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According to Benjamin Davido, MD, PhD (infectious disease specialist, Raymond-Poincaré Hospital, Garches, France), the hospital once again finds itself in an unprecedented and worrisome situation: a triple epidemic. It is experiencing a particularly early flu season, an explosion of cases of respiratory syncytial virus (RSV), and a resurgence of SARS-CoV-2. How can this epidemic situation be explained, and what solutions (such as masking, social distancing, and new vaccination and prevention campaigns) should be considered? Medscape Medical News raised these questions with Davido.
Medscape: There is currently a worrisome epidemic situation in several countries. Was it foreseeable, in your opinion?
Davido: Factually, there is indeed a triple epidemic of flu, RSV infections, and COVID-19. Some numbers are chilling, and it seems no country can escape them: more than 20% of positive flu cases are being reported in the United States, with largely insufficient flu vaccination coverage around the world, and especially in Europe. This scenario had been predicted, because there was a very large wave of flu in Australia this summer. Added to this is the European Center for Disease Prevention and Control alert on bronchiolitis and the resumption of circulation of SARS-CoV-2, with a consequent increase in hospitalizations (+18% in intensive care units in France currently). And that's not counting what is happening in China. We've endured the BQ1.1 variant worldwide, whereas the population is hardly immune anymore, since few people have received the Omicron-targeted bivalent booster (about 10% in France).
This situation is, therefore, particularly worrisome. We are witnessing a season with a significant number of respiratory infections of all kinds, and this is unprecedented in the post-COVID era. Every day, I am called on for hospitalizations for pulmonary infections, including bacterial ones. Over the past 3 months, we've seen a few elderly patients come into the department. Today, the average age of my patients is between 50 and 60 years, and some are occasionally in their thirties, like a patient who, with no comorbidities, arrived last week for pneumonia (severe flu) and had to go through the intensive care unit. I am once again seeing admissions to the ICU, including a 60-year-old woman who had never been vaccinated against COVID. The ICU is logically seeking downstream beds.... We once again need to remember that with Omicron, the risk of death in hospitalized patients is 7%, compared with 12% during the Delta wave.
Medscape: Why is the speed of this epidemic so exceptional?
Davido: Before the COVID-19 pandemic, hospitalizations for flu began between the end of December and the beginning of January, with a peak in late January. Today, 1 in 2 patients I am called to see have the flu. I'm amazed at how quickly it is evolving. We were in a gray area for a while, since we weren't testing for the flu in primary healthcare settings, so it was difficult to assess the arrival of this unprecedented wave of hospital flu in the COVID era. But we are now in an epidemic crisis management situation — we are meeting this week to list the beds available in geriatrics, in anticipation.
As for COVID, with the current variant (BQ1.1), which is even more contagious than the previous one (BA.5), the wave hits very quickly (+37% of cases in 1 week). This is perhaps the only good news. It should pass quickly, but the corollary, of course, will be the hospital overload inherent in severe forms. And once again, if only 10% to 20% of the target population is protected against BA.5, we'll find ourselves in a frankly very embarrassing situation, given the total lack of protective measures, such as masking and social distancing, in day-to-day life.
Regarding RSV, I think we underestimated the situation. We mobilized medical and paramedical staff on bronchiolitis at the hospital to counter a pediatric epidemic, while a double epidemic had just been added in adults. One of our mistakes was that for the past 2 years, we focused so closely on COVID that we couldn't imagine the overflow coming from somewhere else.
Medscape: What solutions can currently be envisioned to limit hospital strain in these unprecedented winter circumstances?
Davido: The faster the waves crash, the faster they'll inundate the hospital, that's for sure. But what's almost astonishing is that, while treatments (such as nirmatrelvir and ritonavir) and vaccines are now available, nothing has been put in place. We've gone from one extreme to the other, namely, from an almost hygienist society — rightly or wrongly — with restrictions going as far as wearing a mask outdoors with no scientific basis for it, to a general exasperation where we no longer want to hear about either COVID or masks. As we lifted all these mitigation measures, we stoked the fire for these viruses of yesteryear (that is, flu and RSV). We are in a completely different place than we were last year, and I'm not even talking about 2020, when there were only about 30 serious cases of flu identified.... Today, whether it's the vaccine or the mitigation measures or both, there are no more rules, no more compass! However, I think that as soon as the meteorological winter arrives, that is to say, December 1, we have to start putting the masks back on in crowded places and anticipate the vaccination of people at risk.
