Can you get flu and COVID-19 at the same time?

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We spoke with Dr. Gabriel Neal, family medicine physician, to learn what might happen if you get flu and COVID-19 at the same time, and how to avoid them. We also talked about a study Texas A&M is leading for a potential COVID-19 vaccine that may also boost efficacy of flu vaccine.

Episode Transcript

Lindsey Hendrix:

We bring you advice and compelling insight on the latest in health, medicine, and scientific discovery. From tips for getting better sleep to discussions about major issues like health disparities in America, we’ll talk about it. You’re listening to Texas A&M Health Talk, part of the Texas A&M Podcast Network.

Lindsey Hendrix:

Hello, and welcome to Texas A&M Health Talk. I’m your host, Lindsey Hendrix, and joining me today is my co-host, Dee Dee Grays. Hey, Dee Dee.

Dee Dee Grays:

Hey, Lindsey. Glad to be here again.

Lindsey Hendrix:

Glad to have you. I think we did a really good job last time, so I’m looking forward to this next interview.

Dee Dee Grays:

I think we did an awesome job.

Lindsey Hendrix:

Yeah.

Dee Dee Grays:

We have to pat myself on the back.

Lindsey Hendrix:

Today’s episode, we’re talking about flu, which we’ve talked about in our communications at the Health Science Center. Every year, we talk about it, time and again, but I felt like it was a very timely topic, not just because we’re entering flu season, but it’s also 2020, and this flu season is going to look a little bit different.

Dee Dee Grays:

Oh, definitely. With COVID-19, I think there’s a lot of questions that are out there that people need answered because the convergence of the flu and COVID, and with the symptoms being so similar, I think the more information we can put out there to help people, the better.

Lindsey Hendrix:

Yeah, absolutely, and I think we picked the perfect guest for this.

Dee Dee Grays:

Oh, yeah.

Lindsey Hendrix:

Yeah. Dr. Neal was great. Yeah. He is a family medicine physician, so he sees cases from the very young to the very old and everything in-between. He also rotates through the hospital, so he gets to see a lot of that stuff, and I thought he brought a lot of really cool knowledge to this, not only because of his clinical experience, but he’s also doing a really cool study on COVID-19.

Dee Dee Grays:

Oh, yes. He’s very knowledgeable, and I think the information that he provided is going to be valuable for all of our listeners out there, so real excited to have such experts.

Lindsey Hendrix:

He brought a lot of great knowledge to the table, and a lot of it is not surprising because it’s about the flu in general and we know that getting a flu shot is the best way to prevent it, but he also talks about what this flu season might look like with COVID-19 and flu converging. So let’s go ahead and start the show. What do you think, Dee Dee?

Dee Dee Grays:

I think we’re ready.

Lindsey Hendrix:

Awesome. Hey, Dr. Neal. Welcome to the show.

Dr. Gabriel Neal:

Thank you so much for having me.

Lindsey Hendrix:

I want to start it off just by asking: We always say that flu season occurs in fall and winter. Is that because of the cooler weather? Why does flu and cold season come around this time of year?

Dr. Neal:

Right, so historically, the flu has been more active in the winter, and there are some very good reasons for that. Part of it is the weather, but the flu, or influenza, has become a year-round illness. But it is far more active in the winter than it is in the summer, mainly because the protective coating around the virus is more stable in colder temperatures than it is in warmer temperatures, and so we see more people becoming infected with influenza during the wintertime because the virus can survive longer outside of the host bodies and then be passed on to other host bodies in the wintertime.

Lindsey Hendrix:

That makes sense. I never knew that. Thanks for clarifying. So, we can have flu all year long?

Dr. Neal:

That’s true, and we still occasionally see a case and we have to think about it when we have patients present with flu symptoms, even in July. I think that there is more to it, though, than just the protective capsule around them. We often are more social and we’re around more people in closed spaces and we have our holiday parties and we have our family get-togethers, and so there’s just a stronger chance, or better chance, of transmitting any particular type of viral infection in the wintertime.

Dee Dee Grays:

I know around this time, they really start pushing to go ahead and start getting your flu shots. I know there’s different strains of the flu, and I’ve heard that they base that off of, I guess other countries have flu season at a different time than we do. Can you explain, how do they determine what flu strain we should be getting at this time, then?

