Signs of the coming storm are already here.
Some children’s hospitals are already over capacity because of an unprecedented wave of severe RSV infections. Before covid, virtually every child contracted RSV by age 2, but masking, distancing and other mitigation pandemic measures have led to an immunity gap, leaving far more children than usual with little to no protection against RSV.
The vast majority of kids who contract RSV will have mild, coldlike symptoms, but some can develop inflammation in their lungs and become very ill. In pre-covid years, the virus caused an estimated 58,000 annual pediatric hospitalizations among children under age 5. That number is on track to being much higher this year. RSV also affects adults, killing about 14,000 Americans 65 and over annually.
The same concerns apply to influenza. The 2017-2018 period was a particularly bad flu season, resulting in 710,000 hospitalizations and 52,000 deaths. This year could portend similar numbers. Last week, the Centers for Disease Control and Prevention reported that not since the 2009 swine flu have so many Americans been hospitalized for influenza so early in the season.
What about covid? While I don’t expect a tsunami mirroring last winter’s omicron surge, covid infections will almost certainly rise in the coming weeks, with a subsequent uptick in hospitalizations and deaths. BA.5 remains the dominant variant, but its BQ.1 and BQ.1.1 offshoots already make up more than one-quarter of new infections and will displace BA.5 in the next few weeks.
Here’s the good news: We know how to treat these “triple threat” viruses.
While there is no vaccine yet for RSV, there are inoculations for flu and covid. Early data show that this year’s flu vaccine reduces influenza hospitalizations by nearly 50 percent, so mass vaccination could substantially alleviate the burden on hospitals. The coronavirus booster likely provides much higher protection against severe disease, and the large proportion of Americans with hybrid immunity from vaccination and prior infection offers an additional safeguard against a crush of covid hospitalizations.
How government, hospitals, employers and schools should prepare
In the short term, the convergence of respiratory viruses will compound the shortage of nurses and other health-care workers, exerting enormous stress on our health-care system. Hospitals are readying their surge-capacity plans. We should soon expect to see parking lots converted to patient-care areas, some non-urgent medical visits postponed and the National Guard deployed to particularly hard-hit areas.
Schools and workplaces can do their part by holding vaccination drives. Since there is substantial opposition to the coronavirus vaccine, I’d encourage educators and employers to speak about flu separately from covid so that the backlash against covid inoculations doesn’t dissuade families from vaccinating their children against the flu or receiving other routine childhood immunizations. In the meantime, the coronavirus booster should be targeted to those most at risk for hospitalization, especially nursing home residents and the elderly.
Now is also the time for day-care centers, shopping centers and restaurants to bring back hand sanitizers and wipes to all shared spaces. Good hand hygiene can reduce transmission of influenza, RSV and other viruses that are spread through direct contact and high-touch surfaces.
The role of government will be limited. Its most crucial role is to invest in “Operation Warp Speed Part 2” to keep ahead of variants by developing better vaccines and treatments. But I don’t think widespread mitigation measures will return. It will be hard to persuade people to stay away from loved ones, stop going to restaurants and postpone travel plans when the risk of severe illness to most individuals is low. Mask mandates require enormous political capital, so I can’t imagine them being a realistic intervention unless a much deadlier virus emerges.
What individuals should do
Knowing that societal mitigation measures won’t return, individuals should take protective measures into their own hands.
That begins with vaccines. Everyone 6 months and older should get the flu vaccine. Since it takes about two weeks to reach maximal effectiveness and flu cases are already high, don’t wait to get the shot. People 65 and older and adults with underlying medical conditions also need to get their coronavirus booster now. Others should consider personal and household circumstances in deciding when to receive the booster.
Older individuals should keep up-to-date on their pneumonia and shingles vaccines. And people should tend to chronic illnesses and schedule elective procedures to reduce the chance of hospitalization during a surge.
Everyone should have a plan for if and when they become ill. Many already have one for covid; they know if they are eligible for Paxlovid or monoclonal antibodies and where to access them. They should take a similar approach with the flu. Know how to get Tamiflu, the antiviral medication that reduces progression to severe influenza, which can also be prescribed to close contacts to prevent them from contracting the flu. And though there is no specific treatment for RSV, parents should know how to reach their pediatrician after hours and which hospital to take their kids to in case of breathing difficulties and other emergencies.
Crucially, people most vulnerable to severe illness should know that if they interact with others while viral levels are high, they will encounter contagious respiratory viruses. I’d encourage them to wear an N95 mask or equivalent in indoor settings. Carry hand sanitizer and use it frequently. Consider limiting maskless indoor gatherings to the most essential. When attending holiday get-togethers, require everyone to obtain a rapid coronavirus test the day of the gathering and stay away from family members with even a hint of a sniffle.
There’s always the possibility that we could be in for a pleasant surprise: Perhaps RSV will peak soon and subside before the worst of the influenza. Perhaps the anticipated covid increase will be a tiny blip.
But covid taught us to anticipate the worst and to prepare for it. This winter, Americans can keep safe while not letting the ongoing threat of viruses dominate our lives.