Viral Swarm: ‘Tripledemic’ Pushes Healthcare Facilities to the Brink
An epic flu season, COVID-19 surge, and RSV roar back
January 1, 2023
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Respiratory infections are causing hospitalizations and deaths nationally in an unprecedented trifecta of influenza, respiratory syncytial virus (RSV), and COVID-19.
Although RSV has plateaued and is dropping in some regions, it has hit pediatric facilities particularly hard when combined with what could be a flu season for the ages.
“I worked in pediatrics for 25 years and it was never like this — we’re in a perfect storm,” says Pat Jackson, RN, BSN, CIC, FAPIC, president-elect of the Association for Professionals in Infection Control and Epidemiology (APIC).
The Biden Administration has promised federal assistance to state governors after some pediatric associations petitioned for the declaration of a public health emergency in a Nov. 26, 2022, letter.
The pediatric groups emphasized that “unprecedented levels of RSV happening with growing flu rates, ongoing high numbers of children in mental health crisis, and serious workforce shortages are combining to stretch pediatric care capacity at the hospital and community level to the breaking point.”1
Adding considerable fuel to the fire, two pediatricians recently authored a scathing editorial that said pediatrics has been largely abandoned, although the field came to the aide of adult facilities when COVID-19 first hit in 2020. Children generally were unaffected then, and the pandemic derailed the seasonal outbreaks that traditionally hit pediatrics: influenza and RSV.
“Health systems were lulled into maintaining reduced workforces and bed capacity modeled on pediatric volumes during the prior year,” the authors write.2 “[Now], an overwhelming burden of viral respiratory diseases is taxing pediatric providers and adding considerable stress to families with infants and young children,” the authors add. “Clearly, the [United States] sacrificed the health and education of children to support a crisis that disproportionately affected adults.”
In a development that could at least afford more children some protection going forward, the Food and Drug Administration (FDA) approved the use of the COVID-19 bivalent booster shots for children as young as 6 months of age.3 Although there are stipulations based on receipt of the primary shots by Moderna and Pfizer, the move lowers the age limit for the booster from 5 years of age, opening up COVID-19 immunization to millions of children.
The challenge is getting people vaccinated. There was a sense of urgency at a Dec. 5, 2022, press conference by the Centers for Disease Control and Prevention (CDC). In addition to “booster fatigue,” there is less uptake of vaccines in general, said Rochelle Walensky, MD, director of the CDC.
“We have seen under-vaccination in many diseases, not just in influenza and COVID 19, but also a drop in pediatric vaccinations as a whole,” Walensky said.
The public may have become complacent when COVID-19 public health measures tamped down other viruses, said Sandra Fryhofer, MD, chair of the American Medical Association (AMA) Board of Trustees.
“Over the last few years, COVID protective measures also prevented spread of flu and other respiratory infections, but we’re really no longer in that bubble,” she said at the CDC briefing. “That’s why it’s so important to get vaccinated for both flu and COVID. And you can get both vaccines at the same time. I know everyone’s tired of getting shots but understand — you could get really sick this year if you don’t get vaccinated.”
Pregnant women also can protect their newborns from influenza and COVID-19 by being immunized for both, as recommended by the CDC.
A ‘Viral Winter’
Although the seasonal influenza vaccine is thought to be a good match with the circulating strains, flu exploded out of the gate and shows no signs of leveling off.
“In Dallas, flu positivity is at 25%,” says Jackson, infection control director at White Rock Medical Center in the Texas city. “That means one out of every four people tested has the flu. And it is just going up — there is no down in the curve yet.”
As of Dec. 9, 2022, the CDC reported that “so far this season, there have been at least 13 million illnesses, 120,000 hospitalizations, and 7,300 deaths from flu. Seven influenza-associated pediatric deaths were reported this week, for a total of 21 pediatric flu deaths reported so far this season.”4
The CDC did not know the vaccine status of these patients but said at the press conference that about 80% of pediatric flu deaths are unvaccinated.
