All signs so far point to a relatively average respiratory virus season in Colorado, but, with three major threats instead of two, that could still cause some strain in the health care system.

Last year, the flu season was moderate, and while COVID-19 still caused significant numbers of hospitalizations, it didn’t rival the gigantic waves in the first two winters of the pandemic. Respiratory syncytial virus, or RSV, roared back, though, overcrowding children’s hospitals and forcing them to take steps like treating teenagers in adult settings.

From October 2022 to May 2023 in Colorado, 8,231 people were hospitalized for COVID-19 and 3,076 were for flu. The Colorado Department of Public Health and Environment doesn’t collect statewide data on RSV hospitalizations, but tallied 2,597 in the Denver area, the vast majority of them involving children.

With COVID-19 in the mix, a typical virus season now is higher-risk than one before the pandemic, said Beth Carlton, associate professor of environmental and occupational health at the Colorado School of Public Health.

“There is hope that (COVID-19) declines to have an impact akin to flu, but that’s still a big impact,” she said.

Dr. Sam Dominguez, an infectious disease physician at Children’s Hospital Colorado, said its clinics haven’t seen large numbers of kids sick with respiratory viruses in the summer, as they did last year. Hopefully, there won’t be a repeat of last year’s surge of severe RSV cases, because so many children who weren’t infected during the earlier years of the pandemic got it last year and now have some immunity, he said.

“A normal year still means lots of RSV,” he said. “It just won’t be overwhelming.”

In a typical year, between 60,000 and 160,000 adults are hospitalized for RSV nationwide, and 6,000 to 10,000 die. The virus is also more severe in infants and toddlers, with 58,000 to 80,000 kids under 5 hospitalized most years.

Unlike in 2022, parents have the option this year to get their infants a monoclonal antibody shot, Dominguez said. Babies are the most vulnerable to severe RSV, because their airways are so small that any inflammation can interfere with breathing. There is some question about whether the shots will reach children before RSV starts circulating widely, but this will be the first season during which kids can get protection from COVID-19, flu and RSV, he said.

“It’s actually wonderful news,” he said. “Three of the major diseases in children, we have ways to prevent.”

The antibody product reduces the risk of RSV cases severe enough to require medical attention by about 70% and is recommended for all children under 8 months, and for those between 8 and 19 months who are at higher risk for severe illness.

People who are 60 or older also have options to prevent RSV this season. Two vaccines were approved this year, though not all insurance plans cover the roughly $300 cost. The shots are more than 80% effective in preventing symptoms such as coughing and shortness of breath, but the Centers for Disease Control and Prevention’s immunization advisory committee didn’t recommend them outright, instead saying that older adults should weigh the risk of RSV against the possibility of rare side effects.

One of the two vaccines for older adults is expected to be recommended in the eighth month of pregnancy. While RSV rarely causes severe illness during pregnancy, antibodies the mother produces can protect the baby in the first months of life. In trials, the shot provided robust protection for at least six months, though the group that received the vaccine had a slightly higher risk of preterm birth than the placebo group. It’s not clear if that reflects a real risk or statistical noise, though.

Flu shots are becoming available this week, and new COVID-19 boosters targeting the XBB.1.5 subvariant are expected to arrive later in September. It’s safe to get both a COVID-19 and a flu shot at the same time, according to the CDC. There isn’t much data about adding the RSV shot to the mix at the same time.

Typically, flu season peaks in December and runs through April, though it arrived and ended early last year.

Dr. Michelle Barron, senior director of infection prevention and control at UCHealth, said the system has seen sporadic flu cases in recent weeks, but the season doesn’t appear to be starting in earnest yet. If the United States follows the pattern in the Southern Hemisphere, we might expect to see significant flu activity in late October or early November, she said. Because Australia and countries in the Southern Hemisphere experience winter during our summer, they can offer some hints about the coming flu season.

Still, it’s a good idea to get your flu shot as soon as possible, so you aren’t caught off guard if the season starts earlier than expected, Barron said. The CDC recommends that anyone 6 months or older get the flu shot, unless they’ve had a severe allergic reaction to it in the past.

“The predictions are just that, predictions,” she said.

The CDC estimated between 140,000 and 710,000 people are hospitalized for flu nationwide each year, and between 12,000 and 52,000 die, depending on the severity of the season.

CDC Director Dr. Mandy Cohen said on a press call Thursday that the respiratory season in the Southern Hemisphere didn’t raise any red flags, though it did start a bit early. Still, hospitals could be strained more easily than in pre-pandemic years because they’re facing three major viruses, she said.

“What we have seen so far was a fairly typical season,” she said. “It doesn’t guarantee that that’s what we’ll see here.”

About 97% of Americans have been vaccinated, survived a COVID-19 infection, or both, meaning they’re less vulnerable to severe outcomes now, Cohen said. That said, immunity wanes and new variants emerge, so people need to stay up to date on their shots and to see if they qualify for antiviral medication if they do get sick, she said.

“We have to use these tools,” she said.

The CDC hasn’t yet released its recommendations on who should get a COVID-19 booster this fall, though experts think they will prioritize people over 65 and those who have chronic conditions, are pregnant, or have compromised immune systems.

People who didn’t receive a booster shot last year can still get one of the updated ones in a few weeks. The existing boosters are still available, but it likely doesn’t make sense for most people to get one now, since one that’s better targeted to the current variants is coming, Cohen said.

The federal government isn’t paying for most COVID-19 vaccines this year, though insurance plans will. A federal program to offer free boosters to uninsured people won’t come online until October, though the Biden administration is trying to move that up to mid-September, according to Politico.

COVID-19 hospitalizations increased 19% nationwide in the last week, though they were still about half what they were at the same point last year. In Colorado, 112 people were hospitalized as of Aug. 29, an increase over the last two weeks, but down from 195 in late August 2022.

While hospitals aren’t testing everyone anymore, which could reduce the number of identified hospitalizations, they are still catching the people who come in with respiratory symptoms, Carlton said.

“We’re starting to see an increase, but fortunately we’re starting from a very low place,” she said.

The state health department’s wastewater data showed viral concentrations were increasing in 23 watersheds, decreasing in 16 and stable in 14. The remaining 15 didn’t have enough data to determine a trajectory. While case numbers and positivity rates are no longer nearly as reliable as they once were, both have been trending up since mid-July.

Nationwide, no variant is dominant, though the EG.5 subvariant of omicron has been increasing its share. The CDC’s most recent estimates showed it accounting for about 22% of infections recently. It doesn’t appear to be significantly different from previous subvariants of omicron, though.

Virus watchers are keeping an eye on another new variant, BA.2.86, Carlton said. Not much is known about it at this point, other than that it appears to be particularly good at evading the immune system, and that it has enough mutations that it might qualify for its own Greek letter, she said. All of the variants that still exist are descendants of omicron.

“It is as different from currently circulating variants as omicron was from delta,” she said. “The impact of it remains unclear.”

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