Are You Ready for the "Twin-demic"? Also Known As the "Double Whammy" of the Flu and COVID-19

Pat Stricker, RN, MEd
Senior Vice President
TCS Healthcare Technologies
 
Background
It has been over 6 months since the novel coronavirus (SARS-CoV-2 ), also known as COVID-19, was identified and declared a global pandemic by the World Health Organization (WHO) on March 11, 2020. During that time, 188 countries have been affected by the virus, causing 29,365,289 reported cases and 939,268 deaths as of September 15, 2020. Unfortunately, the U.S. leads all other countries in the number of cases identified (6,570,889) and the number of deaths (195,047). In addition, the U.S. has had 387,616 COVID-19 related hospitalizations.

Just as we are beginning to see some success in lowering the numbers, we have another situation on the horizon that is frightening -- the start of the annual influenza (flu) season. We will soon be fighting both the flu and COVID-19 at the same time, and that is a truly scary thought. This could be the worst fall season in U.S. public health history!

During the 2019-2020 U.S. flu season, it was estimated that between 410,000 and 740,000 people were hospitalized for the flu. And, since the pandemic began six months ago in March, we have already had 372,217 people hospitalized in the U.S. for COVID-19. In addition, one modeler predicts a 150% increase in hospital bed use for COVID-19 patients between now and December 1 and a 170% increase by January 1. This will cause an enormous strain on healthcare resources.

Fighting both of these viruses at the same time will cause a spike in cases, hospitalizations and deaths. It will also increase the need for even more medical supplies, testing, ventilators and hospital beds. In addition, it will strain the front-line healthcare workers once again, just when they were beginning to find some time to relax and get re-charged.

Everyone has gone through some very difficult times in the last six months, but it doesn’t look like it’s over yet. Some are calling this next phase the “twin-demic.”

Lessons From The Southern Hemisphere
Don’t give up hope yet. Even though it looks frightening, we have to realize that it is impossible at this point to know exactly what the effects of fighting two viruses at the same time will be. Looking at what our neighbors in the southern hemisphere went through earlier this year could give us some idea.

Australia and other countries that are now going into their spring and summer seasons just finished their easiest flu seasons on record. Their seasons are opposite of ours, so they have their flu season from April to September, which meant their flu season started right after the COVID-19 pandemic hit in March. Yet several of these countries reported astonishingly low flu numbers compared to other years, according to the WHO. In Australia, for example, the number of lab-confirmed flu cases fell from 61,000 in August 2019 to 107 cases in August 2020. That is almost like a “non-flu” season.

The low number of flu cases could also have been because it was difficult to diagnosis which disease the patient had, so they were listed as COVID-19 instead of the flu. People were also taking COVID-19 precautions during the flu season (staying home, wearing masks, being cautious about hand-washing and using hand sanitizers, and practicing social distancing) so that also probably helped keep the flu numbers low. The fear of COVID-19 may have prompted more people to get a flu shot, which had some effect. In addition, they may have also had issues with lab tests to identify the flu vs. COVID-19.

Whatever the reasons were for the reduction in flu cases, it gives the U.S. some hope that we will be able to achieve this outcome as well. But the U.S. would need to get serious about wearing masks, being cautious about hand-washing and using hand sanitizers, practicing social distancing and increasing the number of people who receive the flu vaccine. These are all simple things to do, but they could make a big difference in turning the upcoming flu season into a “non-issue” rather than a catastrophe.

Fighting Two Viruses at the Same Time
Let’s take a look at what impact the influenza (flu) virus has when combined with COVID-19. According to the CDC, over the past ten years in the U.S., the flu has caused between 140,000 and 810,000 hospitalizations and between 12,000 and 61,000 deaths each year.

The statistics differ dramatically from year to year depending on the types and severity of the current strains; the efficacy of the current vaccine; the willingness of people to change behaviors, e.g., not going to work when they are sick; having multiple respiratory viruses occurring during the flu season; and delays in diagnosis and timeliness of treatment that could cause severe complications and death.

During the 2018-2019 seven-month U.S. flu season (October 1, 2018 — May 4, 2019) there were about 42.9 million cases of the flu, resulting in 647,000 hospitalizations and 61,200 deaths. In comparison, COVID-19 statistics from the last 6½ months (March — mid-September, 2020) show that there were far fewer cases (over 6.5 million) and hospitalizations (386, 655), but significantly more deaths (195,000 vs. 61,200). The COVID-19 death rate was more than three times that of the flu for hospitalized patients.

