WASHINGTON — A panel of infectious disease experts went live at the virtual 2020 National Foundation for Infectious Diseases (NFID) Influenza/Pneumococcal Disease News Conference to review outcomes from last year’s flu season, discuss the ramification of Covid-19 for this year’s season, and reiterate their annual message — “get your annual flu vaccine now.”
According to the CDC, the 2019-2020 flu season resulted in approximately 38 million illnesses, 18 million flu-related health care visits, 400,000 flu-related hospitalizations, and 22,000 deaths — and kids were hit particularly hard due to the spread of influenza B viruses that kicked of the season, a development that William Schaffner, MD, NFID Medical Director and professor of Preventive Medicine and Infectious Diseases at Vanderbilt Medical Center in Nashville, called “unprecedented” in an interview with BreakingMED.
Schaffner was the moderator for this year’s NFID conference, and he was joined by three panelists: Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases and one of the public faces of the U.S. Covid-19 response; Federico Asch, MD, FACC, FASE, director of the Echocardiography Core Lab at MedStar Health Research Institute and Associate Professor of Medicine at Georgetown University; and Patricia Whitley-Williams, NFID President and professor of Pediatrics and associate dean for Inclusion and Diversity at Rutgers Robert Wood Johnson Medical School.
Schaffner kicked off this year’s conference by noting the sorry state of flu vaccine coverage during the 2019-2020 flu season. According to the CDC, 52% of people in the U.S. received a flu vaccine last year, including 48% of adults and around 64% of children — a small uptick in coverage compared to the 45% vaccination rate among U.S. adults in the 2018-2019 season, but a far cry short of the CDC recommendation that everyone ages 6 months and older receive the shot.
And this year, Schaffner noted, there’s also Covid-19 to contend with.
Combating a Covid-19/Flu ’Twindemic’
“As we look to the months ahead, the scary reality is that we could face a ’twindemic’ of Covid-19 and influenza circulating simultaneously,” Schaffner said. “The two viruses share similar symptoms — people with Covid-19 may assume they have the flu, and vice versa.” But will this frightening fact lead to additional vaccine uptake this flu season?
During his keynote presentation, Fauci said that Covid-19 is “truly a transforming pandemic of historic nature, and we’re not through with it yet. In fact, there’s considerable concern as we enter the fall and the winter months and into the flu season, that we’ll have that dreaded overlap of two respiratory borne diseases, namely influenza and Covid-19.”
Schaffner told BreakingMED that the potential confluence of Covid-19 and influenza will likely cause a great deal of confusion among the U.S. public as patients and physicians alike struggle to distinguish the two illnesses. “They’re both respiratory infections, and the array of symptoms that patients have overlap very substantially—not completely, but very substantially,” Schaffner said, adding that the testing modalities for influenza and Covid-19 are both far from perfect. “Covid [testing] is very specific, but it takes a while for the test results to come back —not very useful, at the moment,” he said. “We have point-of-care tests for flu, but they’re not very sensitive; particularly in adults, you can have a lot of false negative tests. They work better in children. So, the testing we have will help us up to a point, but only up to a point.”
And that is why, Fauci noted, it is vital to make use of “the ability — which we have — of medically avoiding at least one of those and, by public health measures, both of those.”
Fauci shared a series of overlapping symptoms that will make distinguishing flu from Covid-19, and vice versa, a “diagnostic challenge,” including:
- Fever or feeling feverish/chills.
- Shortness of breath or difficulty breathing.
- Sore throat.
- Runny or stuffy nose.
- Muscle pain or body aches.
- Vomiting and diarrhea.
Fortunately, Fauci pointed out that steps for fighting the flu and Covid-19 also significantly overlap. He encouraged people to wear masks or face coverings in public, maintain physical distance of at least 6 feet, avoid crowds, gather outdoors when possible, wash hands frequently, avoid touching eyes, nose, and mouth, clean and disinfect surfaces, stay home when sick, and take antiviral medications if they’re prescribed by your doctor.
And, most importantly, he encouraged people to get the flu vaccine “to protect yourselves, your loved ones, and your community.”
Fauci pointed to the Southern Hemisphere, and particularly Australia and New Zealand, as a model for how to handle the concurrent Covid-19 pandemic and flu season. “They did so many of these things… [and] they had a very, very light flu season… hopefully, together with the flu vaccine, if we do what’s on this slide, we’ll have the same thing.”
Schaffner added that the Covid-19 pandemic might impact the ability of people working from home to get the flu vaccine.
“Many people are now still working from home,” he told BreakingMED. “So, they won’t be able to take advantage of the flu vaccine programs that employers have in the workplace, and they’re going to have to seek out the vaccine on their own. So, it’s important that we encourage and reassure people while we try to motivate them and stimulate them to go out and get the vaccine.”
