Solving the Flu-Meets-Coronavirus Crisis (II)

The Fallback: What we can do now

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Despite officials saying “everyone” should get a flu shot, millions of elderly and other people highly vulnerable to covid-19 find the usual places flu shots are given, such as pharmacies and clinics, too risky and won’t get vaccinated.

What’s needed to avert an even more acute public health crisis when flu season overlaps the coronavirus pandemic is a way to protect seniors and others against the flu without increasing their risk of contracting covid-19.

The best flu-shot solution in the immediate future would be:

- traditional flu shots administered outdoors (20 times less transmission risk than indoors), in a drive-through setup similar to those by which coronavirus tests or food banks have been operating,

- organized to provide maximum protection from infection,

- and catered to serving seniors and other high-risk individuals.

The same considerations for most safely providing flu vaccinations will apply to the provision of covid-19 vaccinations, for the same reasons.

Recap of the Problem

When the flu season kicks off in November, it is now evident that the coronavirus pandemic will still be posing a serious threat to the roughly 50 million Americans age 65 or greater, as well as millions of others with “comorbidities” such as high blood pressure, obesity, asthma, or diabetes. New covid-19 cases in the United States, having surged in the summer, are now at a level still notably higher than in the spring, and are rising again. Experts agree that the covid-19 pandemic will persist through the coming flu season and extend to late 2021.

The increased urgings from public health officials that “everyone” get their flu vaccination mostly ignore the reality that going out to a clinic or pharmacy to get a flu shot poses a possibility of coronavirus contagion that many seniors and others at high risk of infection are afraid to take. In public education we have long recognized that not all students are equal — that some have “special needs.” But when it comes to flu vaccination, public health leaders often have not seemed to recognize that seniors and others at high risk of infections also have special needs.

Even in normal times, usually no more than half, or even less, of the total US population will get a flu shot. And while normally the elderly are more likely than average to get vaccinated, the fear factor associated with the covid‑19 pandemic is likely to invert the normal relationship, with seniors less likely than average to accept flu vaccination that exposes them to close contact with other people. (Note too that a stubborn anti-vaxxer movement keeps trying to discourage people from accepting any kind of vaccine.)

From a behavioral science perspective, there is little reason to believe that mere exhortation or cajoling is likely to overcome the high anxiety millions of elderly and other people feel about the coronavirus infection risk they associate with the typical way flu vaccine is administered. (If just telling people what to do was sufficient to alter behavior, 95% of Americans would be wearing masks.)

The lesson that distance protects against infection has become ingrained in seniors and others at high risk as well as the public generally. Among the venues that self-quarantining seniors and others have learned to avoid are healthcare facilities. Down sharply in 2020 compared to earlier years have been: visits to emergency rooms (down 42%), cancer screenings (down 90–95%), emergency calls for heart attacks (down over 30%), and vaccinations of children (down 96%). The wide provision of telehealth services, allowing visits by video link or telephone, while making healthcare still accessible has also reinforced the notion that in-person care is best avoided. Nearly half of independent primary care doctors who responded to a survey reported that in-person visits to their offices were down 30–50% in 2020.

What’s needed to avert an even more acute public health crisis is a way to protect seniors and others against the flu without increasing their risk of contracting covid-19.

Part I of this essay observed that several technological fixes that are in various stages of research and development could make it possible for people to self-administer vaccination (SAV) for influenza, or other diseases, at home. And it recommended that the same kind of accelerated effort devoted to development of coronavirus vaccines and therapeutics should be devoted to creating a safe and effective SAV solution. But even with that kind of boost, it seems unlikely that a viable SAV solution would be approved and produced before the first quarter of 2021.

In the absence of a means to self-administer flu vaccination at home, what might be a fallback option for protecting seniors 65+ and other people with high risk factors for coronavirus infection from contracting influenza?

When Flu Meets Coronavirus

To answer that, first, it will help to consider what risks may be posed by the overlap of the ongoing covid-19 pandemic with the coming flu season in the United States and elsewhere in the northern hemisphere. A recent JAMA report addressing that question concluded that there is still much uncertainty. Because the discovery of the novel coronavirus is less than a year old, research about its behavior and health impacts is still sketchy and evolving. And despite many decades of experience with and study of influenza, because flu viruses continually mutate and new flu strains periodically migrate from animals to humans, there still is much mystery about the flu. When the two are concurrent — which happened in China when covid-19 first emerged last fall and in the southern hemisphere’s recent flu season which began around May — the uncertainties of each disease are multiplied.

