Hawaii has surpassed 1,000 coronavirus-related deaths, marking a grim milestone in a pandemic that has dragged on now for nearly two years.

The state Department of Health on Saturday reported four new deaths — two each on Oahu and Hawaii island — bringing the COVID-19 death toll to 1,002.

The virus has claimed the lives of not just kupuna, but the parents of young children, three pregnant women and more than 100 residents under the age of 50. In addition to the deaths, an unknown number continue to suffer long-term effects from the virus, which can cause persistent and debilitating symptoms such as severe exhaustion, brain fog, a racing heart and a distorted sense of smell.

Lt. Gov. Josh Green, who is also an emergency room doctor, called the death toll “heartbreaking” as he took a break from his shift at Kohala Hospital on Hawaii island for an Instagram video post. But he said the state is getting to the end of the acute phase of the pandemic.

Hawaii accounts for just a fraction of the nation’s 767,000 coronavirus-related deaths and has the second- lowest COVID-19 mortality rate in the country.

Still, the death toll in Hawaii, which has maintained some of the most far-reaching restrictions on businesses and social gatherings, is testament to the lethality of the virus, which has killed more than three times as many residents in 2021 than in the first year of the pandemic, despite this year’s widespread deployment of vaccines.

Looking ahead, Hawaii’s political and health care leaders have expressed cautious optimism that the new year will bring more of a return to normalcy. Gov. David Ige has been reticent to set metrics for dropping coronavirus restrictions, including restraints on businesses and social gatherings and mask requirements, but he told the Honolulu Star- Advertiser earlier this month he’s hopeful restrictions could cease by the end of the year.

Hawaii’s case count has plateaued at about 100 new coronavirus cases a day for the past month. As of Saturday, the test positivity rate stood at 1.4% statewide, indicating relatively low transmission rates. There were just nine people with COVID-19 in intensive care units statewide as of Saturday, a rate that has remained stable for about a month.

Hawaii also has one of the highest vaccination rates in the country, with 85% of all residents ages 12 and older fully vaccinated, compared to 69% nationally. Additionally, health officials say the delta surge this summer expanded the layer of natural immunity within the population as more residents became infected and recovered.

But there are also troubling signs. COVID-19 cases are again surging across countries in Europe, and the effectiveness of the vaccines administered earlier in the year is waning. Austria is going into a full lockdown as hospitals are overrun, and its leaders plan to require mandatory vaccinations of all citizens beginning in February. Germany, which is now suffering its highest infection rate since the start of the pandemic despite 68% of its population being vaccinated, has also implemented new restrictions and hasn’t ruled out a nationwide lockdown.

The United Kingdom, by contrast, dropped the majority of its coronavirus- related restrictions, including mask and social distancing requirements, in July and August just as new cases were surging. New cases counts have remained high for months, but the death toll has remained proportionally low.

Hawaii Health Director Dr. Elizabeth Char told state lawmakers this month that she’s been closely watching the surge in Europe, which in the past has served as a bellwether of what’s to come in the United States.

On Friday, DOH followed federal guidance that makes booster shots available to all adults in Hawaii. The move comes just ahead of the holiday season, when cases could resurge as more people travel and gather, and levels of immunity among the vaccinated population decline.

State health officials say they expect additional case surges in the future, but it’s not completely clear how this will play out within the state’s highly vaccinated population. And there’s still the threat of the virus mutating in ways that evade the protections of vaccines and new treatment options.

“That’s the real wild card that we are most concerned about,” said Hilton Raethel, president and CEO of the Healthcare Association of Hawaii.

Raethel said vaccine manufacturers could hopefully work quickly to develop a new vaccine. “But that means that everyone then would need to get vaccinated, which is another huge public health effort,” he said.

Despite growing pandemic fatigue, Raethel said he feels the coronavirus- related restrictions in Hawaii were appropriate, but if the state can get through the holiday season, he said January would be a good time to look at lifting safeguards, such as mask mandates.

Raethel stressed the pandemic has taken a toll on residents’ physical health, as they deferred health care, causing more severe illness, as well as on their mental health.

“It wears on people emotionally. It wears on them mentally,” he said. “And that can have a physical manifestation, as well.”