After weeks with just a few new COVID-19 cases, central Missouri counties are seeing new infections that may be a blip or the first indications of a new wave of illness.

Four new cases of COVID-19 in Audrain County were traced to hog farms in Thompson and Paris Monday by the Audrain County Health Department. The four new cases triple the number of known infections in the county and represent the first new positive tests since May 9.

The farms are not considered Concentrated Animal Feeding Operations, or CAFOs, health department administrator Sandra Hewlett said.

Boone County reported another new case Monday, bringing the total to five in two days.

“We currently have two community transmissions, two travel-related and one unknown,” spokesman Lucio Bitoy wrote in an email from the Columbia-Boone County Department of Public Health and Human Services.

“We are keeping a close eye on our case counts and also how each case contracts the illness,” Bitoy stated. “Monitoring these items over the coming days will shed light as to the current trend. We will certainly want to continue to monitor these numbers as we progress in reopening, and we of course will adjust plans if this disease progresses differently than anticipated in mid-Missouri.”

Since the first case was found in Boone County in mid-March, there have been 105 known COVID-19 cases and one death. Of that number, nine cases are considered active. Ninety-five are recovered.

There were three COVID-19 inpatients at University of Missouri Health Care and 21 inpatient cases under investigation on Monday. There are two positive inpatients at Boone Hospital Center.

Statewide, there were 156 new infections reported Monday, bringing the total since early March to 10,945. The state reported 11 additional deaths, bringing the total to 605.

Even a small, unexpected increase needs investigation, Randall Williams, director of the Department of Health and Senior Services, said during a Monday briefing with Gov. Mike Parson.

“That is the kind of thing that we want to stay vigilant about,” Williams said when asked about the Boone County cases. “There is a difference to us between four patients who didn't know each other who got positive versus four patients at one facility.”

One area that will have an aggressive testing push is nursing homes, Williams said. Any time a patient or staff member tests positive at a nursing home, he said, the state will test every patient and every staff member.

At a Columbia nursing home where a staff member tested positive, that full-facility testing will take place Wednesday.

The Neighborhoods by TigerPlace, operated Americare, was notified May 9 that an employee had tested positive. All patients have been quarantined in their rooms and no additional employees or patients have shown signs or symptoms, Americare wrote in a news release.

The quarantine was scheduled to end Tuesday but will be extended until all test results are available, which is expected on Friday, the release stated.

Of 163 nursing homes that have had a patient or staff test positive for COVID-19, Parson said, 72 have not had an active case for 15 days and the state has already done comprehensive testing in 41 of the 91 that remain.

In Kirksville on Monday, the Adair County Health Department announced it was closing its doors to the public and would operate by appointment only.

“A week ago, we had only one active case of COVID-19 and 12 recoveries. Within eight days, we’ve had 17 more confirmed cases,” Jim LeBaron, administrator of the Adair County Health Department, said in a news release.

The new infections are not just confined to people working at places like Smithfield Foods in Milan or Kraft Heinz in Kirksville, LeBaron said.

“Infected people are now spreading the virus to their friends, family and to the community at large,” LeBaron said. “We all shop for groceries at the same places, get gas at the same stations, eat at the same restaurants, and worship at the same churches. And now that people think it’s okay to get out again, they’re putting themselves and others at risk by not taking precautions recommended by the CDC to prevent the spread.”

There was a new infection reported Monday in Howard County, the first since April 13, and a new case in Cole County, the first in a week.

The state is doing other things to loosen testing criteria further to identify and contain new outbreaks, Williams said.

Testing is now available to anyone who is concerned that the symptoms they are experiencing are due to the coronavirus, Williams said.

“If you are a clinician and a patient wants to be tested, please test them,” Williams said.

Missouri has increased the number of tests it is conducting in each of the past four weeks. In mid-April, the state was averaging about 2,300 tests per day and last week, the average was nearly 4,400 tests per day.

Surrounding states have increased faster, however. Missouri was 41st nationally among the 50 states and the District of Columbia in per-capita testing, according to data available Monday afternoon.

Of the nine-state region of Missouri and adjacent states, only Kansas has a lower per-capita testing rate than Missouri. And of the 12 Midwestern states, only Ohio and Kansas have lower testing rates.

“The one thing we are going to continue to do, and I am going to push my directors, and everybody in the state of Missouri as much as I can, we are going to have to get better at testing,” Parson said. “It is going to be a priority of this administration and we are going to continue to push those numbers up.”

Other rural Missouri counties have faced considerable COVID-19 outbreaks. Saline County is considered a rural hotspot. It had 249 cases as of Monday afternoon.

Meat processing facilities in Missouri have either had to shut down or reduce output amid facility outbreaks, including in Saline and Moniteau counties. Triumph Foods in St. Joseph had nearly 500 employees test positive, many without symptoms.

While most of the state began reopening on May 4, in St. Louis city and county, that began Monday. Restaurants and most nonessential businesses began operating, but residents were urged to keep following safety guidelines to slow the spread of the coronavirus.

St. Louis County Executive Sam Page said the reopening of businesses should not be considered a victory because too many people have died and too many families are suffering because of the pandemic. Health officials say 336 people have died from COVID-19 in St. Louis County.

“So we cannot let this gradual and thoughtful reopening be looked at as a return to normal. It’s really far from it,” Page said.

Gyms in St. Louis County are still prohibited from opening because the risk of transmitting the coronavirus is too high. The county will continue to work with gyms on reopening plans, Page said.

A lawsuit filed by the county seeking to shut down two House of Pain gyms that reopened earlier this month in defiance of the county's order will be considered by a federal judge. A hearing on the dispute scheduled in county court Monday was postponed when the attorney for House of Pain said he was taking the case to federal court, The St. Louis Post-Dispatch reported.

Page said the next step in the reopening will depend largely on whether people adhere to restrictions, such as social distancing. He said the county will monitor hospital admissions and tests results, and will consult with hospital systems in determining future decisions on reopening.

Campgrounds and other high-traffic areas in the state’s park system also reopened Monday, although only for those with reservations. Campers will encounter a new cashless, self-check-in system and some areas will limit occupancy.

Beaches at state parks are scheduled to open Thursday.

While most universities and colleges in Missouri are still considering how and when to reopen, two smaller colleges said they plan to have on-campus classes in the fall.

Harris-Stowe State University, an historically black school in St. Louis, and Central Methodist University, a private school in Fayette, both announced they would implement new safety measures to ensure the safety of students, faculty and staff when they return to campus.

The Mexico Ledger, the Kirksville Daily Express and the Associated Press contributed to this report.