For a few fleeting weeks this spring, it appeared as though Canadians could look forward to returning to something like normal prepandemic life. Case counts and hospitalizations had retreated after a second peak in Omicron-variant infections in April. Canada was among the most highly vaccinated countries in the world. And the lifting of public health requirements allowed people to travel without proof of vaccination and attend unrestricted, mask-free gatherings.
But then came BA.4 and BA.5, Omicron sub-variants that can evade immune-system protection from vaccines and prior infections. Their arrival shattered hopes that the country was finally sufficiently vaccinated to bring COVID-19 under some control.
“A year and a half ago, I thought, ‘Oh, once we get everyone double-vaccinated, we’re going to be good.’ But now, it doesn’t look like that’s the case,” Jeff Kwong, a professor of family medicine and public health at the University of Toronto, said last month. “I don’t know what the end game is. I have no idea how this is going to end.”
This seventh and latest COVID-19 wave, driven by BA.5, marks another new phase of the pandemic. And it requires a reimagination of what the pandemic’s end game will be, and how to get there.
For much of 2020, public health efforts were focused on keeping rates of infection from skyrocketing, with measures like social distancing and stay-at-home orders.
And for much of 2021, authorities worked to get vaccines into as many Canadians as possible, in the hopes that the inoculations were, in the words of Ontario’s then-minister of health, Christine Elliott, “our ticket out of the pandemic.”
Doctors and researchers continue to emphasize that vaccines provide strong protection against severe illness and death. But it has become clear that vaccination is not a ticket out – at least, not on its own.
Getting past COVID-19, medical professionals say, will likely require a host of measures, including the continued development of more effective vaccines, global vaccine coverage, paid sick days, a concerted fight against misinformation and attention to indoor air quality.
And however this pandemic ends, they caution, a full return to normal probably won’t come for a long time.
“Most people would like to hear we are closer to the end,” said Giorgia Sulis, a postdoctoral researcher in infectious disease epidemiology at McGill University. “The pandemic is not over. I want to be clear about that. And we are very far from that.”
But first, the good news.
Raywat Deonandan, an epidemiologist and associate professor at the University of Ottawa, describes himself as an optimist by nature. And, when it comes to the pandemic, he remains so for a few reasons.
“Society hasn’t come to a stop, right? That’s the big one,” he said. The sense of apocalypse he felt in spring 2020, when he’d walk through empty streets, has passed.
Aside from that, he said, vaccines have worked astonishingly well at preventing hospitalizations and deaths. The more booster shots people get, he added, the better their protection against those outcomes becomes. “That means this disease is no longer an existential threat.”
Vaccinated people’s cellular immunity against COVID-19 – that is, their B cells and T cells – is fairly durable, he said, and continues to prevent the worst outcomes. But their humoral immunity, which involves the antibodies that prevent infection, wanes over time. (Think of it this way, Dr. Deonandan explained: your humoral immunity keeps invaders off your shores, while cellular immunity happens after the invaders arrive and is important for preventing them from seizing the capitol.)
Even in the absence of new vaccine formulations, he said, it’s highly probable that booster shots of existing vaccines will continue to prevent the worst outcomes.
Still, Dr. Deonandan and others say, Canadians can’t yet afford to abandon efforts to avoid infection.
There is a common refrain among people who advocate for an immediate return to normal that, because of vaccines, COVID-19 is like the common cold. It’s not, Dr. Sulis said, and it shouldn’t be regarded as such.
There may be a time when the disease becomes like a cold, but it’s not yet certain that will happen, she added.
For now, there are vulnerable people, including those with underlying health conditions, who still need protecting.
Long COVID – when symptoms persist for weeks or months after an initial infection – is still an unsolved problem.
And high rates of infection continue to be disruptive to people’s lives, the workforce and the health care system.
Most people who catch COVID-19 don’t end up in hospitals. But, when there are a lot of cases within a population, even a small proportion of serious cases can overwhelm health care facilities.
According to the most recent federal data, the number of people hospitalized with COVID-19 increased to 5,225 from 4,804 between July 18 and July 25, while the number of patients in intensive-care units climbed to 254 from 223 that week. Meanwhile, Canada recorded 253 COVID-19 deaths over the week of July 17 to July 23.
Even though only about 18 per cent of Canadians aren’t vaccinated, unvaccinated people make up the greatest proportion of these death and hospitalization numbers. Overall, between Dec. 14, 2020, and July 3 of this year, nearly 52 per cent of COVID-19 hospitalizations were among unvaccinated patients, compared with 20.5 per cent among those who had two doses, 18 per cent among those who had three doses, and less than 1 per cent among those who had four or more doses.
