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However, even among children with high rates of interaction with the health care system-those with high-risk conditions that can make them especially vulnerable to influenza-vaccination rates are low. Existing literature suggests 33%-59% of hospitalized children have the flu vaccine, despite the CDC's recommendation that such children receive the vaccine while in hospital.

Corresponding author Evan W. Orenstein, MD, of the Emory University School of Medicine, and colleagues, wanted to find out whether implementing a CDS strategy might help providers achieve higher rates of vaccination among hospitalized children. Writing in JAMA Network Open, they explained that existing studies evaluating using CDS to boost compliance with health care maintenance objectives are inconsistent, and other studies have shown that health-record-embedded CDS tools only work if they deliver the right messages to the right providers at the right time.

Orenstein and colleagues devised a study which took place at a tertiary pediatric health system comprising 3 hospitals. A CDS tool was developed that included 3 main components, a default vaccine order for eligible patients, a script to offer the vaccine, and just-in-time education for clinicians with links to reference material.

The intervention was rolled out in the health system for the 2019-2020 flu season. Eligible children who were hospitalized during that time span were split into 2 groups, an intervention group and a control group. A second control group, based on patients who sought care in the 2018-2019 influenza season, was also evaluated.

The study population was mostly boys (52%) with a median age of 8; 50% were Black and 43% were White. Nearly two-thirds (64%) were on a public insurance plan.

The hospitals in the study reported 10,997 eligible hospitalizations during the 2019-2020 flu season. Those patients were divided on a 1:1 basis, with half receiving the CDS intervention. Among those in the intervention group, 31% received the vaccine. Among the concurrent control group, the vaccination rate was 19%. Of the 6743 patients in the 2018-2019 control group, the vaccination rate was 14%.

Orenstein and colleagues said the CDS is built around making the vaccine the default action, rather than framing it as an "addition" to routine care.

"These interventions stress the use of defaults as a behavioral economic strategy to influence behavior, including targeted defaults for clinicians to order the influenza vaccine as well as a nursing staff script emphasizing a default option for families of patients receiving the influenza vaccine during the hospitalization," they wrote.

However, the study also showed that while both vaccine orders and administration increased, the former increased more than the latter, suggesting vaccine refusal or other barriers remain an issue.

"Additional work to understand persistent reasons for low uptake and the potential effect of combining CDS with other behavioral economic and implementation science interventions would likely reduce the burden of influenza in a vulnerable population and provide lessons to improve vaccine coverage for other diseases, such as COVID-19," the authors concluded.
Reference
Orenstein EW, ElSayed-Ali O, Kandaswamy S, et al. Evaluation of a clinical decision support strategy to increase seasonal influenza vaccination among hospitalized children before inpatient discharge. JAMA Netw Open. Published online July 1, 2021. doi:10.1001/jamanetworkopen.2021.17809

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Clinical Decision Support Tool Raises Flu Vaccination Rates in Hospitalized Children

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However, even among children with high rates of interaction with the health care system-those with high-risk conditions that can make them especially vulnerable to influenza-vaccination rates are low. Existing literature suggests 33%-59% of hospitalized children have the flu vaccine, despite the CDC's recommendation that such children receive the vaccine while in hospital.

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If there was one pleasant surprise buried in last year's pandemic havoc, it was that the flu season was remarkably muted. It turns out the measures to thwart COVID-19, like mask-wearing and social distancing, work wonders against the annual bug, too.

But the medical community's flu-fighters were equipped with another weapon that the COVID arsenal didn't have till December: a vaccine. Better equipped than ever, in fact. Flu shot makers delivered a record 194 million doses to the U.S. last season as public health experts warned against the dreaded overlap between the two pathogens. Flu vaccine demand skyrocketed.

And that delivered hefty sales for flu shot heavyweights Sanofi, GlaxoSmithKline and Seqirus at a time when other vaccine revenues sagged. Sanofi led the pack with $2.47 billion in flu shot sales, up 38% compared with 2019, while Seqirus raked in $1.7 billion, up an impressive 30%. England's GSK raked in £733 million, up 35%.

This season, flu shot makers are again gearing up for another record year, with deliveries set to match the historic figures reported in 2020. Despite the widely deployed COVID-19 vaccines from Pfizer, Moderna and Johnson & Johnson, this flu season could prove just as precarious as society tries to roar back to pre-pandemic life, vaccine execs contend.

"A mild season one year may not signal what will occur the following year," GlaxoSmithKline's Leonard Friedland, M.D., vice president and director of scientific affairs and public health, told Fierce Pharma in an email.

Flu suppliers expect to ship more than 190 million doses during the upcoming season, indicating that "supply likely won't be an issue," Friedland said.

Dr. Leonard Friedland (GSK)

RELATED: Vaccine maker Seqirus plots $800M investment into major Australian shot manufacturing center
GSK plans to send more than 50 million doses to the U.S.⁠-about the same amount it produced in 2020. Fellow flu heavyweight, Seqirus, is gearing up to deliver about 60 million doses. That marks a slight drop-5%-from last year but still near all-time highs, said Seqirus' David Ross, VP of commercial operations in North America.

Sanofi, which set aside 80 million doses last year, wouldn't divulge how many shots it is planning to ship this time around. In a midyear report, the company said it expects "record" flu sales in the second half of 2021. Like GSK, it doesn't expect supply to be a problem, said Dan DiVito, who heads the company's respiratory portfolio.

"Whatever demand ends up being, we'll deliver that and we'll have some left over," DiVito told FiercePharma.

'Recipe for disaster'

As the health system battled a flood of COVID-19 patients last year, public health officials pleaded with Americans to get vaccinated against the flu. The goal was to prevent what was ominously termed a "twindemic," or the simultaneous influx of flu and coronavirus patients into U.S. hospitals.

One year and three authorized COVID-19 jabs later, flu shot makers warn the twindemic isn't merely a concern of the past. The delta variant has driven a wave of new infections and has sent hospitalizations rising, mostly among the unvaccinated.

That hasn't stopped many businesses from returning employees to the office (albeit many with vaccine mandates). Nor has it stopped schools from calling students back to the classroom. But after a year spent largely at home, Americans are returning to society more susceptible to viruses they might have otherwise encountered, Sanofi's DiVito said.

Case in point: the recent rise of respiratory syncytial virus, or RSV, DiVito said. The virus, which can cause serious cases of pneumonia and bronchiolitis in infants, has made an uncharacteristically early return, triggering a CDC health advisory in June.

"None of us were exposed to things like flu and RSV that we normally would be each year," DiVito said. A mix of the delta variant and flu among a naive population "could be a recipe for disaster."

A potential boost(er)

With the White House planning to roll out COVID-19 boosters to the general population as early as September-pending an official nod from regulators-flu shot makers could be in for a tailwind.

That's thanks to the CDC's decision in early May to do away with its recommendation that people avoid getting another shot within two weeks of the coronavirus vaccine. Intended to bolster lagging routine immunizations among teens, the CDC move means that some Americans may be able to get their annual flu shots and COVID boosters during the same appointment.
RELATED: Merck, GSK and Pfizer vaccines get a boost as CDC lifts 2-week restriction on pandemic shots
"The availability of vaccines, plus that important guidance from the CDC on coadministration, creates an environment where immunization rates for both flu and COVID should be boosted," Seqirus' Ross said in an interview.

Sanofi is now trying to push the double-shot method with extra safety evidence.

The company kickstarted a mid-stage study this summer that will test the safety of its Fluzone high-dose quadrivalent vaccine alongside a third dose of Moderna's mRNA vaccine in people aged 65 and older.

But as flu vaccination season nears, it's not certain the data will be ready ahead of a wide deployment this fall. Regardless, Sanofi believes it's a good idea for healthcare providers to offer both shots simultaneously in the coming months.

"If you do these things at the same time, they're coming in anyway, that's ideal," DiVito said. "We just have to make sure healthcare providers, the immunizers, view it that way and not like an extra burden."

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Sanofi, GSK and Seqirus prep for near-record flu shot sales as COVID's delta variant cooks up 'recipe for disaster'

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Sanofi, GlaxoSmithKline and Seqirus say they're prepared to match last season's record supply of U.S. flu shots, gearing up to deliver more than 190 million doses. And as the troublesome delta variant wreaks havoc, a new CDC rule means Americans may be able to get their annual flu jab at the same time as a COVID booster.

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https://www.the-scientist.com/news-opinion/flu-and-pneumonia-vaccines-linked-to-reduced-risk-of-alzheimers-67770

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Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: mmwrq@cdc.gov. Type 508 Accommodation and the title of the report in the subject line of e-mail.

The National Immunization Survey (NIS) provides vaccination coverage estimates among children aged 19--35 months for each of the 50 states and selected urban areas.* This report describes the results of the 2007 NIS, which provided coverage estimates among children born during January 2004--July 2006. Healthy People 2010 established vaccination coverage targets of 90% for each of the vaccines included in the combined 4:3:1:3:3:1 † vaccine series and a target of 80% for the combined series ( 1). Findings from the 2007 NIS indicated that>90% coverage was achieved for most of the routinely recommended vaccines ( 2). The majority of parents were vaccinating their children, with less than 1% of children receiving no vaccines by age 19--35 months. The coverage level for the 4:3:1:3:3:1 series remained steady at 77.4%, compared with 76.9% in 2006. Among states and local areas, substantial variability continued, with estimated vaccination coverage ranging from 63.1% to 91.3%. Coverage remained high across all racial/ethnic groups and was not significantly different among racial/ethnic groups after adjusting for poverty status. However, for some vaccines, coverage remained lower among children living below the poverty level compared with children living at or above the poverty level. Maintaining high vaccination coverage and continued attention to reducing current poverty disparities is needed to limit the spread -preventable diseases and ensure that children are protected.

To collect vaccination information on age-eligible children (i.e., those aged 19--35 months), NIS uses a quarterly, random-digit--dialing sample of telephone numbers for each survey area. When respondents grant permission to contact providers, the telephone interview is followed by a mail survey of the children's vaccination providers to validate immunization information. NIS methodology, including how the responses are weighted to represent the population of children aged 19--35 months, has been described previously ( 3). During 2007, the household response rate ( 4) was 64.9%; a total of 17,017 children with provider-verified vaccination records were included in this report, representing 68.6% of all children with completed household interviews. Statistical analyses were conducted using t-tests. Differences were considered statistically significant at p<0.05. A poverty status variable § was added to the logistic regression models to control for racial/ethnic differences among children living at or above the poverty level and children living below the poverty level. This report describes coverage levels for vaccines that have been included in the routine childhood vaccination schedule recommended by the Advisory Committee on Immunization Practices (ACIP) since 2000 or before ( 2).

In 2007, national coverage with the 4:3:1:3:3:1 series was 77.4%; this coverage has been stable since 2004. Coverage with the combined 4:3:1:3:3:1:4 vaccine series (i.e., the 4:3:1:3:3:1 series plus >4 doses of 7-valent pneumococcal conjugate vaccine [PCV7]) is being reported for the first time and was 66.5%. National coverage was>90% for each of the vaccines included in the 4:3:1:3:3:1 series except for>4 doses of DTaP (84.5%); coverage with>3 doses of DTaP was 95.5% ( Table 1). Coverage with>1 dose of varicella vaccine (VAR) reached 90% for the first time. VAR coverage among American Indian/Alaska Native (AI/AN) ¶ children increased significantly, from 85.4% in 2006 to 94.9% in 2007. National vaccination coverage estimates for PCV7 continued to increase, from 86.9% in 2006 to 90.0% in 2007 for>3 doses and from 68.4% to 75.3% for> 4 doses. Among AI/AN children, coverage with the fourth dose of PCV7 increased significantly, from 62.7% to 80.4%.