About 80% of the flu and COVID-19 cases are mild or asymptomatic, according to the WHO. Most people who become ill with the flu recover without serious complications. However, it can be more serious among the elderly, very young children, pregnant women and persons with certain chronic conditions.

Both influenza and COVID-19 have similar symptoms: fever, cough, shortness of breath, fatigue, sore throat, body aches and a runny or stuffy nose. Nausea and vomiting may also be present, but this is more common in children. The most common signs and symptoms of COVID-19 tend to be fever, cough and shortness of breath.

Both the flu and COVID-19 can attack the lungs, potentially causing pneumonia or fluid in the lungs. This causes difficulty with getting enough oxygen into the circulatory system, which can result in acute respiratory failure and damage to the other organs. Other complications, such as sepsis, cardiac injury and inflammation of the heart, brain or muscle tissues can also occur. While these can occur with the flu and COVID-19, the more serious complications seem to occur more frequently with COVID-19.

Differential Diagnosis for Flu and COVID-19
Since the treatment and eventual outcome for each disease is very different, it is essential to quickly determine whether the presenting symptoms are due to the flu or COVID-19. If a patient only has a fever and a cough, it is almost impossible for a physician to determine what they have. Yet a rapid diagnosis can make a big difference in the outcome. That is why the CDC has recently created a rapid test for use in CDC-supported public health labs that checks for both viruses.

Patients with the flu can be given known anti-viral medications, while these are useless against COVID-19. There are no definitive medications for COVID-19 at this time, but it is important to diagnose these patients quickly and correctly because they need to be quarantined as quickly as possible. COVID-19 is twice as contagious as the flu, and 50% of transmissions happen between people who don't show any symptoms. COVID-19 is also much more lethal than the flu, and sudden, severe respiratory problems seem to occur much more frequently with COVID-19.

In addition to lab testing, there also two symptoms that occur in COVID-19 that are not seen in the flu:

• A loss of taste or smell occurs in 85% of patients. People with the flu, a cold, or nasal congestion may also lose their sense of smell, but it is not usually sudden and profound, as in COVID-19. There is also an inability to distinguish between the taste of something sweet or bitter.
• Another COVID-19 warning sign is shortness of breath, which has been reported in about 50% of COVID-19 patients. It usually appears about a week after the onset and signals the potential for a serious respiratory problem.

And don’t forget, patients can get infected with both the flu and COVID-19 at the same time. This can be catastrophic on the immune system, resulting in weakening of the body, an increased risk of long-term effects on other organ systems, and a vulnerability to other complications or secondary infections, such as pneumonia, fluid in the lungs or respiratory failure.

Cases that occurred during the flu season in the southern hemisphere before the pandemic was announced (in December 2019 and January 2020) indicated that having both at the same time worsened symptoms, impaired the immune system, and compromised recovery.

Getting infected with the flu or COVID-19 makes a person even more vulnerable to getting the other, yet having the flu or COVID-19 does not seem to provide immunity to the other. It is even uncertain if there is immunity for those who have had COVID-19.

We all know the recommended prevention measures for COVID-19 by now (wash hands, use hand sanitizer, wear a mask, practice social distancing, and avoid crowds). They also help stop the spread of the flu. However, some people in the U.S are getting lax about wearing a mask and social distancing. That's a big problem, especially since people will soon be indoors more during fall and winter.

Benefits of Flu Shots
So, what can we do beyond those simple prevention measures to help stop the spread of the flu this year?  It is simple — everyone needs to get the flu vaccine and encourage others to do the same!

Flu shots reduce the prevalence of influenza and, if it doesn’t stop someone from getting the flu, it will usually lessen the symptoms. It may reduce the number of days someone is sick or drastically lower the chances of hospitalization or death. It can also reduce the inflammation from the flu that puts patients at greater risk of having a heart attack or stroke, even weeks after the symptoms are gone.

A flu shot not only helps the patient, but it also helps others by reducing the transmission rate from person to person. Lessening the number of flu cases reduces the overall burden and stress on the healthcare system (fewer hospitalizations and ICU admissions), allowing healthcare workers to spend more time caring for the 170% increase in COVID-19 cases that are expected between now and January 1.

