COVID-19, viral illness surge: What you need to know

Returning with a vengeance are the usual suspects of respiratory illnesses as Americans resume pre-pandemic activities, albeit as COVID-19 cases climb, in turn prompting a flurry of health alerts to primary care providers.

Issued June 10 by the Centers for Disease Control and Prevention (CDC), a health advisory to clinicians and caregivers warned of increased “interseasonal” respiratory syncytial virus (RSV) in young children, particularly in the southern U.S., as well as surges in a broad spectrum of non-COVID-19 respiratory viruses, such as rhinovirus and enterovirus, seasonal coronavirus and parainfluenza. The spike in cases likely stems from the relaxation of nonpharmaceutical interventions (NPIs) that helped not only check the COVID-19 pandemic but also keep such viral infections at historically low levels through the winter of 2020-21.

RSV, a common virus that causes mild, cold-like symptoms, can cause severe illness in infants and young children who go on to develop bronchiolitis or pneumonia. Typically flourishing during cold and influenza season, RSV activity remained low from March 2020 to March 2021 but has since spiked, especially across Department of Health and Human Services (HHS) Regions 4 and 6. Lacking sufficient testing ability due to the sudden offseason spread, health officials are unsure of its duration or peak.

Similarly, a study from Houston Methodist Hospital shows RSV isn’t the only non-COVID-19 respiratory illness circulating without abandon from March 2021 onward. In fact, the study found in the month following Texas’ relaxation of COVID-19 restrictions in March the hospital reported: 

• 424% increase in parainfluenza cases (continuing to increase 189% from April to May).
• 211% increase in seasonal coronavirus.
• 166% increase in RSV cases (April to May).
• 85% increase in rhinovirus and enterovirus cases.

“Reports of non-COVID respiratory viral illnesses surging after COVID restrictions are lifted has been reported in Australia and elsewhere, and we’re now starting to see it happen in the U.S.,” notes S. Wesley Long, M.D., Ph.D., medical director of diagnostic microbiology at Houston Methodist and corresponding author of the study, in a news release.

In early March, Texas became the first state to lift mask mandates and capacity limitations, quickly followed by Mississippi, Alabama, Arizona, West Virginia and Connecticut. Whereas some states, such as Georgia and Alaska, never implemented mask mandates, other states, such as Florida, dropped capacity restrictions altogether in fall 2020. What’s more, on May 13, the CDC reversed its national mask guidance for fully vaccinated individuals despite subsequent guidance from the World Health Organization that recommends continuing to wear masks in light of new SARS-CoV-2 variants. Such is the case, the CDC still advises U.S. health care personnel to wear masks and observe infection control guidance when in direct patient contact.

Ocular involvement in viral infections

Michael Duenas, O.D., AOA chief public health officer, says doctors of optometry should take heed of the CDC health alert given that RSV is often an etiology for allergic conjunctivitis. RSV infection of ocular epithelial cells results in the production of numerous cytokines and chemokines involved in ocular inflammation and production of classic signs and symptoms of allergic conjunctivitis, Dr. Duenas says.

“The CDC notification to clinicians about increased RSV activity across parts of the United States once again puts doctors of optometry on notice of their important role in mounting a public health response to communicable disease,” he says. “Importantly, RSV uses the eye as a gateway to mount a respiratory infection, as well as replicate specifically in ocular tissue. This route of exposure, as with SARS-CoV-2, reinforces the need for PPE, including face masks and goggles whenever possible, in the optometry clinic setting.”

Conjunctivitis, a commonly reported ocular symptom of respiratory viral infections, such as RSV, adenovirus and influenza, also can be a presenting symptom of COVID-19. During a lecture at Optometry’s Meeting®, Nicholas Colatrella, O.D., noted that follicular conjunctivitis is the most common ocular presenting sign, but COVID-19 patients may experience lid margin hyperemia, crusted eyelashes and meibomian orifice abnormality.

Dr. Colatrella added that any unusual presentation of common ophthalmic pathology in a patient where it is not suspected, in addition to concerning symptomology, i.e., fever, respiratory involvement, fatigue, headache or new loss of taste or smell, etc., may warrant a COVID-19 suspicion.

