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Fearing a ‘Twindemic,’ Health Experts Push Urgently for Flu Shots
There’s no vaccine for Covid-19, but there’s one for influenza. With the season’s first doses now shipping, officials are struggling over how to get people to take it.
As public health officials look to fall and winter, the specter of a new surge of Covid-19 gives them chills. But there is a scenario they dread even more: a severe flu season, resulting in a “twindemic.”
Even a mild flu season could stagger hospitals already coping with Covid-19 cases. And though officials don’t know yet what degree of severity to anticipate this year, they are worried large numbers of people could forgo flu shots, increasing the risk of widespread outbreaks.
The concern about a twindemic is so great that officials around the world are pushing the flu shot even before it becomes available in clinics and doctors’ offices. Dr. Robert Redfield, director of the U.S. Centers for Disease Control and Prevention has been talking it up, urging corporate leaders to figure out ways to inoculate employees. The C.D.C. usually purchases 500,000 doses for uninsured adults but this year ordered an additional 9.3 million doses.
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, has been imploring people to get the flu shot, “so that you could at least blunt the effect of one of those two potential respiratory infections.”
In Britain, Prime Minister Boris Johnson has been waging his own pro flu-shot campaign. Last month, he labeled people who oppose flu vaccines “nuts” and announced the country’s largest ever rollout of the shots. In April, one of the few reasons Australia allowed citizens to break the country’s strict lockdown was to venture out for their flu shots.
The flu vaccine is rarely mandated in the U.S. except by some health care facilities and nursery schools, but this month the statewide University of California system announced that because of the pandemic, it is requiring all 230,000 employees and 280,000 students to get the flu vaccine by November 1.
A life-threatening respiratory illness that crowds emergency rooms and intensive care units, flu shares symptoms with Covid-19: fever, headache, cough, sore throat, muscle aches and fatigue. Flu can leave patients vulnerable to a harsher attack of Covid-19, doctors believe, and that coming down with both viruses at once could be disastrous.
The 2019-20 flu season in the United States was mild, according to the C.D.C. But a mild flu season still takes a toll. In preliminary estimates, the C.D.C. says that cases ranged from 39 million to 56 million, resulting in up to 740,000 hospitalizations and from 24,000 to 62,000 flu-related deaths.
According to the C.D.C., flu season occurs in the fall and winter, peaking from December to February, and so was nearing its end as the pandemic began to flare in the United States in March.
But now, fighting flu proactively during the continuing pandemic presents significant challenges: not only how to administer the shot safely and readily, but also how to prompt people to get a shot that a majority of Americans have typically distrusted, dismissed and skipped.
With many places where the flu shot is administered en masse now inaccessible — including offices and plants that offered it free to employees on site and school health clinics — officials have been reaching out to local health departments, health care providers and corporations to arrange distribution. From now through Oct. 31, publicity campaigns will blast through social media, billboards, television and radio. Because the shot will be more difficult to access this year, people are being told to get it as soon as possible, although immunity does wane. There will be flu shot tents with heaters in parking lots and pop-up clinics in empty school buildings.
Because of the efforts, vaccine makers are projecting that a record 98 million flu shots will be given this year in the United States, about 15 percent more than doses ordered last year. The Kaiser Permanente health care system will be flooding more than 12 million of its members with flu shot reminders via postcard, email, text and phone calls.
Pharmacies and even supermarkets are expected to play a bigger role than they have in previous years. As of this week, Walgreens and CVS will have flu shots available. Walgreens will be hosting additional off-site flu vaccine clinics in community centers and churches. To reduce contact time, CVS is allowing patients to fill out paperwork digitally.
In New York City, which averages about 2,000 flu-related deaths a year, the health department has been reaching out to hundreds of independent pharmacies to administer the shots, because they are often located in outer-borough neighborhoods where the coronavirus has been rampaging. The health department has a detailed online flu vaccine locator.
“Access is a problem for all adult vaccines,” said L. J. Tan, chief strategy officer for the Immunization Action Coalition, a nonprofit group that works to increase vaccination rates, who was an early promoter of the term twindemic. “Adults may think, If I can get the flu shot easily, I might consider it.”
But as difficult as getting the flu shot to people safely will be, perhaps harder still will be persuading them to actually get it. In the 2018-19 flu season in the United States, only 45.3 percent of adults over 18 got the vaccine, with rates for those ages 18 to 50 considerably lower.
