In my last post I talked about key challenges for EDs—like those in the province of Ontario and in most of the developed world that are emerging from the first wave of COVID-19—as we look ahead to a probable second wave that may overlap with influenza and other seasonal respiratory viruses. Dr. Kieran Moore is an experienced emergency physician with dual certification in public health, and he is the Medical Officer of Health in the Kingston, Frontenac, Lennox, and Addington (KFL&A) region of Ontario. For years he’s provided excellent advice to EM in Ontario and projections regarding when to expect the flu peak and how severe the season is likely to be, and he’s pioneered the development of surveillance systems to support that work. Under his leadership, his region has done spectacularly well in the pandemic thus far, including avoiding a single case of COVID-19 in its long-term care homes (the pandemic has been a major problem for nursing homes and homes for the aged elsewhere in Canada).
In this guest post Dr. Moore provides advice for the province of Ontario that can be generalized to much of the northern hemisphere. Dr. Moore can be found on Twitter: @MOHKFLA.
—Dr. Howard Ovens, June 2020
Charting a course for success requires early planning for influenza and COVID-19 co-circulation
Our regular Influenza season typically runs from November to April and peaks in the second half of December. During the coming 2020/2021 flu season, we may also face co-circulation of COVID-19. Although it varies from year to year, the seasonal surge of influenza alone can stress the health care system significantly. So, with this foresight and what we currently know about preventing the transmission of viral respiratory pathogens, we need to do everything we can to reduce the impact of these viruses on the health of our communities and on the health care system.
Given that our health care system has experienced seasonal surge pressures due to influenza in the past, the challenges we are trying to avoid with COVID-19 are:
- Increased hospital occupancy rates that exceed regular capacity
- Longer ED wait times and stays, with delayed admissions for those requiring acute care services leading to “hallway” medicine
- Cancelled/postponed elective surgeries
- Delayed access to and morbidity/mortality in long-term care and retirement homes due to outbreaks of communicable diseases
- Over-extension of staffing resources due to overtime work, staff infections, and increased workload across the health system
Our hospitals and health system face significant issues in dealing with the impact of seasonal surge due to flu, but if a second wave of COVID-19 were to coincide with a bad flu season, it would stretch our capacity and have a negative impact on the morbidity and mortality of our communities.
We have a slight time advantage that will allow us to prepare for this, but to be successful we need to plan now. Specifically, we need an early and aggressive provincial influenza immunization strategy to minimize the impact of influenza this fall and winter with all partners participating including public health, primary care, pharmacists and employers.
In Canada, around 40% of the population usually gets immunized for influenza.1 The goal has been to immunize more than 80 per cent of those older than 65 years and adults ages 18 to 64 with chronic medical conditions. The actual immunization rates for these groups in our country are around 70% and 43%, respectively.1 To achieve population immunity we would need a much higher vaccination coverage. With an R0 for seasonal influenza of around 1.3 and an estimated vaccine effectiveness of the 2019/2020 vaccine of 45 per cent, this would require a minimum immunization coverage of 51% of the population, an 28% increase from the norm.2,3
Notably, this minimum immunization rate needs to occur among both the general population and among health care workers. To further promote vaccine uptake, the Public Health Agency of Canada’s 2020/2021 flu campaign will target at-risk populations such as seniors and people with compromised immune systems or with underlying medical conditions, while local public health units should plan to promote flu vaccination for all.
Opportunities to learn from other countries who have co-circulation of influenza and COVID-19
There are many good lessons that we have learned to date from Australia, as that country is currently navigating the early stages of its flu season, which typically peaks in August. It is hoped that the experiences from the southern hemisphere, with an early and aggressive influenza immunization strategy, will provide key lessons on how we can strengthen our own prevention and health promotion approaches before entering our “cold and flu” months this fall. However, given the flu virus’s ability to mutate, we cannot guarantee the strain experienced in the southern hemisphere will be the same one we see in the north.
Australia and New Zealand have seen considerable decreases in flu cases this year, which have largely been attributed to health promotion and disease prevention measures introduced in response to COVID-19.4 Both countries have had record vaccination rates this year: Australia administered and recorded more than 2.1 million flu vaccines since March 1, 2020, compared with 624,000 at the same time in 2019—an increase of 237%.5 New Zealand administered and recorded 587,000 flu vaccines as of April 17, 2020, compared with 290,000 at the same time in 2019—an increase of 102%.6 Both governments credit the lower levels of flu-like illnesses this year to their lockdown measures and immunization of their at-risk populations, providing an insight into how others can strengthen its prevention and health promotion strategies in preparation for co-circulation of the flu and COVID-19.
