After 225,000+ COVID-19 deaths, how can health stakeholders avert a twin-demic this fall?

By Asif Dhar, M.D., US Life Sciences & Health Care leader, Deloitte Consulting LLP

It seems we are nearing halftime in our fight against COVID-19, and we are all feeling fatigued. And the second half of this battle could be fraught with new challenges as a formidable player—influenza—comes off the bench. At this point in the game, however, we know which strategies are most effective against both COVID-19 and the seasonal flu. In addition to social distancing and hand washing, we’ve learned that masks can reduce virus transmission rates. We also know that the influenza vaccine is a powerful weapon against seasonal flu.

We crossed two bleak milestones in September—200,000 confirmed deaths in the US related to COVID-19 and 1 million deaths globally. Those numbers are now rising more quickly than they have since the spring and could nearly double by the end of the year, according to some estimates.¹ On October 26, the US reached its highest seven-day average for COVID-19, a rate not explainable by increased testing.

Since this pandemic began, science and data have taught us a lot about the virus and how to limit its transmission. We now know, for example, that wearing masks can significantly reduce transmission when combined with hand washing and social distancing.² Communities that have adhered to those protocols have been able to minimize the spread of the virus.   

Last month, I drove my eldest daughter to Providence, Rhode Island where she will begin the next phase of her life…as a college student. Sending a child to college is always difficult on the parents, but it’s especially challenging in the middle of a pandemic. On the ride home, it dawned on me that my daughter and I were no longer in the same pod. For the last eight months, our family adhered to public health guidance and relaxed social distancing at home. My daughter in now part of a different pod and she and her hall-mates will have to navigate the ongoing infection risks. 

What worries me is what is to come. With colder fall weather, COVID-19 transmission rates are likely to accelerate as indoor gatherings increase. This could also lead to a flu season like no other. A combined flu and COVID-19 pandemic could wreak havoc on our public health system and put our children and the rest of us at risk.

A bad flu season could give COVID-19 the edge

This year’s flu season will overlap with ongoing efforts to contain the transmission of COVID-19, and confirmed cases of influenza have already begun to emerge. A bad flu season, or even a moderate one, could crush an already fragile public health apparatus and result in more lives lost. Life sciences and health care stakeholders, including hospitals and health systems, clinicians, health plans, pharmacies, public health organizations, and government officials, should take steps now to boost vaccination rates among their employees, their patients, and the public. Along with helping to keep people out of doctors’ offices and hospitals, an effective flu-vaccination program can help set the table for successful COVID-19 vaccination campaigns.

Building a strong flu-vaccination program could be challenging. Last year, fewer than half of all US adults (45.3%) got a flu shot.³ Many people don’t get vaccinated because they don’t see it as a priority or view it as an inconvenience. Some people are unwilling to get a flu vaccine because they don’t think it works or they falsely believe it has disproportionate health risks.

But there are also real reasons some communities distrust vaccines, trials, and public health interventions. In the 1930s, for example, the government recruited hundreds of Black men where doctors knowingly allowed syphilis to progress without treatment.⁴ The Tuskegee Study is one of many factors that contributes to mistrust among Black communities in America. There are also challenges with access that exacerbate this mistrust. Last year, just 39% percent of Black adults received the flu vaccine, compared to 49% of white adults.⁵ In an effort to improve trust, the National Medical Association recently formed an independent taskforce of Black physicians who will review decisions about potential COVID-19 vaccines.⁶

A disproportionate number of Americans consume news and information via social media. Could these platforms be used to communicate, in simple language, the importance of flu vaccines and the science behind it? People tend to trust their social networks. Teaming social influencers with public health professionals could help make healthy behaviors as viral as the virus we need to combat. In a recent blog post, my colleagues Greg Szwartz and Sarah Thomas noted that social media has had an enormous influence on shaping the beliefs and behaviors of this generation. Tools that were created to help us stay connected are sometimes used to drive us apart through conspiracy theories and partisan discussions.

