A toddler receives treatment in the hospital for RSV, wearing a mask to help them breathe.

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Telltale signs of a 'tripledemic'

Now is the time to get your flu shots and bivalent boosters as hospitals and health care systems reach capacity with surging cases of flu, RSV, and COVID-19, says Brian Garibaldi of the Johns Hopkins Hospital Biocontainment Unit

Maura Kinney
Office phone

An uptick in sore throats, coughs, and fevers are telltale signs that flu season has arrived in the United States. But this fall, those common symptoms might be a sign of something more sinister: Public health experts warn we are likely facing a "tripledemic," the convergence of flu, COVID-19, and the respiratory syncytial virus, or RSV.

Early data suggests that the U.S. is in for a worse than average flu season, and high levels of RSV in children are already straining pediatric hospitals across the country. These factors, compounded by COVID and the ever-possible chance of a new variant, are sounding alarm bells in health care systems, says Brian Garibaldi, director of the Johns Hopkins Hospital Biocontainment Unit and an associate professor of medicine and physiology in the division of pulmonary and critical care, where he attends in the medical intensive care unit.

A booster shot is administered on the Homewood campus Jan. 11, 2022
Getting vaccinated at Hopkins this fall

A bivalent booster clinic is planned for Nov. 14 on the Homewood campus and is open to all affiliates by appointment via MyChart. Johns Hopkins Medicine offers a walk-in booster clinic as well as vaccination by appointment. Flu shot clinics are scheduled across the university this fall.

"We're dealing with the rise in RSV, the potential for a bad flu season, and another potential COVID surge, in the backdrop of a health care workforce that has been depleted over the last several years," Garibaldi says. "I think that's one of our biggest concerns: Can we sustain ourselves through these surges, provide care for the patients who need it, but also maintain the level of workforce that we need to be able to care for all the other health care issues that are happening in people's lives?"

Health systems have been able to sustain care thus far, but the trends are still concerning—RSV cases are high, both at Johns Hopkins Hospital in Baltimore and at Johns Hopkins All Children's Hospital in Florida. Although COVID-19 case numbers have been stable, he says he's concerned about an uptick in COVID-19 hospitalizations in New York, as the state is typically the bellwether for pandemic trends in the Northeast and mid-Atlantic.

Uncertainty abounds when talking about any infectious disease, but to better gauge what can be expected from this flu season and beyond, the Hub reached out to Garibaldi to get his insight on how to prepare for the possibility of a viral triple threat and stay safe this winter.

What can we expect from the "tripledemic" in the coming months?

It's early to know, but there are signs that we're likely in for a bad flu season. The estimated number of flu cases compared to pre-COVID flu seasons is well above what we would expect to see in October. In the southern hemisphere, which is usually a good benchmark for what our flu season might look like, and in Australia specifically, they had a much earlier peaking flu season with a higher case count. We're seeing similar trends in the U.S. as they saw at the start of the flu season in Australia. The good news is that this year's flu vaccine seems to be very effective at preventing severe disease, based on data from the flu season in Chile. Now would be a great time to go ahead and get your flu vaccine.

"There's a much larger pool of kids who are susceptible to RSV infection, and this is a big issue that we're dealing with at the same time as we're starting to see the flu rise."

The other thing that's important, and has a big impact, is what's happening with other respiratory viruses. RSV is normally most impactful in children, but it can also be a difficult virus for older individuals. I think part of the rise in RSV cases reflects the fact that many young children who normally would have already gotten RSV haven't yet, because of social distancing, masking, and school closures during COVID-19. There's a much larger pool of kids who are susceptible to RSV infection, and this is a big issue that we're dealing with at the same time as we're starting to see the flu rise.

And obviously, COVID is still out there. We're still seeing several hundred thousand cases a week of COVID throughout the U.S., and we're starting to see an uptick in some variants that are probably among the most immune-evasive variants that we've seen. How that plays out will depend on how many people get bivalent boosters, and how local communities respond to rises in COVID cases and hospitalizations.

COVID mitigation strategies—hand-washing, masking, social distancing—help prevent the spread of other illnesses. Should we consider bringing back some of those measures?

We have two or three years' worth of kids who don't have immunity from prior RSV infection, and we've removed a lot of effective mitigation strategies. We've reached a level of personal accountability with COVID. Part of me was hoping that we wouldn't get back to the old normal, where we accepted 30,000 to 50,000 deaths from the flu every year, and that we'd get to a point where we could use what's happening in the community to drive behaviors, such as wearing a mask in the grocery store when flu transmission is high. One of the ways you could tamp down RSV would be to institute some mitigation policies back, particularly in younger kids, but I've heard nothing about that in the media, or from political or health leaders, because it's probably not palatable or tenable right now.