The cumulative hospitalization rate in week 48 — a metric used in CDC surveillance — has not been seen since the flu season of 2010-2011. Of influenza A viruses subtyped this season, an estimated 75% have been influenza A(H3N2) and 25% have been influenza A(H1N1). There also are reports of some circulating B strains. Thus far, no flu strains have shown resistance to antiviral treatment.
“The majority of influenza viruses tested are in the same genetic subclade as — and antigenically similar to — the influenza viruses included in this season’s influenza vaccine,” the CDC stated.
That encouraging finding is tempered by the caveat that the vaccine may not prevent initial infection but will keep many of those immunized out of the hospital and the morgue. Thus, the CDC recommends that everyone 6 months of age and older get vaccinated annually for influenza.
“We have to remember that influenza vaccine works best — as does the COVID vaccine — in preventing serious illness,” says William Schaffner, MD, Vanderbilt professor and medical director of the National Foundation for Infectious Diseases (NFID). “It’s not nearly as good at preventing the disease completely. Of course, it can do that in younger persons with strong immune systems, but older people may get influenza despite being vaccinated. But the vaccine is still a great success if they don’t get admitted to the hospital.”
Although vaccine efficacy data remain to be determined for this season, hospitalizations are occurring in both unvaccinated people and frail vaccinated people. “We have to acknowledge that the vaccine is not perfect,” he adds.
The course of a single flu season is infamously difficult to predict, thus the old infectious disease adage, “If you’ve seen one flu season, you’ve seen one flu season.”
“Last year, we had a late November-early December surge that went into January and we thought that we were going to have a very substantial flu season,” Schaffner says. “About the second week in January, cases just plummeted. It was a very abbreviated flu season, though it smoldered for a long time. We hope this one declines quickly, because if it continues — and there have been other flu seasons lasting for two to three months — we could be in for a very substantial viral winter.”
From an infection control perspective, the three viruses call for similar patient isolation measures, but there are a few key differences.
“We treat COVID with enhanced precautions, wearing an N95 [respirator] and eye protection,” Jackson says. “Flu isolation calls for droplet precautions where [healthcare workers] wear a surgical mask. COVID is probably in some category between droplet and airborne.”
Having spent most of her career in pediatric hospitals, Jackson said isolation precautions for RSV patients typically are a combination of droplet and contact, with personnel using surgical masks, gowns, and gloves.
Healthcare settings also should emphasize respiratory hygiene measures, such as covering coughs to prevent spread among patients in waiting areas and in general.
Jackson reminded that APIC took a firm stand on masks when the CDC moved to loosen recommendations for universal masking in healthcare a few months ago. (See Hospital Infection Control & Prevention, November 2022.)
“We encouraged our members to continue universal masking policies in patient care areas because we were afraid of what this flu season was going to look like,” Jackson says. “Here we are, seeing a very early season and a lot of flu around the nation.”
In that regard, the CDC is considering recommending some measure of indoor masking again to prevent respiratory infections in general, a concept that has been practice for years in some cultures.
“It’s something that we are actively looking into at CDC,” Walensky said. “In the meantime, one need not wait for CDC action in order to put a mask on.”
Currently, the CDC recommends such masking in communities that have high levels of COVID-19 transmission, people traveling on public or commercial transportation, and those at high-risk of complications, she added.
Similarly, Schaffner is encouraging the elderly and people with underlying conditions to mask up for indoor gatherings.
“I am suggesting to people — particularly older people or those with an underlying illness, such as diabetes, heart disease, or lung disease — if you are going to a shopping mall or religious services, a concert or a business meeting, wear a mask,” he says. “I certainly do in those circumstances. I think a lot of people in the high-risk groups have learned over the last two years that social distancing and mask wearing really offer another degree of protection. They will [don masks], but will the general public? I think it is unlikely, but I keep focusing my message on high-risk groups.”
