A ‘tripledemic’ of flu, RSV and COVID feared in California

A confluence of respiratory illnesses has warned some California officials of a potential triple threat that could strain healthcare systems.

Parts of the state are experiencing the earliest start of flu season in recent years, while respiratory syncytial virus — or RSV — is spreading widely, sending significant numbers of young children to the emergency room.

Casting another shadow is the looming threat of COVID-19, which many health experts expect will rebound this fall and winter as more residents head off on vacation and colder weather spurs indoor activities.

“We may be getting into what people are calling a ‘triple disease’ or ‘tridemic,'” warned Dr. Orange County Health Officer Regina Chinsio-Kwong, who declared a public health emergency Monday amid a spike in RSV cases. Respiratory disease is the most common cause of pneumonia and airway inflammation in babies.

Warnings that the spread of another virus could exacerbate the challenges of COVID-19 are not new. In 2020, officials braced for a possible “twindemic” ahead of the typical flu season. And while there was a horrific COVID-19 surge, the flu fizzled out.

The following year was similar: lots of COVID-19 but not too much flu.

However, this year’s flu season has already begun – and is showing a potency not seen in the pandemic era.

“We’re seeing the highest influenza hospitalization rates in a decade,” said Dr. José Romero, director of the National Center for Immunization and Respiratory Diseases at the US Centers for Disease Control and Prevention, at a news conference Friday. So far this flu season, there have been two childhood flu-related deaths nationwide.

San Diego County reported its first flu death of the season, a 55-year-old man who had underlying medical conditions and had not received a vaccine.

“It’s still early in the flu season and we’re already seeing an increase in cases, so we have reason to believe the flu could be extremely disruptive this year,” said Dr. Wilma Wooten, San Diego County Public Health Officer, last week.

Since October, the California Department of Health and Human Services has identified 10 flu deaths and three RSV deaths based on an analysis of death certificates. One RSV death occurred in one child.

“The amount of influenza that we’re seeing is increasing rapidly,” said Los Angeles County Health Officer Dr. Muntu Davis, on Tuesday. “This is the earliest start of the flu season that we have seen in the last five years.”

Every flu season is different, and it’s too early to tell if this year’s activity will pick up or slow down. It’s also not clear whether RSV and flu could increase at the same time, or if the former will give way to the latter — an apparent trend in other parts of the country.

Regions where hospitals are suffering significant capacity strains are in New England, the mid-Atlantic and Washington state, federal officials said Friday. RSV cases are increasing in most parts of the country outside of the South and Rocky Mountains, where RSV may already have peaked and the flu is starting to rise.

In the South, most positive flu samples are from variant influenza A H3N2, “which has historically been associated with heavier seasons, particularly for young children and the elderly,” Romero said.

RSV and influenza activity is increasing nationwide in California. The positivity rate for RSV — more than 15% — is at its highest level in at least six years for this time of year. And flu activity is already considered high in San Diego, Orange, Riverside, San Bernardino and Imperial counties, according to the California Department of Health.

According to Chinsio-Kwong, Orange County’s two primary children’s hospitals are operating “at or above their capacity to care” for children with respiratory illnesses, with emergency room wait times ranging from four to 12 hours. She urged the public to take action to curb the spread of disease.

“We want you to go back in masking to at least reduce your risk of getting sick or spreading disease to others,” Chinsio-Kwong said. She recommended masking “especially in schools, daycares, as long as you are 2 years old”.

“We’ve been doing it like that for the last two years,” she said. “And we know it works because over the past two years we’ve seen a reduction in respiratory illnesses like flu and RSV from using these mitigating factors.”

However, neither she nor other California health officials have suggested a return to widespread indoor mask mandates that have been in effect each of the past two winters. California ended its last statewide mask order in mid-February and LA County ended it in early March.

Chinsio-Kwong said many people may base masking decisions on recommendations from the CDC, which depend on a region’s coronavirus cases and hospitalization rates. But she did recommend people go back into dressing up in public indoor spaces because of the other respiratory illnesses that are circulating.

Melanie Patterson, vice president of patient care services and chief nursing officer at Children’s Health of Orange County, which operates the county’s two children’s hospitals, recommended residents “wear masks indoors and in crowded outdoor areas,” aware of their COVID-19 and flu vaccines, stay at home when sick and wash their hands often. While the coronavirus is primarily transmitted through the air, other respiratory viruses can also be spread by touching contaminated surfaces.

“This isn’t just about COVID anymore,” she said.

Some pediatric infectious disease experts have suggested avoiding bringing newborns into large crowds.

