A looming ‘tripledemic’ could make for a rough winter. Which states may be hit hardest?

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With the flu and respiratory syncytial virus (RSV) surging early this season, ahead of an expected increase in COVID-19 cases, U.S. hospitals are already becoming overrun, especially those serving children.

More than three-quarters of pediatric hospital beds in the U.S. are full, driven primarily by a surge in respiratory viruses, NBC News reported on Nov. 8. In Massachusetts, some hospitals have been forced to postpone pediatric surgeries. In Arizona and Rhode Island, 100% of children’s hospital beds are full.

These scary stats come as flu cases are ticking up before peak season usually hits in December. About 6,500 people have had to be hospitalized with the flu this week, and much of the country is seeing high or very high flu activity, according to data from the Centers for Disease Control and Prevention.

What’s more, the U.S. is facing a health worker shortage, meaning that in some hospitals, beds are open, but there isn’t enough staff to care for the patients who’d fill them, TODAY previously reported.

Experts told TODAY it’s likely that a potential “tripledemic,” as some are calling it, may hit some parts of the country harder, or at the very least, sooner.

What is a tripledemic?

The tripledemic of 2022 refers to the possibility that COVID-19 and and seasonal influenza will surge as RSV, a common virus that primarily effects children under 1 and older adults, continues to send kids to the hospital.

In early October, cases of respiratory viruses, including RSV, were already causing many children’s hospitals to reach capacity, with one facility in Connecticut reporting its worst RSV surge in 25 years, TODAY previously reported. Data from the Centers for Disease Control and Prevention show that RSV hospitalization rates are much higher this year than in the past, but are starting to decline.

Related: Where are kids most likely to get RSV?

“RSV is usually seen in January and February,” Dr. Roberto Posada, a professor of pediatrics at Mount Sinai Kravis Children’s Hospital in New York City, told TODAY. “We hadn’t seen that much in the way of RSV and even influenza over the past two years, and that may be because of masking and people not getting together.” Because of that, people have less immunity at a time when they are gathering more and masking less, Posada said.

Influenza is also on the rise, with the U.S. seeing the highest number of hospitalizations for this time of year in a decade, NBC News reported. The CDC estimates 1,300 and 3,600 Americans have already died from the flu this season, including at least four kids, per NBC News reporting. The percent of people testing positive for influenza is steadily rising, according to CDC data.

And third, putting the “triple” in “tripledemic,” is a possible COVID-19 surge. The reported number of new weekly COVID-19 cases in the U.S. is lower in early November than it was for much of the summer, but experts expect cases to increase as temperatures fall and more people spend time inside, and as large groups gather indoors for the holidays. What’s more, Europe recently saw a COVID-19 wave, which usually means that one in the U.S. will follow some weeks later.

“If you add an omicron surge to the current RSV surge, there’s no place … to put another 50 kids that need to be admitted to the hospital,” Dr. Jason Newland, professor of pediatric infectious diseases at Washington University School of Medicine in St. Louis, told TODAY.

Even though flu and RSV may be a bit early, it’s typical in winter to see a surge of these viruses, Dr. Michael Angarone, associate professor of infectious diseases at Northwestern Medicine in Chicago, told TODAY. But this year is likely to be different: “What we are worried about is having the typical cold and flu seasons combined with SARS-CoV-2,” he said.

The real fear around a tripledemic is the possibility that the three viruses will peak at the same time and inundate hospitals, filling every bed and stretching staff thin, Posada added.

What parts of the U.S. are highest risk for a tripledemic in 2022?

RSV, COVID-19 and flu are more likely to have a severe impact on parts of the country that are colder, said Dr. David Buchholz, a pediatrician and founding medical director of primary care at Columbia University in New York City.

When the air is frigid, people are more likely to huddle indoors and keep their windows closed, which makes transmission of the viruses more likely, Buchholz said. “Where it’s warmer, people are more likely to spend time outdoors and open their windows,” he added.

Another factor pumping up the spread of these three bugs in cold climates is the viruses’ affinity for cool, dry air, Dr. Timothy Brewer, professor of medicine and epidemiology at University of California, Los Angeles, told TODAY. In fact, this phenomenon may explain the burst of flu activity in Texas and the Southeastern U.S., which recently experienced a cold snap, he said.

Sixteen states have flu activity that the CDC has categorized as “very high.” The states that have the highest levels of flu activity as of Nov. 10 are:

  • Alabama
  • District of Columbia
  • Georgia
  • Mississippi
  • North Carolina
  • South Carolina
  • Tennessee
  • Virginia

Brewer also said the parts of the U.S. with the lowest vaccination rates against COVID-19 and flu “will most likely get into trouble with these viruses,” he said. (There’s no vaccine against RSV.)

Many of the Mountain and Southern states have low vaccination rates against COVID-19, per CDC data; in 17 states, including Idaho, Alabama, South Carolina, Wyoming, Tennessee and Mississippi, less than 60% of the eligible population completed the primary series, which is approved for everyone 6 months and older.

In the majority of states, less than 10% of the population has received the updated booster shot targeting the omicron variant, approved for people 5 and up. Most, if not all, of the COVID-19 variants that are circulating right now are descended from omicron.

For last year’s flu season, these states had the lowest flu vaccination rates, according to data from the Kaiser Family Foundation:

  • Mississippi
  • Wyoming
  • Nevada
  • Idaho
  • Florida

How to protect yourself during a tripledemic

The best way for people to protect themselves amid the possibility of a tripledemic is to get the latest COVID-19 booster and a flu shot, Angarone said. So far, it looks like the flu vaccine this year is a good match to the strains of influenza virus currently circulating, Brewer added. There’s no vaccine for RSV, but one could be on the horizon.

Even though most people will not experience severe symptoms with RSV and the flu, “we have to be aware of others when we are sick,” Angarone said. “Even though it’s not COVID-19, you probably should not go to work and get your colleagues sick. You should make sure you are washing your hands.”

Some experts have also continued to recommend masking in indoor, crowded spaces.

For parents of young or immunocompromised children, it’s also important to know the signs of a severe RSV infection and when to seek medical care, TODAY previously reported. These are:

  • Having trouble breathing, such as the skin around the ribs sucking in or the nostrils flaring when the child tries to breathe.
  • Grunting in babies, or difficulty speaking in older kids.
  • Diminished number of wet diapers and other signs of dehydration.
  • Increased or persistent lethargy, such as a child being difficult to wake.
  • Any sign of blue around the lips.
  • Irritability, such as crying that won’t stop.

The good news is RSV and influenza aren’t new, so we know how to prevent and treat them, and there are vaccines available to protect against two of the three viruses that could cause a tripledemic in the coming weeks.


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