Substantial differences were observed in vaccination coverage among states and local areas ( Table 2). Estimated coverage for the 4:3:1:3:3:1 series ranged from 91.3% in Maryland to 63.1% in Nevada. Among the 14 local areas included in the 2007 NIS, coverage with the 4:3:1:3:3:1 series ranged from 82.2% in Philadelphia, Pennsylvania, to 69.6% in San Bernardino, California.

Vaccination coverage levels were higher among AI/ANs compared with whites for measles, mumps, and rubella (MMR) vaccine, hepatitis B (HepB) vaccine, and VAR ( Table 3). Coverage with the fourth dose of DTaP and the fourth dose of PCV7 among black children was not significantly lower than white children after controlling for poverty status. Vaccination coverage with the fourth dose of DTaP and the fourth dose of PCV7 was lower among children living below the poverty level compared with children living at or above the poverty level, but this difference declined from 6.1% in 2006 to 4.8% in 2007 for>4 doses of DTaP and from 9.4% in 2006 to 3.5% in 2007 for> 4 doses of PCV7. Vaccination coverage levels were similar across all racial/ethnic groups for the 4:3:1:3:3:1 series. Coverage differed for this series among children living at or above the poverty level compared with children living below the poverty level, but this difference declined from 4.9% in 2006 to 3.2% in 2007. Coverage between white and black children with the 4:3:1:3:3:1:4 series was not significantly different after controlling for poverty status.

Reported by: N Darling, MPH, M Kolasa, MPH, KG Wooten, MA, Immunization Svcs Div, National Center for Immunization and Respiratory Diseases, CDC.

Editorial Note:

NIS is the only population-based, provider-verified survey to provide national, state, and local area estimates of vaccination coverage among children aged 19--35 months. The results of the 2007 survey indicate that vaccination coverage for vaccines recommended routinely by ACIP since 2000 and before ( 2) reached record high levels. Improvements in vaccination coverage for VAR meant that national coverage estimates for all individual vaccines in the 4:3:1:3:3:1 series were>90%, except coverage with>4 doses of DTaP. Coverage with>4 doses of PCV7 also was <90%. However, 3-dose coverage for both DTaP and PCV7 remained high. Coverage with>4 doses of PCV7 increased significantly to 75.3% in 2007, a substantial increase since PCV7 was first recommended in 2000 (5). However, coverage with >4 doses of DTaP has not changed during the past 5 years. Increasing coverage for the fourth dose of DTaP and the fourth dose of PCV7 would improve national coverage for the 4:3:1:3:3:1 series and the 4:3:1:3:3:1:4 series, which will be used to monitor the Healthy People 2010 immunization objectives beginning with 2009 NIS data. The vaccine shortage that ended in September 2004 (6) might have reduced coverage with the fourth dose of PCV7 among children in the 2007 NIS cohort (i.e., those born during January 2004--July 2006). Use of effective interventions, such as parent and provider reminder/recall, reducing out-of-pocket costs, increasing access to vaccination, and multicomponent interventions that include education might further improve overall coverage in areas where coverage is low ( 7). In addition, closing the coverage gap between areas with the highest and lowest coverage remains a priority. To achieve this, further collaborative efforts among CDC, state immunization coordinators, immunization programs, and other entities are essential.

Vaccination coverage among AI/AN children for VAR, MMR vaccine, and the fourth dose of PCV7 increased significantly in 2007 compared with 2006; in 2007, coverage levels among AI/AN children were higher for two of these vaccines (VAR and MMR vaccine) compared with white children. Improved exchange of data between the Indian Health Service information system and state immunization information systems and implementation of evidence-based strategies such as reminder/recall at Indian Health Service and tribal facilities, might have contributed to these increases in vaccination coverage (A. Groom, CDC, personal communication, August 2008). However, further monitoring is needed to determine whether these levels will be sustained.

As in 2006, the results of the 2007 NIS indicate that differences in poverty status accounted for the observed differences in coverage between white and black children for the fourth dose of DTaP and fourth dose of PCV7. In 2007, these differences in coverage between children living at or above the poverty level compared with children living below the poverty level were reduced by one percentage point for DTaP and by nearly six percentage points for PCV7. Continued efforts are needed to improve vaccination coverage among children of all racial and ethnic groups living below the poverty level.

The 2007 NIS results confirm that the majority of parents are vaccinating their children, with less than 1% of children receiving no vaccines by age 19--35 months. Although vaccination coverage in this age group remains high, recent outbreaks of measles have occurred in certain communities (8). Several factors might explain this apparent paradox. Despite record high coverage with MMR vaccine, nearly 8% of children aged 19--35 months surveyed for the 2007 NIS remained unvaccinated. Measles is highly contagious, and clustering of unimmunized children within geographic areas can increase risk for measles and other vaccine-preventable disease transmission. Clusters of unimmunized children might not be detected by NIS methods and might not be visible in national and state rates. Furthermore, any changes in vaccination behaviors among parents of children born after July 2006 would not have been detected by the 2007 survey. Increased attention to parental concerns about vaccine safety has become apparent in recent years ( 9). The 2008 NIS is collecting information on parental concerns about vaccine safety to better assess parental attitudes and beliefs about vaccines. In addition, CDC and its partners are developing new educational materials that can assist parents in making fully informed decisions about immunizing their children.**

The findings in this report are subject to at least three limitations. First, NIS is a telephone survey, and statistical adjustments might not compensate fully for nonresponse and households without landline telephones. Second, underestimates of vaccination coverage might have resulted from the exclusive use of provider-verified vaccination histories because completeness of these records is unknown. Finally, although national coverage estimates are precise, annual estimates and trends for state and local areas should be interpreted with caution because of smaller sample sizes and wider confidence intervals.

Achieving and maintaining high vaccination coverage levels is important to further reduce the burden of vaccine-preventable diseases and prevent a resurgence of measles and other diseases that have been eliminated in the United States (10). Although vaccination coverage estimates were at record highs and above the Healthy People 2010 target for most of the routinely recommended vaccines in 2007, ongoing efforts through partnerships among national, state, local, private, and public entities are needed to sustain these levels and ensure that vaccination programs in the United States remain strong.

Acknowledgments

The findings in this report are based, in part, on contributions by PJ Smith, PhD, Immunization Svcs Div, and BP Bell, MD, Office of the Director, National Center for Immunization and Respiratory Diseases, CDC.

References

1. US Department of Health and Human Services. Healthy people 2010 (conference ed, in 2 vols). Washington, DC: US Department of Health and Human Services; 2000. Available at http://www.healthypeople.gov/document/html/objectives/14-24.htm.

2. CDC. Recommendations and guidelines: 2008 child & adolescent immunization schedules for persons aged 0--6 years, 7--18 years, and catch-up schedule. Atlanta, GA: US Department of Health and Human Services, CDC; 2008. Available at http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm.

3. CDC. Statistical methodology of the National Immunization Survey, 1994--2002. Vital Health Stat 2005;2(138). Available at http://www.cdc.gov/nchs/data/series/sr_02/sr02_138.pdf.

4. Ezzati-Rice TM, Frankel MR, Hoaglin DC, Loft JD, Coronado VG, Wright RA. An alternative measure of response rate in random-digit-dialing surveys that screen for eligible subpopulations. J Econ Soc Meas 2000;26:99--109.

5. CDC. Preventing pneumococcal disease among infants and young children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2000;49(No. RR-9).

6. CDC. Pneumococcal conjugate vaccine shortage resolved. MMWR 2004; 53:851--2.

7. Briss PA, Rodewald LE, Hinman AR, et al. Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. The Task Force on Community Preventive Services. Am J Prev Med 2000;18:97--140.

8. CDC. Update: measles---United States, January--July 2008. MMWR 2008;57:893--6.

9. Cooper LZ, Larsen HJ, Katz SL. Protecting public trust in immunization. Pediatrics 2008;122:149--53.

10. CDC. Measles---United States, January 1--April 25, 2008. MMWR 2008; 57:494--8.

* Fourteen local areas were sampled separately for the 2007 NIS. These included six areas that receive federal immunization grant funds and are included in the NIS sample every year (District of Columbia; Chicago, Illinois; New York, New York; Philadelphia County, Pennsylvania; Bexar County, Texas; and Houston, Texas); seven previously sampled areas (Alameda County, California; Los Angeles County, California; San Bernardino County, California; Miami-Dade County, Florida; Marion County, Indiana; Dallas County, Texas; and El Paso County, Texas); and one area sampled for the first time (western Washington). Local areas sampled in the NIS might change yearly as state immunization programs target local assessments where they are most needed.

† >4 doses of diphtheria, tetanus toxoid, and any acellular pertussis vaccine, which can include diphtheria and tetanus toxoid vaccine or diphtheria, tetanus toxoid, and pertussis vaccine (DTaP);>3 doses of poliovirus vaccine;>1 dose of measles, mumps, and rubella vaccine;>3 doses of Haemophilus influenzae type b vaccine; >3 doses of hepatitis B vaccine; and> 1 dose of varicella vaccine).

§ Poverty status was based on 2006 U.S. Census poverty thresholds (available at http://www.census.gov/hhes/www/poverty.html).

¶ For this report, persons identified as white, black, Asian, or American Indian/Alaska Native are all non-Hispanic. Persons identified as Hispanic might be of any race.

** Additional information available at http://www.cdc.gov/vaccines.

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Date last reviewed: 9/4/2008

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National, State, and Local Area Vaccination Coverage Among Children Aged 19--35 Months --- United States, 2007

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Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: mmwrq@cdc.gov. Type 508 Accommodation and the title of the report in the subject line of e-mail.

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Some scientists are worried that the upcoming flu season could be very bad - after a year when it seemed to virtually disappear - and are urging people to get their flu vaccine by late October, ahead of the winter season.

But there's some good news.

One health survey, commissioned by CVS and released Wednesday, found that 71% of Americans intend to get their flu shot this year, a 5 percentage point increase from last year. And according to a study, getting both COVID-19 and flu vaccines appears safe and effective.

Worries about the flu come as the state's top doctor said she had advised Gov. Gretchen Whitmer that a mask mandate is needed for K-12 schools to keep children safe when they return to classrooms soon; the governor has yet to take action on that recommendation.

"Getting your flu shot is a great way to be proactive about your health and the health of your community," said Angela Patterson, chief nurse practitioner officer of MinuteClinic. "It's an easy way to protect yourself and those around you."

How a new vaccine might interact with other vaccines usually is looked at before it is approved for use, but that didn't happen with the COVID-19 vaccines, which were authorized because of the pandemic.

A study published in June, however, suggested it was safe to take both vaccines.

Last year, the CDC reported a significant decline in flu cases, likely because of masking, social distancing and other precautions taken to prevent coronavirus spread.

Moreover, Michiganders were urged to get the flu vaccine because officials said it would help improve the health and safety of everyone, especially as the coronavirus ravaged the United States and overwhelmed many hospitals.

This season, however, could be much worse for the flu.
Read more: Michigan's top doctor asks Gov. Whitmer for school mask mandate Tiny Romeo church forced to leave historic building after nearly 2 centuries
The CDC recommends a flu vaccine before flu viruses begin spreading in the community, since it takes about two weeks after vaccination for antibodies to develop in the body and provide adequate protection.

About 45% of the people who participated in the CVS-commissioned survey said they would get a flu shot at a retail pharmacy, followed by 25% at a doctor's office.

Patients with either the seasonal flu, certain respiratory illnesses or COVID-19 can present similar symptoms: fever, cough and body aches.
Contact Frank Witsil: 313-222-5022 or fwitsil@freepress.com.

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Survey reveals how Americans feel about getting flu shot this year

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Some scientists are worried that the upcoming flu season could be very bad - after a year when it seemed to virtually disappear - and are urging people to get their flu vaccine by late October, ahead of the winter season. But there's some good news.

