While the COVID-19 virus has dominated our lives for over the past two years, the lockdowns, mask mandates and social distancing measures it caused gave us a reprieve from influenza and other common winter respiratory viruses. With the lifting of most public health restrictions across Canada, we might be in for a “tripledemic” winter, as COVID-19, influenza and RSV rates surge across the country. Experts are predicting yet another COVID-19 wave heading into the winter, with COVID-related hospitalizations on the rise yet again.
Over the course of the pandemic, we have watched cases ebb and flow through successive pandemic waves. As of this fall, seven such waves have occurred in Canada, each characterized by different profiles: Who is getting sick? What public health restrictions were in place? Who could get a COVID-19 vaccine? Which variants were circulating?
The Waves of the Pandemic
The Faces/Phases Project is a portrait of the COVID-19 pandemic in Canada. Through a series of data visualizations, we cover the first two years of the pandemic starting in March 2020.
But these data only tell part of the story. Behind them are the faces of the pandemic. Alongside these charts, we tell the stories of 10 people who got COVID-19 at different phases of the pandemic. Most recovered, but some are still dealing with the pandemic’s physical, emotional, social and economic impacts.
Surveillance data are inherently messy. Epidemic curves plotting the number of reported cases against time are one tool that epidemiologists use to monitor the pandemic and understand its trajectory. But these surveillance tools– and their interpretation – depend on understanding the constantly changing pandemic context, including public health restrictions, testing capacity and access, vaccine eligibility, and the emergence of new variants.
For this reason, a case of COVID-19 reported at the beginning of the pandemic is not the same as a case detected later in the outbreak, particularly for the current Omicron variants.
“Our projections are constantly adapting to the changing landscape,” says Fahad Razak, an internist at St. Michael’s Hospital in Toronto and the former scientific director with the Ontario COVID-19 Science Advisory Table before it was dissolved in September.
Average cases: 4000+ /week
LTC residents 80+ years old
9.2% hospitalized, 5.6% died
Original Wuhan virus
Not available
Initial COVID-19 cases were driven by outbreaks in long-term care homes, with most cases detected in adults more than 80 years old.
As infection prevention and control measures were enhanced in these settings and vaccines prioritized for older adults, the age distribution shifted to younger groups with cases peaking among 20-29 and 40-49 age groups. This shift was also seen in the sex distribution of cases, with females – who make up the bulk of health-care workforce and are more likely in contact with young children – overrepresented during the first, fifth and subsequent waves.
Confirmed COVID-19 cases by week and age
Once second doses of COVID-19 vaccines became broadly available for adults during the fourth wave, the age distribution of infections shifted to children and youth up to 19 years old, who were too young to be vaccinated. Experts say this could also be a surveillance artifact, fuelled by children returning to in-person classrooms and enhanced testing in schools during the fall of 2021.
Average cases: 22,000+/week
Young adults 20-29 years old
4.1% hospitalized, 1.3% died
Original Wuhan virus
Health-care workers, LTC residents/staff, adults 70/80+ years old, Indigenous people
One way that epidemiologists look at the severity of illness is to measure the case-fatality rate or the proportion of reported cases who died from their infection. But this number depends on accurate reporting of the total number of cases – i.e., the denominator.
Because of inadequate testing at the beginning of pandemic, cases appeared to be falsely low, while severe indicators (like deaths) were much higher relative to the number of reported cases.
Hospitalizations
ICU Admissions
Deaths
During the initial phase of the pandemic when cases mainly occurred in older adults who were at highest risk for severe outcomes and testing was concentrated in long-term care facilities, the weekly average hospitalization rate was almost 10 per cent, while the case-fatality rate was more than 5 per cent. These fell to less than 5 per cent for hospitalizations and less than 1 per cent for deaths in the most recent Omicron waves, even though the weekly rate of hospitalizations and deaths reached their highest levels since the start of the pandemic.
How can this be? It’s a numbers game, say experts. Even though some epidemiologists, and most popular opinion, think that Omicron is less severe than earlier variants, the sheer number of cases during the fifth and subsequent waves translated into a higher number of hospitalizations and deaths.
