Influenza vaccinations are lagging behind what doctors would like to see during Michigan's first two months of flu season, leading some experts to worry that the conditions are ripe for a "twin-demic" with COVID-19.
Vaccine hesitancy could lead to 'twin-demic' of flu and COVID-19
"It's one of the things that I worry about in this phase of the pandemic," said Dr. Natasha Bagdasarian, the state's chief medical executive. "As a physician, I worry that (COVID-19) is still causing disease, morbidity and mortality, but people either could get infected with multiple respiratory pathogens at the same time."
Bagdasarian, an infectious disease doctor who recently succeeded Dr. Joneigh Khaldun, who left for the private sector, said people contracting COVID-19, influenza and respiratory syncytial virus (RSV) could lead to more severe complications.
Michigan's COVID-19 hospitalization rate is again creeping up and now is at six-month highs, according to the state Department of HHS. As of Friday, 2,713 adults and 49 children were hospitalized with confirmed cases of COVID-19s. At least 638 adults are in the ICU and 350 are on ventilators, according to state data.
The overwhelming majority of patients hospitalized with COVID-19 are unvaccinated, state officials said.
"What sort of burden does it place on the healthcare system and (hospital) ICUs if they are overwhelmed by COVID and with people with severe influenza, severe RSV and COVID," Bagdasarian said. "It then makes it harder to take care of patients with other medical problems."
Many physicians in Michigan are encouraging everyone aged 6 months and older to get a flu shot this fall as well as a COVID-19 vaccine for those 5 years old and up.
"We're trying to really make it a clear message that it's important to pay attention and get the flu vaccines this year," Dr. Jim Forshee, chief medical officer with Grand Rapids-based Priority Health. "We're really encouraging people also get the COVID vaccine or boosters."
Forshee said people's urge to mingle this year with the holidays coming as many have been vaccinated and infections dropping during the summer could cause a spike in COVID-19 after the holidays. He said he hopes people mask up, wash hands and social distance again this winter.
Flu avoidance suggestions
Doctors advise taking a few steps to help prevent the flu from spreading:
- Get influenza vaccination
- Wash your hands often with soap and water or an alcohol-based hand sanitizer.
- Avoid touching your eyes, nose or mouth.
- Avoid close contact with sick people.
- Get plenty of sleep and exercise, drink plenty of fluids, and eat healthy food.
- Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
- If you are sick, stay home for at least 24 hours after your fever is gone without the use of fever-reducing medicine.
So far this year, only about 20 percent of the state's 10.1 million population, or about 2 million people, are currently vaccinated for influenza, according to state flu data. At this time in 2020, flu vaccinations topped 3.4 million doses, or 34 percent of the state's adult population.
With the state's COVID-19 two-dose vaccination rate standing at 54 percent and the flu vaccination rate at 20 percent, the conditions are ideal for the beginning of a twin-demic, several experts said. Vaccination rates are much less than the 80 percent to 90 percent range that experts say offers protective "herd immunity."
"The goal is 4 million (flu) vaccinations. It's not a projection because, certainly, we are not keeping pace with where we were in previous years," Bagdasarian said.
Forshee said Michigan's flu vaccination rate is too low.
"If we physicians had our way, we'd like everybody that's going to get their flu shot to a patient by the end of October. It would just make a lot more sense. We require our employees to get it and we have a multi-pronged approach to recommend our members get it," Forshee said.
For example, Priority Health members receive text messages reminding them to get flu shots. During routine phone calls for prescriptions or benefit questions, case managers "are actively promoting flu vaccines and, when appropriate, promoting COVID vaccines."
Forshee said he also is concerned about a potentially worse flu season. He said he isn't sure about a twin-demic, but worries because last year's flu season was so mild, a resurgence is a real possibility.
"Because the flu was at historic lows last year and we've got a lot of people who don't have that normal immunity you build up from either getting the flu or the vaccine, the risk is a little bit higher than usual that we could have a significant flu season," Forshee said.
In Michigan, flu-like diseases and influenza totaled 426,418 in 2018, dropping to 355,394 in 2019 and down to historic low levels of 226,853 in the pandemic year of 2020. So far, 2021's numbers stand at 49,631.
Forshee said much of that decline was due to social distancing, mask-wearing and hand-washing practiced in the state to prevent the spread of COVID-19.
Dr. Steve McGraw, chair of emergency medicine at Providence-Providence Park Hospital, said few patients so far have presented with flu symptoms at Ascension Health's hospitals in Southfield and West Bloomfield.
Symptoms of the flu, which are similar in the beginning to COVID-19, include fever, cough, sore throat, aches of all types, a runny or stuffy nose and fatigue. Other symptoms could include nausea and diarrhea.
McGraw, who practices with Farmington Hills-based Independent Emergency Physicians, said he expects to start to see flu season begin in earnest after Thanksgiving and pick up in late December. Seasonal flu numbers are highest from January through March.
