Three years on since the COVID-19 pandemic hit Hawaii shores, many have resumed living without restrictions, but the state is still reeling from its impacts — and residents are still dying from the disease.

The U.S. death toll from COVID-19 has surpassed 1.1 million. Globally, it’s closing in on 7 million.

In Hawaii, 1,849 deaths have been attributed to the coronavirus, as of Wednesday.

Although the state is in a much better place now in regards to COVID-19, many are reflecting on the lessons of the past three years and taking stock of how to move forward.

“Across the nation, the pandemic revealed the erosion of public health infrastructure and workforce that’s occurred, and the need to continually invest in them,” said state Department of Health Director Dr. Kenneth Fink in a statement. “The challenges of public health communication in a dynamic environment and politicization of science were evident, highlighting the importance of public health agencies being trusted sources of information.”

Fink said that in Hawaii, the pandemic response “demonstrated successful government and private sector partnerships, coalescent communities, and caring individuals’ willingness to help and protect one another — just more examples of what is special about our aloha state.”

DOH will continue to monitor COVID-19 in the islands and respond accordingly, he said, as well as publish information so people can make informed decisions.

It’s been three years since then-Gov. David Ige on March 4, 2020, issued an emergency proclamation on the COVID-19 outbreak. A week later, the World Health Organization declared COVID-19 a pandemic.

The state’s first confirmed case was announced March 6, 2020, in an Oahu resident who tested positive after returning from a cruise on the Grand Princess. Ten days later, a tour guide at Kualoa Ranch with no history of travel tested positive for COVID-19.

The first COVID-19-related death in Hawaii was announced by the end of March.

Fast forward to today, and there have now been more than 381,000 residents infected or reinfected with COVID-19, according to DOH.

The virus continued to evolve to ever-more contagious variants to get past immunity, resulting in successive waves that have come and gone — from alpha to delta to omicron variant BA.2, followed by BA.4 and BA.5, which the bivalent boosters are formulated to target.

Over the winter, omicron subvariants BQ.1 and BQ.1.1 rose to dominance — a spot now taken over by highly contagious omicron subvariant XBB.1.5, also known as “The Kraken.”

The nation has fought back with mitigation measures, vaccines, boosters and treatments for COVID- 19. The White House, signaling that the pandemic is entering a new phase, has announced that national COVID-19 emergency declarations will expire May 11.

So where are we today?

“I think we’ve largely entered an endemic state,” said Tim Brown, an infectious disease expert at the East-West Center in Manoa. “What we’re looking at is a fairly stable level of ongoing transmission in the community that’s not decreasing and not rising.”

Other than small blips following the holidays when people tend to gather, Brown said infection levels appear to be back to where they were last summer.

Hawaii has been at a pretty even keel for infection and positivity rates for the past few months.

On Wednesday, DOH reported a daily average of 74 new COVID-19 cases per day. The average positivity rate was 4.2% and has remained within 4% to 5% since February.

“It looks like XBB.1.5 passed here without doing too much harm,” Brown said. “That’s a good thing. It means immunity protections we have from previous infections and vaccinations held up fairly well against this new variant.”

Endemic, however, does not mean that COVID-19 has gone away, he said, or that people are no longer at risk of infection, hospitalization or death.

“Endemic just means that the pathogen is circulating in the population in a stable way,” he said. “It does not say what that level is or how dangerous that level is.”

COVID-19 still remains “one of the most infectious respiratory diseases we’ve seen,” according to Brown, at levels between chicken pox and measles.

“Living with COVID does not mean burying your head in the sand. It means being aware that COVID is out there.”

That means people at higher risk — including kupuna, the immunocompromised and those with underlying health conditions — still need to take appropriate precautions, such as getting boosted and masking in crowded spaces.

Brown recommends those at higher risk continue to get tested when sick and to be sure to consult with their doctor about treatment with Paxlovid if infected.

There is also the looming possibility of “long COVID,” a condition in which symptoms continue for four weeks to a year or longer after an initial infection.

The state has no official count of residents suffering from long COVID, but the Brookings Institution, a Washington, D.C., nonprofit, estimates the condition is potentially keeping as many as 4 million people out of work.

In the U.S., reported cases of COVID-19 infections, hospitalizations and deaths have all decreased in the past two weeks, according to The New York Times database. But 300 to 400 people in the U.S. are still dying from the disease each day.

Hospitalizations nationally have also been falling steadily for several weeks, with Hawaii being one of two states experiencing their lowest levels in nearly two years.

Although Hawaii hospitals have fewer COVID-19 patients, they are experiencing a higher census than during the pandemic and still grappling with a shortage of workers.

After a series of lockdowns, travel restrictions, vaccine and test requirements and ever-changing rules on the usage of state and county parks in that first year of the pandemic, there are now virtually no COVID-19-related ordinances in effect in Hawaii.

The state’s mask mandate and Safe Travels program requiring proof of vaccination and tests for domestic travelers expired March 25 .

Gone are the early days of uncertainty — of people panic-buying toilet paper. The more pressing issues today are the cost of that toilet paper as inflation and the cost of living in Hawaii continue to rise.

Many major events, including the Honolulu Festival, have resumed in person, with more scheduled to take place this year, including the Merrie Monarch Festival next month. And it seems — at least for some — that COVID-19 has become a distant memory.

A recent study published by the University of Hawaii found COVID-19 fatigue has settled in. More than a third of a cohort surveyed in November said the pandemic was over for them personally, while 10% believed the pandemic was already over. Fewer expressed a willingness to take precautions if there was another large wave.

With pandemic fatigue has come waning interest in uptake for the bivalent COVID boosters, which is at record-low levels. As of Wednesday, only 290,641 residents had received the bivalent booster, representing only 26% of the state’s eligible population.

Many epidemiologists say risks from COVID-19 still remain and warn that vigilance is still necessary. WHO has not declared the pandemic to be over yet and is urging countries to keep up testing and surveillance of known and new variants.

WHO Director-General Tedros Ghebreyesus said in a recent keynote speech that “we are certainly in a much better position now” than at any time during the pandemic.

“It’s very pleasing to see that for the first time, the weekly number of reported deaths is now lower than when we first used the word ‘pandemic’ three years ago,” he said. “The improvement is significant. I am confident that at some point this year we will be able to say that COVID-19 is over as a public health emergency of international concern — and as a pandemic.

“What is most important now is that we all learn the lessons of the pandemic,” he continued. “If we do not, we will repeat the cycle of panic and neglect that has been the hallmark of the global response to epidemics and pandemics for decades.”

THE PANDEMIC IN 3 YEARS

>> Jan. 30, 2020: The World Health Organizaiton declared the outbreak of COVID-19 a public health emergency of international concern.

>> March 4, 2020: Former Gov. David Ige issues emergency proclamation for COVID-19.

>> March 6, 2020: State confirms its first case of COVID-19 in a resident.

>> March 11, 2020: WHO says COVID-19 can be characterized as a pandemic.

>> Dec. 2020: Hawaii receives its first delivery of COVID-19 vaccines.

>> July 2021: Delta variant causes surge in Hawaii.

>> March 25, 2022: Hawaii’s mask, Safe Travels program for domestic travelers come to an end.

>> Jan. 28, 2022: Omicron represents 100% of sequenced variants in Hawaii.

>> May 11, 2023: White House will end the COVID-19 national emergency and COVID-19 public health emergency.