Preparing for Fall: Back to School and Influenza Season

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: public health leaders discuss the importance of working to keep flu at bay during the pandemic; and the push to make sure kids are up to date with their routine immunizations before school starts next month.

DR. NANCY MESSONNIER:
We expect that flu and COVID-19 will both be spreading, putting strain on our healthcare systems. And though we don't yet have a vaccine for COVID, we do have a tool to prevent influenza. This season, getting a flu vaccine will be more important than ever as we work to reduce the impact of respiratory illnesses and the burden on the healthcare system.

DR. JOSE ROMERO:
We're trying to get the message out to the public that it is safe for children to return to their normal visits. And what practitioners are actually doing—they are segregating their ill patients from their well checks and vaccines. Some practices will have warnings for ill visits, and then definitely sanitization of the environment, and then bringing them back.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, we're talking about plans for dealing with the upcoming flu season and the importance of routine vaccinations as a tool to keep people healthy in the midst of a pandemic.

There is no single date on the calendar that marks the official start to the flu season, but it's usually in full swing by early October. In a normal year, public health leaders around the nation would consider their annual flu campaigns enough to keep teams busy, educating communities about the need to make sure people are protected against a virus that's especially dangerous for the very young and the very old.

But what about this year, one marked by a devastating pandemic? The COVID-19 virus displays no signs of weakness with rates of infections and hospitalizations climbing faster than ever. People fearing infection have put off routine medical care while many parents have delayed non-emergency pediatrician visits for their kids, leading to falling immunization rates across the country.

With the nation's schools developing plans to safely reopen their doors this fall, it's important that parents not only consider how their children can stay safe from the novel coronavirus but also from other vaccine-preventable diseases. How, then, do we get 180 million Americans, including tens of millions of school children, vaccinated against the flu while another less familiar virus continues to devastate communities?

We're talking about that today with two experts. Dr. Jose Romero is the interim secretary of the Arkansas Department of Health and chief of the pediatric infectious disease section at Arkansas Children's Hospital. He's along shortly to tell us how his state getting ready to pitch flu shots during a pandemic.

But first, we get the national view from Dr. Nancy Messonnier, director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention.

MESSONNIER:
It's not possible to say completely what's going to be happening in the fall and winter, but we expect that flu and COVID-19 will both be spreading, putting strain on our healthcare systems. And though we don't yet have a vaccine for COVID, we do have a tool to prevent influenza. This season, getting a flu vaccine will be more important than ever as we work to reduce the impact of respiratory illnesses and the burden on the healthcare system.

JOHNSON:
So, how does getting a flu shot help address these concerns?

MESSONNIER:
Well, there's several ways in which it helps.

The first is that if COVID is spreading through a community, the healthcare system really has to be taking care of those patients with COVID.

So, if you could get a flu vaccine and prevent yourself from getting flu, you can stay out of the healthcare system, which is good for our healthcare providers but, frankly, also good for you.

You certainly don't want to have flu and then, for example, have to go see a doctor. You also don't really want a co-infection with flu and with COVID. So, anyway you count it, it's a really important year to make sure that you're getting a flu vaccine.

JOHNSON:
We hear that message every year. There's just no way really to put that in all caps this time around, is there?

MESSONNIER:
I wish there was a way to put it in all caps.

I want to reassure people, as we do every year, that we know a lot about the flu vaccine. We know it's very safe. And even in years where it's imperfect, we also know that it's very effective, especially in keeping people out of hospitals, out of intensive care units, and in preventing people from dying.

JOHNSON:
We have a lot of people in public health around the country listening to this podcast.

What, from your vantage point, should they be doing right now to get ready for flu season?

MESSONNIER:
Yeah, health departments should be planning: they should be planning for flu communication to their partners, and stakeholders, and residents; they should be talking with practices and pharmacies in the area; they should be coming up with innovative ideas for how to do vaccination this year.