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Covid Vaccine possibly more affective than Flu Vaccine

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Covid Vaccine possibly more affective than Flu Vaccine

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https://www.healthline.com/health-news/think-the-covid-19-vaccine-isnt-good-enough-it-may-be-more-effective-than-the-flu-shot

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Long lines for COVID-19 vaccines have become commonplace in the U.S. Michael M. Santiago/Getty Images

Though the coronavirus vaccines and flu shots use distinctly different technologies against two unique viruses, they still have the same job of teaching our immune system how to recognize and attack a virus.

The COVID-19 shots appear to be even more effective at preventing severe disease, along with hospitalization and death.

Experts suspect the vaccine technologies developed during the pandemic will be used to improve existing vaccines such as the flu shot.

All data and statistics are based on publicly available data at the time of publication. Some information may be out of date. Visit our coronavirus hub and follow our live updates page for the most recent information on the COVID-19 pandemic.
As of Feb. 8, more than doses of the Pfizer and Moderna COVID-19 vaccines have been administered in the United States.

The shots are safe, highly effective, and in most cases, cause mild reactions similar to the flu shot.

But, comparing the coronavirus vaccines to the flu shot is like comparing apples to oranges.

For one, the technologies used in the flu and coronavirus shots are significantly different. The viruses also have different attack rates and behavioral patterns.

And though both viruses mutate, the flu virus does so much more frequently, making it difficult to design and distribute a shot that can work perfectly against the leading flu strains each year.

Even so, both sets of shots are proficient at preventing severe illness and death.

Here's how the COVID-19 shots stack up against the flu shot:

Though the coronavirus vaccines and use distinctly different technologies against two unique viruses, they still, on a basic level, have the same job.

The shots "provide an opportunity for the immune response to recognize a foreign protein or antigen," explained Litjen Tan, PhD, the chief strategy officer of the Immunization Action Coalition.

These vaccines' goal is to give the immune system a way to recognize a foreign pathogen and develop a memory response. If and when the body is exposed to the virus, the immune response can be activated faster.

This quick activation of the immune system can either prevent illness or reduce the severity of the disease to varying degrees.

"How you give the opportunity to the immune response to look at this foreign antigen varies [with each type of vaccine]," Tan said.

New data on the Moderna and Pfizer novel coronavirus shots show that most people experience mild reactions after being vaccinated, particularly after the second dose.

These reactions commonly include pain at the injection site and fatigue, headache, myalgia, and chills.

The flu shot is also known to trigger similar side effects - sore arm, a low-grade fever, headache, fatigue, and muscle aches.

According to Tan, the reactions are the same, but the effects reported after the coronavirus vaccines seem more intense.

"The side effects from COVID-19 vaccines are a little bit stronger. It's a more reactive vaccine than flu vaccine," he said.

In both cases, the side effects are a result of the immune system revving up and learning how to fight an infection.

The flu shots' effectiveness fluctuates every year depending on how precisely the shots match the circulating strains, but health experts estimate it ranges from 40 to 60 percent, depending on the season.

Tan says researchers don't conduct clinical trials on the flu shots anymore, so any recent evidence on the flu shot's efficacy comes from looking at flu activity trends in the population.

That data suggests that "influenza vaccine not only prevents 40 to 60 against primary disease, but it's also around that same level in terms of preventing hospitalization and severe illness in both kids and adults," Tan said.

A study published in Pediatrics in 2017 found that the flu vaccine cuts the risk of death in healthy children by about two-thirds, or 65 percent.

And according to the Centers for Disease Control and Prevention (CDC), a person hospitalized with influenza is more likely to die if they're unvaccinated.

Even when the flu vaccine isn't a strong match against the circulating strains, it still confers some degree of protection.

"The greatest benefit is probably reducing the likelihood of someone getting severe influenza, reducing duration of flu symptoms, and limiting spread to others," said Dr. David Hirschwerk, an attending infectious diseases physician at Northwell Health in Manhasset, New York.

The coronavirus vaccines range from about 66 to 95 percent effective at preventing symptomatic disease. All of the vaccines appear to be 100 percent effective at protecting people against hospitalization and death.

"The COVID vaccines, so far, have turned out to be more effective than the flu vaccine, not only in actually preventing COVID but notably in limiting cases of severe COVID," Hirschwerk said.

Emerging evidence suggests efficacy may wane against certain variants.

"We already know that the variant from the UK is a bit less responsive to the vaccine, but it remains very likely that severe COVID can still be mitigated by the current vaccines and even if not perfect, that would remain a substantial victory for public health," Hirschwerk said.

Many of the vaccine developers are already working on booster shots that specifically target emerging variants.

The ease with which the shots can be modified is one of the key benefits of the new technologies used in the COVID-19 vaccines.

Modifying vaccines is much harder with the traditional technologies used.

"It's very hard to react and make changes to variations. We struggle with it every year with flu," Tan said.

According to Tan, scientists evaluate a vaccine's ability to prevent transmission by looking at the amount of virus in people who've been vaccinated.

"The general feeling with flu vaccine is that it does prevent transmission," Tan said.

That said, even though it's thought the flu shot can significantly reduce disease transmission, vaccinated people can still contact influenza and spread it to others.

There's limited data looking at the new coronavirus vaccines' ability to reduce transmission of COVID-19. One small study from AstraZeneca suggests it may cut the spread by up to 67 percent.

When looking at these vaccines' ability to curb disease transmission, it's important to understand that the flu and new coronavirus have different attack rates, Tan says.

COVID-19 has very high attack rates. There are a lot of people who are susceptible because there's little natural immunity in the population. Also, there's no widespread vaccination against COVID-19, and there are no antivirals.

With flu, we can reduce transmission with vaccination because there's a lot of pre-existing immunity in the population. We also have effective influenza antivirals that can lessen the severity of illness, Tan says.

"A lot of people have been exposed to actual flu in the past or have been multiply vaccinated, and every time we vaccinate, we boost [immunity]," he said.

The attack rate of flu compared to COVID-19 is much lower. "The bar is very different," Tan said.

Tan thinks the vaccination advancements we've made during the pandemic will be used to create new vaccines against many other conditions.

The technology could help make existing vaccines, like the flu shot, even better.

"I'm really optimistic that we're going to see some genuine improvements in flu vaccine as a result of our COVID-19 technology," Tan said.

Though the coronavirus vaccines and flu shots use distinctly different technologies against two unique viruses, they still, on a basic level, have the same job of teaching our immune system how to recognize and attack a virus. Both sets of shots trigger side effects that include fatigue, chills, and in some cases, a low grade fever. The COVID-19 shots appear to be even more effective at preventing severe disease, along with hospitalization and death. Health experts suspect the vaccine technologies developed during the pandemic will be used to improve existing vaccines such as the flu shot.

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Here's How the COVID-19 Vaccines Stack Up Against the Flu Vaccine

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Though the coronavirus vaccines and flu shots use distinctly different technologies against two unique viruses, they still have the same job of teaching our immune system how to recognize and attack a virus. The COVID-19 shots appear to be even more effective at preventing severe disease, along with hospitalization and death.

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Estimated Number of People Vaccinated

Based on reports of vaccination from survey respondents, the estimated number of persons who received one or more seasonal flu vaccinations was 41.8 million (95% Confidence Interval [CI]: 41.3-42.3 million) children (6 months through 17 years) and 107.4 million (95% CI: 105.9-108.9 million) adults (≥18 years), for an estimated 149.2 million (95% CI: 147.2-151.2 million) people vaccinated against seasonal flu during July 2016 through May 2017 among the U.S. population. These estimates do not include second doses given to children. The actual number of doses of flu vaccine distributed during the 2016-17 season was 145.9 million, indicating that the flu vaccination coverage estimates in this report may be high. Overestimates of vaccination coverage may be due to a combination of factors, including respondents having higher coverage than persons not surveyed (response bias), recall bias, or other factors. Examples of studies in which medical record validation has been compared with adult patient or parent report of vaccination estimated that coverage by parental report was seven percentage points too high for children 6-59 months and coverage by self-report was 5-11 percentage points too high for adults ≥65 years.( 2;3) While the vaccination coverage estimates in this report were not validated with medical records, the NIS-Flu and BRFSS estimates do provide important information regarding yearly trends in reported vaccination over time.

What Can Be Done?

For children, flu vaccination coverage for the 2016-17 season was similar compared with the 2015-16 season while there was a small increase for adults. Differences in coverage among racial/ethnic populations by age group and variation in coverage by state were noted and consistent with findings from prior flu seasons. Flu vaccination coverage for the 2016-17 season for all groups except children 6-23 months remains below the Healthy People 2020 targetsExternal external icon §§ of 70.0% vaccination coverage for persons 6 months through 17 years and ≥18 years.( 4)

These findings can be used by health care providers to identify people who may be at risk of not receiving a flu vaccination. Optimally, people should receive their flu vaccinations before the influenza viruses begin to circulate in the community. If possible, health care providers should offer flu vaccinations by the end of October and continue to offer vaccinations as long as flu viruses are circulating.( 1)

Strategies to increase flu vaccination coverage in the United States include:

Encouraging use of evidence-based strategies at medical and non-medical sites to increase access to vaccination services (e.g., reducing client costs and vaccination programs in schools and Women, Infants, and Children [WIC] settings), increasing community demand for vaccinations (e.g., client reminder/recall systems), and ensuring that all those who visit a provider during the flu season receive a vaccination recommendation and offer from their provider (e.g., standing orders and provider reminders).(5)

Expanding access through use of non-traditional settings (e.g., pharmacy, workplace, and school venues) to reach people in settings other than traditional physicians' offices during the flu season.(6)

Broadening use of interventions to remove barriers to accessing vaccination.(7)

Encouraging multi-sector collaborations, including culturally relevant communications to reach specific target populations, and implementing effective interventions to reduce vaccination disparities in the United States.(8)

Additional strategies are described in the Community Guide for Preventive ServicesExternal external icon .(5)

Updated recommendations have been published for the 2017-18 flu season.( 1) Updated information includes 1) the composition of U.S. seasonal flu vaccines; 2) the expected flu vaccine products available for the 2017-18 season; and 3) an extension of interim recommendation to not use the live, attenuated influenza vaccine (LAIV) for the 2017-18 season.( 1)

Data Sources and Methods

For this report, the Centers for Disease Control and Prevention (CDC) analyzed data from the National Immunization Survey-Flu (NIS-Flu) for children 6 months through 17 years and the Behavioral Risk Factor Surveillance System (BRFSS) for adults ≥18 years to estimate national, state, and local flu vaccination coverage from the 2016-17 flu season.

CDC analyzed NIS-Flu and BRFSS data collected September (BRFSS) or October (NIS-Flu) 2016 through June 2017 from all 50 states and the District of Columbia to estimate national- and state-level flu vaccination coverage for vaccines administered from July 2016 through May 2017 for the 2016-17 flu season. These findings were compared with 2015-16 flu season estimates. Estimates are also included as a supplemental table to this report for Guam, Puerto Rico, the U.S. Virgin Islands, and selected local areas.

The NIS-Flu has three components: the NIS, which includes households with children 19-35 months, the NIS-Teen, which includes households with children 13-17 years, and a short flu vaccination module, which is conducted for households with children 6-18 months and 3-12 years. The NIS-Flu is a national dual landline and cellular list-assisted random-digit-dialed telephone survey of households. Respondents ≥18 years were asked if their child had received a flu vaccination since July 1, 2016, and, if so, in which month and year; this information was parent-reported and not verified by medical records. The range of the Council of American Survey and Research Organizations (CASRO) response rates for the NIS-Flu across the components of the NIS-Flu were 50.8% to 53.1% for landline and 26.2% to 28.7% for cellular telephones.