"If you're eligible for a COVID vaccine or booster, now is the time to get one. If you're going to be getting a COVID vaccine, you should double that up with the flu vaccine."

It's sort of odd—people are showing up to work again with a cough, and they'll say, "Oh, it's not COVID." I don't think we've strengthened systems in place to allow people to raise their hand and say, "You know what? I think I have an infectious disease. It's not COVID because I tested negative, but I don't have a home test for the flu or RSV. So I'm going to work from home today so I don't get other people sick." People who are able to work from home should not be showing up to work clearly ill.

Accountability still exists in the hospital where we're wearing masks when we have patient encounters, and people are very careful about protecting patients and those who might be at higher risk of severe disease. But that doesn't seem like it translated over into our regular interactions outside of health care, which I think is unfortunate. There's an opportunity to learn from the pandemic. We could be applying some of those same principles from COVID prevention to flu and RSV.

How has COVID affected the way we look at other respiratory illnesses like the flu and RSV?

I wonder if things have changed because of the way our attitudes about COVID have changed. When COVID was first circulating, I think people were appropriately very concerned and doing their best to avoid getting sick if they were in a position to do so. And now that we have vaccines and boosters, oral antivirals, IV antivirals, monoclonal antibodies, dexamethasone, and anti-inflammatories, the death rate from COVID has decreased and the risk of severe disease or death for any one individual has gone down. I think in general, that has led to a relaxing of restrictions related to COVID, which has gotten us back into this mindset of, "Respiratory viruses will happen and, for the most part, you're going to be fine if you get one."

But we're forgetting that there are still going to be thousands of people who die every year from RSV, flu, and COVID for years to come. I don't know what the right balance is, to be very honest. I think we've moved to a system of personal accountability, but we haven't been having the discussions that maybe we should be in terms of defining what that accountability looks like. What's the obligation to test for COVID? What's your obligation to isolate from people if you're feeling sick? How do we navigate sending people to work when they're clearly unwell, and how do we navigate people sending children to school when they're unwell?

I say that recognizing that many people don't have the flexibility to get childcare for their kid who might not be critically ill but might have a transmissible virus. And many people are not able to miss work because of financial considerations. We need to have these discussions and rethink what school and work look like in a world where we have the tools to mitigate death and severe disease from these viruses, but we still have circulating viruses that can cause harm beyond just whether someone gets hospitalized.

What can people do to protect themselves from flu, RSV, or COVID-19?

If you're eligible for the COVID vaccine or a booster, you definitely want to get one. Ideally you want to get that vaccine booster two to four weeks before a surge, which is always hard to predict, but I think there's reason to worry that there might be another COVID variant surge in the U.S. in the coming months. If you're eligible for a COVID vaccine or booster, now is the time to get one. If you're going to be getting a COVID vaccine, you should double that up with the flu vaccine. I think we're now past the point of worrying about getting your flu shot too early in the season—we're seeing enough flu circulating so you want to get vaccinated now.

"If you clearly have a respiratory virus and you're able to stay home from work, then we encourage you to do that, and obviously try to keep your kids from going to school if they're clearly in the midst of an infection, if you can."

I would also ask people to be mindful of their own symptoms. If you clearly have a respiratory virus and you're able to stay home from work, then we encourage you to do that, and obviously try to keep your kids from going to school if they're clearly in the midst of an infection, if you can. Those measures will reduce community transmission and keep those viruses away from the most vulnerable, who are the ones most at risk of developing severe disease or dying.

My family and I are all eligible for vaccines, and we've been vaccinated and boosted with the bivalent booster as well as the flu shot. And we're just asking our kids to be accountable—if they wake up and they're not feeling well, we take their temperature. We're going to test them for COVID if they have a sore throat or a fever. If they're clearly ill, we're going to keep them out of school as best we can, and we hope other people are in a position to do the same.

Simple things like hand washing are a big deal and mitigate the spread of a lot of these respiratory viruses, which will sometimes spread from someone coughing on you, but also will spread when someone coughs on their hand, touches a doorknob, and you touch that doorknob and then wipe your nose. We all became skilled at hand hygiene during the pandemic, and that's something we need to continue to do. I also think people need to be mindful of the level of respiratory viral spread in their community and consider whether or not it might be appropriate to wear a mask in crowded indoor spaces this fall and winter.