CLEVELAND, Ohio — This past winter in Northeast Ohio saw plenty of viruses in circulation, including RSV, COVID-19 and the flu.

But the viral tripledemic health experts feared — defined as a spike in RSV, influenza and COVID-19 cases so high that hospitals could be overrun — didn’t materialize.

RSV cases, or respiratory syncytial virus, among children were indeed high, local health experts said.

But while flu deaths rose from what they were during the pandemic, the 16 deaths so far in Cuyahoga County is below pre-pandemic levels for the flu. And COVID-19 did not match the high number of cases seen last winter.

“COVID-19 really missed the party, which is fine,” said Dr. Amy Edwards, pediatric infectious disease specialist at University Hospitals Rainbow Babies and Children’s Hospital.

“RSV and influenza took up enough of our capacity in Northeast Ohio,” Edwards said.

As the weather warms, more people will want to get out and travel. That creates the potential for an uptick in COVID-19 cases as people gather, said Dr. Steven Gordon, chairman of the department of infectious disease at the Cleveland Clinic.

However, since more people have immunity from previous infections and/or vaccinations, physicians haven’t been seeing high levels of hospitalizations from COVID-19, and are not as worried about a large surge in hospitalizations this spring, Gordon said.

COVID-19 may be responsible for tough RSV season

The interaction between COVID-19 and RSV may have contributed to making this winter’s RSV season one of the worst that Edwards can remember.

It started early. It was aggressive,” Edwards said. “The hospital was overrun with kids who were sick. It was awful.”

RSV is a common respiratory virus that generally causes mild cold-like symptoms, but it can be dangerous for infants younger than 6 months.

Many kids got COVID-19 during the omicron wave preceding the current RSV season. COVID-19 might affect T cells, which fight viral infections, Edwards said.

“If something has fundamentally changed about our interaction with RSV, the next season could be just as bad or worse or whatever — we don’t really know,” Edwards said.

Another possibility is that social distancing due to the COVID-19 pandemic led to a loss of RSV immunity, Edwards said.

When looking at COVID-19 alone, the number of weekly cases in Ohio spiked in December, but soon fell lower in January and February, according to state health statistics.

“COVID-19 was persistent,” Gordon said. “There was not another spike of severe illness associated with the latest circulating omicron variation.”

COVID-19 cases as reported weekly by the Ohio Department of Health peaked at 17,891 on Dec. 22, before dropping and have been below 10,000 every week since mid-January.

In comparison, a year ago, cases topped more than 100,000 a week for several weeks in January.

When looking at influenza, the season began earlier than usual, peaked early and was responsible for high hospitalization rates among children, according to the U.S. Centers for Disease Control and Prevention.

It also brought more flu-related hospitalizations and deaths among adults than were seen during the last two flu seasons.

So far this season, Cuyahoga County has seen 16 flu-related deaths, including two pediatric flu deaths. That compares with 21 deaths during the 2018-19 flu season and 47 in 2017-18.

Cleveland Clinic chart

The Cleveland Clinic Respiratory Virus Positivity Rate Report tracks the presence of COVID-19, respiratory syncytial virus, influenza, and other respiratory viruses. This chart shows the recent RSV trend.Cleveland Clinic

At-home flu-COVID-19 test, RSV vaccine for pregnant women

New vaccines and other measures that slow the spread of winter viruses will help lower the chance of future tripledemics.

A combined influenza and COVID-19 test that can be taken at home, and RSV vaccines for the elderly and pregnant women are among the advances that are available or coming soon.

Soon, pregnant mothers may be able to protect their babies by taking an RSV vaccine during pregnancy. Pfizer announced in November that data from a study showed a single dose of the proposed vaccine, given in the late second or third trimester, effectively protected newborns, according to press reports.

In the first 90 days of the baby’s life, the vaccine was 81% effective at preventing severe lower respiratory tract infections that require hospitalization or assisted breathing, according to clinical trial data. The pharmaceutical company is expected to ask for approval this year.

“If every pregnant woman got vaccinated against RSV, we could essentially empty out our hospitals during RSV season,” Edwards said.

An FDA advisory panel this month recommended approval of two vaccines against RSV in adults over 60, one made by Pfizer and one manufactured by GlaxoSmithKline.

If approved, they would be the first publicly available vaccines for RSV. Full FDA approval for the Pfizer and GlaxoSmithKline immunizations could come later this year, according to press reports.

In addition, Moderna is expected to seek FDA approval for its RSV vaccine for older adults in a few months.

As far as COVID-19, more children under age 5 are now eligible for a booster.

Children ages 6 months to 4 years who have received three doses of the Pfizer-BioNTech shot can now get a booster with the companies’ COVID-19 vaccine — which targets the omicron subvariants. The third shot and the booster must be separated by two months, the FDA said.

The FDA recently issued an emergency authorization for the first at-home test for flu and COVID-19.

In other news, the FDA has revised its fact sheets regarding the Johnson & Johnson COVID-19 vaccine to warn about increased risks for myocarditis and pericarditis, particularly in the first week after vaccination, as well as facial paralysis.

Myocarditis is inflammation of the heart muscle, and pericarditis is inflammation of the lining outside the heart.

At home test

This at-home test for flu and COVID-19, made by Lucira, is the first of its kind. The FDA recently approved its use.Lucira

Are COVID-19 rebound cases tied to Paxlovid treatments?

While the COVID-19 vaccine and natural immunity have kept the virus from running amok as it did last winter, some people who get sick find themselves getting rebound COVID-19.

This is when symptoms return about two to eight days after a person tests negative or no longer feels ill. It’s not a reinfection, and it’s different from long COVID-19, health experts say.

Rebound COVID-19 can happen to both patients who take an antiviral treatment such as Paxlovid, and those who do not, Gordon said.

The CDC last May issued a health alert about COVID-19 rebound and Paxlovid, but some research since then has lowered the concern about a link

Paxlovid and Molnupiravir are two oral antiviral treatments that are used to treat COVID-19 in people with a high risk of developing severe illness. Both are pills taken twice daily for five days. They should both be started within five days of first feeling symptoms.

The Food and Drug Administration concluded this month that Paxlovid is not associated with COVID-19 rebound. Rebound COVID-19 is likely part of the natural course of the infection, the FDA said.

Likewise, a Case Western Reserve University research team published a pre-print study earlier this year suggesting COVID-19 rebound is not unique to Paxlovid. This study has not yet been peer-reviewed.

“We saw anecdotal reports of covid rebound associated with Paxlovid from social media, news (President Joe Biden and first lady) and friends,” said Rong Xu, professor of biomedical informatics and director of the center for artificial intelligence in drug discovery at the CWRU School of Medicine. “We conducted a formal statistical analysis to examine if COVID-19 rebound was specific to Paxlovid.”

This CWRU study examined the electronic health records of more than 13,000 adults across the United States. All contracted COVID-19 between January and June, 2022, and were treated with Paxlovid or Molnupiravir.

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