Even as omicron is surging, the seasonal flu is back: More than 2,500 Americans were admitted to the hospital with influenza in the last week of December. The flu hospitalization rate is still about half of the pre-Covid normal, but it is eight times higher than it was last year when one side effect of pandemic restrictions was that flu cases fell off dramatically.
This is the first glimpse of a harsh new reality that will outlast this wave of the pandemic: Flu season has transformed into Covid-and-flu season — a “flu-rona” wave every winter.
Before the pandemic, the flu alone could sometimes push hospital systems into crisis mode, where they cancel elective procedures and limit other kinds of care. Now there’s Covid-19, which has done the same thing on its own.
Suddenly conjuring more hospital capacity every winter to handle the expected surges of flu and Covid-19 is not going to happen. Thousands of additional hospital beds are not coming in the next few years, and the US would not have the doctors and nurses to staff them anyway. It will take much longer — years or maybe decades — to improve the gaps in America’s health care infrastructure and workforce that have been exposed during Covid-19.
This means the imperative to “flatten the curve,” to limit the spread of these viruses to stop hospitals from being overwhelmed, will be with us for a long time. But the makeup of the curve will change, measuring multiple diseases instead of one.
Public health experts believe now and going forward the US needs a new public health strategy that treats Covid-19 and influenza as one unified threat. We can’t think that we will endure the omicron wave and then all of these problems will be behind us. This is the new reality. Responding to it adequately, along the lines some experts are calling for, would require a massive effort — nothing less than a complete rethinking of how we respond to the annual winter surge in respiratory illness.
“We are on the lip. We are in a transitional phase, moving from pandemic to endemic,” William Schaffner, the medical director of the National Foundation for Infectious Diseases and a Vanderbilt University professor, told me. “With two of these respiratory viruses going on at pretty much the same time, I think that will create a greater stress on the health care system.”
Get ready to live through Covid-and-flu seasons for the foreseeable future
The flu is reliably seasonal. The dominant strains for a given year usually start circulating in October and November before reaching their peak between December and February. Then the virus peters out over the next few months, then a new mutation arrives the next fall.
Every year, influenza strains the US health care system. In the flu season before Covid-19 arrived, 2018-2019, an estimated 29 million Americans were infected, there were more than 380,000 flu-related hospitalizations, and 28,000 people died from the virus. Covid-19 is not as bound by the calendar. US hospitals may endure not only a winter wave, in tandem with the flu, but also periodic spikes throughout the year as well. Both 2020 and 2021 saw small surges in the summer, followed by a massive wave once winter and the cold weather hit.
“It is sort of the worst of both worlds,” said Emily Martin, a University of Michigan epidemiologist. “You’re always gonna expect a really bad winter season, but then you might have other bad times as well.”
The reasons for seasonality are complex. But generally speaking, viruses survive better in colder environments and people’s behavior also tends to change when the weather gets cold — spending more time inside, traveling for the holidays — in ways that makes it easier for pathogens to spread.
Last winter was an aberration: widespread social distancing dramatically reduced the spread of flu. But this winter, the CDC estimates that there have been about four times as many outpatient visits for respiratory illnesses, including flu, as last year, closer to the level seen in the two years before the pandemic.
Meanwhile, Covid-19 is surging again too, with case numbers and hospitalizations surpassing the records set the previous winter. Hospitals also report a significant jump in flu cases compared to last year, with some such as Houston Methodist seeing comparable case numbers to their pre-Covid normal. This rebound in flu is happening at the same time that some hospitals are seeing as many Covid-19 patients as they have at any point in the pandemic so far.
The crunch already being felt by US hospitals has spurred some public health experts to propose comprehensive policy plans that would help the health system tackle the flu and Covid-19 in the future.
“The ‘new normal’ requires recognizing that SARS-CoV-2 is but one of several circulating respiratory viruses that include influenza, respiratory syncytial virus (RSV), and more,” a group of advisers to President Joe Biden’s transition team wrote in a recent medical journal article. “Covid-19 must now be considered among the risks posed by all respiratory viral illnesses combined.”
