Concerned about a dual outbreak of influenza and COVID-19 this winter, public health officials recommended Thursday that long-term care workers and residents — and others — “take flu out of the equation” by getting vaccinated. 

COVID-19 is “truly a transforming pandemic of historic nature — and we’re not through with it yet,” Anthony S. Fauci, M.D., director of the National Institute of Allergy and Infectious Disease at the National Institutes of Health, said at a press conference held by the National Foundation for Infectious Diseases. NFID representatives and other public health and medical organizations urged the public and healthcare professionals to follow the Centers for Disease Control and Prevention recommendation that everyone 6 months and older get vaccinated against the flu annually.

“There is considerable concern that as we enter the fall and winter months and into the flu season, that we’ll have that dreaded overlap of two respiratory-borne diseases, namely influenza and COVID-19,” Fauci said, adding that public health measures can help the public avoid both. 

Both Fauci and NFID Medical Director Wiliam Schaffner, M.D., said that influenza and COVID-19 will present a “diagnostic challenge” because of the shared signs and symptoms of both illnesses. 

“Steps to fight the flu and COVID-19 overlap greatly. We don’t want those two diseases together,” Fauci said. “Some of the good news is, some of the commonly practiced public health measures are good for both of these.”

During the 2019-2020 flu season, the CDC estimates, there were 38 million flu illnesses, 18 million flu-associated medical visits, 400,000 flu hospitalizations, and 22,000 flu deaths. In addition, the agency estimates that flu vaccines prevented 7.5 million flu illnesses, 3.7 million flu-associated medical visits, 105,000 flu hospitalizations and 6,300 flu deaths. Flu vaccination among adults rose to 48%, with coverage higher among older adults compared with younger adults. 

New data released Thursday by NFID showed that only 59% of U.S. adults planned to get vaccinated against the flu this season. In a survey of the public’s attitudes and behaviors around influenza and pneumococcal vaccinations conducted by NORC at the University of Chicago, 46% of U.S. adults said they are worried about co-infection with flu and COVID-19. Approximately 28% reported that the COVID-19 pandemic makes them more likely to get vaccinated against the flu this year, and 25% said that if flu vaccines were offered in alternative settings, such as drive-thru clinics, in addition to medical offices and pharmacies, they would be more likely to get vaccinated.

“That is good news,” Schaffner said.

“In the midst of a pandemic, people should be more motivated than ever before to get a flu vaccine,” he said. “Even in cases when the flu vaccine does not prevent infection completely, it may reduce the severity of illness and prevent serious complications — keeping people out of hospitals during this critical time.”

Public health officials stressed that safe, effective vaccines are available to help prevent flu and pneumococcal disease and that vaccination is critical to protect those most vulnerable — including adults aged 65 or more years and those with chronic health conditions — as well as to reduce potential strain on the U.S. healthcare system. Every year, flu results in an estimated $11.2 billion in direct and indirect costs, they said.

For the 2020-2021 season, vaccine manufacturers estimate that up to 198 million doses of influenza vaccine will be available, surpassing the previous record of about 174 million doses set last year. 

Vaccine options for older adults:

  • The regular dose influenza vaccine, which covers four influenza viruses, for children and adults 6 months and older.
  • An adjuvanted vaccine and a high-dose vaccine, both designed to help initiate a more robust immune response for adults 65 and older.
  • A flu vaccine using recombinant technology, for adults 18 and older.

Daniel B. Jernigan, M.D., from the CDC, said 90 million doses of vaccine have been distributed already, but some locations may not have vaccines in stock yet. He added that the CDC is aware of issues with vaccinefinder.org, which provides information on influenza vaccine locations around the country, currently reporting no available vaccines. Upgrades to the site are causing temporary issues, he said, suggesting that people call the phone number for a vaccination site to confirm available supplies of vaccine.

“Don’t let that be a reason not to get a vaccine right now,” Jernigan said. “We don’t know of any national shortage, but we do know that periodically people will not be able to find it where they want it, when they want it. But that doesn’t mean you shouldn’t get vaccinated.”

Federico M. Asch, M.D., a cardiologist with MedStar Health Research Institute and Georgetown University, said he’s seen some of the worst complications of flu in the cardiac intensive care unit, including myocarditis, an inflammation of the heart muscle, which causes chest pain and results in heart failure and abnormal heart rhythms. 

“We have the potential for a lot of additional confusion since flu and COVID-19 are both contagious respiratory diseases, and many of the same groups are at higher risk for complications for both viral infections,” he said.

In recent years, Asch said, older adults accounted for 50% to 70% of flu-related hospitalizations. Last year, 93% of adults hospitalized for flu-related complications had at least one reported underlying medical condition, including cardiovascular disease, diabetes or lung disease. This situation can lead to life-threatening complications like heart attack, stroke, permanent physical decline, pneumonia, hospitalization and death, he said.

Studies have shown that adults with heart disease have a six times increased risk of having a heart attack within seven days of flu infection, and adults with diabetes are three times more likely to die of flu-related complications, Asch said.

“Bottom line, prevention through annual flu vaccination must be a part of overall disease management for older adults and people with chronic medical conditions,” he said. 

Fauci said that in addition to getting vaccinated, everyday actions can stop the spread of germs, including handwashing, wearing a mask in public and coughing into one’s sleeve.

“It is a global disease that occurs seasonally every year,” he said. “It’s our personal responsibility to protect ourselves, but we also have the responsibility to protect the vulnerable around us, including young children, pregnant women, adults aged 65 and older, and those with certain underlying chronic health conditions. It’s very similar to the situation we see with the current challenge of COVID-19.”

Schaffner said he wouldn’t be surprised if physicians in communities where flu is extensive are treating patients empirically with an antiviral drug while they await the results of a COVID-19 test.

October is the “golden month” for flu vaccination, he said. Some in the scientific community are concerned that highly vulnerable groups, including older adults whose immune systems are not as robust and who were vaccinated in August may not enjoy protections extending into February and March, when flu season peaks in the country, Schaffner added. No formal recommendations exist for revaccination during the season, he said. 

The NFID survey found that almost one in four U.S. adults (22%) who are at high risk for flu-related complications due to age and underlying health conditions were not planning to get vaccinated this season. Similarly, the NFID survey found that 51% of those at high risk for pneumococcal disease reported that they have not been advised to get vaccinated against pneumococcal disease.

Fauci said that pneumococcal disease, which can manifest as pneumonia, ear infections, sinus infections or bloodstream infections, causes 150,000 hospitalizations each year in the United States, with up to 7% of those hospitalized dying from the disease. He called it a “serious disease, particularly for the elderly.”

Two pneumococcal vaccines are available in the United States. PCV13 is recommended for children as well as adults with certain underlying medical conditions, and the CDC recommends PPSV23 for all adults 65 and older. 

Although the Southern Hemisphere already has experienced the height of flu season, which runs from April through the end of August there, Jernigan warned that the U.S. cannot rely on the significant decreases in flu activity there. Back in March and April, he said, the United States was implementing the same measures as the Southern Hemisphere — namely, sheltering in place, mask-wearing and social distancing — and saw flu transmissions decrease. But as restrictions are lifted and people spend more time inside and go back to offices and schools, the likelihood of both COVID-19 and flu cases taking off increases. 

“Be on guard,” Jernigan said. “Take flu out of the equation and get vaccinated.”