RSV, influenza and COVID coinfections in children can be severe

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The United States has faced a triple threat of respiratory viruses over the past few months, with COVID-19, the flu and RSV driving infections and hospitalizations in the Houston area and elsewhere.

Each of the three are capable of causing mild to severe illness by themselves. But it’s also possible to contract more than one virus at a time — and a new study suggests a coinfection may lead to more severe illness in young children.

The term “flurona” became popular on social media last year as a surge in COVID-19 and the re-emergence of the flu caused a wave of infections. However, doctors were seeing patients — particularly young children — with coinfections before the pandemic, said Dr. Amy Arrington, medical director of the Special Isolation Unit at Texas Children’s Hospital.

“It’s not uncommon that we see younger kids getting co-infected,” she said. “I think a lot of parents today in Houston can say they feel like their child’s been sick for the past few months straight.”

Younger children might be more susceptible to coinfections because they haven’t been exposed to a respiratory virus before, Arrington said. They may be getting infected at daycare, or from an older sibling who picked up the virus at school.

Coinfections are uncommon, but doctors might be seeing them more frequently this fall and winter for a few reasons, said Dr. Luis Ostrosky, chief of infectious diseases at UTHealth Houston and Memorial Hermann Hospital.

The collision of COVID-19, the flu and RSV, as well as other respiratory viruses like rhinovirus and enterovirus, has created more opportunity for infection, he said.

“We did see a surge in the three viruses at the same time, which made it more probable to actually get more than one at the same time,” Ostrosky said.

The prevalence of each virus has also led to more sophisticated testing to identify them, Ostrosky said.

The risk posed by a coinfection may not be the same for everyone. New evidence suggests coinfections may lead to more severe illness in young children, according to a study from the U.S. Centers for Disease Control and Prevention.

The study, published Wednesday in the journal Pediatrics, involved data from more than 4,000 children who were hospitalized with COVID-19. It found kids under 5 years old who were also infected with another virus were more likely to need oxygen to help them breathe or be admitted to an ICU.

The study did not find an increased risk for severe illness in children older than 5.

There are likely several reasons younger children are at higher risk for severe illness from coinfections, Arrington said. It’s possible they’ve never been exposed to the viruses before, so their immune systems haven’t “learned” how to respond to them. Children also have smaller airways than adults, so inflammation, secretions and mucus cause more problems for them.

“When you get those airways inflamed, they really struggle,” Arrington said.

The study only involved children, but Ostrosky said adults can also develop more severe illness from a coinfection. One explanation is that different respiratory viruses affect the lungs in different ways, he said.

“When you have, unfortunately, two viruses going at the same time, they could be damaging different parts of the lungs, or the lining of the lung, and things like that,” Ostrosky said. “We do tend to see it being kind of a more severe illness.”

The treatment for a coinfection depends on which viruses you have. The antiviral remdesivir and steroids can be used to treat COVID-19, while the antiviral Tamiflu is used to treat the flu. Other respiratory viruses, including RSV, have no treatment other than supportive care until the illness runs its course, Arrington said.

Fortunately, the prevalence of COVID-19, the flu and RSV has declined in Houston after a “mini-surge” over the holidays,

Data released Tuesday shows Texas Medical Center hospitals admitted an average of 146 new COVID-19 patients per day last week, down from 182 one week earlier.  The positivity rate — or the percentage of people who test positive after taking a COVID-19 test — was 10 percent last week, down from 11.8 percent one week earlier.

Flu, RSV and rhinovirus/enterovirus numbers have also fallen off, but those respiratory viruses are still circulating in Houston, according to data from Houston Methodist.

However, experts have warned the omicron variant XBB.1.5 has begun to make inroads in Houston. The variant appears to be more transmissible than its predecessors and now accounts for 43 percent of cases nationwide, according to CDC data.

“I’m very encouraged that we’re through the surge,” Ostrosky said. “Having said that, we need to not let our guard down because if we do, then we can just immediately go back to a surge.”

The good news is that the strategies for yourself and others — especially young children — remain the same, Arrington and Ostrosky said. They include wearing a face mask, avoiding large indoor gatherings and good hand hygiene. The flu shot and the COVID-19 vaccine, and particularly the bivalent booster that protects against omicron and its subvariants, also offer protection.

It’s impossible to shield young children from everything, Arrington said, so it’s important to protect them against the risk of severe illness from a coinfection.

“It’s hard, but we’ve definitely got some tools in our box that we can use to try to prevent, especially, severe disease,” she said.

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