2022–2023 pediatric care crisis

Last updated
2022–2023 pediatric care crisis
RSV, Influenza, and SARS-CoV-2 (52620877022).jpg
RSV, Influenza, and COVID-19 are among the primary contributors to the crisis

In the waning months of 2022, the first northern hemisphere autumn with the nearly full relaxation of public health precautions related to the COVID-19 pandemic, hospitals in the United States and Canada [1] began to see overwhelming numbers of pediatric care patients, primarily driven by a massive upswing in respiratory syncytial virus (RSV) cases, but also flu, rhinovirus, enterovirus, and SARS-CoV-2. [2]

Contents

With high levels of hand-washing, mask-wearing, and social isolation during the early years of the pandemic, children born during this period had particularly low levels of exposure to RSV, with public health professionals reporting extremely low levels of RSV transmission in 2020 and 2021. In contrast, 2022 evidenced a dramatic reversal. [3]

Starting in September 2022, many emergency departments and intensive-care units in the United States have been either at-capacity or over-capacity, with a variety of hospitals resorting to extreme measures which have included the use of a makeshift tent outside Johns Hopkins Children's Center in Maryland and the proposed deployment of the National Guard in Connecticut. [2]

Outside of North America, in the United Kingdom, pediatric infections also began to spike beyond pre-pandemic levels, albeit with different illnesses, such as Group A streptococcal infection and resultant scarlet fever. [4] As of mid-December in 2022, 19 children in the UK had died due to Strep A and the wave of infections had begun to spread into North America and Mainland Europe. [5] [6]

In late 2023, a similar pattern of pediatric illness appeared to emerge with Mycoplasma pneumoniae in China during the first full autumn and winter season following relaxation of its stringent Zero-COVID policies. [7] Increased rates of pediatric Mycoplasma pneumonia were simultaneously observed in other parts of the world, with Denmark declaring that infections had reached epidemic levels. [8]

Timeline

The crisis had no clear start date, as multiple disease outbreaks occurred over the course of 2022, with cascading effects on healthcare systems already burdened by the ongoing pandemic. Notably, staffing shortages led commentators in the US to say that the system was "crumbling" in August. [9] While authorities at one health region in Ontario spoke of "serious" and "unprecedented" challenges in September. [10] In Canada, warning signs appeared as early as July with a spike in enterovirus ("hand foot and mouth disease") cases [11] which continued into August. [12]

The pediatric care crisis in the United States began to be visible in statistics with high late-summer, August 2022 hospitalization numbers of children infected with rhinovirus and enterovirus, which are both acute respiratory illnesses and often indistinguishable without molecular sequencing or via a specific rRT-PCR assay. By early September, the Centers of Disease Control issued an official Health Advisory about severe respiratory illnesses from Rhinoviruses and/or Enteroviruses D-68. [13]

RSV then began to see its exponential rise to the top of pediatric infections in September and October 2022, with mid and late-autumn SARS-CoV-2 and seasonal flu infections increasing the pediatric care burden later into the year.By mid-autumn, flu cases had already shuttered schools and reactivated remote learning in parts of the American South and mid-Atlantic. [2]

On October 26, the Government of Canada issued an advisory that Canada was experiencing a shortage of children's acetaminophen and ibuprofen due to the spike in infections. [14] By late October, staff infections with respiratory illnesses had compounded the previous staffing shortages in Ontario causing many emergency rooms and other departments at multiple hospitals to close. [15] In the USA staffing shortages and the spike in infections saw 80% of pediatric beds full nationally, with the worst numbers being in Rhode Island where beds were 99% full, causing some hospitals to set up field tents. [16]

On November 7, researchers determined that the United States was concurrently facing epidemics of flu, RSV, and COVID-19 in children. [17] As of early November, 75% of beds in US children's hospitals were full and the crisis had spread to eastern Canada, with a children's hospital in Ottawa reporting over 130% capacity for both intensive care and inpatient beds. On November 1, 2022, California's Orange County declared a pediatric health emergency after seeing record-breaking numbers of children enter emergency rooms in the county's hospitals. [18] At the same time over fourteen thousand students were out of school due to illness in the Edmonton region of Alberta. [19] By November 5, Emily Gruenwold, president and CEO of Children's Healthcare Canada said that "across the country, almost without exception, our children's hospitals are all running at 100 percent occupancy or more" in part because the shortage of over-the-counter painkillers that could suppress fevers lead more parents to bring their sick children to hospitals. [20]

Testing booth for COVID-19, both major influenza strains, and RSV in New York City. Covid Flu and RSV testing.jpg
Testing booth for COVID-19, both major influenza strains, and RSV in New York City.

