As we move closer towards winter, experts continue to warn about a triple threat of deadly viruses striking at once. Health officials are urging people to take safety precautions like wearing masks, not attending indoor gatherings and getting vaccinated to protect themselves from COVID-19, influenza and RSV. Cases for all three are rising in many areas and Dr. Alpana Waghmare, an infectious diseases expert at Fred Hutchinson Cancer Center and a physician at Seattle Children’s Hospital tells the New York Times, “We’re seeing everything come back with a vengeance.” 

Dr. Philip Tierno Jr., Professor, Microbiology and Pathology, NYU Grossman School of Medicine, NYU Langone Medical Center spoke with Eat This, Not That! Health and shares, “What did we learn from the pandemic? By remaining airborne and able to evade forces of gravity, tiny viral particles have been responsible for some of the most devastating infections and pandemics known to man. Flu season however is no different. As employers struggle to bring workers back to the office, flu season is upon us.”

With COVID restrictions lifted and an uptick of COVID-19, influenza and RSV cases, the medical community is bracing for the worst this season. “If you go around the nation and ask hospitals how busy they are, every single one of them will tell you: They’re busy,” Dr. Carlos del Rio, an executive associate dean at the Emory University School of Medicine and Grady Health System in Atlanta, told NBC News.  Dr. J. Wes Ulm, Harvard and MIT-trained MD, PhD with a background in bioinformatics, gene therapy, genetics, drug discovery, consulting and education explains to ETNT! Health what to know about this winter and the three viruses potentially circulating at once. Read on—and to ensure your health and the health of others, don’t miss these Sure Signs You’ve Already Had COVID.

Dr. Ulm explains there’s credible evidence that points to a winter surge. “It’s largely a mixture of early warning signs both domestically and overseas. For COVID, there’s been an unsettling surge in both cases and hospitalizations resulting from infection by the highly immune-evasive omicron BQ.1 subvariant (and the closely-related BQ.1.1 sublineage), particularly in Europe, which given the history and patterns of prior coronavirus outbreaks since February 2020, has generally signified a major wave striking US shores in the coming weeks and months. We’ve indeed witnessed an early spike in BQ.1 cases, hospitalizations, and prevalence in major international hubs like New York, and this infectious front has been advancing with astonishing speed and ferocity, even as compared to previous deadly variants like delta, omicron BA.1, or the until-recently dominant omicron BA.5 lineage. 

As of last week, BQ.1 has already overtaken BA.5 in seroprevalence (the fraction of individuals testing positive with that particular form of the virus) in New York. It’s also swiftly ramping up its spread on the West Coast and everywhere in-between, alongside another recombinant strain dubbed XBB, which has been especially prominent in Singapore, India, and other Asian countries. Of note, the oncoming BQ.1 wave is taking hold rapidly in the US as evidenced not only by traditional testing metrics — which today are distorted somewhat by the popularity of home-testing, with results customarily not reported to public health authorities — but also by its surging levels in regional wastewater measurements, and by the leap in hospital admissions already witnessed in New York and other “canary in the coal mine” infectious hubs. As for influenza, its incidence over the past month has likewise been growing by leaps and bounds. It’s also doing so at a much faster and earlier pace than the prior two flu seasons, which were staved off in large part due to mitigation measures including masking and high uptake of flu shots, which have comparatively subsided so far this year.”

According to Dr. Ulm, “The concern is arising in part due to the concurrence of this fall’s flu outbreak with other serious respiratory infections (and viruses striking other organ systems as well), which is magnifying disease burden throughout the US in a way not witnessed even amid the surges in deadly COVID strains in 2020 and 2021. As rough as the winters of 2020 and 2021 were, patients and hospitals were at least largely spared the stresses of a “twindemic” or “polydemic” encompassing the flu and other viral pathogens — particularly RSV (the respiratory syncytial virus) — layered on top of the COVID waves. 

The last two flu seasons, in fact, were among the lightest seen over the past two decades. It’s already clear that we won’t be so lucky this year, and the flu is disseminating rapidly across the country even as BQ.1 and XBB — both so-called “escape variants” with considerable capacity to evade immunity from antibodies produced against prior COVID strains and vaccine formulations — are likewise spreading quickly. This is especially concerning for two reasons. 

First, US clinical centers are already stressed in part as a result of healthcare staff departures amidst the COVID waves of 2020 and 2021 (including many nurses, physicians, and other healthcare workers themselves suffering from acute cases or long COVID bouts). Thus we have less wiggle room and surge capacity in hospitals across many US regions, particularly in rural and less-populated locales that were already battling personnel shortages.

Second, the current overlapping infectious waves are exhibiting particular virulence in American kids, again to a much higher degree than that witnessed in the previous two years. Evidence from a number of clinical investigations, including a groundbreaking radiographic study out of Germany earlier this fall, have demonstrated that even though children are, on the whole, less acutely affected by COVID than adults, many are nonetheless showing indications of prolonged and statistically significant decrements in lung and immune function in the wake of seemingly minor prior coronavirus infections. This has been leaving many kids more vulnerable to serious cases from other infections — in effect, reducing their respiratory reserve function somewhat as they fight off a new infectious bout, and rendering them more likely to require hospitalization and intensive care from cases that families would have more easily been able to manage at home in previous years. 

