This article appears as part of the Inside the NHS newsletter.

The NHS is reportedly braced for a "tripledemic" of Covid, flu and RSV this winter, with signs that all three respiratory viruses are on the rise again.

So what do we know about infection levels, and just how badly could they affect hospital capacity?

Surveillance

When it comes to Covid, we know very little now about how widely it is circulating compared to the height of the pandemic.

In July this year, one of our best tools for monitoring Covid prevalence in the community – wastewater testing – was temporarily suspended while responsibility transferred from Sepa to NHS Lothian. It is due to resume at the end of October.

In the meantime, fluctuating hospital admissions offer a rough snapshot of whether infections are rising or falling.

In July the NHS had to grapple with its highest level of Covid admissions in more than a year (Image: PHS) Back in mid-July, the number of patients in hospital with Covid peaked at 636 – the highest since the methodology for counting them changed in May 2023 (previously anyone who had tested positive in the prior 28 days was included; now it is limited to the prior 10 days).

That tells us that Covid still has the potential to cause some pretty significant disruption.

Only patients with symptoms are tested now, but if they test positive – even if the symptoms are mild – they still need to be isolated in line with infection control protocols, as does anyone with flu, norovirus, or other contagious pathogens.

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That means wards closed to new admissions, and fewer beds available.

The summer surge in Covid might mean a smaller winter wave, but there is no guarantee. The speed at which the virus is mutates means it is yet to settle into a seasonal pattern.

Between the end of August and the beginning of October there was a 30% uptick in hospital cases, to 240 by October 6.

Flu and RSV remain low, but are beginning to rise too.

Last winter, hospital admissions for RSV were the highest in at least six years and the flu season was unusually long – resulting in around 5000 admissions in total between December and March.

Vaccines against Covid are being offered to fewer people over time, but uptake has also been declining steadily among eligible groups (Image: DerekMcArthur/Newsquest)

Vaccines

Covid and flu jags are currently being rolled out on the NHS as part of the winter vaccination programme.

All adults aged 65 and over are eligible for Covid and flu vaccines, along with other groups such as care home residents, NHS and social care workers, and under-65s with certain health conditions.

Previous campaigns have been associated with declining uptake, however, as "vaccine fatigue" sets in.

Logistical issues - particularly in remote and rural areas such as Highland – have also been blamed, with shortages of vaccinators resulting in cancelled clinics or patients put off by longer journey times to vaccine hubs compared to the GP surgeries where vaccinations were previously done.

By July 7 this year, more than half of adults in Scotland eligible for the Spring Covid booster as a result of weakened immune systems had not yet received it, along with a quarter of over-75s, and nearly a fifth of care home residents.

The NHS will need much higher coverage than that going into winter. 

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An RSV vaccine is also available for the first time this year. It is being offered on the NHS to 75-79-year-olds and to pregnant women, to protect newborns.

Modelling by scientists at Glasgow and Aberdeen universities suggests that, if uptake reaches at least 70%, it could prevent 4,600 RSV-related hospitalisations a year in the UK.

That matters when the NHS is under extreme pressure for beds.