On November 14, the Children's Hospital Association and the American Academy of Pediatrics wrote a joint letter to President Biden and Health Secretary Xavier Becerra, asking that the administration declare an emergency that would unlock funding and regulatory flexibilities akin to the ongoing COVID-19 emergency. This request came as RSV hospitalizations reached seven times pre-pandemic levels among infants 6 months and younger and flu hospitalizations were the highest in a decade. [21] One US state, Oregon, had already declared a public health emergency related to the pediatric care crisis several days prior to the national appeal. [22] The US Department of Health and Human Services decided against a national emergency declaration at the time, deciding to instead support struggling communities on a case-by-case basis. [23]

Also on November 14, the Public Health Agency of Canada's FluWatch surveillance program took action on one major component of the pediatric crisis, declaring the flu an epidemic and noting a spike in pediatric flu hospitalizations above expected levels. [24] Days later, on November 17, the Canadian Medical Protective Association (a legal defense fund for doctors) issued advice to its members about practising out of scope due to the "unprecedented overcrowding occurring in pediatric hospitals across the country". [25] On November 23, a group called "Moms, Grandmoms, and Caregivers for Kids" issued an open letter to the Canadian federal and provincial governments about the crisis because, they said, "There is a palpable sense of hopelessness amongst parents and those that serve kids on the frontlines. Doctors say the crisis will get worse before it gets better, yet we see no tangible signs of action." The signatories to the letter included Lisa Raitt, Penny Collenette, Kathleen Wynne, and Marg McCuaig-Boyd. [26] By the end of November, Canadian pediatric hospitalizations for seasonal influenza alone were 20 times the usual rate of admissions for that time of year. [27] On December 9, the premiers of Canada's provinces and territories held a joint news conference to address the crisis in children's hospitals. [28]

By mid-December, some US children's hospitals were receiving transfer requests from communities far outside of their typical geographic coverage areas. Helen DeVos Children's Hospital of Grand Rapids, Michigan fielded requests from communities in the state's Upper Peninsula, upwards of 300 miles away, and the state of Illinois. Both areas share land borders with Wisconsin rather than lower Michigan, but Wisconsin's hospitals were full. Devos also had to turn away patients and could only accept children who were severely ill. [29]

The UK's spike in severe pediatric Strep A infections also began to spill over into the United States in December 2022, with Colorado, Texas, and Arizona reporting atypically high numbers of cases in children's hospitals, including two deaths in Colorado, while the World Health Organization noted that the Netherlands, Ireland, Sweden, and France had also begun experiencing unusually high levels of Strep A infections. [6] On 22 December, the US CDC issued a health advisory due to increasing levels of Strep A infections in the United States. [30]

A study released on 7 February 2023 found that 40 percent of US households had experienced infection by one of the three primary drivers of the pediatric crisis in North America during the 2022–2023 winter season. [31]

Coinfections

While coinfections have always been a possibility in pediatric medicine, SARS-CoV-2 has made coinfection with multiple viruses much more common, with doctors reporting back-to-back hospitalizations and children presenting with upwards of four distinct respiratory viruses in the span of a single month. [2] According to a CDC report released in December 2022, children who experience a coinfection of SARS-CoV-2 and influenza are more likely to encounter adverse outcomes and require invasive or noninvasive respiratory support than children infected with influenza only. [32]

Contributing factors

In the two decades preceding the crisis, US hospitals experienced a significant decline in the number of pediatric beds due to lower billable procedures in pediatric admissions in comparison to adults. Pediatric beds have also been occupied by greater numbers of young people experiencing mental health emergencies during the COVID-19 pandemic, who have been admitted to ICUs following suicide attempts. [33]

In typical years, without a surge of cases and multiple coinfections, RSV is the most common cause of pediatric hospitalization in developed countries, and Bronchiolitis caused by RSV is more severe and leads to higher hospitalization rates as compared with non-RSV bronchiolitis. [34] [35]