COVID-19 Poised to Surge
Lest we forget, we still are in a pandemic, and this virus never sleeps. As of Dec. 9, 2022, the daily average of new cases was 66,179, an increase of 53% over the prior two weeks. Hospitalizations were 30% higher (37,066) over the same time period. Deaths increased 35% over the prior two weeks, with a daily average of 460.5
Hospitalizations are at the highest level they have been over the past three months, reflecting a post-Thanksgiving increase that was widely predicted. The number of patients in ICUs with COVID-19 also is climbing, meaning all indications are that COVID-19 is taking off again.
“Avoiding a surge seems less and less likely,” Andrea Garcia, MD, vice president of science, medicine, and public health at the AMA, said in a video update. “The relative stability that we had for a number of weeks could be coming to an end.”
SARS-CoV-2 continues to hit the elderly population, with nearly nine out of 10 deaths in those 65 years of age and older, she said.
“That’s the highest rate [in that population] since the pandemic began,” Garcia said, noting people are dying of COVID-19 at about two to three times the rate they die of flu.
There is an ongoing push to get people in high-risk groups vaccinated with the bivalent boosters that include an Omicron component. Only 13.5% of the population over 5 years of age and older have received the shot as of Dec. 9, 2022.6 Early efficacy data make this low vaccine uptake all the more frustrating.
“Early surveillance shows that people who received their updated COVID-19 vaccine this year were nearly 15 times less likely to die from COVID-19 compared to people who are not vaccinated,” Walensky said.
The bivalent booster contains elements of Omicron subvariants BA.4 and BA.5. In a result that was anticipated, new Omicron subvariants have taken over, with BQ.1.1 comprising 37% and BQ.1 at 31% of circulating virus. BA.4 is completely gone and BA.5 was down to 12% of deoxyribonucleic acid-sequenced virus in CDC tracking as of Dec. 9, 2022.7 The FDA and its vaccine advisors knew that this viral mutation was likely when approving the bivalent booster, but reasoned that the subsequent emerging Omicron subvariants would be closely related to their predecessors.
That appears to be the case, since the bivalent vaccines showed “additional protection” in a recent study by the CDC.
“Among symptomatic adults who received testing for SARS-CoV-2 infection at pharmacies nationwide during Sept. 14-Nov. 11, 2022, bivalent messenger ribonucleic acid vaccines provided additional protection against infection compared with previous vaccination with two, three, or four monovalent vaccines alone,” the CDC reported.8 Results from this study show that bivalent boosters provide protection against symptomatic SARS-CoV-2 infection during circulation of BA.4/BA.5 and their sublineages, and restore protection observed to wane after monovalent vaccine receipt.”
“If you’ve received only your primary COVID vaccine series, you are considered fully vaccinated, but you are not considered fully protected,” Walensky said. “To be best protected against severe disease this winter, you should get an updated vaccine as soon as you can.”
RSV Hits Home
There is no vaccine for RSV, which has stormed the stage in a way that makes a prior NFID call to action on this under-appreciated virus seem fairly prescient.9
“Related to our call to action, we said that the general public and even some healthcare workers are just not attending to or are aware of RSV and how it is a lifespan virus,” says Patsy Stinchfield, RN, MS, CPNP, president of the NFID. “We think of it as a pediatric virus, especially in infants and premature babies, so we really were wanting to make sure that healthcare workers and those who care for the elderly were very aware of RSV.”
The explosion of RSV that began in November has sufficiently raised awareness, almost swamping the pediatric health system in the process.
“Careful what you hope for,” she says. “RSV is on everyone’s lips and on the national news. They used to say ‘another virus,’ then started calling it RSV, and now they are actually saying respiratory syncytial virus. We did not anticipate RSV becoming as dominant a virus as it is right now. What we are seeing is really historically early and historically high levels of RSV in much of the country.”
Although it appears that RSV may have peaked and is in decline in some regions of the country, Stinchfield is wary of too much presumption about a virus that is acting atypically.
