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‘Tripledemic:’ What Happens When Flu, RSV, and COVID-19 Cases Collide?

BY CARRIE MACMILLAN December 6, 2022

Doctors share tips on how to stay healthy this winter.

[Originally published: Nov. 22, 2022. Updated: Dec. 6, 2022]

Note: Information in this article was accurate at the time of original publication. Because information about COVID-19 changes rapidly, we encourage you to visit the websites of the Centers for Disease Control & Prevention (CDC), World Health Organization (WHO), and your state and local government for the latest information. 

As a common respiratory virus surges in children across the country, flu cases climb, and COVID-19 simmers in the background, some medical experts are worrying about a potential “tripledemic.” 

There’s no scientific definition for this term; it simply refers to a collision of RSV (respiratory syncytial virus), flu, and COVID-19 to the extent that it might overwhelm hospital emergency departments.

While all three viruses are present right now, they aren’t each peaking at the same time.

“What we are seeing is record levels of RSV in young children. Usually, we see a spike in December or January, but it’s earlier this year,” says Scott Roberts, MD, a Yale Medicine infectious diseases specialist. 

Meanwhile, as of early December, RSV cases reported by Yale were beginning to go down and COVID-19 and flu cases were increasing. A big part of the flu increase, he explains, is our lack of immunity from having not been exposed to the virus for several seasons due to masking and other precautions, many of which have fallen to the wayside.

We asked Dr. Roberts and Thomas Murray, MD, PhD, a Yale Medicine pediatric infectious diseases physician, more questions about the tripledemic, including how we can stay safe, especially as the holiday season nears.

What is happening with RSV and children?

RSV is a common and highly contagious respiratory virus that causes cold-like symptoms. Most kids are exposed to the virus by their second birthday and therefore develop a degree of immunity that makes future cases less troublesome.

Typically, kids and adults (who can still get it) recover within a week or two. “For the average healthy child, being under age 2 increases the risk of hospitalization. But even having said that, the vast majority of kids do not get hospitalized,” says Dr. Murray.

However, it can be more serious for the extremely young and very old, as well as anyone with a compromised immune system or underlying health conditions, such as congenital heart disease or cancer.

Plus, because of COVID-19 precautions, many young children haven’t been exposed to the virus in the last few years, but now with restrictions lifted, many are being infected. And in younger children, especially those less than 3 years old, it can lead to breathing difficulties because their lungs aren’t fully developed.

The good news, says Dr. Murray, is that this is not a new virus and health care providers know exactly how to take care of kids with RSV.

“Right now, the problem really is just the volume of sick children. Kids can get quite sick from it, but we know how to help them,” he says. “Children are admitted to the hospital for extra oxygen or other supportive measures such as positive pressure to help with breathing and keep the lungs open.”

Since RSV started much earlier this year—with many cases in the summer even, which is virtually unheard of—Dr. Murray says the hope is that it dies down sooner than usual, particularly as flu cases increase.

There is no vaccine for RSV but there are several in development. Babies born prematurely or with an underlying medical condition may qualify for RSV antibody injections to help prevent severe disease.

What steps can we take to prevent illness?

Flu, COVID-19, and RSV are all respiratory viruses, but there are differences in how they spread.

“With COVID, we have appropriately focused on air quality, but many of these viruses can also spread by touching contaminated surfaces, which makes handwashing and cleaning contaminated surfaces really important,” Dr. Murray says.

Dr. Roberts agrees. “At the beginning of the pandemic, we were wiping down our fruit, vegetables, and everything with bleach, until we found out that COVID doesn’t spread through surfaces—but rather from sneezing, coughing, and expelling respiratory droplets and aerosols,” he says. “RSV spreads much more through contaminated surfaces. A kid rubs snot on their hands and puts the hand on someone else, and then that kid puts their hand in their mouth, and they can be infected. Handwashing and cleaning surfaces are more critical with RSV than with COVID.”

Flu, on other hand, is somewhere in the middle, and can spread from respiratory droplets, aerosols, and through contaminated surfaces, Dr. Roberts says. It’s important, therefore, to practice what the Centers for Disease Control and Prevention (CDC) calls “respiratory etiquette,” Dr. Murray says. “That means coughing into a tissue and disposing of it immediately in the garbage,” he says.

It may sound obvious, but the best prevention advice for all three illnesses is to avoid others who are sick. “And if you or your child is sick, stay away from others until you are improving and fever-free,” Dr. Murray says. “And if you have a baby, especially a newborn, be very careful about who visits in their first couple months of life. You only want people who are washing their hands and have no symptoms to be near the baby.”

How can we celebrate the holidays safely?

With colder weather keeping more people inside, as well as the holidays approaching, it’s important to take certain precautions, doctors say. First and foremost, now is the time to get your flu shot and make sure you are up to date on your COVID-19 vaccination, including the new bivalent booster.

“The influenza vaccine may not completely prevent you from getting the flu, but it has a really good chance of keeping you from getting seriously ill and being hospitalized and dying,” Dr. Murray says.

If you are going to a holiday gathering, Dr. Roberts advises taking extra precautions in the week leading up to it. “In other words, don’t go to a big, indoor concert with tons of people shouting, where your odds of exposure to COVID or something else will be very high,” he says. “Plus, you can take a rapid test right before you go in the room for a holiday gathering. If everybody does that, it’s an added layer of security. And if you are traveling, wear a mask, even if nobody else does.”

Dr. Murray says it’s also important to pay attention to symptoms. “If you have any symptoms, you really should not congregate with others. But if you insist, wear a mask and segregate yourself during activities such as eating, when you can’t be masked,” he says.

What is happening with COVID-19?

The newest COVID-19 variants, known as “scrabble variants” with their various letters and numbers, may be difficult to keep straight. But it’s encouraging to know that, so far, none of them seem to increase hospitalizations, Dr. Roberts says.

“The variants that are the most concerning are the BQ 1.1 and BQ 1. They're both offshoots of BA.5, and they're rising the quickest. The mutations seem concerning, where we would expect some evasion to our vaccine response, and some of our monoclonal antibody treatments as well appear to be less effective against these variants,” Dr. Roberts says. “The good news is that they are offshoots of BA.5, so if you get the bivalent booster, you should still have that added spike in protection.”

When should you call your child’s pediatrician?

The fear with a tripledemic is that cases rates for all three viruses (flu, RSV, COVID) will go up at the same time, which is why it’s important to be in touch with medical providers at the right time.

“When your child starts to have cough and fever, it's always good to reach out to your pediatrician, to be in touch, says Dr. Murray. “That's very important. With babies, if you see really fast breathing or any blueness around the lips or what we call use of accessory muscles, which is if you start to see the shoulder blades when they're breathing or see the belly really going up and down really fast, or if the baby looks uncomfortable, those are reasons to come to the emergency room,” he says.

In the end, families need to be prepared that the hospital is a very busy place right now, he adds.

“If your child still looks well, then it's really important to start with your pediatrician. But certainly, if you're concerned, the emergency room evaluates your child quickly to see how sick they are,” Dr. Murray says. “And if they're quite sick, they will be seen faster.”