It seems completely crazy to get to this winter period without calibrating our epidemic surveillance tools, whether that means screening tests, vaccine booster campaigns, the use of protective measures, such as masking and social distancing, etc. If we continue like this, the next waves are really going to bury the hospital.
Medscape: Do you think people are sufficiently informed about vaccination or mitigation measures?
Davido: I don't think it's being explained well. Regarding vaccination, we have to stop thinking in terms of the number of doses and rather think in terms of new-generation vaccines. I've heard many accounts of people who don't know that people under 60 can be vaccinated. Some would like to get the boosters but think they aren't allowed to! We clung to the idea of a vaccination that targeted the elderly; it's a very bad message, because you can be 50 years old and have had a myocardial infarction and therefore be at risk. In addition, last year, the vaccination campaigns against the flu and against COVID came out at the same time, whereas today, everyone "manages" as best they can to get vaccinated. If there are no guidelines, no accelerated and outlined path, people are lost. A message like, "Vaccination with the new Omicron vaccine is open to everyone," would have more weight than talking about a fourth vaccine dose.
In the world before, we managed only one disease ― it was the flu ― and there were no mitigation measures. It all ran well. Today, we should probably be making more of an effort. When the bronchiolitis epidemic happened, it should have been said very clearly to put the mitigation measures back in place. However, the Ministry of Health has been completely silent on this subject. We were somehow engulfed by energy and political news. We are no longer "at war" against these viruses (just as we should be against bacteria, since, as a recent Lancet study reminds us, bacterial infections remain the second leading cause of death worldwide).
The moral is that we cannot, overnight, abandon campaigns to fight and prevent infectious diseases; it's not rational. We have to remember and explain basic hygiene. For example, the "energy sobriety" so acclaimed today encourages closing all the windows to save on heating.... However, if there is no more ventilation of the spaces, we are bound to increase the likelihood of contamination. And how does that play out currently in doctor's offices, where we increasingly see patients not wearing masks?
Medscape: How do we envision the future of the fight against these epidemics?
Davido: We have to relaunch strong campaigns to fight against infectious diseases every year, like they do, for example, with breast or colon cancer. And, as in oncology, we must continue to improve and simplify diagnostic tools and optimize treatments. Next year, we expect to see a new arsenal in the fight against bronchiolitis, through RSV vaccines. One example is that there are tools to screen for the flu, COVID, and RSV all at once. We'll have to explain it and put it in place and make all these new tools available, including to the primary care doctor.
There is also real work to be done on the collaboration between primary care and hospital infectious diseases. We will need to optimize the channels, eg, to call on and expand the field of competence of pharmacists and professionals in contact with patients. And more generally, we need to organize care in a broader way and imagine, for example, a "European conductor" for European health.
Medscape: Reinstate unvaccinated caregivers to bail out hospital departments, like they did in Italy?
Davido: I think it's a phony debate, because the real underlying question that is not being asked is, will this solve the hospital's problem? The answer is no. We're talking about around 4000 people, and among them, there are a lot of administrative staff, paramedics, etc. There are hardly any doctors. So, we have to be very careful when we talk about these "caregivers."
Nevertheless, I understand the subtlety of saying that vaccination does not prevent contamination and that everyone wears a mask in the hospital, so as a result, the vaccine becomes optional because it has no protective effect on patients. Beyond this shortcut, if we reinstate these workers, I believe that a tacit agreement should be put in place with them: in the event of a wave of unprecedented magnitude and given the availability of new mRNA vaccines which significantly reduce the likelihood of becoming infected, including with new variants, these people will have to submit to the science and vaccination.
We don't say it enough, but this vaccination of caregivers has largely made it possible, when the waves occur, on the one hand to avoid absenteeism, but also to "unmask" those who claim to be caregivers but do not rely on scientific data. Because I don't think you can be at the bedside of a patient who is suffering from COVID or the flu and tell him, "You were right not to get vaccinated and to end up in intensive care." There are ethics in medical care that are essential.
But we must be extremely clear: to say that the hospital is collapsing because staff were ousted who did not comply with vaccination is completely false. Their reinstatement is certainly possible, but it will not solve the problem in either the short or the long term.
This article was translated from the Medscape French edition.
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Cite this: Triple Winter Epidemic: How Do We Deal With This Extraordinary Season? - Medscape - Dec 29, 2022.