Beyond Single-Pathogen Forecasts: Predicting Shared Respiratory Hospital Burden from Influenza, COVID-19, and RSV

Co-circulating influenza, COVID-19, and respiratory syncytial virus (RSV) create a shared hospital-admission burden, because beds, staff, testing capacity, and respiratory support are allocated to total demand rather than to one pathogen at a time. This makes respiratory forecasting a target-construction problem as well as a modeling problem: disease-specific forecasts preserve attribution, whereas hospitals also need a single planning signal for combined burden. We developed a supervised 1- to 4-week-ahead framework for weekly admissions and compared two total-burden strategies: summing independently generated pathogen-specific forecasts and forecasting the combined admission target directly. Evaluation included retrospective held-out testing and prospective operational forecasts issued before the corresponding admission weeks were observed, with performance summarized using MAE and Percent Agreement (PA; the smaller of model-generated and observed counts divided by the larger). In retrospective total-burden evaluation, the combined-burden model had PA values of 0.85, 0.78, 0.74, and 0.76 and MAE values of 80.63, 200.09, 183.97, and 156.13 from week 1 to week 4 ahead, compared with summed-forecast PA values of 0.85, 0.80, 0.69, and 0.69 and MAE values of 100.14, 200.06, 205.65, and 217.57. Prospectively, the combined-burden model had higher PA and lower MAE at all four horizons, with the largest separations at weeks 3 and 4 ahead. These results support layered respiratory forecasting: pathogen-specific forecasts remain necessary for etiologic interpretation, while combined-burden forecasts better align with hospital preparedness and shared-capacity planning.