A widespread shortage of liquid amoxicillin has also complicated pediatric care for primary bacterial infections, such as Strep A, as well as potentially dangerous secondary bacterial infections arising from a primary viral infection. [36]

Government responses

In the US, Surgeon General Vivek Murthy noted that the federal government was responding to the crisis in a variety of ways. First, it was offering direct support to struggling hospitals by providing personnel, ventilators, and equipment. The federal government also actively assisted in interstate coordination of available beds across given regions. [37] Although the US would not declare a public health emergency specific to the pediatric crisis, HHS Secretary Xavier Becerra wrote, in a 2 December letter to US governors, that the existing emergency declaration for COVID-19 could be broadly applied to the surge in other respiratory viruses related to the relaxation of pandemic public health measures. [38]

Broader crisis

In December 2022, the terms "tripledemic" [39] [40] and "tridemic" [41] [42] were used to describe simultaneous outbreaks of RSV, influenza, and COVID-19 in both Canada and the United States. Accordingly, with cases of RSV at 300% more than would be expected in a normal season and rising numbers of adult infections together with increased COVID-19 hospitalizations, some public health professionals have expressed alarm at the potential for spillover into a widespread medical crisis, not confined solely to pediatric care. [43] [44] [ needs update ]

See also

Related Research Articles

<span class="mw-page-title-main">Pneumonia</span> Inflammation of the alveoli of the lungs

Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severity of the condition is variable.

<span class="mw-page-title-main">Bronchiolitis</span> Blockage of the small airways in the lungs due to a viral infection

Bronchiolitis is inflammation of the small airways in the lungs. Acute bronchiolitis is due to a viral infection usually affecting children younger than two years of age. Symptoms may include fever, cough, runny nose, wheezing, and breathing problems. More severe cases may be associated with nasal flaring, grunting, or the skin between the ribs pulling in with breathing. If the child has not been able to feed properly, signs of dehydration may be present.

<span class="mw-page-title-main">Respiratory syncytial virus</span> Species of virus

Respiratory syncytial virus (RSV), also called human respiratory syncytial virus (hRSV) and human orthopneumovirus, is a contagious virus that causes infections of the respiratory tract. It is a negative-sense, single-stranded RNA virus. Its name is derived from the large cells known as syncytia that form when infected cells fuse.

Community-acquired pneumonia (CAP) refers to pneumonia contracted by a person outside of the healthcare system. In contrast, hospital-acquired pneumonia (HAP) is seen in patients who have recently visited a hospital or who live in long-term care facilities. CAP is common, affecting people of all ages, and its symptoms occur as a result of oxygen-absorbing areas of the lung (alveoli) filling with fluid. This inhibits lung function, causing dyspnea, fever, chest pains and cough.

<span class="mw-page-title-main">Influenza-like illness</span> Medical diagnosis

Influenza-like illness (ILI), also known as flu-like syndrome or flu-like symptoms, is a medical diagnosis of possible influenza or other illness causing a set of common symptoms. These include fever, shivering, chills, malaise, dry cough, loss of appetite, body aches, nausea, and sneezing typically in connection with a sudden onset of illness. In most cases, the symptoms are caused by cytokines released by immune system activation, and are thus relatively non-specific.

<span class="mw-page-title-main">2009 swine flu pandemic</span> 2009–2010 pandemic of swine influenza caused by H1N1 influenza virus

The 2009 swine flu pandemic, caused by the H1N1/swine flu/influenza virus and declared by the World Health Organization (WHO) from June 2009 to August 2010, was the third recent flu pandemic involving the H1N1 virus. The first identified human case was in La Gloria, Mexico, a rural town in Veracruz. The virus appeared to be a new strain of H1N1 that resulted from a previous triple reassortment of bird, swine, and human flu viruses which further combined with a Eurasian pig flu virus, leading to the term "swine flu".

The 2009 flu pandemic in the United States was caused by a novel strain of the Influenza A/H1N1 virus, commonly referred to as "swine flu", that was first detected on 15 April 2009. While the 2009 H1N1 virus strain was commonly referred to as "swine flu", there is no evidence that it is endemic to pigs or of transmission from pigs to people; instead, the virus spreads from person to person. On April 25, the World Health Organization declared a public health emergency, followed concurringly by the Obama administration on April 26.

