Who’s Ready for the Tripledemic?

Mary Beth Campbell is a trained public health professional (who also has a background in harm reduction), but this feature is not a substitute for advice or care provided by a licensed medical or health care professional. All information provided is current at the time of publication, but new information may arise.

In late November, Dr. Mandy Cohen, the Director of the Centers for Disease Control and Prevention (CDC), visited CrescentCare in New Orleans as part of a national campaign to promote respiratory virus vaccines. This visit was also part of a mission to rebuild public trust in the CDC that has eroded since the agency’s confusing messaging during the COVID-19 pandemic, as well as the increasing politicization of public health and misinformation. Explains Dr. Cohen, “It’s why I’ve been traveling across the country… I think showing up is part of [gaining trust], not just saying something from Atlanta or DC but coming to the community and saying, ‘Hey, I’m thinking about you, we’re worried about you… and I want you to be safe.’”

During her visit to New Orleans, Dr. Cohen’s messaging was centered around the three major respiratory viruses for which there are vaccines: influenza (flu), SARS-CoV-2 (COVID-19), and respiratory syncytial virus (RSV). At the time of this writing, vaccination rates in the United States remain low, placing the public at increased risk of infection as well as raising the risk of severe disease and an increased strain on health care facilities. As we leave the December holidays and enter Carnival season, we also find ourselves in the peak of respiratory virus season. Fortunately, we do have the knowledge and tools needed to keep ourselves and our community healthy and safeit is just a matter of using them.

“Sick Season” and the Tripledemic

Respiratory viruses are, as the name implies, any viruses that can be transmitted by an infected person via the respiratory route (e.g., coughing, sneezing, talking) or direct contact (kissing, transfer of oral or nasal secretions directly or on surfaces via hand or mouth). The human respiratory tract is prime real estate for viral infections, since it is constantly filtering air from our external environment, including viruses. There are over 200 known human respiratory viruses. Depending on the type of virus and a person’s underlying health issues, respiratory virus infections run the gamut from mild cold symptoms to severe disease.

Though respiratory viruses can cause disease throughout the yearCOVID-19 being a relevant examplethey typically have a seasonal pattern of circulation. This seasonality can be attributed to many factors, including how easily a virus is transmitted, whether or not a person or population has immunity to a virus, the weather and environment, and human behavior and physiology. In the northern hemisphere (which includes the United States), spikes in incidence (new cases of a disease in a specified time period) occur roughly between fall and early spring. This does not mean that you can’t be exposed to one of these viruses at other times of the year; for example, COVID-19 waves also occur in the summer months, and it is important to keep up with vaccines and other precautions (like hand washing and wearing well-fitting face masks). However, the high number of respiratory virus infections and illness (and from multiple viruses, not just COVID-19), more people gathering inside due to cooler weather, and the number of holiday festivities (including—and especially—Carnival season) in the fall and winter months means that getting vaccinated and engaging in preventive measures during this time is particularly important.

In the past, the CDC and other public health institutions focused on each of these viruses (the flu, RSV, and COVID-19) separately. However, given that there is overlap in their seasonality, modes of transmission, symptoms, and who experiences the most adverse health outcomes, a shift has been made to focus on what has been referred to as a “tripledemic.”

The flu is so ubiquitous (it appears every year, after all), it might be easy to brush off seasonal guidelines. However, though most people may not experience severe disease, it is still worth taking seriously; between 500 and 1,000 people in Louisiana die of flu-related complications each year. Influenza viruses cause acute respiratory infections, and are spread most easily via coughing or sneezing, and hands contaminated with droplets containing the virus. Symptoms typically appear within two days of infection and include acute fever onset, cough, sore throat, body aches, and fatigue. People with the flu can be contagious up to a week after symptoms appear. Though symptoms usually resolve on their own, influenza viruses can cause severe disease in some people, which can lead to hospitalization and long-term health effects (e.g., increased risk of heart attack and stroke, increased risk of developing pneumonia, damage to lungs, worsening of chronic health issues). People at higher risk for severe disease include children, people over the age of 65, people who are immunocompromised, and people with chronic health issues. Influenza viruses also have a high mutation rate, which means that the strain that was circulating one year might be different from the strain that is circulating now. For these reasons, and the fact that immunity (protection) from the vaccine does decline over time, it is important to get the vaccine annually.

