Growing toll of COVID-19 on hospitals & population health should concern us

New data from Statistics Canada and the Canadian Institute for Health Information (CIHI) paint a troubling picture of the growing toll of COVID-19 on population health and provincial health systems. These findings come as public health authorities and governments have rolled back most measures that reduce SARS-CoV-2 (the virus that causes COVID-19) transmission, even as we head into respiratory illness season with hospitals already under severe strain.

For the third year in a row, life expectancy at birth declined in Canada, from 81.6 years in 2021 to 81.3 years in 2022. The decline (-0.3 years) was greater than in 2021 (-0.1 years), but less than 2020 (-0.6 years).

Changes in life expectancy are influenced by a number of factors, including COVID-19 and the toxic drug poisoning crisis. Even as provinces undercount COVID-19 deaths, the official number of these deaths increased in Canada from 14,466 in 2021 to 19,716 in 2022—the highest number of deaths recorded since the pandemic began. As well, COVID-19 took third place for leading causes of death—up from fourth place in 2020 and 2021.

But it is not just the impact of acute COVID-19 infection and death that should concern us. As much as some want to shrug off COVID-19, we can’t afford to be in denial about the ongoing impacts of this virus on population health, health systems and labour force participation.

CIHI data show the following between 2021-22 and 2022-23 (Table 1): 

• the number of COVID-19 hospitalizations increased 19% in Canada (excluding Quebec) and 7% in BC (1,260 more patients were hospitalized in 2022-23 than 2021-22).
• the average length of hospital stay increased 52% in Canada and 64% in BC (almost double the increase in Ontario).
• the estimated total cost of hospitalizations increased 16% in Canada and 5% in BC (from $477.3 million in 2021-22 to $501.9 million in 2022-23).

Additional CIHI data for 2021-22 show that COVID-19 is placing a greater burden on hospital workforces across Canada:

• There was a 17% increase in sick time from the previous year, causing a shortfall of about 6,500 full-time equivalents (FTE) that year.
• There were more than 14 million overtime hours or a 50% increase from the previous year (about 7,300 FTE).
• Although private agency staff (contracted by hospitals to work in hospitals) only comprised about 1% of total worked inpatient hours in Canada, there was an 80% increase in the number of purchased hours from these for-profit staffing agencies. 

In BC, there was a 30% increase in purchased hours for inpatient nursing services between 2019-20 and 2020-21, although public payments to these corporations have increased seven-fold between 2018-19 to 2021-22, according to a CTV investigation.

Sources: Author’s calculations from CIHI, COVID-19 Hospitalization and Emergency Department Statistics, 2021–2022 and 2022–2023, Table 1. Note: COVID-19 hospitalizations include both confirmed and suspected cases. Click table for larger view.

The limitations of official COVID-19 hospitalization data

According to the data, BC has not experienced the greatest COVID-19 hospitalization burden among the provinces.

Ontario, the Maritime provinces and Newfoundland and Labrador saw the greatest increase in the number of patients hospitalized and hospital costs. BC, Alberta, Manitoba and the Maritime provinces experienced the greatest increase in average total length of stay. (Caution should be exercised when interpreting BC hospitalization data since low testing rates and a high testing threshold underestimate COVID-19 cases.)

Nonetheless, these measures of COVID-19 burden on health systems are moving in the wrong direction in most provinces, including BC, even as public health authorities and governments have ended most infection prevention and control strategies aimed at reducing viral transmission in health care and congregate settings. (For example, the BC Centre for Disease Control school guidance suggests COVID-19 be treated as other communicable diseases and health care outbreaks are not often declared.)

