The month of April was a good one for the Dallas County Health Department.
It was the second straight month with less than one new COVID-19 case per day. Vaccinations opened to everyone April 9.
When a handful of cases pushed active infections to 11 on April 30, the message on social media was to remain calm.
"There may be several different reasons why this is happening," the department posted on Facebook, repeating advice health officials have delivered since the pandemic began — wear a mask, observe social distance and stay home if symptoms appear.
"Let's keep up the good work we know how to do, Dallas County! Be kind to one another & wash your hands!" the post read.
But infections increased to 1.7 cases per day in the first two weeks in May. Then 3.7 per day in the second half of the month.
It was enough to give Dallas County, with about 17,000 people northeast of Springfield, the state's eighth highest per capita infection rate for the month.
After holding steady for a while, cases spiked in the second half of June. The Delta variant surge had arrived.
It was already filling hospitals in Springfield and elsewhere in southwest Missouri as regional cases rivaled numbers from the worst winter outbreak.
A 22-county region of southwest Missouri, with less than one-sixth of the state's people, has recorded almost one-third of the new COVID-19 cases since May 1. The Delta variant was first detected in the state in wastewater samples from Branson in early May.
A few weeks later, cases began to climb.
On June 1, the seven-day average of reported cases stood at 400 per day. On Friday, the seven-day average was more than six times higher, at 2,600 per day.
The 58,069 cases reported in July so far is the most since January and fifth most of the 17 months since the first case in March 2020. It is more than three times the number reported in June.
In Dallas County, the June infection rate was double that of May. For July, it has nearly doubled again. Since May 1, more than 3.6 percent of the county's population has tested positive, fifth highest in the state.
And in June, the tone changed on social media.
"We can't keep messing around and pretend that numbers aren't going up," a June 18 post stated. "Just last month this time, the numbers were two active cases, not 44. Please don't act like this is just going to go away."
And on June 23, something new appeared in the increasingly direct messages.
"As we are closing for the day, here is where we stand," that evening's post on Facebook stated. "Active Cases 60, of those 10 are children under 18, 4 are hospitalized."
Two figures in silhouette, one adult-sized and one representing a child, are presented against a blue background with numbers superimposed, 70 on the adult figure and 14 on the child. The graphic illustrates the impact of COVID-19 infections on children in Dallas County, Missouri, and represents the number of active cases June 30.
As of Thursday afternoon, children younger than 18 were one-fourth of the county's 77 active cases.
By highlighting the data about children, Administrator Cheryl Eversole said, she was addressing two concerns. The number of juvenile cases was higher than she had seen, and parents were not taking enough precautions.
"We are seeing parents that are allowing their kids to go to camp for a week, going to vacation Bible school, all these things, and the hosts of these events are not requiring masks," Eversole said.
With no children younger than 12 vaccinated and fewer than a third of those ages 12-17 who are eligible receiving a dose, children easily spread the virus to their parents and grandparents, she said.
"Sure, they are not in a hospital, they are not on ventilators," Eversole said. "But what happens when they go to grandma and grandpa's, or go to the family reunion.
"They aren't feeling good, but it's fine, they are well enough to go. Now you have just exposed your older, more frail family members and what is going to happen then?" she asked.
Disease, death and disputes
At the end of June, University of Missouri professor of immunology Marc Johnson made a sobering prediction.
"I am assuming our overall state case numbers are going to double or triple in the next few weeks," Johnson said.
Johnson, who has been analyzing wastewater samples since last summer to determine levels of COVID-19 in local communities, wasn't wrong. With one day remaining in July, there have been just more than three times as many new infections this month.
One more day with cases equal to the month's average so far and July will go down as the fourth-worst of the pandemic in Missouri. The only time cases were higher was in November, December and January.
Johnson expects cases to continue to rise. If nothing changes in coming weeks, he said Thursday, the peak would likely be in mid-August.
"But things are not staying stable," Johnson said. "People are going back to school so all bets are off."
Since Johnson made his forecast, the state health department has reported almost 60,000 new cases. Almost half the local health departments in the state have seen infection rates above 1,000 cases per 100,000 residents, compared to nine in June.
Infection rates in five local health departments exceeded 2,000 per 100,000 for July.
And since May 1, 12 have experienced more than 3,000 cases per 100,000 residents, with three above 4,000 per 100,000.
Hospitals have filled, with inpatient totals rising from a low point of 628 on May 23 to 1,921 on Tuesday. Net new admissions are averaging 40 per day.
Hundreds have died, but the true number for July won't be known for several months.
State death reporting lags weeks and even months behind because the state health department waits for death certificates to be checked against case reports before adding them to the official count. As of Tuesday, local health departments around the state were reporting almost 1,100 more deaths than the state.
The official state death total was 9,650 Friday, up 339 during July. But 90 of those reported deaths occurred before July 1, including one from January.
For the 22 southwest Missouri counties hit hardest by the Delta variant, the state health department has reported 144 deaths during July. That is barely more, however, than the deaths experienced in the two largest hospitals in Springfield, CoxHealth and Mercy.
They have endured at least 139 COVID-19 deaths this month.
