The Tripledemic as a Precursor to Stakeholder Alignment under the Quintuple Aim

October 2022 heralded another crisis for hospitals and physicians: the tripledemic. Comprised of COVID-19, influenza, and respiratory syncytial virus (RSV), the tripledemic is placing additional strain on hospitals and health resources this winter.¹ These three viruses not only affect children, but they can also impact adults, particularly older adults and adults with comorbidities.² Of note, emergency department visits for these three viruses appear to have declined from their early winter peaks, but we may yet see additional peaks in the influenza and RSV viruses, and accelerated spread of the highly contagious XBB.1.5 subvariant of the coronavirus.³ This season won’t be the last for a potential infectious disease calamity, so every healthcare stakeholder must play a role in mitigating the damage. However, issues such as staffing, vaccine fatigue, misinformation, and operational challenges may inhibit successful interventions. Nobel Peace Prize nominee Peter Hotez, MD, PhD, has warned us of the inevitability of regular COVID pandemics⁴ so the current tripledemic is a precursor to future pandemics/endemics.

A Tripledemic may Increase Hospitalizations and Even Deaths
The Centers for Disease Control and Prevention (CDC) actively tracks influenza yearly, and Americans are advised to have an annual flu vaccine to avoid symptoms of flu, pneumonia, and even death.⁵ The CDC also continues to closely monitor COVID-19, and manufacturers have released several boosters. However, RSV can also cause hospitalizations and even death in older adults and those with underlying comorbidities. 

A Kaiser Permanente study showed that, when compared to influenza, RSV may cause worse outcomes in older hospitalized adults.⁶ Patients with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) were also more likely to have RSV than influenza and to have longer hospitalizations. RSV peaked in November 2022 with a hospitalization rate of 5 per 100,000, which is almost two times higher than the largest peak in 2019 (data 2018-2022).⁷ Because we haven’t had a vaccination near approval for RSV until recently, RSV testing and physician education around RSV in adults has been minimal. In fact, the medical community did not consider RSV to be a serious pathogen until 1970 and epidemiologic data has been limited.⁸ Fortunately, several RSV vaccines for adults are in the pipeline, and Pfizer recently announced encouraging Phase 3 trial data for its RSV vaccine, which demonstrated efficacy in preventing RSV in newborns when given to pregnant women.⁹

Vaccination and Staffing Challenges may Prevent Disease Mitigation

A new vaccine doesn’t help if patients aren’t willing to take it. Vaccine fatigue is defined as “people’s inertia or inaction toward vaccine information or instruction due to perceived burden and burnout.” ¹⁰ While not a new term, it became more widely used during the COVID-19 pandemic in discussions of vaccine side effects, misinformation, and lack of trust toward government and healthcare institutions.¹⁰ To encourage more positive attitudes toward vaccination, the American Medical Association (AMA) has adopted a policy to address health disinformation and organizations including the American Board of Internal Medicine (ABIM) are combatting misinformation through grant programs.¹¹ Other organizations, such as Immunize.org (formerly the Immunization Action Coalition), offer web-based resources for healthcare professionals and the public aimed to increase immunization rates.¹²

The issue of burnout among healthcare professionals is also of concern as we face the tripledemic, future pandemics and pandemic/endemic surges. Healthcare institutions are seeing a loss of HCPs to early retirement and career changes as the tripledemic strains healthcare resources. The Surgeon General, Vivek Murthy, MD, MBA, has called on healthcare organizations, payers, health technology providers, and others to address burnout and health misinformation.^13,14

What do we need to do?

Increase surveillance and distribution resources. Building upon lessons learned from adapting influenza surveillance systems to COVID-19, the World Health Organization (WHO) issued interim guidance in 2022 for end-to-end integration of SARS-CoV-2 and influenza sentinel surveillance¹⁵ but global guidance for RSV surveillance is still in a pilot phase.¹⁶

In the US, RSV surveillance began in 2016 for adults in certain states. While this is an active, population-based system, it only includes adults who have been hospitalized and tested, and thereby underestimates the incidence.⁷ For example, patients who are hospitalized but not tested, or patients who seek care late, are not included.⁷ To better understand the epidemiology of RSV it is imperative that providers begin testing for RSV at the point of care with viral swabs. This not only informs the public early about outbreaks but helps risk-stratify older patients or those with comorbidities who present with an upper respiratory infection.

