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A ‘Tripledemic’? Flu and Other Infections Return as Covid Cases Rise

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For more than two years, shuttered schools and offices, social distancing and masks granted Americans a reprieve from flu and most other respiratory infections. This winter is likely to be different.

With few to no restrictions in place and travel and socializing back in full swing, an expected winter rise in Covid cases appears poised to collide with a resurgent influenza season, causing a “twindemic” — or even a “tripledemic,” with a third pathogen, respiratory syncytial virus, or R.S.V., in the mix.

Cases of flu have begun to tick up earlier than usual, and are expected to soar over the coming weeks. Children infected with R.S.V. (which has similar symptoms to flu and Covid), rhinoviruses and enteroviruses are already straining pediatric hospitals in several states.

“We’re seeing everything come back with a vengeance,” said Dr. Alpana Waghmare, an infectious diseases expert at Fred Hutchinson Cancer Center and a physician at Seattle Children’s Hospital.

Most cases of Covid, flu and R.S.V. are likely to be mild, but together they may sicken millions of Americans and swamp hospitals, public health experts warned.

“You’ve got this waning Covid immunity, coinciding with the impact of the flu coming along here, and R.S.V.,” said Andrew Read, an evolutionary microbiologist at Penn State University. “We’re in uncharted territory here.”

The vaccines for Covid and flu, while they may not prevent infection, still offer the best protection against severe illness and death, experts said. They urged everyone, and especially those at high risk, to get their shots as soon as possible.

Older adults, immunocompromised people and pregnant women are most at risk, and young children are highly susceptible to influenza and R.S.V. Many infected children are becoming severely ill because they have little immunity, either because it has waned or because they were not exposed to these viruses before the pandemic.

R.S.V. causes about 14,000 deaths among adults 65 and older and up to 300 deaths among children under 5 each year. No vaccine is available, but at least two candidates are in late-stage clinical trials and appear to be highly effective in older adults. Pfizer is also developing an antiviral drug.

“As of today, we are seeing equal numbers of Covid, flu and R.S.V. and that’s really concerning because we are very early for flu and R.S.V. activity,” said Dr. Diego Hijano, a pediatric infectious disease specialist at St. Jude Children’s Research Hospital.

“It’s going to be a rough winter,” he said.

Coronavirus cases are low, but are beginning to rise in some parts of the country. Several European countries, including France, Germany and Britain, are experiencing an uptick in hospitalizations and deaths, prompting experts to worry that the United States will follow suit, as it has with previous waves.

Some of the coronavirus variants that are picking up momentum are adept at dodging immunity and drugs such as Evusheld and Bebtelovimab, which are especially important for protecting immunocompromised people.

People with weakened immune systems “remain at risk even despite getting all of the recommended or even additional doses of vaccine,” Dr. Waghmare said.

Public health experts are particularly concerned about a constellation of Omicron variants that seem to dodge immunity from the vaccines and even from recent infection better than previous variants did.

The latest booster vaccines made by Pfizer and Moderna were designed for the variants that dominated this summer but not for these newer variants. Still, they raise antibody levels overall, and should help stave off severe symptoms and abridge the duration of illness, said Aubree Gordon, an epidemiologist at the University of Michigan.

In the United States, flu typically begins to pick up in October and runs through March, peaking sometime between December and February. But in some states, this year’s season is already underway.

About 3 percent of tests nationwide were turning up positive for flu as of Oct. 8, according to the C.D.C., but the rates are higher than 10 percent in some Southeastern states and higher than 5 percent in the South Central region. In Texas, the proportion of tests positive for flu jumped to 5.3 percent in early October from 3.7 percent the week before.

Some southern states are also reporting a rise in the use of ventilators. In New York, health officials declared early this month that flu was already widespread in the state.

Public health experts urged Americans, especially those at high risk, to get a flu shot before cases rise much higher. Like the Covid vaccines, the flu vaccine may not be a perfect match for the circulating variant, but even so, it roughly halves the risk of hospitalization in both children and adults.

Antibodies kick in roughly two weeks after a shot, so a vaccine now may in fact extend protection through the winter wave better than one received in September.

Last year, flu vaccination rates decreased slightly in all age groups compared with the previous year, according to an analysis by the C.D.C. The vaccination rate for children 6 months to 4 years of age, who are at high risk, showed the biggest drop — to 67 percent from 75 percent before the arrival of the coronavirus.

The lower rate may be because mistrust of Covid vaccines has spilled over to those for the flu, or simply because parents have forgotten the danger flu poses to young children. It is too soon to tell whether the numbers will improve this year.

Older adults and immunocompromised people should get both Covid and flu shots, public health experts said. Healthy young adults may also want to opt for both vaccines if they don’t want to get sick or cannot afford to miss work, or to protect others around them who are at higher risk.

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