Millions of Americans gathered maskless in homes and houses of worship this month for Passover, Easter and Ramadan -- the latest evidence that coronavirus has retreated from public view as the pandemic winds down.
But retreat is not the same thing as eradication: Federal health officials say that covid remains one of the leading causes of death in the United States, tied to about 250 deaths daily, on average, mostly among the old and immunocompromised.
Few Americans are treating it as a leading killer, however -- in part because they are not hearing about those numbers, don't trust them or don't see them as relevant to their own lives.
"We're not presenting the data in a way that resonates with the American people," said Deborah Birx, who served as the first White House coronavirus coordinator under President Donald Trump, citing research that finds elevated risks of health complications and death in the months after a covid infection.
The actual toll exacted by the virus remains a subject of sharp debate. Since the earliest days of the pandemic, skeptics have argued that physicians and families had incentives to overcount virus deaths, and pointed to errors by the Centers for Disease Control and Prevention in how it has reported a wide array of covid data.
Those arguments were bolstered earlier this year by a Washington Post op-ed by Leana Wen that argued the nation's recent covid toll is inflated by including people dying with covid, as well as from covid -- for instance, gunshot victims who also test positive for the virus -- a conclusion echoed by critics of the pandemic response, and amplified on conservative networks.
"There's so much corruption here, and it's all driven by those numbers being artificially elevated," Rep. Ronny Jackson, R-Texas, a physician who formerly worked in the White House and now serves on the House panel probing the coronavirus response, said on Newsmax in January.
Health experts and federal officials reject such criticisms, saying they are confident in the CDC's data -- figures that are drawn from medical examiners and coroners completing death certificates and concluding that covid was the primary or contributing cause of death.
"If anything, [the death toll] could even be an undercount," said Debra Houry, the CDC's chief medical officer. For instance, Houry described a scenario where an elderly patient sickened by covid suffered a traumatic fall. "Maybe covid [testing] wasn't done on the autopsy, so that's something that's going to be missed."
Front-line physicians said that severe cases of covid have plummeted from the virus's peak in 2021, when the CDC said more than 3,000 people daily died of covid, but that infections remain a threat to vulnerable populations - and occasionally to otherwise healthy people.
"There are still people who are getting wicked sick," said Libby Hohmann, an infectious-disease physician at Massachusetts General Hospital. She cited two covid patients she'd recently seen in the intensive care unit -- "both vaccinated and near death," with one immunocompromised patient in their 60s dealing with infection from another pathogen, too, and a second patient in their 30s who was previously healthy, but suddenly fighting heart failure.
"For most of us, it's kind of a yawn now, but ... you see these people, covid pushes them over the cliff," she said.
Shira Doron, chief infection control officer for the Tufts Medicine Health System, said she had broader concerns about how covid data is compiled, citing local and regional differences in how death certificates are filled out, and how health officials are tracking the long-term effects of covid infections in ways that they don't with other threats, such as flu viruses. "If you think about causes of death in this country, we certainly don't have any other infectious disease where we are counting it that way," she said.
But Doron noted that her colleagues reviewed about 85 recent deaths at Tufts that occurred after a covid diagnosis, and found "100% accuracy" in those death certificates that listed covid as a cause. Moreover, "there were quite a few patients who our experts felt had died of covid-19, and it didn't make it onto the death certificate," Doron added, saying that many of those overlooked patients had suffered "long, slow declines" after covid infections.
Doron cautioned against extrapolating nationwide from that data -- but "at one hospital, in one city, in one state, we found that death certificates had underestimated covid-19."
Outside researchers also have pointed to a nationwide pattern of excess deaths, or the number of deaths exceeding what would have been predicted for that time period, which has surpassed the number of deaths attributed to covid.
"The non-covid death rate has not returned to pre-pandemic levels," said Andrew Stokes, a Boston University researcher who is part of a team investigating the rise in excess deaths. "We believe that there's an invisible or hidden burden of covid that has persisted essentially into the present, and those deaths are going unrecorded."
Elisa Krcilek, vice president of Mountain View Funeral Home and Cemetery in Mesa, Ariz., said her team had seen a "new normal" of funerals, with higher call volumes than pre-pandemic but lower than at the 2021 peak of covid infections and deaths. She also estimated that covid may have played a role in about 20% of recent funerals, but often as a secondary cause, whereas earlier in the pandemic, about 80% of funerals were for people who died of covid, with the virus cited as a primary cause.
"People that have died [directly from] covid right now are few and far between," she said.
Americans have struggled throughout the pandemic to understand the risks of covid. In one Axios/Ipsos poll conducted last August, 35% of adults said they believed that more Americans were dying from traffic accidents than from covid, compared to 11% who thought covid was the bigger killer.
A little over half of respondents said they didn't know which posed the biggest risk of death.
About 3,850 people died in traffic accidents in August 2022, according to federal data -- about one-quarter of those estimated to have died of covid that month. The CDC says that 3,918 people died from covid in the last week of August alone.
Some advocates have accused the Biden administration of failing to highlight the ongoing covid death toll, saying that the White House has been too eager to turn the page.
"The decision to tolerate preventable deaths in disproportionately vulnerable groups, in exchange for the convenience of more able-bodied, younger, wealthy, and white individuals, is unethical and demonstrates a reckless disregard for the lives of communities disproportionately impacted by covid," the People's CDC, a coalition of public health experts, wrote in a report last week.
White House officials say they have been focused on boosting access to vaccines and treatments, particularly in settings such as nursing homes, and launching an effort to develop more effective therapies.
The virus "is not disrupting our lives in a substantial way," said Ashish Jha, the White House coronavirus coordinator, whose team is set to wind down next month. "[But] is there still more work to do to prevent serious illness and death? The answer to that is yes."
Others charge that the covid death toll has been inflated all along, skewed by inducements that were intended to better measure the toll of the pandemic and offer support for affected families. For instance, FEMA has offered up to $9,000 in assistance for the funerals of those whose death certificates show covid as a cause of death. The program is slated to end next month when the public health emergency is lifted.
"If your government is telling you, if you have a positive covid test, you can get $9,000 [in funeral assistance] ... families are going to say, 'Make sure it's on there,' " said Leslie Bienen, a veterinarian who studies zoonotic disease transmission and has questioned the accuracy of covid data. "I think we'd be naive to think that doesn't influence anything."
Stokes countered with examples of coroners in rural and conservative communities who said they had been asked by families to leave off covid as a cause of death. He also said that families seeking to add covid to a death certificate to qualify for FEMA assistance would need to go through a multi-step process to get the document amended.
Others note that the CDC has revised its death data over time, often a function of state recalculations, and health officials have acknowledged other problems in local and national covid data. For instance, Doron played a role last year in changing how Massachusetts tracks covid hospitalizations, effectively halving the number of reported patients, by counting only severe cases.
Wen, the physician who wrote The Post op-ed that argued covid deaths were overcounted, said she was calling for "uniform standards so that we can put this question to rest once and for all."
"I think that this entire conversation around covid has become so polarized and frankly unscientific when what I'm calling for here is an acknowledgment that we need better standardized methodologies," Wen added.
Houry, the CDC's chief medical officer, defended the agency's process to compile its data, saying that states did not have a consistent reporting process.
"We're really trying to put out data in a timely fashion. And we understand there's going to be limitations to it, and that it's provisional," she said. "But because of that, the data does change."
Information for this article was contributed by Scott Clement of The Washington Post.