BRFSS is an ongoing state-based monthly telephone survey which collects information on health conditions and risk behaviors from randomly selected people ≥18 years among the U.S. population. BRFSS respondents were asked if they had received a flu vaccine in the past 12 months, and if so, in which month and year; this information was self-reported and not verified by medical records. The median state BRFSS response rate was 47.4% for September-December 2016 and 45.5% for January-June 2017. Starting in 2011, BRFSS methods changed by adding persons in households with only cellular telephone service and improving weighting procedures; these changes were reflected in the 2011-12 and subsequent flu vaccination coverage estimates.( 9)

Flu vaccination coverage estimates from both surveys were calculated using Kaplan-Meier survival analysis to determine the cumulative flu vaccination coverage (≥1 dose) July 2016 through May 2017 using monthly interview data collected September (BRFSS) or October (NIS-Flu) 2016 through June 2017. NIS-Flu data were used to estimate coverage for children 6 months through 17 years and BRFSS data were used to estimate coverage for adults ≥18 years. Coverage estimates for all persons ≥6 months were determined using combined state-level monthly estimates weighted by the age-specific populations of each state.( 10) For the 21.8% of NIS-Flu and 6.6% of BRFSS participants who indicated they had been vaccinated but had a missing month and year of vaccination, information was imputed from donor pools matched for week of interview, age group, state of residence, and race/ethnicity. Information on high-risk conditions was missing for 1.1% of adults and race/ethnicity was missing for 1.7% of adults; adults with missing data were not included in the estimates by risk condition or race/ethnicity. Results from both surveys were weighted and analyzed using SAS and SUDAAN statistical software to account for the complex survey design. Differences between groups and between 2015-16 and 2016-17 seasons were determined using t-tests with significance at p<0.05. Differences mentioned in this report were statistically significant.

Limitations

The estimates in this report are subject to the following limitations. First, flu vaccination status was based on self or parental report and not validated with medical records and, thus, is subject to respondent recall bias.( 2;3) A recent study of children 6-23 months included estimates of flu coverage with ≥1 doses based upon provider report; when these estimates were compared with the parent-reported estimates found on FluVaxView, the parent-reported estimates were between 12-17 percentage points higher than provider report for the 2010-11 through 2012-13 flu seasons.( 11) Also in this study, racial/ethnic differences among children 6-23 months were identified based on provider-reported vaccination status, but the pattern of racial/ethnic vaccination differences was different than patterns found on FluVaxView based on parental report.( 11) Incomplete records and reporting, however, might affect provider-reported vaccination histories.( 11) Second, response rates for NIS-Flu and BRFSS surveys were low and nonresponse bias may remain even after weighting adjustments. A comparison of NIS-Flu estimates with those from National Health Interview Survey suggests that the NIS-Flu estimates have a slight upward nonresponse bias.( 12;13) Third, combining NIS-Flu and BRFSS estimates allowed estimation of coverage for all persons ≥6 months; however, differences in survey methodology (e.g., different sampling frame, survey design, exact survey question wording, response rates, and weighting) may result in different levels of bias that are averaged for this group. Fourth, the number of persons vaccinated was overestimated, evidenced by a higher number vaccinated than doses distributed as has occurred previously.( 14)

Authors

Tammy A. Santibanez, PhD; Yusheng Zhai, MSPH; Alissa O'Halloran, MSPH; Katherine E. Kahn, MPH; Anup Srivastav, DVM, PhD; Lin Liu, MS; Elizabeth Ormson, MS; Peng-Jun Lu, MD, PhD; Walter W. Williams, MD, MPH; Stacie M. Greby, DVM, MPH.

Related Links
National Immunization Survey-Flu (NIS-Flu): Behavioral Risk Factor Surveillance System (BRFSS): NIS-Flu/BRFSS vaccination coverage reports: General information about flu:
Footnotes

* Estimates of the percentage of people vaccinated are based on interviews conducted beginning September (BRFSS) or October (NIS-Flu) 2016 through June 2017 and reported vaccinations from July 2016 through May 2017. † Excludes U.S territories. ‡ Percentage vaccinated. Percentages are weighted to the U.S. population. Month of vaccination was imputed for respondents with missing month of vaccination data. § Confidence interval (CI) half-widths. || Statistically significant difference between the 2016-17 season and the 2015-16 season by t-test (p<0.05). ¶ Selected high risk conditions includes people with asthma, diabetes, heart disease, chronic obstructive pulmonary disease, or cancers other than skin cancer. **Statistically significant difference between male and female estimates by t-test (p<0.05). ‡‡ Includes Native Hawaiian or other Pacific Islander, multiracial, and other races. §§ The National Health Interview Survey (NHIS) is the data source used to monitor the Healthy People objectives for flu vaccination (IID-12.11-14). Final NHIS estimates for the 2016-17 season will be available by September 2018. A comparison of estimates from NIS-Flu and BRFSS to NHIS is available.

References

(1) Grohskopf LA, Sokolow LZ, Broder KR et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices-United States, 2017-18 influenza season. MMWR Recomm Rep2017;66:1-21. (2) MacDonald R, Baken L, Nelson A, Nichol KL. Validation of self-report of influenza and pneumococcal vaccination status in elderly outpatients. Am J Prev Med 1999;16:173-177. (3) Brown C, Clayton-Boswell H, Chaves SS et al. Validity of parental report of influenza vaccination in young children seeking medical care. Vaccine 2011;29:9488-9492. (4) U.S.Department of Health and Human Services. Healthy People 2020. Topics & Objectives-Immunization and Infectious Diseases. https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/objectivesexternal icon [serial online] 2015; Accessed September 11, 2015. (5) Guide to Community Preventive Services. Increasing appropriate vaccination. www.thecommunityguide.orgexternal icon [serial online] 2013; Accessed July 30, 2013. (6) Murphy PA, Frazee SGCJP, Cohen E, Rosan JR, Harshburgher DE. Pharmacy provision of influenza vaccinations in medically underserved communities. J Am Pharm Assoc 2012;52:67-70. (7) Poland GA, Shefer AM, McCauley M, Webster PS, Whitley-Williams PN, Peter G. Standards for adult immunization practices. Am J Prev Med 2003;25:144-150. (8) CDC. CDC health disparities and inequalities report-United States, 2013. MMWR 2013;62:3-5. (9) CDC. Methodologic changes in the Behavioral Risk Factor Surveillance System in 2011 and potential effects on prevalence estimates. MMWR 2012;61:410-413. (10) Furlow-Parmley C, Singleton JA, Bardenheier B, Bryan L. Combining estimates from two surveys: an example from monitoring 2009 influenza A(H1N1) pandemic vaccination. Stat Med 2012;31:3285-3294. (11) Santibanez TA, Grohskopf LA, Zhai Y, Kahn KE. Complete influenza vaccination trends for children six to twenty-three months. Pediatrics 2016;137:e20153280. (12) Santibanez TA, Lu PJ, O'Halloran A, Meghani A, Grabowsky M, Singleton JA. Trends in Childhood Influenza Vaccination Coverage-U.S., 2004-2012. Public Health Rep 2014;129:417-427. (13) CDC. Surveillance of influenza vaccination coverage-United States, 2007-08 through 2011-12 influenza seasons. MMWR CDC Surveill Summ 2013;62:1-28. (14) CDC. Interim results: state-specific seasonal influenza vaccination coverage-United States, August 2009-January 2010. MMWR Morb Mortal Wkly Rep 2010;59:477-484.

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behavioral risk factor surveillance system brfss

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Flu Vaccination Coverage, United States, 2016-17 Influenza Season

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Based on reports of vaccination from survey respondents, the estimated number of persons who received one or more seasonal flu vaccinations was 41.8 million (95% Confidence Interval [CI]: 41.3-42.3 million) children (6 months through 17 years) and 107.4 million (95% CI: 105.9-108.9 million) adults (≥18 years), for an estimated 149.2 million (95% CI: 147.2-151.2 million) people vaccinated against seasonal flu during July 2016 through May 2017 among the U.S.

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Centers for Disease Control and Prevention

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Flu Vaccination

Why should people get vaccinated against flu?

Influenza (flu) is a potentially serious disease that can lead to hospitalization and sometimes even death. Every flu season is different, and flu can affect people differently, but during typical flu seasons, millions of people get flu every year, hundreds of thousands of people are hospitalized and thousands to tens of thousands of people die from flu-related causes. Flu can mean a few days of feeling bad and missing work, school, or family events, or it can result in more serious illness. Complications of flu can include bacterial pneumonia, ear infections, sinus infections and worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes. An annual seasonal flu vaccine is the best way to help reduce the risk of getting flu and any of its potentially serious complications. Vaccination has been shown to have many benefits including reducing the risk of flu illnesses, hospitalizations and even the risk of flu-related death. While some people who get a flu vaccine may still get sick with influenza, flu vaccination has been shown in several studies to reduce severity of illness.

How do flu vaccines work?

Flu vaccines cause antibodies to develop in the body about two weeks after vaccination. These antibodies provide protection against flu illness.

Seasonal flu vaccines are designed to protect against the influenza viruses that research indicates will be most common during the upcoming season. All flu vaccines in the United States are "quadrivalent" vaccines, which means they protect against four different flu viruses: an influenza A(H1N1) virus, an influenza A(H3N2) virus, and two influenza B viruses.

For people younger than 65 years, CDC does not preferentially recommend any licensed, age-appropriate influenza (flu) vaccine over another during the 2022-2023 flu season. Options for this age group include inactivated influenza vaccine [IIV], recombinant influenza vaccine [RIV], or live attenuated influenza vaccine (LAIV), with no preference for any flu vaccine over another.

New for this season: For people 65 years and older, there are three flu vaccines that are preferentially recommended over standard-dose, unadjuvanted flu vaccines. These are Fluzone High-Dose Quadrivalent vaccine, Flublok Quadrivalent recombinant flu vaccine and Fluad Quadrivalent adjuvanted flu vaccine. More information is available at Flu & People 65 Years and Older.

All flu vaccines for the 2022-2023 season are quadrivalent vaccines, designed to protect against four different flu viruses, including two influenza A viruses and two influenza B viruses. Different vaccines are licensed for use in different age groups, and some vaccines are not recommended for some groups of people.
Available flu vaccines include:

Standard-dose flu shots that are manufactured using virus grown in eggs. Several different brands of standard dose flu shots are available, including Afluria Quadrivalent, Fluarix Quadrivalent, FluLaval Quadrivalent, and Fluzone Quadrivalent. These vaccines are approved for use in children as young as 6 months. Most flu shots are given in the arm (muscle) with a needle. Afluria Quadrivalent can be given either with a needle (for people 6 months and older) or with a jet injector (for people 18 through 64 years only).

A cell-based flu shot (Flucelvax Quadrivalent) containing virus grown in cell culture, which is approved for people 6 months and older. This vaccine is completely egg-free.

A recombinant flu shot (Flublok Quadrivalent) which is a completely egg-free flu shot that is made using recombinant technology and is approved for use in people 18 years and older. This shot is made without flu viruses and contains three times the antigen (the part of the vaccine that helps your body build up protection against flu viruses) than other standard-dose inactivated flu vaccines, to help create a stronger immune response.

An egg-based high dose flu shot (Fluzone High-Dose Quadrivalent), which is approved for use in people 65 years and older. This vaccine contains four times the antigen (the part of the vaccine that helps your body build up protection against flu viruses) than other standard-dose inactivated flu vaccines, to help create a stronger immune response.

An egg-based adjuvanted flu shot (Fluad Quadrivalent), which is approved for people 65 years and older. This vaccine is made with an adjuvant (an ingredient that helps create a stronger immune response).

An egg-based live attenuated flu nasal spray vaccine (FluMist Quadrivalent) made with attenuated (weakened) live flu viruses, which is approved for use in people 2 years through 49 years. This vaccine is not recommended for use in pregnant people, immunocompromised people, or people with certain medical conditions.

