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Libby Erickson is haunted by what she told her 86-year-old mother as they celebrated a third Christmas amid the pandemic.

"We kept you safe," she told her mother, Sally Albers, "for almost three years."

Sally Albers tested positive for COVID-19 a week later amid an outbreak in her assisted-living facility in Alexandria, Minn. The retired teacher died two days later on Dec. 31, 2022.

Minnesota may have returned to some normalcy in year three of the pandemic as people shed masks and went back to offices, theaters and public places, but the threat remains as the state enters year four. Minnesota hasn't had a day with zero COVID-19 deaths since June 10, and it has averaged six per day since then.

COVID-19 dropped to the second most common cause of death in Minnesota in 2022, but it still led to 3,174 people losing their lives last year. The pace has slowed in 2023, but the 442 COVID-19 deaths so far this year exceed the 418 from seasonal influenza in the past four years combined.

People wouldn't accept the current death rate if it was due to cancer, said Michael Osterholm, director for the University of Minnesota's Center for Infectious Disease Research and Policy, but they do with COVID-19 because six deaths per day isn't as shocking as 75 per day at the pandemic's peak.

Minnesota's early COVID-19 response involved short-term inconveniences, such as mask mandates and limits on crowds, that could be dialed up in response to pandemic waves. What the state encountered over the past year was different — a steady toll too small to demand emergency action but too big to dismiss.

"What we have is this confusion," Osterholm said. "How do we respond to this? How do we even talk about it?"

People who are elderly, or have chronic diseases or weakened immune systems, have been at greatest risk for severe COVID-19 from the start. The delta coronavirus variant exploited a lack of vaccination among healthier young adults in fall 2021, but even then 75% of COVID-19 deaths took place among seniors.

Risks have declined across all age groups since then, just not as much for seniors, who make up 93% of the COVID-19 deaths reported in Minnesota this year.

Erickson said her mother was an inspiration as a friendly special-education teacher who even returned to work after retirement when her school couldn't find a replacement. Erickson provided direct care for her mother, but moved her to assisted living last spring when her job shifted back to in-person work and it seemed safer.

"We thought the pandemic was over, you know," even though fast-spreading viral variants still were circulating, Erickson said. "We didn't want to move her prior to that, because of all the things going around the facilities."

'Relatively healthy state'

Minnesota's COVID-19 death rate ranks 12th lowest among U.S. states and the lowest among border states. Another 6,000 Minnesotans would have died if the state had South Dakota's death rate.

Most states with low COVID-19 death rates have high vaccination rates and used lockdowns and mask mandates early in the pandemic to limit viral spread. That doesn't explain all the variations, though. New Mexico has one of the nation's worst COVID-19 death rates despite its aggressive pandemic response.

Race fueled disparities in COVID-19 death rates early in the pandemic, partly because minorities had more lower-income service jobs that elevated their exposure risks. States with high COVID-19 death rates also tend to have high rates of poverty and people with chronic diseases such as diabetes.

"Minnesota generally ranks as a relatively healthy state, and your underlying conditions are predictors of how well you will fare with COVID," said Kathy Como-Sabetti, supervisor of the Minnesota Department of Health's COVID-19 epidemiology section.

Michelle Mattfield remained cautious, even at 36, because the Crystal, Minn., woman had exercise-induced asthma, severe sleep apnea and other breathing problems. She quit her ground crew job at the Minneapolis-St. Paul Airport a few years ago because of her disabilities and lived at home with her mother and boyfriend.

When all three tested positive for COVID-19, they sought Paxlovid antivirals. Mattfield took her first dose before bed, but died in her sleep Dec. 30. Her mother, Marge Bergman,remains confused by her daughter's rapid demise and upset that her doctor didn't recommend immediate hospitalization.

"I'm trying to follow up and find out more," she said. "I haven't done too much yet, just because of the shock."

While sudden COVID-19 deaths still occur, doctors are facing a new challenge in deciding when to officially attribute deaths to earlier infections.

COVID-19 can cause long-term cardiac complications, which can make it tricky to assess its role later in a death from heart disease, said Dr. Rozalina McCoy, a Mayo Clinic physician who is studying the pandemic's impact on mortality rates.

"I think we're going to be both missing COVID as a contributing cause and also overestimating it at the same time," she said.

Living with the virus

Changes have come and gone since Minnesota reported its first COVID-19 death on March 19, 2020, in an 88-year-old St. Anthony woman.

Free state testing and vaccination centers have closed. Mayo Clinic's COVID-19 modeling forecast has disappeared. Public displays have been removed.

Yellow paper hearts once adorned Edina City Hall in remembrance of more than 100 residents who died of COVID-19. The remembrances were recycled in January, except for a few saved for families upon request.

"Hearts that had been up there for three years were pretty sun-faded," said Jennifer Bennerotte, the city's communications director. "It was time to take them down."

Infectious disease experts said there is a danger in interpreting these signs as if the pandemic is over.

Osterholm said that properly worn, high-filtration masks and vaccine boosters can still reduce risks of severe COVID-19.

"I'm 70 years old and I have underlying health conditions," Osterholm said. "I was at the Bruce Springsteen concert with 18,000 people, but I had my N95 on. We're learning to live with this virus in that regard."

Updated guidance is expected from federal health authorities regarding the COVID-19 vaccination schedule because the effectiveness of recent boosters may have waned. British and Canadian authorities have authorized spring boosters for people at greatest risk of severe COVID-19.

Erickson said her family doesn't need more reminders that the pandemic persists. When her mother was infected, she suspected the worst. She put on protective gear and brought chicken and wild rice for her mother while they talked about old times at the family cabin.

Now Erickson's brother has COVID-19 along with a sister-in-law undergoing cancer treatment. While the sister-in-law is recovering, she remains weakened.

"People are just like, 'If I get it, I get it" these days, she said, "but it still has implications for people that are at risk."

Data editor MaryJo Webster contributed to this report.