“For the most part, RSV is similar to influenza, beginning in late fall and kind of taking off after we gather at Thanksgiving, and then peaks in January and goes down,” she says. “This is the second year in a row we are seeing really unusual behavior by this virus. Remember, we had a July RSV peak [in 2021] that was very out of character at the national level, and now it seems to be a November emergence. It almost seems as if the virus is trying to get back to its usual winter peak.”
As far as the risk across the lifespan, the NFID report emphasized that RSV causes 177,000 hospitalizations and 14,000 deaths annually in the United States in those age 65 years and older. “We are definitely seeing RSV in all age groups, and I can tell you my family is almost like a little case study,” Stinchfield says. “My husband is the oldest at 66. I am 64, our daughter and son-in-law are in their 30s, and their two children are preschoolers — a 3-year-old daughter and 16-month-old son.”
The family outbreak began with a common pattern, with the toddler infected in an RSV outbreak at preschool and bringing the virus home.
“Other kids in the class were tested, so we are pretty sure it was RSV,” Stinchfield says. “She was sick for the seven to 10 days that is common for kids. Her little brother was a little less sick — maybe just a week. Her parents were sick with common cold symptoms, but my husband was the sickest. He had a fever and was in bed, then had a wheezy-type cough for three to four weeks. I have been around RSV my whole pediatric career, so I have some antibodies. I did get a cold, but it was very mild for me. That is a good example of the way RSV goes across the lifespan.”
There is more effort now to identify RSV, in part to discern the virus from flu and COVID-19. The two latter viruses have antiviral treatments available that can prevent disease progression if administered promptly.
“We really want to know if patients have something that is treatable,” she says. “There are more affordable rapid tests that typically are done in clinics and emergency departments. We are looking forward to the day where those types of rapid tests will be used at home like those for COVID. Adding RSV and flu to that [testing panel] is doable.”
REFERENCES
- American Academy of Pediatrics. Pediatric health care organizations call for national response on RSV and flu surge. Published Nov. 15, 2022. https://www.aap.org/en/news-room/news-releases/aap/2022/pediatric-health-care-organizations-call-for-national-response-on-rsv-and-flu-surge/
- Permar S, Vinci RJ. Pediatricians and parents on the brink: This is their March 2020. Stat. Published Dec. 6, 2022: https://www.statnews.com/2022/12/06/covid-influenza-rsv-pediatricians-parents/
- Food and Drug Administration. Coronavirus (COVID-19) update: FDA authorizes updated (bivalent) COVID-19 vaccines for children down to 6 months of age. Published Dec. 8, 2022. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-updated-bivalent-covid-19-vaccines-children-down-6-months
- Centers for Diseases Control and Prevention. Weekly U.S. Influenza Surveillance Report. Updated Dec. 9, 2022. https://www.cdc.gov/flu/weekly/index.htm
- The New York Times. Coronavirus tracker. Updated Dec. 9, 2022. https://www.nytimes.com/interactive/2021/us/covid-cases-deaths-tracker.html
- Centers for Disease Control and Prevention. COVID data tracker. Updated Dec. 9, 2022: https://covid.cdc.gov/covid-data-tracker/#vaccine-delivery-coverage
- Centers for Disease Control and Prevention. COVID data tracker. Variant proportions. Updated Dec. 9, 2022. https://covid.cdc.gov/covid-data-tracker/#variant-proportions
- Link-Gelles R, Ciesla AA, Fleming-Dutra KE, et al. Effectiveness of bivalent mRNA vaccines in preventing symptomatic SARS-CoV-2 infection — increasing community access to testing program, United States, September-November 2022. MMWR Morb Mortal Wkly Rep 2022;71:1526-1530.
- National Foundation for Infectious Diseases. Call to action: Reducing the burden of RSV across the lifespan. Published January 2022. https://www.nfid.org/publications/call-to-action-reducing-the-burden-of-rsv-across-the-lifespan/
Respiratory infections are causing hospitalizations and deaths nationally in an unprecedented trifecta of influenza, respiratory syncytial virus, and COVID-19.
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