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Doubling Down on Preventing Another “Tripledemic”

November 10, 2023

Remember the confluence of surging influenza (flu), COVID-19, and respiratory syncytial virus (RSV) cases last fall and winter, the so-called “Tripledemic”? For some, this term conjures memories of overflowing outpatient waiting rooms, inpatient bed shortages, too many children on ventilators, and overwhelming fatigue. Respiratory illness is the most common cause of pediatric hospitalization in the US,1 with influenza and RSV accounting for 2.1 and 2.7 deaths per 100,000 infants under 1 year of age, respectively.2

The good news is that we healthcare providers now have at our disposal the tools to prevent future “Tripledemics” with the recently licensed RSV monoclonal antibody injection and COVID-19 vaccine joining the flu vaccine in our respiratory disease prevention toolkit. Vaccinations have the potential to dramatically reduce respiratory disease attack rates and to empty our pediatric emergency rooms and inpatient units. According to Drs. Ryan Wolf and James Antoon in this month’s Pediatrics in Review article, “Influenza in Children and Adolescents: Epidemiology, Management, and Prevention,” vaccinated children are half as susceptible to influenza than unvaccinated children. Similarly, vaccinated children may be half as likely to be hospitalized with COVID-19 than unvaccinated children,3 and the RSV monoclonal antibody may prevent up to 80% of RSV-associated respiratory hospitalizations.4 The imperative now is to counsel caregivers effectively about all the tools in our toolkit so that they become as excited as we are about protecting children from respiratory disease during the fall and winter.

The next steps will not be easy. As Drs. Wolf and Antoon describe, pediatric flu vaccination coverage actually decreased from approximately 60% annually before the COVID-19 pandemic to 36% during the 2021–2022 flu season (thereby contributing to the following season’s “Tripledemic”). The authors attribute this drop to public vaccine fatigue, which continues to be a challenge facing pediatric practitioners daily. Children without risk factors are recommended by the Centers for Disease Control and Prevention (CDC) to receive up to 6 additional injections this cold season (1–2 doses of flu vaccine, 1 dose of RSV antibody if <8 months of age, and 1–3 doses of COVID-19 vaccine) on top of their routine, nonseasonal vaccinations. The need for additional injections poses logistical challenges for pediatric practices related to ordering and maintaining adequate stocks, scheduling appointments, administering and billing for injections, tracking who received them, and finally reporting them to immunization information systems. While not a panacea for the extra workload, allowing nurses to administer vaccinations under standing physician orders (ie, without individual orders for each child) and scheduling vaccination-only clinics may help practices avoid a backlog of children in need of injections during the fall and winter. Administering all three preventive therapies against flu, RSV, and COVID-19 together when possible—rather than spreading them out over several visits—reduces missed opportunities for vaccination, thereby resulting in greater respiratory disease protection overall.

Some caregivers may be fazed upon learning their infants require additional injections this cold season. Nonetheless, surveys consistently demonstrate that physicians are caregivers’ primary source for trusted vaccine information. We maintain that trust by continuing to do what we do best by demonstrating our passion for keeping children healthy and treating families with competence, empathy, and compassion.


  1. Kaiser SV, Rodean J, Coon ER, Mahant S, Gill PJ, Leyenaar JK. Common diagnoses and costs in pediatric hospitalization in the US. JAMA Pediatr.2022;176(3):316–318
  2. Hansen CL, Chaves SS, Demont C, Viboud C. Mortality associated with influenza and respiratory syncytial virus in the US, 1999-2018. JAMA Netw Open. 2022 Feb 1;5(2):e220527
  3. Shi DS, Whitaker M, Marks KJ, et al. Hospitalizations of children aged 5–11 years with laboratory-confirmed COVID-19 — COVID-NET, 14 states, March 2020–February 2022. MMWR Morb Mortal Wkly Rep. 2022;71:574-581
  4. Jones JM, Fleming-Dutra KE, Prill MM, et al. Use of Nirsevimab for the prevention of respiratory syncytial virus disease among infants and young children: recommendations of the Advisory Committee on Immunization Practices — United States, 2023. MMWR Morb Mortal Wkly Rep. 2023;72:920–925
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