‘Twindemic’ risk causes push for flu shots

Experts fear outbreaks and hospital overloads

As public health officials look to fall and winter, the specter of a new surge of COVID-19 gives them chills.

But there is a scenario they dread even more: a severe flu season, resulting in a “twindemic.”

Even a mild flu season could stagger hospitals already coping with COVID-19 cases. And though officials don’t know yet what degree of severity to anticipate this year, they are worried large numbers of people could forgo flu shots, increasing the risk of widespread outbreaks.

The concern about a twindemic is so great that officials around the world are pushing the flu shot even before it becomes available in clinics and doctors’ offices. Dr. Robert Redfield, director of the U.S. Centers for Disease Control and Prevention, has been talking it up, urging corporate leaders to figure out ways to inoculate employees. The CDC usually purchases 500,000 doses for uninsured adults — but this year, it ordered an additional 9.3 million doses.

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, has been

imploring people to get the flu shot “so that you could at least blunt the effect of one of those two potential respiratory infections.”

In Britain, Prime Minister Boris Johnson has been waging his own pro-flu shot campaign. Last month, he labeled people who oppose flu vaccines “nuts” and announced the country’s largest-ever rollout of the shots.

In April, one of the few reasons Australia allowed citizens to break the country’s strict lockdown was to venture out for their flu shots.

The flu vaccine is rarely mandated in the U.S., except by some health care facilities and nursery schools, but this month, the statewide University of California system announced that because of the pandemic, it is requiring all 230,000 employees and 280,000 students to get the flu vaccine by Nov. 1.

A life-threatening respiratory illness that crowds emergency rooms and intensive care units, flu shares symptoms with COVID-19: fever, headache, cough, sore throat, muscle aches and fatigue. Flu can leave patients vulnerable to a harsher attack of COVID19; coming down with both viruses at once could be disastrous, doctors warn.

The 2019-20 flu season in the U.S. was mild, according to the CDC. But a mild flu season still takes a toll. In preliminary estimates, the CDC said cases ranged from 39 million to 56 million, resulting in up to 740,000 hospitalizations and from 24,000 to 62,000 flu-related deaths.

According to the CDC, flu season occurs in the fall and winter, peaking from December to February, and so was nearing its end as the pandemic began to flare in the U.S. in March.

But now, fighting flu proactively during the continuing pandemic presents significant challenges — not only how to administer the shot safely and readily, but also how to prompt people to get a shot that a majority of Americans have typically distrusted, dismissed and skipped.

With many places where the flu shot is administered en masse now inaccessible — including offices and plants that offered it free to employees onsite and school health clinics — officials have been reaching out to local health departments, health care providers and corporations to arrange distribution. From now through Oct. 31, publicity campaigns will blast through social media, billboards, TV and radio. Because the shot will be more difficult to access this year, people are being told to get it early, although immunity does wane. There will be flu shot tents with heaters in parking lots and pop-up clinics in empty school buildings.

Because of the efforts, vaccine-makers are projecting that a record 98 million flu shots will be given this year in the U.S., about 15% more than doses ordered last year. The Kaiser Permanente health care system will be flooding more than 12 million of its members with flu shot reminders via postcards, emails, text messages and phone calls.

Pharmacies and supermarkets are expected to play a bigger role than they have in previous years. As of this week, Walgreens and CVS will have flu shots available. Walgreens will be hosting additional off-site flu vaccine clinics in community centers and churches. To reduce contact time, CVS is allowing patients to fill out paperwork digitally.

In New York City, which averages about 2,000 flu-related deaths a year, the health department has been reaching out to hundreds of independent pharmacies to administer the shots because they are often located in outer-borough neighborhoods where the coronavirus has been rampaging. The health department has a detailed online flu vaccine locator.

“Access is a problem for all adult vaccines,” said L.J. Tan, chief strategy officer for the Immunization Action Coalition, a nonprofit that works to increase vaccination rates, who was an early promoter of the term twindemic. “Adults may think, ‘If I can get the flu shot easily, I might consider it.’ ”

But as difficult as getting the flu shot to people safely will be, perhaps harder still will be persuading them to actually get it. In the 2018-19 flu season in the U.S., only 45.3% of adults over the age of 18 got the vaccine, with rates for those ages 18 to 50 considerably lower.

Skepticism to this vaccine runs high, particularly in communities of color, because of long-standing distrust and discrimination in public health. A 2017 study in the journal Vaccine noted that, compared with white Americans, “African Americans were more likely to report barriers to vaccination, were more hesitant about vaccines in general and the flu vaccine specifically, more likely to believe in conspiracy theories and use naturalism as an alternative to getting vaccinated.”

Across all demographic groups, perhaps the most striking reason given for avoiding the flu vaccine is that people do not see it as efficacious as, say, the measles vaccine.

Indeed, it is a good vaccine but not a great one. It must be repeated annually. Immunity takes up to two weeks to kick in. But its efficacy also depends on how accurately infectious disease centers worldwide forecast which strains are expected to circulate in the coming year. And then those strains can mutate.

Although the flu shot confers immunity at all ages older than 6 months, it can be less complete in people older than 65. Depending on many factors, the shot’s effectiveness in a given year can range from 40% to 60%.