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The ‘Tripledemic,’ Explained

In the United States, three big respiratory viruses are competing for attention.

This transcript was created using speech recognition software. While it has been reviewed by human transcribers, it may contain errors. Please review the episode audio before quoting from this transcript and email transcripts@nytimes.com with any questions.

michael barbaro

From “The New York Times,” I’m Michael Barbaro. This is “The Daily.”

This winter, three major respiratory viruses — RSV, the flu, and COVID — are colliding in the US in what health officials are calling a triple-demic. Today, Apoorva Mandavilli on what this collision has to do with our response to the pandemic and why so far the worst impacts are on children.

It’s Tuesday, November 22.

sydney harper

So I think just for, you know, starters, can you tell us your name, who you are, where you live?

sarah stuckey

Yeah, my name is Sarah Stuckey. I live in Bowie, Maryland, so just outside of DC.

michael barbaro

“Daily” producer Sydney Harper recently spoke with a woman whose infant daughter was infected with RSV.

sarah stuckey

Yes, her name is Caroline. She turned nine months old while in the hospital. So Tuesday morning, she had a cough and took her to the pediatrician. The doctor looked at her, said, yeah, she probably has RSV. It’s really going around. But there’s nothing that we can do for it. And they sent us on our way. But Friday morning, she started having trouble breathing.

So we took her to the emergency room. And we got there about 2 o’clock in the afternoon. They were taking her oxygen levels. Her oxygen levels were so low that they thought their pulse oximeters were broken. But once they realize that’s what her oxygen level really was, they took her back right away.

And it was like all hell broke loose in this room. They intubated her. I mean, it was just like mass chaos to get a ventilator in her. And they had an oxygen bag. They were literally pumping oxygen by hand into her.

And then they started telling us that the hospital that we were at did not have a ventilator that could support her needs. She needed a really nuanced ventilator. And they just didn’t have it.

So the doctor started calling hospitals to see where we could go.

And she just kept coming back saying, there’s nowhere that has a room, there’s nowhere that has a room, there’s nowhere that has a room. And I could see the fear on her face and seeing that on her face and just sitting there, you know, watching my baby barely being kept alive and knowing that there was no more that they could do for her at this hospital, I just had the thought like if she dies in this moment, I just can’t, I can’t do anything to help her. And no one else can do anything to help her.

Finally, around, gosh, probably 8:00 or 9:00 PM, we secured a room in Baltimore. Then we had to wait for a Life Flight team. So we waited. And I rode helicopter with Caroline to Baltimore. And we were in the ICU that night.

So it was just this past weekend that she came off the ventilator. And so we’re just there watching her wean from some meds. But otherwise, she’s good. She’s playing and happy and back to her herself, which is just, I don’t even have words to say like how wonderful that is.

So we’re on the way home, but it’ll be another couple of days we think, so.

michael barbaro

Apoorva, we just heard the story of a mother whose nine-month-old daughter ended up in the hospital with RSV, which is a virus I don’t think a lot of people know that much about. I say that because I didn’t know that much about it until my 18-month-old son got it a few weeks ago. And like this woman’s daughter, he ended up in the hospital with it. So you can consider me very invested in this story. And so that’s where I want to begin this conversation with RSV and how it fits into the viral landscape of this moment.

apoorva mandavilli

I’m sorry to hear about your son, Michael. I hope he’s OK now.

michael barbaro

He is. He’s much better. I appreciate that.

apoorva mandavilli

So, yeah, RSV is sending a lot of kids to pediatric hospitals. A lot of young, young kids are ending up in emergency rooms needing help with their breathing and so on. The problem is that RSV is really making its way around the country when we’re also looking at new variants of COVID that are coming up and COVID cases are starting to pick up. And this is one of the most intense flu seasons we’ve seen in a very long time. So you’ve got basically three big respiratory viruses all competing for attention and sending a lot of people to hospitals and making people very sick.

michael barbaro

Right, a kind of public health trifecta.

apoorva mandavilli

If you will, or a triple-demic or a tri-demic or all these words that are floating around.

michael barbaro

Well, let’s start with RSV and what we need to know about that particular virus. Give us the background we need to understand it.

apoorva mandavilli

RSV is not a new virus. It stands for respiratory syncytial virus. It’s a respiratory virus. It’s like all the other ones.