"I don't expect it to be a horrible flu season because I think people are still being more careful with their hygiene and staying home when they are sick," he said. "I suspect we'll have more COVID than we do now. But nothing like last winter. If for no other reason than people in the more densely populated areas are by and large vaccinated."
But he does believe there will be more flu this season than in previous years because so few people were exposed to the influenza virus last season. He said people won't have the potential added defense against illness that natural immunity or vaccinations can bring.
While the flu vaccination will not protect against COVID-19, it can reduce the impact of flu-related respiratory illnesses, hospitalizations and deaths, studies show. Because it is possible to have the flu and COVID-19 at the same time, doctors anticipate that patients with co-infection will likely be sicker and have poorer outcomes.
In a new study, researchers at the University of Miami Miller School of Medicine have found that the flu vaccine may provide vital protection against COVID-19.
Researchers looked at medical records of 74,754 patients around the world and found the annual flu shot reduces the risks of stroke, sepsis and deep vein thrombosis in patients with COVID-19. Patients with COVID-19 who had been vaccinated against the flu were also significantly less likely to visit the emergency department and be admitted to the intensive care unit, according to the study in the medical journal PLoS (Public Library of Science).
Each year, 5 percent to 20 percent of the population nationally get the flu each year — and some 33,000 people die — at a cost of $11.2 billion a year in direct medical expenses to individuals and businesses, according to the Centers for Disease Control and Prevention.
Getting the annual flu vaccine is an especially important preventive step. Adults 65 years and older are at a much higher risk of developing such serious complications as heart attacks and stroke from the flu, like pneumonia and hospitalization, compared to younger adults, said the National Foundation for Infectious Diseases.
On the other hand, the Journal of the American Medical Association estimated that COVID-19 cost the U.S. $16 trillion through the fall of 2020 when treatment, premature deaths, long-term complications and lost economic output are factored.
To minimize the chances of a twin-demic, Bagdasarian called on the public to get flu shots and coronavirus vaccines for those still unvaccinated. The CDC has said it is safe to get both shots at the same time.
"We're in a difficult intersection in time here in Michigan because No. 1, we are already at high rates of COVID transmission around the state. It is much higher than at this exact time last year," Bagdasarian said.
With the weather getting colder and heading into holiday season, Bagdasarian worries about greater community spread of COVID-19.
Bagdasarian said she still is concerned that too few people are getting flu shots while COVID-19 infections are still spreading.
"I wonder how much is being driven just by pandemic fatigue and people not wanting to talk about infectious diseases anymore," she said. "I also think there are people who are not as excited about social distancing and wearing a mask this year."
A potential bright spot: The pandemic has increased willingness of people to stay home when sick rather than powering through an illness and potentially spreading it to others, Forshee said.
To boost flu and COVID-19 vaccination numbers, McGraw said physicians need to make the flu shot a priority in their messaging.
"I've had patients come in and I tell them they don't have COVID but they could have flu and we can test them for that," he said. "I remind them this is a great time to get a flu shot because it is getting colder and they will be inside for the holidays."
McGraw said those people who say they don't generally get flu shots sometimes reconsider when they see how seriously ER staff treat infectious diseases.
"We separate patients who may have COVID or other respiratory illness when they arrive," he said. "When they see we're all wearing masks and how careful we are, some say, 'Yes, I'm going to reconsider and get vaccinated.'"
Forshee said Priority Health's data shows older people are getting vaccinated for coronovirus and influenza at much higher percentages than those younger. Priority's Medicare population is above 80 percent vaccinated compared to 40 percent in the general population.
"We know that younger individuals have such good immune systems and they respond so well to vaccines, but we also know that young young people transmit the virus and put others at risk," Forshee said. "Young people also get COVID and the flu themselves, not as severely, but they do get it."
A recent survey of more than 1,000 U.S. adults commissioned by the National Foundation for Infectious Diseases found that while more than 60 percent of Americans agreed the flu shot was the best way to prevent flu deaths and hospitalizations, 44 percent said they were unsure about or not planning to get a flu vaccine this year.
The top reasons cited for flu vaccine hesitancy by surveyed adults is low effectiveness and they are also worried about side effects. Studies show that the flu vaccine reduces the risk of flu illness by 40 percent to 60 percent, according to a recent CDC report.
"People tell me all the time that they are healthy and don't need vaccines," McGraw said. "It's individual. There's people that get a flu shot every year and have no problem with it. For some reason, they have been very reluctant to get the COVID vaccine. A lot of the reasons are hard for me to understand completely."
McGraw said some political leaders are intentionally misleading the public.
"COVID vaccines are demonstrably safe and effective, and in fact, statistically, even more effective than flu shots, and we have a long history with those," he said. "Getting a vaccination will largely protect people from significant or life threatening disease. Not being vaccinated, unfortunately, could lead severe prolonged illness, disability or even death."
This story first appeared in our sister publication, Crain's Detroit Business.
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