For instance, since the coronavirus is significantly more infectious than influenza, seniors and others sheltering and practicing other measures to avoid covid‑19 infection (washing hands, wearing a mask, and so on) would seem to be even less likely to contract the flu. And in fact, countries in the southern hemisphere have reported markedly fewer influenza cases during fall and winter than usual.

While that seems to be encouraging news, many of those countries have applied pandemic containment measures much more stringently and persistently than the United States has, and also have had higher rates of flu vaccination. And the flu season in the southern hemisphere has been unusually mild even in covid-19 hotspots such as Brazil. Given that, epidemiologist Michael Osterholm has cautioned that we cannot safely assume that a similarly mild flu season is going to happen in the northern hemisphere. [NB: As of January 2021, the number of flu cases in the United States is also down sharply from past years.]

It’s not even clear how many people contract both diseases when the covid-19 pandemic and flu season are concurrent. In places where the two diseases overlapped, some reports find only about 1% of covid-19 patients also had the flu while some other reports found 10% or more had both infections.

If people are simultaneously infected with coronavirus and influenza, it does seem to make treatment more complicated and maybe more difficult. Because the symptoms of flu and coronavirus infections can be similar, the JAMA report emphasizes that quicker and more readily available testing is needed to distinguish what is causing the patient’s illness, since the two diseases have different treatments. It’s also uncertain whether vaccines or therapeutics for flu might make covid-19 infections better or worse, and vice versa.

The other key conclusion of the JAMA report is that the possible convergence of a severe influenza season and a large surge or second wave of the coronavirus pandemic could overwhelm hospitals. It is that daunting prospect that particularly has driven public health leaders to implore “everyone” over the age of six months to get a flu shot.

The Fallback Solution

Getting back to the key question above, since an SAV solution is unlikely to be available within the next six months at least, what could be a fallback option for protecting seniors 65+ and other people with high risk factors for coronavirus infection from contracting influenza?

Option 1: Skip the flu shot

One obvious solution is to just skip the flu shot. As noted earlier, the same mitigation measures that help stem the spread of covid-19 — particularly isolation as well as distancing, hand washing, disinfecting, and masks — also block the spread of influenza since the two infections are transmitted in similar ways, mainly by air. Since seniors and other high-risk individuals have a compelling reason to continue those mitigation practices to avoid coronavirus infection, they plausibly may not need to do anything else to avoid catching the flu, since the coronavirus is significantly more infectious than influenza normally is. To the extent the continuation of those mitigation measures at a national level result in a significantly milder flu season, the risk to the individual of catching the flu is also much reduced.

Strictly self-quarantining can reduce the risk of catching flu, covid-19, or another infectious disease to near zero. For people who can do that, it may be the least risky option. A notable problem with that strategy though is that circumstances may arise to compromise or break the quarantine. Disasters of one sort or another — storms, floods, earthquakes, fires, and such — may force people to leave their homes. Emergency management protocols have been adapted to the pandemic so, in particular, evacuees now are placed in individual hotel rooms instead of being directed to group shelters. Still, close interaction with other people is more likely to occur, and isolation will be compromised.

Less dramatically, mundane household failures — such as a burst water pipe, a broken furnace, a burned-out refrigerator or other appliance —may require one or more people to come into the home to repair or replace what’s broken. And old people, who usually have comorbidities besides age, or younger people with similar health issues, are prone to noninfectious illnesses that may need acute care, such as heart attacks, strokes, or seizures, as well as all sorts of accidents.

Such untoward incidents that break the self-quarantine may expose the elderly or infirm to coronavirus or influenza or both. As yet there is no vaccine or sure-fire treatment for covid-19, but there is a vaccine for influenza (also some possibly helpful treatments).

Option 2: Get a flu shot

So the second option, getting a flu shot, might be considered beneficial, if the risk of exposure to the coronavirus could be reduced to zero or near-zero (keeping in mind that people vary in their personal tolerance for risk).

For seniors and other high-risk people afraid of exposure to coronavirus, the best flu-shot solution in the immediate future would be:

• traditional flu shots administered outdoors, in a drive-through setup similar to those by which coronavirus tests or food banks have been operating,
• organized to provide maximum protection from infection,
• and catered to serving seniors and other high-risk individuals.

A web search revealed that a handful of drive-through flu shot clinics have started in several locations scattered around the United States. So the concept is clearly possible. But many more such clinics are needed — not only to be available everywhere in the country, but to be offered at multiple times and multiple locations in each community. The clinics should be staged not just at the beginning of the flu season, but several times over the span of the season.

