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As a physician at a Boston community health center that serves a large minority population, Dr. Julita Mir has had a close-up view of the coronavirus pandemic’s devastating impact, even beyond the obvious.
Mir tells of the patient from Guatemala who tearfully begged for a letter authorizing her to work despite having COVID-19 symptoms, and of a patient from Vietnam who postponed his liver ultrasound for six months as he sheltered in place, only to find out in mid-August that he had a fairly large tumor. Mir also knows of people taking Tylenol before a temperature check so they can pass and get the OK to work that day.
But as the U.S. approaches 200,000 deaths from COVID-19, more than any other country, what really troubles Mir is not so much what she has seen but what she envisions for the upcoming months as a combination of factors threatens to negate recent gains – and result in a deadly fall.
“My main fear is we will see cases of maybe influenza, maybe COVID, maybe some of the other respiratory viruses,’’ Mir said, “and because rapid testing is not available on a widespread basis, we will be in front of the people and we won’t know what they have.’’
Many in the medical community share her concerns.
The return of students to schools and colleges amid the coronavirus prevalence, mixed with the approaching flu season and easing of restrictions after a second round of tightening, makes for a worrisome scenario for public health specialists.
In California, which has the most people and COVID-19 cases of any state, the daunting challenges ahead may be further complicated by the smoke-filled air from an already hyperactive fire season that still has two months to go.
‘Hard to think of a positive scenario’
Dr. John Swartzberg, professor emeritus of infectious diseases and vaccinology at the University of California-Berkeley, said he expects the current national trend of decreased coronavirus-related deaths to continue through September, but then pick up gradually in October and even more so in November. Deaths from COVID-19 typically trail infections by about a month.
“It’s hard for me to think of a positive scenario where things are going to get better in October and November,’’ said Swartzberg, who is highly critical of the pandemic response by President Donald Trump’s administration. “I don’t see behavior changing adequately. I don’t see testing ramping up. I see political winds continue to be oppressive to doing the right things.’’
Swartzberg spent 30 years in clinical practice and said it wasn’t hard to diagnose the flu through a phone call or in-person consultation with a patient. That changed with the arrival of COVID-19, which presents very similar symptoms to the flu and other diseases caused by respiratory viruses that flourish in the fall and winter, when cold weather prompts people to move indoors.
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Absent readily available coronavirus testing with quick results – still a major hurdle across much of the country – the resulting confusion and proliferation of cases of COVID-19 and the flu could result in what some are calling a “twindemic,’’ which could overwhelm the health care system.
According to the Centers for Disease Control and Prevention, the flu has killed an average of 37,000 Americans per year since 2010. CDC Director Dr. Robert Redfield has said he’s especially worried about the possible impact on the coronavirus crisis of an early peak to the flu season, which typically gets going in late October, gathers steam in the next two months and crests in January and February.
With children and young adults back in classrooms for the first time since the hurried shutdown of schools and colleges in March, the chances for disease transmission are markedly enhanced, even when it’s still not certain how much kids spread the coronavirus. Recent studies indicate they can be transmitters even if asymptomatic.
“There’s a question about what role schools are going to play with COVID, but there’s absolutely no question what role schools play with influenza,’’ Swartzberg said. “Schools are the breeding ground for influenza. The kids bring it home to mom and dad and grandma and grandpa.’’
Older populations are at higher risk for the harshest effects of COVID-19, and developing the illness at the same time or successively with the flu could be fatal.
School reopenings have already yielded clusters of coronavirus cases in several states, at times forcing a return to remote learning. Colleges have been an even bigger trouble spot, reporting more than 10,000 positive tests from the beginning of the fall term through the end of August, and more than a dozen colleges across the country have reported more than 1,000 cases. The University of Alabama alone recorded more than 1,000 cases in the first nine days of class, and more than 2,300 students have tested positive so far.
A New York Times survey of more than 1,500 institutions of higher learning revealed at least 88,000 infections and 60 deaths since the pandemic began.
A glimmer of hope out of Australia
Dr. George Rutherford, an infectious disease specialist at UC-San Francisco who heads California’s contact tracing program, calls middle schools, high schools and universities “big incubators of COVID-19,’’ pointing out they have been the sources of massive outbreaks in other parts of the world.
