Can We Avoid the Double Whammy of Flu Season Amid COVID?

Public health officials have kept up a steady stream of warnings over the last few months about the approaching flu season. They present a scenario in which the return of seasonal flu swamps health systems still struggling to manage the ongoing coronavirus pandemic, catapulting us back into a situation reminiscent of the dark days of spring in which hospitals are swamped and medical care suffers. To stop the flu and this dangerous “twindemic,” they say, it’s paramount that as many Americans as possible get the ordinary seasonal flu vaccine. This message has been covered exhaustively in the media in recent weeks, and public health officials and vaccine manufacturers have been working hard to build awareness and lower barriers to vaccine access. The CDC has ordered 9.3 million doses to distribute to the uninsured, an 18-fold increase over a normal year.  

The only question now is: Will people listen?

The struggle to get people to get a flu vaccine isn’t new. Every year around this time, public health types whip out their megaphones and start telling people to go get their shot. After all, the flu is no joke: It kills tens of thousands of Americans every year. Substantial effort goes into making the vaccine as easy to get as possible: You can get a flu shot at the grocery store, at the pharmacy, at pop-up clinics at work or school. Go to any doctor’s appointment after Labor Day; they’ll probably pester you about getting vaccinated for flu.

And yet, every year, only about half of Americans actually get the shot.

There are a few reasons for this. One is simple misinformation. While the much-maligned “anti-vaxxer” movement tends to focus its conspiratorial ire on pediatric vaccines like the measles shot, one bit of flu-vaccine misinformation has proved difficult to squash over the years: That the flu vaccine gives you the flu. Epidemiologists attribute the longevity of this myth to a common correlation-causation problem. After you get a vaccine, it may take from one to three weeks for your body to actually build up its immune defenses to a degree where you can be considered “immunized”; if you come down with it in the meantime, it’s natural to wonder whether the vaccine had something to do with it, even though that’s medically impossible.

That sort of misinformation isn’t the biggest reason people don’t get a flu shot, however. Far more people—four times as many, according to one 2015 study—just don’t get vaccinated because they don’t think it will do them any good. Either they don’t think the vaccine is effective, or they don’t think they need to go out of their way to avoid what is, after all, just the common flu.

The basic problem, health communication experts say, is the disconnect between the medical purposes of a vaccine and its public health purposes. As a general rule, when it comes to vaccines, these purposes go hand in hand. You get vaccinated so you won’t get sick—medical. And when a critical mass of people get vaccinated, the disease can’t find enough targets to spread widely, and even the people who weren’t vaccinated benefit—public health.

For a seasonal illness like the flu, the public health purpose of the vaccine is there, but for many people, the medical purpose is not. And, for most people, the medical purpose is the salient one when it comes to deciding whether or not to get a vaccine. If you’re young and healthy, odds are the flu won’t do anything more than give you a nasty few days in bed. On top of that, the flu vaccine’s effectiveness varies wildly from year to year, depending on how well its developers have managed to forecast which strains will be circulating in the months to come during the development stage.

“For infectious diseases, even a vaccine that’s 70 percent effective can have massive population protective effects, in terms of reducing transmission,” Dr. Jeff Niederdeppe, a professor of communication at Cornell who specializes in strategic health messaging, told The Dispatch. “Yet when an individual is considering getting a flu shot, ‘Oh, well, three out of 10 times I’m going to get the flu anyway?’ That’s a very different calculation for that person.”

All this is discouraging stuff for those who are hoping to see a spike in flu vaccinations this year. But they’re hoping that one crucial difference may shake up the calculations: Compared to most years, people this year should have a substantially heightened interest in the public-health side of the coin. Getting vaccinated for flu doesn’t just mean saving yourself a few days’ misery: If everyone gets vaccinated, it’s that much less respiratory virus going around this fall, that much more attention doctors and epidemiologists can devote to keeping COVID at bay, and that much likelier communities can continue to tentatively reopen.