Subsequent bouts over the summer and early fall by the flu and other viruses like RSV, enterovirus D68 (EV-D68), and rhinovirus have concomitantly been sweeping across the United States with almost unprecedented prevalence, severity, and early seasonal onset in the pediatric population, placing additional stresses on parents, school systems, and hospitals. The flu outbreak is already proving deadly for many kids and leading to the temporary closure of many classrooms and even entire schools in a number of states and districts.”

The flu is a common virus that everyone gets, but it’s dangerous for some. 

The Centers for Disease Control and Prevention, “estimates that flu has resulted in 9 million – 41 million illnesses, 140,000 – 710,000 hospitalizations and 12,000 – 52,000 deaths annually  between 2010 and 2020.” Those at the greatest risk include people over 65 and immunocompromised. 

Dr. Ulm explains, “The flu has always had the potential to cause fatal infections for a small but still significant percentage of patients, particularly for seniors and young kids, with its virulence varying from one flu season to another since the notoriously deadly Spanish flu pandemic of 1918. As with COVID-19 — which has been significantly more lethal than the flu — there is a wide confluence of factors in explaining the variance of severity across the population, so it’s difficult to predict why some patients (including many previously fit and healthy individuals) can have especially rough bouts. Evidence is mounting, however, that enduring effects from a previous COVID case, as evidenced by the aforementioned German study in kids, can reduce pulmonary reserves in a way that renders many more vulnerable to a severe flu infection.”

Dr. Ulm says, “RSV, as mentioned, is the respiratory syncytial virus, an almost ubiquitous infectious agent at some point for kids in infancy and early childhood (and for many adults). It’s a staple of pediatric practice in part because children’s lungs and bronchial passages are still developing, and their relatively smaller airways are more vulnerable to troublesome symptoms that may require medical attention. In the vast majority of cases, it’s self-limited, and kids can be taken care of at home until the infection passes. RSV infections have been much more pervasive and severe so far in the summer and fall of 2022, however, and although the reasons have yet to be fully established, there are indications that prior COVID infections may be sensitizing some kids’ lungs in a way not seen in prior RSV seasons.6254a4d1642c605c54bf1cab17d50f1e

Clinicians and public health officials are still piecing together this puzzle, but at least one contributing factor is that mitigations for prior COVID waves in the US — and in particular masking, improved ventilation, and air filtration in crowded indoor spaces — have largely been withdrawn or diminished across the country. This, in turn, has had a knock-on effect for other respiratory infectious agents as well, making it easier for them to spread from person to person and from one community to another. There are, moreover, no immunizations available for RSV (unlike the series of inoculations that protect kids against other childhood pathogens), though there is some encouraging evidence that a vaccine may soon become available.”

Dr. Ulm tells us, “It’s understandable that parents, teachers, public health authorities, and Americans in general are tired of COVID and other respiratory pathogens given the stresses and restrictions of the COVID-19 pandemic since the winter and spring months of 2020. Unfortunately, SARS-CoV-2 — the virus that causes COVID — is a force of nature, capable of mutating and adapting much more effectively than previously appreciated, and it will continue to gather steam, provoke outbreaks, and induce both short-term and long-term illness if not confronted. And now, the latest COVID wave is advancing in lockstep with outbreaks of the flu, RSV, and other viruses. 

The good news is that the vast majority of patients, both pediatric and adult, will survive these infections and most will likewise have mild bouts. With that said, COVID in particular is increasingly being demonstrated to exert potentially lasting long-term effects on a variety of organ systems, not only in the lungs of many patients but in many other tissues as well. Public health efforts like improved ventilation and air filtration, coupled with a good-fitting mask in indoor spaces subject to crowding (such as public transportation or poorly ventilated classrooms), remain important steps. Both the flu and COVID have vaccines which, while they don’t prevent the spread of the disease (particularly for COVID), nonetheless help to mitigate the diseases’ severity. 

This is just as important from a public health perspective as for patients on an individual level, since less serious cases also help to keep patients out of the hospital, and to preserve precious (and often scarce) hospital beds, ICU space, and available staff being strained by the repeated upsurges in cases. Although BQ.1 and XBB are classified as COVID escape variants, the new bivalent booster has nevertheless proven valuable, like its predecessors, in diminishing the severity of an infection.” And to protect your life and the lives of others, don’t visit any of these 35 Places You’re Most Likely to Catch COVID.

Wes Ulm, MD, PhD, is a physician-researcher, musician (J. Wes Ulm and Kant’s Konundrum) ,and novelist, and earned a dual MD/PhD degree from Harvard Medical School and MIT. He is part of the Heroes of the COVID Crisis series in relation to his ongoing efforts in the drug discovery and public health arena.