Jennifer Stephens wanted to wait.
She had heard from friends who got vaccinated: stories of seizures, of others becoming infected even after a shot. Then there was the short suspension of Johnson & Johnson’s one-dose vaccine in April to investigate the potential for blood clots.
The approved vaccines have all gone through multiple rounds of trials that have shown them to be safe and effective. Still, the 38-year-old thrift store worker hesitated. Until Thursday morning.
Stephens and her teenage son received their first doses at a walk-in clinic run by the local public health agency. The power of the variants changed her mind.
A woman Stephens works with at a church-run shelter is on a ventilator in the hospital, she said. And her son works at a funeral home where they believe some of the bodies of virus victims have been taken.
“It was more contagious and it was more dangerous,” she said. At least with a shot, if she does become infected, “it won’t be as bad.”
In the last month, Stephens’ community of Livingston County was one of two in northern Missouri leading the nation in COVID-19 infection rates.
At the outbreak’s peak in late May, 29% of tests were coming back positive in the 15,000-person county, with two virus variants identified in the county and six deaths. This month, three variants have been identified and two have died.
Rural Missouri is contending with surges in COVID cases that are afflicting counties with some of the lowest vaccination rates in the state, worrying health officials who are closely watching the spread of new forms of the virus, including the virulent Delta variant. The spikes are occurring as summer travel picks up and after most communities have dispensed with mask orders and other mandatory precautions.
Missouri now leads the nation in new cases per capita, according to calculations by The New York Times.
Positivity rates in Livingston are now on the decline, but the uptick has spread to Macon County next door. In southwest Missouri, cases are surging both in rural counties as well as the more urban Greene County, home of Springfield, where the rate of new infections has nearly tripled over the past month.
The outbreaks are a stark contrast to plummeting case rates in Kansas City, where a larger percentage of the population is vaccinated. This week, the metro area marked its lowest daily average for new cases in more than a year.
But in rural Missouri, health officials have hit a wall trying to drive up vaccination rates. Reluctance among residents is coming at the worst possible time, with some officials uncertain that previously infected individuals will contribute to local immunity in the face of new variants.
“You have some immunity to that particular strain,” Krista Nebluck, administrator of the Linn County Health Department, said of the original version of the virus that swept across the United States last year. “But you don’t have any immunity to other variants.”
“And that’s the fear, that we’re going to have these peaks and valleys, with variants that come through,” Nebluck said.
The rural outbreaks are driving additional hospitalizations, again straining the regional medical system. As cases rise across southwest Missouri, Springfield-based CoxHealth is treating more than 70 virus patients and again turning to traveling nurses to staff their facilities.
Cox CEO Steve Edwards said at current rates, the number of COVID in-patients in June will be comparable to what the hospital experienced in February, before the widespread availability of vaccines. Throughout the pandemic, about 75% of COVID patients admitted to the hospital have come from outside Greene County, he said.
Edwards did anticipate some kind of rise in the number of virus patients this summer as society opened up, but originally projected perhaps 25 in the hospital at any given time.
“This is more than double that,” Edwards said.
In Macon County, population 15,000 south of Kirksville, five people are hospitalized and “not doing well,” said Mike Chambers, the county health administrator. Two patients have died in the past month. Just 35% of adults are fully vaccinated, according to data compiled by The New York Times.
“We are seeing spillover” from Linn County, where many Macon County residents work, Chambers said.
Throughout the pandemic, the Midwest had been able to look to the coasts for a sense of what’s coming, Edwards said. Those roles are now reversing.
“I believe for the first time we’re sort of going to help people understand what the Delta variant means and how it will spread,” Edwards said.
The Missouri Department of Health and Senior Services on Wednesday acknowledged a rise in the Delta variant, which was first detected in India. Robert Knodell, the agency’s acting director, emphasized the importance of vaccination.
“Our greatest concern in Missouri is areas with lower vaccine uptake,” Knodell said.
Those areas aren’t difficult to find. Across much of southeast Missouri, rates of full vaccination for adults remain below 30%. In the southwest, none of the counties surrounding Springfield have vaccinated more than 40% of adults, according to The Times data.
Statewide, 46.5% of Missouri adults are fully vaccinated, the state health agency says. Overall, 37.2% of the population has been vaccinated.
Nationally, vaccination rates are generally lower in rural areas, according to an analysis by the Centers for Disease Control and Prevention of vaccinations between December and April. At the time, a nearly 7-point gap existed between urban and rural areas.
“The danger is that as a nation, I think, we’re done with the pandemic, but it’s just not the case in rural counties,” said Alex Morgan, CEO of the National Rural Health Association. “Because of the smaller numbers of a lot of these small towns, they just aren’t going to elevate to national attention.”
Kansas so far hasn’t experienced the rural flare-ups now threatening Missouri, though officials are watching closely for trouble signs. Gov. Laura Kelly told reporters this week she scrutinizes case numbers “to see where Kansas is and what, if anything, might be coming to get us again.”
Dana Hawkinson, medical director of infection prevention and control at the University of Kansas Health System, said earlier this month hot spots will continue appearing “depending really now on vaccine coverage.”
In rural Missouri, more than half a dozen health department administrators told The Star the same story: Vaccine demand was high when it first became available, especially among seniors. But as access widened and more people were eligible, fewer patients showed up.
Those who were encouraged to get vaccinated told nurses and administrators of concerns that ranged from fears of side effects to conspiracy theories.
“It’s political,” said Livingston County Health Center administrator Sherry Weldon. “That’s just the bottom line.”
Locals willing to try incentives
Missouri officials have embarked on a $5 million vaccine outreach campaign. The state also has received $55 million from the CDC for vaccination efforts, and is sending $20 million to local public health agencies.
Local authorities say they’re trying creative approaches to boosting interest.
In Shannon County in southern Missouri, administrator Kandra Counts was contacting a well-respected local physician, hoping he would sit down for an interview and ease residents’ fears.
In southwest Taney County, home of tourism destination Branson, administrator Lisa Marshall said the health department has shifted from vaccination events to a “strike team model,” sending nurses to any business or workplace that requests it to vaccinate staff.
“In the beginning we would ask for at least 20” people to want a vaccine for Marshall to send a team, she said. “At this moment we aren’t putting a size limit. If you’ve got a few people we’ll come out and vaccinate as many as we can.”
Some states are using monetary incentives to encourage vaccines, including lotteries. A 22-year-old engineer recently won $1 million in Ohio’s giveaway.
It’s an option Gov. Mike Parson didn’t seem to buy when asked about it on Tuesday.
“You really got to think through that, because what’s it going to be next year for something else?” he said. “We’ve got all options on the table, but it’s just going to take a little longer” for many more Missourians to accept a vaccine.
Local health administrators also said they did not know if an incentive would work. But Weldon said she would be willing to try it.
“We would like to see the state help in encouraging people,” she said. “Some people are totally against incentives, but some people need that little push to go ahead.”
Morgan said his organization is focused on touting the benefits of vaccinations to individual communities. He described centering the discussion on keeping local businesses and families safe.
“Movie stars and politicians, those just aren’t working,” Morgan said.
Rural health administrators said most residents, like Stephens, still want to “wait and see” others get vaccinated without problems before they get a shot.
But Stephens said after seeing the variants, she weighed the risks and wanted to move on from life in a pandemic.
To prevent spread of the virus at the funeral home where her son works, mourners aren’t allowed to come inside to sign the guestbook. And many businesses have signs directing un-vaccinated people to wear masks.
“It feels like you’re still in a bubble, and not moving on,” she said. “I say, don’t be fearful. Just get it, to keep others safe.”
The Star’s Katie Bernard contributed reporting