVID-19 pneumonia deaths among vaccinated patients at its hospitals in southwest Missouri.

An additional eight fully vaccinated Mercy Springfield patients have died since June 1, spokeswoman Sonya Kullmann wrote in a text. That amounts to 12 percent of the 68 total deaths at that hospital during that time.

"They all had other serious health conditions," she wrote, adding seven of the patients were older than 75 and one was older than 65.

COVID-19 vaccines greatly reduce the chance of severe illness and death and remain effective against the variants, including the delta variant. Like many other vaccines, they are less effective in people with weakened immune systems and frail elderly.

Dr. Joshua Sharfstein, vice dean for public health practice and community engagement at Johns Hopkins University, said the deaths were partially a reflection of the level of COVID-19 spread.

The state ranks fourth nationally in the number of new cases per capita in the past 14 days. And the seven-day rolling average of daily deaths in Missouri has risen over the past two weeks from 12 per day July 13 to 17.29 per day Tuesday, according to data from John Hopkins University.

Health officials are blaming low vaccination rates and the fast-spreading delta variant for sending hospitalizations in the state soaring.

"There are so many cases that you are going to see more breakthroughs," Sharfstein said. "That is why you are seeing them in Missouri because you have so many cases."

Just 47.7 percent of Missouri residents have received at least one dose of the vaccine, far lower than the national rate of 57.1 percent, state and federal data shows. Many counties in southwest Missouri have vaccination rates that are less than half the state average.

"I do think that scenario that we are hoping for is that if enough people get vaccinated, then the virus will find it much harder to move around in the population and that will protect everyone, including children and people who don't respond to the vaccine," he said.

Meanwhile, health officials in St. Louis County said in a news release they had documented more than 600 cases in which vaccinated people tested positive for COVID-19, and they stressed the total is likely higher. They said Thursday they would release more details soon.

The issue of breakthrough cases and masking has gotten more attention after the Center for Disease Control and Prevention announced it now recommends even vaccinated people wear masks indoors in places where the coronavirus is surging. Under the guidance, those recommendations would apply to all but three of the state's counties.

The University of Missouri- Columbia said Thursday all students, faculty, staff and visitors, regardless of vaccination status, will be required to wear masks in classrooms and meeting spaces where social distancing isn't possible starting Monday.

Some restaurants in the St. Louis area have announced plans to limit indoor dining to vaccinated customers only, seating unvaccinated customers outdoors.

"Given the events of the last 18 months, our businesses can not afford the threat of unvaccinated individuals are exposing our staff and guests to unnecessary health risks," wrote Bengelina Hospitality Group, which runs Elaia, Olio and Nixta restaurants, in a Facebook post. It also said the restaurant group was only hiring vaccinated people.

Apotheosis Comics and Lounge also announced beginning Thursday, only customers who can show proof of vaccination against the coronavirus will be allowed to sit at the in-store bar.

The restrictions go a step further than what is required under mask mandates that took effect this week in St. Louis County and St. Louis city. They demand even the vaccinated wear masks if they 5 or older, but include exceptions for people who are seated in a restaurant or bar eating and drinking.

The St. Louis area mandates have been hotly contested, with Missouri Attorney General Eric Schmitt suing and the St. Louis County council voting to overturn the county mandate. St. Louis County Executive Sam Page insists the mandate remains in effect, but Schmitt said it isn't. He tweeted his office is seeking a court order to halt enforcement.

Schmitt also has threatened to sue over a Kansas City mask mandate set to take effect Monday.

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