Are any of the available flu vaccines recommended over others?

What if a preferentially recommended flu vaccine is not available?

If none of the three flu vaccines preferentially recommended for people 65 years and older is available at the time of administration, people in this age group should get any other age-appropriate flu vaccine instead.

Who Should Be Vaccinated?

Everyone 6 months and older in the United States should get an influenza (flu) vaccine every season with rare exception. CDC's Advisory Committee on Immunization Practices has made this "universal" recommendation since the 2010-2011 flu season.

Vaccination to prevent flu and its potentially serious complications is particularly important for people who are at higher risk of developing serious flu complications. A full list of age and health factors that confer increased risk is available at People at Higher Risk of Developing Flu-Related Complications.

More information is available at Who Needs a Flu Vaccine.

Who Should Not Be Vaccinated?

Different influenza (flu) vaccines are approved for use in people in different age groups. In addition, some vaccines are not recommended for certain groups of people. Factors that can determine a person's suitability for vaccination, or vaccination with a particular vaccine, include a person's age, health (current and past) and any allergies to flu vaccine or its components. More information is available at Who Should and Who Should NOT get a Flu Vaccine.

When should I get vaccinated?

For most people who need only one dose of flu vaccine for the season, September and October are generally good times to be vaccinated against flu. Ideally, everyone should be vaccinated by the end of October. Additional considerations concerning the timing of vaccination for certain groups of people include:

Most adults, especially those 65 years and older, and pregnant people in the first or second trimester should generally not get vaccinated early (in July or August) because protection may decrease over time. However, early vaccination can be considered for any person who is unable to return at a later time to be vaccinated.

Some children need two doses of flu vaccine. For those children it is recommended to get the first dose as soon as vaccine is available, because the second dose needs to be given at least four weeks after the first. Vaccination during July and August also can be considered for children who need only one dose.

Vaccination during July and August also can be considered for people who are in the third trimester of pregnancy during those months, because this can help protect their infants for the first few months after birth (when they are too young to be vaccinated).

Where can I get a flu vaccine?

Flu Vaccine Finder Widget 001

Find flu vaccines in your area.
Everyone 6 months of age and older needs a flu vaccine.

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Flu vaccines are offered in many doctor's offices and clinics. Even if you don't have a regular doctor or nurse, you can get a flu vaccine somewhere else like a health department, pharmacy, urgent care clinic, college health center, and even in some schools and workplaces.

Why do I need a flu vaccine every year?

A flu vaccine is needed every year for two reasons. First, a person's immune protection from vaccination declines over time, so an annual flu vaccine is needed for optimal protection. Second, because flu viruses are constantly changing, the composition of flu vaccines is reviewed annually, and vaccines are updated to protect against the viruses that research indicates will be most common during the upcoming flu season. For the best protection, everyone 6 months and older should get vaccinated annually.

Does flu vaccine work right away?

No. It takes about two weeks after vaccination for antibodies to develop in the body and provide protection against influenza virus infection. That's why it's best to get vaccinated before influenza viruses start to spread in your community.

Influenza (flu) vaccine effectiveness (VE) can vary. The protection provided by a flu vaccine varies from season to season and depends in part on the age and health status of the person getting the vaccine and the similarity or "match" between the viruses in the vaccine and those in circulation. During years when the flu vaccine match is good, it is possible to measure substantial benefits from flu vaccination in terms of preventing flu illness and complications. However, the benefits of flu vaccination will still vary, depending on characteristics of the person being vaccinated (for example, their health and age), what flu viruses are circulating that season and, potentially, which type of flu vaccine was used. More information is available at Vaccine Effectiveness - How well does the Flu Vaccine Work.

Can I get seasonal flu even though I got a flu vaccine this year?

Yes. It's possible to get sick with flu even if you have been vaccinated (although you won't know for sure unless you get a flu test). This is possible for the following reasons:

You may be exposed to a flu virus shortly before getting vaccinated or during the period that it takes the body to gain protection after getting vaccinated. This exposure may result in you becoming ill with flu before the vaccine begins to protect you. (Antibodies that provide protection develop in the body about 2 weeks after vaccination.)

You may be exposed to a flu virus that is not included in the seasonal flu vaccine. There are many different flu viruses that circulate every year. A flu vaccine is made to protect against the four flu viruses that research suggests will be most common.

Unfortunately, some people can become infected with a flu virus that the vaccine is designed to protect against, despite getting vaccinated. Protection provided by flu vaccination can vary widely, based in part on health and age factors of the person getting vaccinated. In general, a flu vaccine works best among healthy younger adults and older children. Some older people and some people with certain chronic illnesses may develop less immunity after vaccination. Flu vaccination is not a perfect tool, but it is the best way to protect against flu virus infection.

What protection does a flu vaccine provide if I do get sick with flu?

Some people who get vaccinated may still get sick with flu. However, flu vaccination has been shown in studies to reduce severity of illness in people who get vaccinated but still get sick. A 2021 study showed that among adults, flu vaccination was associated with a 26% lower risk of ICU admission and a 31% lower risk of death from flu compared with those who were unvaccinated. A 2017 study showed that flu vaccination reduced deaths, intensive care unit (ICU) admissions, ICU length of stay, and overall duration of hospitalization among hospitalized adults with flu.

Vaccine Benefits

What are the benefits of flu vaccination?

Below is a summary of the benefits of flu vaccination and selected scientific studies that support these benefits.

Flu vaccination can keep you from getting sick with flu.

Flu vaccine prevents millions of illnesses and flu-related doctor's visits each year. For example, during 2019-2020, the last flu season prior to the COVID-19 pandemic, flu vaccination prevented an estimated 7.5 million influenza illnesses, 3.7 million influenza-associated medical visits, 105,000 influenza-associated hospitalizations, and 6,300 influenza-associated deaths.

During seasons when flu vaccine viruses are similar to circulating flu viruses, flu vaccine has been shown to reduce the risk of having to go to the doctor with flu by 40% to 60%.

Flu vaccination has been shown in several studies to reduce severity of illness in people who get vaccinated but still get sick.

Flu vaccination can reduce the risk of flu-associated hospitalization.

Flu vaccine prevents tens of thousands of hospitalizations each year. For example, during 2019-2020 flu vaccination prevented an estimated 105,000 flu-related hospitalizations.

A 2018 study showed that from 2012 to 2015, flu vaccination among adults reduced the risk of being admitted to an ICU with flu by 82%.

Flu vaccination is an important preventive tool for people with certain chronic health conditions.
Among people with diabetes and chronic lung disease,flu vaccination has been shown in separate studies to be associated with reduced hospitalizations from a worsening of their chronic condition.

Flu vaccination during pregnancy helps protect pregnant people from flu during and after pregnancy and helps protect their infants from flu in their first few months of life.

A 2013 study showed that during the 2010-2011 and 2011-2012 flu seasons vaccination reduced the risk of flu-associated acute respiratory infection in pregnant people by about one-half.

A number of studies have shown that in addition to helping to protect pregnant people from flu, a flu vaccine given during pregnancy helps protect the baby from flu for several months after birth, when babies are too young to be vaccinated.

Flu vaccine can be lifesaving in children.
A 2017 study was the first of its kind to show that flu vaccination can significantly reduce children's risk of dying from flu.

Getting vaccinated yourself may also protect people around you, including those who are more vulnerable to serious flu illness, like babies and young children, older people, and people with certain chronic health conditions.

Despite the many benefits offered by flu vaccination, only about half of Americans get an annual flu vaccine. During an average flu season, flu can cause millions of illnesses, hundreds of thousands of hospitalizations and tens of thousands of deaths. Many more people could be protected from flu if more people got vaccinated.

*References for the studies listed above can be found at Publications on Influenza Vaccine Benefits.

Vaccine Match

What is meant by a "good match" between viruses in the vaccine and circulating influenza viruses?

A "good match" is said to occur when the flu vaccine viruses used to produce flu vaccine and the viruses circulating among people during a given flu season are "like" one another such that the antibodies induced by vaccination protect against infection caused by circulating viruses.

What if circulating flu viruses are different from vaccine viruses?

During seasons when one or more of the circulating viruses are different or "drifted" from the vaccine viruses, vaccine effectiveness against the drifted viruses can be reduced. It's important to remember that flu vaccine protects against four different flu viruses and multiple different viruses usually circulate during any one season. Even if the effectiveness of the vaccine is reduced against one virus, vaccination can still be effective at preventing flu illness caused by the other circulating viruses. For these reasons, CDC continues to recommend flu vaccination for everyone 6 months and older even if vaccine effectiveness against one or more viruses is reduced.

Why is there sometimes not a good match between a vaccine virus and circulating viruses?

Flu viruses are constantly changing (called " antigenic drift") - they can change from one season to the next or they can even change within the course of one flu season. Experts must pick which viruses to include in the vaccine many months in advance in order for vaccine to be produced and delivered on time. (For more information about the vaccine virus selection process visit Selecting the Viruses in the Influenza (Flu) Vaccine.) Because of these factors, there is always the possibility of a less than optimal match between circulating viruses and the viruses used to produce vaccine.

The production process for some seasonal vaccines also may impact how well vaccine works against certain viruses, especially influenza A(H3N2) viruses. Growth in eggs is part of the production process for many seasonal flu vaccines. While all influenza viruses undergo changes when they are grown in eggs, changes in influenza A(H3N2) viruses are more likely to result in antigenic changes compared with changes in other influenza viruses. These so-called "egg-adapted changes" are present in most of the vaccine viruses recommended for use in egg-based vaccine production and may reduce their effectiveness against circulating influenza viruses. Advances in vaccine production technologies (for example, cell-based and recombinant technology) and advanced molecular techniques are being explored as ways to improve flu vaccine effectiveness. Learn more by visiting, Advancements in Influenza Vaccines.

Will this season's vaccine be a good match for circulating viruses?

It's not possible to predict with certainty if a flu vaccine will be like circulating flu viruses because flu viruses are constantly changing. A flu vaccine is made to protect against the flu viruses that research and surveillance indicate will likely be most common during the upcoming season. Over the course of the flu season, CDC studies samples of circulating flu viruses to evaluate how close a match there is between viruses used to make the flu vaccine and circulating flu viruses. More information about the 2022-2023 flu season and recommended vaccines is available.

Vaccine Side Effects (What to Expect)

Can a flu vaccine give me flu?

No, a flu vaccine cannot cause flu illness. Flu vaccines that are given with a needle (flu shots) are currently made in two ways: the vaccine is made either with a) flu vaccine viruses that have been killed (inactivated) and are therefore not infectious, or b) with proteins from a flu virus (which is the case for recombinant influenza vaccine). Nasal spray vaccine is made with weakened (attenuated) live flu viruses and also cannot cause flu illness. The weakened viruses are cold-adapted, which means they are designed to only reproduce at the cooler temperatures found within the nose. The viruses cannot reproduce in the lungs or other areas where warmer temperatures exist.

What side effects can occur after getting a flu vaccine?

While a flu vaccine cannot give you flu illness, there are different side effects that may be associated with getting a flu shot or a nasal spray flu vaccine. These side effects are usually mild and short-lasting, especially when compared to symptoms of flu.

A flu shot: The viruses in a flu shot are killed (inactivated), so you cannot get flu from a flu shot. Some minor side effects that may occur are:

Soreness, redness, and/or swelling where the shot was given

Headache (low grade)

Fever

Muscle aches

Nausea

Fatigue

The nasal spray: The viruses in the nasal spray vaccine are weakened and do not cause influenza illness. In children, side effects from the nasal spray may include:

Runny nose

Wheezing

Headache

Vomiting

Muscle aches

Fever (low grade)

In adults, side effects from the nasal spray vaccine may include:

Runny nose

Headache

Sore throat

Cough

If these problems occur, they begin soon after vaccination and usually are mild and short-lived. A flu shot, like other injections, can occasionally cause fainting. Tell your provider if you feel dizzy or have vision changes or ringing in the ears. As with any medicine, there is a very remote chance of a vaccine causing a severe allergic reaction, other serious injury, or death. People who think that they have been injured by a flu vaccine can file a report with the Vaccine Adverse Event Reporting System (VAERS).

