The COVID-19 pandemic is likely to persist, fueled by nearly 120 million unvaccinated Americans who are allowing the virus to sustain itself and potentially incubate into new, deadlier variants.

The pandemic began ravaging the country in waves nearly 20 months ago, leaving almost 800,000 dead to date.

But the U.S. toll could easily hit 1 million or more before enough people are vaccinated or enough of the unvaccinated die off to curb the virus’s spread, according to a New York Independent examination of federal data.

Ten months since the first COVID-19 vaccine was approved, more than 120 million Americans have not yet received one dose. About 48 million are children under age 12, who have just been authorized to received shots.

That means an estmated 72 million people older than 12 are resisting vaccination.

The current vacination rate is well below the 75 percent minimum estimate public health experts have recommended for a population to reach “herd immunity,” according to data released by Johns Hopkins University.

That’s the point where a large enough portion of the community is immune to COVID-19 to make further spread unlikely.

The unvaccinated population act as a petri dish that allows the virus to replicate enough to sustain the pandemic and possibly mutate into deadlier, more infectious forms.

The highest share of unvaccinated Americans are 30-49 years old (41 percent). That means out of 85 million people in that age group, 34 million have yet to receive a shot.

Just over 63 million people are 50 to 64, and 20 percent, or 12.6 million, are unvaccinated. Only 9 percent, or 7.3 million out of the 54.9 million over the age of 65 are unvaccinated.

Compared to 18- to 29-year-olds, the rate of death among 30- to 39-year-olds is four times higher; 10 times higher among 40- to 49-year-olds; 25 times higher in the 50 to 64 age group and 65 times higher in the 65 to 74 group.

Around 29 percent, or 203,385 deaths, from COVID-19 in the United States have been among adults 85 years and older as of Nov. 18., despite accounting for 2 percent of the population, according to Centers for Disease Control (CDC).

Those between the ages of 18 and 64 accounted for 189,647 deaths through Nov. 18.

Researchers divided in nine teams, including Johns Hopkins Infectious Disease Dynamics group, have projected what could happen over the next six months.

Based on four scenarios, including authorizing vaccines for children and the possibility for new variants, death rates could vary from 60 to 800 per day.

The first, most optimistic scenario, examines outcomes if child vaccinations start for children 5 to 11 years old without any new variants. 

It projects continuous declines in the number of deaths per day. By mid-March 2022 , about 60 deaths a day are expected as opposed to 2,000. 

That number would double to about 120 deaths to as many as 500 a day without 5-12 year old immunizations. The scenario also assumes transmission is declining, in large part because of broader immunity in the population.

If a new variant emerges that is 50 percent more transmissible than the Delta variant, the death toll could rise to 400 per day by mid year. That assumes young children are widely vaccinated.

With a new variant and limited child vaccinations, the death toll could double to an estimated 800 a day, according to the models.

Last year the winter months–December, January and February–proved to be the deadliest. As many as 3,000 people were dying every day of Covid-19. Nearly 250,000 people died in the United States over that time.

Unvaccinated Americans have died at 11 times the rate of those fully vaccinated since the Delta variant became the dominant strain over this past summer, according to federal CDC data.

In contrast, vaccinated people were 10 times less likely to be admitted to hospital and five times less likely to be infected than unvaccinated people, according to one study that tracked adults across 13 states and cities.

At some point, the virus will start to run out of people to infect because they are vaccinated, had the virus and recovered or are dead.

Until then, the unvaccinated–mostly younger Americans and Republicans, according to one survey–are most likely to sustain the pandemic into the new year and beyond, increasing the possibility of new variants.

One study examining cases in Virginia, between Jan. 1 and Nov 13, found that the rate of infection varied from 1,049 per 100,000 among the vaccinated to 4,910 per 100,000 among the unvaccinated.

The unvaccinated developed an infection at 4.7 times the rate of the fully vaccinated, the study found. Of the 5.4 million vaccinated Virginians, only 1 percent developed a breakthrough infection.

Against that backdrop, the unvaccinated are increasingly being viewed as an impediment to bringing the pandemic under control.

In Europe and elsewhere, where yet another resurgence in infections is underway, some countries are taking steps to clamp down on the unvaccinated.

Most notably, in Austria, Chancellor Alexander Schallenberg announced a broad lockdown for a maximum of 20 days an imposed a legal requirement to get vaccinated before Feb. 1, 2022.

Austria is posting record case numbers and has one of the lowest vaccination levels in Western Europe.

In Germany,  several days of record infections prompted Health Minister Jens Spahn to call for “a national emergency.”

“Probably by the end of this winter, as is sometimes cynically said, pretty much everyone in Germany will be vaccinated, cured or dead,” Spahn said.

In regions with high hospitalisation rates, the unvaccinated are being barred from public spaces like cinemas, gyms and indoor dining.

In the United States, the Biden administration has chosen to impose vaccine mandates on companies with 100 or more employees, federal agencies, the armed forces and federal contractors.

But Republican states are suing to block the mandates amid a flood of misinformation on Fox News and other hard-right news outlets, often promoting treatments that are ineffective against the virus.

In Florida and Texas, Republican lawmakers are going so far as to pass laws banning mask mandates and other prevention methods in schools.

In a key development, a state appeals court upheld an earlier injunction against the Texas ban.

At the same time, pediatricians say cases in children have risen by 32 percent from about two weeks ago, according to The New York Times.

“We’re not just fighting a epidemic; we’re fighting an infodemic. Fake news spreads faster and more easily than this virus and is just as dangerous,” said Dr. Tedros Adhanom, Director-General of the World Health Organization (WHO).

With winter approaching, it may be time to consider more restrictions on the unvaccinated. Or brace for the next wave of infections and death.