Officials say the high early spread of flu and RSV may be partly because many people — particularly children — were not exposed to these diseases during the pandemic era and are more vulnerable now.

“In the last two years, the activity of respiratory viral diseases has been severely affected by COVID-19, resulting in the circulation of other viruses often being atypical in nature. We suspect many children are now being exposed to some respiratory viruses for the first time, having avoided those viruses at the height of the pandemic,” Romero said.

While the coronavirus remains in a lull across the country, the latest data suggests transmission is no longer declining. LA County recently saw a slight increase in the average daily number of new cases.

In the seven days ended Friday, LA County reported 1,083 coronavirus cases per day, a 10% increase from the previous week. The apparent fall low occurred in the week ended October 16, when the case rate was 869 cases per day.

On a per capita basis, LA County reports 75 cases per week per 100,000 residents. A fall rate of 100 or more is considered a high transmission rate; LA County’s current rate is considered significant.

Los Angeles and Orange counties are also reporting increases in the coronavirus positivity rate, along with the rest of the state.

“We are no longer seeing the steady decline in cases that we have been reporting since July, and reported case numbers appear to have plateaued since October 16,” Davis said. “Since hospitalizations are a lagging indicator, we will continue to monitor whether changes in case numbers are affecting admission numbers.”

Officials attribute the mildness of the past two flu seasons in part to infection-prevention measures put in place for the COVID-19 pandemic. However, the vast majority of these have been lifted and residents can now individually choose to wear a face mask or otherwise change their behaviour.

“With the holidays just around the corner, vaccination is your best protection against infection,” Romero said.

Recent data shows that nearly 26% of children under the age of 5 who have recently visited emergency departments in LA County are there for the flu-like illness, and that percentage has risen sharply in recent weeks. Among 5-11 year olds, 21% of ER visits are for influenza-like illness.

In children, compared to adolescents and adults, a higher percentage of emergency department visits are typically attributed to influenza-like illness. While the percentages aren’t unusual, “It’s unusual that we have so many children in the [emergency department] Reporting a flu-like illness so early in the season,” Davis said.

The percentage of LA County respiratory samples that tested positive for RSV in October — about 20% — is also at a five-year high. That’s up from 6% to 7% last October and significantly higher than the 1% in the three previous Octobers.

“As with the flu, we cannot predict whether this is an early peak or the start of a tough season. But we know that RSV activity is unusually high for this time of year and it requires precautionary measures,” Davis said.

The percentage of ER visits for young children related to RSV is also at a three-year high in LA County. County officials said this week they have yet to see a major increase in bed occupancy at pediatric hospitals — although they did note that could be changing, especially as many hospitals have few pediatric beds to begin with.

Children’s Hospital Los Angeles said it can accept patients but its emergency room capacity is stretched due to RSV and other respiratory illnesses. The emergency room can sometimes be so strained that CHLA can’t always accept referrals from other emergency rooms, said chief medical officer, Dr. james stone

Almost 10% of LA County emergency department visits for children under the age of 5 are related to RSV or acute bronchiolitis, a swelling of the airways typically caused by RSV. That’s higher than at any time in the last three years, according to the county department of public health.

Symptoms that warrant a phone call or a doctor’s visit include difficulty breathing, persistent chest or abdominal pain, excessive vomiting or dehydration, febrile sweating, and severe weakness or muscle pain.

Additional signs of concern in children are fevers over 104 degrees; a lower, persistent fever, coupled with symptoms such as rapid or difficult breathing; a blue discoloration of the skin, which may indicate a lack of oxygen in the blood; lack of tears when crying, decreased urination, or confusion; or greater irritability or not wanting to be held.

“Parents and carers should never hesitate to call their pediatrician if they have concerns about their child’s health. You know your child best. Trust your instincts, ask questions and seek help if you feel it is necessary,” said LA County Public Health Director Barbara Ferrer. “Please do not wait until symptoms are severe before accessing treatment and care.”

Last year, COVID-19 claimed more than 315,000 lives nationwide. Influenza claims an average of 35,000 deaths per year, while RSV causes 100 to 500 deaths annually in children under the age of 5 and more than 14,000 per year in seniors 65 and older.

Anyone, including those who are uninsured and need help finding a healthcare provider in LA County, can call 211, 24 hours a day, seven days a week.

Parents seeking care for uninsured children in Orange County can call (800) 281-9799.

https://www.latimes.com/california/story/2022-11-04/tripledemic-of-flu-rsv-and-covid-is-feared-in-california A ‘tripledemic’ of flu, RSV and COVID feared in California

Alley Einstein

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