The flu vaccine is far from 100% effective, which can confuse the public. It’s true that over the past decade, flu vaccines have averaged 44% efficacy rate, according to data from the US Centers for Disease Control and Prevention (CDC).⁷ Even that level of efficacy can dramatically decrease community spread, but it won’t be as effective unless the broad population is inoculated. Case in point: During the 2018-2019 flu season, CDC estimates vaccination prevented 3,500 deaths, 58,000 hospitalizations, and 2.3 million medical visits. Among older adults, the vaccine reduced hospitalizations by an average of 40%. One CDC study estimated that increasing flu vaccination coverage by just five percentage points could prevent between 4,000 and 11,000 hospitalizations.⁸ Increasing vaccination rates can be incredibly difficult.

Despite overwhelming evidence to the benefits of vaccines, adoption rates tend to be low. Our brains are not great at evaluating population-risk as opposed to personal-risk. I don’t believe people choose not to be vaccinated because they are selfish. I think they simply don’t understand the benefit, and we collectively need to explain it in a way that makes sense to specific groups.

Can we stop a twin-demic?

US Surgeon General Jerome Adams recently warned that this will likely be the “most important flu season of our lifetimes."⁹ Every preventable case of flu, he noted, could be confused with COVID-19. Anyone who is sick with the flu, which often includes a fever and cough, might wonder if they have COVID-19 and get tested. This could further strain a public health system that continues to struggle to keep up with demand for tests. Testing remains one of our most powerful tools to keep COVID-19 from spreading. While some organizations have successfully boosted their testing capacity, adding an outbreak of influenza could place such high demand that capacity increases wouldn’t keep up.  

Deloitte’s Testing Coordination Center (TCC) connects participants with data about the supply of COVID-19 diagnostic tests and the demand for them. Our most recent data indicates that around 1 million tests are being conducted each day. Demand for tests is likely to increase further if millions of flu cases present from December through March. However, any stress on the testing apparatus could make it less effective. Furthermore, additional clinical demand on retail and ambulatory clinics and hospitals could place additional demands on clinicians and facilities that are already strained. Finally, the social impact of businesses quarantining suspected cases and the impact to businesses and families could be profound.

Making flu vaccines convenient could help

I just got a flu shot last week at my physician’s office. Many of my friends got vaccinated at their grocery store or pharmacy. This year, public health organizations, medical groups, and employers are coming up with creative ways to make sure everyone has access to a flu shot. Here are a few examples:

• Drive-thru flu shots: The COVID-19 pandemic prompted the Fond du Lac County (Wisconsin) Health Department to set-up three free drive-thru vaccination sites to improve immunization rates among children.¹² In New York state, the Monroe County Department of Health teamed up with a local pharmacy chain to offer drive-thru flu shots.¹³ Similarly, the VA Medical Center in Topeka, Kansas recently set up a drive-thru vaccination site for veterans.¹⁴
• Mobile clinics: In Arizona, Mesa Public Schools teamed up with the Mesa fire department to run a free vaccination clinic at shopping malls during the fall and winter months.¹⁵ In California, Sharp Coronado Hospital will offer free flu shots outside during its annual Community Flu Clinic.¹⁶
• Use of public figures: In August, Michigan Governor Whitmer (D) received her flu shot during a televised press conference—part of the Michigan Department of Health and Human Services’ statewide media campaign, which seeks to vaccinate 1 million more people this year compared to last year.¹⁷

Could the fight against COVID-19 lead to a milder flu season?