Others say it’s difficult to directly compare Omicron with earlier variants. That’s because the population landscape has changed. Most people now have some underlying immunity to SARS-CoV-2 either through prior infection, vaccination or both.
“The population weighted average is overwhelmingly weighted toward people who have prior immunity,” says Jean-Paul Soucy, a PhD candidate at the University of Toronto and co-founder of the COVID-19 Canada Open Data Working Group.
In contrast, most cases of earlier variants, like Delta or the original Wuhan virus, were in people who had no immunity. There are also better treatments available now for COVID-19 infection, such as antivirals like Paxlovid.
Xyril Shane Dumangeng, 42
Warehouse worker in TorontoI contracted COVID-19 in April 2020. People were coming to work with symptoms because we didn’t know much about COVID at the time. We thought it was just a flu.
There were no COVID precautions in place. We wore masks because of the dust, but that was it. An outbreak was announced at my workplace and about 50 per cent of my co-workers had symptoms. Two people in their mid-40s passed away. I also gave COVID to my wife.
Two people in their mid-40s passed away.
My symptoms were like a bad flu: body aches, fever, profuse sweating, lack of appetite, fatigue and chills. I still experience fatigue and sometimes shortness of breath and chest pains. I’ve received two doses of the vaccine, but I figured I don’t need the booster if I survived unvaccinated, plus I have the protection from my prior infection.
I was off work for 14 days and I was eligible for the Canada Emergency Response Benefit (CERB). However, it was a thousand dollars less than if I would have worked. This put financial pressure on the household; we couldn’t buy certain foods and clothing.
Cynthia Hetherington, 44
Personal support worker in Milton, Ont.One of our long-term care residents was symptomatic in November 2020 so she received a COVID test. My instinct was to hug her right away, wipe away her tears and tell her everything will be OK. Then I took a step back and thought: “Oh my God. I’m going to get COVID.” I tested positive a few days later.
The virus doesn’t care who you are, how old you are or your current health condition.
I moved to a quarantine hotel that was paid for by my work. My symptoms were headache, loss of smell, exhaustion and low mood. It was scary being so isolated. Six months later, I was in the ER with a blood clot in my leg. My physician said doctors were finding this with people who have had COVID.
When I contracted COVID, there was an outbreak in my long-term care centre. We lost around 60 out of 200 residents. The virus doesn’t care who you are, how old you are or your current health condition. The vaccine made an instrumental impact in our facility. The vaccine also created a divide between the vaccinated and unvaccinated staff. When vaccines became mandatory for health-care workers, some ran to get their vaccines and others just left the job.
Aeryn Roberts, 3 and Atlin Roberts, 1
in Richmond, B.C. (as told by their mother, Stephanie Roberts)In December 2020, we suspected our family caught COVID-19 from our daughter’s preschool, except it was hard to tell because my husband was the first to develop symptoms. Once my husband tested positive at a PCR testing site, I got tested a day later and it came back positive too. We had to wait out the 10-day quarantine period to get our kids tested because we couldn’t go to the centre during our isolation period. Both of my kids tested then positive. My son had symptoms of an upset stomach early on during our initial quarantine. However, my daughter never developed symptoms. She needed to isolate 10 days from her positive test for a total of 20 days.
COVID is all my children know, and it affected how they developed.
It was impossible for my husband and me to isolate from our kids because they were so young. Luckily, I was on maternity leave while our family was isolating and during school closures, but if I was working at the time, child care would have been very difficult. The isolation was very hard on my 3-year-old daughter. She was confused, asking to see her friends and to go to school.
COVID is all my children know, and it affected how they developed. My son takes more time to warm up to new people due to lack of social interaction. He doesn’t have as close of a relationship with his older relatives because he couldn’t see them for so long. My daughter understands a greater emphasis on cleanliness. It’s interesting to observe her going for picnics with her friends and knowing that they can’t share food or touch each other’s things.
