COVID-19 and Influenza Surveillance

How does COVID-19 relate to the flu?

People with COVID-19 and people with influenza (the flu) can have similar signs and symptoms or even none at all. Even though individual infections may look the same, there are some important differences between the two diseases.

  • Both COVID-19 and flu can cause severe illness and even death, but a larger proportion of COVID-19 cases result in hospitalization or death. 
  • More severe outcomes of COVID-19 tend to increase with age, while negative outcomes for the flu affect the very young and the very old. 
  • The reproductive number, R0 (pronounced R naught), is a value that describes how contagious a disease is. For the flu, the R0 tends to be between 1 and 2, which means that for every person infected with the flu, one to two additional people become infected. For COVID-19, the R0 is higher, between 2 and 3. With COVID-19, there are also some documented examples of “superspreaders” who can infect a large number of people. 
  • The incubation period, or the time between infection and when you have symptoms, and the length of illness are both shorter for the flu than they are for COVID-19. 
  • For flu, there is a vaccine to help prevent getting sick  and there are medicines to treat the flu for people who do get sick.  

It’s important for public health and healthcare providers to be able to tell the difference between influenza and COVID-19.

How does VDH conduct surveillance for COVID-19? How does that differ from flu?

Surveillance is the practice of tracking and measuring the burden and trend of a disease’s impact on a community. VDH conducts surveillance for many diseases and conditions, but the specific methods can vary by disease or condition.

For some diseases, including COVID-19, VDH conducts surveillance by counting every case and trying to measure the exact impact of the disease. The benefits of counting individual cases include:

  • Interviewing individual people with COVID-19 allows us to look for behaviors and risk factors that may be associated with illness or severity. For COVID-19, we’re asking questions about living conditions, symptoms, underlying conditions, and travel history.
  • Interviewing people with COVID-19 also allows us to ask questions about exposure that may help uncover outbreaks. Asking each person about where they work or where they go to childcare or school may identify a cluster of illnesses that are connected. This can help prevent more people from getting sick at those locations.
  • Knowing exactly who is sick with COVID-19 allows public health to contact them to provide instructions and recommendations on self-isolating to prevent further spread of the virus. 
  • Knowing who is sick also allows us to conduct contact tracing to notify people of their exposure and provide quarantine recommendations and support.

VDH is using the “Box It In” strategy to try and control the spread of COVID-19. This strategy of isolation of cases, contact tracing, quarantine of close contacts, and testing is how countries like New Zealand, South Korea, and Singapore were able to control their outbreaks. This strategy requires that we count individual cases of COVID-19.

While there are benefits to counting individual cases, there are also challenges:

  • The process of interviewing individual cases is very time-consuming for public health staff.
  • The process of inputting individual-level data for each case of a common disease can be time-consuming for healthcare providers.
  • Individual case counts require a large data infrastructure for exchanging, storing, and processing a high volume of data very quickly and a large workforce to analyze the data and ensure their quality.

For some diseases, the benefits of counting individual cases outweigh the challenges. For others, they don’t. Seasonal influenza is an example of a disease where VDH does not count individual cases. All the challenges above apply to influenza surveillance with the addition of the following:

  • Most people who get sick with the flu don’t seek care for it.
  • Among people who do seek care, most are diagnosed with a rapid influenza diagnostic test (RIDT) or by their symptoms alone. Diagnosing flu like this works well in the clinical setting as it can provide access to antiviral medication that treats the flu. Unfortunately, neither RIDTs nor symptom-based diagnoses are consistent or detailed enough to meet public health case classification.
  • The confirmatory tests that are available (PCR, viral culture, and DFA [direct fluorescent antigen]) for the flu are more expensive and are not used for most cases. Counting cases based on these tests alone would introduce bias towards individuals who are wealthier, better insured, sicker, or whose healthcare system prioritizes these test types. 

So instead of counting each case of flu, VDH uses other data sources to monitor each flu season. These variables include:

  • Influenza-like illness (ILI)
    VDH receives data about every visit to an emergency department (ED) and a lot of visits to urgent care centers through its syndromic surveillance program. These data include some demographics and a chief complaint, or why the patient is seeking care. The chief complaint may include their specific symptoms, a specific disease, or a known exposure. VDH can track which of these visits meet the criteria of having an influenza-like illness, which is defined as specific mention of flu, or as a fever with either a cough, a sore throat, or both.
    This surveillance system is voluntary and some healthcare systems have just started participating in the last few years. To account for an overall increase in the number of visits we’re analyzing, VDH reports out the percentage of total ED and urgent care visits that have an influenza-like illness.
    This data source is not a count of cases and not everyone who meets ILI criteria will have the flu. This source does provide a good estimation of the intensity and timing of the flu season. 
  • Confirmatory lab reports
    As mentioned, some tests available for the flu are considered confirmatory, including PCR, viral culture, and DFA. One of the major benefits to these test types is that they can provide more detailed information about what type of flu virus a person is infected with. Knowing whether we’re experiencing a flu season with more A(H1N1), A(H3N2), or B can be important for evaluating what communities are at highest risk for complications and negative outcomes. This information also helps us evaluate how effective the vaccine is every year.
    This data source is not a count of cases. Instead, it’s intended to provide insight into which viruses are circulating at a given time.
  • Outbreaks
    Outbreaks of flu are common. VDH counts any cluster of illness with two or more lab-confirmed cases of flu as an outbreak. Reported outbreaks can be a good indicator of how much flu is being transmitted within a community.
  • Geographic Spread
    The geographic spread of the flu, sometimes called the activity level, is a calculation of how many of the five health regions in Virginia are experiencing flu transmission. This is a calculation based on ILI, confirmatory lab reports, and outbreaks. This isn’t a measure of intensity or severity. Instead it answers a yes/no question of whether flu is circulating in a specific area of the state. This can help make the data more local. Before the COVID-19 pandemic, some healthcare systems based their mask-wearing and visitation policies on the geographic spread to avoid introduction of a deadly virus into communities at higher risk. 
  • Pneumonia and Influenza (P&I) Deaths
    Patients who die from influenza most often die from a complication rather than from the viral infection itself. They could develop pneumonia, a bacterial co-infection, or their underlying conditions could get worse. In order to avoid underestimating the deaths associated with the flu, public health tracks deaths coded as pneumonia and/or influenza together.
    P&I deaths can be used to measure the severity of a flu season. If there’s nothing else that might impact the data, a season with more deaths can point to a more deadly virus.
  • Influenza-Associated Pediatric Mortality
    Influenza-associated pediatric mortality is a flu-associated death of a child and is a nationally notifiable condition, meaning that VDH reports every case we receive to CDC. This data source helps measure the severity specific to the younger population. While the numbers are typically pretty small in any one state, CDC analyzes data from around the country and reports on specific findings from these cases. 