It causes you to, get the sniffles, get a sore throat, get a cough. And it’s not a big deal for most people. It’s a big deal for people who are older than 65 and especially for really young kids.

michael barbaro

Why?

apoorva mandavilli

Well, if you think about young kids, like their respiratory pathways like their little airways are so tiny that all you need is a little bit of congestion and they’re going to have trouble breathing. They’ll have a fever. They’ll cough a lot. And if they’re really, really sick, they can have wheezing. Their skin may turn a little bluish. I mean, those are really the danger signs. That’s when you want to take the kid to the ER.

michael barbaro

And that’s because their air waves and their whole respiratory system are just kind of working overtime?

apoorva mandavilli

Right, and they have very little breathing capacity to begin with. So it can be very easily overwhelmed. So we are talking about kids under one. I mean, by the time most kids are two, in normal times, they are already infected with RSV. What’s happening this year though, is that this is really our first pandemic winter when we are not wearing masks, when we’re not doing social distancing, right, we’re not really taking precautions.

michael barbaro

Right.

apoorva mandavilli

And so what’s happening is that all the viruses that were pushed aside by COVID or by our precautions the past couple of winters are now back in full force. So there are a lot of kids in the country who are two, three, four who’ve either never been infected with RSV at all until now or were infected maybe once and didn’t get a chance to build up a lot of immunity. So you’re seeing just a much bigger pool of kids who can get infected with RSV and get pretty sick.

michael barbaro

That’s interesting. So we should think of RSV as a pretty run-of-the-mill virus that under normal circumstances might not do all that much damage, might not be something we would devote an episode of “The Daily” to, that has been kind of supercharged by the pandemic. Because the pandemic, like you just said, kept so many kids protected from viruses. So it’s washing over a bunch of kids who have kind of emerged from the basement of America’s collective pandemic experience and are now getting sick at once.

apoorva mandavilli

Right, I mean, in a normal year, you know, RSV is something that pediatricians think about and maybe some parents will think about. But come to this winter, you’ve got the kids who would have gotten it in 2020, the kids who would have gotten it in 2021, and the kids who would have normally gotten it now all getting RSV at the same time. So it’s just a giant pool of susceptible kids.

michael barbaro

Well, Apoorva, give us a sense of the scale of children being hospitalized because of RSV and maybe give us some numbers around that.

apoorva mandavilli

As of a couple of weeks ago, 80 percent of the country’s pediatric hospital beds were full. And in many parts of the country, there are no pediatric beds available.

michael barbaro

Wow.

apoorva mandavilli

Like the mom we heard from earlier in this episode, you know, there are parents who are having to drive hundreds of miles to get their kid to a doctor. And big hospitals like Johns Hopkins Children’s Center in Baltimore, Maryland, they’re getting transfer requests from New York and West Virginia.

michael barbaro

Hours and hours away.

apoorva mandavilli

Exactly, hundreds of miles away. And they don’t actually have extra beds to spare anyway. And it’s starting to pick up in parts of the country where it was actually a little bit slow. So in Oregon, the season officially began October 29. And, already, the numbers have more than tripled.

michael barbaro

Wow, in just two weeks?

apoorva mandavilli

Exactly. And on Monday, the governor issued an executive order that would allow hospitals to staff pediatric wards with volunteer nurses and doctors. Because they simply don’t have enough staff.

michael barbaro

Wow, I mean, these sound like descriptions that are as worse, if not even worse than what we talked about during the pandemic.

apoorva mandavilli

You know what? That’s partly because during the pandemic, kids were not at high risk.

michael barbaro

Right.

apoorva mandavilli

So we really got away from the idea of kids being at risk of respiratory diseases even though, in a normal year, they are at risk of things like flu. So this year, we’ve got a whole bunch of kids who are all getting very sick with RSV, with flu, and ending up in these hospitals.

michael barbaro

If hospital beds are that full, like you’re saying, I have to imagine that a kid coming into the emergency room with just about anything else is not getting a bed.

apoorva mandavilli

Absolutely. This is actually really a precipitation of a problem that’s been brewing for many years now. Pediatric hospitals have been shutting down in big numbers because kids are just not as profitable to treat as adults. And so hospitals have been closing them down. In Illinois, there are something like 48 counties that have no pediatricians at all.

michael barbaro

Hmm. So RSV is squeezing a system that is already smaller than it probably should be.

apoorva mandavilli

Smaller than it probably should be and that got even smaller during COVID when a lot more pediatric resources were pivoted to treating adults, because that’s where they were needed.

michael barbaro

Got it. So when a kid gets sick with RSV, Apoorva, what kind of treatments are available?

apoorva mandavilli

There actually aren’t any. So the best thing to do is to do things for the kids that just makes their symptoms a little bit better, like a steam shower. But, you know, I don’t want to give the impression that this is a really dangerous disease and that it kills a lot of kids. Most kids, if they get really sick and end up in the ER, are going to get a little breathing help, maybe get put on a ventilator, and then they’re going to come home within a day or two.

