The 2023-2024 school year has officially started in the United States, and so has respiratory virus season. There will be no shortage of nasty bugs circulating in classrooms and sickening kids this fall.
Last year, the country saw a rebound of several seasonal viruses after a pandemic lull. A surge in respiratory syncytial virus, or RSV, among babies and young children last fall led to an explosion in hospitalizations, overwhelming children's hospitals around the country, TODAY.com previously reported.
A simultaneous wave of COVID-19 and an unusually early and severe influenza season last fall created a triple threat of respiratory viruses or "tripledemic" that lasted well into winter.
As fall approaches, health officials are already preparing for another possible tripledemic of COVID-19, RSV and flu in the U.S., Dr. Mandy Cohen, the new director of the U.S. Centers for Disease Control and Prevention, previously told NBC News.
Recently, there was a summer increase in COVID infections and hospitalizations around the country. In August, a school in Kentucky had to close less than two weeks into the school year after one-fifth of its students came down with COVID, strep or the flu.
Now that many respiratory viruses and diseases are settling back into their pre-pandemic seasonal patterns and people have returned to pre-pandemic behaviors, what can we expect to see this fall and winter among children?
Will there be a tripledemic this fall?
It’s still too early to tell exactly how this fall and winter will play out compared to last year and how another tripledemic could impact children, experts note.
"There remains the possibility of a tripledemic as RSV, influenza and COVID-19 cases increase in various places globally," Dr. Thomas Murray, associate medical director for infection prevention at Yale New Haven Children’s Hospital in Connecticut, tells TODAY.com.
"I think there are two wildcards that are going to be very important to watch," says Murray. The first is whether or not there will be a major fall resurgence of COVID. "When it comes back, it tends to affect the other respiratory viruses," Murray adds.
The second wildcard is how the RSV vaccine for older adults and the newly approved monoclonal antibody injection for children under 2 will affect RSV transmission, says Murray. Clinical trial data suggests that good uptake of these could reduce hospitalizations, he adds.
Regardless, there are a number of illnesses that parents can always count on circulating among children once school is back in session. Parents should not panic, but be aware of these common classroom contagions, various symptoms and how to keep kids healthy.
Strep throat
"No matter which region you are in, the first thing we tend to see as pediatricians is strep throat," Dr. Victoria Regan, a pediatric specialist at Memorial Hermann in Houston, tells TODAY.com.
Strep throat is a highly contagious bacterial infection of the throat and tonsils caused by group A streptococcus bacteria, and it’s most common among children and teens, per the CDC. Strep is spread between people through respiratory droplets, and it can flourish in classrooms when children are in close contact, Regan adds.
Strep can occur at any time of year, but peak season is usually from December to April, says Regan. During the spring of 2023, there was an “explosion” in strep among children, and pediatricians around the country continued to see a high number of strep cases through the summer months, the experts note.
“It’s definitely something parents should be on the lookout for, especially with the increased numbers that we’ve seen,” Dr. Shannon Godsil, pediatrician at Omaha Children’s Hospital & Medical Center, tells TODAY.com.
Strep throat symptoms include a sore or scratchy throat; red, swollen tonsils; fever; pain with swallowing; and headaches or body aches, per the Mayo Clinic. This spring, there were reports of children presenting with unusual strep symptoms, including congestion and cough, TODAY.com previously reported.
Testing is key, because strep can be treated with antibiotics and symptoms tend to improve within two days of starting medication, Regan notes. If left untreated, strep can lead to complications like abscesses, ear or sinus infections, or rheumatic fever.
COVID-19
"As frustrating as it is that we might be seeing COVID every year, I think that’s probably our new normal," says Godsil.
Coronavirus infections and hospitalizations have been on the rise across the U.S. in recent weeks. Since school has been back in session, many pediatricians have seen an uptick in pediatric COVID cases, according to Regan and Murray.
“The exact numbers are difficult to know for sure because most testing is at home antigen testing and not reported,” says Murray. Additionally, the CDC stopped tracking new COVID cases when the federal public health emergency ended in May 2023.
"Fortunately, in the pediatric population, it is not causing an increase in hospitalizations," says Regan.
