Flu Season 2021-2022: Primary Care Fears & Patients on the Fence

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This time last year there was great concern about the potential for a “twindemic,” with SARS-CoV-2, influenza, and other seasonal respiratory viruses circulating at the same time. While COVID-19 cases surged in the winter of 2020, the twindemic did not happen and influenza was largely out of sight.

During the 2020-2021 influenza season in the US, the proportion of respiratory specimens that tested positive for influenza was dramatically lower than previous seasons. Last year, only 0.2% (n=1675) of over 818 900 respiratory specimens tested positive for influenza, compared to the 3 seasons before the pandemic when the proportion of positive specimens peaked between 26.2% and 30.3%, according to the Centers for Disease Control and Prevention (CDC).

Influenza-associated hospitalizations were also the lowest on record in 2020-2021, and there was only 1 infant mortality due to influenza, compared with 199 the previous season, according to the CDC.

While last year’s hiatus from influenza was fortunate, physicians might be concerned about what this season might bring. What does the 2021-2022 influenza season look like for physicians? And what challenges will primary care physicians in particular face this year?

Clinicians Fear “Tripledemic”

In recent weeks, COVID-19 cases, hospitalizations, and deaths have been declining, while the number of people either fully vaccinated or partially vaccinated increased. For this reason, certain states have begun to relax their COVID-19 mitigation measures (eg, stay-at-home orders, mask mandates), which has health care professionals worried about a rise in other seasonal respiratory viruses.

In an interview with Patient Care Online, the president-elect of the American Academy of Family Physicians (AAFP), Sterling Ransone, MD, said other AAFP members have expressed concern over a potential resurgence of not only influenza, but respiratory syncytial virus (RSV) too.

“In certain states where folks are not wearing masks and practicing appropriate public health measures, we're worried that a lot of these respiratory illnesses will emerge, especially in our pediatric patients,” stated Ransone. “We're incredibly worried that RSV will take another hold, and then we'll have a ‘tripledemic.’ Potentially the Delta variant of COVID, influenza, and RSV all hitting at approximately the same time. How do we take care of these patients? How do we have sufficient physical resources to care for their needs?”

RSV—a leading cause of bronchitis, bronchiolitis, and pneumonia—causes on average 58 000 hospitalizations and 100 to 500 deaths among children aged less than 5 years, and 177 000 hospitalizations with 14 000 deaths among adults aged ≥65 years, according to the CDC.

Similarly to flu levels last season, the number of RSV cases in the US were nearly nonexistent between May 2020 and February 2021; however, the CDC issued a health advisory in June 2021 due to increased RSV activity in parts of the southern US.

If cases of RSV and influenza do increase this season, it will be critical for clinicians to distinguish RSV, flu, and COVID-19 from each other as they all look similar, but have different therapies, according to William Schaffner, MD, medical director of the National Foundation for Infectious Disease (NFID).

“There will be an imperative to distinguish these infections, and they look very much alike. This is going to be a challenging season,” stated Schaffner to Patient Care Online.

The potential for a "tripledemic" or even for an increase in one circulating respiratory virus this season could make conditions particularly difficult for physicians in rural areas, Ransone says. He speaks from experience, having practiced rural medicine for more than 2 decades.

“Frequently in a more urban environment, if there's an emergency and your ER is full, you can divert them to another hospital. We don't have that luxury here, so you have to take all the folks who are coming in,” said Ransone.

Because of this, small group and solo practices may not have the time needed to do what is needed for optimal patient care, said Ransone. “Frequently, it takes a lot of time to have the conversation with the patient to help them overcome their concerns about vaccines. Mental health issues, which have seen a huge flare in the last year, it takes time to deal with those and in a rural environment, we don’t have a lot of the paraprofessionals and other professionals that we need to help them. So, it gets put on the rural practitioner.”

Ransone discussed his concerns about the impact on clinicians in more remote areas of increasing patient loads and long clinic hours. In particular, Ransone worries about compassion fatigue and burnout among physicians.

“The compassion fatigue that we're seeing right now is just really starting to reach epidemic levels because they're [clinicians] so stressed and we don't have the time we need in order to counsel the patients in an appropriate manner,” said Ransone.

Vaccine Hesitancy

A reprieve from influenza last season does not mean this year will be the same. Immunization Action Coalition (IAC) president and chief executive officer Kelly Moore, MD, MPH, told Patient Care Online, “It’s incredibly important that we go ahead and move full force in encouraging our patients to be vaccinated this year, just like they would have before COVID.”

Ensuring patients are up-to-date on their influenza vaccination can help protect the most vulnerable at risk for severe disease and reduce the overall seasonal burden of respiratory illnesses and COVID-19 infection.

A recent study published in the American Journal of Infection Control found that persons vaccinated against influenza were 24% less likely to be infected with COVID-19 than those who were not. Also, vaccinated patients who tested positive for COVID-19 were less likely to require hospitalization or mechanical ventilation and had a shorter hospital length of stay. In addition to preventing infection, influenza vaccination has been shown to reduce infection severity, hospitalization, and mortality.

Despite the well-known benefits of influenza vaccination, every year many patients are hesitant and often because of circulating misinformation. The CDC lists many of the most common misperceptions about influenza vaccination heard in clinical practice including that it is better to be infected with influenza than to get the flu vaccine, getting the vaccine gives you the flu, vaccinated individuals can still be infected with influenza, and getting a flu vaccine can make people more susceptible to other respiratory viruses.

Flu vaccine hesitancy is particularly high among parents. A recent national survey found approximately one-quarter of US parents are hesitant about having a child receive a flu shot primarily because of doubts surrounding its efficacy.

How can physicians fight flu vaccination misinformation and hesitancy? According to Moore, approaching a patient who is unsure about being vaccinated with data or more information doesn’t increase their motivation to receive it.

“When you look at a patient's decision to vaccinate, it's really a matter of trust,” she pointed out. “And that can happen whether they're highly literate in health issues or not so literate in health issues. If they trust their health care professional, their physician, their nurse practitioner, their pharmacist, a strong recommendation from a well-informed health professional actually is proven to be the most influential in that patient's decision to get vaccinated.”

With a patient you know well who is concerned about getting vaccinated against influenza Moore suggests, “…address that concern, and then restate your strong conviction that vaccination is the best way to protect their health. Sometimes people [clinicians] forget to come back to their original recommendation. It’s important to always return to that. And even if they don't make that decision today, keep bringing it up the next time. And if they really trust you, they will often change their mind and make a decision even if they don't understand all the science.”

Take Away Messages

The challenges this respiratory virus season might bring could be overwhelming to an already stressed primary care workforce, but NFID’s Schaffner wants all clinicians to remember they are not alone.

“We're all in this together. COVID keeps throwing us curveballs, we'll have to go with it,” said Schaffner. “We will all have to work very hard to remind our patients about flu, remind them that it’s also a very serious illness, that the vaccine is effective.”

IAC president Moore had a similar message for primary care clinicians, which started with a sincere thank you.

“I am not on the front lines of this battle. I have been in the background trying to provide all the support we can to help frontline clinicians do their jobs. But this has been an unimaginable year and a half. And I know that my friends and colleagues who are on the frontlines are absolutely exhausted. So, first of all, thank you, you are remembered, and we are here to help.”

“Vaccines are amazing tools, and they will do their job with time. But it's a lot of work to get them into the arms of the people who need them. And I'm so grateful for the work that everyone is doing and continues to do to protect the public from vaccine preventable diseases,” concluded Moore.