michael barbaro

Right.

apoorva mandavilli

Ideally, what we’d have is vaccines to prevent RSV in the first place. But, unfortunately, we don’t quite have those available yet either.

michael barbaro

Hm.

apoorva mandavilli

We are close, but not yet.

michael barbaro

How close?

apoorva mandavilli

As it happens, we have something like four vaccines that the FDA is already looking at and another dozen or so in clinical trials that are in pretty late stage. So in a couple of years, we’ll probably have a lot more options.

michael barbaro

But for now, we’re kind out of luck. So this virus that is infecting children at this unusually rapid rate and filling all these hospital beds and forcing parents, like the one we talked to, to make these kind of extraordinary trips out of state by helicopter to get to a hospital, this virus cannot be prevented and it cannot be treated?

apoorva mandavilli

That is correct. There is one way to prevent infections in really young babies, but that drug is so expensive — it’s a monoclonal antibody, which we saw being used for COVID as well.

michael barbaro

Right.

apoorva mandavilli

And because it’s so expensive, it’s really only used for very premature babies who really need it. So other than that, we have nothing.

michael barbaro

We’ll be right back.

So Apoorva, let’s talk about the second virus in this trifecta, as you described it, which is this year’s flu. And full disclosure, I have not gotten my flu vaccine. I feel guilty about it. We can talk about that later. What is the story of this year’s flu?

apoorva mandavilli

This is our familiar foe, right? We’re used to thinking about the flu. But what’s happening this year, as with RSV, is that we’re seeing it come in really intensely. So according to the CDC, there have already been more than 4 million infections with the flu and we’ve had 2,100 deaths. And hospitalizations for flu are also way up, the highest they’ve been in a decade, according to the CDC.

michael barbaro

Why is the flu worse this year than it’s been in the past? And maybe that’s a naive question because I know with the flu, it’s always kind of a crapshoot, right? Like the flu is whatever the flu is in a year. But is there an explanation for why it’s rough this year?

apoorva mandavilli

No, it’s a good question. Because normally, the flu doesn’t really pick up till December and the peak is sort of January through March. We don’t fully know why. Part of it is probably, as we were talking about with RSV, that a lot of people didn’t get the flu for the last couple of years. And so there’s just more people, more susceptibility.

And part of it is also that COVID has made viruses behave really weirdly. The flu and RSV have sort of come at unusual times of year or too early, too late, all year round, sort of there’s just a lot of weird patterns going on with viruses.

michael barbaro

What do you mean by that? How does COVID impact something like the timing of when people get the flu or the severity of the flu season?

apoorva mandavilli

Well, we don’t exactly know why. There are some theories. So one is this theory called viral interference, which says, you know, if you get COVID first, your immune system has revved up and that might prevent you from getting sick with something else. So you wouldn’t get sick with the flu. And so the flu doesn’t really have a chance against COVID. What has happened in the past couple of years is that we’ve seen these viruses come at unusual times, right?

We haven’t seen flu and COVID at the same time. We haven’t seen RSV and COVID at the same time. So that’s really caused some scientists to think that that’s what’s happening, that this viral interference is real.

But we’ll see. This winter, it looks like they might all be up at the same time. So that theory might be wrong. The short answer is really —

michael barbaro

Interesting.

apoorva mandavilli

— we don’t know. We don’t know why this is happening and why these viruses are behaving so strangely.

michael barbaro

But the theory does suggest that viruses might, in a sense, wait their turn. But if this year we have multiple viruses coming at the same time, we don’t really know if they’re going to be waiting their turn. They might be very impolite and they might all want to sit at the table at the same time.

apoorva mandavilli

They might. And some of us might end up getting all of them or two of them or some combination. So, yeah, we’ll have to see.

michael barbaro

OK, but unlike for RSV, there is a vaccine for the flu. It’s widely available. It’s generally seen as very effective.

apoorva mandavilli

Yes, there is, Michael. And you should go get one. And so should everybody else. So, you know, for flu, we do have this vaccine. And, actually, this year’s vaccine is pretty well matched against the strain that circulating. So, yeah, I got my flu vaccine. And I would say everybody who can get one should get one as soon as possible.

michael barbaro

OK, I’ll get my vaccine. Let’s finally talk about COVID. This is our third year with that virus in the United States. And it’s in this conversation the third virus in that trifecta. What is the state of COVID this fall and winter?