This year, CDC has given immunization programs additional funding—which is part of the CARES act—to enhance their capacity to support staffing, communication campaigns, and mass vaccination.

I want health departments to work with us to ensure that everyone, every child and every adult, gets caught up on the routines immunizations and gets their flu vaccine this year.

JOHNSON:
People get their shots at the doctor's office, but they also get them in grocery stores, pharmacies, and other locations—clinics. There are a lot of places where you can go to get the shot.

How do we make those locations as varied as they are safe so that people will go get that vaccine without fear of maybe coming down with a case of COVID-19?

MESSONNIER:
Yeah, I think that's really an important issue.

People do get vaccinated, not only at their provider's office but at many other locations; and, frankly, easy access to the flu vaccine means more people getting vaccinated. So, we expect more people than ever will be interested in getting a vaccine, and that's why we have provided guidance to all of those groups so that they can make sure that patients can get vaccinated safely.

That information is up in our website and it's things like: minimizing the chance of exposure by screening patients for COVID-19; ensuring patients wear face masks and healthcare workers wear medical masks; and maintaining social distancing with at least a separation of six feet while people are waiting for their flu vaccine.

Again, I think we should do everything we can to encourage people to get vaccinated and that also means being very visible about reassuring them that we can do it safely.

JOHNSON:
It seems like, for obvious reasons, there is much more focus now on germs and staying away from them.

Do you think that this heightened awareness because of this awful pandemic will have any positive affect on the flu season?

MESSONNIER:
Yeah, I mean, that's really an interesting question.

COVID has caused many of us to pay more attention to the way that germs are spread, and the question really is, "Is this going to slow the spread of influenza as well as other respiratory diseases?"

You know, both flu and COVID are spread by respiratory droplets, and the precautions that we recommend for COVID-19 are also the same precautions we recommend for influenza—social distancing, good hand hygiene, covering your cough—so the same measures may be effective in preventing the flu and we should continue to practice them.

But frankly, the single best way to prevent seasonal influenza is to get the flu vaccine each year; and, while it's really important to continue social distancing and all of these other measures, it isn't enough. People should still go out and get their flu vaccine as an extra measure of protection.

JOHNSON:
Let's talk about supply for a minute.

What's the prediction there? Will we have enough?

MESSONNIER:
Yeah, we work every year with the flu vaccine manufacturers and this year they're projecting more vaccine than they've ever had before—and that's somewhere upwards of a 180 million doses of flu. CDC has also purchased additional flu vaccine this year, which we're providing to health departments so that they can focus on populations at greater risk.

For me, one of the most important issues is making sure this year that no flu vaccine sits on the shelf. We want to make sure that every one of those 180 million doses of flu vaccine goes to protect someone from the flu.

JOHNSON:
And you said just a minute ago—but to highlight it—you think more people will get the shot this time around.

MESSONNIER:
I am certainly hoping that more people will get a shot and we should certainly be planning on it.

We often find that flu vaccination coverage rises after a particularly bad flu year—we saw that after the 2017-18 season—and we hope that people realize that, by getting vaccinated, they are not only protecting themselves but potentially alleviating some of the burden on their healthcare system.

I hope that this year we will achieve record levels of flu vaccination, but I also hope that we'll maintain that in subsequent years because getting a flu vaccine isn't just this year, it's an every year endeavor.

JOHNSON:
The drive to get kids vaccinated has suffered because people have been staying home, skipping routine appointments with their physicians and other health care providers.

Where do you see that issue going in the next six weeks as we discuss how school looks in the fall?

MESSONNIER:
Yeah, I understand that there's been lots going on in the minds of parents and educators as school starts back up.

Ensuring that routine vaccination is maintained—or reinitiated if vaccines were missed because of the pandemic—is essential for protecting children and communities from vaccine-preventable diseases and outbreaks. My kids actually delayed their routine appointments because of COVID; but, frankly, they're getting seen and they're getting their well-child checks. It's really important.

