COVID-19 pandemic

Get a Flu Shot to Prevent a “Twindemic”: Health experts say vaccinations are more important than ever

“Twindemic” is the trendy buzzword for the nightmare scenario in the medical community right now: seasonal influenza rampaging at the same time as the COVID-19 pandemic, two respiratory illnesses with similar symptoms – fever, headache, cough, sore throat, muscle aches, fatigue – stressing health care resources, especially hospital beds.

“Getting vaccinated against the flu is important every year, but it is particularly important this year because of how important it is that the healthcare system not be overwhelmed,’’ RI Department of Health (RIDoH) spokesman Joseph Wendelken told Motif. “Two of the three field hospitals [set up months ago in RI as reserve to handle demand surge from COVID-19] are ready, should they be needed. We don’t have perfect projections for what the burdens on the hospital system could look like, because flu seasons vary considerably from year to year. We also don’t know how COVID and the flu will impact each other. For example, outbreaks of both virus in the same community would be very concerning. On the other hand, it is possible that some of our infection prevention measures, such as social distancing and mask wearing, will reduce our rate of flu and flu hospitalizations.”

Jason McDonald of the US Centers for Disease Control and Prevention (CDC) told Motif, “Efforts to reduce the spread of COVID-19, such as stay-at-home and shelter-in-place orders, have led to decreased use of routine preventive medical services, including immunization services. Ensuring that people continue or start getting routine vaccinations during the COVID-19 pandemic is essential for protecting people and communities from vaccine-preventable diseases and outbreaks, including flu. Routine vaccination prevents illnesses that lead to unnecessary medical visits and hospitalizations, which further strain the healthcare system.”


McDonald of the CDC emphasized to Motif that the benefits of vaccination accrue to both the public health system and individuals. “For the upcoming flu season, flu vaccination will be very important to reduce flu because it can help reduce the overall impact of respiratory illnesses on the population and thus lessen the resulting burden on the healthcare system during the COVID-19 pandemic. A flu vaccine may also provide several individual health benefits, including keeping people from getting sick with flu, reducing the severity of illness if one does get flu and reducing the risk of a flu-associated hospitalization.”

A spokesperson for the World Health Organization (WHO), who could not be quoted by name in keeping with WHO policy, told Motif, “There are significant concerns with a severe influenza season occurring during COVID-19 pandemic. It will burden already stretched health systems, complicate clinical management and other responses [such as] laboratory testing and contract tracing, as both have similar clinical symptoms, and only laboratory tests can differentiate them.” Asked by Motif what medical interactions there might be between flu and COVID-19, the WHO responded, “No evidence so far to show that infection of one could increase the susceptibility for another. Actually non-specific immune response to one may provide some protection against another for a short time, though unclear how long it could be.”

Screen capture from showing 115 places to get the influenza vaccine for adults 18 years or older within 10 miles of ZIP code 02909 in Providence. (Source: Michael Bilow)

Vaccines are available from doctors, community health care centers, and pharmacies such as CVS and Walgreens, usually at low or no cost typically covered by insurance with no co-pay. The full cost to a completely uninsured patient at a commercial pharmacy would be about $40 for the normal adult flu vaccine and about $70 for the stronger vaccine with adjuvant for age 65 or older, but such patients could also go to community health care centers for free. HealthMap, a national project run by Boston Children’s Hospital in combination with the Harvard Medical School and the CDC, is a web site – – that allows users to find where to be vaccinated against a number of illnesses; a search for providers of flu vaccine suitable for adults 18 years of age or older within 10 miles of ZIP code 02909 in Providence (chosen because it is a known COVID-19 hotspot) returned 115 results. The website allows fine-grained searches, such as locating egg-free vaccines for those with severe allergy.