<span class="mw-page-title-main">2009 swine flu pandemic in Canada</span> Disease outbreak in Canada

The 2009 swine flu pandemic in Canada was part of an epidemic in 2009 of a new strain of influenza A virus subtype H1N1 causing what has been commonly called swine flu. In Canada, roughly 10% of the populace has been infected with the virus, with 428 confirmed deaths ; non-fatal individual cases are for the most part no longer being recorded. About 40% of Canadians have been immunized against H1N1 since a national vaccination campaign began in October 2009, with Canada among the countries in the world leading in the percentage of the population that has been vaccinated. The widespread effect of H1N1 in Canada raised concerns during the months leading to the XXI Olympic Winter Games, which took place in Vancouver in February 2010.

The 2009 flu pandemic was a global outbreak of a new strain of influenza A virus subtype H1N1, first identified in April 2009, termed Pandemic H1N1/09 virus by the World Health Organization (WHO) and colloquially called swine flu. The outbreak was first observed in Mexico, and quickly spread globally. On the 11th of June 2009, the WHO declared the outbreak to be a pandemic. The overwhelming majority of patients experience mild symptoms, but some persons are at higher risk of suffering more serious effects; such as those with asthma, diabetes, obesity, heart disease, or those who are pregnant or have a weakened immune system. In the rare severe cases, around 3–5 days after symptoms manifest, the sufferer's condition declines quickly, often to the point respiratory failure. Although Ukraine was not (very) affected at first there was on outbreak of the virus in Western Ukraine in early November 2009 that led to the closing of public buildings and cancellation of meetings for three weeks.

<span class="mw-page-title-main">Theresa Tam</span> 3rd chief public health officer of Canada

Theresa Tam is a Canadian physician and public servant who currently serves as the chief public health officer of Canada, who is the second-in-command of the Public Health Agency of Canada (PHAC). Tam initially took the role as acting CPHO following the retirement of her predecessor, Gregory Taylor, on 16 December 2016. She was formally appointed on 26 June 2017.

<span class="mw-page-title-main">2017–2018 United States flu season</span> 2017–2018 influenza outbreak

The 2017–2018 United States flu season lasted from late 2017 through early 2018. The predominant strain of influenza was H3N2. During the spring months of March–May, influenza B virus became dominant.

Allison Joan McGeer is a Canadian infectious disease specialist in the Sinai Health System, and a professor in the Department of Laboratory Medicine and Pathobiology at the University of Toronto. She also appointed at the Dalla Lana School of Public Health and a Senior Clinician Scientist at the Lunenfeld-Tanenbaum Research Institute, and is a partner of the National Collaborating Centre for Infectious Diseases. McGeer has led investigations into the severe acute respiratory syndrome outbreak in Toronto and worked alongside Donald Low. During the COVID-19 pandemic, McGeer has studied how SARS-CoV-2 survives in the air and has served on several provincial committees advising aspects of the Government of Ontario's pandemic response.

<span class="mw-page-title-main">Impact of the COVID-19 pandemic on other health issues</span> Health consequences of outbreak beyond the COVID-19 disease itself

The COVID-19 pandemic has had many impacts on global health beyond those caused by the COVID-19 disease itself. It has led to a reduction in hospital visits for other reasons. There have been 38 per cent fewer hospital visits for heart attack symptoms in the United States and 40 per cent fewer in Spain. The head of cardiology at the University of Arizona said, "My worry is some of these people are dying at home because they're too scared to go to the hospital." There is also concern that people with strokes and appendicitis are not seeking timely treatment. Shortages of medical supplies have impacted people with various conditions.

Viral interference, also known as superinfection resistance, is the inhibition of viral reproduction caused by previous exposure of cells to another virus. The exact mechanism for viral interference is unknown. Factors that have been implicated are the generation of interferons by infected cells, and the occupation or down-modulation of cellular receptors.

<span class="mw-page-title-main">Alternate care site</span> Non-traditional medical treatment facility established in a public health crisis

An alternate care site (ACS) is a medical treatment facility established in a non-traditional setting during a public-health crisis as a means of providing additional capacity to deliver medical care within a given area. The term encompasses both civilian-operated medical facilities established in non-traditional places such as hotels, gymnasiums, and convention centers, or other "structure[s] of opportunity," as well as military field medical units being used for public-health purposes. Usually, the option of establishing an ACS becomes relevant once the scale of an emergency extends beyond a single metropolitan area. Though commonly established by public-health authorities, ACSes can also be established by private entities, such as large employers. ACSes have been widely used as part of the response to the COVID-19 pandemic, and in other recent crises such as the Western African Ebola virus epidemic.

