In the present study we compared the prevalence and clinical characteristics of patients hospitalized in the season 2023/24 due to infection with either SARS-CoV-2 or Influenza or RSV. This analysis comprised patients of all ages from internal, neurological and pediatric wards. The distribution of infection types across ages was similar to that observed in the same setting in 2022/23, with about 53% SARS-CoV-2, 23% Influenza A and 22% RSV as single infections, the remainder attributable to rare combined infections. Clinical characteristics of patients were also similar to those observed in 2022/23 [15], and the need for oxygen supply or NIV was again highest with RSV infection [15] in both, adults and children. However, in contrast to 2022/23, the proportion of adult patients requiring oxygen upon admission was highest with Influenza A infections not with RSV as previously.
In order to monitor the onset of the season of infections, we started data collection 2 months earlier than in the 2022/23 season [15]. This did not affect the numbers of Influenza A and RSV infections, since these occured only from November 2023 on, i.e. later than in 2022/23. Prior to November 2023, only SARS-CoV-2 was found. This was the reason why in total SARS-CoV-2 appeared slightly more prevalent than in the previous analysis [15]; when limiting the data collection to the same period of time (October to February), proportions between the numbers of infections were very similar to those of 2022/23. Conversely, when taking the longer period of data collection starting in August 2023 as a basis, the proportion of RSV in adults had slightly decreased. However, with respect to data provided by the Robert-Koch-Institute [19], the stop of recording at the end of February 2024 may have led to a slight underestimation of the prevalences of Influenza A and RSV regarding the total season 2023/24.
Nevertheless, compared to 2022/23 the relative risk for ICU admission as well as that for mortality from RSV had increased, although the absolute numbers were still markedly lower than that of SARS-CoV-2. RSV infection was associated with 4.7-fold increased risk of death compared to SARS-CoV-2 even when taking into account a number of confounders; Influenza A did not differ from SARS-CoV-2. This was confirmed in younger patients, since RSV also appeared as the most problematic and frequent infection, similar to 2022/23 [15]. These observations are in line with the findings by Ciofi et al., who monitored children with acute respiratory infections in an Italian hospital over the time period of 2018 to 2023 [2].
All analyses were performed in a similar manner as in our previous study covering the season 2022/23 [15]. The only difference was that the observation started two months earlier but a separate analysis (Supplemental Table S2) showed that with omission of these two months even increased the similarity of findings. An additional advantage was that data was retrieved from the same hospital which served the same population in the same area, had the same medical personnel and used the same criteria for diagnosis and treatment as before. This ensured a high degree of comparability between the results. When identifying risk factors, it turned out that the presence of oxygen supply upon admission was associated with a highly increased likelihood of ICU admission as well as death just as previously. The following discussion will perform comparisons with the frequencies and patterns observed in the previous season.
The distribution of infections over age was similar to that of 2022/23, with a bimodal pattern showing high numbers in patients of age much less than 18 years as well as in older patients and a peak at about 80 years. The peak in the young patients occurred at very low ages, similar to [2, 4, 15, 17], while there were only few patients between 18 and 50 years of age. Considering the time course of infection from August 2023 to February 2024, it appeared that in both younger and older patients RSV occurred later compared to 2022/23 [15], as it was present only from November 2023 onwards. Similarly, Influenza A in adults occurred later. Regarding infections with SARS-CoV-2, the contribution was about 50% and similar to that in the previous year. In the early phase of the observation period, SARS-CoV-2 was the only contributor. Regarding the relative numbers of infections, there was a slight but not statistically significant increase in SARS-CoV-2 from 48 to 53% and a slight decrease in RSV from 28 to 22%, whereas the relative frequency of Influenza A only very slightly increased from 22 to 23%. The percentages came even closer to the 2022/23 results, if August and September 2023 data was omitted from the analysis.
In adults, ICU admission was most often for RSV (28.6%), like in the season 2022/23 (19.2%). Also, mortality with SARS-CoV-2 and Influenza A was similar as in 2022/23 (9.0% and 6.8% vs. 8.8% and 8.6%) but mortality with RSV was much higher (11.1% vs. 20.0%), this is in contrast to the findings of Hamilton et al., which observed the highest mortality for SARS-CoV-2 in a large study with over 70000 patients [17]. The overall result was that due to the same risk for ICU admission and death for SARS-CoV-2 and Influenza A, the pattern for these two infections remained stable over time. In contrast, the reduction in the relative frequency of RSV was partially compensated by the higher risk for ICU admission and death [8]. Taken together, these observations suggest that the pattern of infections leading to hospital admissions had reached a fairly stable state since 2022/23 and that at the same time RSV in adults still posed the relatively highest risk for adverse outcomes.