Furthermore, HCPs should begin preparing a strategy for RSV vaccination when it becomes available. Off-season vaccine strategies may be an effective way to combat vaccine fatigue by allowing the RSV vaccine to be given at a different time of year from influenza and COVID-19. In addition, this will help manage the workflow during the busy fall and winter seasons. Historically, patients tend to seek vaccination during the peak occurrences of a viral surge. For example, in the fall, a physician’s office could hold a flu clinic —this would be a great time to check that all other vaccines are up to date. Many vaccines can be given any time of year, such as vaccines to prevent pneumonia, shingles, or Tdap (diphtheria, tetanus, and whooping cough), yet HCPs often do not offer “off-season” vaccine clinics.The advent of the COVID vaccines, and soon the RSV vaccine, offer opportunities to rethink this approach. Several states have employed incentives to increase vaccination rates over the summer, for example, the North Carolina Department of Health and Human Services offered $100 cash cards during the summer of 2021 for residents who received their first COVID-19 vaccine.¹⁷ Further, Bach and Goad (2015) have noted that vaccination services offered year-round by community pharmacies lead to better patient care and vaccine access for patients. These examples lead to an obvious question: If you build it, will they come?

Address misinformation and vaccine hesitancy. Health misinformation and disinformation (mis/dis/information) have been described as the “inadvertent spread of erroneous information (misinformation) or deliberately created and propagated false or misleading information (disinformation).”¹⁸ It is a causal factor in growing mistrust of healthcare professionals,¹⁸ and experts increasingly acknowledge it as an adverse social determinant of health (SDOH) contributing to health disparities.¹⁹

The decline in trust of life science and healthcare professionals, mis/dis/information, and their dangerous impact on public health were themes commented on by Francis Collins, MD, PhD, and other speakers during The Washington Post’s recent forum, “Trust in Science.”²⁰ Social isolation created by the pandemic and a lack of enduring relationships with primary care providers has exacerbated this distrust.²¹

A report issued by the Commonwealth Fund found that among high-income countries, the US had the lowest percentage (43%) of adults with “a regular doctor or place of care and have been with them for five years or more.”²² Another overlooked factor contributing to lowered trust includes a lack of understanding and health literacy among the public (and sometimes even scientists), that “science is a process of learning and discovery, and sometimes we learn that what we thought was right is wrong.”²³

Given that scientific understanding of COVID-19 (and other viruses) continues to evolve, information and recommendations follow suit.²⁴ While one might think that this continual search for understanding should generate confidence in science, it may paradoxically contribute to an erosion of public trust, due to a lack of permanency in recommendations. The issue is complex and public and behavioral health professionals have also cited an array of factors, including political and religious beliefs and disease risk perceptions, which impact vaccine adoption.²⁵

Furthermore, Morgan and colleagues have reported research highlighting the importance of considering “experiences of racial discrimination and the enduring effect of historical medical exploitation that targeted communities of color,” when developing programs to address COVID-19 vaccine behavior.²⁶

A complex problem necessitating a “whole-of-society” effort. Given the complexity of the problem within America’s fragmented healthcare ecosystem, it is not surprising that the Surgeon General has called for a “whole-of-society effort” to curb the impact of health misinformation.²⁷

