By Adam Urquhart

Granite State News Collaborative 

Health care officials in New Hampshire are expecting a resurgence of Covid-19 moving into flu season. 

In response, some hospitals will be testing for a range of respiratory viruses in patients who are presenting symptoms, meaning an individual could be tested for influenza, Covid-19, respiratory syncytial virus (RSV) and other respiratory viruses simultaneously. As it is, the flu and Covid-19 share very similar symptoms. 

At Catholic Medical Center (CMC) in Manchester, officials are going to be pursuing testing that will immediately test people for these viruses, which Dr. Joseph Pepe, president and CEO, (cq) said will basically be one test that looks for all of them. He believes a lot of people are going to want to get tested because they will want to distinguish themselves between the flu and Covid-19. 

Similar testing for a range of respiratory illnesses will also be done at Dartmouth-Hitchcock Medical Center (DHMC). Dr. Michael Calderwood, Associate Chief Quality Office at DHMC, specializes in infectious disease (cq) and explained that with the same swab, health care professionals can run testing for these viruses. 

“This is one of the most important years in our lifetime for people to get vaccinated with the flu because if the flu is bad this year in the midst of Covid, or even another covid surge, then the hospitals will fill up and this could make March, April and May look like it was nothing at all,” Pepe said. 

Officials at CMC are expecting a Covid-19 resurgence. Looking at the last three pandemics, Pepe explained that they have had a second surge, including the 1918 influenza pandemic. 

“We are hoping that it doesn’t occur but we are expecting it to occur, and unfortunately, it may overlap with the flu season,” Pepe said. 

In the meantime, people are encouraged to get a flu vaccine as it is most effective for about six months after receiving vaccination. Calderwood said that there is a lot of discussion around whether the flu season will come later this year, explaining that there is some suspicion that it will. 

Flu activity is most common during the fall and winter months, although seasonal influenza viruses are detected year-round in the United States, according to the Centers for Disease Control and Prevention (CDC). Although the timing and duration of flu season varies, activity typically begins to pick up in October. 

However, the custom of mask wearing is something that has not been done in prior flu seasons and so the transmission will likely be slower. Calderwood said while flu cases tend to begin in the early to mid-fall, it is possible that those will begin later in the fall because of masking. 

Moreover, patients at Portsmouth Regional Hospital (PRH) will also be tested simultaneously for influenza and Covid.  Dr. David Itkin is an infectious disease specialist (cq) at PRH and said that the hospital is also expecting and anticipating a surge from Covid and potentially influenza cases this fall. He also cited concern that there has been a little bit of laxity on behavior and education, with a need to ramp that up in anticipation. 

Itkin believes that the dynamic being looked at involves the changing weather, plus more people being indoors and less social distancing happening. The impact of schools and universities is another factor. 

“Nobody has a crystal ball,” Itkin said. “I can’t say, but I think that it’s going to be realistic to look at perhaps October, November or December, somewhere within there, for all of these factors to form the perfect storm,” Itkin said. 

Itkin said the surges are definitely going to be related to human activities, such as how much society reopens, how careful it is in reopening, weather-related and likely other unknown factors at this point as well. 

Itkin also emphasizes that the pandemic is not over at this point, and that if there was a brief pause or respite from the severe activity of the illness that just, “fasten your seatbelts.” 

“Europe is seeing this already,” Itkin said. “We’re certainly seeing this in universities in all 50 states. I think, really, just get ready for what’s coming, and I think it is certainly coming at this point.” 

Officials at St. Joseph Hospital in Nashua are also anticipating a surge in cases of Covid, and the expected influenza cases. Dr. Eduardo Velez stated that this has to do with the fact that people will necessarily gravitate towards indoor environments where transmission of both viruses is optimal. Dr. Velez is the Medical Director, ICU and Pulmonary Function Laboratory (cq) at the hospital and added that it is very likely officials at the hospital will have to test patients for both Covid and influenza when they present with symptoms such as fever, cough or sore throat. 

“Influenza and Covid have many overlapping symptoms, and it is essentially impossible to differentiate them just by examining a patient,” Velez stated via email. 