There are two conditions related to influenza where the benefits of counting individual cases outweigh the challenges. These are:

  • Influenza-Associated Pediatric Mortality
    It’s a tragedy when a child dies from a disease that can be prevented. VDH counts individual cases of children who die from the flu to better define the risk factors and complications that result in this outcome. Since we started counting flu-associated deaths in children,, there have been between one and six deaths each flu season. 
  • Novel Influenza A Infections
    Flu viruses, especially flu A strains, are constantly changing or mutating. Human infections with novel (new) flu viruses can result from spillover (where a sick animal infects a human), genetic drift (where small mutations in the viral genome result in a new virus), or genetic shift (where two different flu viruses swap parts of their genomes to create something completely new). All three of these instances can result in a new virus that the human population does not have any immunity to, potentially leading to a pandemic. The global community is very concerned about flu pandemics so we  closely monitor for these situations, perform contact tracing, and thoroughly investigate the circumstances. In the United States, there have been two cases of human infection with a novel flu A virus in the past two years. Neither of these occurred in Virginia and neither resulted in subsequent infections.

Both of these conditions are important, but relatively rare, so the time VDH spends investigating and counting these cases is worthwhile.

So what do these data tell us about the 2020-2021 flu season so far?

For surveillance purposes, each flu season in the United States begins during week 40 and lasts until  week 20 of the following year. For the 2020-2021 season, that means September 27, 2020 to May 22, 2021. As of November 30, 2020, VDH has only received a handful of positive confirmatory lab reports. ILI has not been elevated in any region. There have been no outbreaks or pediatric deaths. There is no evidence yet to indicate that the flu is widely circulating in Virginia. For the most up-to-date information, see the Weekly Influenza Activity Report.

We can also look at the Southern Hemisphere’s previous flu season to gauge what to expect in the Northern Hemisphere for the upcoming flu season. This process does not allow us to predict the future, but it can provide context and clues. During the Southern Hemisphere’s 2020 winter, they observed almost no flu activity. You can see the World Health Organization’s data on flu surveillance from Australia, New Zealand, South Africa, Chile, and Argentina here.

There are a few factors that could contribute to seeing such low levels of flu activity:

  • Decreased attention or shifted priorities among healthcare providers could result in decreased testing and differences in coding behavior.
  • Decreased public health capacity could result in delays in reporting data.
  • Mitigation measures put in place to stop the spread of COVID-19 have also been effective in limiting flu transmission.

Of these three possibilities, the third is the most likely to have a large impact, followed by the first. We know that the Southern Hemisphere did not test as many people for flu as they would have during a typical flu season. We also know that among those who were tested, a much smaller percentage were positive than we would have normally expected.

VDH will continue to monitor influenza and publish the Weekly Influenza Activity Report throughout the 2020-2021 flu season. We’re also working on ways to compare the relative burden of each disease in case we do see more flu. As of November 2020, however, there is no evidence of significant flu circulation in Virginia. 

This is good news for now. As we face rising case counts of COVID-19 going into the holiday season, it’s going to be very important to make sure there are hospital beds available for those who need them. This means taking all of the recommended steps to protect ourselves and our families against COVID-19 and influenza:

  • Get your flu vaccine if you haven’t already done so! It’s not too late to vaccinate. To find a flu vaccine site near you, see here
  • Wear a mask. As of November 15, 2020, Governor Northam expanded the mask mandate established by Executive Order 63 to require all Virginians aged 5 years and older to wear masks in indoor public settings and business establishments.
  • Avoid large gatherings. Virginians should limit indoor and outdoor in-person gatherings to 25 people, based on Executive Order 67
  • Practice good respiratory etiquette. Cough or sneeze away from other people into your elbow or a tissue.
  • Practice good hand hygiene. Wash your hands with soap and water for 20 seconds. Use an alcohol-based hand sanitizer that contains at least 60% alcohol if soap and water aren’t available.
  • Get tested if you have symptoms or think you’ve been exposed.
  • Follow isolation policies if you test positive and quarantine policies if you’ve been exposed to someone who tested positive.