After more than two years of being suppressed thanks to COVID-19 measures, influenza is back in the United States with a vengeance. Combined with surges of other respiratory viruses and a likely new wave of COVID-19 infections, the U.S. could be in for a rough winter ahead, experts warn.
The 2022 to 2023 flu season is already off to an early start, with cases rising rapidly over the last few weeks in parts of the South and Southeast. Texas and Georgia are among several states reporting unusually high numbers of confirmed flu cases for this early in the season.
One high school in Virginia canceled all activities after roughly half the student body, about 1,000 students, called out sick with flu-like and gastrointestinal symptoms, TODAY previously reported.
The early flu season coincides with an unprecedented surge in RSV (respiratory syncytial virus) and other respiratory viruses among young children that's pushing pediatric hospitals around the country to the brink, TODAY previously reported.
Experts are concerned about a "triple threat" virus surge or a "tripledemic" of influenza, RSV and COVID-19, which could overwhelm health systems and stretch medical resources. These include medications like antivirals, which can be used to treat flu.
Influenza antivirals like Tamiflu have been gathering dust on the proverbial shelf for the last two years while the flu largely disappeared during the COVID-19 pandemic. Now, these are reportedly back in demand and at much higher levels than what was seen in October prior to 2020.
While there are no confirmed shortages of these flu antivirals, some experts worry that an early surge in prescriptions for medications like Tamiflu could put stress on pharmacies that did not order enough stock to meet demand this early in the season.
Where is flu increasing in the U.S.?
According to the latest data from the U.S. Centers for Disease Control and Prevention, influenza activity is increasing in most of the country, with the Southeast and South-central regions reporting the highest levels of flu activity. Hot spot states include Texas, Georgia, Tennessee, South Carolina, and New York, per the CDC, and flu activity is also very high in the District of Columbia.
“Many of us, myself included, are anticipating a moderately severe flu season,” Dr. William Schaffner, professor of infectious diseases at the Vanderbilt University Medical Center in Nashville, Tennessee, told TODAY.
The dropping of mitigation measures like masking and distancing, coupled with lower population immunity due to reduced exposure to influenza viruses over the past few years, is sparking concern among experts, TODAY previously reported. What's more, fewer flu shots have been administered at this point in the season than in 2021 and 2020, per CDC data. (Experts say the best time to get your flu shot is by the end of October.)
"There’s this concept out there right now going around — vaccine fatigue, where people are simply getting tired of recommendations and ideas that we all need to vaccinate," Dr. Dhaval Desai, director of hospital medicine at Emory Saint Joseph’s Hospital in Atlanta, told TODAY.
In Texas — where flu cases typically ramp up in December or January — influenza activity began increasing as early as mid-September, Dr. Luis Ostrosky, an infectious disease specialist at UTHealth Houston and Memorial Hermann in Houston, told TODAY. “Undoubtedly, we’re having an early flu season, and the numbers are increasing very rapidly."
Following national trends, the most frequently reported viruses in Texas are influenza A, and these cases are rising among both adults and children, said Ostrosky. “We are seeing some clusters in schools, but it is everywhere … in our emergency rooms, urgent cares, in the hospital, primary care clinics.”
Georgia, which currently has the highest flu rate of any state (aside from District of Columbia), is also experiencing an early uptick in cases this fall compared to previous seasons before the pandemic. “The biggest message that we can take from that right now is it’s really time to vaccinate,” Desai said.
In Tennessee, both flu cases and hospitalizations are on the rise. “We are already seeing patients being hospitalized with laboratory-confirmed influenza ... substantially more than usual at this time of the year," said Schaffner. "We’re about a month early.”
Tennessee is seeing a mixture of both influenza A viruses, H1N1 and H3N2, as well as some influenza B, Schaffner explained. “That’s a little unusual, because conventionally, you have a dominant strain if there’s going to be one, (but) it hasn’t sorted itself out yet.”
The timing, duration, circulating strains and severity of flu seasons tend to vary every year, according to the CDC. However, it's clear that flu is ramping up earlier than typical pre-pandemic seasons.
How is this impacting demand for antivirals?
There are already reports that demand for flu antiviral medications is surging, and some pharmacies in hot spot states are scrambling to fill the higher-than-usual number of prescriptions for this early in the season, according to Ostrosky.
There are four FDA-approved antiviral drugs recommended for use by the CDC to treat flu this season: oseltamivir phosphate (brand name Tamiflu), zanamivir (Relenza), peramivir (Rapivab), and baloxavir marboxil (Xofluza).
According to GoodRx, a digital health care platform that monitors flu cases through its Tamiflu tracker, prescriptions have surged recently. “Although it’s very early in the season, our initial data point shows that fills are higher at this time of year than they have been since 2013,” Tori Marsh, director of research at GoodRx, told TODAY.
“So far, Tamiflu fills are 5.6 times higher than they were at the start of the flu season last year, and if we average the fill rates for the start of flu season in the previous nine years, this year is 3.3 times higher,” said Marsh, referencing a graph showing the weekly fill rate by flu season. Data from the CDC tell the same story, she added.
