Rhonda Suter was holding her breath Friday morning.


As the Ozark County health administrator, she’s among the first to see residents’ COVID-19 test results. But Suter soon exhaled. It was another negative report. Ozark County got to continue its streak with no cases at all.


Ozark County, which is a county east of Branson, was, on Friday, one of only two Missouri counties where no one has tested positive for COVID-19. Hickory County, between Truman Lake and Springfield, was the other.


On Saturday, the streak ended for Ozark County, leaving only Hickory County as the only reporting jurisdiction in the state without a coronavirus infection.


In an interview Friday morning, Suter said she knew that it was only a matter of time before the report showed a positive result.


"I know we are on that narrow stick and it is going to happen," Suter said. "We have people tested everyday and so far, we have been fortunate enough not to have a positive one."


The news came on a day when Missouri set a new single-day record for COVID-19 cases, with 389 reported by the state Department of Health and Senior Services reports. The previous high was on May 4, when the state reported 368 new infections.


And for the week ending Saturday, which included a streak of six days with more than 200 new infections, the state set a record for average daily increases. The 254.3 cases per day exceeds the previous high of 247.6 per day set in the week ending April 11.


The increasing case counts are part of a pattern seen in many Missouri counties, the state, the nation and worldwide as the pandemic accelerates after what appeared to be a plateauing of new cases.


There was at least one new case in 47 local health jurisdictions on Saturday, with almost 60 percent of new cases coming outside the state’s largest two metro areas. The largest concentrated new outbreak was in the Joplin area, where Newton County reported 54 new cases, Jasper reported 40 and Joplin, which straddles the county line, adding three more.


Boone County set a record for average number of new cases. The nine new cases reported Saturday brought the seven-day average to 7.9 new infections per day, eclipsing the previous high of 5.4 cases per day in the first week of June.


Nationally, while not a record, the average number of cases being reported daily increased by almost 15 percent, to almost 25,000, after three weeks of about 21,000 new cases a day.


Worldwide, the average daily increase in new infections hit a record, rising more than 10 percent to nearly 145,000 a day.


When the week began, there were three counties in Missouri the coronavirus had not yet reached.


Wayne County, in southeast Missouri, was the first to learn it had a case, on Thursday morning. Wayne County Health Center Administrator RaeJean Crutchfield isn’t sure about the origins of the first case.


But it could be because for every reason Wayne County had avoided the virus up to that point – smaller population centers, little to no manufacturing, decreased thru traffic due to lockdowns – there is a corresponding risk.


"That’s why I said it’s gonna happen," Crutchfield said.


Yet, Crutchfield’s perspective on why Wayne County avoided a positive case for so long does offer some insight into how Ozark maintained its streak for so long, and how Hickory still has.


DISTANCE IS THE DEFAULT


At first glance, it’s surprising that it took this long for Wayne County to find its first positive case of COVID-19. It’s a rural county with limited health services and an aging population, all of which are typical risk factors for an outbreak.


Nearly one-quarter of the 12,873 residents are over 65, much higher than the state average of 16.9%. Although age is a complicating factor once patients test positive for COVID-19, Crutchfield thinks Wayne County’s proportion of elderly citizens has actually been an asset in delaying an outbreak.


"Most of the older people in the area, they pretty much have tried to stay in the best they can," she said.


The same can be said for Hickory and Ozark counties. Both have fewer than 10,000 people; 32.8% of Hickory County’s residents are over 65, as are 28.8% of Ozark’s. All three counties also have much higher rates of people with disabilities than the state as a whole.


Health administrators from both counties said locals, especially elderly residents, and county leaders took the pandemic seriously early.


Additionally, social services mobilized to help support residents as they stayed home. In Hickory County, the senior center has been offering meals curbside.


But even for those who have wanted to venture out, there aren’t many places to go in these counties, Crutchfield said.


"I think a lot of it is (in a) rural area … We don’t have as many gatherings and stuff," Crutchfield said. "If they are doing something, it’s usually outside."


It’s a simple explanation. Elderly populations are less likely to mingle in large groups, and even if they wanted to, there aren’t a lot of places to go. That makes social distancing the social default.


But this advantage comes with a corresponding disadvantage. Smaller population centers may mean fewer social interaction, but it also means less access to resources.


"We don’t have a lot of places to go shopping, so everybody that does shop in the county would be shopping in the same few grocery stores," Hickory County Health Department Administrator Dawn Vader said.


Or, in the case of Wayne, traveling to surrounding counties with known COVID-19 cases to get groceries. There are 212 cases in the seven counties surrounding Wayne County, most notably in Stoddard, where 126 residents have tested positive. Crutchfield said it’s typical for residents to drive out of the county to shop at a major grocery store chain, increasing the risk of accidental transmission.


Ozark County, located on the Missouri-Arkansas border, is surrounded by 63 cases on the Missouri side and 16 in its neighboring Arkansas counties.


Out-of-county travel poses a risk for Missouri’s last no-COVID county as well.


There are 83 cases in the five counties surrounding Hickory.


The degree to which Hickory County residents are able to limit their contact with people in nearby cities with known outbreaks, may help them maintain their streak. But soon, that might not be up to them.


SEASONAL RISKS


Just because rural areas can account for easier social distancing, doesn’t mean all rural areas have fewer risk factors associated with COVID-19 outbreaks.


Of the 10 local health jurisdictions with the highest infection rates, seven are counties with fewer than 26,000 people and two have fewer than 10,000. Saline, Moniteau and Audrain counties are all on that list and show how rural manufacturing can play into an outbreak.


But Hickory and Ozark don’t have any major manufacturing centers within their jurisdictions.


"Our biggest economic thing is our rivers and lakes," Suter said. "A lot of the people hadn’t been traveling."


Ozark County is home to an arm of Bull Shoals Lake. Hickory County also boasts a significant lake system – Pomme de Terre Lake.


Although decreased travel amid lockdowns meant less thru traffic and fewer chances of travel-related transmission, that could change as people who live in larger population centers look for in-state summer travel options.


"I don’t believe that we’ll go through this whole thing without one (case)," Vader said. "Especially the more people that come and visit Hickory County because … a lot of people (from the cities) have lake homes."