As for people who are worried about running out to their physician to get their flu vaccine, Schaffner encouraged them to call ahead to their health care provider to see whether or not their clinic has strategies in place for rapid and safe vaccination. And, if people should become ill, he strongly urged them to call or email their physician rather than going into the clinic and spreading their illness in the waiting room.
And what impact might the politization of the U.S. Covid-19 response have on the upcoming flu season?
Schaffner told BreakingMED that it “makes our response… much more difficult because it interferes and confuses the public health messages. And it’s quite clear the public is very confused about Covid. Because there’s been a lack of national leadership, we now have this crazy quilt of different responses, according to which state your in — and even within states there are differences; what we do in Nashville is different than what’s happening in the counties around us. That doesn’t make any public health sense, but it’s really driven by politics rather than the epidemiology of Covid, or… the epidemiology of influenza.
“I mean, we recently passed 200,000 deaths in the United States,” he continued. “I mean, that’s stunning — a really bad flu season, two years ago, was 80,000 deaths, and we’ve already gone way beyond that with Covid. But there are people out there who really don’t ’believe’ in Covid, who think it’s a hoax, or overblown. It’s hard to get to those folks because of the political coloration that the response to Covid has taken. It makes it very difficult.
“I would be very surprised if everyone in our national leadership got vaccinated against influenza, and let everybody know that they were getting vaccinated against influenza,” he said. “That’s what we would need — I don’t think were going to get that.”
And The Survey Says?
Leadership aside, to find out what U.S. adults are thinking about influenza and pneumococcla disease vaccination in the context of the Covid-19 pandemic, the NFID commissioned a survey — and the results, Schaffner noted, were “both hopeful, and also concerning.”
According to the NFID-commissioned survey — currently available on the NFID’s website — “Overall, most U.S. adults believe vaccination is the best protection against flu, but many do not plan to get vaccinated during the 2020-2021 flu season.”
The survey, which was conducted by the National Opinion Research Center (NORC) at the University of Chicago from Aug. 17 to 19 and which included 1,000 complete responses (897 via web and 103 via phone), found that while 68% of U.S. adults agree that flu vaccination is the best preventive measure against flu-related deaths and hospitalizations, only 59% of respondents actually plan to get vaccinated this year, while 15% were not sure — “a slight increase from the survey we commissioned last year,” Schaffner noted, “but we still have a very long way to go.”
The top reasons cited by those who were unsure or who do not plan to get the flu vaccine included:
- 34% do not think the flu vaccines work very well — a large drop from 51% the previous year, which suggests that messaging from the health care community “around the benefits of partial protection is working,” Schaffner noted. “We keep needing to hammer that point home.”
- 32% said they never get the flu.
- 29% are concerned about side effects from the vaccine with 22% concerned the vaccine will give them the flu.
- 17% are concerned about potential Covid-19 exposure if they go out to get the flu vaccine.
In addition, 22% of respondents who are at high risk for flu-related complications said they don’t plan on receiving the vaccine. And, while 59% of white adults and 65% of Hispanic adults plan to get the vaccine, 62% of Black adults said they were not sure or were not getting the vaccine.
The survey also found that, while U.S. adults are concerned about contracting Covid-19, they are not nearly as afraid of the flu: 46% of respondents reported being “extremely worried” about Covid-19 infection, while only 23% were similarly worried about the flu. An additional 46% of respondents reported concern about being infected with Covid-19 and flu simultaneously, with Black (61%) and Hispanic adults (53%) reporting the greatest concern.
Notably, 28% of respondents said the Covid-19 pandemic makes them more likely to seek out the flu vaccine.
The survey also revealed the troubling fact that 51% of adults who are at higher risk for pneumococcal disease, a potentially dangerous complication of the flu, reported that they have not been advised to get a pneumococcal vaccine. In fact, among adults age 65 years and older and those with underlying conditions, who are at the highest risk, 46% were not familiar with pneumococcal disease, 65% were not sure of their vaccination status or had not received a vaccine, and 89% of those who have not received it were either unsure or do not plan to receive the vaccine.
“There’s a gap we need to fill,” Schaffner said.
Comorbidities, Disparities, and Pediatric Vaccinations
Another major focus of this year’s conference was the prevention of flu among patients with underlying medical conditions, overcoming racial disparities in health care, and improving flu vaccination among U.S. kids.
In his presentation, Asch pointed out that last flu season, 93% of adults hospitalized with the flu had at least one reported underlying condition that put them at higher risk for complications — typically diabetes, cardiovascular disease, obesity, and chronic lung disease. And, he noted, the Covid-19 pandemic will complicate the flu season for this population, as most patients who are at high risk for complications from one virus are also at risk from the other.
