Q&A: ‘We’ve Never Been Here Before’ … Flu on Top of COVID

We’ve entered a lot of uncharted territory in this annus horribilis, and more lies before us. Linda Spaulding, RN, BC, CIC, CHEC, CHOP, tells Infection Control Today® that “we’re looking at just a few days away before we might be seeing some flu activity.” Because sometimes the flu comes early. That might be true this year even when another uninvited guest—coronavirus disease 2019 (COVID-19)—refuses to leave. Spaulding, a member of ICT®’s Editorial Advisory Board, expects that the flu-COVID combination will further strain a healthcare system that’s been struggling to contain a raging pandemic all year. “And don’t forget, you know when the flu is here, we also have a lot of other respiratory viruses during that time,” says Spaulding. “It’s not just influenza A and influenza B we see during flu season. We still have the common cold, we have rhinoviruses, we have all kinds of things circulating during that time, along with flu and COVID. It’s going to be a very, very busy few months.”

Infection Control Today®: So how complicated can this get: the flu on top of COVID-19?

Linda Spaulding, RN, BC, CIC, CHEC, CHOP: This can get very complicated. And I don’t think it’s a matter of will it be complicated or not? I really think it’s going to be. Currently, we’re still dealing with a large number of COVID cases throughout the United States as well as throughout the world. But we don’t have enough testing for COVID in place yet to be able to give us the things we need during flu season because we’re going to be having to do flu swabs as well as COVID swabs because both COVID and the flu have similar symptoms. So, in the past, we only had to worry about flu. You started getting a lot of people with the respiratory tract infection, and fevers. You probably had a flu outbreak going on. Now, you don’t know if it’s going to be flu or COVID. And unfortunately, there’s going to be no way to distinguish between the two, unless we have really good testing and being able to test a lot. And right now, we don’t have that capability in the United States. We’ll be able to test for flu, no problem. But the COVID test, we’re still going to have problems. In the past, the flu swab will come out negative, and then we would send it on for PCR testing. And then that would confirm: Do we have a flu outbreak going on or not? So now we’re going to have to do the rapid flu. If it’s negative, we’re going to have to send it for PCR. But the labs are going to be inundated because not only will they get flu swabs for PCR, they’re also going to get COVID swabs for PCR. And they’re having a hard time keeping up with COVID. Now, unless labs are able to increase their manpower, they’re going to have to double or triple the lab work. And so that’s going to mean a decrease in time getting results back for probably even influenza PCRs.

ICT®: You’re saying is it’s probably going to get crazy, but what can infection preventionists do besides brace themselves?

Spaulding: Well, there’s a lot they can still do. And we’ve been dealing with COVID enough, so they know that they have to isolate, they have to wear PPE. For flu, we wouldn’t be suggesting the same PPE as we do for COVID. But you’re not going to have a flu ward, a COVID ward, say like in long-term care, because you’re not going to know if it’s COVID or flu. And unfortunately, I think long-term care is going to get hit pretty hard, because a lot of the resources will still go to acute care. Because their numbers of hospitalizations are going to possibly double also. So, good handwashing, proper use of PPE, keeping residents in their rooms, doing occupational therapy and physical therapy in their rooms, restricting visitors. Visitors just are not going to be able to come in because they can bring the flu in, they can bring COVID in. Some places have opened up that you can go outside and sit with your loved one and visit. But I think when flu season comes on and the flu outbreaks start, that’s going to come to a halt. Flu vaccine is extremely important. And don’t forget, you know when the flu is here, we also have a lot of other respiratory viruses during that time. It’s not just influenza A and influenza B we see during flu season. There’s more flu circulating. We’re only testing for the flu that they suspect is going to cause the most deaths for that year. That’s how they decide what the flu vaccine is going to be. They is still respiratory syncytial virus (RSV) among young kids, and even the elderly. A couple of years ago, I worked up in RSV outbreak in a long-term care facility of all adults. We still have the common cold, we have rhinoviruses, we have all kinds of things circulating during that time, along with flu and COVID. It’s going to be a very, very busy few months.

