A fear “twindemic”—an influenza epidemic sheathe in a COVID-19 pandemic—never materialized, much to the relief of crucial care specialists and their hospitals’ administrators.

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Instead, flu cases and also deaths in the united state and worldwide dropped to unprecedented lows, and influenza continued to be scarce this summer for the 2nd consecutive flu season in the southern Hemisphere.

Between October 3, 2020, and July 24, 2021, the the 1.3 million specimens tested by clinical laboratories and reported come the united state Centers for an illness Control and also Prevention (CDC), 2136 were positive for influenza virus, and 748 deaths were coded as influenza, according to CDC data noted to JAMA.

In a typical season, 75 come 150 children die of influenza in the US, pediatric infectious condition specialist Paul Offit, MD, manager of the Vaccine Education facility at the children’s Hospital that Philadelphia, detailed in one interview. Last flu season, the said, 1 child died.

As in vault years, “it is likely that over there were plenty of more” flu deaths in the US, a CDC spokesman noted in an email. Not all flu deaths space reported to the CDC, and also not every deaths due to flu-related symptom are detailed as together on fatality certificates.

However, the doesn’t define the eye-popping differences between the 2020-2021 flu season and also its predecessor. In the 2019-2020 season, more than 38 million human being in the US became sick with influenza and virtually 22 000 of them died, the CDC estimates.

Except because that a couple of places, such together western Africa, “the flu was essentially nowhere” this past fall and also winter, virologist Richard Webby, PhD, the St Jude Children’s research study Hospital, 1 of 6 civilization Health company (WHO) Collaborating Centers for influenza, said JAMA in one interview.

How an ext than a year with virtually no influenza bodes because that the coming flu season is unknown, and potential scenarios variety from a repeat of critical season’s number to an to explode in cases.

Several what ifs will recognize the upcoming season’s magnitude: the COVID-19 pandemic’s severity this fall and also winter, the level to i m sorry SARS-CoV-2 mitigation measures continue to it is in used, and how well vaccines room matched to circulating influenza viruses.


The unexpected yet welcome plummeting the influenza situations during the COVID-19 pandemic “certainly verified that numerous of the social-distancing things we to be doing were very effective,” Vanderbilt University school of medication infectious condition and health policy professor wilhelm Schaffner, MD, stated in an interview.

On optimal of mask wearing, social distancing, and handwashing, Schaffner noted, most global travel to be halted and also many nations closed schools, keeping children—“the great engine the the distribution of influenza virus”—at home and also away from each other.

“It’s impossible to tease out which of those had the biggest effect,” epidemiologist Alicia Budd, MPH, of the CDC’s Influenza Division, said in one interview.

Despite this mitigation measures, COVID-19 ongoing to spread, demonstrating the SARS-CoV-2 is much an ext contagious than the influenza virus, Schaffner added.

“Obviously, because we’re now all opened up and going earlier to school, us anticipate that these old methods of spreading the flu virus will come into play this fall,” the said.

The CDC freshly recommended face masks for all students, faculty, and staff in K-12 schools this fall, however Texas, Arkansas, and also Arizona have actually banned mask mandates and also Florida branch Ron DeSantis has pledged to perform the same. In a current statement, Nebraska governor Pete Ricketts said, “Schools have to convene in person without mask or vaccine requirements.”

In Japan, and also in some other parts the Asia, it has actually long to be customary for civilization to stay masks when sick, however “I don’t think over there is any type of evidence that flu seasons have been milder in Japan,” epidemiologist Benjamin Cowling, PhD, that The college of Hong Kong school of windy Health, told JAMA in an email.

Still, claimed Cowling, who studies the public health of influenza, “I would encourage civilization to think about wearing masks to safeguard others if they are having flu symptoms and using public transfer or visiting overfilled areas.” In addition, that said, human being who room worried around contracting influenza, such as those who space immunocompromised, should more than likely wear a mask during flu season.

“I anticipate we will check out masks used an ext often in the post-COVID era 보다 we supplied to watch in the pre-COVID era,” Cowling added.


Ask anyone whose work focuses on influenza to define the scourge in a single word, and also they are likely to answer “unpredictable.”

Past flu seasons have followed no pattern. A soft one is sometimes followed by a significant one, occasionally by an additional mild one, and vice versa.

“It’s tough to say what the influence of a very, an extremely low influenza season is,” Ann Moen, MPA, cook of influenza preparedness and an answer at the WHO, claimed in an interview. “If it proceeds like this, it i will not ~ be unreasonable to think the you’re walking to have actually a more severe season.”

The reason? “I think some areas that have totally reopened will be fragile to big flu seasons due to the fact that of the loss of population immunity in the past 18 months,” Cowling said.

