COVID 4 years later: Deaths down, restrictions eased for weary public, but risks remain 

Within a few weeks of the March 11, 2020, declaration of COVID-19 as a pandemic, hundreds of New Yorkers were dying of the disease every day, and Long Island and New York City hospitals that were overflowing with patients put refrigerated trailers in parking lots to store the bodies of the dead.

Schools and many stores were closed, in-person dining was banned, nonessential workers worked from home — and fear was rampant of a deadly virus whose trajectory was unknown.

COVID-19 still causes severe symptoms and death, and experts don't know how many of the millions of Americans with long COVID will continue to endure the sometimes debilitating long-term effects of the virus.

But today COVID-19 has largely receded into the background. Deaths and hospitalizations have fallen sharply. Mask-wearing is uncommon. Uptake of the updated vaccine is low.

In a sign of the decreased threat from the virus that causes COVID-19, the Centers for Disease Control and Prevention this month ended its recommendation that those who test positive for COVID-19 isolate for at least five days. The new guidelines say people with COVID-19 can end isolation if they’ve been fever-free for at least 24 hours without medication and their symptoms are improving. Masks and other precautions are recommended for the following five days.

The agency said the new guidelines also apply to the flu and RSV [respiratory syncytial virus] — illustrating how, as the CDC states, “its health impacts increasingly resemble those of other respiratory viral illnesses.”

Dr. Jessica Justman, a professor of medicine and epidemiology at the Columbia University Mailman School of Public Health, said COVID-19 remains potentially dangerous for medically vulnerable people, especially older adults. But, she said, the mandatory restrictions and intense adherence to precautions couldn’t last forever.

“If four years into this we were all still living in a state of high-level red alert, I don’t think we could do it,” said Justman, senior technical director of Columbia’s global health program ICAP, which addresses COVID-19 and other diseases. “We had to get to this point.”

The World Health Organization still defines COVID-19 as a pandemic, but in May 2023 it said the pandemic was no longer a “global emergency.” The same month, the federal government declared COVID-19 was no longer a national public health emergency.

Nearly 1.2 million Americans and 10,800 Long Islanders have died of COVID-19-related causes, according to death certificates analyzed by the Centers for Disease Control and Prevention.

But 80% of the Long Island deaths were in 2020 and 2021, and the death toll fell from 1,675 in 2022 to 476 in 2023. The 2023 figure is still provisional.

“It’s really only the sickest, the oldest and the most immunocompromised patients we need to worry about right now,” said Dr. Gita Lisker, director of the respiratory care unit at Long Island Jewish Medical Center in New Hyde Park.

COVID deaths compared to flu 

The number of COVID-19 fatalities currently is in the upper range of annual flu deaths. There were nearly 50,000 COVID-19 deaths nationwide in 2023, according to provisional CDC data. That compares with an estimated 4,900 to 51,000 annual flu deaths between 2010 and 2023, not including the minimal number of deaths in the 2020-21 flu season, amid COVID-19 restrictions.

Hospitalization rates for COVID-19 are still higher than for the flu — 97 per 100,000 people versus 52 per 100,000.

But COVID-19 hospitalizations have fallen precipitously. The peak day for COVID-19 hospitalizations on Long Island was April 10, 2020, when there were 4,108 patients. The peak day last year, Jan. 3, 2023, was 912, and the peak day this year was 661 on Jan. 3.

Justman said the biggest reason for the huge drop in deaths and severe disease is that the body’s immune system can more effectively fight the virus because of vaccines and previous infections.

That has led to a more relaxed attitude from the public, which sees the virus as less cause for concern and is less likely to receive updated vaccines or take precautions such as wearing masks, she said.

Justman said vaccinations can help anyone — including young, healthy people — have a milder case of COVID-19. But, she said, the focus of vaccination efforts should be on the most vulnerable, including older adults and people who are immunocompromised.

Some existing medical conditions can make severe disease more likely, but “I think of these as layers,” with the risk increasing with age and the number of conditions, she said. A young person with diabetes or obesity who is otherwise healthy is at significantly less risk than an older adult with medical conditions, she said.

New reality

But as the public’s interest in COVID-19 has waned, the challenges in getting even high-risk people to treat the disease seriously have increased, said Dr. Joshua Sharfstein, a public health professor at the Johns Hopkins Bloomberg School of Public Health in Baltimore.

“I think there's just an enormous desire after such a turbulent period to go back to normal,” he said. “The challenge is to adapt to the new reality by protecting yourself. … We need more people who are at risk taking the vaccine and getting treatment quickly if they get sick.”

Early in the pandemic, there were no treatments or vaccines. Paxlovid, which if taken shortly after symptoms emerge can significantly reduce the risk of severe disease in high-risk people, was authorized for use in December 2021.

The first vaccines were administered in December 2020.

Sharfstein said one reason vaccine uptake isn’t higher is that much of what the public hears about vaccines is false.

