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Home , Flu season

September 2020 | Volume 69, Number 5

Contact: 971-673-1111 | [email protected] | www.healthoregon.org/cdsummary

FLU IN THE TIME OF COVID-19

very year, we put out the call for As COVID-19 rose from faraway area were hospitalized with , people to get vaccinated against disease emergence to pressing and 26 (3.7%) of them died during their influenza. This year, the call is threat, CDC established hospitalizations. E a new surveillance system, COVID- Following the start of surveillance on particularly pressing. The 2020–2021 flu season begins amidst a pandemic 19-Associated Hospitalization Surveil- March 1, COVID-NET hospitalizations of another respiratory disease and an lance Network (COVID-NET), based rose rapidly before peaking with 72 hos- unsettling number of unknowns — the on FluSurv-NET, to identify and review pitalizations during the week of March th pathophysiology of COVID-19, treat- laboratory-confirmed COVID-19 hospi- 29 . After substantial declines during ment strategies for this new disease, talizations. This surveillance captures May–June, COVID-19 hospitalizations in- and the design and delivery of a novel cases admitted from March 1, 2020, creased again during the summer, reach- . We worry about influenza and onwards and in Oregon includes resi- ing 67 hospitalizations each during the th th SARS-CoV-2 coinfection and the po- dents of Clackamas, Multnomah, and weeks of July 5 and August 9 . In total, tential for a synergistic increase in dis- Washington counties. 1,090 Portland tri-county residents with ease severity: little is known about the The 2019–2020 flu season was COVID-19 were admitted from March 1 possible interactions of the two , unusual in that it was initially domi- to September 5, 2020, and 125 (11.5%) but both have been associated with nated by influenza B circulation. Flu died during their hospitalizations. serious cardiovascular complications, activity crested at the end of the year The period from March 1 to April 30 for example.1,2 Moreover, we foresee with 89 FluSurv-NET hospitalizations (from the start of surveillance for Port- an increased burden on our health during the week of December 29, land Metro COVID-19 hospitalizations to systems — personnel, hospital beds, 2019 (Figure). The season then took the end of the 2019–2020 surveillance personal protective equipment, speci- on a bimodal character as declines season for influenza) tells the compli- men collection kits, testing supplies, in influenza B activity were overlaid cated story of the real-world interactions and laboratory capacity — as we col- with increases in influenza A/H1N1, of these two respiratory diseases. On lectively battle seasonal flu (itself noth- most notably in late February 2020. the one hand, precautions put in place ing to sneeze at, with 12,000–61,000 Over the course of the season, 708 in March (under Governor Brown’s ex- nationally per year3) and an individuals in the Portland tri-county ecutive orders as well as electively un- infectious disease disaster unlike any the world has seen in a century.4 Figure. FluSurv NET and COVID-NET hospitalizations, Clackamas, Multnomah, and Washing- ton counties, October 1,2019– September 5, 2020 INFLUENZA AND COVID-19 HOSPITALIZATIONS Oregon is one of 13 states that participates in the Influenza Hospital- ization Surveillance Network (FluSurv- NET), a Centers for Disease Control and Prevention (CDC) Emerging Infections Program surveillance net- work that covers more than 27 million people (approximately 8% of the US population) in 80 counties.5 In Oregon, FluSurv-NET identifies patients who are residents of Clackamas, Mult- nomah, and Washington counties and who are hospitalized within 14 days of a positive laboratory test for influ- enza from October 1 to April 30 each flu season. Detailed chart reviews are conducted to collect case risk factor and outcome information. Table. 2020–2021 U.S. Components

