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Here's What Could Lie Ahead For The US In The Third Year Of The Pandemic

(CNN) -- Things seem to be looking up as the US crosses into year three of the Covid-19 pandemic. Vaccines still do a good job of keeping people alive and out of the hospital. There's increasing access to tests and treatments. The numbers of cases, hospitalizations and deaths are heading in the right direction.

If living in a Covid world has taught us anything, however, it's that the coronavirus can surprise even the smartest public health experts, and the world certainly isn't out of the woods yet.

A new variant could easily develop and slip past the protection of current treatments and vaccines, setting us back to what life was like in 2020. That makes it hard to predict what happens next week, let alone in a few months.

However, based on what they're seeing now, here's what the experts think could happen in the next year of the pandemic. Each of these predictions has an unspoken "variant depending" at the end.

What will spring and summer be like?

The numbers in the US look good. Only 2% of the US population -- that's about 7 million people -- lives in a county with a "high" Covid-19 community level, according to data from the US Centers for Disease Control and Prevention. The rest are at "low" or "medium" community levels, areas where there's no recommendation to wear a mask or where the immunocompromised should take extra precautions.

In fact, over the next four weeks, the CDC forecasts decreases in hospitalizations and deaths. The trend could continue, particularly as the weather improves and people head outside, where it's less likely that they'll catch Covid.

These positive trends could mean the US will see a normal or at least near-normal spring and summer (variant depending, of course).

"I am very optimistic," said Dr. William Lang, WorldClinic medical director and former White House deputy physician. "I'm optimistic for what things look like for everybody being able to get back to normal activities over the summer."

But normal doesn't mean a return to pre-2020 life. "Fewer" cases still mean tens of thousands of Americans are getting infected. And as of Friday, even with deaths at the lowest level in three months, there are an average of about 1,200 Americans dying from Covid-19 each day, according to Johns Hopkins University.

"Everyone has to recognize, relatively speaking, we're still very early in this, right? This is not going away," said Dr. Abraar Karan, an infectious disease fellow in the Division of Infectious Diseases and Geographic Medicine at Stanford University.

If the pandemic moves into more of an endemic phase, meaning enough people have immune protection through natural infection and vaccination, it doesn't mean you can burn your masks. Rather, it means the spread of Covid will slow and result in fewer deaths and hospitalizations. But this state of endemicity is not guaranteed.

One metric to watch is a rising trend in cases and hospitalizations in the UK. Karan thinks that is mainly happening because of waning immunity, and the US could see similar trends.

"With the combination of our immunity waning and the virus mutating, future surges are unpredictable," Karan said.

What about autumn and winter?

With the unpredictability of the coronavirus, it's hard to know what will happen in the fall and winter, said David Montefiori, a virologist at Duke University Medical Center.

READ: You asked, we're answering: Your top questions about Covid-19

"This virus has thrown us some real curveballs," Montefiori said. Some experts say the coronavirus could eventually become seasonal like flu, but he doesn't think it's there yet.

"Thinking of this as a seasonal virus like flu, that hasn't been the case so far. The variants seem to be periodic," Montefiori said. "Roughly every four to six months, we have a new variant."

He is optimistic, though, because Americans have so much immunity built up through vaccination, infection or a combination of the two.

"We might have another surge later this year, even early summer, but if there isn't one, that's saying the immunity we've built up as a population is doing a good job."

The concern, of course, is that a variant emerges that escapes the vaccines. "The good news is that vaccines can be quickly modified," Montefiori said.

With more access to tests and treatments now, many experts believe that the US is better prepared for a fall or winter surge than it was last year. Some say Covid-19 cases could climb for a while when colder weather sends people back inside and as they become more complacent about taking precautions.

"Ultimately, the virus is going to have a tough time in our population, but it's going to take a long time," said Dr. John Swartzberg, a clinical professor emeritus at UC Berkeley's School of Public Health. "I think the real long view is, endemicity is going to be the case. Eradication is not possible."

Much depends on how quickly the planet can get vaccinated, Swartzberg said. The more people are vaccinated, the fewer there are to serve as hosts where the virus can mutate and produce -- you guessed it -- variants.

Less than 10% of people in low-income countries are vaccinated, according to the International Rescue Committee. The US and other countries have pledged to send more vaccines overseas this year.

What's next for vaccines for adults?

You may be need a fourth shot of the Covid-19 vaccine this year. The CDC already recommends that those who have weakened immune systems get one. Public health officials in the US have said they are very carefully monitoring if, or when, a fourth dose may be needed for the broader population, with a potential fall timeline in mind.

The vaccines still seem to protect against hospitalization and death, particularly if you are boosted, but protection could wane over time and is a little less effective against the Omicron variant. The currently authorized boosters are made to protect against the original coronavirus from late 2019.

The next vaccines could be specifically tuned to the variant -- or variants -- that are in circulation, Moderna Chief Medical Officer Dr. Paul Burton said Wednesday. Or they could be a combination shot.

Moderna and Pfizer have confirmed that they are testing vaccines that focus on Omicron.

Pfizer CEO Albert Bourla said his company will soon submit data on another vaccine dose for federal health officials to consider.

"I think our data suggests that they're protecting, they are improving dramatically the protection, the fourth dose compared to the third, for Omicron after some time, after let's say three to six months," Bourla said in a Washington Post Live discussion on Thursday.

Globally, there are 234 other Covid-19 vaccines in development. Perhaps furthest along in the process is the one from Novavax. It is in the middle of the regulatory process with the FDA and could be authorized this year.

