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WELLNESS WATCH: Preventing a “Twindemic”

Written by Patricia Blanchette, MD, MPH, University Health Partners of Hawaii Chief Medical Officer

Featured photo: As part of their clinical skills training, third-year medical students practice injections on one another. Samuel Bell (JABSOM MD 2022) gives a shot to classmate Andy Hwang, as their colleague Maggie Kwock supervises them.

August 28, 2020 — A few weeks ago, the term “twindemic” appeared in the New York Times in the context of the rising fear of an outbreak of influenza this fall at the same time as the COVID-19 outbreak was still upon us.  Comparing the strategies available for the prevention and treatment of influenza with what is available to us for COVID-19 underscores the advances that have been made in influenza and what still awaits us for prevention and treatment of COVID-19.  

Personally, I am reminded of a family history of my mother having lost 2 young sisters to the flu in the late 1920’s.  She was also very sick, but survived.  My grandparents were devastated.  This history helped explain to me why my mother was always “first in line” to get her flu shot every year, made sure we got ours, and could not understand why some people needed to be convinced of its importance.  

In warm weather climates and in places with a great deal of tourist activity, the “season” for flu is less predictable.  There are many bad cases reported in every month.

There are some theories that with social distancing and mask wearing influenza transmission may be less, resulting in a better flu season.  Others are extremely concerned about the similarity in the symptoms of influenza and COVID-19, leading to undertreatment of influenza when a COVID-19 test is negative and an influenza test is not done.  With symptoms of flu, both tests should be done.

Influenza vaccine is indicated in almost every person aged 6 months or more.  This year there is good news in that this is the first year that Fluzone HD (high dose) indicated for persons aged 65 or more is quadrivalent, protecting against 2 influenza A strains and 2 influenza B strains.  Previously, the HD was only trivalent.  The regular adult vaccine has been quadrivalent for some time.  Fluad, the vaccine with an adjuvant, is also approved for use in persons 65 and older, but the hospitalization rate has not yet been compared to the reduced hospitalization seen with Fluzone HD.  These are inactivated virus vaccines that cannot cause a person to get the flu, as some people still fear.

Flumist, the vaccine that is sprayed into the nose is recommended for people aged 2 to 49.  However, there is a caution about its used in health care workers, as there is some shedding of the attenuated virus used in its production and the theoretical risk that this attenuated virus could cause the flu when shed near a severely immunocompromised person.

The other good news with influenza is that there are now two effective medications, oseltamivir (Tamiflu) and baloxivir marboxil (Xofluza).   Given early in the disease, both are known to be effective, with Xofluza requiring many fewer doses.  The cost of a full recommended treatment has been comparable. 

Wouldn’t we be excited about having two effective and recommended oral medications for COVID-19!   

Right now, the best way to prevent and beat down the possibility of a “twindemic” is to focus on prevention, early recognition, testing for both influenza and COVID-19, and early treatment of influenza.   In an outbreak of influenza, treatment of contacts before laboratory confirmation is indicated.  

Comparative effectiveness of high-dose versus standard-dose influenza vaccination on numbers of US nursing home residents admitted to hospital: a cluster-randomised trial
Crossref DOI link: https://doi.org/10.1016/S2213-2600(17)30235-7
Published: 2017-09

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