Achieving the minimum immunization coverage combined with adequate knowledge, attitudes, and behaviours may even allow for a non-severe flu season. Particularly, sustained health promotion and disease prevention messages related to maintaining physical distancing, frequent hand washing, and keeping group interactions to a minimum, as well as wearing face masks in public, continue to be extremely important.
The role of assessment centers in anticipating the co-circulation of influenza and COVID-19
Beyond adequate flu vaccination coverage and proper attitudes and behaviour, COVID-19 presents additional challenges to our health care system. As part of emergency response strategies to COVID-19, 143 assessment centers to date have been created in Ontario to manage patient traffic and, where possible, divert patients away from acute care settings.7 With the potential problem of managing co-circulation of the flu and COVID-19, we need an ongoing commitment to fund distributed and accessible COVID-19 assessment centers and to transition them to acute respiratory illness assessment centers in the fall.
Keeping these centers open (or a similar model based in primary care) will decrease the burden on EDs and primary care while streamlining the use of personal protective equipment (PPE) and testing. Historical data from the H1N1 pandemic of 2009 support this, as assessment centers reduced the burden on EDs in KFL&A by assessing approximately 2,100 patients with influenza-like illnesses.8 Having these assessment centers should maintain the efficient and effective assessment and testing of patients and help prevent nosocomial transmission to patients and health care workers.
The Ontario Emergency Medicine Provincial Table has discussed expanding the testing at these assessment centers to include influenza A/B, RSV, and COVID-19 for the fall. This will need to include a four-test PCR platform from one swab or other reliable point-of-care testing. This platform enables differentiation between these four major pathogens and appropriate treatment, and it enables cohorting to minimize the isolation times specific for the pathogens both at home and, if required, in hospital.
These illnesses resemble each other—attacking the respiratory system and causing fever—and this is a challenge that directly affects the number of tests needed for flu and for COVID-19.
Our ability to rule out flu depends on whether the patient has been immunized for flu in the first place. It also will depend on the flu vaccine matching the strain of influenza circulating at the time—something we are hopeful for but, nevertheless, is a game of cat and mouse. Each year’s flu vaccine is created with worldwide co-operation and effort. First, 100 countries’ national influenza centers send data to the World Health Organization. Then, five virology centers—in Atlanta, Beijing, London, Melbourne, and Tokyo—analyze the data and design a vaccine composed of three or four strains of influenza A and B.9
This added complexity of vaccine design further underlines the need for robust assessment sites. In addition to the 143 assessment centers created in Ontario, hospitals have prepared secondary acute respiratory assessment sites. These sites could be used to provide investigations, start treatment, and refer critically ill patients for ICU admission directly from the primary acute respiratory assessment sites, removing the need for patients to visit EDs.7 These sites would also reduce the number of cases of respiratory illness in EDs, facilitating the maintenance of sufficient ED capacity for non-respiratory issues. This strategy would support the anticipated seasonal surge and co-infection of pathogens and limit the impact on the ED and the risk of nosocomial transmission. We are working on this in my region, but we still need to understand if this aligns with the provincial strategy and whether funding for assessment centers will continue into 2021.
We could also consider the provision of antivirals at assessment sites for influenza for those without a drug plan.
A coordinated response to co-circulation of influenza and COVID-19
These assessment sites should be promoted by primary care providers by encouraging patients who present with respiratory illnesses to get assessed at these centers rather than in EDs. Integrating an electronic medical record for use in assessment centers would considerably improve monitoring and surveillance as well as the timely sharing of information, and it would facilitate the longitudinal follow-up and case/contact management of patients between assessment centers and primary care. Data could be collected in real time, linked to lab data, and analyzed, and the assessment could be shared with primary care providers.
There is an opportunity for health system partners to work together to develop a coordinated plan to prepare for, respond to, and recover from the coming influenza season and predicted co-circulation with COVID-19. A coordinated health system response is both proactive and reactive and requires a common understanding of the roles and responsibilities of different health care providers.
Additional actions and considerations:
- Maintain the enhanced communication lines established through our pandemic response efforts. Improve communication during the season, use medical directives to facilitate streamlined access to care, and operate assessment centers during a severe infection surge to help reduce strains on the health system.
- Provide consistent signage in different hospitals, primary care clinics, and the community to convey clear messages to the public. Include messaging on self-treatment, when to seek medical care, and how to reduce transmission within the community. An integrated muli-component social medical campaign should be used to ensure the information is available to all members of the community, including print (posters, newspapers), radio, social media, waiting room monitors, and websites.
- Bolster the community’s commitment to reduce transmission through behavior change. This includes ensuring social and physical distancing, keeping group interactions to a minimum, routinely maintaining adequate hand hygiene, wearing face masks in public, and staying home when feeling sick with early testing.