Most people have been exposed to RSV by the time they turn two years old; however, adults can still be affected by it. It is transmitted by the usual methods: virus droplets transmitted via coughing or sneezing, direct contact (e.g., kissing), and touching a surface that has the virus on it. Typically, people who are infected with RSV are contagious for three to eight days, and might actually transmit the virus before they exhibit symptoms. RSV symptoms are, in general, standard respiratory infection symptoms: coughing, sneezing, runny nose, decrease in appetite, fever, and wheezing. In young children, older people, and people with underlying health conditions, there is an increased risk for bronchiolitis (inflammation of the small airways in the lung) and pneumonia, which may lead to hospitalization or death. RSV vaccines are currently recommended only for pregnant people, infants, and people over 60 years old as a single dose.

We are at the stage with COVID-19 that many people are either fatigued by messaging or have come to believe that it is no longer a major health issue. However, severe disease can and still does occur, even if most people might experience mild to moderate illness. The virus is still most easily spread when a person who is infected with the virus coughs, sneezes, or even breathes droplets that contain viral particles. Other people may become infected if they breathe in these droplets, if they come into contact with their eyes, nose, or mouth, or in some cases, if they touch a surface that contains infected droplets. It is very important to note that individuals can transmit the virus even if they do not have symptoms. COVID-19 symptoms can occur between two to 14 days after a person has been exposed to the virus and include symptoms similar to influenza and RSV infections (fatigue, muscle ache, fever, cough, runny nose, sneezing, shortness of breath) as well as sore throat, loss of taste or smell, and gastrointestinal symptoms (nausea, vomiting, diarrhea).

Long-term effects of COVID-19, commonly known as “long COVID,” have been observed in some people post-infection and range from fatigue to heart, respiratory, neurological, and digestive issues. Says Dr. Cohen, “I’m hearing more and more of [long COVID], even with a mild case… someone who is 65 [is at the] highest risk of heading to the hospital, but it’s really our adults 20 to 50 who are getting long-COVID symptoms, and [the vaccine] is a way to protect yourself from that.” Risk of severe disease also increases with underlying health issues (e.g., heart and lung disease, weakened immune systems). While children are not considered to be at the highest risk for severe COVID-19 disease, Dr. Cohen wants “parents to know that while COVID affects kids less than adults, we still see kids who can get really sick from COVID-19. When we look at the data on kids with COVID-19 who are in the ICU, about half of those kids don’t have an underlying condition. This means that healthy kids are getting really sick, and unfortunately, in some cases, dying from COVID-19. We want to do everything in our power to keep children out of the hospital.” She adds, “As a mom myself, I chose to get both my daughters the updated COVID vaccine and the flu vaccine this year—and I would not recommend anything to the American people that I wouldn’t recommend for my own family.”

Viral Trends

According to the Louisiana Department of Health’s Respiratory Virus Dashboard, COVID-19 and influenza hospitalizations for the general population have been on the rise. “That’s one of the reasons we chose [to come] to New Orleans,” states Dr. Cohen. “We saw increases in virus[es] in the South, and we wanted to get some additional messages out. If you don’t know what’s happening, you can’t respond.” As of December 2023 the majority of emergency department visits related to all three major respiratory viruses were children between the ages of 0 to 11 years old (approximately 40% of visits), with the highest number of visits observed in children ages 0 to 1 years old. Combined respiratory virus illness accounted for 12.7% of all emergency department visits across the state (6,690 visits), with flu accounting for 8.7% and COVID-19 and RSV accounting for much of the remaining 4% (2.7% and 1.2%, respectively). It is estimated that, nationwide, between October and December 2023 there were between 38,000 to 80,000 flu-related hospitalizations and between 2,300 to 6,800 flu-related deaths; these ranges account for gaps in disease surveillance across states. The CDC’s “Weekly US Map: Influenza Summary Update” indicates that Louisiana’s influenza-like illness (ILI) level is “very high”; per the LDH’s “Weekly Influenza Surveillance Report,” Louisiana’s ILI level is at 8.7% and above the national baseline and increasing, compared to the overall U.S. ILI activity of 4.4% (also on the rise). As of the last reporting period before publication, 46 people in Louisiana have died of flu since the beginning of the 2023-24 respiratory virus season. COVID-19 deaths are also still occurring in the state, with 123 reported COVID-19 deaths between mid-September and December 16.