Given the early results in the U.S., the prospects for the coming months are not encouraging.
“To have the fate of the western world resting in the hands of 12- to 22-year-olds, it’s a little scary,’’ Rutherford said.
However, Rutherford finds a sign of hope in reports out of Australia, whose flu season precedes and often serves as a harbinger for the one in the U.S. Australia’s winter concluded Aug. 31, and Rutherford said the country of 25 million experienced its mildest flu season in five years.
There might be other reasons at play too, but it appears measures taken to keep the coronavirus at bay were a contributing factor.
“The smart money says there’s been much less circulation of influenza in Australia over this winter and it may well be a secondary effect of increasing respiratory precautions, like wearing masks and social distancing,’’ Rutherford said.
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The Australian government also launched an aggressive immunization campaign, increasing the number of flu vaccines it secured from 13.2 million in 2019 to 18 million and promoting the free shots. One survey revealed in late May that 72% of Australians had either been inoculated for the flu or intended to.
That figure may be out of reach for the U.S., where less than half of Americans received a flu shot last year. Redfield told WebMD last month that the CDC has procured an extra 10 million doses and he’s hoping 65% of Americans will get the vaccine, thereby blunting the impact of the flu coinciding with COVID-19.
Mir, the infectious disease doctor in Boston, said many families have failed to come in to have their children vaccinated this year out of fear of being exposed to the coronavirus.
She has also heard of pushback against a COVID vaccine once it’s available, which is consistent with a Gallup poll released Aug. 7 that showed 35% of Americans would not get the vaccine even if it were free and approved by the Federal Drug Administration.
Vaccine rejection has become a major issue for public health officials, part of what Dr. Anthony Fauci, the nation’s top infectious disease specialist, has referred to as an “anti-science bias.’’ The problem may have been exacerbated by increasing evidence of political pressure on the CDC and the FDA.
‘Failure of public trust’ a complicating factor
Barbara Koenig, a bioethics expert at UC-San Francisco who served on the advisory committee to the CDC’s director, notes that there’s a social dimension to the pandemic response that’s reflected in the public’s attitudes toward wearing face masks, maintaining social distance and accepting vaccinations.
“In some cases the idea that freedom is the most important value is very, very powerful,’’ Koenig said. “We also are existing in a moment of failure of public trust or lack of trustworthiness, and a reduced belief in scientific expertise. Those things make our efforts to deal with both flu and COVID difficult.’’
And they only figure to add to the hardship experienced by patients in health centers like the one where Mir practices. One of those patients, the woman from Guatemala, was not seeking treatment for her illness but rather authorization to work through it.
Mir told her she needed to isolate herself.
“She started crying, saying, ‘I have no money. I live paycheck to paycheck. Give me cough medicine and I promise I’m not going to cough in front of anyone. Give me a letter so I can work this week and feed my family,’’’ Mir recalled. “This is an example of how some people have suffered through this pandemic.’’
According to some forecasts, the suffering will continue. The often-cited COVID-19 model from the University of Washington’s Institute for Health Metrics and Evaluation projects more than 231,000 U.S. deaths by Nov. 3 – Election Day – and more than 279,000 by Dec. 1, five days after Thanksgiving.
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But in the last week, deaths have steadily declined, reaching 650 per day, down from the approximately 1,000 daily deaths the country averaged in August. Meanwhile, the IHME model predicts daily fatalities will peak at 1,038 in October and 2,267 by the end of November.
Though some health experts such as Redfield and Dr. Deborah Birx of the White House coronavirus task force have said the U.S. can still turn around that trajectory with stricter adherence to masking and distancing guidelines, the model’s prediction is in line with what other medical professionals in the private field expect.
Dr. Matt Lambert, an emergency room physician in Washington, D.C., who has expressed skepticism that universities can operate safely with students on campus amid the pandemic, said a synergy between the flu and COVID-19 will lead to a surge in hospitalizations and deaths in the fall and winter.
“Partially because of human behavior, and partially because of how viruses behave seasonally, I think we’ll start to see a trend upward right around the end of October,’’ Lambert said, citing gatherings at schools and elsewhere as a factor. “I think we could see significantly higher numbers than what we’re seeing right now.’’
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