Skepticism to this vaccine runs high, particularly in communities of color because of longstanding distrust and discrimination in public health. A 2017 study in the journal Vaccine noted that, compared with white people, “African Americans were more likely to report barriers to vaccination, were more hesitant about vaccines in general and the flu vaccine specifically, more likely to believe in conspiracy theories and use naturalism as an alternative to getting vaccinated.”
Across all demographic groups, perhaps the most striking reason given for avoiding the flu vaccine is that people do not see it as efficacious as, say, the measles vaccine.
Indeed, it is a good vaccine but not a great one. It must be repeated annually. Immunity takes up to two weeks to kick in. But its efficacy also depends on how accurately infectious disease centers worldwide forecast which strains are expected to circulate in the coming year. And then those strains can mutate.
Although the flu shot confers immunity at all ages over six months, it can be less complete in people over 65. Depending on many factors, the shot’s effectiveness in a given year can range from 40 to 60 percent.
“But a vaccine not given won’t protect anyone,” said Dr. Jane R. Zucker, assistant commissioner for the Bureau of Immunization at the New York City Health Department, which has been hosting webinars for providers about how to have conversations about the flu shot with hesitant patients.
As health officials note, should a vaccinated person contract the flu, the severity will almost certainly be reduced, hospitalization rarely necessary. Especially with Covid-19 raging, public officials reason, those odds look pretty good.
Another reason people give for not getting the shot is they think it makes them sick.
“People who say ‘I’ll never get it because it gives me the flu’ have not had the flu and don’t know what it is,” said Patsy Stinchfield, senior director of infection prevention at Children’s Minnesota.
“What you’re feeling is your body’s immune response to the virus’s antigens,” said Ms. Stinchfield, a member of the C.D.C.’s influenza work group. “You may feel flu-ish. And that’s a good thing. It’s your body’s way of saying, ‘I am ready for the flu, and I won’t get as sick if I get the real one.’”
Public campaigns will describe the shot as a critical weapon during the pandemic. “Hopefully people will say, ‘There’s no Covid vaccine so I can’t control that, but I do have access to the flu vaccine and I can get that,’” Ms. Stinchfield said. “It gives you a little power to protect yourself.”
Other campaigns will emphasize familial and community responsibility.
Usually, flu vaccine compliance rates among people ages 18 to 49 are low. Vermont’s, for example, is only about 27 percent.
Christine Finley, the state’s immunization program manager, believes that rates will improve because of the pandemic’s stay-at-home households. “People are more aware that the risks they take can negatively impact others,” she said. “They’re often taking care of young children and older parents.”
If any example could prove instructive about protective behavior and flu vaccines during the coronavirus epidemic, it could well be Australia.
Australia’s flu vaccine rate tends to be modest, but this year demand was high. The government’s rollout of the shot began earlier than usual for the June-through-August winter because the coronavirus pandemic was exploding. Though the government had also issued strict no-entry limits among many states and territories and bans on international travel, the flu shot was one of the few reasons people could emerge from lockdown.
The prevalent strain circulating in the country is Type A, the most common and virulent form of flu, said Dr. Kelly L. Moore, a public health expert at the Vanderbilt University School of Medicine.
According to the C.D.C., Type A is the most likely to circulate globally. It mutates readily, particularly as it jumps between animals and humans.
“There are two strains of Type A influenza in the vaccine,” Dr. Moore said, “and so the very best way to protect yourself is to get the shot.”
Reported cases of flu in Australia have dropped 99 percent compared with 2019.
“Australia’s milder-than-usual flu season is likely the result of a number of factors — strong flu vaccination uptake, social distancing, but also severely decreased movement of people,” said Dr. Jonathan Anderson, a spokesman for Seqirus, a supplier of flu vaccine.
But though American public health authorities usually look to Australia’s flu season as a predictive, Australians say this year it’s not a reliable indicator.
“This situation is of no comfort as these measures do not apply to the United States where the populace has never been effectively physical distancing,” nor have the country’s entry restrictions been as onerous, said Dr. Paul Van Buynder, a public health professor at Griffith University in Queensland, Australia.
All that Americans can do is get vaccinated against flu, he added, because circulation of the coronavirus remains high.
“It is likely they will have a significant influenza season this northern winter,” he said.
More than 1,000 people in the US have died of coronavirus nearly every day this month
The Covid-19 death toll in the United States has soared to more than 170,000, just 18 days after the nation marked 150,000 lives lost.
As cases have increased in the US, the lull between grim milestones has grown shorter. It took 54 days for the number of people killed by the virus to go from one to 50,000, and then 34 days to cross 100,000 mark on May 27. Now, more than 5.4 million people have been infected and 170,052 have died, according to data from Johns Hopkins University.