They argued that public health officials should begin by discarding distinct case and death counts for flu, Covid-19, RSV, and other respiratory illnesses. Instead, they say we should focus on the aggregate risk of all these diseases combined. Based on the available evidence, we should expect that risk to peak every winter.
These experts said the goal should be to keep the collective effect of all these infections at or below those of a severe flu season. In the 2017-2018 flu season, for example, the US had 41 million cases, 710,000 hospitalizations, and 52,000 deaths. And that was without Covid-19, another highly contagious and dangerous virus that will make future winters even more difficult for the health care system to manage.
“We know during a pretty bad flu season, that can put a strain on things,” Richard Webby, influenza expert at St. Jude Children’s Research Hospital, told me. “Now we’re talking about two flu seasons.”
This is all still somewhat hypothetical. It’s possible, Webby pointed out, that the flu and Covid-19 won’t surge simultaneously, but will trade off, spiking and fading in cycles, over months. Alternating waves might decrease the risk of an enormous flood of patients overwhelming hospitals at any particular moment, but they would still create a sustained crisis every winter that strains hospitals for months without a break.
The steps to avoid worst-case scenarios of overwhelmed hospitals and rationed care might sound familiar.
Anand Parekh, chief medical adviser at the Bipartisan Policy Center, said any strategy for navigating the Covid-and-flu seasons to come should have at least four components: vaccination, testing, treatment, and masking.
But executing that plan is easier said than done. The US has struggled with some of these interventions throughout the pandemic. Deploying them annually would require a fundamental shift in how US hospitals and all of society approach the winter season. We can no longer muddle through every year and hope for the best.
Vaccination is the best way to stop a bad Covid-and-flu season before it starts.
Every year, the FDA fast-tracks approval of that season’s flu vaccine, which must be updated annually to protect against whatever flu strain is expected to become dominant. A similar routine could happen with Covid-19. The former Biden advisers, in their plan, wrote that people should anticipate a need for periodic, possibly seasonal Covid-19 vaccines as well and urged the federal government to start preparing an expedited approval process. Moderna has also announced it’s working on a shot that would combine its flu and Covid-19 vaccines. So, in theory, you would have to get only one shot each year to be protected from both Covid-19 and the flu.
The problem is that, historically, the United States has not done a good job of vaccinating people against the flu. Fewer than half of US adults get their flu shots every year. Even among people over 65, the most vulnerable to dying from the flu, the vaccination rate is usually stuck under 70 percent.
A Covid-and-flu public health response could build on the momentum of the Covid-19 vaccination campaign. Though the US has struggled somewhat compared to its European peers, it is still outperforming the typical flu vaccine drive, with more than 70 percent of eligible Americans receiving at least two shots, including almost 90 percent of people over 65.
Mandates and other policies — such as paid sick leave that makes it easier for people to take time off, a policy that surveys have found makes it more likely people will get the Covid-19 vaccine — could help push vaccination rates higher, Biden’s former advisers said.
2. At-home testing
Surveillance is critical, starting with early-warning systems. Public health institutions have long monitored the flu and they are already tracking Covid-19 in a similar manner. Monitoring the amount of virus detected in local wastewater has proven to be a reliable leading indicator of new Covid-19 waves during the pandemic. And widespread, reliable testing will be essential — including at-home tests for both Covid-19 and the flu.
Right now, flu tests are common at the doctor’s office, but there’s never been an option for people to administer a test themselves at home. In their recommendations for adjusting to an endemic Covid-19 world, former Biden advisers urged the government to invest in new technologies that could test for multiple pathogens at once. Public health experts are imagining a future in which people can take one test, find out if they have the flu or Covid-19 or neither, and respond accordingly. They could isolate rather than going into their work and spreading it to other people; several experts told me they hoped it would become more common after the pandemic for people to stay home if they are sick. People at higher risk of severe flu symptoms could also get prescribed antivirals earlier, when those medications are most effective.
“I think it is highly likely, finally, that home testing will become something that virtually everybody becomes comfortable with,” said Mara Aspinall, an Arizona State University professor who publishes a newsletter on Covid-19 testing. “A lot of at-home testing in this scenario is really important and I think will be a key factor going forward.”