Crystal Lynton, 43
Social Worker in Spruce Grove, Alta.I was a multitasking mom that worked full time and brought my kids to activities. I played baseball and other sports. It’s not just my life, but my whole family’s life that has changed from me contracting COVID and developing long COVID. I was exposed to COVID on the job. I’m a social worker and I used to work out in the community. In December 2020, I tested positive and shortly after so did the rest of my family. My symptoms were extreme fatigue, difficulty breathing, a bad cough and high fever. People always say that COVID-19 symptoms only last two weeks, but then two weeks came and went, and I did not feel better. I could barely walk within my house. I spent Christmas Eve eating a package of noodle soup because no one had the energy to cook. No one expected it to be as bad as it was.
It’s crazy how much long COVID has changed my life.
Long COVID didn’t really have a name back then. It was just starting to be talked about. It was extremely irritating when people said “it’s just the flu” because of how debilitated the virus left me. I was frustrated that my doctor said to just take vitamins and exercise, while I knew physical exertion would be worse for my body. I applied to a number of programs and long COVID clinics but was denied access because of my Workers Compensation Board claim. When I finally did get access to a 10-week program, the information was helpful, but everything was held virtually, which limited how much medical help I could receive.
I’m constantly trying to find ways to conserve energy. If I want to wash the floor tomorrow, I can’t do anything too taxing today. Most people just shower, put on makeup, do their hair, and all before lunch without having to think twice about it. I can’t work full-time anymore. I work reduced shifts doing desk duties and can’t go into the community anymore. It’s crazy how much long COVID has changed my life, and no one knows how long this will last. I feel like there are no answers.
Average cases: 28,000+/week
Young adults 20-29 years old
4.9% hospitalized, 0.6% died
Alpha variant
Widespread roll-out
The emergence of new variants, first Alpha and Delta and then Omicron that have higher transmissibility but varying levels of severity and susceptibility to vaccines, has further muddied the surveillance picture.
Variants of Concern
When you look at the pandemic’s trajectory in Canada, the Delta wave was actually much smaller than previous waves, despite this variant being more contagious and causing more severe illness than its earlier counterparts. That’s likely because the Delta wave coincided with the peak of two-dose vaccinations in Canada.
In contrast, Omicron, which has the greatest number of mutations compared with the original Wuhan strain, was associated with the highest numbers of reported cases to date, despite gaps in our surveillance. This variant is better able to escape immunity from vaccines and emerged at a time when the effectiveness of most people’s second shot had started to wane.
Canadian Blood Services reports that more than 60 per cent of Canadians were infected with COVID-19 by the end of August 2022 based on seroprevalence data, which looks for the presence of antibodies to SARS-CoV-2 in the blood – a marker for past infection. This compares to only 30 per cent after the first Omicron wave in March 2022 and only 5 per cent at the end of the Delta wave in November 2021.
Experts believe we should expect more variants in the future.
“We’ve had a wave almost every six months, and the factors driving these waves have remained unchanged,” says Razak, including large numbers of people getting infected and low vaccination rates globally. “These things create the environment for the virus to mutate.”
Canadians first got access to COVID-19 vaccines in December 2021. However, due to early supply shortages, initial vaccine doses were initially prioritized for high-risk individuals, including residents and staff of senior living facilities, adults more than 70-years-old, Indigenous people and frontline health-care workers.
Vaccine Eligibility
Vaccine eligibility for adult Canadians expanded during the third wave, with provinces taking different approaches. Most used an age-based strategy, with groups becoming eligible in descending age order, while other provinces prioritized different occupations, risk groups or regional “hot spots” of infection.
Children were the last to get access to vaccines because clinical trials initially excluded these younger age groups. Youth 12 years and over got access to their shots starting in May 2021, while younger kids 5-11 had to wait until November 2021. Health Canada only approved COVID-19 vaccines in children younger than 5 this past summer.