More information about the safety of flu vaccines is available at Influenza (Flu) Vaccine Safety.

Vaccine Supply and Distribution

How much influenza vaccine is projected to be available for the 2022-2023 influenza season?

Flu vaccine is produced by private manufacturers, so supply depends on manufacturers. Vaccine manufacturers have projected that they will supply the United States with as many as 173.5 million to 183.5 million doses of influenza vaccines for the 2022-2023 season. These projections may change as the season progresses. All flu vaccines for the 2022-2023 season will be quadrivalent (four component). Most will be thimerosal-free or thimerosal-reduced vaccine (93%), and about 20% of flu vaccines will be egg-free.

Where can I find information about vaccine supply?

Information about vaccine supply is available on CDC's Vaccine Supply & Distribution.

Special Consideration Regarding Egg Allergy

People with egg allergies can receive any licensed, recommended age-appropriate influenza (flu) vaccine ( IIV4, RIV4, ccIIV4, or LAIV4) that is otherwise appropriate. People who have a history of severe egg allergy (those who have had any symptom other than hives after exposure to egg) should be vaccinated in a medical setting, supervised by a health care provider who is able to recognize and manage severe allergic reactions. Two completely egg-free flu vaccine options are available: Flublok Quadrivalent recombinant flu vaccine and Flucelvax Quadrivalent cell-based flu shot.

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Influenza (flu) is a potentially serious disease that can lead to hospitalization and sometimes even death. Every flu season is different, and flu can affect people differently, but during typical flu seasons, millions of people get flu every year, hundreds of thousands of people are hospitalized and thousands to tens of thousands of people die from flu-related causes.

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Jana Broadhurst, MD, PhD

The Centers for Disease Control and Prevention (CDC) voluntarily recalled a PCR test they'd been using.

The recall was not because the polymerase chain reaction (PCR) test was inaccurate. It was because they have a different test that can check for both influenza and COVID-19 simultaneously - which is known as the "multiplexed method."

We caught up with pathologist and microbiologist Jana Broadhurst, MD, PhD, to understand what this means for testing accuracy. Dr. Broadhurst is director for the Nebraska Biocontainment Unit Clinical Laboratory and Emerging Pathogens Laboratory.

A brief summary of what happened:

The CDC's original PCR test has been voluntarily recalled in favor of a more efficient multiplex PCR test

The CDC's original PCR test gave accurate, dependable results. It was not recalled because of accuracy (sensitivity or specificity) concerns

All PCR tests for COVID-19 are designed to only give positive results if SARS-CoV-2 (the virus that causes COVID-19) is present

PCR tests are more accurate and reliable than antigen tests

Does the recall mean the original CDC PCR test gave inaccurate results?

No. The PCR test was extraordinarily accurate in identifying the right virus: SARS-CoV-2.

"Just because the original test wasn't built to detect influenza doesn't mean that it wasn't accurately reporting results," Dr. Broadhurst explains. "We can be very confident that a positive result from a PCR test represents a true case of SARS-CoV-2 because of how these tests were designed."

Did previous PCR tests confuse COVID-19 cases for influenza cases?

Not at all. "The reported numbers were based on highly accurate laboratory tests," says Dr. Broadhurst. "The original test could detect the presence of SARS-CoV-2 with very high specificity," - meaning the test does its job very well.

A PCR test is an excellent identifier of COVID-19 cases, because of something called specificity. Basically, specificity means that the test is designed to only detect one type of virus. Dr. Broadhurst says, "The PCR test is validated against many different coronaviruses and common respiratory viruses, including influenza so that it would not give false-positive results." Meaning, researchers subjected the test to many different samples to see if it would give the wrong result. It correctly identified SARS-CoV-2 out of all of these samples.

So why did the CDC recall the PCR test?

The CDC is choosing to use a multiplexed PCR test rather than the original PCR test to save time.

All PCR tests give either a positive or negative result for each virus it detects. For SARS-CoV-2:

Positive means the test found SARS-CoV-2, the virus that causes COVID-19

Negative means you likely don't have COVID-19 - but you may have influenza or another coronavirus. So you'd have to get a second test to see if it's something else

But a multiplexed test can determine both viruses at the same time, saving the patient an uncomfortable nasal swab.

Which is a more accurate test for detecting COVID-19 - PCR or antigen?

PCR tests are more accurate than antigen tests. "PCR tests are the gold standard for detecting SARS-CoV-2," says Dr. Broadhurst. "It is the most accurate testing modality that we have. And now many PCR tests can detect both SARS-CoV-2 and influenza at the same time."

How do we know COVID-19 cases aren't actually influenza?

Every PCR test must be validated, meaning checked for its sensitivity and specificity. The Nebraska Medicine PCR test has been extensively vetted with multiple ways of validation.

Dr. Broadhurst explains, "At the beginning of the pandemic, we went through a very rigorous process. That includes demonstrating the specificity of the test to exclude anything that may cause a false positive."

Dr. Broadhurst, microbiologist Paul Fey, PhD, microbiology fellow Hannah Creager, PhD, and other experts worked together to ensure a trustworthy test. To ensure specificity, they tested clinical samples and also used databases of genetic sequences.

1. Our researchers took clinical samples from before Nebraska had community spread of COVID-19 and ran the samples through the test. These clinical samples included known results of influenza and other common viruses. The PCR test reported negative on all of them, which makes sense.

2. Researchers also looked through large databases of viral genetic sequences - the building blocks of a virus. That way, they ensured the PCR test only picked up a piece unique to SARS-CoV-2 and not another coronavirus or influenza. "Comparing these genetic sequences means we can avoid cross-reactivity," says Dr. Broadhurst.

Have the criteria for a positive PCR test changed, making PCR tests report fewer COVID-19 cases?

No. This World Health Organization (WHO) notice did not change the criteria for a positive COVID-19 test.

You may have heard rumors about something called the "cycle threshold" being changed. The WHO notice was simply reaffirming that test results must be appropriately analyzed, and that some tests may need to be repeated to confirm the result, which is a common practice. It doesn't mean that PCR tests with higher cycle thresholds are invalid or inaccurate.

The bottom line: PCR tests remain the gold standard for detecting an active COVID-19 infection. The tests have accurately detected COVID-19 cases since the pandemic began. Highly trained clinical professionals are skilled at correctly interpreting PCR test results and notices like this one from the WHO.

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PCR test recall: Can PCR tests tell the difference between COVID-19 and the flu?

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The Centers for Disease Control and Prevention (CDC) voluntarily recalled a PCR test they'd been using. The recall was not because the polymerase chain reaction (PCR) test was inaccurate. It was because they have a different test that can check for both influenza and COVID-19 simultaneously - which is known as the "multiplexed method."

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Questions & Answers

How effective are flu vaccines?

CDC conducts studies each year to determine how well influenza (flu) vaccines protect against flu. While vaccine effectiveness (VE) can vary, recent studies show that flu vaccination reduces the risk of flu illness by between 40% and 60% among the overall population during seasons when most circulating flu viruses are well-matched to those used to make flu vaccines. In general, current flu vaccines tend to work better against influenza B and influenza A(H1N1) viruses and offer less protection against influenza A(H3N2) viruses. More information is available at " Does flu vaccine effectiveness vary by type or subtype?" and " Why is flu vaccine typically less effective against influenza A H3N2 viruses? ".

What are factors that influence how well flu vaccines work?

How well flu vaccines work (or their ability to protect against a certain outcome) can vary from season to season. Protection can vary depending on who is being vaccinated. At least two factors play an important role in determining the likelihood that vaccination will protect a person from flu illness: 1) characteristics of the person being vaccinated (such as their age and health), and 2) how well the vaccines "match" the flu viruses spreading in the community. When flu vaccines are not well matched to some viruses spreading in the community, vaccination may provide little or no protection against illness caused by those viruses. However, the vaccines may still provide protection against other flu viruses that circulate during the season. When there is a good match between flu vaccines and circulating viruses, vaccination provides substantial benefits by preventing flu illness and complications.

Each flu season, researchers try to determine how well flu vaccines work to prevent flu. Estimates of how well a flu vaccine works can vary based on study design, outcome(s) measured, population studied, and type of flu vaccine. Differences between studies must be considered when results are compared. More information is available at How Flu Vaccine Effectiveness and Efficacy are Measured.

What are the benefits of flu vaccination?

Below is a summary of the benefits of flu vaccination and selected scientific studies that support these benefits.

Flu vaccination can keep you from getting sick with flu.

Flu vaccine prevents millions of illnesses and flu-related doctor's visits each year. For example, during 2019-2020, the last flu season prior to the COVID-19 pandemic, flu vaccination prevented an estimated 7.5 million influenza illnesses, 3.7 million influenza-associated medical visits, 105,000 influenza-associated hospitalizations, and 6,300 influenza-associated deaths.

During seasons when flu vaccine viruses are similar to circulating flu viruses, flu vaccine has been shown to reduce the risk of having to go to the doctor with flu by 40% to 60%.

Flu vaccination has been shown in several studies to reduce severity of illness in people who get vaccinated but still get sick.

Flu vaccination can reduce the risk of flu-associated hospitalization.

Flu vaccine prevents tens of thousands of hospitalizations each year. For example, during 2019-2020 flu vaccination prevented an estimated 105,000 flu-related hospitalizations.

A 2018 study showed that from 2012 to 2015, flu vaccination among adults reduced the risk of being admitted to an ICU with flu by 82%.

Flu vaccination is an important preventive tool for people with certain chronic health conditions.
Among people with diabetes and chronic lung disease,flu vaccination has been shown in separate studies to be associated with reduced hospitalizations from a worsening of their chronic condition.

Flu vaccination during pregnancy helps protect pregnant people from flu during and after pregnancy and helps protect their infants from flu in their first few months of life.

A 2013 study showed that during the 2010-2011 and 2011-2012 flu seasons vaccination reduced the risk of flu-associated acute respiratory infection in pregnant people by about one-half.

A number of studies have shown that in addition to helping to protect pregnant people from flu, a flu vaccine given during pregnancy helps protect the baby from flu for several months after birth, when babies are too young to be vaccinated.

Flu vaccine can be lifesaving in children.
A 2017 study was the first of its kind to show that flu vaccination can significantly reduce children's risk of dying from flu.

Getting vaccinated yourself may also protect people around you, including those who are more vulnerable to serious flu illness, like babies and young children, older people, and people with certain chronic health conditions.

Despite the many benefits offered by flu vaccination, only about half of Americans get an annual flu vaccine. During an average flu season, flu can cause millions of illnesses, hundreds of thousands of hospitalizations and tens of thousands of deaths. Many more people could be protected from flu if more people got vaccinated.

*References for the studies listed above can be found at Publications on Influenza Vaccine Benefits.

Are flu vaccines effective against all types of flu and cold viruses?

Seasonal flu vaccines are designed to protect against infection and illness caused by the flu viruses that research indicates will be most common during the upcoming flu season. Flu vaccines do not protect against infection and illness caused by other viruses that also can cause flu-like symptoms. There are many other viruses besides flu viruses that can result in flu-like illness* (also known as influenza-like illness or "ILI") that spread during the flu season. These non-flu viruses include, but are not limited to, the following:

SARS-CoV-2 (the virus that causes COVID-19),

rhinovirus (one cause of the "common cold"), and

respiratory syncytial virus (RSV), which is the most common cause of severe respiratory illness in young children and a major cause of severe respiratory illness in adults 65 years and older.