Dr. Neal:

It’s not an exact science when it comes to choosing the flu vaccine. Frankly, some years, the flu vaccine does not really match up with the flu virus that occurs, but then there are years where it matches really well and you get excellent efficacy. We can talk about efficacy in a minute, but the scientists that are developing the vaccine have to guess a little bit, and it’s not just a blind guess, they make an educated guess. They are trying to monitor the way that the various flu viruses, particularly in Asia, are mutating, and there’s different ways flu viruses can mutate. There’s a lot of different permutations that the flu virus can have, and when there’s this major shift, then you see then that the vaccine that they may be developing in anticipation of a small change then doesn’t work at all. It’s a little bit of a guess. There are really smart people sorting what type of vaccine they need to develop every year, but there definitely are years that are more hit or miss.

Lindsey Hendrix:

Even if it’s not predicted correctly, is there still a benefit to getting the flu vaccine?

Dr. Neal:

Oh, absolutely. I mean, you’d be crazy not to give it a shot, literally or figuratively, however you want to think about that. We don’t necessarily know year to year how effective it’s going to be, but on average, it’s about 40 to 50 percent effective, and that may not be the kind of percentage that gets everyone excited, but what that translates into is tens of thousands of fewer hospitalizations and thousands and thousands of fewer deaths every year because of the flu vaccine. So, I like to say that, look, don’t just get the flu vaccine for yourself, get it for the people around you, because I think that is a very noble reason to get the flu vaccine, and the flu vaccine has been demonstrated to be incredibly safe to get.

Dee Dee Grays:

We know generally they emphasize everyone to get and recommend everyone to get their flu shot in October. If I get my flu shot in December or January, is that too late? Is there such a thing as too late to get your flu shot?

Dr. Neal:

December or January is not too late. Typically, we stop giving the flu shots out in April or May because at that point, the season has passed, and usually at that point, the vaccine supply has kind of dwindled, but you still can get it. There’s no harm in getting a flu vaccine in April or May or June, there’s not. But the earlier you can get it, right, the more protection it’s offering you during the flu season. Really, the flu season in Texas, but certainly nationally, can peak in different areas at different times, and so some parts of the U.S. might see a November, October, November, early surge of flu cases. Other places might have more of a January, February flu surge, as it is the case in Texas. S,o even if it’s December, January, you’ve forgotten to get the flu shot, get it because at least locally where we’re at, there still is a lot of value in having it for those January, February, March months.

Dee Dee Grays:

Symptom-wise, what are the symptoms? I also have horrible allergies, so I think I’m sick with everything at that time, so what are those symptoms that we should be looking out for and when do you think that someone, “Hey, you’re serious enough to where you really need to go see a doctor”?

Dr. Neal:

Flu symptoms can vary a lot, but the classic presentation of the flu is fever, muscle aches, and fatigue. Those three symptoms are very common to influenza, and for anybody who’s ever had influenza, you know what I’m talking about. I’ve had it myself once and was basically in bed for three days and I’m a pretty healthy person, so it was rough. You can have runny nose, you’re going to have sore throat, you can have cough. Influenza can cause pneumonia and shortness of breath and even coughing up blood can all be symptoms of influenza, but fever, muscle aches, and fatigue are the classic triad.

Dr. Neal:

When you get tested, of course, it’s basically, well, when you’re running a fever and you have muscle aches, or you have a cough when you go in to see the doctor. Being tested for the flu is really just based on that suspicion, and so you could have the flu and just have a fever, you could have the flu and just have a fever and a cough. You could have a flu with just muscle aches and a cough, any one of those permutations, right, could potentially be influenza. Why this might matter with getting tested and having that diagnosis confirmed is that there are medications that you can receive from your doctor that can shorten the duration and severity of the flu if that medicine is initiated early enough in the illness.

Dr. Neal:

Now, this poses a little bit of a challenge, because what we’re looking to do is start that antiviral, anti-flu medication within 24 hours of the onset of fever. That’s the hallmark for that particular medication, and so a lot of times when the flu season really ramps up and doctors are aware that the flu is prevalent in their community and when patients have those symptoms, they essentially do not do flu tests anymore. They say, “The flu prevalence here is high. You have the symptoms. There’s no reason to suspect that it’s not the flu, so here’s your medication.”

Dr. Neal:

I mean, that’s a very reasonable approach when the prevalence of the flu is high enough and the patient’s symptoms are consistent enough. What doctors have to do, though, is consider other possibilities, and that’s where going in and being seen by the doctor and talking to them and examined by them can be very important so that they don’t miss something like mononucleosis, or this year, COVID, right, to name a few that can mimic influenza and need to be diagnosed separately.