Fifty-two per cent of COVID-19 deaths were among the unvaccinated, compared with 18 per cent among those with two doses, 19.5 per cent among those with three doses, and 1.5 per cent among those with four or more.
If Canadians stay the current course, with few public health requirements and few people willing to receive additional vaccine doses, Dr. Sulis believes COVID-19 infections will continue to happen at rates that disrupt the functioning of hospitals, and the situation we’re seeing today is what our pandemic future will look like.
The much-touted idea of stamping out localized outbreaks when they occur isn’t realistic, she said, because the high transmissibility of new variants drives widespread transmission that is difficult to track. “The scenario is just that we will see case waves everywhere,” Dr. Sulis said. “If the virus is circulating at this rate, it is much more likely that new variants will emerge.”
In the first year of the pandemic, Andrew Morris, an infectious diseases physician at Toronto’s Sinai Health and the University Health Network, was an advocate for a “COVID zero” strategy – meaning a society-wide push to drive down COVID-19 case numbers as much as possible.
The aim was never to eliminate COVID-19 altogether, since that would likely have been impossible, Dr. Morris said. He still thinks COVID zero was a good idea, but he acknowledges it would not work now, with highly transmissible variants circulating and more than 6 million new confirmed cases per week globally.
Those who continue to cling to that goal – “I hazard to call them COVID zero zealots,” he said – now clash with those who are keen to declare the pandemic over. What’s missing in the current discourse, and what has been lacking from the start, he argued, is a strategy.
The first thing needed in a pandemic strategy is a clear recognition that the current mRNA vaccines against COVID-19 are not the panacea many had hoped for, Dr. Morris said. The initial efficacy studies for the Pfizer, Moderna and Oxford-AstraZeneca vaccines were far better than Dr. Morris and others had anticipated. “As has happened many times in the pandemic, we lacked humility to say, ‘You know, we don’t really know what it’s going to be like in the future,’” he said, noting that waning immunity from those vaccines has played into skeptics’ accusations that doctors and scientists lied about what the shots could deliver.
Though he emphasized the continued importance of people getting at least three doses, he said Canadians will need to rely in the future on new vaccines still under development, such as intranasal vaccines, which are applied by spraying mist in recipients’ noses.
Those may be more protective than existing vaccines, more tolerable to people who are averse to injections, and provide longer-lasting immunity, he said.
Other elements needed in a pandemic strategy include efforts to combat misinformation, according to Dr. Morris. He said this should begin among children in schools. He also called for wider recognition that COVID-19 transmission is airborne, which he said means places where people work and congregate need better air circulation and filtration.
For his part, Dr. Deonandan said it is important to have an active COVID-19 surveillance system, which would involve regularly testing random segments of the population to get a sense of who is being infected, what proportion are very symptomatic, and how long they are affected by the disease.
He also called for paid sick days to be made more widely available. This, he said, would give people less incentive to infect their co-workers. And he said it is important for there to be more treatment options for COVID-19, beyond anti-viral drugs like Paxlovid.
Dr. Morris acknowledges that none of this is new. Even though there are still many unknowns about the virus and how it will evolve, he said, “We have all the knowledge and tools to not allow this to be a huge problem for us.
“What would really make things better would be political will to act.”
Without a pandemic strategy, Dr. Morris believes Canadians will rely on luck, and will continue floundering from crisis to crisis. If the country adopts these measures and manages to get COVID-19 under control, he said, there may be occasions when Canadians will need to bring back face masks. But otherwise: “I think what it will look like is what life was like before the pandemic.”
Throughout history, people’s lives have eventually returned to normal after pandemics and epidemics, according to Mark Humphries, a professor of history at Wilfrid Laurier University.
This is partly a result of biological processes. But there’s also a type of social and cultural adaptation that takes place during a pandemic. Even though the virus that caused the influenza pandemic of 1918 continued to circulate, newspaper coverage of it began to decline soon after. By 1921, people had largely moved on, Dr. Humphries said.
“History allows us to be somewhat optimistic in the sense that we do find a way to co-exist with most viruses,” he said. But, he added, “It doesn’t mean that there wasn’t immense suffering and things like that.”
Ultimately, this pandemic will not be over until every country in the world is able to vaccinate their populations, Dr. Sulis said. While high-income countries like Canada are now delivering fourth doses, some low-income countries are still struggling to deliver first doses to their most vulnerable citizens.
“We have to understand that this is also something that matters to us directly because it favours the massive circulation of the virus” and the emergence of new variants, she said. “We cannot take for granted that future variants will evolve to where it’s a progressively less aggressive virus.”
In the meantime – and Dr. Sulis anticipates it will be a long meantime – learning to live with the virus will mean learning to live with its many unknowns and surprises. “That’s probably the hardest part: accept that we have to deal with uncertainty,” she said.
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