The “Tripledemic”

A MEDICAL RECORD INTERVIEW WITH JAMIE CHMIELOWSKI, MD, AND DEBRA POWELL, MD

The following interviews were conducted at the height of the recent surge in COVID-19, Influenza and Respiratory Syncytial Virus infections. While cases have declined, we are thankful for all of our physicians and staff who have labored selflessly in the care of our community and who remain vigilant in anticipation of what challenges may yet lie ahead.

Thank you to Dr. Chmielowski and Dr. Powell for sharing your time and expertise on this timely topic, aptly named “Tripledemic.” continued on next page

Medical Record: Dr. Powell, let’s begin with the BIG question. As we currently see case numbers decline, is the COVID-19 Pandemic officially over? If so, are we now in a new Endemic phase? And what does that mean for health care providers and their patients?

Dr. Powell: I know that we all wish that this would be the case but no, the COVID-19 pandemic is not officially over. We are seeing evolution of the virus over time with new viral strains emerging. The predominant strains currently circulating are variants of Omicron called BQ.1, BQ1.1 and XBB.1.5. They collectively make up over 85% of the strains detected. These strains are more infectious than the prior BA.5 variant that was the predominant strain over the prior 6 months. The good news is that these newer strains are not more severe than the BA.5 variant. Endemic means that the organism is circulating in the community on a regular basis and the infection is becoming more stable and manageable.

COVID-19 is transitioning to this status in many areas of the world, while other areas, such as China, are seeing high circulation and hospitalization rates. If COVID-19 will continue to circulate at a low chronic level year-round vs. becoming seasonal is not clear.

Medical Record: Dr. Powell, why has the SARS-CoV-2 virus been so persistent? Even with the annual influenza virus we see a seasonal pattern, however, COVID-19 appears to have been with us throughout the year. When we had viral surges during the COVID-19 pandemic, what role have virus variants played and why did it seem this virus could so readily mutate? Can we expect to continue to see such variants well into the future? What will be the role of new vaccines and how important are immunizations especially now for COVID-19 and Influenza?

Dr. Powell: SARs-CoV-2 appears to be less influenced by the season and has been able to mutate and become more infectious. Also, the antibodies produced are not long lasting and not totally protective. This has allowed the organism to infect patients even if they had prior infection or were immunized. The good news is that prior immunity does provide protection against severe disease and death. The new bivalent vaccines provide better protection against the Omicron variant as they contain proteins from the original COVID variant and the Omicron variant. It is important for everyone to be updated with the new bivalent vaccine to optimize their protection.

Medical Record: Dr. Chmielowski, what have you and your colleagues been seeing in your Pediatric offices over the past several weeks regarding viral infections? We have heard of the “tripledemic” of COVID-19, Influenza, and RSV all surging this Fall and Winter. Why is that the case? Are you able or is it even important to determine who has which illness? Are any of these three potentially more harmful to children and does the age of the child matter?

Dr. Chmielowski: We have certainly seen an increase in sick patients over the last several weeks, not only an increase in the number of patients, but also in the severity of their illnesses. Most children are suffering from respiratory symptoms and high, unrelenting fevers that last multiple days. Also, we are seeing so many children who essentially have been sick since September with back-to-back viral illnesses. It seems as if many aren’t going a week being totally healthy before they get sick again.

We have absolutely felt the pressure from the “tripledemic” of COVID-19, flu, and RSV. Flu and RSV seemed to hit harder and earlier than most years due to a combination of the lifting of COVID-19 restrictions and the multitude of novice immune systems amongst our “COVID babies” who are now being exposed for the first time to all these germs at the same time. In the outpatient world, unless we are concerned about the need for quarantine or are considering medication for a high-risk patient who presents within the first 48 hours of symptoms, which is rare, it isn’t necessary to perform the tests to see which viral illness they are suffering from. These tests are invasive and fairly expensive. As a rule, in medicine, it is never a good idea to perform a test that will not change your management! Therefore, we do not recommend performing viral tests unless it will change our treatment recommendations.

Supportive care is the recommendation, regardless of which virus is the cause, and the most important thing for us is to discuss with families the worrisome signs for which they should call us. For all these viruses, infants and children with compromised immune systems or underlying respiratory diseases are at highest risk. As with COVID-19 and flu, the RSV virus can affect infants, children, and adults, but infants are at highest risk for complications due to their small lung size and their inexperienced immune systems.

Medical Record: Dr. Chmielowski, how have you and your staff kept up these past several weeks with the volume of patients? Your number of phone calls must have been overwhelming. How do you triage who you must see and who you are comfortable treating over the phone? What is your sense of how parents/ families have managed all of this—including an onslaught of illness for almost three years now?

Dr. Chmielowski: Through many hours of hard work, teamwork, and dedication to the children and families of this community, we have gotten through it day by day. I am so blessed to work alongside the most amazing group of healthcare providers, as well as nonmedical staff, at Reading Pediatrics who make it possible for us to literally take hundreds of phone calls every day and provide care to the children in our neighborhoods.

We have done our best to keep the sick children out of the hospital. We’ve increased the number of sick appointments available, stayed open as late as possible in the office, added more weekend appointments, and provided more phone triage nurses to both answer the calls of worried parents and prioritize those whose children need urgent appointments from those that can be safely managed at home or be seen on a non-emergent basis.