Flu antivirals work primarily to prevent complications, hospitalizations and mortality due to influenza, Ostrosky explained, but they can also lessen symptoms and shorten the duration of illness.
“The key is that they need to be given as early as possible in the viral phase of the disease when the virus is very actively replicating. That is usually within 48 hours of noticing symptoms,” said Ostrosky. If antivirals are taken after 48 hours, there’s still some effect, but it diminishes with time, Schaffner noted.
Those who benefit the most from flu antivirals are individuals at higher risk of flu complications, Ostrosky said: people over 65, people with compromised immune systems and people with underlying comorbidities, particularly pulmonary issues.
These also include children who are immunocompromised or have underlying conditions, including asthma, said Desai. (People should talk to their health care provider about which antiviral is right for them based on factors like age and health status, the experts noted).
Flu antivirals require a prescription from a doctor, but unlike with COVID-19 antivirals, you do not need a positive flu test to get a prescription, Ostrosky noted. “We pretty much prescribe it to anybody that has either documented or highly suspicious flu in the correct epidemiological context.”
“If somebody presents with an influenza-like illness (fever, sore throat, congestion) and the area is seeing high flu activity, that’s what we call a high pretest probability of flu,” said Desai. In these cases, patients at high risk are recommended to start treatment with Tamiflu right away while waiting for test results, he added.
(Note: COVID-19 antivirals are a completely different medication and do not work to treat flu, Desai said).
Tamiflu can also be used for prevention when someone has been exposed to influenza or will be entering a setting with a lot of sick people. Flu antivirals are not a substitute for the flu vaccine, per Food and Drug Administration.
How could this impact pharmacies?
Although the FDA and CDC have not listed any official shortages, Ostrosky noted, the early surge in flu cases and subsequent surge in prescriptions for antivirals could be a potential issue for pharmacies that weren’t prepared for this level of demand in October.
“I believe it’s not a real problem of supply, but a problem of ordering and logistics. … Most pharmacies were expecting to order their stock later in the season, and this is catching them off guard,” said Ostrsoky.
“Anecdotally, I’ve been hearing people that are having trouble getting the antivirals in the drugstore, or sometimes they’re offered the brand name instead of the generic, which seems to be more available,” said Ostrosky. Brand name medication may be more expensive depending on insurance coverage, he added, which could make the medication cost-prohibitive for some.
“Right now we don’t see a shortage of flu antiviral medications, (and) manufacturers have not reported a shortage in anything we can ascertain from the resources that we have access to,” Brigid Groves, senior director of practice and professional affairs at American Pharmacists Association, told TODAY in an interview. While it is possible that some pharmacies do not have their typical stock at this point, there is plenty of supply behind the scenes, Groves said.
“Likely what happened is … because the ordering and use of (flu antivirals) hadn’t been quite as high the past couple of years, they didn’t get restocked on the pharmacy shelves right away,” said Groves, adding that she had not heard any reports of pharmacies experiencing issues placing orders for more stock.
Although it is unclear how this flu season will pan out, the experts noted that cases will only increase moving forward. In the U.S., flu season typically peaks between December or February, but severe activity can continue as late as May, per the CDC.
“Obviously, we’re only seeing the tip of the iceberg in our surveillance system,” Schaffner said.
As cases go up, "we are going to see an increase in demand for Tamiflu and any antiviral that’s on the market,” said Desai, especially among high-risk populations.
However, Groves reassured that supply should be able to meet demand: “We'll start to naturally see more stock coming into pharmacies and getting onto the shelves.”
In the event of a possible shortage, Ostrosky speculated that this could warrant guidelines to prioritize access for people who benefit the most from antivirals in the high-risk groups.
“We don’t encourage patients to stock up or hoard medications, (and) we want to ensure that there is enough supply around for everyone, in particular for those (high-risk) patients,” said Groves. “It’s much more preferable for people to get assessed and then to get the medication that’s best for them."
Getting a flu shot is the best way to prepare for flu season
The good news is that you can protect yourself from the flu and serious complications by getting the seasonal flu vaccine. The CDC recommends everyone ages 6 months or older get their flu shot by the end of October, but it can still offer protection if you get it later in the season.
“Now, it’s actually a great time to get your flu shot, because it's going to be able to protect you throughout the duration of flu season,” said Groves. Getting your flu shot now gives your body enough time to build up immunity, Groves added, which is important if you live in a state where cases are already increasing.
“The worst case scenario we’re preparing for is the famous twindemic, where we would see both a large number of influenza cases and a new COVID surge,” said Ostrosky. A twindemic could put a severe strain on an already stressed health care system, Desai said, so it’s important to focus on prevention now.
All of the experts emphasize the importance of getting both a flu shot and the updated COVID-19 booster as soon as possible, and continuing to practice preventive measures like staying home when sick, masking in crowded indoor spaces, and practicing hand hygiene.
“The flu can be deadly. … It’s not something we want to mess around with,” Desai said. During seasons between 2010 and 2020, the flu caused anywhere between 12,000 to 52,000 deaths annually, according to the CDC.
“Vaccination is our main weapon right now,” Desai added.