This time last year at UPMC Children’s Hospital of Pittsburgh, Chief of Emergency Services Dr. Raymond Pitetti and his team were overwhelmed with sick children.

At the beginning of December 2022, the department saw a spike in activity from a combination of respiratory syncytial virus (RSV), covid-19 and flu cases, referred to by some as a “tripledemic.”

This year, the team is still running to keep up with a flood of respiratory illness in children from the same three bugs, though things are less surprising than last year, Pitetti said.

“Overall, we’re very busy in the emergency room. The majority of the children that are coming in have respiratory illnesses,” he said. “The number of children that are identified with RSV is greater than what we saw last year.”

The busiest period in the ER tends to be between 3 and 4 p.m., as kids get home from school, Pitetti said. Increasingly, parents are starting to bring their little ones at all hours, he said.

“We’re very busy from the first of the morning on,” he said. “We’re maximizing our resources to the best that we can, with bringing in extra people when we can and when we have to, and making sure we’re fully staffed at all times. But there’s a large number of children coming in.”

RSV is not a new illness, but it tends to impact very young children the most severely. Most of the time, it causes mild, cold-like symptoms, but it can lead to more serious illnesses such as bronchiolitis and pneumonia. The virus impacts the lungs and breathing passages and can cause severe illness or death.

Between Oct. 2 and Dec. 2 in Allegheny County, there have been 1,241 cases of flu and 832 cases of RSV. In Westmoreland County, there have been 458 cases of flu and 177 cases of RSV. The RSV cases are about 790 cases higher in Pennsylvania as a whole than they were at this time last year, though last year’s peak was earlier and much greater.

Covid cases in Allegheny County for the week of Dec. 2 numbered 621, a jump from the previous week’s 528.

Busy offices

At Alle Kiski Pediatrics, Dr. Kultar Shergill says he’s been getting more calls than last year from concerned parents.

Unlike covid, he said, RSV has few guidelines on how children should quarantine or what they should do if they’re exposed, so parents often have questions.

“This is just the beginning of RSV. RSV kind of peaks in the early months of the year — January-February are usually the worst months,” he said. “With RSV, we’ve had kids admitted to Childrens’ with low oxygen (and) pneumonia. They’re mostly under a year of age. These aren’t kids with any preexisting conditions; these are healthy kids.”

Dr. Jennifer Bradford of the North Huntingdon office of Pediatric Associates of Westmoreland says her location has been seeing more respiratory illness.

“It’s not unusual for this time of year,” she said. “We have had a few RSVs in our office. I would say we are having a lot of that, flu right now too is pretty much the majority of our visits.”

Bradford recommended parents keep vigilant about how their child or infant is breathing. If they’re breathing very quickly, have a very high fever or are getting dehydrated, they should take them to the emergency room.

If they have a lower temperature of 101 or 102 degrees but are breathing fine, and only have a cough or nasal symptoms, coming to the pediatrician is a good idea.

“Really, if we’re worried that the infant is going to need extra oxygen support, need to be admitted to the hospital, need IV fluids, that is when we need to start thinking about the ER,” she said.

Seasonal uptick

UPMC Chief Medical Officer Dr. Don Yealy said that of the three viruses, covid fluctuates the least.

“It never completely went away, but it does have tendency to go up and down,” he said, noting the region has been experiencing an uptick in covid cases over the past few months.

“(Covid is) most likely to trigger hospitalization and intensive care, but any one of the three can do it,” he said.

Dr. Joseph Aracri, chair of AHN Pediatric Institute, said AHN has seen more RSV and flu this year, too. Weekly RSV cases in Pennsylvania have nearly tripled since early November, he said in a released statement.

“Our AHN outpatient pediatric offices have seen an increase in cases of respiratory syncytial virus and influenza, which tracks with what we’re seeing nationally, and we anticipate these numbers will continue to rise this month as we gather and travel for the holidays,” he said.

Predicting peaks

Timing the peaks of the three viruses can be a challenge. Yealy noted influenza usually starts somewhere in that December-January time frame, and runs for a few months. Covid fluctuates throughout the year, and RSV peak usually starts slightly sooner.

“When you put the three together, where the peaks overlap is right about now,” he said.

Holiday gatherings are a major culprit for the rise in respiratory illness, Yealy said.

“Viruses like people who are close together, who are indoors, because they don’t have to travel all that far to find a new victim,” he said. “It’s not that the cold weather changes anything else. It’s really about contact.”

Not all hospitals and regions are seeing RSV. Dr. Carol Fox, chief medical officer at Independence Health System, said the peak may not have hit yet.

“We’re seeing really, at least as measured by the hospitals, very little RSV, and not a whole lot of flu,” she said. “Typically for us, our flu season really starts to rev up in January and February. We really haven’t seen very much of either of those things yet. Covid, we’re definitely seeing some, it’s been fairly steady, but compared to last year at this time, there’s about 40% less cases that we’ve diagnosed than we did last year.”

Fox emphasized that as a respiratory disease, RSV can be a “very significant illness” in young children.

“Their respiratory system is not as well developed,” she said, noting people over 60 or people with existing conditions also can be at risk. “It’s like flu — you can get sicker than the average person and require hospitalization, and we want to avoid that at all costs if possible.”

Impacts

Though the level of respiratory illness activity is busier, Yealy says UPMC is ready to take on the challenge.

“We’re not overwhelmed by any of the respiratory viruses yet,” he noted. “They’re clearly on the upswing. We’re ready and able to take care of people who have these infections.”

Independence Health is in a “constant state of readiness,” Fox said.

“Having been through the covid pandemic, it helped us to learn how to be flexible quickly and make adjustments when we need to,” she said. “We’ve not really needed to per se as a result of respiratory illnesses. We’ve been quite busy, but it hasn’t been necessarily an overwhelming amount of folks presenting with respiratory symptoms.”

Dr. Brian Parker, AHN’s Chief Quality & Learning Officer, said there hasn’t been a significant increase in the number of patients hospitalized for the three diseases in recent weeks, but the system expects to see “increased respiratory illness activity” during and after the holidays.

“Of the patients who are hospitalized at AHN with these respiratory illnesses, most are elderly, immunocompromised and/or have a chronic disease. In general, they experience short stays of 2-3 days,” he said. “Regarding flu, our region has seen a typical flu season thus far in which the ramp up of flu cases has been steady.”

An RSV vaccine became available for the first time this year, and is recommended for expectant mothers to protect their children and people over 60. However, it’s a little too early to see if the vaccine will have an impact on this year’s respiratory virus season.

“I’m really glad that there’s an RSV vaccine, and I’m very hopeful that in the years to come it will have a huge impact,” Pitetti said. “I’m not as hopeful, because it just rolled out, that it’s going to have a big impact this season.”

“It’s a little too early to tell. I’m interested to surveil this and see,” Yealy said. “It’s just too early in the season yet. It’ll probably be a few months before we can even speculate about that.”

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