Transcription:
When COVID-19 and Influenza Collide: Strategies for Managing Two Epidemics

Melanie Cole: The overlap of COVID-19 and influenza has experts in the US concerned. We may soon face two epidemics at the same time, and this combination could precipitate a crisis unlike any other. Welcome to Better Edge a Northwestern Medicine Podcast for physicians. I'm Melanie Cole, and I invite you to listen in, as we discuss managing COVID-19 and influenza season. Joining me is Dr. Benjamin Singer. He's a Pulmonologist and an Assistant Professor of Medicine in the Division of Pulmonary and Critical Care at Northwestern Medicine. Dr. Singer, I'd like to first start with sort of a working definition of the differences. Tell us about the difference between the flu and COVID. Give us some similarities and some differences that you've noticed.

Dr. Singer: So of course, influenza is a virus that causes a spectrum of illness in the respiratory system ranging from very mild, all the way through life threatening pneumonia, similar to what we see with COVID-19. And while COVID-19 has that similar spectrum ranging from very mild or even asymptomatic all the way through life threatening pneumonia and critical illness, it seems to be much more likely to cause that severe type of infection than what we typically are used to with pneumonia from influenza.

Host: Well, thank you for that. So as COVID-19 begins to surge across the nation, what are the most pertinent areas for concern as we enter this flu season, what can physicians and healthcare professionals expect to see if we continue on this current trajectory?

Dr. Singer: Well, historically it's important to remember that influenza causes an epidemic every year. Influenza creates a burden on our healthcare system. Now this year is of course complicated by the unfolding COVID-19 pandemic. And while we have been able in the United States to have areas that can control the outbreak for periods of time, it's quite difficult to maintain very low levels for long periods of time. Like we would need to see over the months of a flu season. Now there are a few things to consider. Some of them are good signs and some of them might be worrisome signs. One of the good signs is that the Southern hemisphere, which of course is in the summer just finishing their summer and finishing their flu season has had a very mild season when it comes to influenza. And a lot of this may be due to social distancing and wearing masks and the sorts of things that we're trying to do in the United States. But of course, if we don't do them, they're not going to be effective. So if we do our diligence with regard to masks and social distancing, we might expect that flu season could be on the lighter side, but the contrast and the worrisome thing is that if we're unable to do those things, we could be facing outbreaks of influenza and COVID at the same time.

Host: So, can having one virus put you at risk for another? Do you have evidence about how COVID-19 might influence the course of a flu outbreak doctor? And to make things more complicated, can having one virus change a person's chance of getting infected with another?

Dr. Singer: Yeah, so there's a lot buried in those questions. So the fundamental thing is, can you have both influenza and COVID-19 at the same time? And the answer is probably yes, we have a few cases of that happening. It is not particularly rare to have COVID-19 and come down with pneumonia from another type of organism that could be influenza, could be a bacteria. And so it can happen. And we see that in our ICU with some regularity. But when we talk about the whole population and how these viruses might influence one another, I think it really comes down to how we as a society, choose to conduct ourselves and how strict we are about wearing masks, social distancing. And the really important thing, which is probably our best way to defend against severe influenza, getting a flu vaccine.

Host: And that's one of the bigger differences, right? In an editorial you authored for Science Advances, you outlined four factors that could influence the severity of the upcoming flu season. Can you walk us through some of these strategies, Dr. Singer?

Dr. Singer: Yeah. The first is the transmission idea. So things that can influence the spread of either of these viruses, and this is what we've been talking about in terms of masks and social distancing, and the like. Of course, vaccination, we have a vaccine for influenza that while not perfectly effective in preventing the vaccine, probably even among people who still get the virus after receiving the vaccine, can mean that they are facing a more mild infection, meaning less likely to come into the hospital or even the ICU. So widespread vaccination against influenza is a very powerful tool to offload the healthcare system while we are still facing a COVID-19 pandemic. Which of course we don't yet have a vaccine against.

Host: More about the seasonal flu vaccine, you've discussed it a few times briefly. Does it have any impact on COVID-19? And you and I were talking about this off the air, why is this so important this year specifically?

Dr. Singer: There is very limited evidence that vaccination against influenza may prepare the immune system to better handle COVID-19, but that remains very unclear. I think the top level headline answer is that the flu vaccine is protective against the thing that it's supposed to protect against, which is of course, influenza. Now the importance of getting the flu vaccine year after year is always evident because of how many people are afflicted with flu and unfortunately die from flu every year. But this year, if you add up the total number of cases of viral pneumonia, and you think about the number that are due to influenza, the number that are due to COVID, we could be facing a very large number. And because we can reduce the number of severe pneumonia cases due to influenza, that really is the reason then to encourage widespread uptake of the flu vaccine.

Host: What a great point. Thank you for making that so very clear. Talk to us more about the co-infection aspect. If they have overlapping symptoms, making diagnosis even more challenging, can you share strategies your team has implemented to distinguish between the two diseases and if even that's important? And address coinfection, what symptoms are most important to note, what are you all doing to distinguish this?