CDC has developed a suite of materials to remind parents about the importance of well-child visits and vaccinations, including a new web page specifically dedicated to routine vaccination during COVID-19. We've suggested that state immunization programs promote back-to-school as a time to catch up on missed vaccines and to make them more accessible.

But we also understand that schools may need to provide a more liberal grace period for parents who need a little extra time getting their kids caught up with their vaccines. We just want to make that grace period as short as possible and make sure that those kids don't fall through the cracks, they indeed go ahead and get vaccinated.

There's going to be a lot of challenges this fall. We don't want vaccine to be another challenge. We need to make sure that everyone go through the normal back-to-school routine and gets vaccinated.

JOHNSON:
When you talk to your colleagues in public health at all levels on this issue, what do you ask them to do when it comes to addressing the back-to-school question?

MESSONNIER:
When I talked to my colleagues about influenza vaccination and routine childhood vaccines, what I tell them is that, in the rush of everything else—of COVID and all the other things that are going on in our communities and societies—we can't skip on the things that we know protect our kids, and that always includes routine vaccinations and flu vaccines. And, you know, I'm making sure that my kids get their routine childhood checks, get their routine care, and I encourage every parent to do the same.

CDC is working closely not only with health departments but with ANA and AAFP so that they can be encouraging their members to get those messages out to their patients, and also to do reminder recalls so that patients know that it's time to come back in and get vaccinated before school starts.

JOHNSON:
You want to everyone that talks to that family or touches that family at every level talking about this.

MESSONNIER:
I want everyone talking to the parents about what they need to do to keep their kids safe. Flu vaccine is an important component.

You know, every year I make sure my kids get their flu vaccine, but I also make sure that my parents who are in their eighties get their flu vaccine. And certainly I do, and my husband does.

And I guess that's what I'm hoping, that the message will continue to resonate with people that it's about protecting our kids by getting them vaccinated. But frankly, it's also about protecting our parents, and grandparents, and ourselves by getting the vaccine.

JOHNSON:
When does the flu season start this year officially? Is there a date?

MESSONNIER:
We usually consider the flu vaccination season to start around the beginning of October.

This year, in particular, we're recommending that people continue to get vaccinated. A lot of times people get vaccinated and if they're not vaccinated by Thanksgiving, they decide it's too late and not worth getting. But this year in particular, we're going to continue to promote flu vaccination through December.

Some people may not be able to get it earlier in the year—they may be home because COVID is going through their communities, they may have other constraints that make it more difficult—and so we really want folks to know that the protection from flu vaccine continues.

We never can predict what a flu season is going to look like. We don't really know fully and exactly when the first flu cases will start, nor do we know exactly when the flu season will end. And so, there's no time too late this year to get a flu vaccine.

JOHNSON:
As it relates to messaging, then, is it the same, otherwise? We're not really adjusting the timing in particular, but are we adjusting the talking points?

MESSONNIER:
Yeah, we are adjusting the talking points some.

You should expect to hear from CDC on the importance of vaccines, but you should also expect us to be talking about the unpredictability of flu and COVID circulating at the same time.

Last year after the national measles outbreak that threatened our elimination status, we really developed messaging that focused on vaccinating with confidence so we could strengthen public trust in vaccines and prevent vaccine-preventable disease outbreaks. And we're talking, therefore, about protecting communities, empowering families, and stopping myths.

We'll be building on those priorities this year, encouraging people to get vaccinated to protect themselves, but also to protect their loved ones and to protect their communities. So, our messaging will include some of the same elements, but we're also really going to try to tailor those messages in the current season we're in.

And you'll also see us really trying to focus efforts on those who are at highest risk, both from influenza and from COVID—so, the elderly, people with underlying health conditions, the very young. This year, the elderly and those with underlying health conditions—again, because of the intersection of COVID and influenza—are increasingly important.