RIDoH and CDC recommend seasonal flu vaccine for everyone age 6 months or older, unless they have a specific allergy or other unusual medical condition (such as a history of Guillain-Barré syndrome) that precludes it. The US Department of Health and Human Services (HHS) on August 19 issued an emergency directive allowing pharmacists to administer vaccines to children aged 3 to 18. Wendelken of RIDoH told Motif, “Rhode Island pharmacies already have authorization to vaccinate children down to age 9. The HHS declaration allows pharmacies to vaccinate children as young as 3, so they can vaccinate if they want to. At this point, we’re not sure who will.” RIDoH has an active childhood vaccination program with information for parents.

It takes about two weeks after vaccination to achieve full immunity, so it is best to be vaccinated beginning in mid-September but doing so even months later is still beneficial and worthwhile. In a typical flu season, which (in the Northern Hemisphere) runs September to April but peaks December to February, less than half of Americans choose to be vaccinated, despite widespread availability. Wendelken said in RI usually roughly 78% of children between 6 months and 17 years are vaccinated, but only 56% of adults 18 years and older are. In recent years, RI has been one of the states with the best childhood vaccination rates, and only recently made a substantial recovery from a huge drop during April and May due to COVID-19 stay-at-home orders and closure of many health care providers. Wendelken said RI ordered 29% more doses of flu vaccine this year than normal, about 683,000 instead of 530,000. “We are going to be doing more outreach to community partners to set up community located flu clinics this year, and we envision having flu shots available at COVID-19 testing sites for asymptomatic people.”

While COVID-19 is much deadlier (see sidebar), seasonal flu is a major public health threat in its own right. The CDC retrospectively estimated that the relatively mild 2019-2020 flu season resulted in 24,000-62,000 deaths, 410,000-740,000 hospitalizations, 18-26 million medical visits, and 39-56 million infections out of a US population about 330 million. Wendelken said that RI had 1,300 flu-associated hospitalizations during the 2018-2019 flu season, although the 2019-2020 season “was very abnormal because we were encouraging people to not go directly to healthcare facilities unless it was an emergency.”

Many avoid the flu vaccine because they are either under the mistaken impression that “just the flu” would not be so bad, or they believe misinformation about the vaccine itself. The CDC publishes common questions and answers trying to combat such wrong beliefs, explaining that the vaccine cannot cause the flu (“The vaccines either contain inactivated virus, meaning the viruses are no longer infectious, or a particle designed to look like a flu virus to your immune system” and “Side effects of the flu vaccine are generally mild and go away on their own within a few days”). Single-dose packages of flu vaccine do not contain thimerosal, a preservative with ethylmercury, which in any case is different from methylmercury that is of concern for mercury poisoning. Another misconception is that a vaccine is pointless if it is deemed, for example, “only” 60% effective: but that actually means someone vaccinated is almost three times less likely to be infected.

While the flu often is not a severe illness for most people, it can still be debilitating: heightened strict rules due to COVID-19 require anyone with flu or flu-like symptoms to stay home from work or school and isolate in quarantine for about two weeks; the era of going to work or school while sick is over, and doing so while previously regarded as muddling through with a strong work ethic is now understood to be dangerous to others. For essentially the same sub-populations at high risk from COVID-19 – healthcare workers, first responders, pregnant women, those 65 or older, or with underlying health conditions – the risk of bad outcomes from seasonal flu is greater and therefore being vaccinated is especially recommended. Guidance from WHO and RIDoH also considers anyone who lives with or is a caregiver for someone at medically high risk to be strongly recommended for vaccination.

Asked by Motif whether there would be conflict in scheduling production resources between seasonal flu vaccine and an eventual COVID-19 vaccine, WHO responded, “Since March influenza activity is historic low. The predominant virus strains of this coming winter are yet to be seen. WHO will issue recommendation in September on viruses to be included in vaccines for Southern Hemisphere 2021 season [March-October]. Seasonal vaccines are always ordered in advance. We know that [there is] more demand for the upcoming season and manufacturers are meeting the demands. Production platforms for influenza and COVID-19 vaccines are different, therefore negative impact from COVID vaccine development is less likely.”