Why aren’t we hearing about COVID waves anymore? Because COVID is at ‘a high tide’ — and staying there

Visit any supermarket, school or sports facility these days and you'd be hard pressed to find signs that COVID-19 is still among us.

Hardly anyone wears a mask anymore. We've moved on from social distancing. People are eating out, going to the cinema and getting together again.

There are places, however, where the virus is still very much an everyday, top-of-mind consideration. Chief among them: hospitals.

COVID hospitalizations in Canada are about six times higher today than they were at the lowest point of the pandemic.

What's the reason for the disconnect? Why do we seem so nonchalant about a virus that killed more people last year than during the first two years of the pandemic?

Partly, it's because the virus is now attacking in a much less dramatic way.

After the massive Omicron waves at the beginning of last year, we failed to see the kinds of towering peaks and deep troughs of hospitalizations that had been characteristic of the pandemic's first two years. Vaccinations and prior infection have helped protect many of us.

But while COVID hospitalizations this year and last have proven less erratic, they have remained at significant levels. The virus was the number one illness-related cause of hospital admissions for all of last year. And the trend appears to be continuing in 2023.

In effect, the first Omicron wave - that dramatic rise in cases prompted by a then-new variant that came crashing down upon our medical system more than a year ago - has left us numb to the continuing presence of the virus. What might have generated alarming headlines before Omicron simply isn't enough to do so anymore.

But even if COVID's waves have become less imposing, the water level remains high.

Omicron's first wave was terrible, the worst of the entire pandemic, and I think what's happened is people have started using that wave like a new standard against which subsequent hospitalization levels are judged," says Blake Murdoch, senior research associate at the University of Alberta's Health Law Institute.

But if you actually look at what's happening with hospitalizations, since Omicron subvariants emerged, it's a giant wave that's lasted not only much longer, but is also just as high as those we saw in 2021 or even higher at some points.

It's like a high tide that's always elevated, and this steadier state can mean a higher total burden over time."

To be sure, hospitals are not seeing anywhere near the sheer volumes of critically ill patients suffering from COVID pneumonias that they did during the first two years of the pandemic, a relief and a reality reflected in the current low ICU admission levels both nationally and in Ontario.

Hospitals are instead experiencing what doctors and nurses describe as a slow burn of patients admitted with COVID infections.

It's no longer a tidal wave. It is a steady stream," says registered nurse Erin Ariss, president-elect of the Ontario Nurses' Association. Patients are still coming in with COVID. ICU admissions are still happening related to COVID, and we're also seeing patients arrive with issues that arose from contracting COVID in the first place."

The persistent cases are creating a continuing drag on the health system - one that simply didn't exist three-plus years ago.

We do not have a system that is designed for any additional drag in a persistent, chronic way," says Dr. Fahad Razak, an internist at St. Michael's Hospital and an associate professor at the University of Toronto.

Think of this as the incremental effect of many factors now piling together - a tightly constrained baseline system, worn-out health-care human resources from the pressures of the last three years, and an increasing number of people with some kind of chronic illness from their COVID infection, plus the extra increment of recently infected people coming in."

It's a glimpse of what the future of an endemic state of the disease that transformed our lives for three years might look like.

Ontario's health care - before the pandemic

It's worth noting that things weren't exactly smooth sailing in Ontario's hospitals before the pandemic.

A 2019 study by the Ontario Hospital Association found the province had fewer acute hospital beds per 1,000 people than any other province and was tied with Mexico for fewest beds in the western world.

Premier Doug Ford was elected in 2018, promising that he was going to end hallway medicine.

Thanks in part to COVID, we are still waiting to see if that becomes a reality. Current infection numbers don't provide a promising picture.

The Omicron tsunami'

It's called infection-acquired seroprevalence, and it reflects the presence of COVID antibodies in people's blood due to infection.

Before the Omicron wave began in late December 2021, infection-acquired seroprevalence was around six per cent of Canadians. By this past February, it had jumped to a stunning 77 per cent.

That means at least 27 million Canadians were infected between Dec. 1, 2021, and Jan. 31, 2023, according to the COVID-19 Immunity Task Force, a national group of experts formed to determine the extent of COVID infection in Canada.

That's what we call the Omicron tsunami," says Dr. Tim Evans, executive director of the task force and a professor at McGill University. It just gives you a sense of how transmissible the Omicron variant has been. It continues even today to be very widespread in Canada, and this is unlike any of the previous variants, which were much less transmissible."

There were an average of 70,000 new infections a day in the first half of 2022, he says. Since July, that's slowed, but it remains at a rate of an average of 50,000 new daily infections.

Evans points out that the sheer number of people infected with Omicron - even if it causes a milder illness for most - will result in a high number of hospitalizations.

If 70 per cent of the population in the course of the last year were infected, as opposed to only six or seven per cent over the first two years, even if the hospitalization rate is cut in half, you've got 10 times as many people being infected. So you're going to have an absolute number of hospitalizations which is very significant."

Seniors at risk

Recent figures from the Canadian Institute for Health Information show that while COVID may no longer be drowning the health-care system, it is still flooding it with patients.

So far this year, Canada is seeing an average of 4,170 daily COVID hospitalizations, down from last year's daily average of 5,621, but close to double the hospitalizations seen in 2021 and nearly triple what they were in 2020.

COVID is slowly working its way through our population, and we've managed to hold some of it in check with vaccination and other strategies," says Tara Moriarty, an infectious disease researcher at the University of Toronto.

But, she notes: If you're going to infect that many people, you're going to have a lot of serious outcomes."