The hospital's response will be guided by the experience gained with Covid, and guided by data about local rates of illness and transmission. Velez explained that the hospital will follow guidelines from the CDC, as well as continue to look at what hospital systems in other countries have done to successfully manage infections. 

“It is expected that the combination of the flu season with the ongoing COVID pandemic will strain hospitals,” Velez stated via email. “That said, it is possible that the social distancing and mask use measures that are being implemented by the population, together with more awareness of influenza vaccination, may decrease the impact of influenza compared to prior years.”

Lessons Learned, Planning ahead

The hospitals will be using lessons learned from Covid-19 in their response going into flu season. At CMC, one thing that was realized is the need for widespread rapid testing. Pepe said that is very important for where patients go inside the hospital, as well as to keep people and staff safe so that the hospital can have infectious patients in one area and noninfectious patients in another area. 

Moving into flu season, CMC will continue that widespread, rapid testing with flu and Covid testing, hand hygiene and mask wearing. Pepe also believes that tighter control of visitors to the hospital will continue during flu season. Additionally, the hospital has installed thermal temperature scanners that instantly take people’s temperatures as they walk through them, which will also continue through flu season. Pepe believes the hospital also learned a lot about the supply chain and how that does not work in high demand situations.

“So the supply chain situation broke down and so I believe that the lesson learned here is that every state should have their own emergency pandemic stockpile that’s not dependent on supply chains or the federal government,” Pepe said. “I think that that was a major situation that could have been a whole lot worse.”

At Portsmouth Regional Hospital, Itkin believes one lesson learned thus far is for people to not let their guard down, with a need to educate and reeducate. He explained that it is going to be a matter of kind of going back to the basics in terms of reviewing screening protocols, how to use and put on and take off personal protective equipment (PPE). Itkin also underscored the importance of the basics for infection prevention which are hand sanitation, mask use and distancing. 

“I think that overtime, particularly over the last couple of months as the Covid activity has slowed considerably, I see that healthcare workers, much like the general public, is letting down their guard a little bit,” Itkin said. 

One of the things learned at the hospital in terms of its overall approach is about creating scalable systems in terms of how the hospital was built up geographically with creating surge units, for example. Even though these have been scaled down in recent months because there has not been a need, they have not gone away. The hospital has the capability of scaling those up again, which Itkin said can easily be ramped up when needed. 

At DHMC, Calderwood said one lesson learned is that science does not move at the speed of the 24/7 news cycle, meaning health care professionals are constantly needing to adapt to new information and figure out how to best communicate this out to providers, patients and the public at large. 

At St. Joseph Hospital, Velez stated that what was probably the most important lesson learned is that in pandemic situations, guidance from federal and state governments, as well as help with logistics equipment, may not materialize soon enough. 

Velez explained that organizations have to keep their ears to the ground and be ready to implement decisions and measures by themselves based on the available data. St. Joseph Hospital was able to assemble a team that constantly assessed the situation and planned, trying to anticipate problems before they hit. 

“Collaboration from hospitals all over the world in terms of sharing knowledge and organizational resources was invaluable and we took advantage of this even before state and federal guidance was available,” Velez stated. 

Moving into flu season, Velez added that the hospital will continue to have a team approach to anticipate potential problems, and hopefully be prepared for the unexpected. 

In the meantime, health care professionals and the public at large are awaiting the much anticipated Covid vaccine. Pepe said people can argue about whether this vaccine is going to come at the end of the year or the beginning of next year, but the point is that a vaccine is coming at least a year earlier than any other vaccine. 

“We have never had a vaccine against a coronavirus,” Calderwood said. “We are looking at vaccine methods that are different than those that we’ve used before. We’re looking at kind of genetic vaccines, trying to deliver RNA which you can use as the building blocks for protein development. But again, oftentimes with vaccines we are giving a dead virus or a weakened virus to allow the human immune system to develop a response. In this case, we are using different methods that are faster and that’s the benefit because it will get us a vaccine much quicker than we’ve ever been able to do, but there are a fair number of unknowns.” 

Calderwood further explained that early evidence suggests a good response and very good safety, adding that much larger trials are needed before they are ready for primetime. Calderwood said that is what is going on right now in this country and across the world. 

These articles are being shared by partners in The Granite State News Collaborative. For more information visit collaborativenh.org.