COVID-19 and flu season: A ‘daunting prospect’ for hospitals

With COVID-19 cases surpassing 5 million in the United States and influenza season approaching, experts are weighing the prospect that hospitals will have to respond to surges of the two respiratory illnesses at the same time.

“It is essentially guaranteed that we will have a level of COVID in the health care system through the entire flu season, but whether there is a surge depends a lot on community mitigation efforts and community prevalence,” Paul D. Biddinger, MD, medical director for emergency preparedness for Mass General Brigham, told Healio.

“If we have a surge with a severe flu season with relatively low levels of COVID, that's very different than having two surges that coincide,” Biddinger said. “I think if the two surges coincide, we will absolutely see increased demand for personal protective equipment and supply chain disruptions for lab testing and critical care supplies.”

He said standard COVID-19 prevention measures could have a positive impact on the upcoming influenza season.

Paul D. Biddinger

“Attention to hand hygiene, covering coughs, wearing masks and keeping a distance all should decrease influenza transmission,” he said. “As part of the COVID-19 response, many systems including ours are putting even more emphasis than usual on their influenza vaccination campaigns. This is important for preserving health, as it always has been, but also for blunting a potential rise in cases during a COVID surge and decreasing the number of respiratory viral syndrome patients that need differentiation about whether they have COVID, the flu or something else.”

U.S. hospitals implemented new policies following the severe 2017-2018 influenza season, during which more than 900,000 people were hospitalized, exceeding the total number of staffed hospital beds in the country. Experts remain concerned about the health care system’s ability to meet the challenges of another severe influenza season.

The cocirculation of SARS-CoV-2, the coronavirus that causes COVID-19, and influenza could stretch hospital capacity even further, experts indicated.

“A severe flu season concomitant with COVID-19 in the fall could be a daunting prospect for hospitals, as both viruses would compete for the same resources such as ICU beds and personal protective equipment,” Amesh A. Adalja, MD, senior scholar at Johns Hopkins Center for Health Security, told Healio.

Adalja agreed that COVID-19 mitigation efforts would likely impact the transmission of influenza. There may be evidence that it already has.

According to Adalja, the southern hemisphere has seen a comparatively less severe influenza season, possibly as a result of such efforts. He also noted that the influenza season in the U.S. “ended abruptly” last spring when COVID-19 prevention measures were implemented.

Biddinger noted two major challenges for hospital capacity in the upcoming influenza season: the timing of influenza cases alongside COVID-19 surges and the need for isolation and cohorting patients — which is largely dependent on testing capacity.

“We need to make sure that we know whether someone does or does not have the flu when they're admitted, as we always have, and also does or does not have COVID when they're admitted in order to assign the correct room and correct infection control precautions,” Biddinger said.

“Since there are still a large number of hospitals without private rooms, determining someone's infection control status for two different diseases when they have fever and respiratory symptoms is going to be much more challenging,” he said. “Trying to find ways to rapidly test for both viruses in an efficient and effective way is going to be critical for hospitals to maintain effective flow.”

It will also be critical to get vaccinated against influenza — “more important than ever,” Biddinger said.

“The most helpful thing we can do is identify what actions are most useful to decrease both diseases in the community, as well as what actions we can take within the health care system to be best prepared for a surge of either or both,” he said.

Recently published research demonstrated that influenza vaccination has no effect on coronaviruses, after an earlier paper suggested it might increase the risk for illness from seasonal coronaviruses. Numerous studies have reported patients coinfected with influenza and SARS-CoV-2.

Influenza vaccination rates have increased, but only 52% of U.S. adults said in a survey last year — prior to the pandemic — that they planned to get immunized. More recently, data from PCC, a firm that specializes in pediatric electronic health records, indicated that pediatric vaccinations have declined because of COVID-19.

However, AstraZeneca announced recently that it scaled up production of its quadrivalent influenza nasal spray vaccine (FluMist) by 25% in anticipation of increased demand because of COVID-19.

Adalja predicted that influenza vaccine uptake will be “very high” during the upcoming season as the public attempts to not only prevent themselves from getting sick, but also heeds “the message that we want to keep flu at as low of a level as possible in order to have room to take care of coronavirus patients in the hospital.”

“It will be very important to study the interaction of these two viruses in the fall and understand how they impact each other,” he said. “It may be the case that because of people becoming accustomed to respiratory protection from viruses, many of the coronavirus pandemic mitigation measures may become more commonly adopted during flu season —and flu seasons may become less severe because of them.”

References:

• AstraZeneca. AstraZeneca ships FLUMIST® QUADRIVALENT vaccine in the US for 2020-2021 flu season. https://www.astrazeneca-us.com/content/az-us/media/press-releases/2020/astrazeneca-ships-flumist-quadrivalent-vaccine-in-the-us-for-2020-2021-flu-season-08132020.html. Accessed August 13, 2020.
• Cuadrado-Payán E, et al. Lancet. 2020;doi:10.1016/S0140-6736(20)31052-7.
• Johns Hopkins. COVID-19 dashboard. https://coronavirus.jhu.edu/map.html. Accessed August 13, 2020.
• Konala VM, et al. Eur J Case Rep Intern Med. 2020;doi:10.12890/2020_001656.
• Wu X, et. Emerg Infect Dis. 2020;doi:10.3201/eid2606.200299.