apoorva mandavilli

It’s a little bit different than when we’ve talked about COVID the last couple of winters. You know, it’s not as serious, at least it looks like right now. Because when you think about it, pretty much everybody in the country has either been infected multiple times or has had many, many shots. And so we all have a pretty thick layer of immunity against COVID. What is different this year though, is that there are a couple of variants that are really picking up steam that are very good at getting around that immunity. And so a lot of us will probably get infected, even if we don’t get really sick.

michael barbaro

Well, how will the variants of this winter likely compare with those of, say, Omicron? We have come to see COVID over time as less and less lethal and, frankly, less and less of a serious health threat for healthy people. Should we keep viewing COVID this way this winter?

apoorva mandavilli

It seems like it at the moment. I mean, so the new variants — there are two — are still versions of Omicron, which is the one that was circulating last winter. But that version, BA.1, was somewhat immune evasive, which is why a lot of us got infected. But as we’ve gone on through the year, the variants of Omicron that have been coming up have been increasingly immune evasive.

And these two, the ones that we’re looking at now, BQ.1 and BQ.1.1 is what they’re called, they are incredibly immune evasive. So there was just a study where scientists looked at exactly how much. And they said it’s five times as able to get around the immune system as BA.5, which is the most recent one in the summer, and 175 times more so than the very first coronavirus that we saw back in January 2020.

michael barbaro

So all of that makes me wonder about vaccines. Because you keep describing these variants as extremely evasive of immunity. Does that immunity include the immunity conferred by vaccines? How good is the current COVID booster when it comes to the variants you’re talking about?

apoorva mandavilli

Unfortunately, yes, it does mean that the boosters that we have right now are probably not going to prevent you from getting infected with the coronavirus.

michael barbaro

That’s depressing.

apoorva mandavilli

It is depressing. We were hoping for a good match. And the Biden administration was trying to guess by having an Omicron-specific booster available. But it turned out to be a match for BA.5, which is the variant that was around in the summer when they were making this decision. And that’s on its way out.

michael barbaro

I mean, are we now in a phase of the pandemic where boosters, vaccines for COVID are just going to inevitably struggle to keep up with the speed with which COVID changes?

apoorva mandavilli

We will, unless we change our strategy. There are ways to get around this. We could try to develop what’s called a universal coronavirus vaccine that would be good against lots and lots of different versions of the virus so you wouldn’t have to play this guessing game.

michael barbaro

So why aren’t we — why aren’t we doing that?

apoorva mandavilli

That’s a good question. There are efforts to do that. But it’s hard to do. And so I think we’ll probably see one in two to three years, if that. There is one really important caveat, which is that older people and immunocompromised people and pregnant women should all go get a booster. Even if it’s not that great against these new variants, it will give them a boost in antibodies in general. And they need that in order to fight off severe disease and death and bad outcomes. So they should still go get this booster.

michael barbaro

I want to ask you a final COVID question. I think it’s a question that agonizes a lot of us who are making decisions every day about getting on the subway or going to the theater or doing those increasingly without masks. And everyone’s telling us that that’s OK. But I am curious if given the situation you’re outlining with COVID for this winter if we’re doing it wrong?

apoorva mandavilli

Ideally, yeah, we would all still be wearing masks because that would take care of RSV and flu and COVID and everything we’ve been talking about. But since we’re not doing that, I would say still to try and avoid crowded indoor spaces. Wear a mask if you can, at least in those situations. Wash your hands. Stay home if you’re sick, all the things that we to do to protect other people and ourselves from getting sick.

michael barbaro

Got it. So paint a picture of what the dead of winter is going to look like when all three of these viruses we’re talking about — RSV, the flu, these COVID variants — really start to intersect.

apoorva mandavilli

I really don’t like making predictions, which we’ve talked about before, in part, if you remember.

michael barbaro

We have.

apoorva mandavilli

Thanksgiving last year when we found out about Omicron and that completely transformed what we were facing as a country.

michael barbaro

So you’re saying you don’t want to make a prediction that could be upended by something in four days, sure.

apoorva mandavilli

Exactly. But I can give you a range of what we might expect. So the worst case is if all of these viruses continue to increase — the flu continues to pick up, RSV continues to pick up, COVID really picks up — then we’re looking at a pretty bad winter with the health care system completely buckled under, lots and lots of people sick. Best case scenario, viral interference theory, which we talked about, is real and all of these viruses will take their turn politely, as you said.

michael barbaro

Right. And our system won’t buckle. It’ll just be a rough winter, not an awful winter.

apoorva mandavilli

That’s a good way to put it.

michael barbaro

Well, Apoorva, as always, thank you very much. I am going to get my flu vaccine, truly.

apoorva mandavilli

I’ll check back in with you next week.

michael barbaro

Please don’t. Thanks, Apoorva.

apoorva mandavilli

Sure.

michael barbaro

We’ll be right back.