At the time of this writing, the dominant influenza strain circulating in the United States was influenza A (H1N1), the same strain that caused the 2009 swine flu pandemic; this strain is included in the current influenza vaccine. The dominant COVID-19 strain, HV.1, is highly contagious and previous COVID-19 vaccines provide less protection against it. When asked about this, Dr. Cohen explains, “I keep hearing folks say, ‘I don’t need to get vaccinated because I’ve had COVID before,’ or ‘I’m just so tired of all the vaccines,’ and I think it’s most important to remind folks that the viruses change. This is not just a booster, it is an updated vaccine matched to the new ways the viruses change. Your protection does decrease over time and you want to get that updated boost.”

Protection Through Preventive Action

Vaccine hesitancy is, of course, one barrier to vaccine uptake and can be attributed to such factors as misinformation, mistrust of medical providers and the health care system, political influence, and concerns about vaccine safety. Another barrier to vaccine uptake is simply access to the vaccine. With the end of the COVID Public Health Emergency in May, access to the COVID-19 vaccine changed, which has caused some anxiety and confusion. Now that the U.S. government is not purchasing these vaccines, the updated COVID-19 vaccine is only available via the commercial marketplace. Individuals who have insuranceprivate, Medicaid, or Medicareshould have all three respiratory vaccines covered. For individuals who are uninsured, or whose insurance does not cover certain vaccines for some reason, there are so-called “bridge” programs in place to provide vaccine access. Per Dr. Cohen, “CDC’s Bridge Access Program provides free updated COVID-19 vaccines to an estimated 25 to 30 million uninsured adults who would have otherwise lost access this year.” She adds that “While CDC already has a program to provide free vaccines to children, a similar program does not exist for adults. The Bridge Access Program is a temporary solution to fill the gap, but scheduled to end in December 2024. To ensure equitable access to vaccines for all adults, a longer-term solution has been proposed to establish a Vaccines for Adults (VFA) program, like our Vaccines for Children program. This program would cover all recommended vaccinations at no cost for uninsured adults.” At the time of this writing, there are no updates on whether or not there will be funding for a VFA program, but the Bridge Access and VFC programs are in effect. For public health and medical professionals, it is especially important to make this information known and to help people access it.

Though navigating the system can be a challenge, there are several options to access flu, COVID-19, and RSV vaccines in New Orleans (see sidebar). According to its official Instagram profile, CrescentCare’s vaccine clinic is currently open to the public. Louisiana’s public health units (PHUs), located throughout the state, are also offering the updated COVID-19 vaccine; be sure to check with your local PHU to ensure that they have vaccines on hand. As part of the Biden Administration’s Federal Retail Pharmacy Program (FRPP) the COVID-19 vaccine, along with influenza and RSV vaccines, should be available at retail pharmacies, including CVS, Walgreens, Walmart, and Costco. The shift of vaccine distribution as a private-public sector partnership naturally brings up real concerns about the privatization of U.S. health care and public health, and may very well have implications in the long term. In the short term, these retail pharmacies seem to be where most of the vaccine access is available. Even then, you will need to visit vaccines.gov to find a location where the vaccines are available and to book an appointment; drop-in appointments do not seem to be an option. While flu and RSV vaccines seem to be readily available for kids, there have been challenges accessing COVID-19 vaccines, especially for children under 3. Children’s Hospital of New Orleans is offering vaccines by appointment, though at last check this was reserved for registered patients. Dr. Cohen does acknowledge that there have been gaps in pediatric access to the vaccine: “Our retail pharmacies don’t vaccinate kids under 3… so sometimes [pediatricians] don’t order the [COVID-19] vaccine because they don’t know how many people will want it… We have a great partnership with the American Academy of Pediatrics, and we’ve done a lot of outreach with pediatricians to make sure they understand the process.”