Twindemic and tripledemic are terms used during the COVID-19 pandemic, referring to the possibility of a severe flu season happening alongside an increase in cases of COVID-19 during the fall and winter of 2020 and 2021, as well as respiratory syncytial virus in the winter of 2022. A consequence of a twindemic may be a mixture of two different infections in the same person at the same time. The term twindemic is a portmanteau of "twin" and "pandemic".

The impact of the COVID-19 pandemic on hospitals became severe for some hospital systems of the United States in the spring of 2020, a few months after the COVID-19 pandemic began. Some had started to run out of beds, along with having shortages of nurses and doctors. By November 2020, with 13 million cases so far, hospitals throughout the country had been overwhelmed with record numbers of COVID-19 patients. Nursing students had to fill in on an emergency basis, and field hospitals were set up to handle the overflow.

Anna Banerji M.D., O. Ont. is a Toronto infectious disease doctor, tropical disease specialist, pediatrician, public health specialist, academic, and activist. She is the founder and chair of both the North American Refugee Health Conference in Canada and the Indigenous Health Conference, and the co-founder of the Society of Refugee Healthcare Providers. She was awarded the Dr Peter Bryce Henderson for her advocacy for Indigenous children.

There has been a nursing shortage in Canada for decades. This became more acute in the period between 1943 and 1952 as Canada's health services were expanding, and the number of hospital beds increased along with the number of hospitalizations. By the mid-1940s across Canada the shortage, estimated at 8,700, led to a re-organization and re-conceptualization of nursing in Canada, according to a 2020 journal article in BC Studies. The nature of nursing was changing with new and time-consuming responsibilities, such as the administration of penicillin. During that period, there was no unemployment for nurses, especially if they were willing to be mobile. However, working conditions for nurses were very poor, with low wages combined with long hours; nursing force retention was challenging. As well, since almost all nurses were women, they had responsibilities at home they had to manage. In response to the shortage of nurses, women who had trained as registered nurses (RNs) but had left the workforce when they married, were encouraged to return to work; volunteers were engaged; nursing courses were accelerated; and new categories of regulated nursing were added to registered nursing—"practical nurses" and "nursing assistants." At that time, a "utopia of nursing" referred to teams of nursing staff which included registered nurses and other regulated nursing and hospital worker support personnel. Some of these auxiliary positions were also open to First Nations women and other racialized groups.

<span class="mw-page-title-main">2023 Chinese pneumonia outbreak</span> Disease outbreak in northern China

In November 2023, China's health authorities reported an outbreak of respiratory illnesses in several parts of northern China. As hospitals became overwhelmed in Beijing and Liaoning, the World Health Organization (WHO) requested detailed information from China regarding the surges in respiratory health, while advising the community to take important precautions. China complied, responding that "no unusual or novel pathogens were found" in the provided data.