“Flu can exacerbate underlying conditions and lead to life-threatening complications like heart attack, stroke, permanent physical decline, pneumonia, hospitalizations, and even death” Ache said. “Patients with diabetes and heart disease are most vulnerable and need the added protection to their immune system.” He pointed to recent studies which found that adults with heart disease are six times more likely to suffer a heart attack within 7 days of contracting the flu; in addition, the risk of flu-related hospitalization for adults with diabetes is six times higher, and this population is three times more likely to die due to flu-related complications.
“Bottom line, prevention through annual flu vaccination must be a part of overall disease management for older adults and for patients with chronic health conditions — and it is just as important as eating a balanced diet, quitting smoking, getting more exercise, or even being compliant with medication,” Asch said. “The benefit of annual flu vaccination cannot be understated, because we know it lowers rates of serious infection, hospitalization, cardiovascular events, and death.”
Asch also took a moment to address disparities in vaccine coverage among communities of color: “Sadly, complications from pneumonia and influenza combined are a leading cause of death among Hispanics. And yet vaccination coverage remains particularly low among this population; for the 2019-2020 flu season, vaccination coverage among Hispanic adults was only 38.3%… improving access to and acceptance of flu vaccine among communities of color and Hispanics must be part of our national strategy to prevent illness and reduce stress to the U.S. healthcare system as they fight flu and Covid-19.”
Whitley-Williams also took on the topic of disparities in flu coverage among non-white racial groups, noting that “officially, non-Hispanic Black children have lower flu vaccination rates than children in all other racial and ethnic groups.” She added that the finding in the NFID survey that Black adults are more worried about contracting Covid-19 and flu at the same time makes sense, given that Black adults are more likely to be hospitalized and die from both Covid-19 and the flu.
“We know that there are multiple variables at play here in communities of color,” she said, “including, but certainly not limited to, unconscious bias, institutional racism, distrust of the healthcare system, and vaccine hesitancy. Despite these hurdles, we cannot become complacent in our attempts to drive change. Now is the time for change — now is the time for everyone to get a flu vaccine.”
Whitley-Williams also noted that the conjunction of Covid-19 and flu will likely have an impact on kids as they transition back to in-person schooling. “As you know, children are super-spreaders of flu, as they are other respiratory viruses, but they do pass on more of the flu virus for longer periods of time compared to adults,” potentially bringing illness home to their parents, grandparents, neighbors, and friends. “I still love the kids, though,” she quipped.
While Whitley-Williams acknowledged that it is good news that pediatric flu vaccination rates were 63.8% for last year’s flu season, she argued that this is “not nearly good enough,” pointing out that the 2019-2020 flu season led to a total of 189 pediatric flu-related deaths — and, “what is truly devastating is that more than half of these children were healthy — they had no pre-existing conditions,” she added. “The flu vaccine is not perfect, we know that…but it will reduce severity and duration of disease and will help save children’s lives.”
Doing What We Can, With the Tools That We Have
Asked what clinicians could do to help increase flu vaccine uptake in their communities, Schaffner told BreakingMED that “the single greatest determinant of the acceptance of the vaccine is the nature of the provider’s recommendation, which — and here’s the point — should not be diffident. It’s not sufficient for the provider to say to the patient… as they’re finishing the visit, ’Tom, it’s that season of the year, you ought to think about getting the flu vaccine — we have it available right here in the clinic.’ This doctor thinks that’s a recommendation — that’s not a recommendation. That’s not the way you say to a patient, ’hey Tom, you’ve got pretty bad diabetes here, you ought to think about getting a treatment.’ We don’t say that. We need to be more insistent, ’Tom, it’s that time of the year — as you leave, you will receive your influenza vaccine.’ That’s the way to get people vaccinated. Make it definitive, make it insistent.”
“Is the flu vaccine perfect?” Schaffner asked at the conference. “Of course not, we know that. Flu vaccine effectiveness can vary from season to season among different age and risk groups. But it’s important, very important, that people understand that flu vaccines help prevent tens of thousands of hospitalizations each year, and other serious complications such as heart attack and stroke. Even if you do get flu, despite getting vaccinated, please, hear this — you are likely to benefit from having a less severe and shorter illness, and you are far less likely to get pneumonia; you’re less likely to be hospitalized; and you’re less likely to die. Hello? What’s wrong with that?”
“We cannot emphasize any more strongly the importance of what we’re saying today about the benefits of influenza vaccine in general, even if we were not in the middle of the Covid challenge,” Fauci said in closing out the conference. Influenza vaccinations are important to prevent infection and to modify infection when you get it. The things that we are talking about now, it is a serious disease, it is not trivial.
“Let’s do what we can, with the tools that we have — and we have a good tool,” Fauci added.
John McKenna, Associate Editor, BreakingMED™
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