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Medical News & Perspectives
August 20, 2020

Flu Vaccination Urged During COVID-19 Pandemic

JAMA. 2020;324(10):926-927. doi:10.1001/jama.2020.15444

As the US heads into influenza season with the novel coronavirus pandemic still raging, public health authorities stress that it’s more important than ever for people to get their flu shot. Although influenza’s disease burden varies from year to year, evidence clearly shows that vaccination can reduce flu severity and prevent hospitalizations—critical considerations at a time when the health care system is burdened by coronavirus disease 2019 (COVID-19).

The COVID-19 crisis also presents a unique opportunity: effective messaging from the US Centers for Disease Control and Prevention (CDC) on down could amplify demand for the underutilized flu vaccine in a year when the pandemic has heightened public concern about health.

Case in point: southern hemisphere countries such as Argentina and Australia, where flu season runs from April through September, have stocked up on vaccine, boosted the number of people immunized, and used innovative approaches such as opening vaccination clinics in churches, schools, and theaters.

L.J Tan, PhD, the Immunization Action Coalition’s chief strategy officer, said that to emulate those successes and avoid what he calls a “twindemic” of COVID-19 and flu, the US needs not only safe, easy access but a “strong unified message about the importance of the flu vaccine.”

Building on the perennial focus on older adults due to their risk of severe illness and death from the flu, this year’s messaging also will underscore the vaccine’s importance for racial and ethnic minorities, all people with chronic conditions, and health workers.

In a call to action, the CDC has urged physicians to leave no stone unturned in ensuring their patients get vaccinated. The agency has also provided guidance for safely administering vaccines during a pandemic.

“People Don’t Value It”

Still, no one is predicting a dramatic upturn in flu vaccinations.

In the US, flu season begins in October and runs into spring, although vaccination campaigns can begin as early as August. Tan declined to pinpoint a goal but said he’d “do a jig” if vaccinations reach 190 million this season. That’s 60% of the eligible population and about 20 million more than in the 2018-2019 season.

But old habits die hard. Richard Zimmerman, MD, MPH, of the University of Pittsburgh’s Department of Family Medicine and its Center for Vaccine Research, said that although fear and publicity might increase vaccinations by a few percentage points, “overall apathy and opposition to flu shots is hard to overcome.”

Low uptake has long flummoxed experts, even as the CDC recommends the vaccine for nearly everyone aged 6 months or older. In 2010, the US Department of Health and Human Services through its Healthy People 2020 campaign set a goal to vaccinate 70% of the population, with higher targets for certain groups. But the country isn’t close to meeting those objectives.

Even when the vaccine was in relatively high demand during the 2018-2019 flu season, 45% of US adults and 63% of children were vaccinated. The rate was 68% for people 65 years or older—the group with the highest flu mortality risk.

Only 48% of young and middle-aged adults with high-risk conditions including asthma, diabetes, heart disease, chronic obstructive pulmonary disease, and most cancers had a flu shot that season.

Uptake has lagged despite efforts to make the vaccine cheap and widely available. “People don’t value it,” said Mayo Clinic infectious disease specialist Gregory Poland, MD.

This year, skeptics note, public health agencies are stretched thin by COVID-19 and in some cases political forces have undercut their mission. Although the CDC may be the most notable example, state health departments haven’t been spared. New York City’s health commissioner, Oxiris Barbot, MD, resigned August 4, 2020, after clashing with Mayor Bill de Blasio over COVID-19 safety measures.

What’s needed is a “cross-sector push to get people vaccinated this year, and I’m dubious about the leadership being there to pull it off,” said Joe Smyser, PhD, MSPH, chief executive officer of the Public Good Projects, which in June launched a campaign called Stronger to counter antivaccine messages.

Misinformation is another looming concern. A false claim that flu vaccines increase the odds of contracting COVID-19 was promoted on social media, based on an erroneous interpretation of a 2019 military study that examined whether individuals who received flu vaccinations are more susceptible to other viruses.

Poland said the push to get people vaccinated for flu “is happening in a culture that is science resistant.”

Misunderstanding also could lead to unnecessary infections. Catherine Martin, executive director of the California Immunization Coalition, worries that COVID-19 precautions such as social distancing and hand washing might lead people to think they aren’t susceptible to the flu. She’s also concerned that preliminary reports of less flu in the southern hemisphere will trigger complacency. “Just because (flu) is not showing up in Australia doesn’t mean it’s not going to show up here,” she said.

Messages will also have to be worded carefully to ensure people understand that influenza and the novel coronavirus are separate pathogens, said Vanderbilt University infectious disease specialist William Schaffner, MD, medical director of the National Foundation for Infectious Diseases. “We don’t want to give people the notion that you vaccinate against the flu and that will provide protection against COVID,” he said.

The Fear Factor

Anxiety does appear to motivate people to roll up their sleeves. For example, CDC data show that the number of distributed flu vaccine doses rose almost 9% in 2018-2019, a year after a particularly destructive season in which the flu hospitalized an estimated 810 000 people and killed 61 000.