Lindsey Hendrix:

Yeah, that brings up the next point I was going to make which is those symptoms seem awfully familiar with all of the symptoms that align with COVID-19, so I assume that would be another reason to go in to see your doctor and get tested.

Dr. Neal:

Right. This winter is going to be really tricky because influenza is going to be present, COVID is going to be president, respiratory syncytial virus is going to be present, other adenoviruses. There’s just a whole host of other possibilities that are hard to differentiate from each other, and so going in and seeing your doctor and being tested makes a lot of sense, and so there’s going to be a lot of doctor visits and a lot of testing this winter, but it won’t just be for COVID like it was through the summer, it will also be for influenza and respiratory syncytial virus and others.

Dee Dee Grays:

What can people start doing now to help prevent getting the flu beyond just getting the flu shot?

Dr. Neal:

Right on. Well, again, getting the flu shot’s a big deal and encouraging their friends and families to get the flu shot, because the more people that you have around you regularly that are protected offers you protection. That’s that herd immunity idea that we know. Then all the things that we’re doing to protect ourselves from the coronavirus are also effective at preventing the spread of influenza, so wearing masks, washing our hands, and social distancing are all things that can absolutely reduce the spread of influenza and protect you from getting influenza as well. So, my big advice to everybody is get your flu shot and then keep doing all the things you’re doing to protect yourself from COVID. I’m hopeful that we’ll have a lighter year, a lighter flu year. I’m not talking about the severity of the strain, because that has nothing to do with our efforts that we take to prevent illness, but in terms of just the number of cases and the spread of influenza, that could really be dampened by the efforts we’re making for coronavirus.

Lindsey Hendrix:

Yeah, I think that’s good news for this flu season, is people are already taking a lot of those measures to prevent all kinds of infectious diseases. I mean, not just influenza. Like you said earlier, there’s all kinds of respiratory and infectious diseases that could be going around this fall and winter.

Dr. Neal:

I want to add to that, that I think doctors and providers are really going to be in a tricky spot this year, worse than usual. Let me give you an example. A patient two years ago would call in, in the middle of January, say, “I’ve got fevers, I’ve got muscle aches, and I feel terrible. I’m really tired,” and the doctor or the nurse might talk to them over the phone and say, “Are you having a sore throat?” “No.” “It sounds like you have the flu. We’ll send in a prescription for the anti-flu medication,” right? They take the medicine and they get better and then they’re on their way, right? If they get worse, they come in and get checked. That’s not a real complicated decision.

Dr. Neal:

But this year, that same patient calls in, the doctor or the nurse is going to say, “We need you to come in and get tested,” right? Because we need to check you for COVID. We need to check you for influenza and sort this out because we’re not going to be doing you any favors with influenza medication if you have COVID, and if you have COVID, we’ve got to isolate you longer than if you have influenza. Typically, with influenza, we’re going to say, “Stay home until your fever is finished for a day and you’re feeling better and you go back to work,” but with COVID, it’s like you got 10 days, plus fever-free, plus the symptoms getting better, and it’s a much longer time out of school, out of work, out of their life, basically. And that’s been one of the hardest things about COVID that’s different than influenza is that COVID seems to stick around longer and cause symptoms longer and spread longer, and so isolating people once they have COVID is an important step that we’re taking. Then isolating those contacts, we don’t normally isolate flu contacts, right?

Lindsey Hendrix:

Right.

Dr. Neal:

If your child has the flu, we don’t say, “You can’t come to work,” but now with COVID, your child has the COVID, you’re probably home. They’re not going to be allowed to come in and you’re isolated for 14 days, according to the CDC guidelines. So I think we’re actually going to see a big hit to gross domestic product, to productivity for businesses across the country, across the world because of the steps that are necessary to separate people with COVID from otherwise healthy people.

Dee Dee Grays:

We also know that holidays are probably going to look a lot different for a lot of families this year with COVID and the flu, and a lot of the recommendations that are out there that even I’ve seen Dr. Fauci even talk about how his kids may not even be coming now, and I know other experts have also talked about how maybe our gatherings need to be smaller than what they normally are. It’s just going to be a whole different situation, I think, for this holiday. I know even my family has where my sister may or may not be coming in because she has to fly, so that’s a huge different now this year with the flu and COVID.