Vaccine Uptake
Vaccine uptake increased dramatically once vaccines became available for the broader set of Canadians starting in March 2021, with most Canadians getting their second dose by the end of summer 2021. Starting in September 2021, Canada’s National Advisory Committee on Immunization (NACI) began recommending a third or booster dose for people whose immune systems were compromised, older adults and seniors in congregate living settings. NACI’s recommendation was later expanded to include a broader set of Canadians in December 2021 and now includes recommendations for an additional booster shot this fall, preferably with the newly approved, Omicron-containing bivalent vaccines.
As of October 2022, more than 85 per cent of Canadians had received at least two doses of COVID-19 vaccines. Excluding the almost 2 million children under 5 who only recently became eligible, only about 7 per cent remain completely unvaccinated.
Average cases: 19,000+/week
Kids <12 years
4.6% hospitalized, 0.7% died
Delta variant
Anyone over 12 years old
All Canadian provinces declared states of emergency at the start of the pandemic in March 2020. Over time, public health restrictions were gradually eased, only to be put back in place once case numbers began to increase again.
Researchers at the University of Oxford in the United Kingdom started tracking the government responses with the Oxford Stringency Index, a composite score of nine indicators for public health restrictions. It shows stricter lockdowns in large provinces like Quebec and Ontario as well as the maritime provinces that formed an Atlantic bubble, which restricted out of province travel during the early phases of the pandemic.
Oxford Stringency Index
Most provinces began gradually easing restrictions during the fall of 2021, with some lifting all restrictions, including mask mandates and vaccine passports, by the spring of 2022. This change shifted the responsibility for pandemic precautions from governments to individuals.
“The onus is now placed on the individual to make decisions, but without access to reliable information and data,” says Jennifer Kwan, a family physician in Burlington, Ont., advocating for more government policies to protect people, such as masks, improved ventilation, and other “layers of protection.”
Emma Kay, 19
Undergraduate student in Waterloo, Ont.During the 2020-2021 school year, I lived in residence. I couldn’t go into my friends’ rooms and school was all online. One day in March 2021, I was so frustrated with being isolated that I went to my first party off campus, which is where I contracted COVID. I isolated for 14 days in an isolation residence; my meals were brought to my door, and I couldn’t go outside.
After getting COVID, I felt more fatigued. I had to restructure how I study because I used to study late into the evenings.
I was so frustrated with being isolated that I went to my first party off campus.
At the time I got COVID, I wasn’t eligible to receive the vaccine. I got my first dose a month later, and then I got my second and third doses, too. Even after all the vaccines, I contracted COVID again in March 2022. When I got COVID during the third wave, I was afraid to tell people because of judgment. I didn’t want people to think I was reckless. I was just trying to meet people during a very isolating year at school.
Sam Black, 58
Philosophy professor in Burnaby, B.C.I contracted COVID from my wife in March 2021 and so did my two children. At the time, none of us were eligible for a vaccine. When COVID first came into the picture, I knew I needed to prepare by staying fit because I have an underlying condition called pulmonary sarcoidosis, which creates inflammation in my lungs.
My symptoms were body aches, temperature irregulation and fatigue, which were very debilitating. At the three-week mark, I saw on an at-home oximeter that my oxygen was 92 per cent and I went to the hospital.
Making an impact is part of who I am, and I’m not sure how I’m going to replace that.
Chronic fatigue has to be the most debilitating long COVID symptom; my lung capacity is significantly worse. I barely got through teaching through the last term at a 50-per-cent load. For this year, I’m on long-term disability, which will be approximately 70 per cent of my salary.
What has changed is my ability to contribute to the greater community. As a professor, I mentor students and am actively involved in certain aspects of their lives. Making an impact is part of who I am, and I’m not sure how I’m going to replace that.
Cailyn Guo, 20
Undergraduate student in London, Ont.In October 2021, I thought I had the “freshman flu.” I had both my vaccines and I didn’t go to any parties, only lectures. But after seven days of symptoms, including cold, cough and fever, I landed in the emergency room and tested positive.
It created a divide between my housemates and me because they judged me.
