In recent months, like a lot of people, I’ve pushed off preventive care — or done it virtually, when possible — because I’m scared of getting COVID-19. Typically, in-person preventive care is how I get immunized. During some routine visit, a doctor or nurse will ask if I’ve gotten my flu shot yet. Then they’ll offer to administer one, and I’ll say, “Sure, go for it,” and roll up my sleeve. Without a built-in opportunity to get the flu vaccine, it’s tempting to skip it this year.
Many Americans don’t even entertain the idea of getting a flu shot, research suggests. In a January poll from the American Academy of Family Physicians, one-third of respondents said they hadn’t gotten one and didn’t plan to. Millennials were the age group least likely to get vaccinated, as well as least informed about the health risks of the flu (86 percent got at least one flu fact wrong). Millennials also had more excuses for not getting vaccinated than older adults; they were twice as likely as boomers to say they forgot or didn’t have time.
My personal excuse: I live in Florida, a current COVID hotspot, so I’m following disease-prevention guidelines to the letter and then some. I’m not traveling. I work from home, and so does the only other person I live with. With such a small chance of getting or passing along the flu, is it worth venturing out for a flu shot?
Yes, yes it is.
Last year, 45 percent of American adults got a flu shot, according to the Centers for Disease Control and Prevention. This tepid figure is nowhere near the rate we’d need to reach herd immunity (70 to 80 percent), but according to CDC data, it is higher than annual adult vaccination rates over the last decade. Public health experts say vaccination is more important than ever this year. Still, they fear too few people are hearing the message.
“We’re hopeful that the more severe the pandemic might be, that people will do everything they can to decrease their risk,” says Dr. Benjamin D. Singer, a pulmonologist and assistant professor at Northwestern University Feinberg School of Medicine. “How to convince them is a different question.” Singer recently wrote an editorial in the journal Science Advances about how the spread of COVID-19 could complicate healthcare during the 2020-2021 flu season. “People always ask about the best way to boost the immune system,” he says, “and the No. 1 way you do that is with a vaccine.”
Officially, the 2019-2020 flu season concluded at the end of July, but peak flu season is November through February. Since COVID-19 diagnoses started ramping up in the US as peak flu season was winding down, we haven’t had to endure a full season with both viruses circulating at once. While the flu vaccine won’t protect people from getting COVID-19, one of the primary ways flu shots “work” is by preventing infections severe enough to warrant a hospital visit. Flu hospitalizations also increase the burden on hospitals already overwhelmed with COVID-19 cases.
Optimists predict that measures to help contain COVD-19, such as increased social distancing, vigilant hand-washing and greater use of hand sanitizer, could reduce the spread of the flu in the US this year. Australia’s rate of flu infection plummeted during its season. In April, the country saw 229 flu cases, compared to 18,000 in April 2019. Health officials speculate that stepped-up disease prevention awareness, along with school closures, might have contributed to the decrease. But they also said vaccination rates were much higher than usual: More than twice as many Australians got the flu shot in 2020 than in 2018.
Evidence also suggests the flu season may have ended abruptly in Japan when people started taking the precautions against COVID-19 seriously, says Dr. Stephen S. Morse, professor of epidemiology at Columbia University. Whether Americans will follow suit, however, remains to be seen.
For one thing, vaccine hesitancy appears to be on the upswing, and some of the usual avenues for people to get the flu shot have dried up, making vaccination less convenient. Health experts worry that if we have a bad flu season, dueling pandemics could overwhelm healthcare workers and facilities. But even if the coming flu season doesn’t earn pandemic status, it’s likely to complicate the fight against COVID-19.
“It’s hard enough to get people vaccinated even when there isn’t a pandemic,” says Dr. Jean S. Moorjani, a pediatrician in Orlando, Florida. “There’s so much hesitancy and mistrust, I feel like we’re bracing ourselves for the next few months.” Patients (or patients’ parents) are often skeptical that the flu shot is worth getting, Moorjani says, and will ask, “Is it really that effective? I get sick anyway.”
Poor flu vaccine compliance in the US may fall even further with COVID-related fears and anti-vaccine myths, says Dr. Don L. Goldenberg, a rheumatologist, professor emeritus of medicine at Tufts University School of Medicine and the author of How the COVID-19 Pandemic Is Affecting You and Your Healthcare.
“That would be disastrous for a number of reasons,” Goldenberg says. “No. 1, COVID-19 and influenza both cause lung infection/inflammation, and if [these] spread at the same time, [that] likely would overwhelm hospitals and ICUs and lead to severe shortage of critical items, such as ventilators.”