Kenneth Lawenda, O.D., optometric regulatory specialist, suggests doctors of optometry be alert to the concurrent surges in both routine viral infections and the virus causing COVID-19, especially as localities begin relaxing NPIs, such as mask mandates, and unvaccinated children begin returning to school in as little as a month’s time.

“The COVID vaccines have proven to effectively control the spread of the virus and decreased hospitalizations of the public,” Dr. Lawenda says. “However, there is a segment of the population that is against vaccinations and have decided not to receive the shots. We have seen increasing hospitalizations in those states where the percentage of residents vaccinated have trailed the nation. This can result in a more vulnerable population and continued spread of the virus and its variants.”

Health officials concerned by climbing COVID-19 case counts

In the U.S., new-onset COVID-19 cases bottomed out in June with the lowest level of daily cases—about 11,300 cases per 7-day average—since the pandemic took hold in March 2020. Some 67% of American adults have received at least one dose of vaccine, missing out on President Joe Biden’s 70% goal by Independence Day, and eliciting questions about whether the approximate herd immunity range of 70-85% of the total population is fully attainable.

Central to that question are low vaccination rates in areas of the U.S. and dwindling demand for COVID-19 vaccinations. Now, with the introduction of a new SARS-CoV-2 variant believed to be more transmissible, these areas are seeing greater community spread. In fact, HHS data from July 7 show that 21 states are experiencing increases in hospitalizations with 13 seeing double-digit increases. Of those 13 states, nine have 50% or less of their population fully vaccinated.

The new SARS-CoV-2 “delta” variant, first identified in India, is now the most commonly circulating strain in the U.S. with evidence that it may spread about 225% faster than the alpha variant. The strain is almost singlehandedly responsible for a 10% rise in daily COVID-19 cases at June’s end, the Wall Street Journal reports.

The SARS-CoV-2 delta variant poses other unique problems, aside from transmissibility. Notably, its symptoms are vaguer than alpha, Dr. Lawenda notes, and overlap with RSV. Citing an infectious disease specialist, Dr. Lawenda emphasized that delta may elude the immune system more effectively, which is a contributor to growing infection rates among unvaccinated individuals. Such is the case, the White House launched “surge response” teams to stop spread of the COVID-19 variant in the 1,000 hardest-hit counties.

The AOA Health Policy Institute  notes that doctors of optometry and staff—regardless of vaccination status—should continue to wear well-fitting face masks at all times while in the health care facility, as well as eye protection when engaged in close patient contact (less than 5 feet). Additionally, patients and visitors of health care facilities should wear their own well-fitting face mask upon arrival to and throughout their stay in the facility.

“The eye as a route of exposure places optometrists in a unique and more vulnerable position in primary care,” Dr. Duenas says. “With the rise of the delta variant and possibility for additional variants of concern in the U.S. and rise of non-SARS-CoV-2 respiratory viruses, the extended use of PPE in the clinical optometry setting is here to stay—for at least the foreseeable future. Doctors of optometry should remain alert, embrace their unique position within health care by continuing to invigorate their public health response and integrate their practice into medical care, just as they overwhelmingly did by diverting patients from emergency departments early in the COVID-19 pandemic.”

While Americans are eager to return to a pre-pandemic normal, public health officials and the White House reiterate that the pandemic is not over. On July 6, President Biden suggested this moment signifies a new chapter in the U.S. pandemic response, where instead of mass vaccination sites, a neighborhood-by-neighborhood approach is necessary to facilitate vaccinations. Those efforts would be led by family doctors and pharmacies.

In the months leading up to HHS’ decision to expand vaccination authority under the Public Readiness and Emergency Preparedness Act on March 12, the AOA and affiliates advocated for doctors of optometry to not only receive priority access to vaccines to maintain communities’ eye health needs but also be recognized for their ability to serve as emergency vaccinators. Prior to that expansion, numerous states secured explicit recognition of doctors’ of optometry authority to administer COVID-19 vaccines.