How does COVID-19 end in the US? Likely with a death rate Americans are willing to 'accept'

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SAN FRANCISCO – What does the end of COVID-19 in America look like?

Perhaps no end at all, but a resigned acceptance of a bearable level of death.

"We as a country are willing to tolerate a certain level of risk and still go about a normal level of life," said Dr. Aaron Carroll, a pediatrician and professor of pediatrics at Indiana University School of Medicine. "It's becoming clear that that's likely what we're going to have to do with COVID. We're going to have to learn to live with it." 

In a "good" flu season, nearly 100 Americans a day might die of influenza, Carroll said at an American Public Health Association panel recently.

That 100 deaths a day during flu season is what Americans tolerate, said Dr. Monica Gandhi, an infectious disease expert at the University of California, San Francisco.

"So it's probably what we'd accept for COVID," she said.

Video: What we learned from Fauci's early COVID emails

As of June 3, COVID-19 was killing an average of 363 Americans a day, according to the Centers for Disease Control and Prevention. That's down from more than 3,000 a day at the height of the pandemic in January, and with more vaccinations, the daily death toll continues to fall.

Experts note the SARS-CoV-2 virus that causes COVID-19 could be almost entirely controlled in the U.S. with near-universal vaccination, if Americans were willing. That's how smallpox was eradicated in 1980.

But the waning of the COVID-19 pandemic will be spotty. Look at the differences between San Francisco and Nashville.

In San Francisco County, no one has died of COVID-19 for nearly a month , according to the local health department. But In Davidson County, Tennessee, home to Nashville and 185,000 fewer people, eight have died in the past two weeks.

The difference is vaccination rates. In San Francisco, 78% of people over the age of 12 have had at least one shot. In Davidson County it's 47%.  

"We're sending vaccine that's been allocated to us back to the CDC," said Dr. William Schaffner, an infectious disease expert at Vanderbilt University in Nashville. "It makes our hearts cry."

Pandemic, epidemic, endemic

To an epidemiologist, a pandemic is the worldwide spread of a new disease. An epidemic is an unexpected increase of a disease in a given geographic area. A disease becomes endemic when it is always present but limited to a particular group or region.

Right now, COVID-19 is a pandemic globally, an epidemic in the United States and on the cusp of being endemic in highly vaccinated areas. 

Worldwide, the pandemic will end when the World Health Organization – which declared a global pandemic on March 11, 2020 – says it is over. That probably won't come for many months or even years, until enough people are vaccinated or protected from COVID-19 by having survived an infection. The virus is still rampaging through countries like India, Uganda and Colombia, with thousands dying every day.

The U.S. could see a reprieve by July 4th. That's when President Joe Biden hopes 70% of Americans will be at least partially vaccinated and infection rates will be low enough to declare the outbreak over in the United States – bringing it down to endemic levels.

At that point, there will effectively be two Americas: one vaccinated, the other not.

Last month, Gov. Jared Polis of Colorado said, “If you have been fully vaccinated, the pandemic is largely over for you."

For the unvaccinated, it won't be. If they get sick, "there's just as much chance of them getting severely ill or dying from COVID-19 as there is today," Schaffner said. 

In many regions, COVID-19 will fade into the background, while in others, it will continue to be a significant source of outbreaks, said Dr. Robert Wachter, chairman of the University of California at San Francisco's department of medicine.

The wild card is whether new variants emerge that aren't as well-controlled by current vaccines, requiring booster shots.

"Assuming there is no variant that comes out that is truly vaccine resistant, I'm going to expect mild surges, probably in the winter, in places with low vaccination rates," Wachter said. 

But as with much about the SARS-CoV-2 virus, that's not certain because it's so new. There's not yet enough data to answer many pressing questions, such as how long vaccines or natural immunity from previous infections lasts, said Ajay Sethi, a professor of population health at the University of Wisconsin-Madison school of medicine. 

Gandhi doesn't think variants will be a huge problem. As vaccination rates rise, there will be less circulating COVID-19 and fewer chances for it to evolve.

As long as COVID-19 rages in other countries, however, it will have the chance to keep mutating, no matter how low transmission rates become in the United States.

"COVID is a reminder that we should care about equity, but even if you don’t want to care about it, you need to care because we're so interconnected globally," said Anne Rimoin, a professor of epidemiology at the UCLA Fielding School of Public Health.

If the vaccines remain effective, boosters may never be required, or perhaps only every two or three or more years.

But that in itself could become a problem because people will forget how bad things could be and won't be motivated to be protected, Wachter said. 

"It's going to recede in people's memories and then when they're asked to take a booster, you can't presume they'll get the shot," he said.

In the end, only high levels of vaccination will truly allow the entire country to return to normal, said Dr. Walter Orenstein, associate director of the Emory Vaccine Center, former director of the immunization program at the CDC.

"This virus," he told public health officers, "will not eradicate itself."

This article originally appeared on USA TODAY: When will COVID-19 end in US? When deaths are at point people 'accept'

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