Erik Frederick, chief administrative officer at Mercy Hospital, tweeted the deaths are hard on his team, the same as during the winter. But there were no vaccinations at that time.
"The difference now is that most of this could be prevented," Federick tweeted. "That adds an extra layer of anguish."
And in a tweet Thursday, CoxHealth CEO Steve Edwards urged people to wear masks and for local officials to mandate them.
"Politicians, please listen to science, not the angry mob," Edwards wrote. "I know it takes courage."
Rather than pull together, however, it has seemed state and local officials are fighting over how severe the problem is and what to do about it.
One of the hardest to convince that the state was reaching crisis levels, it seems, was Gov. Mike Parson.
On May 19, two weeks after the Delta variant was first detected in wastewater, Parson celebrated the low case numbers the state was experiencing.
"Missouri has now seen 13 consecutive weeks of stable COVID-19 case counts. This is great news and shows that our administration's balanced approach to fighting the virus and economic recovery is working," he said.
At the end of June, when case counts had doubled in the intervening six weeks, Parson noted "a few counties in Missouri that are continuing to experience an increase."
It wasn't until July 21, with cases running 150 percent higher than the end of June, that Parson stated the reality on his Twitter account. By that point, Springfield had asked for an "alternative care site" to relieve pressure on hospitals and Parson had reluctantly agreed to offer incentives to get vaccinated.
Parson in the meantime picked fights with President Joe Biden's administration, accusing it of plans to send "agents door-to-door to compel vaccination" and with Springfield over the alternative care site.
At first, Parson said the state "would most probably fill the request," then sent the paperwork back because it didn't state the request properly. On Thursday, after waiting another two weeks for action, Springfield canceled the request.
Parson said it was canceled because case numbers had fallen in the region. Springfield officials said it was because of the delays and because local hospitals had found emergency space.
The governor wasn't the only statewide official fighting over COVID-19 issues as July comes to a close. St. Louis and St. Louis County reimposed mask mandates this week for indoor spaces and were immediately sued by Attorney General Eric Schmitt.
When Kansas City Mayor Quinton Lucas said he would order masks be worn in his city starting Monday, Schmitt threatened another lawsuit.
"Dude, the order hasn't even been filed yet. What are you suing about?" Lucas responded on Twitter. "Do you want us to just schedule a debate on Fox News so you can get the press? I'm down!"
In the middle of July, during an appearance on the CBS Sunday news show Face the Nation, Springfield Mayor Ken McClure issued a warning to the rest of the state:
"My message is that the surge is coming," McClure said.
In the intervening two weeks, daily case counts have declined in Greene County and many other southwest Missouri counties but soared in other parts of the state. In the week before McClure spoke July 18, the state added 13,386 cases. In the seven days ending Friday, the total was 18,202, more than all of May and just 996 below the total for June.
In the seven jurisdictions that make up the Missouri portion of the St. Louis Metropolitan Statistical Area, cases are up 33 percent in the past seven days.
On the western side of the state, case rates have grown even faster. In the seven days through Friday, the 10 counties in the Missouri portion of the Kansas City MSA have seen a 44 percent increase over the previous week.
As of Friday, the overall infection rate for Missouri in July was 943 cases per 100,000 residents. If cases statewide in August match the July rate for the 22 southwest counties that have been hardest hit, the state will add more than 114,000 new infections and it will be second only to November for total cases.
The wastewater analysis can identify which COVID-19 strains are circulating in a community, and the most recent mapping report of samples collected the week of July 12 shows 46 communities where the Delta variant is dominant.
The analysis can also detect when cases are about to spike.
"With our tool, when we have seen an increase in the viral load of 40 percent or greater in one week, it is followed by a 25 percent increase in cases, at least," Jeff Wenzel, chief of the state health department's Bureau of Environmental Epidemiology, said in late June.
Johnson said he's watching Platte City, in Platte County of northwest Missouri, and Sikeston, in Scott County in the Bootheel. Both are showing big increases in viral loads in their wastewater, he said.
The July infection rate in Platte County is up 600 percent from June. In Scott County, it has increased 686 percent.
Platte County's health board will discuss a mask mandate at its Tuesday night meeting, health department spokesman Aaron Smullin said.
"We don't have any directive or anything prepared, we are just looking at data and that sort of information," Mullin said. "We have some folks that are queued up to speak about the potential of a mandate or directive."
In Scott County, the health department has added one employee and increased the hours of another to keep up with contact tracing, said Diana Knutson, a registered nurse with the department.
She's worried about two big public events coming up soon — the Sikeston Rodeo, which starts Aug. 11, and the Semo District Fair, which begins Sept. 11.
"We will just have to wait and see," Knutson said.
In the meantime, health officials said they will continue to push vaccinations. As of Thursday, average daily shots stood at 11,604 per day, up 45 per day from the level on July 21, when Parson announced the state incentives.
The problem with vaccine resistance can be shown in a number of ways. In Dallas County, the health department canceled two vaccination clinics, it said on Facebook, "due to lack of interest."
"What the hell is wrong with these people?" one person posted in response. "Do they all WANT to die?"
The Missouri Independent is a nonprofit, nonpartisan news organization covering state government and its impact on Missourians.