By September 5, the number of deaths could grow to 189,000, according to a projection from an ensemble forecast by the US Centers for Disease Control and Prevention.
More than 1,000 coronavirus deaths have been reported nearly every day this month. Since July 27, only five days have been under that threshold.
Cases and deaths are climbing as a potential vaccine is still months away and as students return to school for in-person classes amid growing outbreaks among younger populations.
‘We’ve got to break through to our young people’
While older Americans are more at risk for severe illness from coronavirus, health experts and officials are continuing to warn that younger populations are at the forefront of its spread.
“We’ve got to break through to our young people that they are not immune to the virus,” Chicago Mayor Lori Lightfoot said.
The city has seen a steady increase in cases, which she attributed to 18 to 29-year-olds.
Also steadily increasing is the number of cases among children, according to CDC guidance.
Early data led many experts to believe that children did not contract or spread the virus in the same way that adults do. But as more research has been done into their age group, that belief is changing, the CDC said.
“Recent evidence suggests that children likely have the same or higher viral loads in their nasopharynx compared with adults and that children can spread the virus effectively in households and camp settings,” the guidance states.
The new guidance comes as many schools have opened their doors to bring students back for in-person learning. Several have already experienced outbreaks, prompting quarantines and closures.
The Los Angeles Unified School District (LAUSD), which will begin its school year virtually this week, is launching a new program “that will provide regular COVID-19 testing and contact tracing to school staff, students and their families,” Superintendent Austin Beutner announced in a news release Sunday.
“Extraordinary circumstances call for extraordinary actions, and while this testing and contact tracing effort is unprecedented, it is necessary and appropriate,” Beutner said.
Infections reported as colleges reopen
Cases have also cropped up at colleges and universities as students return to campus.
Oklahoma State University announced Sunday that at least 23 sorority members in an off-campus house tested positive for the virus. The entire house is in isolation or quarantine and “will be prohibited from leaving the facility,” the university said.
Less than a week after starting classes, the University of North Carolina at Chapel Hill announced its fourth cluster of coronavirus on Sunday. The clusters were located at two residence halls, a private apartment complex that serves students and the Sigma Nu fraternity.
The North Carolina Department of Health and Human Services defines a cluster as five or more cases in close proximity.
The latest cases come after some universities reported infections even before the new school year began.
Over the summer, at least 38 students living in 10 University of Washington fraternity houses tested positive for the virus. And officials at UC Berkley confirmed 47 cases in just one week in July. Most of those cases, the university said in a statement, came from “parties connected to the CalGreek system.”
Positivity rates climbing
Health officials are hopeful that a new saliva test could give Americans a fast and inexpensive way to learn if they have Covid-19 and help to prevent increasing spread.
The SalivaDirect test, from researchers at the Yale School of Public Health, received emergency use authorization from the Food and Drug Administration on Saturday.
“If cheap alternatives like SalivaDirect can be implemented across the country, we may finally get a handle on this pandemic, even before a vaccine,” said Nathan Grubaugh, a Yale assistant professor of epidemiology.
The test comes as frustration grows over testing delays and shortages. Seventeen states are performing fewer tests this past week compared with the previous week, according to the Covid Tracking Project.
But while testing has gone down in those states, test positivity rates have increased in 34 states.
The test positivity rate is the percentage of tests being performed that come back positive for the virus. It is one of the metrics experts encourage officials to monitor when making reopening decisions.
Part of Illinois will be under new guidelines after three days in a row with a test positivity rate of 8% or higher, according to a news release from Gov. J.B. Pritzker.
Beginning Tuesday, all bars, restaurants and casinos in the Metro East area of Illinois will close by 11 p.m. Party buses will be closed and gatherings will be limited to 25 people or less, Pritzker said Sunday.
“If the data shows we need to go backwards in our reopening, I won’t hesitate to tighten restrictions to protect our collective health,” said Pritzker.
Payers win again, court rules Admininistration violated law in axing ACA cost-sharing payments
Dive Brief:
- A federal court ruled Friday that insurers are owed subsidies mandated by the Affordable Care Act to help them cover people with low incomes in the exchanges and the Trump administration violated the law when it halted the payments in 2017.
- In a separate but related ruling, the same court found that payers that were able to raise premiums to offset the loss of those payments in 2018, however, should not receive the entire unpaid amount.
- The judges with the U.S. Court of Appeals for the Federal District in their decision relied on a recent ruling in favor of insurers from the U.S. Supreme Court on a separate cost-sharing program in the ACA. “We see no sufficient basis for reaching a different conclusion,” they wrote.