Flu vaccinations provide protection from the flu and its potential complications. The data from the 2010-2011 – 2015-2016 seasons showed that they prevented the following during those six years:

• 1.6 — 6.7 million illnesses
• 790,000 — 3.1 million outpatient medical visits
• 39,000 — 87,000 hospitalizations
• 3,000 — 10,000 respiratory and circulatory deaths each season

The CDC also noted that during the 2018-2019 U.S. flu season, vaccinations averted more than 4 million cases, 2 million doctors' visits, about 58,000 hospitalizations and 3,500 deaths.

But not everyone gets a flu shot each year. About 50% of Americans do not get vaccinated, including most children who die from the flu. The CDC found that, of the 140,000 to 810,000 Americans who get hospitalized with the flu each year, the majority of those who experience pneumonia or respiratory failure had not received the flu vaccine.

Given these statistics, why do Americans not receive the flu shot? It is a simple, almost painless, way to prevent a “nuisance illness” or one that could be much more serious and even life-threatening.

Reasons for Not Receiving Flu Shots
A survey of more than 1,000 people conducted by the National Foundation for Infectious Diseases (NFID) found that 60% of adults said flu vaccines were the best preventive measure against flu-related deaths and hospitalizations, but only 52% planned to get one. The reasons given for not getting a shot included: they don’t work (51%); concerns about side effects (34%); and afraid they might get the flu from the shot (22%).

The NFID survey also found that:

• The elderly account for most flu-related hospitalizations, yet only 68% of long-term care workers, who interact with them, reported getting a flu shot. That's much lower than the rate among other healthcare workers (81%).
• Almost 63% of children got the flu vaccine in 2018-2019, an increase of almost 5% from 2017-2018. That increase was good, but we need to do much better this year.
• Children are at high risk for getting the flu and a flu shot will decrease their chance of getting it and spreading it to others.
• Of the children who died from the flu between 2010 and 2016, only 22% were fully vaccinated.
• Many parents do not want their children vaccinated because they worry the child will get the flu from the shot, which is not true.
• Other parents are not aware that flu-related complications can be life-threatening for children and that a flu shot can prevent those complications.

We need to educate people and increase the number of people who get vaccinated for the flu.

Flu Vaccine Information
We need to educate our clients/patients and their families to get them to understand why they should receive their flu shot this year (and every year). The CDC Seasonal Influenza (Flu) website is a great source of information for case managers. It is also a good resource for the general population since it is written in a way that is very easily understood by patients and family members.

Studies show that flu vaccines can reduce the risk of getting the flu by 40% – 60%. All public health agencies recommend that persons aged 6 months and older, who do not have contraindications, should be vaccinated against the flu during September or October. Because this season is expected to be more virulent than usual, this time frame will help provide protection against the flu later into the season.

The CDC has published a Morbidity and Mortality Weekly Report (MMWR) on its website called the Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2020–21 Influenza Season that provides detailed recommendations and identifies:

• Who should be vaccinated and when they should receive the vaccination
• The types and composition of licensed U.S. vaccines available; this site is updated as needed
• Contraindications and precautions of vaccinations and use of vaccines (Table 2).
• Updated information about vaccines for people with egg allergies
• Recommendations for the use of vaccines for the 2020–21 season
• The two new vaccines approved and recommended for people 65 years and older
• How the flu vaccine might cause reduced symptoms that could lead to confusion when trying to diagnose and treat the flu vs. COVID-19
• Guidance for vaccine planning during the pandemic
• Vaccine specifics

The CDC website also lists other useful information about Influenza:

• Questions and Answers on specific flu-related topics
• Questions and Answers about the 2020-2021 Flu Season
• Disease burden of Influenza

Types of Vaccines
The CDC website lists all the available U.S. approved vaccines, but it does not specifically recommend specific vaccines. That determination is left up to the physician or licensed pharmacist, based on the individual needs of the patient.

There are two new vaccines this year, Fluzone High Dose and FLUAD, which are specifically approved and intended for people aged 65 and older. The following are four of the most common vaccines:

• Quadrivalent – the typical, standard vaccine; it provides protection against the four expected strains of flu for this year: Influenza A H3N2, H1N1, and two strains of Influenza B
• Fluzone High Dose* – a popular high dose, quadrivalent, inactivated vaccine that contains four times the antigen in a standard dose; this replaces the previous high dose trivalent vaccine; only approved for people 65 and older; 24% more effective than the standard dose and associated with a lower risk of hospitalizations
• FLUAD* – a newer, standard dose, inactivated quadrivalent vaccine with an added immune stimulant that helps create a stronger immune response; this is being offered in addition to the previous trivalent; only approved for people 65 and older; 51% effective in preventing flu-related hospitalizations in people 65 and older
• FLOBLOK – a unique vaccine that is processed without EGG; for use with patients 18 and under

* These are provided with no out-of-pocket cost for Medicare patients. Both are egg-based and not appropriate for those with egg allergies.