The problem is that public hospitals in BC—and across the country—are under severe strain and many are routinely closing emergency departments or delaying scheduled surgeries. In BC each week, 15,000 health care workers, on average, call in sick, compared to 9,000 in pre-pandemic times. This high level of ongoing strain on provincial health systems cannot be sustained without a significant increase in the workforce, hospital bed capacity and public expenditure—without restricting access to basic health care services. But the health care workforce is fixed in the short-term as it takes years to train additional providers and evidence also suggests that we are not retaining the existing workforce. Without a change in COVID-19 strategy, the toll of this disease on population health is likely to compound already-severe health system challenges  and give proponents of privatization greater fodder, despite the fact that two-tier health care and for-profit delivery increase wait times and costs.

The long-term effects of COVID-19

Over the last three years, much attention has been rightly focused on the acute phase of COVID-19, which can lead to severe outcomes including hospitalization and death. However, we now know much more about the long-term complications associated with COVID-19.

A growing body of biomedical evidence tells us that COVID-19 presents as a respiratory infection in the acute phase, but it should be understood as a multi-system disease that can cause organ damage and long-term complications (or long COVID) even when individuals experience “mild” acute infections. An estimated 15% of adult Canadians—or 1.4 million people—say they experienced long COVID, which includes  respiratory, cardiovascular, neurological and cognitive impairments that can be debilitating. Vaccination may reduce risk, but does not eliminate it. Long COVID is a risk with each reinfection.

As biomedical researchers search for answers to understand the effects of this virus on multiple organ systems, the risk of vascular and neurologic complications should be reason enough to improve efforts to reduce transmission. A new study found that SARS-CoV-2 “infects coronary vessels, including plaque inflammation that could trigger acute cardiovascular complications and increase the long-term cardiovascular risk.” In children, COVID-19 infection is associated with increased risk of developing type 1 diabetes and the same relative risk for long COVID as adults. Long COVID research points to a range of abnormalities in the nervous system, brain, heart and lungs. COVID-19 is a multi-system disease, not simply a respiratory illness.

Provinces need COVID-19 public health strategies

In a welcome move on September 28, BC Provincial Health Officer Dr. Bonnie Henry and Health Minister Adrian Dix announced the return of universal masking in hospitals and health authority facilities (not including doctor’s or dentist’s clinics). This measure will help protect patients and health care workers from COVID-19 infection and reduce the potential for health care facilities to amplify community transmission. 

However, the return of mandatory hospital masking will not be sufficient to blunt COVID-19 surges this fall and winter nor the pressures placed on health care, public services and workplaces. As experts and advocates have argued, we cannot rely on a vaccine-only approach to COVID-19, with very limited public health interventions. Instead, we need a paradigm shift in how government and public health officials respond to the ongoing burden of COVID-19 through a “vaccines-plus” strategy. This would entail: 

• Clear public education that COVID-19 is airborne and spreads like cigarette smoke.
• Public education that tight-fitting masks and respirators like N95s are superior to surgical and cloth masks.
• improving and regulating indoor air quality in workplaces and high-risk congregate settings (e.g., schools, daycares, health care), through ventilation, air filtration and carbon dioxide monitoring.
• A culture of rapid testing in order to prevent spread and public provision of lab-based testing to confirm diagnosis.
• Provision of at least 10 days paid sick leave since public health guidance relies on workers having sufficient sick leave for themselves and caregiving responsibilities.
• Staying up-to-date on vaccination.

The good news is that these measures are low-burden and low-cost for government relative to the growing cost of inaction. For example, purchasing HEPA air filtration units for every classroom and child care facility would cost roughly $70 million with annual filter replacement costs around $30 million. (Or schools could build DIY Corsi-Rosenthal air purifier boxes for a fraction of the cost, which some districts have prevented parents from donating.)

Research shows that 70% of US household COVID-19 transmissions started with a child. When epidemiologist John Snow discovered that infected drinking water caused cholera in 19th Century London, governments rose to the challenge and developed sanitation systems. Likewise, we need to clean the air of airborne pathogens.

If we want to sustain public health care in this country, maintain timely access for everyone and protect population health, governments must develop smarter policy strategies to reduce the burden of COVID-19. Ignoring the ongoing impact of COVID-19 is not a strategy.

Topics: COVID-19, Health care