Those not planning to be immunized for flu cited a variety of reasons, including 17% who fear they might get COVID-19 if they go out to get a flu shot. Other reasons were familiar anti-vaccine myths:

  • 32% said they never get the flu
  • 29% are concerned about potential side effects from the vaccine
  • 22% are concerned about getting flu from the vaccine

“We in the infectious disease community have been talking about a potential double-barreled respiratory virus season when flu and COVID-19 converge,” NFID Medical Director William Schaffner, MD, said at a recent press conference. “There is a real risk that, even if we only have a moderate flu season, we could be in for a rough few months ahead.”

It will be an unusual flu immunization for healthcare workers as well, since those working from home will be difficult to reach through typical inhouse campaigns.

“Our employee health teams had to come up with a plan to make sure individuals working virtually can get the vaccine,” says Connie Steed, MSN, RN, CIC, director of infection prevention and control at Prisma Health in Greenville, SC. “We have developed drive-throughs for flu vaccine that these employees can use, including giving them certain times of the day at every one of our locations.”

Although flu vaccine efficacy can vary year to year, Schaffner made the traditional argument that immunization could keep you out of the hospital or the morgue.

“Flu vaccines help prevent tens of thousands of hospitalizations each year and other serious complications, such as heart attack and stroke,” Schaffner said. “Even if you do get flu — despite getting vaccinated — you are likely to [have] a less severe and shorter illness. You are far less likely to get pneumonia or to be hospitalized, and you are less likely to die.”

The NFID survey found that 46% of U.S. adults are worried about co-infection with flu and COVID-19. The fear of co-infections was cited by 28% as making them more likely to get immunized for flu.

Complicating matters, the two respiratory diseases present the clinician with very similar symptoms — with the possible exception of the loss of sense of smell that can occur with COVID-19.

“Flu or COVID-19 — it really is a diagnostic challenge,” said Anthony Fauci, MD, director of the National Institute of Health’s National Institute for Allergy and Infectious Diseases. “We refer to it as flu-like illness, fever, chills, cough, stuffy nose, body aches, headaches, and maybe even some [gastrointestinal] symptoms, particularly among children, with vomiting and diarrhea. Steps to fight the flu and COVID-19 overlap considerably. We don’t want these diseases together, but the good news is some of commonly practiced public health measures are good for both of these.”

This was not a message that was greatly emphasized at the NFID press conference, in part because the annual event is heavily focused on convincing people to get the seasonal flu shot. However, the Centers for Disease Control and Prevention (CDC) recently reported a very mild flu season in the Southern Hemisphere through a combination of immunization and COVID-19 measures, such as masking. In fact, the first signs of this effect were seen at the tail end of the 2019-2020 flu season in the United States.

“Following widespread adoption of community mitigation measures to reduce transmission of SARS-CoV-2, the percentage of U.S. respiratory specimens submitted for influenza testing that tested positive decreased from 20% to 2.3% and has remained at historically low interseasonal levels (0.2% vs. 1%-2%),” the CDC noted.1 “Data from Southern Hemisphere countries also indicate little influenza activity.”

Although there are caveats and cautions, the CDC suggested this finding may carry implications for future flu seasons if masking is more normalized after the pandemic.

“Although causality cannot be inferred from these ecological comparisons, the consistent trends over time and place are compelling and biologically plausible,” the CDC said. “Like SARS-CoV-2, influenza viruses are spread primarily by droplet transmission; the lower transmissibility of seasonal influenza virus (R0 = 1.28) compared with that of SARS-CoV-2 (R0 = 2-3.5) likely contributed to a more substantial interruption in influenza transmission.”

In any case, the CDC has developed a new rapid test that can detect and differentiate both SARS-CoV-2 (Flu SC2) and influenza A and B. The Multiplex Assay “provides a sensitive, nucleic-acid-based diagnostic tool for evaluation of specimens from patients in the acute phase of infection,” the CDC notes.2

Overall, the CDC estimates there were 38 million flu illnesses, 18 million flu-associated medical visits, 400,000 flu hospitalizations, and 22,000 flu deaths during the 2019-2020 season.

In addition, the CDC estimates that flu vaccines prevented 7.5 million flu illnesses, 3.7 million flu-associated medical visits, 105,000 flu hospitalizations, and 6,300 flu deaths last season.

Flu Risk to Children

Although COVID-19 certainly has caused some infections and deaths in children, they generally have fared well against the virus compared to other age groups. Influenza, on the other hand, can cause severe disease in children.

“The 2019-2020 flu season was terrible for kids,” said Patricia Whitley-Williams, MD, a pediatrician and president of the NFID. “There were 188 flu-related deaths reported in children to the CDC. This matches the record set in 2017-2018 for the highest number of pediatric flu deaths reported during a regular flu season. We also know that the number of pediatric deaths reported to the CDC each season is likely lower than the actual number.”

What is truly devastating is that more than half of these children were healthy — they had no preexisting conditions, she added.

Flu vaccination is critical because it can reduce a child’s risk of death significantly, she said. For example, take a 6-year-old child vaccinated three years ago. He developed a local reaction at the site and the parents forbade future vaccinations, she noted.

“The family members did not receive flu vaccine either. Fast-forward to January of 2020 — this child is now 9 years of age and has influenza A,” Whitley-Williams said. “He was subsequently admitted to the hospital and quickly developed a secondary bacterial pneumonia. Before you know it, he was in a life-threatening situation in our pediatric intensive care unit — all because of not getting a flu vaccination. Thank God the child did recover and was vaccinated. I can tell you this was a learning lesson for that family — all of the family members got vaccinated.”

Social Equity Concerns

The NFID survey found that Black (61%) and Hispanic adults (53%) are more likely to be worried about contracting both infections at the same time compared to White adults (39%). However, despite this concern, about 62% of Black adults said they are either unsure about getting the shot or will not get immunized this year.

“This disconnect is a big concern,” Whitley-Williams said. “Black adults are more worried about being infected with COVID-19 and flu at the same time — more so than their whiter counterparts. This makes sense. Black adults in the [United States] are more likely to be hospitalized and to die from COVID-19 as they are for flu.”

The NFID survey also found that 39% of Blacks will not take an antiviral medication for flu, even if recommended by a healthcare provider. Explanatory factors for these attitudes include unconscious bias, institutional racism, and a warranted distrust of traditional medicine by at-risk populations.

The survey also found that 22% of U.S. adults who are at high risk for flu-related complications (e.g., adults age 65 years and older and adults with diabetes, asthma, or heart disease) are not planning to get vaccinated this season.

Interviews for this survey were conducted between Aug. 17 and Aug.19, 2020, with adults age 18 years and over representing the 50 states and the District of Columbia. The survey included 1,000 complete responses — 897 via the web and 103 via telephone.


  1. Olsen SJ, Azziz-Baumgartner E, Budd AP, et al. Decreased influenza activity during the COVID-19 pandemic — United States, Australia, Chile, and South Africa, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1305-1309.
  2. Centers for Disease Control and Prevention. CDC’s diagnostic multiplex assay for flu and COVID-19 at public health laboratories and supplies. Updated Sept. 3, 2020.