Locations for Receiving Flu Shots
This year, there are unique obstacles in getting people vaccinated. Typically about a third of U.S. adults and 80% of children get their flu shot at a doctor's office, but many offices are either overwhelmed or working with limited hours and staff. And many people are hesitant to visit a doctor’s office, due to COVID-19. Another nearly 15% of adults typically get their flu shot at work, yet this year people are working from home and do not go into the office. Shots are also frequently offered at large events, fairs and other activities where there are a lot of people gathered. However, that too, is an issue, since large gatherings are not being held.

So, this year presents some big challenges about how and where to get people vaccinated. It calls for us to be more creative!

Many doctors’ offices and clinics are planning larger out-of-office events at churches or community centers.

• State-licensed pharmacists are now allowed to administer flu shots to children starting at age 3, as well as adults. However, some pharmacies are choosing not to vaccinate children and others are starting at age 4 or 6, so people should call first to find out more information. Some locations may require appointments while others may allow walk-ins without an appointment.
• Unique programs are being developed by local health departments, community organizations, churches and health systems for people of color and those from lower socio-economic areas, who have already suffered a disproportionate amount of sickness and death from COVID-19.
• Special educational programs and campaigns are being developed to explain the importance and value of flu shots to groups that typically do not get vaccinated.
• In preparation for this season and the expected 50% increase in people who will be receiving flu shots, the CDC purchased 10 million doses of flu vaccine for uninsured adults, compared to the usual 500,000 doses.

Remember, it is best to get the flu shot in September or October to cover the entire season, but if they forget or do not get it by the end of October, they can still do it later. It is better to get it later rather than not at all. Also, vaccines do not become effective until about 2 weeks after getting the shot.

As for the cost of vaccines, they are typically free at a physician’s office or pharmacy, if the person has Medicare or other health insurance. However, they should call first or check online to get more details. Pharmacies and public health agencies are also gearing up to offer free or low-cost flu shots to those who do not have insurance.

The following are places that case managers can refer their patients and families for free or low-cost flu shots. They should call or check online first to get more details about pricing:

• Local pharmacies are available by appointment or for walk-ins. Many offer discount coupons on their website. Examples include CVS, RiteAid, Walgreens, Target, Walmart, Costco, etc.
• Community and county or public health agencies will be offering free flu shots.
• Colleges typically offer free vaccinations for students, although that may be different this year due to the lack of on-campus students, staff, and classes.
• The Veterans’ Administration (VA).
• VaccineFinder and other similar websites – enter zip code and it shows nearby locations with addresses and phone numbers.
• Websites like GoodRx that provide a list of pharmacies with pricing. They also offer discounts off the standard rate.
• Other free clinics and events will be available and advertised on TV, in the newspaper and online as we go through September and October.

Conclusion: Getting a Flu Shot This Year Is Critical
Historically, only about 45% of U.S. adults and 63% of children get vaccinated against the flu each year, according to the CDC. This year, because of our “twin-demic,” we all must get a flu shot and make sure we do everything we can to get others to get their flu shot also. It is extremely important!

Some may say “I don’t need to. It’s just the flu, so I’ll take my chances,” but that’s not the point. Although the flu is usually mild or moderate, it can also be deadly, especially when combined with COVID-19. This year, every hospitalization for influenza means that patient is going to be in the hospital with other COVID-19 patients. And that’s not the place to be! It increases their risk of getting COVID-19 also and draws healthcare workers away from caring for COVID-19 patients. Hospitals are going to need every person they can get to care for the increased volume of COVID-19 patients that is expected.

So, be sure to talk with all of your clients/patients and their family members to make sure they are going to get vaccinated for the flu. Check out online options for free or low-cost vaccination sites in your area, so you can provide them to your clients/patients.

We need to be totally ready to deal with this “twin-demic” as soon as it hits, which means we have to plan for it NOW. Flu vaccinations are a major factor in helping to lessen the seriousness of the flu and COVID-19 “double whammy.” We can do this, and we can succeed!