What's next for vaccines for kids?

Pfizer and Moderna are expected to report results from their trials involving children under the age of 5 in the next few weeks.

Pfizer is also working on trials of a third vaccine dose for children ages 5 to 11. Children 12 and older can already get a third shot, as can kids 5 and older who are immunocompromised.

For the littlest kids, scientists think a vaccine may not be authorized until April. Pfizer originally said it thought it could have one out earlier this year, but it added a third dose of the vaccine to its trials to see if it is more effective.

The vaccines can't come soon enough for some parents. During the Omicron surge, the largest increase in hospitalization rates was among kids ages 4 and under, according to the CDC.

But many more kids for whom vaccines are now authorized still need to get them. They are the age group with the lowest vaccination rate in the US.

"There still hasn't been nearly as much uptake as vaccines as we would want," said Dr. Shira Gertz, a pediatric critical care physician and researcher at Cooperman Barnabas Medical Center in New Jersey. "Getting a vaccine is so much better than getting the disease."

The politics of it might be tricky, but schools could require that kids get vaccinated against Covid-19 before they return to class in the fall, like they do with other diseases. Only a handful of schools currently do, like those in Los Angeles, the District of Columbia and New Orleans, according to the Center on Reinventing Public Education.

What's next for treatments and tests?

There are 23 antivirals and 63 other treatments in late-stage clinical trials, according to Bio, a pharmacy industry association.

Although Pfizer's Covid-19 vaccine is authorized for people as young as 5, treatments for children remain limited. It's begun a Phase 2 and 3 clinical trial of its Covid-19 antiviral treatment, Paxlovid, in children ages 6 to 17.

For treatments to work effectively, people have to get them quickly. The Biden administration's new test-to-treat program allows pharmacies with clinics to test someone for Covid-19 and immediately prescribe medication if they test positive. That program will play an even more vital role if cases surge again.

What's next for masks?

Hawaii is the last state in the country to end its indoor mask mandate. That ends March 25.

On Thursday, the federal requirement that people wear masks on public transportation, including planes, was extended for another 30 days.

People may be sick of them, and masks have become a hot political subject, but broader mask mandates could always come back if case numbers rise and hospitals fill up.

Masking is hugely effective. Research from January 2021 that analyzed several studies of mask use in adults found that masks reduced the transmission of the virus significantly. And a National Institutes of Health study published Thursday found that during the Delta surge, schools with mandatory masking had 72% fewer cases of in-school transmission than those with mask-optional policies.

"I think readers need to remember that even if we say 'this is what we're doing now,' we reserve the right to change stuff as needed," said Dr. Sharon Nachman, chief of the Division of Pediatric Infectious Diseases at Stony Brook University in New York. Americans need to be flexible and adjust to the threat around them, she said.

What about money for all these mitigation measures?

Money to pay for the tests and treatments and vaccine research won't last forever, and more funding is not in the latest federal spending bill. The $15.6 billion earmarked for pandemic preparedness got stripped out. That was only half of what the Biden administration had asked for.

The spending bill raises the CDC budget by $582 million, but it leaves out the pandemic waivers that gave schools extra federal funds to cope with Covid-19 outbreaks.

The money that has bolstered many rural "safety net" hospitals expires soon. Safety net hospitals are those that, by legal obligation or mission, provide health care regardless of someone's ability to pay or insurance status. So more rural hospitals could close this year, and the US has already lost a record number of them during the pandemic.

It's a tenuous time. Dr. Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officials, said supplies of therapeutics, testing and vaccines are finally at a level where they meet demand.

"If there's issues with funding and any of those areas of progress start to fall off, we're going to be right back to the situation where we're playing catch-up and don't have enough," he said.

On Wednesday, House Appropriations Committee Chairwoman Rosa DeLauro, D-Connecticut, introduced a standalone Covid supplemental bill to manage the pandemic at home and around the world, but it's unlikely to pass.

What about the long-term consequences of Covid?

Scientists continue to study people with long Covid to try to understand the condition's symptoms and treatments. As many as 30% who've tested positive for the virus may have long-term symptoms like fatigue, breathing trouble, joint and chest pain, and heart problems, studies show.

Mental health has been an ongoing challenge for adults and kids during the pandemic. Four in 10 adults reported symptoms of anxiety or depression during the pandemic, up from 1 in 10 before the pandemic. In communities of color, mental health issues are disproportionately undertreated. For kids, the Biden administration's national mental health strategy, announced this month, will try to address some provider and program shortages to address their needs.

More than 206,800 children in the US have lost their primary caregiver to Covid, and advocates are also pushing for programs to address their needs.

Will this ever be over?

People need to be flexible and not let down their guard too soon, the experts say.

"When places relax measures at the wrong moment, transmission spikes dangerously, and we lose more lives," Pan American Health Organization Director Dr. Carissa F. Etienne said Wednesday, urging countries to base decisions on risk assessments and health data and to tighten public health guidance if cases start to rise.

The bottom line, Lang said: Covid is here to stay, but the pandemic part could be in our rearview mirror -- or at least move into a more manageable stage -- if people get vaccinated and boosted.

"The Covid vaccine is much more effective in preventing deaths than the flu vaccine in preventing deaths," he said. "So, you know, we really can combat this thing by people getting vaccinated and boosted."

Gertz also recommends that people pay attention to the numbers around them.

"We have to continue to be diligent and aware of what's going on in our immediate surroundings," she said. That doesn't mean people will be in masks forever, but they should wear them when necessary, and take prevention measures like washing their hands. "Actually, we should always wash our hands."

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