And finally, this year we're going to be focusing more on communities of color. During the 2018-19 season, flu vaccination among Blacks was 10 points lower than their white counterparts, and Hispanics were 12 points lower than their white counterparts. This is a discrepancy that we've seen year after year.

Data shows that these groups are disproportionately affected by COVID-19, so we're really going to be working with our local partners and trusted messengers to reach those groups about the safety, and importance, and effectiveness of flu vaccine.

JOHNSON:
Does the CDC have any materials on that issue online right now? Or are you planning to offer some soon?

MESSONNIER:
We have our general contingent of flu materials online.

But, in fact, this summer—and I actually think this week—we're working on testing additional messages to see how they resonate with their communities, and we're doing additional outreach with experts in these fields to make sure that we're appropriately tailoring the messages.

So, look to our website as the summer progresses as we hone those messages. We really want to make sure we understand what people's concerns are and what messages resonate right now in this situation that we're in so that we can, you know, get people motivated to get their flu vaccine.

JOHNSON:
Just two more quick questions.

You mentioned, a minute ago, the messaging addressing some of the myths and some of the other things that go on around vaccines all the time. Outbreaks are sometimes tracked to communities that, for one reason or the other, choose not to participate in vaccine programs.

How do you message this year to the vaccine hesitant communities?

MESSONNIER:
Yeah, that's a great question.

I think the number one thing that anyone can do—whether they are a doctor talking to a parent, or a parent talking to another parent—is to listen. Allowing people to express their concerns will increase their willingness to listen when you respond.

For parents, you should also assume a parent will vaccinate. The overwhelming majority of parents do choose to vaccinate to protect their children. You want that to be the norm.

We want this to be about confidence in our vaccines, confidence in our vaccination program, and, frankly, confidence in the public health providers and the healthcare providers that are recommending vaccines.

JOHNSON:
Lastly, the role of public health professionals—how important is that in this cause, and what do they need to know right now for the months ahead?

MESSONNIER:
Yeah, it's incredibly important. People still trust their healthcare providers the most to help them make healthcare decisions, and public health officials and healthcare providers are really the best equipped to stamp out those messes and give the correct information and correct messaging around vaccination.

They should use every opportunity, especially during the flu season, to promote flu vaccine to everyone who is eligible, especially for those who are at higher risk for both flu and COVID. So, I hope that the public health officials out there listening understand that, in this, they are still incredibly important. Their voice matters a lot.

Their voice matters to their patients; but, frankly, their voices also matter to their communities. They are community leaders and, in their own communities, people really look to those that are part of the community to help give advice. So, I hope that we really can all stand together against flu this year.

JOHNSON:
Many children are behind on their routine vaccinations because of the pandemic, kept out of doctor's offices by parents fearing exposure to the COVID-19 virus.

But Dr. Jose Romero, Arkansas' interim health secretary and chief of the pediatric infectious disease section at Arkansas Children's Hospital, wants parents to know providers are responding to those concerns.

ROMERO:
We're starting to take a number of approaches to this. As with the national numbers, our numbers have decreased during this COVID epidemic.

First and foremost, we're trying to get the message out to the public that it is safe for children to return to their normal visits. That's first and foremost.

Each institution—depends on where you are—but each institution is implementing different standards for their children. So, for example, in Arkansas Children's Hospital where I work, there is segregation of the patients so that the well-child and the immunization patients are kept separate from those children who have illnesses. There are a drive-through vaccine clinics that are available.

We're advocating that physicians use, at this time, the catch-up schedules rather than traditional two-four-six months schedule in order to get these children caught up. We're going, as much as possible, out and talking about the need to make sure that the 12-month immunizations—12-month, 18-month—immunizations are up to date; in particular, that issue of the measles vaccine.

JOHNSON:
Let's talk about your communication effort because so much of what happens on this front has to do with what you're saying to parents.

How are you communicating all of this to the target audiences?

ROMERO:
So, this is an effort by the children's hospital—and by us—through media and advertisements to let the public know, to let the parents know.