Dr. Neal:

Yeah. I think that there’s a lot of benefits to social isolation when you have COVID and when you’ve been in contact with COVID, you’re an exposure. The challenge with profound isolation in a low-risk setting—what I mean is, there’s no known exposure, you don’t have symptoms—is the psychological impact and the mental health impact of social distancing. And so, what Dr. Fauci says, of course, makes sense. We’ll probably need to be a little more careful. However, I think that there’s a lot of depression and anxiety and just profound loneliness that are causing mental illness that is just as bad as COVID, in some ways, if not worse, that I think just like you weigh the effects of a treatment, right, and sometimes patients and people will say, “I don’t want the treatment. I will take the disease. The treatment really is worse than the disease.” Right? That’s okay for them to make that decision, so I think we have to temper our low-risk social isolation with the mental health aspect of being isolated.

Dr. Neal:

I don’t have a perfect algorithm. I don’t have an equation you can apply. These are decisions that we sort out ourselves on an individual level. Certainly, people are going to do dumb things, they’re going to have 50-person parties, just go crazy and spread COVID, and that’s a mistake. But I think that, “Do I go visit my parents for Thanksgiving?” Yeah, I probably would, right, unless I was worried about giving my parents COVID. I know that that’s affected my family. My parents would love to go visit my brother’s son and his family out of California, but the risk associated with that is something that they’re having to weigh.

Lindsey Hendrix:

Speaking of the COVID-flu connection, we were talking about the flu vaccine earlier, but you’re also involved with the development of a different kind of vaccine, which is for potentially application to COVID-19. Can you tell us a little bit about that?

Dr. Neal:

There is a tuberculosis vaccine that has been around for decades and is given to millions of children every single year. Billions of doses have been given many decades to people all over the world to protect them from tuberculosis. The way that the BCG vaccine works is that it creates a sort of permanent innate immune response to tuberculosis that has a generalized effect on the body’s immune response to lots of other organisms as well, and through the decades, research on people who’ve been vaccinated with the BCG vaccine has demonstrated that the BCG vaccine benefits them whenever they get sick from other things as well. People don’t tend to get as sick from other viruses, and it boosts the effect of other vaccines when they get those, such as with the yellow fever vaccine.

Dr. Neal:

The type of immunity that the BCG vaccine develops in our bodies has been postulated to help prevent death and severe illness related to COVID. And so, the study that we’re doing is we are taking health professionals, firefighters, policemen, and paramedics right now, and we are either giving them a placebo injection of saline or giving them the BCG vaccine, and we’re tracking them over a six-month period to see if they get severely ill from COVID or not.

Dr. Neal:

We’re comparing those two groups, and our hypothesis is that the BCG vaccine will help protect them from severe illness and death and days missed of work related to COVID, and so the nice thing about this is that the BCG vaccine is already proven to be very safe to give. Lots and lots of people have had this vaccine over decades, and so we’re repurposing a known vaccine for potential protection from coronavirus, and that is something that could be done more rapidly than the development of a specific and novel vaccine for coronavirus directly. It’s not going to keep you from being exposed to the virus, right? That’s not it. It’s about how seriously ill do you get once you have been exposed to the coronavirus.

Lindsey Hendrix:

Yeah, that is so cool. I love that you can use a-

Dr. Neal:

Yeah, re-purposing other treatments or new things is awesome.

Lindsey Hendrix:

… Yeah, seriously. Like you said, it really accelerates the whole process, which is cool.

Dr. Neal:

Right on. It’s something that people have asked me is, “If I get the BCG shot in your study, can I still have the flu shot?” and of course, the answer is yes. It’s very likely that folks who get the BCG vaccine will have a better response to this year’s flu vaccine as well, so we’re excited about that possibility. We just haven’t used the BCG vaccine in the U.S. the way that they have in other countries, so it’s been harder to measure that kind of effect.

Dee Dee Grays:

If someone did receive the BCG, let’s say they’re from another country, came over here, and they had it as a child, is there any studies, or do you know if whatever they had, if they got it in the past, that it would still possibly help protect them now?

Dr. Neal:

Right. There are researchers looking into that question right now, and it’s sort of a mixed bag. I’ve seen reports of studies suggesting that in countries where the BCG vaccine is given to every child, that it would appear that they have less morbidity and mortality related to the coronavirus, but there’s also been some studies, or analysis of those studies, that have suggested there’s not really, so I don’t think that it’s clear yet whether having a childhood BCG vaccine protects you from COVID, okay? It may. I’ll be interested to see as more and more data emerges on that, whether that proves to be true, but we’re hopeful that people who receive a BCG vaccine as an adult in our study do see a benefit from the BCG vaccine.

