On Thursday evening, the national death toll from COVID-19 passed 123,195 on its way to the total late Saturday afternoon of 125,434.

The number might seem unremarkable except for one thing — it equals the number of people living in Columbia.

In been barely four months, the contagion has killed enough people to fill a bustling Midwest college city. Until recently, it seemed, the nation had the coronavirus corralled, with cases averaging about 21,000 a day for much of May and early June, down from an early April peak of nearly 31,000 cases per day.

But in the past two weeks, that has changed. The average number of new cases per day is at a new peak of 36,000, and, as cases increased nationally, Missouri and Boone County have followed along.

After setting a peak for new cases per day in the week ending June 20, last week Missouri was 50 percent higher, at 381.6 per day. In Boone County, the count has gone from from 7.8 cases per day in the week ending June 20 to 10.8 per day last week.

A significant testing effort has been underway in Columbia since early in the pandemic, with drive-through testing locations at both major hospitals. The hospitals alone have conducted 26,360 tests, with 462 positive results.

The biggest concern in the recent increase in cases is the share of tests that are positive, going locally from less than 1 percent in early May to above 8 percent last week.

That means there is community transmission and people need to take the steps necessary to protect themselves, said Scott Clardy, assistant director of the Columbia Boone-County Department of Public Health and Human Services, in a Friday interview.

In that interview, he said the department views the rising numbers with increasing alarm.

"Cases are going up, yes, but we can still do something about it but it is going to take an effort on everybody’s part," Clardy said.

While there has been incredible suffering elsewhere in the nation, Missouri has largely been spared the worst of the pandemic like overflow makeshift hospitals, refrigerator trucks converted to morgues and mass graves that became necessary emergency measures elsewhere.

The Missouri National Guard scoped out the Hearnes Center and Mizzou Arena in late March as possible overflow hospitals. The most total cases have been in the St. Louis and Kansas City metro areas.

Of the state’s 996 deaths, 715 were in St. Louis and St. Louis County.

The biggest question raised by the recent increase in new cases is whether Missouri can now expect to endure what East Coast states suffered and, according to state Health Director Randall Williams, Illinois continues to suffer.

"The answer is we peaked on April 7 here in Missouri," Williams said. "States like Illinois and other states have not reached their peaks yet."

On April 7, Missouri recorded 315 new cases and had reported 3,037 total. Tests performed that day had a positive rate of 10.4 percent. The recent positive rate on tests averaged about 4 percent for the seven days ending Tuesday, the latest date data is available.

The death rate among known cases both in Missouri and the nation is about 5 percent of the people who test positive.

But Missouri has a low infection rate, which means that while the state has about 1.7 percent of the national population, it has had only about 0.8 percent of the nation’s deaths.

Illinois is ninth in the nation for rates of infection and deaths. Missouri’s infection rate is less than half the national average and deaths in the state are less than one-third the rate experienced in Illinois.

The recent high numbers of positive tests include hundreds of people who are asymptomatic, Williams noted.

"I would much rather have 350 test positive who are asymptomatic than have 350 people in nursing homes test positive who are symptomatic," Williams said.

In Boone County, the experience has been even better. The infection rate has been half that of the state and, with only two deaths, far fewer than would be expected.

A combination of things have helped the county through the pandemic with few deaths, Clardy said.

"Boone County was not the first area of the state or the country to be impacted, so we were able to get a little bit ahead of things and do more preparation," he said.

Quick action to shut down the University of Missouri, public schools and, on March 25, the local stay-at-home order, halted the early spread of the virus, he said.

The availability of health care, with better facilities than most of the surrounding regions, has also played a big role in helping patients recover, Clardy said.

"The last thing I would say is that particularly in Missouri, if you look at some of these areas that have had higher death rates, they have had pretty bad outbreaks in nursing homes or long-term care facilities," he said. "We have had some outbreaks in nursing home facilities but the outcomes of those have not been disastrous."

The homes have taken quick action to isolate cases and prevent spread of infection, he said.

"The nursing homes have done an awesome job of getting that contained," Clardy said.

Williams said he watches positive test rates, hospitalizations and the kinds of positive cases being reported.

The state’s lone daily data point on hospitals still being reported is total hospitalizations, without data on ventilator use or ICU availability. On Saturday, that number, which is delayed 72 hours, was 680, up 153 from the day before. That is still well below the peak of hospital use in late April.

With hundreds of asymptomatic cases showing up in community or outbreak testing, the state must estimate how many will get sick and, of that number, how many will need hospital care.

"If you follow those people out for 10 days, about half of them who get the virus — understanding now, that's not hard science, that's more anecdotal — about half will in fact become symptomatic," Williams said.

Of those who have symptoms, about 80 percent do not require hospital care, he said.

That would translate to about 10 hospital cases for every 100 asymptomatic people.

The bigger question, Williams said, is how many people who are asymptomatic can spread the disease and when in the cycle of infection does that happen.

"We know you are most infectious when you are coughing and symptomatic and shedding virus," he said. "But we want to know how many asymptomatic people are infectious. And we don't know the answer to that yet."