Worldwide, 10% come 30% the the populace is exposed come the flu during a common season, Webby noted. “Take away 2 complete seasons, and also that’s a lot of people” there is no immunity, that said, including that it’s an overwhelming to job the magnitude of the influence this might have.

“I nothing think anybody is ready to placed down your dollars and bet top top what horse is walk to victory here, since flu is therefore darn fickle,” Schaffner said.

A recent post by researcher in Spain discussed whether the COVID-19 mitigation measures might have to be a double-edged sword.

The write-up focused on influenza and respiratory syncytial virus (RSV), which additionally plummeted last winter. The authors noted that “the absence of circulation of specific pathogens have the right to lead to a decrease in herd immunity versus them. This can promote the increase of an ext serious, longer-lasting epidemics that start sooner.” Indeed, Australia skilled a delay seasonal RSV rise in late September 2020 when physical distancing restrictions were relaxed, and also researchers in ~ a new York City hospital freshly reported comparable findings.

Important measures to against a possibly serious influenza pandemic may include increased influenza vaccine production and also massive influenza immunization programs along the present of those because that COVID-19, the authors in Spain concluded.

“With all the emphasis on COVID vaccine, us want human being to store in mental this year the prestige of flu vaccine,” Budd said.

Flu vaccine manufacturers job they will provide 188 million to 200 million sheep in the us for the upcoming flu season, according to the CDC. GlaxoSmithKline recently announced the it expects to distribute 50 million doses of the influenza vaccine in the US, much more than in any kind of previous flu season.

And that’s after this past flu season set a record for vaccine distribution, with around 194 million doses dispersed by the end of February. As of at an early stage February, 55% of us adults had actually been immunized versus the flu—10 percent points higher than the estimated coverage a year earlier.

Out of caution this previous flu season, the CDC’s Advisory Committee on Immunization methods advised intervals the at the very least 2 weeks in between receiving a COVID-19 vaccine and any other vaccine. However the CDC now deems that practice unnecessary, so people can be immunized against both COVID-19 and influenza in ~ the very same visit.


Influenza viruses mutate regularly, which is why—at the very least for now—the vaccines are updated annually.

Every February, based on surveillance data, the that recommends the 4 vaccine viruses for the north hemisphere’s upcoming flu season. It can not be a last-minute decision since it bring away at least 6 months for manufacturers to produce large quantities the vaccines.

The who conducts influenza surveillance 24/7-year-round, Moen noted. “We bend over backwards come make certain if flu is the end there, we’ll discover it.”

But what if only a tiny amount of influenza is circulating? Does that make that more difficult to predict which strains the vaccines should target? and is there a greater chance that this season’s vaccines i will not ~ be a an excellent match to circulating strains?

“That’s one absolutely precious question,” Webby said. “I think there to be a tiny bit much more apprehension about the selection” of influenza strains for the 2021-2022 vaccines.

In their finest years, vaccines alleviate immunized individuals’ chances of contracting the flu by around 60%, according to the CDC, which began tracking efficiency in the 2003-2004 season. But even in years in i m sorry flu vaccines no a great match because that circulating viruses, millions of cases are prevented.

Early on, the pandemic disrupted influenza monitoring in most countries, although the recovered in numerous by early 2021.

“Globally, we experienced as lot or more testing than usual because that influenza, but many countries did battle to maintain influenza security in the challenge of the COVID-19 pandemic,” Moen said. “Some nations did not maintain influenza monitoring for a variety of reasons, such as lack of reagents, prioritization for just COVID-19 testing, and also diversion the flu employee to COVID-19 work.”

From September 1, 2020, come January 31, 2021, 139 countries, areas, or regions reported data to FluNet, the an international influenza security platform, according to the WHO. That’s contrasted with 161 countries, areas, or regions a year earlier.

Overall sampling the specimens might have been up, in part because nations were experimentation for both SARS-CoV-2 and influenza. “We do an all-out effort to assist countries view that they might do both,” Moen said. But far fewer turned up influenza than in previous years. For example, Moen noted, in so late June and early July that 2021, the 6 that Collaborating Centers, which include the CDC, experiment 156 000 specimens, only 600 of i beg your pardon were optimistic for influenza.

So regardless of increased testing, the who based its recommendations for the 2021-2022 north hemisphere flu vaccine on considerably less data around circulating influenza viruses 보다 in typical years, i beg your pardon the company said raises uncertainty about the full degree of the viruses’ genetic and also antigenic diversity. In various other words, v relatively few viruses accessible for characterization, it’s possible that some likely to attitude a hazard went undetected. Also so, the WHO detailed that new groups the influenza virus subtype A(H3N2) to be found, bring about an upgrade in the referral for the A(H3N2) component of vaccines.

“There’s never any type of guarantee about these things,” Moen acknowledged. “Of course, you want to have actually as countless as feasible to do a decision, however you can only do a decision through what friend have.”


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