Here’s what else you need to know today.

Was there any — do you remember any conscious thought of like I’ve got to do something or should I run?

archived recording (richard fierro)

No, no, when I got oriented and I saw him with people in front of him, I just went. I didn’t ask. I didn’t fucking think about it. You just do.

archived recording (david philipps)

Yeah.

michael barbaro

On Monday, my colleague, Dave Philipps, interviewed the man who ended the rampage inside an LGBTQ club in Colorado Springs by confronting the gunman, who ultimately killed at least five people there on Saturday night.

archived recording (richard fierro)

And it was pop, pop, pop, pop. All I saw was the flash of the muzzle.

michael barbaro

The man, a US Army veteran named Richard Fierro, told Dave that he was at the club with his wife, daughter, and their friends when he saw the gunman enter and open fire.

archived recording (richard fierro)

archived recording (david philipps)

— you, dude.

archived recording (richard fierro)

I don’t know if this gun was loaded. I don’t know if he was trying to shoot me. I didn’t know I was going to take this dude down.

archived recording (david philipps)

Oh, yeah.

michael barbaro

Fierro said he charged across the room, tackled the gunman, seized his gun, and began to beat him with the weapon.

archived recording (richard fierro)

I grabbed him. I pulled him down, jumped on his back, I’m banging all over him. Because I didn’t want him to get up. He’s fucking —

michael barbaro

Minutes later, police arrive and arrested the gunman, a 22-year-old who now faces charges of murder and hate crimes. After the shooting, local officials, including the mayor of Colorado Springs, credited Fierro with saving countless lives.

archived recording (richard fierro)

I’m a fat old vet. And if I went over there and I had to do something. That was it.

archived recording (dave philipps)

Yeah.

archived recording (richard fierro)

That was it.

michael barbaro

Today’s episode was produced by Sydney Harper, Rachel Quester, and Asthaa Chaturvedi. It was edited by MJ Davis Lin and Lexie Diao with help from Marc Georges. It was fact checked by Susan Lee, contains original music by Dan Powell, Marion Lozano, and Rowan Niemisto, and was engineered by Brad Fisher. Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly.

That’s it for “The Daily.” I’m Michael Barbaro. See you tomorrow.

Sydney HarperRachel Quester and

MJ Davis Lin and

Dan PowellMarion Lozano and


This winter, three major respiratory viruses — respiratory syncytial virus or R.S.V., the flu and the coronavirus — are poised to collide in the United States in what some health officials are calling a “tripledemic.”

What does this collision have to do with our response to the coronavirus pandemic, and why are children so far the worst affected?


Apoorva Mandavilli, a science and global health reporter for The New York Times.

Image
Receiving a coronavirus test. Viruses that were pushed aside by Covid-19 or by precautions the past couple of winters are now back in full force.Credit...Jordan Macy for The New York Times
  • 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.

There are a lot of ways to listen to The Daily. Here’s how.

We aim to make transcripts available the next workday after an episode’s publication. You can find them at the top of the page.


Apoorva Mandavilli contributed reporting.

Fact-checked by Susan Lee.

The Daily is made by Lisa Tobin, Rachel Quester, Lynsea Garrison, Clare Toeniskoetter, Paige Cowett, Michael Simon Johnson, Brad Fisher, Chris Wood, Jessica Cheung, Stella Tan, Alexandra Leigh Young, Lisa Chow, Eric Krupke, Marc Georges, Luke Vander Ploeg, M.J. Davis Lin, Dan Powell, Dave Shaw, Sydney Harper, Robert Jimison, Mike Benoist, Liz O. Baylen, Asthaa Chaturvedi, Rachelle Bonja, Diana Nguyen, Marion Lozano, Corey Schreppel, Anita Badejo, Rob Szypko, Elisheba Ittoop, Chelsea Daniel, Mooj Zadie, Patricia Willens, Rowan Niemisto, Jody Becker, Rikki Novetsky, John Ketchum, Nina Feldman, Will Reid, Carlos Prieto, Sofia Milan, Ben Calhoun and Susan Lee.

Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly. Special thanks to Sam Dolnick, Paula Szuchman, Lisa Tobin, Larissa Anderson, Cliff Levy, Lauren Jackson, Julia Simon, Mahima Chablani, Desiree Ibekwe, Wendy Dorr, Elizabeth Davis-Moorer, Jeffrey Miranda, Renan Borelli, Maddy Masiello and Nell Gallogly.

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