Lindsey Hendrix:

Is the BCG vaccine one of those where it’s like one and done, or is it more like the flu vaccine where you have to get it annually or boosters every so often?

Dr. Neal:

In terms of its indication for tuberculosis prevention, it’s a one-and-done shot. You get it as a young child and you get a little scar usually on your arm where they give it to you and then you’re done, there’s not an indication to have it a second time. But there’s no harm in having it a second time, and there are people in our study who had it as a child, but then were able to either get placebo or the BCG vaccine as part of the study again. So, having a prior BCG vaccine was not an indication to having it as part of study.

Dee Dee Grays:

With the convergence of the flu and COVID, can you get both of them at the same time?

Dr. Neal:

Certainly. You can certainly have coronavirus and influenza at the same time. We don’t know just how bad that is, but there’s real concern that having both at the same time. We don’t know yet, but if you get the flu and you get over it, but then a week later, or a month later, you get coronavirus, are you more likely to have a more severe illness related to the coronavirus because you recently had lung inflammation from the influenza virus? Possibly. If you get coronavirus and you recover from that, you still have inflammation occurring in your lung that’s mild and you get the flu, is that putting you at a higher risk for influenza hospitalization and death? Maybe. There’s just a real concern that the confluence of these two viruses, particularly because they affect the lungs, both of them so much, that it can be a real disaster to have them both at the same time or to have them back-to-back. The truth is we don’t know. We don’t know yet. There’s not enough data to say, but I think it’s pretty reasonable to think having two serious respiratory illnesses in the same winter would be bad.

Dr. Neal:

Then, of course, there’s the question of, does having coronavirus increase your risk of death from bacterial pneumonia? Does it increase your risk, you know what I’m saying, for other viruses, like adenovirus, as an example that can cause pretty bad colds and pneumonia in children? There’s also a virus called the respiratory syncytial virus that affects young children, so if a young child has coronavirus and then has the flu and then has respiratory syncytial virus, or all three at the same time, what’s that look like? Bad, right? We’re going to see this winter what happens, but this is why having the flu shot, getting back to that, is important because it is one of the things we can do to try and prevent serious illness, at least from influenza, and then depending on how that affects the coronavirus illness or respiratory syncytial virus illness, we’ll have to see.

Lindsey Hendrix:

I think wrapping it up in a nice, pretty bow, just get your flu shot and keep doing everything you’re doing to prevent COVID, and hopefully, hopefully that can help prevent all of these convergences and all of the mess that could happen with the health care system if people are coming in with all of these viruses at the same time.

Dr. Neal:

Right, and hopefully in the near future, we’ll have some other preventative measures we can take. I mean, who knows what will come of our study and who knows how the COVID vaccine development’s going to go? None of us have a crystal ball for that, but we can keep our fingers crossed and hope for the best there.

Dee Dee Grays:

If we do have some listeners, though, that want to be part of the trial, how would they go about doing that?

Dr. Neal:

Well, that’s a great question, Dee Dee. There’s a link that we can provide that takes them to the screening questionnaire, right? They can complete the questionnaire and that will tell them whether they’re eligible for the study or not, and so happy to provide that. There’s a link on the Texas A&M website, the Health Science Center. We’ll be circulating this information on Facebook as well, but it’s just a link to a survey, they take it, and then they take off from there.

Lindsey Hendrix:

If you’re not in front of your computer or device right now, I happen to know the URL at the top of my head. It is health.tamu.edu/bcgtrial, so that’s where you can go to take that questionnaire.

Dr. Neal:

Right on. I’ll throw out my email for any of the listeners. It’s gneal@tamu.edu, and if they want to send me an email, I will email them the link. No problem. Another way to get it.

Lindsey Hendrix:

Fantastic. Good question, Dee Dee. Well, you’re doing amazing work, both in the clinics, at the hospitals and in the research lab, so kudos to you and good luck with everything.

Dr. Neal:

Thank you so much. It’s been a real pleasure to be on the program today. I’m very grateful and would be honored to ever come back.

Lindsey Hendrix:

Oh, absolutely. We will most certainly have you back. Well, you have a great day, Dr. Neal. Thank you.

Tim Schnettler:

Thank you for joining us on Texas A&M Health Talk, a production of the Texas A&M University Health Science Center. Visit us on the web at vitalrecord.tamhsc.edu, where you’ll find answers to all of your health questions. Until next time, stay healthy.