As mentioned previously, with less than half of US adults having regular and enduring primary care relationships, the roles of other healthcare professionals in advancing vaccine adoption assumes greater importance. For example, care managers and pharmacists can identify individuals needing vaccines, and screen for and address barriers (e.g., social determinants of health) to vaccine adoption among their patients. Flu vaccination rates for adults ages 18-64 have ranged between 40.0%-57.7%, leaving considerable opportunity for improvement.²⁸ These sub-optimal performance metrics could be addressed systemically through collaborations among quality, public/population health, pharmaceutical manufacturers and others in the healthcare ecosystem to close vaccination gaps. The authors anticipate an acceleration in 2023 of cross-sector, multi- and omni-media collaborations among HCPs, government, pharmaceutical companies, and other stakeholders, “utilizing behavioral technologies (social networking, psychological), marketing (social listening and messaging), public health methodologies (health literacy), AI and other digital technologies to innovate fresh approaches” to diminish the adverse impact of mis/dis/information on public trust.²¹ Finally, in his book, Preventing the Next Pandemic, Hotez describes vaccines as “the most powerful biotechnologies ever invented,” and exhorts us to include their defense in vaccine diplomacy initiatives as we contend with certain, future pandemics.²⁹

Mitigating staff burnout calls for aligning under the Quintuple Aim. Despite Hotez’ cautionary exhortation, defense of vaccines by health workers contributes to burnout, which has been associated with adverse patient and staff well-being. Burnout increases medical errors and hospital-acquired infections (HAIs), staff shortages, and poor staff physical and mental health outcomes. As the Surgeon General reiterated in his advisory, many causes contribute to burnout, including societal, cultural, structural, and organizational factors.²⁶

More specifically, infection preventionist Rebecca Leach has written eloquently of the compassion fatigue and potential for burnout experienced by frontline and other healthcare staff. In particular, she associates fatigue and burnout with caring for patients critically ill with infectious diseases (IDs), especially while seeking to prevent the spread of further disease through accurate and empathic communication with patients, families and colleagues who may be hesitant or opposed to vaccines.³⁰

The healthcare ecosystem (eg, HCPs, health systems and plans, life science companies, patient advocates, quality, prevention, and population health specialists) is increasingly obligated to align with the Quintuple Aim and support the five aims: care-team well being, better patient care, healthier people, affordability, and health equity. Within the context, as Hotez predicts, of future pandemics and endemics, stakeholders should coordinate under the auspices of the Quintuple Aim and address burnout and other insidious factors like disinformation associated with the spread of IDs.

There is a moral/ethical force that harkens to the Hippocratic Oath behind the Surgeon General’s whole-of-society appeal. Without the personal and professional well-being advocated by the Quintuple Aim, the moral energy to confront untruth with truth and supplant errors of practice with error-free practice would be diminished. To achieve the goals of the Quintuple Aim, strategic alliances within the healthcare ecosystem must further involve not only concern for patients but also for health workers who care for them. Without this mutuality of support there is little incentive for health workers to stay in a profession where unending episodes of burnout appear inevitable because herd immunity seems unlikely.

This consequence is further complicated by a landscape in which “emerging outbreaks of epidemic-prone infectious diseases can occur at any time.”³¹ These strategic alliances can create synergistic tactics, including collaborations and solutions to support the well-being of health workers and patients. In a subsequent article the authors will offer prescriptive tactics leveraging alignments involving life sciences, providers, payers, infection preventionists and quality stakeholders that address worker/patient well-being in an environment that, as Hotez suggests, will normalize the expectation of continued pandemics/endemics.

Conclusion: Aligning With the Quintuple Aim to Prepare for Future Pandemic

As Dr Hotez warned, “The virus is telling us something. COVID pandemics will be pretty regular. It's not a matter of if but when.”⁴ Changes in weather patterns, as well as social factors (eg, poverty, anti-science attitudes) will continue to alter infectious disease development and transmission, accordin to Hotez. Therefore placing a greater emphasis on “caring for the caregivers” to stem the tide of staff shortages and associated adverse clinical outcomes will be crucial.

Creating a wholistic pandemic strategy for the future will be critical. Public/private partnerships among HCPs, health plans and systems, infection preventionists, public/population health experts, life science and other healthcare stakeholders will be vital to developing synergistic efforts to advance the Quintuple Aim and mitigate future calamities like the COVID-19 pandemic.

References

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