There’s a long history of tests moving from doctor’s offices into the home. Aspinall pointed to pregnancy tests as one example of a diagnostic test that used to be done almost exclusively by doctors until at-home tests came to market and flourished. The same thing happened for HIV testing and is already underway with Covid-19.
But there is still work to do to prepare for that shift. It would start with making tests available for free or at a reasonable cost. Experts have criticized the Biden White House’s current plan of asking people with private insurance to submit their bills for reimbursement; his former transition advisers pointed to the example of states sending free kits to their residents as one possible model to follow.
A lot of at-home testing will be useful for surveillance, but only if people report the results. That has already been a problem with at-home Covid-19 tests. In one memorable case, public health officials in Las Vegas realized only weeks after the fact that a Phish concert on Halloween had been a superspreader event. They had no idea because people took tests at home and never reported the results.
The point being: Sorting out which tests to use when and what to do with the results has already been a struggle in the heat of the pandemic. Coming up with clear guidelines and educating the public will be necessary if we are to get the most out of at-home tests in the Covid-and-flu seasons to come.
Frequent testing lets people know that they should isolate. If they are at higher risk of severe illness, they can get on antivirals quickly. The current therapies are most effective at stopping serious symptoms that could require hospitalization if they are taken within the first few days of an illness. Research in the last decade has found that flu antivirals are too often underprescribed for patients who would benefit most; improving prescription rates is only more critical now that the health system will be contending with both the flu and Covid-19 going forward.
That’s because the goal of these plans is really to “flatten the curve” by preventing as much severe illness as possible, which reserves hospitals’ capacity for the most vulnerable patients and also allows them to treat all of the other patients who need hospital-level care.
Capacity at “the brick and mortar hospitals that are needed for care for the severely ill will continue to be finite,” Schaffner said. “There will not be a major increase there.” That means alleviating the pressure on hospitals is crucial. But it will take more than a lot of at-home testing to achieve it.
The former Biden advisers said the US needs to come up with a mechanism so that, the moment somebody tests positive for Covid-19, they are offered treatment. They also said that it may make sense for certain at-risk populations to be prescribed antivirals preemptively, as a prophylactic.
Other experts also argued it needs to be as easy as possible for people to get flu and Covid-19 treatments, either over the counter at the pharmacy or after a brief doctor’s visit.
“Over-the-counter testing and over-the-counter treatment can be really powerful going forward,” Martin said.
4. Masks and other non-pharmaceutical interventions
Other successful pieces of the pandemic response should also stick, experts said. We have the playbook and we’ve now run more plays from it than ever before.
Masking has become normalized for many people, and experts expect public health authorities to continue to recommend it for particular populations or even for everybody if respiratory viruses are spreading rapidly. Medical providers have more experience using telemedicine during health emergencies, in order to reduce the risks of exposure while still providing guidance and remote care for their patients. Public health experts say Covid has demonstrated the importance of good ventilation, which could be improved in schools and other public spaces to reduce the chances of transmission.
During severe outbreaks of flu or Covid-19 or both, experts think companies could more readily switch to remote work now that managers and workers are accustomed to it. Social distancing measures — mask mandates, even restrictions for large gatherings — could be put back in place on a selective basis, now that we have experience with them because of Covid-19.
If, that is, politicians are willing to implement them and the public will abide by them. The current crisis has revealed just how delicate even the best-laid plans are because they are subject to backlash, confusion, and politicization. In some states, lawmakers have actually acted to limit the ability of local governments or public health officials to take these steps on their own in the middle of a public health crisis.
“Public health laws are being dismantled in many jurisdictions, dramatically limiting the ability of public health officials to require actions that limit disease transmission,” said Ron Bialek, president of the Public Health Foundation. “Unfortunately, for too many elected officials, making political points has become a higher priority than serving and helping to protect their constituencies.”
We are not going to leave Covid-19 behind. The same policy problems and debates that have defined the pandemic will be with us in the flu/Covid-19 seasons going forward.
“The role of government in this communicable disease arena will continue to be under discussion. We’re divided about this,” Schaffner said. “It’s not going to be eliminated by a reflection on what did and didn’t work with Covid.”