Note that at least some of the existing drive-through flu shot clinics only provide the standard flu vaccine, not the high-dose quadrivalent vaccine recommended for people 65 and older. To give priority to elderly people the right vaccine must be provided by the drive-through clinics.

Cars line up for covid-19 testing near San Antonio (Press-News)

Public health experts recommend that seniors and others at high risk should not get their flu shots too soon, but should wait until late October. Because the protection from a flu vaccination is thought to last about six months, the intent is to have it cover the bulk of the typical flu season, from November to April. However, even in normal times, over half of Americans and a third of American seniors don’t get flu shots at all. So it is not too late to plan and implement the large number of drive-through flu shot clinics needed.

The reason the flu shot clinics should be outdoors is simple: We know that just being outdoors reduces the risk of transmission of coronavirus (or influenza or any other airborne pathogen). Exactly how much being outdoors reduces the risk is uncertain, and depends on multiple variables. But experts believe the difference is substantial. Julia Marcus, an epidemiologist at Harvard Medical School, has suggested that, other things being equal, virus transmission could be about 20 times less likely outdoors compared to indoors.

Drive-through rather than walk-up clinics are required to best serve the needs of seniors and other people at high risk. Cars provide a significant barrier to transmission, and a queue of cars inherently spaces people much farther apart than what commonly happens when standing in line. (And for many seniors, standing in line is just too onerous.)

Ensuring maximum safety would require that the person administering the inoculations be tested for covid-19. To assure that shot-givers are not infected, and not able to transmit the coronavirus, they should be tested daily and results of the tests—CDC guidelines say that test results for healthcare personnel should be delivered within 24 hours — should be negative before they are allowed to administer inoculations.

Unfortunately, it is well known that over nine months after the first case of covid-19 infection was confirmed in the United States, the country’s testing capacity is still inadequate. Even professional (and some college) sports teams — which have urgent economic interests in keeping their players, coaches, and other staff healthy and performing — are testing their athletes and staff members only every other day, using expensive and slow PCR tests that are hard pressed to yield results within 24 hours. Meanwhile the United Kingdom has rolled out advanced testing technology that does not require samples to be sent to a lab, does not require expert staff to operate, and can deliver reliable results in 90 minutes or less. The US testing problem is not unsolvable; the country simply has lacked the political leadership needed to solve it.

Beyond the testing requirement, the person administering the flu shot should make maximum use of personal protective equipment (PPE) and practice all proper hygiene protocols. The “personal” in PPE may be a bit misleading. While it is primarily intended to protect the healthcare worker from infection, when properly used it also helps protect patients. Unfortunately (again), because there still are shortages of PPE in the United States, we can’t take it for granted that all healthcare workers will be properly equipped. For maximum protection of seniors and other highly vulnerable patients, full use of proper PPE should be required.

Among other things, that means persons administering flu shots should wear medical-grade N95 respirators (no exhale valves), not just surgical masks. Research indicates that N95 masks block 95% or more of virus-size particles, while the figure for surgical masks is about 80%. To further protect healthcare workers, some existing drive-through flu shot clinics also require patients to wear face masks. While for epidemiological purposes mask-wearing is intended mainly to reduce transmission of virus from the wearer to others, it also helps to some extent to protect the wearer from inhaling virus-laden droplets. So having patients wear masks increases safety all around and should be required. Drive-through flu shot clinics should be prepared to provide masks to people who show up without them.

Among the array of required hygiene practices for the drive-through clinics, the persons administering the flu shots should clean and disinfect their hands and change gloves before each shot.

Drive-through clinics, especially those catering to seniors and other high-risk persons, should require appointments. Without appointments, there is a significant potential that people seeking vaccinations could wait in line for hours only to be turned away when vaccine or other necessary supplies run out. That possibility only adds to the anxiety seniors and others already feel about going to get a flu shot — anxiety that the drive-through program is intended to assuage.

At least some of the drive-through clinics offered should be limited to seniors and high-risk individuals only.

