As we enter the winter holiday season, we find ourselves in the midst of what some are calling a tripledemic of respiratory illnesses: respiratory syncytial virus (RSV), Covid and influenza A. While all are circulating rapidly, RSV is dominant right now.
RSV is a highly contagious virus whose initial symptoms mimic those typical of any upper respiratory infection: cough, fever, congestion and runny nose. While some will experience RSV as no more than a common cold, for others it will progress to more serious lower respiratory tract disease (bronchiolitis or pneumonia), with sustained symptoms and breathing difficulties.
Pediatric clinics and hospitals are bursting with patients experiencing respiratory and other viral symptoms.
Infants, with their small airways, are particularly susceptible to more severe respiratory symptoms. The single most frightening experience I had as a new mother was when my eldest, at 5 months old, developed RSV bronchiolitis. Over the course of an evening, we watched him develop all the warning signs of more serious respiratory illness — rapid breathing, rib retractions and, finally, work of breathing so severe he could no longer nurse. Our pediatrician, concerned about low oxygen levels and dehydration, directed us to the emergency department where my child was treated.
Norms are powerful, and right now, we have swung toward a national norm of rejecting any communitywide adaptations to continuing life as usual. But a number of factors should motivate us to swing back and embrace some prevention measures: mounting school and work absences, child care burden and a true health system crisis.
Right now, pediatric clinics and hospitals are bursting with patients experiencing respiratory and other viral symptoms. While many cases are RSV, Covid, influenza and other viruses are also in the mix and contributing to visits and hospitalizations; the fact that they are all occurring together is significant for the stress it puts on the health care system.
In my state of Oregon, the governor declared a state of emergency, anticipating the need for additional resources to support health systems, and the two pediatric specialty hospitals, which provide most of the state’s ICU-level care for children, have shifted to crisis standards of care, meaning that “critical care resources are severely limited, the number of patients presenting for critical care exceeds capacity, and there is no option to transfer patients to other critical care facilities.” In other words, we have gotten to the stage where we cannot provide the care we usually provide.
Under crisis standards, hospitals may adjust staffing plans. For example, nurse ratios may change in critical or acute care units, or helping hands and nurse extenders may be used to support assignments with more patients or increased acuity. But adjusting staffing plans can only do so much.
Strain on pediatric hospitals is creating a domino effect, causing delays for elective surgeries.
A surge in patients on top of chronic staffing shortages means little room to simply expand care capacity. Community illness also means that more health care workers themselves are becoming ill and are unable to work. In some places, sheer physical space is limited and hospitals are setting up tents to care for children. Strain on pediatric hospitals is creating a domino effect, causing delays for elective surgeries. And outpatient pediatric clinics must care for the vast numbers of children who may not need hospital-level care but are symptomatic enough to need to be seen, crowding out routine care visits. On top of all this, care for febrile illnesses is strained further by shortages of many standard therapies, including fever-reducing medications, albuterol, antibiotics and anti-virals.
While most hospitalizations for RSV are of young children, adults can also become seriously ill from RSV, especially if they have comorbidities: The second most common age group hospitalized with RSV are adults older than 65. All the common respiratory viruses in high circulation at the moment look very much alike in terms of symptoms, are spread from person to person through close contact, and have a continuum of severity. That is to say, there is no RSV, flu or Covid-specific strategy for prevention. We need a range of approaches to interrupt transmission of these contagious respiratory viruses as much as possible so we can avoid illness and protect those more vulnerable to severe disease, including the very young, older folks and those with immunocompromising conditions and other chronic illnesses. Effective preventive measures include getting vaccinated against influenza and Covid-19; staying home from school, work or holiday gatherings with any symptoms of illness; wearing masks in public indoor space; optimizing ventilation and encouraging testing before close gatherings. It also helps to wash hands frequently, avoid sharing cups or utensils and disinfect surfaces (countertops, handles and door knobs). In short, we should assume that viruses are attempting to attend our gatherings this season, and make it as inhospitable for them as possible.
Dr. Esther Choo
Esther Choo, M.D. M.P.H., is an emergency medicine physician, health policy researcher and founding member of Equity Quotient, a company that advises organizations on building cultures of equity. She has provided commentary on the pandemic and other health care topics through appearances on MSNBC, CNN, the BBC and Yahoo! Finance and editorials published in The Lancet, the British Medical Journal, The Washington Post, NBC Think and USA Today. 
