Five years since the pandemic began, COVID may now be endemic, experts say

Five years after the pandemic began, COVID-19 is now more consistent with an endemic disease, U.S. health experts said.

It has become similar to influenza — an endemic disease — in terms of the risk of severe illness, hospitalization and death, experts said. The coronavirus, which causes COVID, is now less deadly, though it is more transmissible and is expected to continue experiencing waves, some of which could be severe, they said. The coronavirus has evolved through four variants.

“This pandemic did what pandemics usually do — settle into endemicity, which means constant vigilance on our part,” requiring ongoing vaccination and therapeutics to keep the virus under control and reduce the severity of symptoms, said Monica Gandhi, an infectious-disease expert at the University of California at San Francisco.

While health authorities have not declared an end to the pandemic phase in the United States, President Joe Biden did so, in effect, by signing a resolution in 2023 ending the coronavirus national emergency, experts said.

Formal declarations marking the end of pandemics are unusual, and there is no clear threshold for when a disease transitions from pandemic to endemic, but the endemicity of COVID is largely agreed upon in the medical community, said William Schaffner, a professor of infectious diseases and preventive medicine at Vanderbilt University.

“It’s ingrained into our way of life,” he said.

‘Recovery and maintenance’

The end of the public health emergency declaration “reflected a shift away from the emergency response phase to the recovery and maintenance phases,” Paul Prince, a spokesman for the Centers for Disease Control and Prevention, said in an emailed statement. “While COVID-19 infections remain common, individual infections are less likely to result in severe illness for most people in the United States than was the case in 2020.”

But the number of coronavirus cases still is high compared with all other viruses except flu, said William Hanage, an epidemiologist at the Harvard T.H. Chan School of Public Health.

Influenza is surging across the country, leading to at least 520,000 hospitalizations and 22,000 deaths so far this flu season, which started in late September, the CDC said.

“The only infectious disease that the United States accepts more than 10,000 deaths a year from is influenza — or at least it was, until now,” he said. “We’ve still got considerably more than that with COVID.”

This season, the overall rate of COVID-related hospitalizations was about 55 per 100,000 people, compared with the 2020-2021 season, which saw a rate of 520 per 100,000 people. Deaths from COVID have also dropped to 47,000 in 2024 from 367,000 in 2020.

The de-escalation is, in part, from acquired immunity both from natural infection and vaccination, the evolution of the virus to less deadly variants and that many of the most vulnerable patients have already died, experts said.

The data may be skewed because data collection and reporting mandates were relaxed with the end of the national emergency.

What has remained consistent is that older adults, those with certain risk factors including immune system deficiencies and unvaccinated people are at greater risk of severe illness and death.

So far this season, the COVID hospitalization rate was more than nine times greater for those older than 65 compared with those younger than 65. In February, 90 percent of deaths from COVID were among those older than 65. Roughly a quarter of adults over 65 have received the latest booster vaccine as of the end of 2024.

“It’s desperately unfortunate that we’ve gotten to this point where so many people who could have been protected are not,” Hanage said.

Aside from the initial illness, roughly 5.3 percent of U.S. adults, or 14 million people, were living with long COVID late last year, according to Census estimates. The often disabling condition is characterized by fatigue, brain fog and other symptoms.

Vaccine remains a defense

For years, research has shown that the coronavirus vaccine is effective at preventing severe illness, hospitalization and death.

While more than 80 percent of adults in the United States have had at least one vaccine dose, only 23 percent have gotten a booster this COVID season, the data show.

“I think the problem is some people will be lulled into the idea that this virus is going to burn out,” said Eric Topol, a professor of molecular medicine at Scripps Research. “I don’t think that’s true at all.”

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Federal health authorities said boosters are most important for people older than 65, have certain medical conditions such as cardiovascular disease, diabetes and weakened immune systems, or have never been vaccinated against the virus.

“We know that immunity is not long-lasting,” Topol said. “The virus continues to evolve and find new ways to challenge our immune system.”

Additionally, many people with weakened immune systems — whether because of age or illness — may not have the same durability of protection. “When you set that against the fact that the virus is continuing to evolve, they are more likely to get infected and more likely to be severely ill,” Hanage said.

In general, if coronavirus vaccination rates were comparable to flu vaccine rates, which is about 46 percent for adults as of March 1, health experts said they would expect to see a dramatic decrease in COVID-related mortality.

If the coronavirus continues to devolve, there may come a time when boosters may not be needed annually, but the frequency needed is not clear, said Rob Murphy, an infectious-disease expert at Northwestern University.

While COVID-related hospitalizations and deaths are down, surveillance will remain an important tool to keep the coronavirus under control, experts said. Scientists lean heavily on surveillance, mainly wastewater and genomics — sequencing the genomes of the virus — to identify future variants and predict the immune system response to it. But, experts said, genomic surveillance has fallen away as reporting mandates have been reduced.

“We’re seeing a general, historical turning away from infectious diseases right now,” Hanage said. “If you stop monitoring what’s going on in the wild, you increase the chance that something unexpectedly comes along and bites you.”