Dive Insight:
The Affordable Care Act took into account that payers participating in the exchanges it created would be somewhat flying blind when setting premium rates for a new population. To safeguard them, multiple programs were established to help manage the inherent risk.
One of them was the risk corridors program, which was supposed to redistribute some of the profits insurers received in the exchanges to other companies seeing losses. But far more companies reported losses than profits, and the program quickly ran out of funds to pay out.
The Trump administration argued the ACA does not properly appropriate the funding anyway.
The high court, however, ruled in April those insurers are owed about $12 billion from the program and that the language indeed creates what is called a money-mandating provision.
The decisions released Friday use that precedent for one of the other risk programs, which provided the subsidies for coverage of people with low-incomes, called cost-sharing reduction payments.
HHS abruptly stopped making the payments in October 2017, making the argument that the money had not been appropriated. But litigation of the issue goes back farther. Republicans in Congress sued HHS in 2014 making the same claim.
In 2018, with the payments still halted, payers increased their premium rates to help account for the lack of cost-sharing reduction payments, and thus received additional premium tax credits (a practice known as silver loading). The judges Friday said that although they agreed with a February 2019 decision from the U.S. Court of Federal Claims that the payers were owed the payments, they disagreed that insurers should be reimbursed in full despite the 2018 premium adjustments.
“The complexity of the process cannot obscure the underlying economic reality that the government is paying at least some of the increased costs that the insurers incurred as a result of the government’s failure to make cost-sharing reduction payments,” they wrote.
The judges remanded the case back to the Court of Federal Claims to determine the amount Maine Community Health Options is owed, and instructed them to take into account what amount of silver loading can be attributed to the loss of the payments.
Montana Co-op is owed $1.23 million for missed 2017 payments and Sanford Health Plan is owed $360,254.
Patient-provider encounter trends have stabilized, but remain significantly lower than before COVID-19
Dive Brief:
- In-person doctor visits plummeted during the start of the COVID-19 crisis in the United States, but have rebounded to a rate somewhat below pre-pandemic levels, according to a new analysis issued by The Commonwealth Fund and conducted by researchers from Harvard Medical School, Harvard University and the life sciences firm Phreesia.
- According to data compiled through Aug. 1, all physician visits were down 9% from pre-pandemic levels. That’s significantly improved compared to data from late March, when visits were down 58%. Although the rebound got major traction beginning in late April, it began plateauing in early June, when all visits were 13% lower than normal. As of early August, in-person visits were down 16% compared to pre-COVID levels. States that are currently coronavirus hot spots are seeing bigger declines than states where the case levels are lower.
- Meanwhile, telemedicine encounters have settled in at rates much higher than pre-pandemic levels. However, they still make up just a fraction of patient-provider encounters for care. As of the start of this month, they comprised 7.8% of all such encounters. That’s compared to a peak of 13.8% in the latter part of April. Prior to COVID-19, they were only 0.1% of all visits.
Dive Insight:
COVID-19 has widely disrupted healthcare delivery in the United States. However, it is becoming clear that as the pandemic has become a part of everyday life for the time being, how patients visit their medical providers has also settled into a pattern.
According to Harvard researchers using data from Phreesia’s more than 50,000 provider clients, the plunge in patients seeing their physicians has rebounded from its nearly 60% dive in early spring. However, with all patient-physician encounters still consistently down from pre-COVID levels, the study’s authors warn that “the cumulative number of lost visits since mid-March remains substantial and continues to grow.”
Meanwhile, COVID-19 hotspots in the South and Southwest are depressing patient-provider encounters for the time being. Encounters were down as of late July by 15% in Arizona, Florida and Texas, compared to 12% in the Northeast and 8% in all other states.
Among medical specialties, only dermatology has seen a rebound beyond pre-COVID levels, with encounters up about 8% overall. But primary care visits are down 2%; surgery encounters, 9%; orthopedics, 18%; and pediatrics are in a 26% decline.
That the encounters between patients, doctors and other providers remains lower than normal has sparked some concerns about practices and other medical enterprises moving forward. HHS just earmarked $1.4 billion for nearly 80 children’s hospitals across the United States to try to shore them up financially.
The private sector has also undertaken an initiative to encourage patients to return to their providers. Insurer Humana, along with the Providence and Baylor Scott & White healthcare systems, launched an advertising campaign last month to encourage patients to seek out healthcare needs, even during the historic pandemic.
