Are We Prepared for the Upcoming Flu Season?

The original article, “CDC’s Flu Czar Says She’s Ready for the Fall Offensive,” was published on Infection Control Today.

Did you see much influenza this year? Neither did anybody else. That’s because the mitigation measures used to turn back the COVID-19 tidal wave—hand hygiene, masking, social distancing—might have been only somewhat effective against SARS-CoV-2 (or perhaps not applied with enough effort, many medical experts would argue), but they stopped the flu in its tracks. Does that present a problem for the coming 2021–2022 flu season as government officials ease up on those measures? Not really, says Lynnette Brammer, who heads the domestic influenza surveillance team at the Centers for Disease Control and Prevention (CDC). True, the vaccines that will be used to fight the flu this fall are already being manufactured and those vaccines—as is the case with flu vaccines each year—are created based on the previous year’s flu data. Of which, as mentioned, there’s been a dearth. “We haven’t had as much data as we have had in previous years, but we did still have a good bit of data,” Brammer tells Infection Control Today®. In addition, fighting COVID-19 greatly improved the health care system’s surveillance capabilities when it comes to respiratory diseases. That and a huge influx of funding to improve state public health departments, and technological and systemic innovations created because of COVID-19, will keep influenza manageable, Brammer bets. Still, she warns that “the diagnosis of respiratory disease this coming fall will probably be a little bit more complex than it was over the past year.”

Infection Control Today®: Will the flu cause us a lot of problems in the fall?

Lynnette Brammer: Flu can cause lots of problems every fall. We say all the time—and I know people get tired of hearing it, but I think right now it’s truer than ever—flu is incredibly unpredictable. Just in a regular year there can be huge variation and how severe flu season is. And the upcoming one will be no different. It could be severe, or it could be a mild flu season, we don’t know. But there’ll be a lot of new factors at play this coming year.

ICT®: Such as?

Brammer: We’re coming off all of these mitigation measures, which did do a really good job at combating flu. We’re starting to loosen up on those. [For instance], the mask wearing for people that are vaccinated against COVID. And we’re starting to get together with our families again. Eventually, we’ll start domestic and international travel again, I assume. And, you know, all of those things…. And the kids will go back to school in the fall. And all of those things will have an impact on flu virus circulation.

ICT®: How is the flu vaccine created each year? In a nutshell, how’s it done?

Brammer: Well, it’s done in this collaborative, worldwide process. We work with the World Health Organization to participate in international surveillance for influenza. Countries across the world collect specimens from people with respiratory illness and test them for influenza. And then the positives, a subset of those go on to specialized centers around the world where more detailed characterization of the viruses occur. We see what they look like. We look at people who’ve been vaccinated. Their responses against those viruses that look a little bit different. Look at the vaccine effectiveness for the current year against those viruses and decide what viruses look like they’re, one, spreading and have a chance to become a predominant virus. And, two, which one of those probably you might not be protected against with the current vaccine components. And from that, they’ll then decide, “OK. We think we need to update this component or that component.” There’s always four in the vaccine. There are two influenza B’s and two influenza A’s. And these decisions are made in February, late February, early March. And the vaccines are produced and start getting distributed in the very late summer months, and are administered in the fall.

ICT®: So, these decisions have already been made about what kind….

Brammer: Absolutely. They have.

ICT®: I’m sure you’ve had this question put to you recently. Do we have enough data to figure out what we can expect from the flu this year?

Brammer: We haven’t had as much data as we have had in previous years, but we did still have a good bit of data. There weren’t a lot of influenza viruses circulating anywhere, but there were some. And what we saw back, oh, gosh, I don’t even remember when it was … I guess it was back in late fall. In some areas of the world as they started to loosen up some of their mitigation measures, their mask wearing and such, they started to see flu outbreaks. And so, we had access to those viruses, and have looked at those. And we looked at the antibody responses people made against last fall’s flu vaccine and tested it against those viruses to see if it looked like they would cover or not.

ICT®: Relatively speaking how much fewer data do you have this year as opposed to any other year? Is it like 50% less information than you usually have?

Brammer: I don’t know. I don’t remember the numbers well enough to know exactly how many viruses were looked at. But we feel like it’s not so much the number that you look at. When there’s very little out there, there’s less to see. If you think of it as a proportion of what’s out there. I think we saw as much or maybe even more of what was out there. It was just so little be seen. You’re not missing anything if the viruses aren’t circulating. So, because of this huge international network, we feel like we’ve got a really good representation of the viruses that were circulating.

ICT®: But because there’s so little to be seen, does that call into question what conclusions you reached? Not you personally, or even the CDC, but health experts reached about what to do about the flu in October?

Brammer: I don’t think so. Because, yes, there were fewer viruses, but those are the viruses that are there, and those are the viruses that will give rise to the viruses that circulate you know, if they do, in the coming fall.