In addition, both COVID and the flu carry the same increased risk of infection and death, particularly for older patients and racial minorities, he says: “These groups will be more at risk for co-infection with both viruses, as well as for poor outcomes from either infection.”
In case you didn’t catch that: It is possible to have the flu and COVID-19 at the same time, which can make diagnosis and treatment for both more difficult.
“Healthcare providers may have difficulty determining the correct diagnosis, especially if testing for COVID-19 continues to be inadequate,” Goldenberg says. “This may result in inappropriate quarantine and treatment recommendations.”
Because researchers are still learning about COVID-19, they can’t yet say whether having both viruses at the same time increases your chances of dying.
“Logically, with two severe viruses, I think the risk for dying would be higher, but it’s unclear,” Singer says. “The only way to know is to do a test that comes back very quickly. We have to know quickly who has it so they can isolate, and it also helps with contact tracing.”
There are psychological ramifications of severe illness as well. Even pre-COVID-19, evidence suggested that surviving a severe flu infection can be traumatic.
“There are a lot of long-term, well-known effects from being in the ICU, because it’s a stressful environment,” Singer says. “There are also neurological muscle problems and profound weakness after a severe course of the flu. It’s not trivial.”
Another complication that doctors can still only guess at is whether recovering from COVID-19 might make you more susceptible to contracting the flu, and vice versa.
“Unfortunately, the risk for severe flu illness in people recovering from COVID-19 infection is largely unknown,” says Dr. Joi Lucas, a pediatric pulmonologist in central Florida.
Conversely, she adds, people should vaccinate against the flu to protect themselves from severe respiratory complications that make them even more susceptible to COVID-19.
“Illness with the flu alone is concerning, so the commingling of COVID-19 and the flu may be debilitating,” Lucas continues. “Studies have shown people with COVID-19 have persistent chest X-ray abnormalities, and the long-term effects of infection with the virus are unknown.”
“A great deal of thought and effort has gone into how to return to normal care, including immunizations, as safely as possible.”
The CDC has issued COVID-19-specific flu vaccination guidelines for the upcoming season, noting that people who suspect they might have COVID-19 should hold off getting a flu shot to avoid putting healthcare workers and other patients at risk. The agency also recommends that healthcare providers screen for symptoms before patients come in for their appointments; limit and monitor entrances and exits to decrease patients’ exposure to one another; and implement social distancing guidelines such as floor markers, roped-off areas and electronic check-ins whenever possible.
CDC officials also say that they’re working with healthcare providers to develop innovative vaccination distribution measures to keep vaccine administrators and patients safer, such as drive-through clinics, mobile clinics and curbside vaccinations. But if al fresco flu shots aren’t available in your area, don’t despair. Flu shot administrators at doctors’ offices and pharmacies should be familiar with the proper protocols to administer this year’s flu shot safely.
“From my experience with helping to develop return-to-work plans at my own university’s medical center, a great deal of thought and effort has gone into how to return to normal care, including immunizations, as safely as possible,” Morse says.
People should be more concerned about the steps they take to get to vaccination sites than the sites themselves, he says.
“By time you get there, that’s probably the safest place you’ll be outside your own home,” Morse says. “Places that are giving these immunizations have been taking careful precautions, from extra cleaning to increasing ventilation, social distancing and keeping patients separated if applicable. To the best of my knowledge, no one wants to be known as the place where someone went for a flu shot and got COVID instead.”
The best time to get a flu shot is September or October, according to the United Nations and the CDC. It’s possible, research suggests, that getting one too early could mean not having enough flu-fighting antibodies in your system through February, when the virus’s spread is typically at its peak.
If you’re able to work from home right now, it might be tempting to rationalize that your risk of getting the flu is small enough to warrant skipping a flu shot this year. But health experts hope everyone who should get a flu shot (read: like me) will.
“It’s hard to know over the course of months who you’re going to be exposed to, even if day to day, you’re working from home,” Singer says. “You never know when you might have to make an unexpected trip. And there’s a very small risk in going out to get the vaccine compared with the potential benefit from being vaccinated.”
A couple weeks ago, I ran an informal Facebook poll about the flu shot and got a range of answers from 32 friends and acquaintances. Those not planning to get vaccinated cited reasons including needle fears, doubts over the flu shot working and not needing one because they’re vigilant about hand-washing. Few seemed aware of experts’ contention that flu vaccination is particularly important during the pandemic.
But most people said they will get a flu shot, some for the first time in many years on account of the pandemic — which Dr. Morse might find encouraging right now.
“I’m heartbroken,” he said in a recent email regarding the spread of COVID-19. “I’ve devoted the last three decades of my career to trying to prevent something like this from happening.”