ST. PAUL — In January 2021, the world was hopeful as newly approved COVID-19 vaccines appeared to promise an end to a global pandemic wearing on into its second year. But a year later, the situation seems dire as ever as yet another variant of SARS-CoV-2 sends infection rates across the U.S. soaring to heights not seen since the worst days of the pandemic.

The highly infectious omicron variant of COVID-19, which appears to spread more quickly than the already more infectious delta variant that preceded it, has only worsened an already bleak picture in Minnesota and the Dakotas, where hospitalizations and key metrics public health risk grew from the fall into early winter in a persistent fourth wave of infections.

Minnesota entered 2021 with fewer than 500,000 confirmed infections, but by the end of the year hit the 1 million mark. As of Thursday, Jan. 6, 1,469 were hospitalized for COVID-19 in Minnesota, a number close to highs not seen since late 2020. A seven-day average positive test rate of 15.6% at the end of December topped the very worst of the pandemic. North Dakota this week also saw its highest positive rates of the pandemic, and hospitalizations in South Dakota reached their highest levels in over a year.

Michael Osterholm, director of the Center for Infectious Disease Research at the University of Minnesota, warned early on that variants could spoil any hope of a return to normalcy.

Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota and former state epidemiologist at the Minnesota Department of Health. Submitted photo.
Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota and former state epidemiologist at the Minnesota Department of Health. Submitted photo.

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"As someone quite involved with the pandemic response, I was in a different place," he told Forum News Service. "I publicly stated a year ago that I thought the darkest days of the pandemic could still be ahead of us. That was not a popular comment, but I understood the potential impact of these variants."

Dr. Jack O'Horo with the Mayo Clinic, who has worked closely with COVID-19 patients in intensive care since the beginning of the pandemic, said he and his colleagues took vaccines and declining cases in January 2021 as a victory but also shared Osterolm's caution.

"There was a very profound sense of relief when the counts were going down, and the vaccinations were going up," said O'Horo, a Rochester-based physician. "But there was also the evidence of a variant and concern about that variant coming here."

As cases started to ebb further in the late spring and early summer of 2021, the delta variant, identified in India in late 2020 and designated a variant of concern by the World Health Organization in May 2021 was spreading worldwide. It was first identified in the U.S. in February and by the end of the year would make up nearly all the infections in the country.

Still, for a moment in mid-2021, the pandemic appeared to have shrunk back to a point where many in the public felt they could let their guard down. In late June, Minnesota positive test rates dipped to a pandemic low of 1% and COVID-19 related hospitalizations dropped below 100 in July. Just a half-year before, more than 1,800 hospitalizations nearly pushed the state's health care system to the breaking point.

But even during that lull, it wasn't a break for health care systems, said Dr. Peter Henry, Brainerd Lakes area Chief Medical Officer for Essentia Health, who heads the care provider's COVID-19 response. When the virus started to let up in early 2021, hospitals and clinics then had to deal with deferred care such as cancer screenings and routine care for patients with diabetes and cardiovascular disease, Henry said.

There was little respite for health care workers pushed to the limit from treating COVID-19 patients. The state lost about 1,000 staffed hospital beds due to staffing issues since the beginning of the pandemic, according to Henry, who said Essentia Health has partnered with the University of Minnesota to recruit more nurses in order to counter losses.

Essentia Health officials held the same cautious optimism as Osterholm and O'Horo, and prepared for yet another round of COVID-19 infections.

"People were very taxed and stressed and there was some relief," Henry said. "But I don't think that any of us really felt there wasn't a potential surge coming forth in the future."

How it started ... how it's going

Samples are loaded into a sequencer at the Minnesota Department of Health Public Health Laboratory. Some but not all positive COVID-19 tests have their entire genome analyzed in order to determine their variant. Minnesota Department of Health / Contributed photo
Samples are loaded into a sequencer at the Minnesota Department of Health Public Health Laboratory. Some but not all positive COVID-19 tests have their entire genome analyzed in order to determine their variant. Minnesota Department of Health / Contributed photo

O'Horo groups the pandemic into three phases. The first he calls the "unknown" phase, a period that extended from March to December 2020 where no vaccines were available and health care professionals were still refining how to treat coronavirus disease. At this point, the key tools for combatting COVID-19 — and lessening an overrun on hospitals were still public health measures like masking and social distancing. Some relief came in early 2021 with the vaccine.

"There was a lot of hope that we would have a reprieve for a few months," O'Horo said. "But amongst those who were keeping an eye on the international situation with India in particular there was a lot of concern that this would be coming back again."

By August, the concerns of public health officials and many doctors were realized: Delta had taken a major foothold in the U.S. and was driving a renewed wave of infections that could once again overwhelm hospitals. Then opened what O'Horo calls the variant phase.

By December 2021, hospitalizations reached more than 1,600 and appeared to be approaching an all-pandemic high for the state. "We're heartbroken. We're overwhelmed," said a full-page newspaper advertisement from major Minnesota health care providers pleading with the public to take greater precautions against the virus.

The plea from the health care systems came just weeks after the WHO identified a new variant of concern in late November: omicron. Officials identified the new strain in the U.S. shortly after, and while cases and hospitalizations around the region dipped slightly by the end of the year, they were rocketing up once more by early January as omicron became the dominant variant in the U.S.

"It has certainly been something of a blow to morale when there was that light at the end of the tunnel at one point," O'Horo said. "With all that being said it looks like we are far closer to the end of the pandemic than we've ever been between the effectiveness of vaccination and ... the milder nature of omicron."

O'Horo says it seems like there could finally be an end in sight, meaning we could be entering a third phase of the pandemic – one where we truly begin to learn how to deal with the disease. Though it's likely there are still a few tough weeks ahead.

"The peak will be the next three to four weeks," said Osterholm, the university infectious disease expert. "It's going to be a challenge, we're going to see many of our everyday work locations severely stressed, health care is going to be at the top of the list … We're going to have a lot of people out sick."

While the evidence so far suggests omicron is less deadly than previous variants, its infectiousness still poses a significant threat to the health care system.

"Proportionally, the people may have a lower rate of serious illness," Osterholm said. "But if that many more people who are infected you can still have the same burden."

And while it's generally accepted that viruses tend to become more infectious and less deadly over time, Osterholm says there's no guarantee that's the case with SARS-CoV-2 — even if the newest variant seems to be following that course.

His concern? We have no idea what might come next.

"That's true now for omicron, but we don't know if the next one may evade immune protection from omicron and from delta and be more infectious — we just don't know."