Does flu vaccine effectiveness vary by type or subtype?

Yes. The amount of protection provided by a flu vaccine may vary by flu virus type or subtype and by vaccine, even when the viruses used to make flu vaccines are similar (or 'well matched') to the influenza viruses that are causing illness that season. Since 2009, VE studies looking at how well flu vaccines protect against medically attended illnesses have suggested better protection against influenza B or influenza A(H1N1) viruses than against influenza A(H3N2) viruses. A metanalysis of 76 published VE studies conducted in countries in both the Northern and Southern Hemispheres after the 2009-2010 flu pandemic found flu vaccines performed the best against influenza A(H1N1)pdm09 viruses followed by influenza B viruses. In contrast, flu vaccines were least effective against influenza A(H3N2) viruses. Across all the studies included in the meta-analysis, the pooled VE estimate against all influenza viruses for the Northern Hemisphere was 37 percent. For influenza A(H1N1)pdm09 viruses, the pooled VE estimate for the Northern Hemisphere was 56 percent. For influenza A(H3N2) viruses, the pooled VE estimate for the Northern Hemisphere was 22 percent. And lastly, for influenza B viruses, the pooled VE estimate for studies from the Northern Hemisphere was 42 percent. Overall, VE estimates were lower when the viruses used to make flu vaccines were antigenically different (not well matched) to flu viruses causing illness that season, and VE also appeared to decline with the age of the people studied.

Why is flu vaccine typically less effective against influenza A(H3N2) viruses?

There are several reasons why flu vaccine effectiveness against influenza A(H3N2) viruses may be lower compared to other flu viruses.

1. While all flu viruses undergo frequent genetic changes over time, the changes that have occurred in influenza A(H3N2) viruses have more frequently resulted in differences between the virus components of the flu vaccine and circulating influenza viruses (i.e., antigenic changes) compared with influenza A(H1N1) and influenza B viruses. That means that between the time when flu viruses are selected to begin producing vaccines and when flu vaccines are delivered, A(H3N2) viruses are more likely than A(H1N1) or influenza B viruses to have changed in ways that could impact how well the flu vaccines work.

2. Growth of viruses in eggs is part of the production process for many seasonal flu vaccines. While all influenza viruses undergo changes when they are grown in eggs, changes in influenza A(H3N2) viruses tend to be more likely to result in antigenic changes compared with changes in other influenza viruses. These so-called "egg-adapted changes" are present in vaccine viruses recommended for use in vaccine production and may reduce their potential effectiveness against circulating influenza viruses. Other vaccine production technologies, e.g., cell-based vaccine production or recombinant flu vaccines, do not use eggs in vaccine production to avoid egg-adapted changes to the viruses used to make vaccines. CDC also is using advanced molecular techniques to improve flu vaccines.

How effective are flu vaccines in older adults?

In numerous studies since 2010, standard dose flu vaccines offered some protection in adults 65 and older against flu illness resulting in a doctor's visit as well as flu-related hospitalization, but protection was inconsistent in this age group during some flu seasons ( 1-3). As a result, beginning with the 2022-2023 flu season, CDC and the Advisory Committee on Immunization Practices (ACIP) preferentially recommended the use of higher dose and adjuvanted flu vaccines for people 65 years and older. The preference applies to Fluzone High-Dose Quadrivalent vaccine, Flublok Quadrivalent recombinant flu vaccine and Fluad Quadrivalent adjuvanted flu vaccine. This recommendation was based on a review of available studies which suggests that, in this age group, these vaccines are potentially more effective than standard dose unadjuvanted flu vaccines. Because flu viruses and the effectiveness of flu vaccines can vary from one season to another, it is not known whether, in any given flu season, if one of these preferentially recommended flu vaccines will always be more effective in people 65 and older.

If older people have weaker immune responses to flu vaccination, should they still get vaccinated?

There are many reasons why people in this age group should be vaccinated each year:

First, people 65 years and older are at increased risk of serious illness, hospitalization, and death from flu.

Second, while the effectiveness of flu vaccines can be lower among some older people (particularly against influenza A(H3N2) viruses), there are seasons when significant benefit can be observed (this is particularly true against influenza A(H1N1) and influenza B viruses).

Third, flu vaccination has been shown in several studies to reduce severity of illness in people who get vaccinated but still get sick.

Flu vaccines can protect against more serious outcomes like hospitalization and death. For example, one study concluded that one death was prevented for every 4,000 people vaccinated against flu.

Fourth, in adults 65 years and older, hospitalizations can mark the beginning of a significant decline in overall health and mobility, potentially resulting in loss of the ability to live independently or to complete basic activities of daily living. While the protection older adults obtain from flu vaccination can vary significantly, a yearly flu vaccination is still the best protection currently available against flu.

In addition, people who are 65 and older differ in overall health, level of activity and mobility, and health care seeking behavior. This group includes people who are healthy and active and have responsive immune systems, as well as those who have underlying medical conditions that may weaken their immune systems and their bodies' ability to respond to vaccination. Therefore, when evaluating the benefits of flu vaccination, it is important to look at a broader picture than what one study's findings can present.

How effective are flu vaccines in children?

Flu vaccination has been found during most seasons to provide a similar level of protection against flu illness in children to that seen among adults. ACIP recommends any licensed, age-appropriate flu vaccine for children without preference for any one flu vaccine over another. In several studies, flu vaccine effectiveness was higher among children who received two doses of flu vaccine the first season that they were vaccinated (as recommended) compared to "partially vaccinated" children who only received a single dose of flu vaccine ( 4-6).

In addition to preventing illness, flu vaccine can prevent severe, life-threatening complications in children, for example:

A 2022 study showed that flu vaccination reduced children's risk of severe life-threatening influenza by 75 percent.

A 2020 study found that during the 2018-2019 flu season, flu vaccination reduced flu-related hospitalization by 41 percent and flu-related emergency department visits by half among children (aged 6 months to 17 years old).

In 2017, a study in the journal Pediatrics was the first of its kind to show that flu vaccination also significantly reduced a child's risk of dying from flu. The study, which looked at data from four flu seasons between 2010 and 2014, found that flu vaccination reduced the risk of flu-associated death by half (51 percent) among children with underlying, higher risk medical conditions and by nearly two-thirds (65 percent) among healthy children.

A 2014 study showed that flu vaccine reduced children's risk of flu-related pediatric intensive care unit (PICU) admission by 74 percent during flu seasons from 2010-2012.

Is it true that getting vaccinated repeatedly can reduce vaccine effectiveness?

Scientists continue to study and learn more about how prior or repeat flu vaccinations affect vaccine effectiveness. Studies have shown that previous flu vaccinations or infections can affect the immune response to flu vaccination in variable ways. A 2021 study conducted over six flu seasons (2012-2013 to 2017-2018) found that among people who get a flu vaccine each year (i.e., repeat vaccinees), getting the current season's flu vaccine generally was beneficial in reducing flu illness that results in a medical visit. There was no significant loss in protection among study participants who received the current and prior season's flu vaccine compared to those who were only vaccinated during the current season. Importantly, among people with prior season vaccination, current season vaccination provided significant added protection in some seasons overall and against A(H1N1)pdm09- and influenza B-associated illnesses. These findings support the current ACIP recommendations for annual flu vaccination and demonstrate that study participants vaccinated during the prior flu season benefit overall from getting vaccinated during the current season.

Some studies have shown reduced flu vaccine effectiveness-particularly against A(H3N2) viruses-among people who were vaccinated in both the current and prior season compared with those who had only been vaccinated in the current season. However, this finding could be the result of study bias related to the "carryover" benefits of the prior season's vaccine. Of note, when the benefits of current flu vaccines are analyzed separately for people only vaccinated this season and people vaccinated both this season and the prior season, benefits of current season flu vaccination are observed for both groups. CDC is learning more about how repeat vaccination affects vaccine effectiveness, but current findings continue to support the Advisory Committee on Immunization Practices' recommendations for annual flu vaccination.

What networks does CDC use to study how well flu vaccines work?

Information about the networks CDC uses to study flu vaccine effectiveness is available at CDC's Influenza Vaccine Effectiveness Networks.

Where can I get more information?

1. Edward A. Belongia, Danuta M. Skowronski, Huong Q. McLean et al. Repeated annual influenza vaccination and vaccine effectiveness: review of evidence. Expert Review of Vaccines. 2017 Jun; 16(7): 723-36. doi: 10.1080/14760584.2017.1334554.

2. Marc Rondy, Nathalie El Omeiri, Mark G. Thompson, et al. Effectiveness of influenza vaccines in preventing severe influenza illness among adults: A systemic review and meta-analysis of test-negative design case-control studies. Journal of Infection. Sept 2017; 65: 381-394. doi: 10.1016/j.jinf.2017.09.010

3. Kate Russell, Jessie R. Chung, Arnold S. Monto et al. Influenza vaccine effectiveness in older adults compared with younger adults over five seasons. Vaccine. Feb 2018; 36(10): 1272-1278. doi: 10.1016/j.vaccine.2018.01.045.

4. Chung J, Flannery B, Gaglani M et al. Patterns of Influenza Vaccination and vaccine effectiveness among young US Children Who Receive Outpatient Care for Acute Respiratory Tract Illness. JAMA Pediatr. 2020 Jul 1;174(7):705-713. doi: 10.1001/jamapediatrics.2020.0372.

5. Thompson M, Clippard J, Petrie J et al. Influenza Vaccine Effectiveness for Fully and Partially Vaccinated Children 6 Months to 8 Years Old During 2011-2012 and 2012-2013: The Importance of Two Priming Doses. Pediatr Infect Dis J. 2016 Mar;35(3):299-308. doi: 10.1097/INF.0000000000001006.

6. Feldstein L, Ogokeh C, Rha B et al. Vaccine Effectiveness Against Influenza Hospitalization Among Children in the United States, 2015-2016. Journal of the Pediatric Infectious Diseases Society. 2021 Feb; 10(2):75-82. https://doi.org/10.1093/jpids/piaa017.

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Vaccine Effectiveness: How Well Do Flu Vaccines Work? | CDC

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Influenza vaccine effectiveness questions and answers - CDC

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https://pittsburgh.cbslocal.com/2021/08/23/doctors-safe-to-get-flu-shot-and-covid-19-booster-shot-around-same-time/

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PITTSBURGH (KDKA) - We've been hearing about them for months, and it's finally time for COVID-19 booster shots.

Doctors recommend getting the booster eight months after the second shot, and for many - that falls smack dab in flu shot season.

READ MORE: COVID-19 In Pittsburgh: Allegheny County Health Department Reports 263 New Cases

KDKA's Meghan Schiller asked the experts what people need to know about mixing the two.

"I think ideally it might be two shots this year, but to get them both at the same time would certainly be efficient," said Dr. Amy Crawford-Faucher, family doctor and Vice Chair of Allegheny Health Network's Primary Care Institute.

KDKA's cameras were rolling as people lined up for another dose of protection at Allegheny General Hospital.

"I feel much safer because I don't want to lose my kidney," said Esperanza Bier.

Bier just received a new kidney and said she's vaccinated to honor her donor. She's one of many immunocompromised people now eligible for a COVID-19 booster shot.

"I was in dialysis close to three or four years," said Bier.

Schiller: How are you feeling now?

Bier: Oh, it's wonderful.

The CDC just announced we'll need booster shots for maximum protection, but for many - the third shot overlaps with flu season.

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"When the COVID vaccines first came out, we said no other vaccines within two weeks of a COVID vaccine. So that recommendation changed a few months ago," said Dr. Crawford- Faucher

But doctors now say people can now get their flu shot and COVID booster shot around the same time. Turns out, people always could, but scientists didn't want overlap for one reason.