Prime adds 46th hospital
Ontario, Calif.-based Prime Healthcare announced Aug. 14 that it has completed the acquisition of St. Francis Medical Center, a 384-bed hospital in Lynwood, Calif.
Here are four things to know about the deal:
1. Prime purchased St. Francis Medical Center out of bankruptcy. The hospital entered bankruptcy in 2018 when its previous owner, El Segundo, Calif.-based Verity Health, filed for Chapter 11 protection.
2. Under the $350 million deal, which closed after a four-month review process, Prime committed to invest $47 million in capital improvements at the hospital. Those investments include installing Epic’s EHR and Omnicell systems for automated medication dispensing. Prime said it also plans to expand the hospital’s service lines.
3. A spokesperson told Becker’s Hospital Review that Prime extended offers to approximately 80 percent of the more than 2,000 employees at St. Francis Medical Center. “In the midst of this pandemic and economic challenges, Prime has remained deeply committed to St. Francis, the caregivers, patients and community, and we continue to evaluate staffing and will post additional positions based on future community needs,” the spokesperson said.
4. With the addition of St. Francis Medical Center, Prime owns and operates 46 hospitals in 14 states. The company has nearly 40,000 employees.
‘We’ve got to do better than this’: College students raise alarm by packing bars, avoiding masks
Local officials from Georgia to Alabama to Oklahoma reacted with horror and anger on Sunday, warning that unless students take social distancing and mask rules seriously, the fall semester could come to a swift end.
“Why?” tweeted Walt Maddox, mayor of Tuscaloosa, Ala., above a photo of hundreds of mostly mask-free University of Alabama students outside downtown restaurants. “We are desperately trying to protect @tuscaloosacity.”
Some universities are already battling coronavirus outbreaks, including the University of North Carolina at Chapel Hill — where four viral clusters have emerged one week after in-person classes started — and Oklahoma State University, where a single sorority house has 23 confirmed cases.
There’s no national consensus on how to approach college this fall, with many schools going at least partially online and others trying mass testing of students. But other large schools are welcoming everyone back to campus and relying on masks and social distancing to avoid outbreaks — a plan, as local leaders noted this past weekend, that could crumble if students don’t abide by the recommendations.
In Dahlonega, university officials chided the hundreds of students who gathered at an off-campus housing complex for the Saturday night party. In-person classes are scheduled to start Monday for the school’s roughly 19,000 students.
“We are disappointed that many of our students chose to ignore COVID-19 public health guidance by congregating in a large group without social distancing or face coverings,” a school spokeswoman told the Gainesville Times.
At Alabama’s two biggest schools, football players were particularly vocal in sounding the alarm as they watched fellow students congregate without face coverings. Although many of college football’s biggest conferences have canceled their fall seasons, the Big 12, ACC and SEC are pushing ahead — assuming campus outbreaks don’t interfere.
At Auburn University, wide receiver Anthony Schwartz tweeted Saturday that he had “seen crowds of people and none of them are wearing masks.” Chris Owens, a center at the University of Alabama, tweeted a photo on Sunday afternoon of a crowd of students with barely any face coverings in sight, asking: “How about we social distance and have more than a literal handful of people wear a mask? Is that too much to ask Tuscaloosa?”
Alabama’s athletic director, Greg Byrne, also warned that the scenes in Tuscaloosa put the season at risk.
“Who wants college sports this fall?? Obviously not these people!!” he tweeted Sunday. “We’ve got to do better than this for each other and our campus community. Please wear your masks!”
Maddox, the mayor, said he would ask the school’s police force to help Tuscaloosa police enforce mask rules. “Wearing a mask and practicing social distancing is not much to ask for to protect yourself, your family, your friends … and the jobs of thousands of people,” he tweeted.
In Stillwater, Okla., the editor at Oklahoma State’s student newspaper shot videos this weekend of packed clubs and bars and long lines outside downtown establishments.
The campus was already on high alert after the school announced Saturday it had quarantined dozens of students inside the Pi Beta Phi sorority house following at least 23 positive tests on Friday. “I’ve decided.. I’m not going to class on Monday,” Tre Sterling, a defensive back on OSU’s football team, tweeted above videos of student crowds downtown.
Stillwater Mayor Will Joyce said the city council would consider new pandemic rules on Monday, including an “emergency declaration, if necessary.”
“Every single person in Stillwater has a responsibility to help,” he tweeted. “Take every precaution you can to slow the spread. Wear your mask, avoid crowded areas, wash your hands, be a good neighbor.”
HENRY KOTULA 