The intensity of a COVID surge this fall may depend on the severity and contagiousness of emerging variants, says Murray.
The dominant COVID strains circulating in the U.S. right now are the EG.5 or “Eris” subvariant, followed by F.L.1.5.1 (aka “Fornax”), and XBB.1.16 or “Arcturus," according to CDC data. These are all descendants of the omicron XBB lineage and close relatives of XBB.1.5, the strain targeted in the new COVID-19 booster, TODAY.com reported previously.
"The SARS-CoV-2 virus has the potential to mutate further," Godsil adds, so there is a chance this fall will bring an entirely new strain. Since July, scientists have been monitoring a highly mutated variant called BA.2.86, aka “Pirola," but recent data suggests it may not be as contagious or immune-evasive than previously thought.
While it's unclear what COVID-19 will look like this fall and winter, especially among kids, vaccination is key, the experts note. The CDC recommends the updated booster for all children ages 6 months and older to protect against serious outcomes from COVID-19. It should be available nationwide by mid-September.
Data show the vaccine is safe, effective and has fewer side effects than if a child gets COVID-19, says Regan. "No children have died from the COVID vaccine, but we do have children that die from COVID."
"If a child does test positive, they should stay home for at least five days, and masking is recommended for older children the next five days ... until there are two negative tests," says Regan.
Respiratory syncytial virus or RSV
"Even before COVID, RSV was always a really worrisome thing for pediatricians in the fall," says Godsil.
RSV is a common respiratory virus among children that usually causes mild, cold-like symptoms, per the CDC. It can also cause wheezing and breathing difficulties, especially in children with underlying lung diseases. In severe cases, it can lead to complications like pneumonia, Regan notes, adding, "It is the No. 1 reason for infant admissions."
In the U.S., RSV season typically lasts from October to March. Last fall, RSV hit many parts of the U.S. much earlier than expected. "We saw a significant national increase in RSV cases and hospitalizations compared to prior years," Dr. Karen Acker, pediatric infectious disease specialist at NewYork-Presbyterian/Weill Cornell Medicine, tells TODAY.com.
“It was intense, and kids were very sick,” says Murray.
Last year's RSV surge was likely due to a combination of dropping COVID precautions and increased social mixing. Additionally, many babies and young children were more vulnerable because their immune systems had not been exposed to seasonal viruses during the pandemic, TODAY.com previously reported.
"It seems we are still trying to establish what the new seasonal trends will be," says Murray. While it's still too early to tell exactly how this RSV season will pan out, it is underway — and there have already been increases in RSV hospitalizations in Florida and Georgia, Regan notes.
On Sept. 5, the CDC issued a health advisory warning about increases in RSV activity in parts of the Southeastern U.S. in recent weeks. "We anticipate seeing an increase in RSV cases this fall and winter," says Acker.
There is no specific treatment for RSV, but supportive care is recommended while the virus runs its course, which usually takes about one week. Fortunately, the FDA has approved a new preventative RSV treatment, a monoclonal antibody injection.
"It is recommended by the CDC, ACIP and AAP for all infants up to age 8 months of age during RSV season and higher risk children up to age 2," says Regan. Studies have shown the injection is safe and decreases the rate of hospitalizations for infants by up to 80%, she adds. It should become available later this month.
“If there’s high uptake and if it works as well as it did in the clinical trials, that could have a significant impact on the number of babies coming through our emergency room with RSV," says Murray.
A new RSV vaccine is also available for pregnant individuals (to prevent RSV in newborns), and individuals ages 60 and older.
If a child has RSV, "parents should reach out to their pediatrician or go to their local emergency room if they see any signs of respiratory distress or dehydration," says Acker.
Influenza
Every year, parents can count on influenza keeping kids out of school. "We are starting to see flu B in our pediatric population (in Texas)," says Regan. Flu cases are expected to increase in October and November, Acker adds.
The flu is a highly contagious viral infection that causes mild to severe illness, per the CDC, and flu symptoms include fever, cough, sore throat, stuffy nose, body aches, fatigue and chills. Most kids will recover on their own, but prescription flu antivirals like Tamiflu can limit disease severity.