So, it's through the media, in general, that we're doing this.

JOHNSON:
Have you had to change the messaging this year? It's not a normal year. I assume you've had to do that.

What's different about your messaging this time around?

ROMERO:
What's different is that there is this heightened awareness of the possibility of COVID infection, and that really is what's changing, I think, the dynamic between our parents—the parents of these children—and interacting with our institutions.

One thing I think that's important to know about us—that is, our state—is that 50%, or a little bit more than 50%, of all vaccines administered in this state are administered by the health department through their local health units. So, we are a prime deliverer of vaccinations in the state.

We have a message that we're trying to get out, and will be getting out more in the future, trying to bring those people back into our clinics.

JOHNSON:
There's messaging for the entire population, and then there's messaging specific to minority populations.

What are you doing with those groups to make sure they understand how important it is to have their kids vaccinated, especially now?

ROMERO:
Yes, so, we have a significant population of Latinos and Pacific Islanders—specifically Marshallese—in our state, and so we are targeting our messages specifically in linguistically appropriate manners, both written and verbal. We're working with community organizations within those minority communities to get the message to them in a linguistically appropriate manner.

I think without that, we're not going to be able to reach those populations appropriately.

JOHNSON:
Do you expect, when all is said and done, vaccination rates for children will still be below what they might've been had there been no pandemic?

ROMERO:
Yeah, unfortunately, I think that will be the case. I don't think we're going to be able to convince all parents about this issue about coming in and getting their vaccinations.

I think we're going to try to get very close to it, but it will take us a while to go back to pre-COVID vaccine levels.

JOHNSON:
What impact, then, do you think that will have on children's ability to actually get back into the classroom?

ROMERO:
It certainly could impact. You have to have these immunizations documented before you can go to school.

There may be a grace period given to get these children back into school—which is also an issue that we're currently dealing with, is trying to educate parents about the possibility of actually returning to in-classroom education.

JOHNSON:
I suspect this involves a lot of coordination with the school districts.

ROMERO:
It does, and we do interact with the Department of Education here.

We're developing guidelines for a return back to school, so we will be interacting very, very closely with them.

JOHNSON:
What are you asking the healthcare providers in your state to do as it relates to trying to tackle this problem and get those rates up?

ROMERO:
Yeah, so, again, I think it goes back to the original message that I talked about—that is, first of all, try and explain to the parents the importance of these vaccinations.

And because a lot of these vaccinations, as you know, are given in the first year of life, you know, we want the pediatricians, the family practitioners, to really drive the message home that we do not want to delay routine healthcare for children—that is, the well-child visit. And so, we're trying to get them to tell that to the parents, and we're seeing that in the media.

We're also telling the practitioners to use the accelerated schedule—that is, the catch-up vaccination schedule—when appropriate, and to be sure that those children are coming in for their visits as much as possible.

JOHNSON:
What can the state do to help the providers get those messages out?

ROMERO:
I think that part of it is—our role is—really the messaging, is getting that information out to the public, providing the practitioners—if they don't have a script—a script which they can use. I think most of them have already begun to do this. Our role is really going to be informational.

And, as I said before, because we deliver 50% of the immunizations in the state, I think we have an active role in this, in trying to get those patients back into our local health units for immunization.

JOHNSON:
Can you tell us about some of the steps that the state and providers are taking to make sure the environment is safe for children when they go in to get their shots?

ROMERO:
Of course, yes.

So again, I'll refer back to the children's hospital. So, as I said before, and what practitioners are actually doing, they are segregating their ill patients from their well checks and vaccines. Some practices will have mornings for ill visits, and then definitely sanitization of the environment, and then bringing them back.

We make sure that the patients' parents understand this. We screen these children, right—I mean, we want to make sure that these children do not have any symptoms, or the parents don't have any symptoms, that would warrant not allowing them to come into clinic because of concern for COVID.