There were significant academic repercussions. I missed two weeks of lectures, most of which were not recorded. Because lectures were only available in-person, I saw many people, including myself, attend with COVID symptoms because we didn’t want to fall behind.
I had to let my floor in residence know that I had COVID, and the news spread quickly. It created a divide between my housemates and me because they judged me.
I also tried out for the figure-skating team while I had a mild cold. After receiving a positive test result, I emailed the coaches. I didn’t make the team for violating COVID protocols and missing tryouts. This was very disappointing because figure skating has been a huge part of my life.
It was hard seeing people going out for homecoming and getting sick with no repercussions. I felt like I was the only person at school who really suffered from not only the symptoms of COVID, but more importantly the social stigma and academic consequences.
Average cases: 99,000+/week
Young adults 20-29 years old
3.8% hospitalized, 0.6% died
Omicron BA.1 variant
Anyone over 5 years old
Through his tracking of the pandemic, Soucy sees specific eras of testing in Canada. In the initial wave, only a tiny fraction of cases were being tested, he says, followed by a relatively long period of adequate testing once provincial labs came on board and testing capacity increasing to match the demand.
But then came Omicron.
Starting in late December 2021, most provinces did away with mass testing as labs became overwhelmed by Omicron cases. For example, in Ontario, testing became restricted to symptomatic high-risk individuals and those working in high-risk settings. Testing of asymptomatic contacts of cases and confirmatory testing of positive rapid antigen tests was no longer recommended.
“The trends (for Omicron) become kind of impossible to directly compare with that second or first period,” notes Soucy. We also saw new data sources, such as wastewater surveillance, which tracks SARS-CoV-2 virus shedding in stool and doesn’t require access to testing, come online during this period.
Kwan, who until May 2022 had been tracking the pandemic weekly through her Twitter feed @jkwan_md, also saw a discrepancy in the numbers.
Through her family medicine practice, Kwan can pay attention to what people are saying on the ground to see if it matches up with the data. “There were so many patients with COVID-19 recently, but the (surveillance) numbers were not reflecting that because of undertesting,” says Kwan. “We know that case numbers are not as reliable.”
The lack of access to testing can have downstream effects on other surveillance indicators.
“Certainly, the most important change that’s happened over the entire course of the pandemic has been the change in access to testing toward the end of last year,” says Razak. “After that change occurred, we lost the ability to reliably know at an individual level how many people were infected.”
He predicts that we were likely undercounting the number of infections by two- to three-fold in the early phases before restrictions on testing were put in place. That’s because people with mild or asymptomatic infections wouldn’t necessarily seek out a test. However, after the change in access to testing, this ratio could be as high as 10- to 20-fold.
During the peak of the first Omicron wave, the Ontario COVID-19 Science Advisory Table estimated that rates were peaking between 100,000 and 120,000 cases per day in Ontario – a huge discrepancy compared to the reported number of cases based on testing alone.
Not only have the metrics changed over time, but what they mean has also changed. “We’re getting to the point where we don’t need to know every single case that’s being reported,” says Isha Berry, a recent PhD graduate at the University of Toronto and, along with Soucy, one of the co-founders of the COVID-19 Canada Open Data Working Group.
Rather she focuses on the upward or downward trends in the data. “For decision-making and for the general public, I don’t think knowing the exact number is as crucial at this point in the pandemic.”
Average cases:40,000+/week
Older adults 70+ years old
7.5% hospitalized, 1.0% died
Omicron BA.2 variant
Anyone over 5 years old
Michelle Levy, 51
Family doctor in St. John’s, NLIn February 2022, after receiving three doses of the vaccine, I contracted COVID from my daughter, who got COVID from school. My symptoms were mild: a cold, sore throat and fatigue.
Burnout in a way has been normalized: being short staffed, longer hours and more patient deaths.
In March 2022, there was an outbreak in the long-term care dementia unit where I work. The outbreak hit us later in the pandemic, likely due Newfoundland’s strict border rules, which ended in 2022. Every single patient was presumed positive. All the patients had dementia. Those with mild symptoms would wander out of their rooms, which made it difficult to keep patients isolated. We lost one-fifth of our patients during this outbreak.