The 2022 to 2023 season was one of the earliest and most severe flu seasons the U.S. has seen in a long time, TODAY.com previously reported. It's too early to tell what this year's season will look like, the experts note, but there are some worrisome signs.
Australia's flu season, which runs from April to September, is often a harbinger of what to expect in the U.S. in the fall. This summer, Australia had heavy flu season, says Regan. "We're anticipating ours to be a little rough again this year," she adds.
“Influenza has always been cyclical, and there are good years and bad years depending on the kind of strain that is circulating and how well it matches what’s in the influenza vaccine,” says Murray. Regardless, it’s crucial to get kids vaccinated, he adds, because even during a less severe flu season, children can get very sick.
"Unfortunately, there are children who die from influenza every year, including healthy kids with no underlying diseases," says Godsil.
The seasonal flu shot is safe and effective for everyone ages 6 months and older. The experts recommend children get the shot in September or October. "Get it by Halloween," says Godsil.
Colds and other viruses
Every fall, parents can expect to see the usual gamut of viruses that cause cold symptoms, like congestion, sneezing, runny nose, headache and cough, the experts note. These include but are not limited to rhinovirus, adenovirus, parainfluenza and hMPV.
Rhinovirus is the most common cause of colds among children and has continued to circulate in high numbers in recent years, says Murray. Less often, it can lead to hospitalizations.
Another common cause of respiratory illness among kids are human parainfluenza viruses, Murray adds. In addition to cold symptoms, parainfluenza can present in babies as croup, which causes the airways to swell and create a “barking” cough, Murray says.
Non-polio enteroviruses can also cause mild respiratory illness, Murray adds, and cases tend to ramp up in the late summer and fall.
The vast majority of children who get the common cold will recover on their own within a week and do not need treatment, the experts note. “For a lot of these respiratory viruses, it’s just supportive care, providing fluids, and close monitoring to make sure breathing is not getting worse,” says Murray.
Pinkeye
Parents can also expect to see more pinkeye this fall, says Godsil, which can be caused by viruses or bacteria. Symptoms typically include redness, watering, itching or discharge in one or both eyes.
Pinkeye infections are highly contagious, Godsil notes. Young children often have trouble keeping their hands to themselves and out of their faces, which makes it easy for pinkeye to run rampant through day cares and schools.
Viral pinkeye is often preceded by a cold or respiratory illness, such as COVID-19. It will clear up along with cold symptoms on its own, says Godsil, whereas bacterial pinkeye is treated with antibiotic eyedrops or ointment.
“There’s lots of factors that help us decide whether it is probably bacterial or viral,” Godsil adds, which is why it’s important to consult a health care provider if a child has pinkeye symptoms.
Stomach viruses
Another common — and very unpleasant — illness that keeps kids out of school every year is gastroenteritis, or an inflammation of the lining of the gastrointestinal tract, which causes vomiting, diarrhea, and stomach cramps, the experts note.
Often called "stomach flu" or "stomach bug," the viruses that cause gastrointestinal illness are highly contagious and can spread like wildfire through classrooms and among families at home.
Norovirus, the most common viral cause of gastroenteritis, surged this past winter and spring around the country, TODAY.com previously reported.
Most children will recover on their own at home with supportive care. Hydration and rest are key, the experts note. "Stomach-related viruses tend to last three to five days, and children tend to do quite well," says Regan.
How to keep children healthy
Children should get vaccinated when possible, the experts emphasize. This includes the required vaccines to enter school, such as polio, chickenpox, and the MMR shot, as well as recommended vaccines, like the flu shot and COVID-19 booster, which are safe to get at the same time.
Beyond vaccination, the experts recommend teaching children to practice routine hand-washing (for at least 30 seconds with soap and water), to avoid touching their faces with unwashed hands, and to cover coughs or sneezes.
Cleaning contaminated surfaces and improving ventilation indoors can also stem the spread of bugs in the classroom. "Masking remains an option for those who are worried about their own health or want to prevent the spread to others," says Murray.
"If your child is sick, keep them home, whether that be from school, a party or a sports game," says Godsil, adding that children can return to school once their symptoms have resolved.
Sending children to school sick can delay their recovery and infect classmates, says Regan. "It really does pay to keep your child home a couple days and get them fully recovered before they return to school."