ICT®: What’s different about this year? I mean, everything’s changed—the health care system, after what we’ve just been through. And I imagine your job has changed, and what you’re looking at has changed. What’s changed?

Brammer: Oh, a lot has changed. In a lot of ways, flu and SARS-CoV-2 viruses are similar enough that our surveillance systems can be pretty similar. As we’ve expanded surveillance for COVID, surveillance for flu is improving, too. All the investment being made in state public health departments and public health laboratories. It’s a huge advantage for COVID. But it’ll be a huge advantage for flu, too. We are adding new surveillance pieces. There will be some new electronic data that becomes available to us. We’re hoping to have a more robust surveillance—high alert, at least in emergency departments. Our hospital emergency department syndromic data. We’ve worked with our colleagues over in T-cells at CDC, and that network is expanding. We’re going to have much more robust data and a much better geographic coverage. That will work for COVID, but it also works for flu. We’re getting a lot more data and we learned a lot. We always had talked about being prepared for an influenza pandemic. And being able to scale up our systems. Well, COVID scaled up our systems way more than we ever dreamed about scaling up for. But now we’ve got systems that can handle really large volumes of data. And that’s going to be really nice. Flu will certainly benefit from those improvements. We’ve found some of our systems didn’t work as well as they had in the past because health care seeking behavior had changed. That has led us to think a lot about: Well, OK, if people change where they go for health care, how do our surveillance systems react so that we can continue to monitor? In the coming years, not all in one year, but in the coming years, we’ll continue to evolve our surveillance systems to deal with some of the unanticipated issues that we saw over the past year.

ICT®: Last year, infection preventionists and other health care professionals were worried about emergency rooms being filled with people who had respiratory illness and they weren’t going to be able to tell whether they had the flu or COVID-19. That did not really materialize.

Brammer: Right.

ICT®: Is that still a possible problem that you have to deal with this flu season? Do they have flu? Or do they have COVID?

Brammer: I think it will be an issue that people are going to have to deal with this fall. I mean, as mitigation measures loosen up, we’re starting to see some of the other respiratory viruses begin to circulate again at a little bit higher level. So far, not flu, but some of the others, but flu will follow. And as last year was, the diagnosis was a lot easier, because almost all the respiratory illness was due to one thing, and that probably isn’t going to be the case for much longer. We’ll have to see. But it does look like some of the other respiratory viruses are coming back. We expect flu will come back. It’s just a matter of how quickly. But, again, some of the things that happened in the last year will help us. There’s more testing available. There are some of these multiplex tests that will test for flu and SARS-CoV-2 and respiratory syncytial virus. The tools will be there.

ICT®: I believe you just mentioned the multiplex test. That’s fairly new technology is it not or am I mistaken?

Brammer: There have always been these multiplex respiratory panel tests that had multiple respiratory viruses on them. They were less available in point-of-care sites. Doctors’ offices, emergency departments, perhaps. But now there are some that are point-of-care multiplex tests. Public health labs have a multiplex test that’s flu and SARS-CoV-2. So, there are more tools available to more people.

ICT®: Have things been invented because of COVID that you can now use during flu season?

Brammer: Yes. I think just across the board. Like I mentioned earlier, our ability to handle large amounts of data at CDC is improving every day. It has gotten much better. We’re getting new assays that are available. The financial support that’s coming to state public health is going to be hugely helpful. The public health system in the country had been underfunded for a long time and now they’re getting a lot of money and that infrastructure is being rebuilt. That’s going to be an advantage for COVID for flu for all of public health.

ICT®: You mentioned improvements in surveillance systems. Can you give me an idea of what that might look like on the ground? Something that would have happened pre-COVID is now happening a different way post-COVID?

Brammer: Let me think of some good examples. Just simple things like we monitor influenza-like illness through ILINet, which is our system for that. We’ve added about 1000 new providers. The National Syndromic Surveillance Platform, which collects syndromic surveillance data, which we use in ILINet…. They’re now pushing to have all hospitals participate in that. That’ll be a huge advantage. We had it in the majority of states, but there were a couple of states still that were really underrepresented. That’s going to basically help us fill these gaps that we had beforehand. And then we’re working with new partners to get additional data sources—electronic health record data, and a lot of new sources of data that we just didn’t have available to us in the past

ICT®: Ms. Brammer is there something about the coming flu season and how infection preventionists need to react to it that I neglected to ask you that you think is pertinent and that they should know about? Or any other health care professional should know about for that matter?

Brammer: I think—and I’m sure they’ll be acutely aware—that the diagnosis of respiratory disease this coming fall will probably be a little bit more complex than it was over the past year. But there are these new assays out there that can be useful. And we expect that there are more resources for the states to do surveillance. They will have better surveillance data on which they can depend to help make treatment decisions.

This interview has been edited for clarity and length.