Contributing to increased hospitalizations, Moriarty says, are the immune-evasive properties of Omicron and its subvariants now circulating, increased transmissibility, and the waning effectiveness of booster vaccines administered in the fall.

Those age 60 and over make up 70 per cent of all COVID hospitalizations in Canada to date.

And, as COVID continues to circulate, there are many more people who could still fall ill.

Moriarty estimates that about 15 to 20 per cent of the population has yet to be infected with Omicron thanks to social distancing, masking and vaccination.

Most of these folks are seniors and that makes them - lacking any prior exposure to the virus - particularly susceptible to more severe health outcomes if and when they eventually become infected, says Dr. Gaston De Serres, an epidemiologist at the Quebec National Institute of Public Health.

Despite all the transmission that has happened since the beginning of the pandemic, a large proportion of (people age 60 and older) have still avoided being infected," he says.

And the first infection can be a particularly dangerous one.

What we see in various studies is that the first time you're infected by COVID-19 is where you have the greatest risk of being hospitalized. After you've been infected the first time, if you are reinfected, then the risk of hospitalization is much lower."

COVID's effect on hospitals

Today's COVID footprint in hospitals is different from the earlier waves of the pandemic.

Back then, the demand for ICU beds and ventilators from critically ill patients pushed the health-care system to its breaking point. Recent hospitalizations may be relatively high, but they aren't completely drowning the system.

At the University Health Network these days, COVID patients occupy between 25 and 30 beds.

It is something we're coping with," says CEO Kevin Smith. But that's 25 or 30 more beds than we would have once consumed and these patients are in them."

A steady level of the virus - and recent increase - detected in Ontario through wastewater surveillance backs up this idea of an ongoing churn" of infections that doesn't drop back to the levels seen in 2020 and 2021 between waves, says Razak.

Some of it is low-grade, some of it is enough to knock people out of work, and some of it is overlapping with this essentially persistent body of people who are in hospital," he explains.

He notes, however, that there is significant disagreement in the medical community around whether many of the recent admissions are directly attributable to COVID or incidental to patients' hospitalizations.

In other words, the argument on one side is that COVID is not causing people to be hospitalized - it's just a virus that is infecting a lot of people in society and so when people get sick, a lot of people end up testing positive," Razak says. On the other hand, even though COVID is not presenting for most patients in a classic COVID pneumonia' pattern that we saw earlier in the pandemic, it could still play an important role in hospitalizations by exacerbating underlying chronic health conditions like heart failure or COPD."

Razak adds that he suspects that at least for an important subset of patients, COVID infection is still contributing to the reason they end up in hospital, but that is an active area of scientific study."

Toronto emergency physician Dr. Lisa Salamon argues that the debate around whether patients are admitted to hospital with COVID" versus for COVID" is largely one of semantics. She argues that if COVID exacerbates an underlying health condition to the point where the patient requires hospitalization, COVID is what caused the need for hospitalization.

I see a lot of elderly people coming in with what I call failure to cope' or general weakness and we end up finding out that they have COVID and that is what has caused them to decline," she says. In my mind, they should be admitted for COVID' but that's not always the way it ends up getting marked down. We're seeing a lot of that."

As a result, she says, the problem is bigger than what the numbers show.

Let's say a 75-year-old gets COVID and is very weak and they fall and break their hip. Their admission is hip fracture, but if they weren't weak from COVID, they would never have fallen and suffered a hip fracture," Salamon says.

It's significant because if they didn't get COVID, they never would have been hospitalized."

Will we see another deadly mutation?

Whether this sustained high level of COVID hospitalizations will be the new normal is unclear.

It will depend on how the virus evolves.

At the moment, the Omicron subvariant XBB.1.5 - known by its nickname Kraken" and considered to be the most transmissible strain to date - is dominant in Canada.

If a new mutant appears that is able to escape immunity given by prior infection or vaccination, then there are plenty of people the virus could infect," says De Serres, with the Quebec National Institute of Public Health.

Then you may have a substantial proportion of people who will become sick again, with some (infections) dribbling into the older age group where you will see these hospitalizations."

Hospital administrators, for their part, aren't waiting for another COVID mutation to push up demand for hospital beds again and are already working to accommodate the higher admissions seen over the past year, should they continue.

University Health Network CEO Smith says that as COVID becomes endemic, he expects to continue to see patients admitted either because of or in combination with the virus.

A virus becomes endemic when a certain level of infection is maintained within a place or population for an extended period of time.

I suspect that will be for the longer term," says Smith. I think we have to get used to having this as a new disease that requires hospitalizations."

At CHEO, a pediatric hospital and research institute in Ottawa, hospitalizations due to all causes are up 17 per cent this year compared to 2022. That includes anywhere from one to four beds out of the hospital's 145 beds currently occupied by COVID patients.

That's four more beds occupied today for disease that didn't exist three years ago," says CEO Alex Munter. In the pediatric world, COVID is, in terms of a cause for admission, one more of a series of additional demands for beds.

Munter says COVID is more evidence of a desperate need to right-size" the pediatric health-care system, one that saw emergency departments across the province overwhelmed with children suffering from respiratory syncytial virus (RSV), influenza and COVID, cancelled surgeries and seriously ill children sent far from home for critical care this past fall.

Clearly the data would suggest we're going to continue to have a certain level of occupancy across the whole system," he adds. That's going to need to be part of the reality that we plan for."

Kenyon Wallace is a Toronto-based investigative reporter for the Star. Follow him on Twitter: @KenyonWallace or reach him via email: kwallace@thestar.ca