The important question, Dr. Niederdeppe said, needs to be “what is lost by not doing the vaccine?”

“What do people value? People want their lives back, they want to go back to being able to do the things they could do,” he said. “They want to be able to go to football games, they want to be able to go to concerts. They want to be able to gather with people. And my hunch is that [we need] messaging that says, you know, you getting the flu vaccine helps us have a chance at doing that, because we’re not overloading the health care system, we’re not gonna be shutting things down to offset the spread of this thing.”  

Even with such a winning message calibrated, challenges to getting it into the public bloodstream remain. For starters, after six months of pandemic, people are just worn out of trying to stay up to date on the latest medical information. Citing data from social media analytics firm NewsWhip, Axiosrecently reported that online engagement on stories about the coronavirus fell dramatically throughout the summer, currently hovering about where they were in mid-February, before the virus ever upended our lives at all.

“Nobody has any extra brain bandwidth right now,” said Dr. Megan Ranney, an emergency physician and professor at Brown University. “We’re all skating on the edge between distance learning and working from home and figuring out new technology and worrying about our parents or kids. Americans don’t have a lot of extra emotional or intellectual energy right now.”

Then there’s the fragmentary nature of today’s media. Getting a public health message out there isn’t just a matter of buying up ad slots on network TV or Google Ads, particularly when it’s a message you’re trying to get into the hands of everybody in the country. (That problem is exacerbated, Dr. Niederdeppe said, by the fact that we’re currently at the point in an election cycle where a huge chunk of the available ad time everywhere is being snapped up by political campaigns.)

“I think back to a time when, you know, the messaging was on TV or in your newspaper,” said Dr. Cindy Prins, a professor of epidemiology at the University of Florida’s College of Public Health. “And now there are so many outlets for messaging, and so many different populations that need to be reached in different ways. And I’m just not sure that all of those channels are really getting this hard push of, boy, we need everyone to get vaccinated for flu.”

The CDC is accordingly taking a flood-the-zone approach to its educational efforts about the vaccine this year. A spokesperson tells The Dispatch that efforts include “social media, press conferences, web page spotlights, radio media tours, op-eds, and other publications,” and “a digital campaign to educate the general public and people who are at increased risk from influenza and COVID-19 complications.”

Private companies are lending a hand as well. Spokespeople for CVS and Walgreens, two of America’s biggest pharmacy chains, told The Dispatch that they’re stepping up their efforts to market the flu vaccine this year. Walgreens representative Alexandra Brown added that “our approach this season differed because we placed more emphasis on early consumer awareness on the importance of flu shots, as well as leaned into our mass personalization approach through digital channels and mass media.” 

CVS’s Matt Blanchette said that they’re preparing for a big surge: “We anticipate delivering 18 million flu vaccinations this year, which is approximately double the amount provided during the 2019-2020 flu season.”

It’s too early to know whether these messaging campaigns are bearing fruit. One encouraging sign, at least, can be found in surveys of vaccine intentionality: A study commissioned by CVS in July found a significant month-over-month increase in people who intended to get the vaccine: 66 percent said they would definitely or likely get it, compared with only 34 percent in January.  

But intending to get something done is one thing; actually following through is another story. An NORC poll in late 2018 found that 57 percent of adults had either gotten a flu shot already or intended to do so; in the end, however, only 45 percent of adults were vaccinated, according to the CDC.

All things considered, America’s pandemic response has been going reasonably well recently: Large swaths of the economy have reopened, millions of children have returned to school (while millions more are still learning from home), yet new cases have been falling relatively steadily since late July, daily COVID deaths have slowed to below 1,000 a day, treatments for the seriously ill continue to improve, with mortality rates dropping as a result, and a vaccine is seemingly on the horizon.

With all those trends moving in the right direction, the seasonal flu may be our final pandemic hurdle. But it’s a high hurdle nonetheless. Over the next month, we’ll find out how well we’ve done in clearing it.

Photograph by John Nacion/SOPA Images/LightRocket/Getty Images.