STRAIN EGG-BASED CELL- OR RECOMBINANT- BASED VACCINES A/H1N1 A/Guangdong-Maonan/SWL1536/2019 A/Hawaii/70/2019 (H1N1)pdm09-like (H1N1)pdm09-like A/H3N2 A//2671/2019 (H3N2)-like A/Hong Kong/45/2019 (H3N2)-like B/Victoria B/Washington/02/2019-like (Victoria B/Washington/02/2019-like (Victoria lineage) lineage) B/Yamagata B/Phuket/3073/2013-like (Yamagata B/Phuket/3073/2013-like (Yamagata lineage) lineage) dertaken by individuals) to prevent the influenza vaccine dose is considered a • CDC FAQ for the 2020–2021 Influen- transmission of COVID-19 helped to “precaution” for vaccination. Live at- za Season: www.cdc.gov/flu/season/ bring about a precipitous decline in in- tenuated influenza vaccine (LAIV) use faq-flu-season-2020-2021.htm fluenza activity. On the other hand, we requires additional consideration, and • CDC FluView: https://gis.cdc.gov/ can see the combined burden of these there are newly listed contraindica- grasp/fluview/fluportaldashboard.html two diseases from March to April (Fig- tions for it: asplenia (both anatomical • CDC COVIDView: www.cdc.gov/ ure). This graph also invites us to con- and functional), presence of a cochlear coronavirus/2019-ncov/covid-data/ covidview/index.html sider the costs of nine straight months implant, and any cranial cerebrospinal of sustained respiratory disease activ- fluid (CSF) leak. As in previous years, REFERENCES ity — and with no end in sight. LAIV should also be avoided by im- 1. Chow EJ, Rolfes MA, O’Halloran A, et al. Acute cardiovascular events associated with munocompromised persons and their THE 2020–2021 FLU SEASON influenza in hospitalized adults: A cross-sec- Vaccination against influenza takes close contacts, pregnant persons, kids tional study. Ann Int Med 2020. doi:10.7326/ M20-1509. on a new urgency this year—to pre- 2–4 years of age with , kids of any age receiving salicylates (aspirin), 2. Nishiga M, Wang DW, Han Y, Lewis DB, vent both the misery of la grippe and Wu JC. COVID-19 and cardiovascular or persons who have recently received concern for COVID-19, which presents disease: from basic mechanisms to clinical with similar symptoms; the latter is influenza antiviral medications — with perspectives. Nature Reviews Cardiology. 2020:1–16. important for the individuals who might expanded timeline restrictions: within 48 hours for and , 3. Centers for Disease Control and Preven- be asked to isolate themselves and for tion. Disease Burden of Influenza. Influenza 5 days for , and 17 days for (Flu). www.cdc.gov/flu/about/burden/index. health care systems that will expend 4 additional personal protective equip- baloxavir. html. Accessed 4 September 2020. 4. Grohskopf LA, Alyanak E, Broder KR, et al. ment and testing supplies in ruling Two new vaccine licensures mean that quadrivalent protection will be Prevention and control of seasonal influenza out SARS-CoV-2 infection. Influenza with vaccines: Recommendations of the vaccination is recommended for all available for the high-dose and ad- Advisory Committee on Immunization Prac- individuals 6 months of age and older juvanted vaccines recommended for tices — , 2020–21 influenza ≥ season. MMWR Recommendations and without medical contraindications be- adults ages 65: Fluzone High-Dose Quadrivalent (HD-IIV4, requiring a Reports. 2020;69:1. fore the end of October. This season’s 5. Centers for Disease Control and Prevention. flu vaccine features updated influenza slightly higher dose volume (0.7 mL) Influenza Hospitalization Surveillance Net- A/H1N1, A/H3N2, and B/Victoria than its trivalent predecessor) and work (FluSurv-NET). www.cdc.gov/flu/week- 4 ly/influenza-hospitalization-surveillance.htm. components, though the specific viral Fluad Quadrivalent (aIIV4). Multiple studies — including one based on Or- Accessed September 2020. strains differ by vaccine brand (Table).4 6. Robison SG, Thomas AR. Assessing the While vaccination is broadly recom- egon FluSurv-NET and immunization effectiveness of high-dose influenza vac- mended for all persons, it is particu- registry data — show that both high- cine in preventing hospitalization among seniors, and observations on the limitations larly needed for those at higher risk of dose and adjuvanted vaccines provide better protection for older adults than of effectiveness study design. Vaccine. complications, including children <5 2018;36:6683–7. and adults ≥50 years of age, persons do standard-dose vaccines, though 7. Gravenstein S, Davidson HE, Taljaard M, et with chronic health conditions, im- CDC’s Advisory Committee on Immu- al. Comparative effectiveness of high-dose versus standard-dose influenza vaccination munocompromised persons, pregnant nization Practices has expressed no preference for one formulation over the on numbers of US nursing home residents and postpartum persons, American In- admitted to hospital: a cluster-randomised 6–9 dians and Alaska Natives, and people other. In general, better to vaccinate trial. The Lancet Respiratory Medicine. living in congregate settings. Addition- with what you have than to miss an op- 2017;5:738–46. 8. DiazGranados CA, Dunning AJ, Kimmel M, ally, people who live with or take care portunity that may never be made up. There are plenty of unknowns on et al. Efficacy of high-dose versus standard- of any of these high-risk groups are a dose influenza vaccine in older adults. priority for vaccination.4 the path ahead—with our first fall and NEJM. 2014; 371:635–45. winter with COVID-19 and the flu sea- 9. Van Buynder P, Konrad S, Van Buynder J, et The sole contraindication for inacti- al. The comparative effectiveness of adju- vated and recombinant influenza vac- son never easy to predict — but one known is that the influenza vaccine is vanted and unadjuvanted trivalent inacti- cines is a history of a previous severe vated influenza vaccine (TIV) in the elderly. allergic reaction to a prior influenza available and offers protection. And Vaccine. 2013;31:6122–8. vaccine or one of its components. A that now is the time to get one. history of developing Guillain-Barré FOR MORE INFORMATION syndrome within 6 weeks of a previous • Oregon FluBites: http://bit.ly/flubites PUBLIC HEALTH DIVISION

Providence Portland Medical Center designates this enduring material for a maximum of .5 AMA PRA Category 1 creditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Portland Providence Medical Center is accredited by the Oregon Medical Association to sponsor continuing medical education of physicians. You can get this document in other languages, large print, braille or a format you prefer. Contact the Public Health Division at 971-673-1222. We accept all relay calls or you can dial 711. for TTY.