The response to COVID-19 appears to have had at least one positive side-effect. Six countries in the southern hemisphere—Argentina, Australia, Chile, New Zealand, Paraguay, and South Africa—have fundamentally eliminated the flu this year. Part of the reason for this has to do with communication from public health officials. The precautions we’ve been taking to reduce the spread of COVID-19—social distancing, mask-wearing, hand washing, working from home, limiting travel, and staying away from large gatherings—are also effective in preventing the spread of the flu. Case in point: According to Deloitte’s Simulation Modeling and Resourcing Tool (D.SMaRT), US counties that had a mandatory mask-wearing policy in place were 6% less likely to experience a COVID-19 outbreak when compared to similar counties without such a policy. D.SMaRT runs millions of simulations at the county level that consider mask mandates combined with data about the mobility of the population based on smart-phone data. County-level simulations can also be generated to show that stricter distancing efforts could help regions counter infection spikes and reduce hospitalization rates.

But understanding the data and the science is not enough. There are serious gaps between the reality (data and science) that are accessible to people, and the perceptions they have about vaccination. Public health messages should address the way humans make decisions (e.g., with emotion, over-confidence, and hyperbolic emphasis on the present versus the future). An effective, behavioral-science-based, communications campaign could reduce incidence of flu in the Northern Hemisphere and decrease demand for COVID-19 testing. While social media can be weaponized to sow the seeds of doubt, it also could be weaponized for the greater good. Social influencers and modern communication tools can and should be used to educate the public and encourage people to get a flu vaccine.

Ensuring victory over COVID-19 and the seasonal flu will likely require individuals and communities to rally together and continue to employ the strategies we know are effective.

Half-time is just the right moment in to reflect on what works, what lies ahead, and how to get to the endzone together. This is not the time to lose hope. I am worried about my oldest daughter and her college pod. Will they protect themselves, their classmates, and their teachers by getting a flu shot? If we all do what we can we can, get a flu shot, wear masks when in public, and socially distance, science makes it clear we can avoid a twin-demic. We can avoid a catastrophic hit to our public health system and pave the way for a stronger recovery and think of ways to thrive so this never happens again.

Endnotes

^{1.        Model updates, Institute for Health Metrics and Evaluation, September 17, 2020}

^{2.        COVID-19: How much protection do face masks offer?, Mayo Clinic, August 20, 2020}

^{3.        Flu Vaccination Coverage, United States, 2018–19 Influenza Season, CDC, September 26, 2019}

^{4.        US Public Health Service Syphilis Study at Tuskegee, CDC, March 2, 2020}

^{5.        2010-11 through 2019-20 Influenza Seasons Vaccination Coverage Trend Report, CDC}

^{6.        Not trusting the FDA, Black doctors’ group creates panel to vet Covid-19 vaccines, STAT, September 21, 2020}

^{7.        US health officials urge influenza and pneumococcal vaccination amid COVID-19 pandemic, National Foundation for Infectious Diseases, October 1, 2020}

^{8.        Flu vaccination coverage, United States, 2018–19 influenza season, CDC, September 26, 2019}

^{9.        Experts, organizations team up to reduce risk of 'twindemic' with COVID-19 and flu, KSTP.com (ABC News), September 19, 2020}

^{10.     Rapid scaling up of COVID-19 diagnostic testing in the US, The NIH RADx Initiative, The New England Journal of Medicine, September 10, 2020}

^{11.     Trump Administration will deploy 150 million rapid tests in 2020, US Dept. of Health and Human Services, August 27, 2020}

^{12.     Press release (seasonal influenza clinics), Fond du Lac County (Wisconsin) Health Department}

^{13.     Press release (flu), Monroe County, New York}

^{14.     Press release (drive thru flu clinics for veterans), VA Eastern Kansas Health Care System, August 24, 2020}

^{15.     Press release (Mesa Fire and Medical Department supports monthly immunization clinics and are back in service!), Maricopa County Community Health Department}

^{16.     COVID-19 and flu shot update from Sharp Coronado Hospital, The Coronado Times, September 16, 2020}

^{17.     Michigan announces ‘facing the flu together campaign, WNEM (CBS News), August 25, 2020}

^{18.     The southern hemisphere skipped flu season in 2020, The Economist, September 12, 2020}

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