“They may hear from their doctor that it's a good idea to get vaccinated, and then by the end of the week, they’ve heard 50 more conspiracy theories from other people or other sources,” Sharfstein said.

Perry Halkitis, dean of the Rutgers School of Public Health in New Jersey and a public health psychologist, said decisions on vaccination often are based on emotion or politics.

“When the vaccine came out, people were like ‘Oh, everybody is going to be vaccinated,’ and I was like ‘No! Human beings are human beings and they never do what is in their best interest. They do things that they believe or makes them feel good,’” he said.

Democrats are far more likely than Republicans to have received the initial vaccines, as well as the updated ones, according to a survey conducted last fall by the San Francisco-based health policy nonprofit KFF. Older adults, college graduates and people with high incomes also are significantly more likely to be vaccinated.

Long COVID science 'still unclear'

Growing evidence indicates that vaccines reduce the risk of long COVID, which are lingering effects of the virus weeks, months or years after infection.

The most common symptoms include fatigue, dizziness, brain fog and gastrointestinal problems, research shows.

The long-term impact of long COVID is uncertain, experts said.

“There are more and more people with reinfections, and we really do not know what that means,” said Sean Clouston, an epidemiologist and professor of public health at Stony Brook University. “The science is still unclear as to what exactly the future holds. What happens 10 or 15 years from now when you’ve been reinfected four times?”

Amid the uncertainty, the number of people with long COVID appears to be falling. A study by CDC researchers found that the prevalence of long COVID among adults reporting a previous COVID-19 infection fell from 18.9% in June 2022 to 11% in June 2023 — although the decline turned into a plateau in January 2023. Reasons for the decline could include less severe infections, vaccinations and treatments, researchers said. More than a quarter of adults with long COVID said they had “significant activity limitations,” a number that did not change during the study period, the CDC said.

Long COVID is one of many unknowns of COVID-19’s impact. It’s unclear how long immunity from vaccinations and infection will last, and whether the virus will one day change enough to become more dangerous, Justman said.

“Nobody knows how it’s going to evolve,” she said. “I can’t predict at all if it will suddenly pop up with some type of mutation that completely evades the various antibody and T-cell-mediated immunity that many of us now have.”

It’s also impossible to predict when the next pandemic will emerge, said Dr. William Schaffner, a professor of infectious diseases at the Vanderbilt University School of Medicine in Nashville.

Lessons to be learned on politics, masks 

Schaffner hoped lessons can be learned from the mistakes made during COVID-19. But, he said, a major challenge for the next pandemic is the “terrific lack of trust in leaders — in political leaders and public health leaders, and in public health advice.”

With COVID-19, political leaders at the state and national level often did not back up public health officials on matters such as mask-wearing, he said. The vaccines were “brilliantly developed under aegis of the [Trump] administration in charge at the time,” but were then not promoted well, said Schaffner, pointing to how President Donald Trump received his vaccines quietly, without publicity. His immunization was not disclosed until after he left office.

One reason the 2009-10 swine flu outbreak — which the CDC said killed more than 12,400 people — was not worse was that public health officials and political leaders were on the same page, and the outbreak was not politicized, with news conferences taking place at CDC headquarters in Atlanta, not in political settings in Washington, Schaffner said. Officials also acknowledged there was a lot about the flu outbreak that was unknown, and that new information would emerge and recommendations would change, he said.

The CDC lost trust during COVID-19 by not communicating clearly and frankly, Schaffner said.

Early recommendations that widespread use of masks was unnecessary was based in part on an effort to conserve masks for health care workers, and because the SARS and MERS outbreaks earlier this century involved coronaviruses that were transmitted less easily than, it was determined later, COVID-19, he said.

Yet even as data from China showed that COVID-19 was being spread widely throughout communities, and not just through close contact with people who had active symptoms, as with SARS and MERS, the CDC was slow to change its recommendations, he said. And when masking was recommended, in part because of a changing understanding of the virus, and in part because more masks were available, there was not a clear explanation why the advice changed, he said.

“That colored the acceptance, or nonacceptance, the skepticism, of subsequent public health recommendations,” he said. “You’ve got to be straight with the people.”

Halkitis said that for the next pandemic, there needs to be more focus on people's behavior, instead of the pathogen.

“If we continue to focus on the virus, vaccinations and mitigation strategies that prevent the spread of the disease and not focus on why people are not taking the vaccine, why people are not wearing masks, why people continue to disbelieve that this is a real problem, … we'll make no progress when it comes to the next pandemic,” he said.

Amid the mistakes and disappointments have been real achievements, Schaffner said.

COVID-19 showed that sharing research into how the virus spread and which interventions work, as well as other information, can lead to major — and faster — advances in understanding a pandemic, he said.

In addition, there was a “brilliant and rapid development of the vaccines and therapies for COVID,” and of tests for the virus, including tests that nonprofessionals could easily do at home.

“As a consequence of all of those things,” he said, “literally millions of lives have been saved around the world, and disease prevented.”