A 3D computer-generated rendering of a whole influenza (flu) virus. CDC.

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As the omicron variant of the COVID-19 virus makes its way across the nation and delta variant cases surge once again, North Carolina health officials see the possibility of another viral threat: influenza.

Last year, many health officials warned of the possibility of a “twindemic,” in which high amounts of both flu and COVID-19 cases occur at the same time. Instead, the flu rate stayed low, a blessing many health experts attribute to greater precautions being taken during the pandemic than in a normal flu season.

This season, experts predict flu cases will increase as local governments relax restrictions and more people forgo masks and social distancing.

Flu deaths are tracked, but individual cases are not. The COVID-19 dashboard allowing the public to track COVID cases is unique to the pandemic.

The state does offer weekly snapshots of flu-like and COVID-19 activity across the state in the “Respiratory disease surveillance summary,” published by the N.C. Department of Health and Human Services on Thursdays during the reporting season from October through May. Providers across North Carolina submit samples to the state.

As of Dec. 9, both the DHHS summary and data from the national Centers for Disease Control and Prevention showed a low but rising number of flu cases in North Carolina.

Emergency department visits for “COVID-like illness” increased in most parts of the state. Only one region showed lower amounts of visits as of Dec. 4 than it had the week before. All other areas of the state showed more or the same number of visits.

The CDC classified North Carolina’s influenza-like illness activity and that of Tennessee and Virginia as “low.” South Carolina and Georgia were listed as “moderate.”

As of Thursday, there had been no flu-associated deaths reported this season in North Carolina. The flu reporting season began Oct. 3 and will conclude on May 21.

Possible protection

As cases of flu rise and temperatures drop, DHHS is encouraging residents to “layer up.”

Just as residents can wear layers of clothing in the winter to protect themselves from chilly temperatures, DHHS recommends stacking different types of defenses against respiratory illnesses.

“It is possible to be co-infected with flu and COVID, and if you have both at same time, you are at an increased risk of severity of illness, because they are two different viruses, two different infections, and both at same time is an increased risk of disease severity,” said Dr. Elizabeth Cuervo Tilson, state health director and chief medical officer for DHHS.

Many flu symptoms overlap with COVID-19 symptoms

According to the DHHS website, flu symptoms can include “fever or feeling feverish/chills, cough, shortness of breath or difficulty breathing, fatigue, sore throat, runny or stuffy nose, muscle pain or body aches, headache, (and/or) vomiting and diarrhea, but this is more likely to occur with children.”

Some people may notice different symptoms that might indicate a COVID-19 infection.

“Flu viruses can cause mild to severe illness, including common signs and symptoms listed above,” DHHS states on its website. “COVID-19 seems to cause more serious illnesses in some people. Other signs and symptoms of COVID-19, different from flu, may include change in or loss of taste or smell.”

Testing can help reduce uncertainty.

The flu shot doesn’t always prevent infection, but even if an infection occurs, the shot can reduce the degree of the symptoms, Tilson said. Along with the COVID-19 vaccine, it represents a good first layer of protection.

The CDC recommends that members of the public receive a flu vaccine as quickly as they are able to, practice proper hygiene and basic preventive steps, including staying home when ill, communicating with health care providers when symptomatic and following their provider’s instructions regarding antiviral medications in the event of a flu infection.

Anyone presenting symptoms of the flu or COVID-19 can receive testing for a diagnosis and should seek treatment quickly, according to Tilson.

Masks are another layer, Tilson said. Social distancing when possible offers another protective tool.

Last year’s low levels of flu illustrated how well those layers work, according to Tilson.

“We had almost no flu spread because hand-washing, masks and limiting crowds were effective in preventing the spread of respiratory viruses, COVID and flu,” Tilson said.

According to the CDC, between 12,000 and 52,000 deaths were caused by flu each year nationally between 2010 and 2020. The 52,000 high point came in the 2017-18 season, but then dropped to 28,000 the following year.

As more people leave their masks at home or skip vaccines, cases will likely rise this year compared to last year, according to Tilson.

“What we’ve been stressing is no one prevention strategy is 100,% and that’s why it’s important to layer strategies,” Tilson said.

“Vaccines are really important, but not 100%. Masks are not 100%. Social distancing is not 100%. So, the best thing people can do is layer those protection strategies to protect themselves and their loved ones.”

Tracy Jones, the epidemiology nursing supervisor at the Robeson County Health Department, encourages everyone who is eligible to get their flu and COVID-19 vaccines.

“Don’t let your guard down,” Jones said.

“Don’t become complacent. I’m tired of wearing masks also, but I’m also tired of reading death reports and seeing all these case reports coming in and reporting clusters and outbreaks to the state. People just need to realize that the longer we go with this low vaccination rate, the longer this (corona)virus has to mutate.”

Four hundred and forty-four deaths occurred from COVID-19 in Robeson. A “couple of those” were residents with co-infections of COVID-19 and flu and occurred during last flu season, according to Jones.

Jones estimated the Health Department has administered at least as many vaccines this year as it has in previous years.

“For older people, we do offer the high-dose flu vaccine here,” Jones said. “We actually ran out and had to order more. It was one of the first times I can remember that happening that we had to order more high-dose flu vaccines.”

The tricky part is getting younger residents to get their flu shot.

“We have folks who come here every year to get flu shots, and the majority is the older population,” Jones said.

“They will continue to get flu shots. They have been for years. We’ve never had a large number of young folks come here to get their flu shots, so that hasn’t changed.”

The Health Department also offers the shots to pregnant women during maternity clinics.

Jones wants people to understand that while most people recover, the flu can be serious.

“I always promote the flu vaccine,” Jones said. Even before COVID started, she always told people how many people die every year from flu. “It’s not an old disease. It’s still present. It still kills people.”

In Guilford County, the Health Department tries to enter into a dialogue with residents.

Kenya Smith Godette, communications manager for the Guilford County Division of Public Health, said the county has partnered with local media outlets to ensure residents have access to information. 

Every two weeks, Dr. Iulia Vann, the division’s health director, speaks with FOX8 to address viewers’ questions and concerns. Recently, Vann answered community questions about the efficacy of the flu vaccine, how long protection from the shot lasts and other viewer questions on the program.

The clips are often posted to the Guilford County Division of Public Health’s Facebook page along with other information.

“People were really curious about children getting immunized against flu and about nasal sprays, so we did some on what’s effective for that age group,” Smith Godette, communications manager for the Guilford County DPH, said. “People are wondering if pregnant people could get it, so we addressed that, too.”

Smith Godette said the county also hopes residents will consider taking COVID-19 tests before attending holiday gatherings to reduce the spread of respiratory illnesses.

COVID-19 vaccines and flu shots can safely be administered during the same visit, whether the COVID-19 shot is a first dose, second dose or booster.

According to Tilson, surveys indicate that more residents are expressing confidence in the COVID-19 vaccine. She attributed it to the good experiences many have had with it as well as the ever-increasing amount of data related to it.

“That’s been really nice, seeing the increasing vaccine confidence and the understanding that the benefits greatly outweigh the risks,” Tilson said.

Many pharmacies offer both the flu and COVID-19 shot. To help find a location, try the vaccine finder at Vaccines.gov or call 800-232-0233.

Imari Scarbrough

Imari Scarbrough is a contributing writer to Carolina Public Press. Email her at imari.scarbrough@gmail.com