The prospect of 2 serious respiratory viruses circulating simultaneously “is a bad situation. I think most people get that,” said Marcus Plescia, MD, MPH, chief medical officer of the Association of State and Territorial Health Officials. “I think this year people are scared and so we will get more participation.”

Perhaps a sense of public responsibility will emerge, too. CDC Director Robert Redfield, MD, noted in a Time magazine interview that although less than half of US residents usually get a flu shot, this is the year to reconsider. “[T]hat decision may make available a hospital bed for somebody else that really needs it for COVID,” he said.

The CDC has dispersed an extra $140 million to states and other jurisdictions this year to promote flu vaccinations, said Ram Koppaka, MD, PhD, a medical officer in the agency’s National Center for Immunization and Respiratory Diseases. He said priority groups include people with chronic health conditions, racial and ethnic minorities, and long-term care workers. Along with older individuals, many are at higher risk of both influenza and COVID-19.

Although the CDC maintains that all health care workers should be vaccinated for patient safety, only 68% of long-term care workers were vaccinated for flu during the 2018-2019 season compared with 95% of people working in hospitals, where Koppaka said state or institutional requirements must be observed.

Local Efforts

State and local health departments said they will use the infusion of federal funding for large media campaigns and outreach to vulnerable groups.

In California, $20 million in extra CDC funding will be used to support immunization providers and educate the public that flu vaccination can protect Californians and conserve scarce hospital and clinic resources during the pandemic, a spokesperson for the state’s health department said in an email.

Martin said she’s seeing greater collaboration on flu vaccine messaging among hospitals, physician organizations, public health departments, schools, and other organizations. Universities including the University of California, Purdue in West Lafayette, Indiana, and the University of Tennessee System have announced that they’ll require students, faculty, and staff who return to campus to have flu vaccinations.

Efforts are also underway to make sure that people feel safe wherever they choose to get vaccinated. Although doctors’ offices and pharmacies already follow CDC guidance to minimize the risk of contracting COVID-19, local vaccine coalitions are exploring options such as holding clinics in parking lots and large indoor spaces like gyms and sports arenas, Tan said.

Drive-through clinics, which have been held safely for years in some communities, are expected to proliferate. While retail pharmacies profit from the foot traffic that comes with vaccinations, at least 1 grocery store chain, Hy-Vee, announced that its drive-through clinics would start in August.

Paving the Way

But these initiatives can only be effective if vaccine is available. Several experts said they anticipate a large enough supply to meet the potential increased demand. At the CDC’s urging, manufacturers announced they’ll boost production by about 10% this year, according to news reports. The CDC also took the unusual step this year of purchasing 9.3 million adult doses for states and local jurisdictions—a substantial hike over the usual 500 000 in a normal flu season, Koppaka said.

Vaccine makers project that they’ll supply 194 million to 198 million doses during the 2020-2021 season, and more could be ordered. “The vaccine manufacturers always tell us that they can make as much as we can use, and they can continue to provide vaccine throughout the season,” Schaffner said.

That’s critical because even minor supply disruptions can be detrimental. Claire Hannan, MPH, executive director of the Association of Immunization Managers, whose members work for state health departments, said she worries about temporary shortages that can result from demand spikes or manufacturing hiccups. “It’s difficult messaging to say to people, ‘It’s really important to get your flu shot, but wait until next week,’” she said.

Although Koppaka characterized the CDC’s extra support for flu vaccinations this year as COVID-19 related, others view these efforts as a step toward improving the vaccine infrastructure, which currently allows many people to fall through the cracks.

At the very least, they said, it’s a trial run for distributing an eventual COVID-19 vaccine. At that point, Hannan said, public health officials will need to prioritize many of the same vulnerable populations.

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    2 Comments for this article
    COVID-19 vs Influenza: a Difficult Clinical Differential Diagnosis
    Giovanni Ghirga, Pediatrician | Civitavecchia, Italy
    COVID19 and influenza will be difficult to distinguish clinically in unvaccinated patients because of common symptoms (fever, cough, dyspnea), blood test findings (leucopenia and lymphopenia), and chest computed tomography appearamces (ground-glass opacity and consolidation with bilateral lung involvement). Influenza testing for every suspected case will be unfeasible during the epidemic. This has a therapeutic implication in influenza / SARS-COV-2 co-infection because early administration of neuraminidase inhibitors like oseltamivir and zanamivir, effective against influenza, could ameliorate the course of the co-infection.
    CONFLICT OF INTEREST: None Reported
    Coexistence of Both Infections May Increase Disease Severity and Mortality
    Rajeev Gupta, MD, DM (Cardiology) | Mediclinic Al-Jowhara Hospiral, Al Ain, UAE
    It is great to notice the initiatives. The message is timely and life-saving. Influenza vaccination is no longer a choice but an imperative during this time. If influenza complicates any illness like acute myocardial infarction, mortality increases. Likewise it may increase the severity of COVID-19.
    CONFLICT OF INTEREST: None Reported
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