For the first time since July, California hospitals have topped daily totals of 5,000 patients with COVID, an alarming sign as cases continue to spike from Thanksgiving with the next round of holiday gatherings on the horizon.

Hospitalizations are one of the most significant indicators of the virus’ impact, because fewer people are reporting positive tests in this third winter of the pandemic. Across the Golden State, hospitals are now just a few dozen beds shy of the peak of 5,181 from this summer’s surge, despite the official COVID case rate registering at just half of this summer’s peak.

But with cases continuing to rise, hospitals are bracing for a further influx of new patients — and not just from COVID. Hospitals also are dealing with one of the worst flu seasons in five years, and the respiratory illness RSV has been overwhelming pediatric wards.

“Last year we were dealing with an explosion of one disease,” said Dr. John Swartzberg, clinical professor emeritus of infectious diseases and vaccinology at UC Berkeley’s School of Public Health. “This year we’re dealing with a surge of three.”

Swartzberg said hospitals already are stressed, “and we have not yet seen the full effect of Thanksgiving, we haven’t seen any effect of the Christmas parties, much less Christmas, much less the New Year.” He thinks it is “highly likely” hospitalizations will continue to rise over the course of the month, and influenza hospitalizations are rising quickly, too.

On Thursday, much of California entered the CDC’s high transmission level for COVID-19. Now, all of the Bay Area, the Central Valley and Southern California have reached that level. In addition, eight of the 58 counties — Santa Clara, San Benito, Santa Cruz, Tuolumne, Kings, Los Angeles, San Bernardino and Imperial — are in the high community risk level, which reflects the COVID-19 impact on local hospitals. L.A. reached a benchmark that could trigger a return to an indoor mask mandate. Other counties have not considered a return to masking yet.

The good news: Three years in, and the pandemic hasn’t ended, but the risk of getting severely ill and dying from a COVID infection has dropped dramatically, thanks to vaccinations and therapeutics.

So why are more patients ending up in the hospital now?

“There’s no evidence that there’s increased virulence,” Swartzberg said, although he warns “there’s no guarantee that won’t be the case” with future variants.

The real culprit? There’s a lot of COVID out there, even though the state’s official case rates don’t fully reflect it.

“We were counting better this summer,” he said, but now we are catching fewer real-life COVID cases in our official COVID counts. That’s happening primarily because of the prevalence of home testing, which rarely gets reported to tracking agencies.

Even so, the official tallies say that cases across California have nearly tripled since late October, with the case rate topping 22 daily cases per 100,000 residents last week, according to Thursday’s update by California Department of Public Health.

“Case data is not worthless,” Swartzberg said, “but it’s not very valuable,” at least in terms of measuring the level of COVID in the real world. He points to other data sources, such as asymptomatic test positivity rates and wastewater data, which measures levels of the virus in a community by testing its sewage. “There’s an enormous amount of COVID in the wastewater, more than we’ve seen in a long time.”

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Wastewater data around the Bay Area is indeed showing signs of COVID spiking and has reached all-time highs, since the data started being collected about a year ago in Palo Alto and parts of San Francisco and Santa Clara counties.

Amid the surge, public health officials have been encouraging people to get the most recent COVID booster and to get their annual flu shots. The Food and Drug Administration on Thursday authorized both the Pfizer and Moderna COVID-19 booster shot updated for omicron variants of the virus for children as young as 6 months, paving the way for the shots to be available to infants, toddlers and preschoolers if the Centers for Disease Control and Preventions recommends them.

But interest in the booster has been low, despite the pleadings from national, state and local health officials. The CDC reports nearly 40 million Americans ages 5 and up now recommended for the boosters have gotten one, but that’s less than 13% of those eligible. In California, 5.5 million, or less than 15% of those eligible, have had the updated booster.