Dr. Singer: So, unfortunately, most of the symptoms that come along with influenza and COVID-19 overlap, so it's fever, cough, shortness of breath, weakness, body aches, and there may be some things that are peculiar to COVID-19 like a tendency to lose one's smell or sense of taste. But beyond that, the only way to know with any certainty, whether this is influenza, whether this is COVID or another respiratory virus is with testing. And so this gets back to the widespread availability of rapid diagnostics to understand if you're a patient in front of you has flu, has COVID, or something else. And the second question you asked was, does that matter. And for mild cases, the treatment isn't going to be very different. It's mostly just supportive care, but it matters in terms of self isolation and not spreading these viruses to others in your household or in your immediate environment. And for more severe cases, these viruses are treated very differently. There are different antiviral medication options for influenza versus COVID. We have evidence that steroid medications may benefit patients with severe COVID-19, whereas they may be actually harmful for patients with influenza when it becomes severe. So particularly when people are coming into the hospital, it's important to make this diagnosis in addition to understanding what other co-infections they may have, if they do get to the point where they are severe enough to need the ICU and be treated for other forms of pneumonia.

Host: Well, I think we certainly have learned a lot. And if flu does outbreak, then people will learn about social distancing and even self quarantine and isolation in that way, which is not something we've really ever given a lot of thought to people go to work, they do what they got to do. If they have a cold or the flu, even though they shouldn't. And in all these years, we shouldn't have been, I think this is going to teach people a little bit different way of dealing with some of this. So what are some of the most critical protocols, rapid diagnostics that need to be implemented in this clinical setting to effectively manage both of these illnesses?

Dr. Singer: Well, that's right. And it really comes down to availability of tests that have a rapid turnaround time so that people can know their status and implement self isolation. And then of course, the contact tracing, which has been unfortunately hampered by a lot of different factors in the United States, but access to rapid testing and sequentially, following people to understand their context is a really important and evidence based way to prevent spread of COVID-19 in particular.

Host: I think it's important that we discuss health disparities, Dr. Singer, and the critical role physicians play in addressing public health concerns. What are your top recommendations for physicians to help overcome disparities for underrepresented and vulnerable populations, especially during this pandemic, because we've learned that they are more vulnerable and susceptible to things like the COVID-19 pandemic?

Dr. Singer: Yeah, it is an exceptionally important part of the conversation and something that I was thrilled to be able to write about in the science advances editorial. So the underlying issues surrounding healthcare disparities have an enormous historical context. And the susceptibilities that we're seeing among communities of color in Latin X populations, Native Americans have almost certainly less to do with race and more with racism, more with the social constructs that have limited access to care, limited people's ability to care for underlying health conditions that can ultimately complicate COVID-19. And so certainly awareness of these issues on the part of physicians is an important first step, but is in no way an answer to the larger societal problems that are really laid bare in the face of the pandemic.

Host:

Certainly true. Are there any lessons Dr. Singer that we can take from the H1N1 pandemic and apply it to COVID and the pending flu season?

Dr. Singer: Yeah. So H1N1 in 2009 was probably our last viral pandemic, but it certainly looks like a very small pandemic, certainly compared to what we're facing now by orders of magnitude. I think some things that we have learned since the H1N1 pandemic is the ability of viruses to persist in the population. So since 2009, that H1N1 pandemic strain has been circulating every year. And so has been included in the flu vaccine every year. And this just gets to the idea that COVID-19 even after we have a vaccine will likely be circulating in our population for some time to come.

Host: One of the things I find most interesting right now, and disheartening Dr. Singer, and a challenging aspect of this pandemic is the vast amount of misinformation and fear associated with COVID-19. Can you offer any advice to physicians, and indeed patients, who are counseling their patients regarding these challenges? What would you like them to be able to say, to counter some of this misinformation?

Dr. Singer: Yeah, it's an amazingly important point and we have really learned that misinformation kills and certainly the conversation about sources of information and integrity of scientific data is a much larger conversation than in a podcast that we have time for today. But I think from the standpoint of physicians, I think evaluating the source of the information, critically trying to understand the methods used to generate data use to back up a position. These are things that as physicians we're trained to do. And I think that we should use these skills to evaluate information critically so that when we counsel our patients, we're doing it with the best scientific rationale that we can.

Host: Absolutely. As we wrap up Dr. Singer, and what a great episode, this is so informative for other providers, what else would you like them to know to take forward to their patients, to optimize patient outcomes and really to help with this confluence that could possibly come this way, this fall about the flu and managing COVID?

Dr. Singer: I think one thing that physicians are starting to do is they look toward flu season is reach out to their patient panels and talk about action plans. So what to do, if you wake up one morning with a fever, what do you do? Do you call the office? Do you try to get a test? What is the actual action plan for you and your family if you have a symptom, so that things aren't overwhelmed in the midst of flu season, there's at least some anticipatory guidance? So at Northwestern, we are working very hard to develop action plans around both flu and COVID-19 headed into the winter and we have a lot more great information on our website, which is nm.org.

Host: Thank you so much, Dr. Singer, what great information so important for us to hear right now to refer your patient, or for more information on COVID-19, please visit our website at nm.org to get connected with one of our providers. And that concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians, please remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.