We make sure that, for example, we take opportunities to administer these vaccines. So, in the infectious diseases clinic, any child that comes in for a routine visit, for an ID problem, has their immunization records screen—we have a statewide immunization registry. We'd pull these up, we look and see if they're up to date, and we offer the vaccines that are deficient or are coming up to that individual at that time.

So, we're taking advantage of these immunization opportunities when they come in to see the specialist.

JOHNSON:
How about clinics that operate in grocery stores and pharmacies?

What can be done there to make sure those environments are safe for kids?

ROMERO:
So, again, we don't have these in our state for children at this time.

But to do that, you have to, again, adhere to the issues of sanitation around the area where the patient is or the child is, making sure that you're screening individuals that are coming into that area, protecting them, segregating them from other individuals—if possible—within that environment.

JOHNSON:
As if COVID-19 weren't enough to worry about, we're coming up on another flu season here very quickly.

Remind us who is at risk for catching the flu or having trouble with it, and why the flu vaccine is so critical, especially this year.

ROMERO:
So, we know that children are at high risk for adverse event from influenza—so, those children six months to six years are at higher risk for adverse events.

Secondary comorbid conditions—obesity, diabetes, heart disease, pulmonary problems—that children would have would place them at higher risk for morbidity and mortality from that. So, we want to make sure that those individuals are targeted.

We know that, for example, premature infants need to be vaccinated when the time comes, because they can have airway abnormalities as a result of their prematurity.

So, we are coming up to a possibility of a confluence of both influenza and COVID during the fall. The ability to have a child immunized against influenza—to provide a degree of protection against that particular disease—makes it somewhat easier to discern whether the child may have COVID or not, and I think that's what we need to do in order to make sure that these children are protected.

We don't know what the outcomes would be for dual infections, which could occur if we have a high prevalence of COVID disease in our community and high prevalence of influenza disease in our community.

What is the risk of having both at the same time? We know that co-infections do occur in children with other viral agents, and that has the potential to make COVID worse or flu worse.

In general, we know that children seem to have a milder disease than adults do, but we don't know what the confluence of both will do.

JOHNSON:
Is that part of your messaging this year around the flu vaccine?

ROMERO:
Yes. When I speak to physicians, I point out that that is one of the issues.

It also is that, if a child has a febrile illness and has been immunized against influenza, then there's a higher possibility that—if there is a high prevalence of COVID in the community—that may be COVID.

And so, it eliminates one possibility—or decreases one possibility, I should say—it doesn't eliminate it, but it decreases one possibility as to the etiology of that child's febrile illness.

JOHNSON:
How are you feeling about uptake on the flu vaccine side of this issue?

Do you think you're going to be able to hold onto those numbers, or do they suffer as well this year?

ROMERO:
I think it will depend a lot on the prevalence of COVID in our community. I think parents are concerned enough about COVID and they'll want to protect their children as much as possible against a secondary infection.

I'm hopeful. I really am hopeful that we'll have a better uptake of influenza vaccine this year that we have in the past.

JOHNSON:
Finally, it's possible some parents will choose to keep their kids at home and learning online this fall; many school districts around the country are offering that option as they talk about plans for August and September return-to-classes.

Is the argument any different for vaccinating your child if he or she is going to a classroom or sitting at the kitchen table? Does it matter?

ROMERO:
No, not to me—and, I don't think, to my colleagues—because, while the child may be segregated at home, the parents most likely are not. They're going into the environment and they can bring the virus into the family. So, I think that you need to protect the child as much as possible from every means possible. That means immunizing the child itself, as well as the family.

This is an example of cocooning the child. You want to make sure that all the individuals that are going to come in contact with this child receive their immunization—that is, the parents, or grandparents, aunts, uncles—they should all be immunized this year in order to protect these children.

JOHNSON:
You can find links to the resources mentioned in this episode in the show notes.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And if you have comments or questions, we'd like to hear from you. Email us pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.