As has been and remains the case, vaccines are just one tool in disease prevention. Vaccines prevent serious illness, reduce the risk of long-term health issues, and decrease transmission, but getting vaccinated does not necessarily mean you will not get sick. Other methods to prevent transmission are also needed. Contrary to misinformation campaigns, face masks have been found to be generally effective in reducing respiratory virus transmission, and wearing masks does not weaken our immune systems. Dr. Cohen reiterates standard messaging around protection against respiratory viruses: “This includes… staying home if you are feeling sick, and getting tested so you know what you have and can get treatment. Additionally, we know there are additional layers of protection we can use to protect ourselves, like staying away from people who are sick, washing our hands, improving ventilation, and wearing a mask to protect us from these respiratory viruses as well.” Not everyone has the luxury of staying at home when they are sick, for reasons including lack of sick time, lack of childcare, lack of secure housing, and barriers to health care. Though these underlying issues are not currently addressed by the CDC’s prevention plan, they need to be considered. These issues also strengthen the case for the general population to engage in prevention measures; this is not just to protect you or your loved ones, but our neighbors who might be in more vulnerable positions.

Next Steps 

If you did not get vaccinated against any of these viruses earlier in the respiratory virus season, all is not lost: There is still time to receive vaccine protection. Since Carnival season is now upon us, it is all the more reason to minimize your risk of more serious disease and of transmitting any of these three viruses to others, especially people at higher risk of serious illness. With the politicization of vaccines and public health in general, it can be easy to be distracted from what is truly important. Vaccines and other preventive measures are not just protection for the individual; they protect those among us who are the most vulnerable to serious disease, and are just one of many ways we can continue to show up for our communities.

Vaccine and Testing Resources

  • All three vaccines are available at CrescentCare, by appointment. 504-821-2601.
  • To check which retail pharmacies have the vaccines you need and to schedule an appointment, visit vaccines.gov.
  • Louisiana’s public health units (PHU) are offering COVID-19 vaccines. Check to see if your local PHU is offering vaccines and make an appointment via ldh.la.gov/index.cfm/directory/category/192.
  • Oschner Urgent Care offers COVID-19 and flu testing and flu shots (ochsner.org/services/urgent-care-services). If you are insured, these services are covered with a co-pay. If you are uninsured, visits may vary in cost from $150 to $300, depending on the services received.
  • If your child is a patient at one of the Children’s Hospital of New Orleans clinics, you can schedule their appointment directly through their pediatrician’s office at chnola.org/locations or via the patient portal. If you do not have a Children’s Hospital pediatrician, visit the following: chnola.org/provider-directory.
  • The Vaccines for Children program provides access to free vaccines for children who are uninsured and/or whose families are not able to cover the cost of vaccines: cdc.gov/vaccines/programs/vfc.
  • If you are an adult who is uninsured, or whose health insurance does not cover COVID-19 vaccines, visit the CDC’s Bridge Access Program website to be connected to free vaccine services: cdc.gov/vaccines/programs/bridge.
  • The federal government is once again offering free, at-home COVID-19 tests. You can order four tests to be shipped (no charge) directly to you from covid.gov.
  • The New Orleans Health Department has a list of health care facilities offering COVID-19, and in some cases flu and RSV, testing in New Orleans: nola.gov/health/coronavirus/testing. Be sure to call the facilities in advance to determine pricing and availability.

Illustrations by Deanna Larmeu

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