- Ensure that acute respiratory assessment centers are staffed with personnel who are trained in maintaining best practices, including maintaining 2-metre distancing and using PPE consistently and properly.10
- Have cohorting in health care settings involve both patients and health care personnel being physically isolated into four different units (influenza A, B, RSV, and COVID-19), limiting the potential for cross infection and nosocomial transmission.
- Screen outpatients and test them to identify asymptomatic or presymptomatic flu and COVID-19 cases to allow for fast and appropriate action to limit transmission to other patients and health care personnel.
- Use medical directives to guide the activities of medical and non-medical personnel and facilitate faster access to care during an influenza surge.
- Prepare for the increased demand for primary care providers that is anticipated for this fall, which could make it difficult to find staff for assessment centers and treatment clinics. Consider using medical directives to staff these clinics (including primary care provider–run clinics and nurse-led clinics), and make use of local medical trainees including medical students, nursing students, and resident physicians.
- Employ active surveillance systems monitoring for any early signs and symptoms combined with data-driven decision making. It will be important to ensure that there are adequate resources and supplies available and accessible to high-risk areas with sufficient infrastructure support.
- Ensure our elderly are protected in the community, retirement homes and long term care facilities with high immunization rates and ongoing screening, testing, and enhanced early detection of viral pathogens with robust prevention and outbreak management resources. They must anticipate a surge in illness and prepare for absenteeism of workers in partnership with the health system.
It remains to be seen whether influenza and COVID-19 will overlap. The actions we take now will determine how well we navigate the coming waves and resulting surges of illness. We’re aiming for something closer to smooth sailing across smaller waves as opposed to capsizing or, worse, sinking in rough waters.
—Dr. Kieran Moore is the Medical Officer of Health in the Kingston, Frontenac, Lennox, and Addington region of Ontario.
Dr. Moore and Dr. Ovens have no conflicts of interest to declare.
- Public Health Agency of Canada. Vaccine uptake in Canadian adults 2019. https://www.canada.ca/en/public-health/services/publications/healthy-living/2018-2019-influenza-flu-vaccine-coverage-survey-results.html. Published November 27, 2019. Accessed June 10, 2020.
- Biggerstaff M, Cauchemez S, Reed C, Gambhir M, Finelli L. Estimates of the reproduction number for seasonal, pandemic, and zoonotic influenza: a systematic review of the literature. BMC Infect Dis. 2014;14:480. Available from: https://pubmed.ncbi.nlm.nih.gov/25186370/. Accessed June 10, 2020.
- Dawood FS, Chung JR, Kim SS, Zimmerman RK, Nowalk MP, Jackson ML, et al. Interim Estimates of 2019–20 Seasonal Influenza Vaccine Effectiveness — United States, February 2020. MMWR Morb Mortal Wkly Rep. 2020;69(7):177-182. Available from: https://www.cdc.gov/mmwr/volumes/69/wr/mm6907a1.htm. Accessed June 10, 2020.
- Government of Ontario. COVID-19 assessment centre locations web page. https://covid-19.ontario.ca/assessment-centre-locations/. Accessed June 10, 2020.
- Australian Government Department of Health. FluTracking website. https://info.flutracking.net/. Accessed June 10, 2020.
- Record 16.5 million flu vaccines to protect Australians [media release]. Canberra, Australia: Minister for Health Greg Hunt; April 19, 2020. https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/record-165-million-flu-vaccines-to-protect-australians. Accessed June 10, 2020.
- Record number of New Zealanders protected with flu vaccine [media release]. Wellington, New Zealand: Associate Health Minister Julie Anne Genter; April 27, 2020. https://www.beehive.govt.nz/release/record-numbers-new-zealanders-protected-flu-vaccine. Accessed June 11, 2020.
- Mather R, Moore K. Influenza Preparedness Workshop Report. Kingston, ON: KFL&A Public Health, 2019. Available from: https://www.kflaphi.ca/wp-content/uploads/Influenza-Preparedness-Workshop-Report_final_3-logos.pdf. Accessed June 11, 2020.
- Centers for Disease Control and Prevention. Selecting Viruses for the Seasonal Influenza Vaccine. https://www.cdc.gov/flu/prevent/vaccine-selection.htm. Published September 4, 2018. Accessed June 11, 2020.
- World Health Organization. Algorithm for COVID-19 triage and referral: patient triage and referral for resource-limited settings during community transmission. Manila, Philippines: WHO Regional Office for the Western Pacific; 2020. Available from: https://apps.who.int/iris/handle/10665/331915. Accessed June 11, 2020.