References

  1. Shingler, Benjamin. "What to know about RSV, a virus surging among young children in Canada". CBC News .
  2. 1 2 3 4 Wu, Katherine (31 October 2022). "The Worst Pediatric-Care Crisis in Decades". The Atlantic. Archived from the original on 31 October 2022. Retrieved 1 November 2022.
  3. Roth, Clare (27 October 2022). "Doctors say respiratory infection RSV may surge this winter". Deutsche Welle. Archived from the original on 31 October 2022. Retrieved 1 November 2022.
  4. Mackintosh, Thomas; Durbin, Adam (3 December 2022). "Father of girl, 4, fighting for life with Strep A infection is 'praying for a miracle'". BBC News. Archived from the original on 3 December 2022. Retrieved 4 December 2022.
  5. "Strep A kills three more children as UK activates alternative medicines plan: At least 19 children have died and scarlet fever cases are more than treble what they were in previous high season". The Guardian. 15 December 2022. Archived from the original on 17 December 2022. Retrieved 17 December 2022.
  6. 1 2 Wetsman, Nicole; McLean, Nicole (16 December 2022). "US children's hospitals are tracking increases in severe strep infections". ABC News. Archived from the original on 17 December 2022. Retrieved 17 December 2022.
  7. Sparrow, Annie (28 November 2023). "Chinese Hospitals Are Housing Another Deadly Outbreak". Foreign Policy. Archived from the original on 29 November 2023. Retrieved 30 November 2023.
  8. Schnirring, Lisa (29 November 2023). "Denmark reports Mycoplasma pneumonia epidemic | CIDRAP". Center for Infectious Disease Research and Policy at the University of Minnesota. Archived from the original on 30 November 2023. Retrieved 30 November 2023.
  9. J.D, Sai Balasubramanian, M. D. "The Healthcare Industry Is Crumbling Due To Staffing Shortages". Forbes. Retrieved 2022-11-02.{{cite web}}: CS1 maint: multiple names: authors list (link)
  10. "Health-care worker shortage presenting serious challenge to Niagara hospital system - Niagara Health News, Updates & Publications | Niagara Health System | Système De Santé De Niagara". www.niagarahealth.on.ca. Retrieved 2022-11-02.
  11. "Hand-foot-and-mouth disease outbreaks higher than in years past: AHS - Edmonton | Globalnews.ca". Global News. Retrieved 2022-11-02.
  12. Sweet, Jennifer. "Doctors see hand, foot and mouth disease make comeback in N.B." CBC News .
  13. "Severe Respiratory Illnesses Associated with Rhinoviruses and/or Enteroviruses Including EV-D68 – Multistate, 2022". CDC Health Alert Network. Centers for Disease Control and Prevention. 9 September 2022. Archived from the original on 31 October 2022. Retrieved 1 November 2022.
  14. "Infant and children's acetaminophen and ibuprofen shortage". www.canada.ca. 2022-10-26. Retrieved 2022-11-02.
  15. "Ontario hospitals continue to deal with significant staffing shortages | Globalnews.ca". Global News. Retrieved 2022-11-02.
  16. Christensen, Jen (2022-10-28). "Staff shortages make patient surges harder for children's hospitals -- and the situation won't get better soon". CNN. Retrieved 2022-11-02.
  17. Tanne, Janice Hopkins (2022-11-07). "US faces triple epidemic of flu, RSV, and covid". BMJ. 379: o2681. doi: 10.1136/bmj.o2681 . ISSN   1756-1833. PMID   36343961. S2CID   253371039.
  18. Prater, Erin (1 November 2022). "Viral infections like RSV, the flu, and COVID have one Southern California county declaring a pediatric health emergency. It's far from alone". Fortune. Archived from the original on 2 November 2022. Retrieved 2 November 2022.
  19. "14K+ Edmonton students off sick as respiratory illnesses spike in region | Globalnews.ca". Global News. Retrieved 2022-11-07.
  20. "'We are so overwhelmed': Children's hospitals across Canada stretched as RSV cases, flu-like illnesses spike". CTVNews. 2022-11-05. Retrieved 2022-11-07.
  21. Kimball, Spencer (18 November 2022). "Children's hospitals call on Biden to declare emergency in response to 'unprecedented' RSV surge". CNBC. Archived from the original on 21 November 2022. Retrieved 21 November 2022.
  22. Rideout, Nicole (15 November 2022). "Oregon governor declares RSV in children a public health emergency". OHSU News. Archived from the original on 19 November 2022. Retrieved 21 November 2022.
  23. Weixel, Nathaniel (25 November 2022). "White House resists declaring emergency as flu, viruses surge in children". The Hill. Archived from the original on 25 November 2022. Retrieved 26 November 2022.