To summarize the requirements of a drive-through flu shot clinic:

1. Flu shots should be administered outdoors in a drive-through setup — again, because the risk of coronavirus transmission is about 20 times lower outdoors than indoors.
2. Drive-through flu shot clinics should give first priority to seniors and others at high risk. (But outdoor vaccination should eventually be the default option for all population cohorts under pandemic conditions.) Priority to seniors means having the high-dose vaccine recommended for people 65 and older.
3. Drive-through clinics should be offered at multiple locations and multiple times over the course of the flu season, in every community in the country.
4. Infectious disease experts say that seniors and others at high risk should aim to get their flu vaccinations not sooner than late October. (Because the flu vaccine wears off after about six months, the experts’ concern is that the vaccination should last through most of the flu season.)
5. Ensuring maximum safety would require that the person administering the inoculations be tested for covid-19, and have a negative result.
6. Healthcare personnel administering the flu shots should make maximum use of personal protective equipment (PPE) — including medical-grade N95 masks — and practice all proper hygiene protocols, including hand washing and changing gloves before each shot.
7. Patients should wear masks when receiving shots; masks should be provided to those who don’t have them.
8. Drive-through clinics, especially those catering to seniors and high-risk individuals, should be provided by appointment only.
9. To eliminate unnecessary contact, any required paperwork — such as for insurance — should be able to be submitted remotely before the clinic. (Insurance cards or other ID can be shown through closed vehicle windows.)
10. The drive-through vaccination clinics should be not just offered but recommended as part of an overall pandemic mitigation strategy. (Anything that reduces the risk of infection for anyone benefits the whole community by curtailing the spread of both the coronavirus and the influenza virus.)

Implications for public health

Public health authorities may be undercutting achievement of their goal to protect and improve public health by simply saying, as they mostly have been, “Everyone should get a flu shot.” Different cohorts of the overall population bring different risks, conditions, and emotions to the choice of flu vaccination.

Keep in mind that the effectiveness of flu vaccine varies considerably from season to season ranging between 10% and 60% effective at preventing the flu infection. Even if the vaccine fails to prevent infection, it may reduce the severity and duration of flu symptoms. The flu season has to be underway for some time before there are enough data to know how effective the current vaccine is.

Manufacturers of flu vaccines start working on production of the next season’s vaccine around six months in advance, based on estimates, guesses really, from the World Health Organization of which strains of influenza are most likely to be prevalent eight months in the future. The difficulty of that forecasting is compounded by the continual mutations of flu viruses. So when authorities urge people to get a flu shot before the season even begins, the individual trying to choose between no-shot and flu-shot is vexed by not knowing whether the flu shot will really convey any significant benefit, and comparing that to the possible risk of contracting a more deadly infection by going to the pharmacy or supermarket, or other venue where the shots are given.

For seniors and other people with comorbidities, the question of what to do is thus more complicated, confusing, and frightening than blithe “just do it” exhortations seem to recognize. (The situation is not helped by political ferment in an election year that is shaking public confidence in what scientists, doctors, and government health agencies are saying.) As is too often the case, physical health is getting far more attention than mental health, even though surveys indicate that a third or more of the public is suffering from depression and anxiety. Note too that anxiety stimulates stress hormones that suppress the immune system, increasing vulnerability to infection. So anything that reduces the number of things that seniors and others at high risk have to worry about confers a collateral benefit to public health. Under the circumstances a bit more visible dose of empathy would help.

In particular, it would help to recognize that the elderly and infirm have some reasons to be afraid of leaving their homes or contacting other people, even for medical care. That high-risk group accounts for a large majority of the cases of serious illness and deaths from covid-19, and from influenza as well. That is why they face a much higher risk of bad consequences from infections than younger, healthier people do. (That’s not to say that the young and healthy can’t have bad outcomes too — they do, but are less likely to.)

For seniors and others at high risk, the choices of no-shot and flu-shot involve some troubling risk and uncertainty either way. And each entails a real risk of fatality. For public health agencies who clearly prefer the flu-shot choice, doing everything possible to minimize or even eliminate risk — rather than just saying “don’t worry” — is likely to achieve greater compliance and better results.

Finally, there are hopeful signs that safe and effective vaccines for covid-19 will start to become available by January 2021 or even sooner. All indications are that the top priority for initial distribution of the covid-19 vaccines will be, first, healthcare and other frontline workers, and then elderly (65+) and others with health conditions that put them at high risk for serious illness or death. And the same considerations for most safely providing flu vaccinations will apply to the provision of covid-19 vaccinations, for the same reasons. In fact, Bill Gates recently recommended distributing covid-19 vaccine via drive-through clinics similar to those used for coronavirus testing. So getting drive-through flu shot clinics up to speed now will help develop the infrastructure and experience for providing covid-19 vaccinations later.

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© 2020, Lewis J. Perelman. Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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Published 09/20/20. Last revised 1/22/21