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Earlier this month, Taison Bell walked into the intensive-care unit at UVA Health and discovered that half of the patients under his care could no longer breathe on their own. All of them had been put on ventilators or high-flow oxygen. “It was early 2022 the last time I saw that,” Bell, an infectious-disease and critical-care physician at the hospital, told me—right around the time that the original Omicron variant was ripping through the region and shattering COVID-case records. This time, though, the coronavirus, flu, and RSV were coming together to fill UVA’s wards—“all at the same time,” Bell said.
Since COVID’s arrival, experts have been fearfully predicting a winter worst: three respiratory-virus epidemics washing over the U.S. at once. Last year, those fears didn’t really play out, Sam Scarpino, an infectious-disease modeler at Northeastern University, told me. But this year, “we’re set up for that to happen,” as RSV, flu, and COVID threaten to crest in near synchrony. The situation is looking grim enough that the CDC released an urgent call last Thursday for more vaccination for all three pathogens—the first time it has struck such a note on seasonal immunizations since the pandemic began.
Nationwide, health-care systems aren’t yet in crisis mode. Barring an unexpected twist in viral evolution, a repeat of that first terrible Omicron winter seems highly unlikely. Nor is the U.S. necessarily fated for an encore of last year’s horrors, when enormous, early waves of RSV, then flu, slammed the country, filling pediatric emergency departments and ICUs past capacity, to the point where some hospitals began to pitch temporary tents outside to accommodate overflow. On the contrary, more so than any other year since SARS-CoV-2 appeared, our usual respiratory viruses “seem to be kind of getting back to their old patterns” with regard to timing and magnitude, Kathryn Edwards, a vaccine and infectious-disease expert at Vanderbilt University, told me.
But even so-so seasons of RSV, flu, and SARS-CoV-2 could create catastrophe if piled on top of one another. “It really doesn’t take much for any of these three viruses to tip the scale and strain hospitals,” Debra Houry, the CDC’s chief medical officer, told me. It also—in theory—shouldn’t take much to waylay the potential health-care crisis ahead. For the first time in history, the U.S. is offering vaccines against flu, COVID, and RSV: “We have three opportunities to prevent three different viral infections,” Grace Lee, a pediatrician at Stanford, told me. And yet, Americans have all but ignored the shots being offered to them.
So far, flu-shot uptake is undershooting last year’s rate. According to recent polls, as many as half of surveyed Americans probably or definitely aren’t planning to get this year’s updated COVID-19 vaccine. RSV shots, approved for older adults in May and for pregnant people in August, have been struggling to get a foothold at all. Distributed to everyone eligible to receive them, this trifecta of shots could keep as many as hundreds of thousands of Americans out of emergency departments and ICUs this year. But that won’t happen if people continue to shirk protection. The specific tragedy of this coming winter will be that any suffering was that much more avoidable.
Much of the agony of last year’s respiratory season can be chalked up to a terrible combination of timing and intensity. A wave of RSV hit the nation early and hard, peaking in November and leaving hospitals no time to recover before flu—also ahead of schedule—soared toward a December maximum. Children bore the brunt of these onslaughts, after spending years protected from respiratory infections by pandemic mitigations. “When masks came down, infections went up,” Lee told me. Babies and toddlers were falling seriously sick with their first respiratory illnesses—but so were plenty of older kids who had skipped the typical infections of infancy. With the health-care workforce still burnt out and substantially pared down from a pandemic exodus, hospitals ended up overwhelmed. “We just did not have enough capacity to take care of the kids we wanted to be able to take care of,” Lee said. Providers triaged cases over the phone; parents spent hours cradling their sick kids in packed waiting rooms.
And yet, one of the biggest fears about last year’s season didn’t unfold: waves of RSV, flu, and COVID cresting all at once. COVID’s winter peak didn’t come until January, after RSV and flu had substantially died down. Now, though, RSV is hovering around the high it has maintained for weeks, COVID hospitalizations have been on a slow but steady rise, and influenza, after simmering in near-total quietude, seems to be “really taking off,” Scarpino told me. None of the three viruses has yet approached last season’s highs. But a confluence of all of them would be more than many hospitals could take. Across the country, many emergency departments and ICUs are nearing or at capacity. “We’re treading water okay right now,” Sallie Permar, the chief pediatrician at Weill Cornell Medical Center and NewYork-Presbyterian Hospital, told me. “Add much more, and we’re thrown into a similar situation as last year.”