  24. "FluWatch report: October 30 to November 5, 2022 (week 44)". Public Health Agency of Canada. 2022-11-14. Retrieved 2022-11-14.
  25. "CMPA - Pediatric care crisis – Practising outside of scope". CMPA. Archived from the original on 2022-12-09. Retrieved 2022-12-09.
  26. Kids, Moms, Grandmoms, and Caregivers for. "Open Letter to Prime Minister Justin Trudeau and the Premiers: Our kids are in crisis - It's time to work together and prioritize children". www.newswire.ca. Retrieved 2022-12-09.{{cite web}}: CS1 maint: multiple names: authors list (link)
  27. Jones, Nicola (12 December 2022). "Flu causes huge spike in child hospitalizations in Canada". Nature. Archived from the original on 12 December 2022. Retrieved 12 December 2022.
  28. "Canadian premiers set to speak as viral surge overwhelms children's hospitals | Globalnews.ca". Global News. Retrieved 2022-12-09.
  29. Wells, Kate (15 December 2022). "Children's hospitals are struggling to cope with a surge of respiratory illness". NPR. Archived from the original on 15 December 2022. Retrieved 15 December 2022.
  30. Jacquez, Joe (22 December 2022). "CDC issues warning about rise of invasive strep A infections in children". The Hill. Archived from the original on 23 December 2022. Retrieved 23 December 2022.
  31. Weixel, Nathaniel (7 February 2023). "'Tripledemic' infected nearly 40 percent of households, survey finds". The Hill. Archived from the original on 7 February 2023. Retrieved 8 February 2023.
  32. Adams, Katherine; Tastad, Katie; Huang, Stacy; et al. (16 December 2022). "Prevalence of SARS-CoV-2 and Influenza Coinfection and Clinical Characteristics Among Children and Adolescents Aged <18 Years Who Were Hospitalized or Died with Influenza — United States, 2021–22 Influenza Season". MMWR. Morbidity and Mortality Weekly Report. 71 (50): 1589–1596. doi:10.15585/mmwr.mm7150a4. PMC   9762905 . PMID   36520656 . Retrieved 19 January 2023.
  33. Beaumont, Hilary (30 November 2022). "US children's hospitals overwhelmed by RSV cases". Al Jazeera. Archived from the original on 30 November 2022. Retrieved 30 November 2022.
  34. Welliver, Robert (November 2003). "Review of epidemiology and clinical risk factors for severe respiratory syncytial virus (RSV) infection". The Journal of Pediatrics. 143 (5): 112–117. doi:10.1067/S0022-3476(03)00508-0. PMID   14615709 . Retrieved 2 December 2022.
  35. García, Carla; Bhore, Rafia; Soriano-Fallas, Alejandra; Trost, Margaret; Chason, Rebecca; Ramilo, Octavio; Mejias, Asuncion (1 December 2010). "Risk Factors in Children Hospitalized With RSV Bronchiolitis Versus Non–RSV Bronchiolitis". Pediatrics. 126 (6): e1453–e1460. doi:10.1542/peds.2010-0507. PMC   3761792 . PMID   21098154 . Retrieved 2 December 2022.
  36. Pearson, Rachel (27 December 2022). "The Post-COVID "Immunity Gap" Continues to Pummel Pediatric Wards". The New Yorker. Archived from the original on 28 December 2022. Retrieved 28 December 2022.
  37. "Surgeon General Vivek Murthy advises on flu, RSV and COVID-19". ABC News. 1 December 2022. Archived from the original on 2 December 2022. Retrieved 2 December 2022.
  38. McPhillips, Deidre (2 December 2022). "As respiratory viruses strain US health care systems, Biden administration tells states how it's ready to help". CNN. Archived from the original on 4 December 2022. Retrieved 4 December 2022.
  39. "CDC updates the status of the 'tripledemic'". NPR.org. Retrieved 2022-12-09.
  40. Barbaro, Michael; Harper, Sydney; Quester, Rachel; Chaturvedi, Asthaa; Lin, MJ Davis; Diao, Lexie; Georges, Marc; Powell, Dan; Lozano, Marion (2022-11-22). "The 'Tripledemic,' Explained". The New York Times. ISSN   0362-4331 . Retrieved 2022-12-09.
  41. "After Covid Pandemic, Canada Now Faces "Tridemic": Report". NDTV.com. Retrieved 2022-12-09.
  42. "'Tridemic' threatening to overwhelm health care systems as flu, RSV, COVID cases rise". PBS NewsHour. 2022-11-22. Retrieved 2022-12-09.
  43. Ponder, A’Leeyah (31 October 2022). "RSV cases surging in adults". WFIE 14 News. Archived from the original on 1 November 2022. Retrieved 1 November 2022.
  44. Gawthrop, Elisabeth; Clary, Benjamin (28 October 2022). "Uptick in COVID-19 hospitalizations and a surge in RSV cases in Minnesota". MPR News. Archived from the original on 31 October 2022. Retrieved 1 November 2022.