Although the characteristics of RSV patients were only gradually different from those of the other two infections, the importance of these differences became relevant in the multivariable analysis of mortality risk. Compared to the unadjusted data in Table 3 that showed increased mortality for RSV but without statistical significance between infections, multivariable analysis as shown in Fig. 3 demonstrated that the risk of death from RSV became statistically significant when simultaneously considering a variety of cofactors such as the presence of oxygen upon admission, age, male sex and the level of CRP. When taking itno account these confounders, the risk was elevated by a factor of more than 4 compared to SARS-CoV-2, while for Influenza A the risk remained essentially the same as for SARS-CoV-2. This suggests that the pattern of patient characteristics was relevant in order to identify specific risks from RSV infection. A stratification of mortality according to the age groups 18–59, 60–74 and 75 + years revealed that the risk was similar for SARS-CoV-2 and Influenza A in all groups, and elevated for RSV (data not shown). Although case numbers were very low, in the group 18–59 years the exact test according to Fisher-Freeman-Halton indicated even an increase of mortality from about 2% for SARS-CoV-2 and Influenza A to 22% with RSV. Whether these observations have implications for the identification of groups that may particularly benefit from RSV vaccination, remains to be studied.
Regarding ICU admission, the pattern of odds ratios was similar to that for death and RSV still showed at least a tendency for increased ICU admission, although this was not statistically significant. Considering that fact that the risk of death increased and that for ICU admission decreased with age, age might have played a role for the fact that RSV was not significant regarding ICU admissions even in multiple regression analyses. A study from Ambrosch et al. showed similar results, they observed patients with SARS-CoV-2, RSV or Influenza A/B in the period from 2017 to 2020. They found, that the risk for ICU admission and in-hospital mortality for RSV was higher than for Influenza A, but lower than the risks with SARS-CoV-2 infection [18].
Regarding the pattern of symptoms, RSV showed the highest relative frequency of dyspnoea and cough compared to the other two infections, just as in 2022/23 [15] and in the findings of Ambrosch et al. [18]. This is also in line with the results obtained by Surie and coworkers, showing that the percentage of self-reported dyspnoea was also highest in patients with RSV and reached about 80% [8]. In contrast, we found fever to be most frequent with SARS-CoV-2, and not with Influenza A as in 2022/23. Whether this reflected a difference in patient characteristics or a change in virus characteristics, cannot be decided from our data.
With respect to comorbidities, the observation that heart failure and asthma were most prevalent for RSV was similar to that of 2022/23. Regarding a state of immunosuppression, Influenza A instead of RSV showed the highest prevalence, while regarding dementia, this was least prevalent with Influenza A. Overall, there appeared to be no major changes in the pattern of comorbidities, although their number was higher in SARS-CoV-2 compared to the previous season.
We included patients of all ages, and for those under the age of 18 years there are a number of pediatric papers [1–4]. Just as in 2022/23, none of the younger patients died, but there were still ICU admissions, and these were most frequent for RSV, although numbers appeared to be lower than in 2022/23. The need for low-flow or high-flow oxygen supply was much higher in young patients with RSV compared to SARS-CoV-2 [1] and Influenza A, and in addition oxygen upon admission was most frequent in RSV. Essentially the same was true when restricting the analysis to children of age less than 3 years.
As in the previous analysis, we included laboratory parameters, blood gases and vital parameters into our analysis. There were, however, no apparent major differences compared to the season 2022/23 and no obvious clinical traits that could be linked to these parameters [18]. These parameters also turned out to be non-informative when included as additional predictors in multiple logistic regression analyses of ICU admission and death together with the set of predictors shown in Figs. 2 and 3, except for CRP.
This analysis has a number of limitations. First, this was a monocentric study, limiting its generalization, however, data of a large recently published cohort study comprising 7998 adults from 25 hospitals in 20 US states from February 1st, 2022, to May 31th, 2023, showed very similar results [8]. In this analysis rates of mechanical invasive ventilations or death were significantly higher in patients with RSV compared to SARS-CoV-2 or Influenza infection. Secondly, we had no information on vaccination status which might have been of interest, as Surie and coworkers reported that RSV infection was significantly worse when compared specifically with vaccinated COVID-19 or influenza patients [8]. Thirdly, our study was a retrospective analysis of available data, and it is possible that (electronic) patient records were not complete; this partially referred to BMI and symptoms upon admission. Symptoms were not recorded for children, as they could not reliably express them due to their young age. It was also not possible to collect this information retrospectively. Furthermore, in most cases no blood samples were taken in children, thus there were also no blood biomarkers available. Fourthly, diagnoses were taken from the discharge letter based on ICD-10 coding, and we cannot exclude the possibility that they had not been correctly coded.