As we head into March and April, the United States could face a serious and simultaneous threat from three concurrent respiratory virus infections: Influenza, measles, and the new SARS-2 coronavirus (also known as SARS CoV2 or COVID-19 infection). Having all three viruses circulating in America would present formidable challenges to state, local and federal public health agencies, as well as hospitals and frontline health care workers. A triple epidemic could also inflict serious damage to the American economy and even affect the presidential election in November.

All three viruses can cause serious pneumonia leading to hospitalization and complications that can result in death. They are also highly contagious. Both influenza and measles are transmitted through physical contact with droplets expelled through a cough or sneeze by an infected individual, or via inhalation of the virus in the atmosphere. Studies are underway to confirm if COVID-19 also spreads through these routes.

Influenza. The CDC estimates that, so far in this 2019-20 winter flu season, more than 14,000 people have died, including 92 children. However, experts predict that we have not yet peaked in terms of the total numbers of flu cases and deaths. Some U.S. flu seasons now last until May, and this might be one of those years. It could also mean this 2019-2020 flu season could be one of the worst in terms of pediatric deaths among unvaccinated children.

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COVID-19. The new SARS-2 coronavirus from Wuhan, China has spread to at least 24 countries, and there are worries that human-to-human transmission will soon occur outside of China to cause a global pandemic. So far, there are only 15 cases in the U.S., however, the CDC Director Robert Redfield now indicates that regular human-to-human transmission is a strong possibility in the coming weeks. A major reason for this concern is based on studies from China showing that a single infected individual will on average infect two to four additional individuals, a significantly higher rate of transmission than most seasonal flu viruses.

The new SARS-2 coronavirus from Wuhan, China has spread to at least 24 countries, and there are worries that human-to-human transmission will soon occur outside of China to cause a global pandemic. So far, there are only 15 cases in the U.S., however, the CDC Director Robert Redfield now indicates that regular human-to-human transmission is a strong possibility in the coming weeks. A major reason for this concern is based on studies from China showing that a single infected individual will on average infect two to four additional individuals, a significantly higher rate of transmission than most seasonal flu viruses. Measles. In 2019, measles returned to the U.S., where more than 1,200 cases occurred. Measles came back because of local declines in vaccination coverage – a consequence of aggressive and unopposed antivaccine misinformation campaign – and the fact that the measles virus is one of the most contagious. We don’t know for sure what will happen in 2020, but because antivaccine activities remain strong in multiple states, and historically measles peaks in late winter and early spring, outbreaks should be anticipated.

Therefore, in the coming weeks, we could see a scenario unfold in which measles returns, influenza remains widespread, and COVID-19 transmission takes off. To respond, we’ll need to urgently reshape a U.S. health system in which we can isolate, diagnose, and care for large numbers of patients with respiratory signs and symptoms, such as cough, fever, and shortness of breath.

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Accordingly, the CDC is working to broaden its disease surveillance program so that patients with flu-like symptoms in five U.S. cities – Chicago, Los Angeles, New York, San Francisco, and Seattle – will get tested for both flu and COVID-19. However, this initiative would need to expand nationally once COVID-19 starts to emerge.

If measles also appears, then we’ll face an additional strain as local and state public health agencies scramble to trace contacts and contacts of the contacts. Slowing or halting a measles epidemic is both labor-intensive and expensive, and requires months, as we saw last year in New York City when more than 50 were hospitalized, including many in intensive care units. Frontline health care workers will be at special risk from these three respiratory illnesses.

The consequences would extend beyond public health. We saw how China sustained significant economic damage due to collapses in business, trade, transportation and stock markets, as well as political fallout and loss of confidence in its leaders. If this were to happen in the U.S., it might affect the outcome of the 2020 presidential election.

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Vaccination remains the most effective and cost-saving means to prevent flu and measles, so ensuring that our nation’s children and adults get vaccinated remains a priority. State legislatures will need to cooperate and close vaccine exemptions in more than 40 states. Several SARS CoV2 vaccines are in development, but it is unlikely one will be available for 2020.

We may need to build temporary health facilities to care for patients and train health care professionals in infection control measures. There is a significant risk that all three major respiratory infections will soon occur simultaneously in many parts of the U.S., and we must take steps to get ready.

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