That forecast isn’t certain. RSV, which has been dancing around a national peak, could start quickly declining; flu could take its time to reach an apex. COVID, too, remains a wild card: It has not yet settled into a predictable pattern of ebb and flow, and won’t necessarily maintain or exceed its current pace. This season may still be calmer than last, and impacts of these diseases similarly, or even more, spaced out.
But several experts told me that they think substantial overlap in the coming weeks is a likely scenario. Timing is ripe for spread, with the holiday season in full swing and people rushing through travel hubs on the way to family gatherings. Masking and testing rates remain low, and many people are back to shrugging off symptoms, heading to work or school or social events while potentially still infectious. Nor do the viruses themselves seem to be cutting us a break. Last year’s flu season, for instance, was mostly dominated by a single strain, H3N2. This year, multiple flu strains of different types appear to be on a concomitant rise, making it that much more likely that people will catch some version of the virus, or even multiple versions in quick succession. The health-care workforce is, in many ways, in better shape this year. Staffing shortages aren’t quite as dire, Permar told me, and many experts are better prepared to deal with multiple viruses at once, especially in pediatric care. Kids are also more experienced with these bugs than they were this time last year. But masking is no longer as consistent a fixture in health-care settings as it was even at the start of 2023. And should RSV, flu, and COVID flood communities simultaneously, new issues—including co-infections, which remain poorly understood—could arise. (Other respiratory illnesses are still circulating too.) There’s a lot experts just can’t anticipate: We simply haven’t yet had a year when these three viruses have truly inundated us at once.
Vaccines, of course, would temper some of the trouble—which is part of the reason the CDC issued its clarion call, Houry told me. But Americans don’t seem terribly interested in getting the shots they’re eligible for. Flu-shot uptake is down across all age groups compared with last year—even among older adults and pregnant people, who are at especially high risk. And although COVID vaccination is bumping along at a comparable pace to 2022, the rates remain “atrocious,” Bell told me, especially among children. RSV vaccines have reached just 17 percent of the population over the age of 60. Among pregnant people, the other group eligible for the vaccines, uptake has been stymied by delays and confusion over whether they qualify. Some of Permar’s pregnant physician colleagues have been turned away from pharmacies, she told me, or been told their shots might not be covered by insurance. “And then some of those same parents have babies who end up in the hospital with RSV,” she said. Infants were also supposed to be able to get a passive form of immunity from monoclonal antibodies. But those drugs have been scarce nationwide, forcing providers to restrict their use to babies at highest risk—yet another way in which actual protection against respiratory disease has fallen short of potential. “There was a lot of excitement and hope that the monoclonal was going to be the answer and that everybody could get it,” Edwards told me. “But then it became very apparent that this just functionally wasn’t going to be able to happen.”
Last year, at least some of the respiratory-virus misery had become inevitable: After the U.S. dropped pandemic mitigations, pathogens were fated to come roaring back. The early arrivals of RSV and flu (especially on the heels of an intense summer surge of enterovirus and rhinovirus) also left little time for people to prepare. And of course, RSV vaccines weren’t yet around. This year, though, timing has been kinder, immunity stronger, and our arsenal of tools better supplied. High uptake of shots would undoubtedly lower rates of severe disease and curb community spread; it would preserve hospital capacity, and make schools and workplaces and travel hubs safer to move through. Waves of illness would peak lower and contract faster. Some might never unfold at all.
But so far, we’re collectively squandering our chance to shore up our defense. “It’s like we’re rushing into battle without armor,” Bell told me, even though local officials have been begging people to ready themselves for months. Which all makes this year feel terrible in a different kind of way. Whatever happens in the coming weeks and months will be a worse version of what it could have been—a season of opportunities missed.
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Katherine J. Wu
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