ST. LOUIS 鈥� Labor Day marked the end of a summer unlike any other in recent memory for the St. Louis area, filled with dramatically altered traditions, cancellations and 鈥� to the disappointment of health officials鈥� persistently high case totals of COVID-19.

By the Monday holiday, Missouri鈥檚 average daily case counts were nearly eight times higher than on Memorial Day, May 25, when residents were just beginning to emerge from weeks of stay-at-home orders. Deaths in that time have more than doubled.

In Illinois, the average daily case count over the same time initially dipped, falling almost 400% in June, but steadily rose through July and August and has since returned to Memorial Day levels.

The rising numbers in both states this summer have been driven by more social interactions, rising cases among younger people and outbreaks reaching rural counties previously untouched by the virus, according to health officials.

In response, state and local governments have established an ever-changing patchwork of restrictions and initiatives aimed at reversing the trends before the region heads into autumn.

Heading into Labor Day weekend, Dr. Anthony Fauci, the nation鈥檚 top infectious disease expert, named Illinois and Missouri among seven states 鈥渁t risk of surging鈥� after the holiday weekend.

鈥淭hose states are starting to see an increase in the percent positive of their testing,鈥� Fauci told Bloomberg News this week. 鈥淭hat is generally predictive that there鈥檚 going to be a problem.鈥�

In total, Missouri鈥檚 count rose from 12,167 to 93,434 confirmed COVID-19 cases this summer from Memorial Day to Labor Day. Deaths in that time went from 685 to 1,659.

Some of that rise comes from about a 90% increase in testing in Missouri this summer, but the average percentage of tests coming back positive also skyrocketed from about 3% at the end of May to 13.8% Monday.

Illinois hasn鈥檛 seen as steep a rise, but it passed a benchmark of 250,000 confirmed COVID-19 cases on Monday. Since Memorial Day, the state鈥檚 count rose from 112,017 to 250,961 cases and deaths increased to 8,179 from 4,884. Illinois鈥� average positivity rate remained at about 4.2% Monday, but the Metro East region was at 9.7%.

Memorial Day mania

The numbers are not what health experts had hoped for this summer, but signs appeared early that people were willing to return to up-close-and-personal social gatherings despite the pandemic threat.

Missouri lifted its stay-at-home orders May 4, while St. Louis and St. Louis County kept those restrictions in place until May 18.

A week after the orders lifted in St. Louis, Missouri made the national news over Memorial Day weekend when videos of large crowds gathered at pool bars in the Lake of the Ozarks circulated online. In response, St. Louis Mayor Lyda Krewson and St. Louis County Executive Sam Page issued travel advisories requiring anyone who had visited the lake over the holiday to self-quarantine for two weeks.

In Illinois, Gov. J.B. Pritzker kept stay-at-home orders in place through the end of May. Even so, Pritzker said he was 鈥渄ismayed鈥� over large weekend gatherings Memorial Day weekend, including reports of large crowds in Lake Geneva, Wisconsin, a popular weekend destination near the Illinois-Wisconsin state line.

Dr. Alex Garza, head of the St. Louis Metropolitan Pandemic Task Force, issued a caution after the parties.

鈥淲e let our guard down or act like the virus is gone,鈥� Garza said May 26, 鈥渋t will continue to improve the odds of hitting our region again with a second wave and those really hard-fought investments that we鈥檝e made to suppress the curve will be wasted.鈥�

Case averages began to rise about two weeks after Memorial Day in Missouri and spiked again with the St. Louis region and Missouri hitting a peak in cases at the end of July.

A rise in rural areas

This summer, the pandemic hit rural Missouri and Illinois.

At the end of May, Missouri counties outside of the Kansas City and St. Louis metro areas were reporting a combined average of well under 100 cases a day, according to and sociologist Chris Prener. That number was up to more than 825 daily cases by Sept. 6, with particularly high counts in areas around Joplin and the state鈥檚 Bootheel this summer.

The trend is likely to continue. Cases outside of the state鈥檚 two largest metro areas are on an upward trend, as case counts around St Louis and Kansas City have been falling since the end of July.

Similar patterns were seen throughout the country this summer, following trends from earlier pandemics, Lisa Sattenspiel, an anthropology professor at the University of Missouri, told the Post-Dispatch in June when rural cases began to surge.

鈥淭here were several counties in Missouri where the impact of the disease was actually much greater in 1920 than it was in 1918 or 1919,鈥� said Sattenspiel, whose research focuses on infectious disease. 鈥淚t took a while for the flu to actually get into these communities, and when it did, it ran its course.鈥�

Illinois has seen the worst of the virus shift from Chicago to Southern Illinois, including the Metro East suburbs of St. Louis.

The rate of positive tests grew so high there that in August state health officials reimposed limits on bars and restaurant service. Indoor public dining is prohibited until numbers improve.

Gov. Mike Parson has resisted a statewide approach for Missouri, leaving local governments to grapple with their response.

Lacking a statewide mask mandate, for example, places including St. Louis, St. Louis County, Kansas City, Columbia, Joplin and Branson all imposed local mask requirements this summer.

Counties in other hard-hit areas like St. Charles County have not. And to the south, in Jefferson County, the health board approved a mask mandate Aug. 27 despite ongoing protests over the issue, only to revoke that move a day later amid complaints about a lack of public notice.

Death rates

The rate of deaths caused by the virus has not yet matched the spring.

The fatality rate in Missouri fell from 7% in April and May to less than 1% in August, according to the Missouri Department of Health and Senior Services.

While a higher percentage of known COVID-19 patients are surviving, the average number of daily deaths has been rising for several weeks.

The 7-day average for daily deaths returned to near-peak levels this weekend, but the spike was caused by a backlog of more than 80 deaths that were previously unreported due to data errors, according to the state health department.

In Illinois, deaths remain down considerably. The state had a 7-day average of about 22 deaths Monday, compared with a mid-May peak of about 117.

Garza, of the St. Louis Metropolitan Pandemic Task Force, has said that improved treatments, plus a rise in younger patients and fewer cases from nursing homes helped to bring the rate down.

Nationally, though, health experts are looking to fall with a warning that viruses tend to spread more easily in cooler weather.

鈥淢y feeling is that there is a wave coming,鈥� Eili Klein, an epidemiologist at Johns Hopkins University School of Medicine 鈥淎nd it鈥檚 not so much whether it鈥檚 coming but how big is it going to be.鈥