ICT®: Two people come into the hospital with respiratory disease. One has COVID-19 and one has the flu. How long it will take healthcare workers, including infection preventionists, to know which one is which?

Spaulding: If the hospital has a good rapid test, and there are a lot of rapid tests on the market, but not all of them are accurate. But if the hospital is lucky enough to have one of the accurate tests, then you can probably get results back in 15 minutes, a half hour. For influenza, you should be able to get influenza results back in 15 minutes to a half hour. But remember, that’s only a rapid test for influenza, and 20% of the rapid tests might be false negatives. You still have to go to PCR. PCR tests usually run up to 48 hours to seven days depending on the lab capability in whatever particular part of the country you’re working. It’s still going to take some time. And my concern is if the rapid for flu comes back as positive, can we be assured that that person doesn’t have COVID, also?

ICT®: Can we?

Spaulding: We don’t know. We haven t had a flu season with COVID yet. We’re going to have to see how it all plays out. And how many co-infections do we have of COVID and influenza. Or we just treat everybody as if they have the flu and COVID. PPE up for everybody that has a respiratory tract infection. Now in kids, it’s a little different. Because here in Miami, where I am right now, kids are presented with diarrhea, not fever. And, so, you go looking for the GI bugs in kids but in this particular area, we know if a child comes into an ER with diarrhea that we have to think COVID, because that might be the only sign they have. That kind of causes a problem in the mix too.

ICT®: Is there anything systemically that infection preventionists can maybe talk to hospital administrators or leadership teams about that they can try to put in place to handle this situation?

Spaulding: Nothing more than PPE and handwashing and flu vaccine. That’s the only arsenal we have.

ICT®: What about drive-through testing?

Spaulding: Drive-through testing has been done for COVID. It could be done for flu. But even a lot of the drive-through places have closed down because of lack of testing supplies. Like I say, we’ve never been here before. When flu starts hitting really hard, we’re going to start seeing: “OK, how are we going to adjust for this?” Depending on the situation, because the problem we might have in Florida may not be the problem you have in Ohio. They might have a whole totally different problem. Whatever we’re doing isn’t going to work for them and vice versa. The CDC will monitor it closely. And then they will help us adjust what we have to do in different areas of the United States.

ICT®: When does flu season typically begin? November?

Spaulding: Well, they look at usually October through May, but a lot of states have seen outbreaks of influenza in September. So, we’re looking at just a few days away before we might be seeing some flu activity.

ICT®: Any final words of advice for infection preventionists other than to do what they usually do?

Spaulding: Contact tracing. Good hand washing. Get the flu vaccine. I’d like to say get plenty of rest, but if you’re a nurse these days, you’re already exhausted. Plenty of rest isn’t going to help you. And that’s really about it. You know, monitor what’s going on. Employees at the hospitals and long-term care facilities need to be looking toward infection control to give them the information they need. Because infection control is usually monitoring the situation very closely. They can recommend when we see by surveillance every morning, we’re getting into trouble. We’re starting to see more flu. We’re starting to see different symptoms. We have an uptake of RSV. All those things. Infection control people really have to monitor closely all respiratory viruses that are out there and be sure that you’re working actively with management to help put in place whatever needs to be put in place. And, communicate well with the nursing staff. Communicate well with all departments. Because if housekeeping sees nurses wearing a particular PPE, but they’re not being given it to wear, they’re going to be scared. “Why do they get better protection than me?” You’ve got to have all that line of communication open and really work hard at it.

ICT®: What about the lines of communication to public health officials? Is that something above an infection preventionist’s is pay grade?

Spaulding: No. Infection control or infection prevention talks to the Department of Health, frequently, sometimes on a daily basis. And our Department of Health will let us know: “Hey, there’s an uptake in the cultures that we’re getting.” Because they will get a download from all the hospitals and they will be able to watch when there’s an increase in influenza or an increase in respiratory disease, an increase in diarrheal disease. That kind of stuff. We get that information from the Department of Health because they have data put in from all the hospitals that come to them on a daily basis. And they can analyze that data, and then give us a heads-up: “This week, we’re seeing an increase in this particular thing.” The communication is usually very good between IPs and the Department of Health.

This interview has been edited for clarity and length.