As COVID-19 Lingers, Flu Could be a Complicating Factor

Gary L. LeRoy, M.D., FAAFP, president of the American Academy of Family Physicians, has an apt analogy for the “new normal” of COVID-19: It’s like going from being childless to being a parent.

“There are things that you can’t do anymore,” he says. “You have to make these adjustments in your life to accommodate the absence of things that you would normally do.

If COVID-19 adds a major new level of complication to the daily life of Americans, especially those working in healthcare, the arrival of influenza season could be thought of as the birth of a second complicating factor.

Ever since the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus forced a massive shutdown of the American economy this spring, public health officials have been concerned about what might happen if the new virus were not contained by the time flu season rolled around this fall and winter. Now, with the season just around the corner, everyone from the family practitioner to the CEO of a major health system is preparing to deal with potential outbreaks of the two conditions, both of which can be life threatening.

Similar symptoms

COVID-19 and flu both come with symptoms such as fever, cough, runny nose and body aches, according to the CDC. Both are highly transmissible, spread mostly by airborne droplets that are exchanged when people are close together and talk, cough or sneeze. The illnesses will resolve in many patients without the need for medical intervention, although a subset of patients with COVID-19 and flu will experience severe symptoms and require hospitalization, and a subset of those will die.

But there are also important differences. Young children are apparently more at risk of suffering from a severe case of flu than they are of COVID-19, although a small number of those with COVID-19 develop multisystem inflammatory syndrome in children. Most people with flu will be contagious for about a day before they start feeling sick and will be contagious for as many as seven days thereafter. With COVID-19, patients can be contagious for multiple days without symptoms, if they show symptoms at all. The CDC says those patients are contagious for at least 10 days after the onset of symptoms. Another difference is that loss of taste and smell has been reported in patients with COVID-19.

Lastly, the FDA has approved multiple vaccines to prevent flu infection and multiple antiviral medications to treat it. Although a dozen or so COVID-19 vaccines are in clinical trials and the world is awaiting the results, so far none of them have been approved.

Precaution without diagnosis

LeRoy says at the family practice level, screening questions will remain a key starting point in controlling both infections. However, the screening questions don’t always identify patients who could have been exposed to COVID-19, he notes. And the onset of flu season will mean that affirmative responses could have a wider range of causes.

In midsummer, LeRoy started noticing his proportion of telemedicine visits going down, which in turn led to a rise in patients making what he calls “oh, by the way” comments. “(In other words,) …‘Oh, you know, I had a sister or a relative or somebody that tested positive for COVID(-19). Do you think I should get tested?’” he said. “And I’m (thinking), why the heck are you sitting in my exam room?”

Such patients aren’t flaunting protective procedures intentionally, he said, they are simply unaware of the risk they could pose to other patients and to staff.

In an ideal world, patients with flu or COVID-19 should be treated with telemedicine whenever possible. Depending on the level and location of testing available in a particular area, they may simply recover at home and never receive a conclusive diagnosis of either flu or COVID-19. However, LeRoy says one challenge in such cases is making sure patients understand that they must take the utmost precautions, even if they never receive a firm diagnosis.

“I’m finding that I have to be very specific to people about what I mean by ‘quarantine,’” observes LeRoy, “because they (say), ‘Okay, I won’t go to work, but I’m going to go…pick up some groceries.’”

Both at once

Paul Auwaerter, M.D., MBA, a professor and clinical director at the Division of Infectious Diseases at Johns Hopkins Medicine, said one of the key prevention measures health systems typically take is requiring all staff to get a flu shot, ideally by November. Around the same time, hospitals will start routinely testing patients for the flu. “This is a bit more complicated now because we have COVID-19,” he says. The hope, notes Auwaerter, is that tests for the SARS-CoV-2 virus will be incorporated into some of these molecular respiratory panels. The FDA has granted emergency approval for such an assay, although it is not yet clear when it will be available, nor is it known which types of providers will be first in line to receive the supplies.

Like family practices, hospitals and clinics will need to manage which patients come into the office and which are treated with telemedicine, says Auwaerter. He typically takes a proactive approach with patients who have suspected flu, “in the sense that I would want them to come to the office and see if they’re struggling,” he said.

However, with COVID-19 it could be riskier to invite those patients to the clinic, he said.

A similar problem will be found in the emergency department, because it will be impossible to immediately distinguish between patients with COVID-19 and those with influenza, and a patient with one disease could infect a patient with the other disease. “We know from a number of reports that both viruses can be acquired at once,” Auwaerter remarks.

He said that staff treating patients with flu typically wear standard personal protective equipment (PPE) once patients are admitted to the hospital, but patients with COVID-19 typically require a negative-pressure room to account for the aerosolization of the virus. Johns Hopkins has converted entire floors to treat patients with COVID-19 and suspected COVID-19. Once flu season arrives, however, those floors might be in higher demand. “People with influenza may be cohorted into these floors,” Auwaerter said. “Now, they’re not at any increased risk for getting COVID-19. But these are people (who) we immediately can’t distinguish if they have COVID-19 or not.”

He says hospital leader needs to prepare for the flu season by continuing to do everything they can to secure PPE and think proactively about personnel issues that may arise.

COVID-19 knock-on effect

With the risk of additional stress on the healthcare system, both LeRoy and Auwaerter said flu vaccination will be of critical importance. Auwaerter hopes the increased awareness will push flu vaccination rates above the 40% mark seen in the past.

But there is also a chance that COVID-19 social distancing and mask wearing will have a knock-on effect on flu. Instead of a perfect storm, there may be double prevention. Moreover, the lack of international travel may also mean that the flu virus, which tends to swirl around the world, will stay put.

There may also be a bystander effect on the common cold, which tends to be caused by a coronavirus — not SARS-CoV-2, but a coronavirus nonetheless.

“And so, given the fact that influenza A, influenza B, the common cold (rhinovirus), coronavirus-type…common cold viruses, and…SARS-CoV-2 are all spread in similar manners, I suspect that you will see less of the common cold,” LeRoy says, “because not just healthcare workers, but practically everybody is (taking) universal precautions now.”

As a case in point, LeRoy said he gets a summer cold every single summer, even although he is a “fanatic” about washing his hands. “So far, I haven’t gotten a summer cold,” he says. “And it’s probably because other people around me are taking…precautions because of COVID(-19).”

If there’s a silver lining in the pandemic, perhaps these precautions are it, LeRoy says, although he couldn’t help being a bit superstitious. “Now I’ll probably get something just because I’m opening my big mouth about it,” he jokes.

Jared Kaltwasser is a healthcare writer based in Iowa.