Burnout in a way has been normalized: being short staffed, longer hours and more patient deaths. At one point, there were just physicians on the ward. All the nurses, administrators and receptionists were sick with COVID and us physicians were trying our best to provide the same level of care. Outside of work, the stressors continued. I have three kids and at times they were in virtual school. I had to wear many hats: mother, teacher and physician.
Gemmalyn V., 41
Caregiver in TorontoIn January 2022, my two daughters, my husband and I all tested positive for COVID. Somehow, my son never caught it. I’m not sure where we picked it up, possibly my daughter’s school, but COVID was spreading so rapidly we don’t really know. At the time, I had received two vaccines. I had body aches and a cold. However, my 1-year-old daughter developed a fever and a horrible cough, and we called her pediatrician who prescribed a puffer. It was very scary to be a mother and see my child so sick.
I was so scared to go into work. I was always wearing a mask and washing and sanitizing my hands.
As a caregiver, I was so scared to go into work. I was always wearing a mask and washing and sanitizing my hands. Even though wearing a mask all day isn’t comfortable, I know it’s the safest way to go. The families I work for were good with social distancing protocols, and throughout the pandemic we tried to keep our distance from one another.
Celina Clarke, 31
Server in TorontoI started working at a brewery in sales and as a server in August 2021. When the mask mandate was lifted, it was a relief. However, when the sixth wave hit in April 2022, I contracted COVID at a staff party. After that, I wore a mask in the workplace.
Working in an enclosed space with customers was stressful. If I could have worked from home, I would have.
My symptoms were fatigue, headache, sore throat and congestion. After five days of isolation, I returned to work while I still had mild symptoms. After a few days, I decided to isolate again until my symptoms went away. I received three paid sick days, which was a big help financially. I happened to schedule some time off, so I didn’t miss much salary. I’d received three vaccine doses by my time of infection.
When Omicron hit, our restaurant closed, and we were only working retail. Thankfully, I was employed for the same number of hours. Working in an enclosed space with customers was stressful. If I could have worked from home, I would have. I only entered the industry in August 2021, so I missed most of Ontario’s lockdowns. But if I was in the industry earlier, I know it would have been frightening with all the uncertainty and closures.
Average cases: 23,000+/week
Older adults 70+ years old
8.6% hospitalized, 1.2% died
Omicron BA.4/5 variant
Anyone over 6 months old
Data Sources:
- Berry I, Soucy J-PR, Tuite A, Fisman D. Open access epidemiologic data and an interactive dashboard to monitor theCOVID-19 outbreak in Canada. CMAJ. 2020 Apr 14;192(15):E420. https://art-bd.shinyapps.io/covid19canada/
- Little N. COVID-19 Tracker Canada. 2022 Oct 28. https://covid19tracker.ca/vaccinationtracker.html
- Oxford COVID-19 Government Response Tracker. Oxford, UK: Blavatnik School of Government, University of Oxford; 2022 Oct 30. https://www.bsg.ox.ac.uk/research/research-projects/covid-19-government-response-tracker
- Public Health Agency of Canada. COVID-19 daily epidemiology update. Ottawa: Government of Canada; 2022 Oct 28. https://health-infobase.canada.ca/covid-19/epidemiological-summary-covid-19-cases.html
- Public Health Agency of Canada. Canadian COVID-19 vaccination coverage report. Ottawa: Government of Canada; 2022 Oct 17. https://health-infobase.canada.ca/covid-19/vaccination-coverage/
- Statistics Canada. Preliminary dataset on confirmed cases of COVID-19, Public Health Agency of Canada. Ottawa: Government of Canada; 2022 Oct 14. https://www150.statcan.gc.ca/n1/pub/13-26-0003/132600032020001-eng.htm
- Various national and provincial government websites, surveillance reports, and media releases
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What an incredible look back. Thank you