"Because we were just rolling this out to lots of people, we really wanted to be pure in knowing that if you had a reaction, it was due to the COVID vaccine and not from something else you got in your body," said Dr. Crawford- Faucher.

Top researchers already started discussing a combo shot that covers both the coronavirus and the flu. UPMC's Dr. Graham Snyder told KDKA expect two shots for now.

"It's plausible that we could every winter get a combo influenza vaccine and COVID vaccine, but it's way too early to say that's going to happen. But that plausibly could happen," said Dr. Snyder, UPMC's medical director of infection prevention and hospital epidemiology.

People in line for the booster shot at AGH didn't seem to mind that another shot is in their not-so-distant future.

"I would get the flu shot. I get it every year," said Marie Geubtner, nurse and booster shot recipient.

"So, I did that booster too, I get all my boosters, all my shots all the time," said Mary Louise Pastorok, Allegheny Health Network's booster shot recipient and senior executive assistant.

Doctors warn against skipping the flu shot, saying we won't see a repeat winter with low flu cases for these reasons:

"A major contributor to the reason we saw no flu virus was because many of us were staying at home, we're working from home, we're doing school from home, we were limiting the number of contacts we all had and we were masking," said Dr. Snyder. "Now, obviously, that has changed and will probably remain changed going into this winter."

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That's why doctors say schedule both, in whatever order works out best for your schedule.

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Doctors Say It Is Safe To Get Flu Shot And COVID-19 Booster Shot Around Same Time

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PITTSBURGH (KDKA) - We've been hearing about them for months, and it's finally time for COVID-19 booster shots. Doctors recommend getting the booster eight months after the second shot, and for many - that falls smack dab in flu shot season.

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1. "An Evolving Situation"

There are three moments in the yearlong catastrophe of the COVID-19 pandemic when events might have turned out differently. The first occurred on January 3, 2020, when Robert Redfield, the director of the Centers for Disease Control and Prevention, spoke with George Fu Gao, the head of the Chinese Center for Disease Control and Prevention, which was modelled on the American institution. Redfield had just received a report about an unexplained respiratory virus emerging in the city of Wuhan.

The field of public health had long been haunted by the prospect of a widespread respiratory-illness outbreak like the 1918 influenza pandemic, so Redfield was concerned. Gao, when pressed, assured him that there was no evidence of human-to-human transmission. At the time, the theory was that each case had arisen from animals in a "wet" market where exotic game was sold. When Redfield learned that, among twenty-seven reported cases, there were several family clusters, he observed that it was unlikely that each person had been infected, simultaneously, by a caged civet cat or a raccoon dog. He offered to send a C.D.C. team to Wuhan to investigate, but Gao said that he wasn't authorized to accept such assistance. Redfield made a formal request to the Chinese government and assembled two dozen specialists, but no invitation arrived. A few days later, in another conversation with Redfield, Gao started to cry and said, "I think we're too late."

Perhaps Gao had just been made aware that the virus had been circulating in China at least since November. Certainly, Redfield didn't know that the virus was already present in California, Oregon, and Washington, and would be spreading in Massachusetts, Wisconsin, Iowa, Connecticut, Michigan, and Rhode Island within the next two weeks-well before America's first official case was detected.

Redfield is convinced that, had C.D.C. specialists visited China in early January, they would have learned exactly what the world was facing. The new pathogen was a coronavirus, and as such it was thought to be only modestly contagious, like its cousin the SARS virus. This assumption was wrong. The virus in Wuhan turned out to be far more infectious, and it spread largely by asymptomatic transmission. "That whole idea that you were going to diagnose cases based on symptoms, isolate them, and contact-trace around them was not going to work," Redfield told me recently. "You're going to be missing fifty per cent of the cases. We didn't appreciate that until late February." The first mistake had been made, and the second was soon to happen.

Matthew Pottinger was getting nervous. He is one of the few survivors of Donald Trump's White House, perhaps because he is hard to categorize. Fluent in Mandarin, he spent seven years in China, reporting for Reuters and the Wall Street Journal. He left journalism at the age of thirty-two and joined the Marines, a decision that confounded everyone who knew him. In Afghanistan, he co-wrote an influential paper with Lieutenant General Michael Flynn on improving military intelligence. When Trump named Flynn his national-security adviser, Flynn chose Pottinger as the Asia director. Scandal removed Flynn from his job almost overnight, but Pottinger stayed, serving five subsequent national-security chiefs. In September, 2019, Trump appointed him deputy national-security adviser. In a very noisy Administration, he had quietly become one of the most influential people shaping American foreign policy.

At the Journal, Pottinger had covered the 2003 sars outbreak. The Chinese hid the news, and, when rumors arose, authorities minimized the severity of the disease, though the fatality rate was approximately ten per cent. Authorities at the World Health Organization were eventually allowed to visit Beijing hospitals, but infected patients were reportedly loaded into ambulances or checked into hotels until the inspectors left the country. By then, sars was spreading to Hong Kong, Hanoi, Singapore, Taiwan, Manila, Ulaanbaatar, Toronto, and San Francisco. It ultimately reached some thirty countries. Because of heroic efforts on the part of public-health officials-and because sars spread slowly-it was contained eight months after it emerged.

The National Security Council addresses global developments and offers the President options for responding. Last winter, Pottinger was struck by the disparity between official accounts of the novel coronavirus in China, which scarcely mentioned the disease, and Chinese social media, which was aflame with rumors and anecdotes. Someone posted a photograph of a sign outside a Wuhan hospital saying that the E.R. was closed, because staff were infected. Another report said that crematoriums were overwhelmed.

On January 14th, the N.S.C. convened an interagency meeting to discuss the virus. Early that morning, the W.H.O.-relying on China's assurances-tweeted that there was no evidence of human-to-human transmission. The N.S.C. recommended that screeners take the temperatures of any passengers arriving from Wuhan.

The next day, President Trump signed the first phase of a U.S.-China trade deal, declaring, "Together, we are righting the wrongs of the past and delivering a future of economic justice and security for American workers, farmers, and families." He called China's President, Xi Jinping, "a very, very good friend."

On January 20th, the first case was identified in the U.S. On a Voice of America broadcast, Dr. Anthony Fauci, the head of the National Institute of Allergy and Infectious Diseases, said, "This is a thirty-five-year-old young man who works here in the United States, who visited Wuhan." Trump, who was at the World Economic Forum, in Davos, Switzerland, dismissed the threat, saying, "It's one person coming in from China. It's going to be just fine."

On January 23, 2020, all the members of the U.S. Senate gathered for the second day of opening arguments in President Trump's impeachment trial. It was an empty exercise with a foreordained result. Mitch McConnell, the Majority Leader, had already said that he would steamroll Democratic attempts to introduce witnesses or new evidence. "We have the votes," he decreed.

The trial posed difficulties for the four Democratic senators still running for President. As soon as the proceedings recessed, on Friday evenings, the candidates raced off to campaign for the weekend. One of them, Amy Klobuchar, of Minnesota, recalled, "I was doing planetariums in small towns at midnight." Then it was back to Washington, to listen to an argument that one side would clearly win. In the midst of this deadened theatre, McConnell announced, "In the morning, there will be a coronavirus briefing for all members at ten-thirty." This was the first mention of COVID in Congress.

The briefing took place on January 24th, in the hearing room of the Health, Education, Labor, and Pensions Committee, which Lamar Alexander, Republican of Tennessee, chaired. Patty Murray is the ranking Democratic member. A former preschool teacher, she has been a senator for twenty-seven years. Her father managed a five-and-dime until he developed multiple sclerosis and was unable to work. Murray was fifteen. The family went on welfare. She knows how illness can upend people economically, and how government can help.

A few days earlier, she had heard about the first confirmed COVID case in the U.S.-the man had travelled from Wuhan to Washington, her state. Murray contacted local public-health officials, who seemed to be doing everything right: the man was hospitalized, and health officials were tracing a few possible contacts. Suddenly, they were tracking dozens of people. Murray said to herself, "Wow, this is kinda scary. And this is in my back yard."

But in the outbreak's early days, when decisiveness mattered most, few other politicians were paying attention. It had been a century since the previous great pandemic, which found its way from the trenches of the First World War to tropical jungles and Eskimo villages. Back then, scientists scarcely knew what a virus was. In the twenty-first century, infectious disease seemed like a nuisance, not like a mortal threat. This lack of concern was reflected in the diminished budgets given to institutions that once had led the world in countering disease and keeping Americans healthy. Hospitals closed; stockpiles of emergency equipment weren't replenished. The spectre of an unknown virus arising in China gave certain public-health officials nightmares, but it wasn't on the agenda of most American policymakers.

About twenty senators showed up to hear Anthony Fauci and Robert Redfield speak at an hour-long briefing. The health authorities were reassuring. Redfield said, "We are prepared for this."

That day, Pottinger convened forty-two people, including N.S.C. staffers and Cabinet-level officials, for a meeting. China had just announced a lockdown of Wuhan, a city of eleven million, which could mean only that sustained human-to-human transmission was occurring. Indeed, Pottinger's staff reported that another city, Huanggang, was also locked down. The previous day, the State Department had heightened its travel advisory for passengers to the Wuhan region, and the meeting's attendees debated how to implement another precaution: sending all passengers coming from Wuhan to five U.S. airports, where they could be given a health screening before entry.

The next day, Pottinger attended a Chinese New Year party on Capitol Hill. Old diplomatic hands, émigrés, and Chinese dissidents relayed stories about the outbreak from friends and family members. People were frightened. It sounded like sars all over again.

Pottinger went home and dug up files from his reporting days, looking for phone numbers of former sources, including Chinese doctors. He then called his brother, Paul, an infectious-disease doctor in Seattle. Paul had been reading about the new virus on Listservs, but had assumed that, like sars, it would be "a flash in the pan."

If flights from China were halted, Matt asked, could America have more time to prepare?

Paul was hesitant. Like most public-health practitioners, he held that travel bans often have unintended consequences. They stigmatize countries contending with contagion. Doctors and medical equipment must be able to move around. And, by the time restrictions are put in place, the disease has usually infiltrated the border anyway, making the whole exercise pointless. But Matt spoke with resolve. Little was known about the virus except for the fact that it was spreading like wildfire, embers flying from city to city.

Paul told Matt to do whatever he could to slow the virus's advance, giving the U.S. a chance to establish testing and contact-tracing protocols, which could keep the outbreak under control. Otherwise, the year ahead might be calamitous.

No one realized how widely the disease had already seeded itself. Fauci told a radio interviewer that COVID wasn't something Americans needed to "be worried or frightened by," but he added that it was "an evolving situation."

2. The Trickster

In October, 2019, the first Global Health Security Index appeared, a sober report of a world largely unprepared to deal with a pandemic. "Unfortunately, political will for accelerating health security is caught in a perpetual cycle of panic and neglect," the authors observed. "No country is fully prepared." Yet one country stood above all others in terms of readiness: the United States.

During the transition to the Trump Administration, the Obama White House handed off a sixty-nine-page document called the Playbook for Early Response to High-Consequence Emerging Infectious Disease Threats and Biological Incidents. A meticulous guide for combatting a "pathogen of pandemic potential," it contains a directory of government resources to consult the moment things start going haywire.

Among the most dangerous pathogens are the respiratory viruses, including orthopoxviruses (such as smallpox), novel influenzas, and coronaviruses. With domestic outbreaks, the playbook specifies that, "while States hold significant power and responsibility related to public-health response outside of a declared Public Health Emergency, the American public will look to the U.S. Government for action." The playbook outlines the conditions under which various federal agencies should become involved. Questions about the severity and the contagiousness of a disease should be directed to the Department of Health and Human Services, the Federal Emergency Management Agency, and the Environmental Protection Agency. How robust is contact tracing? Is clinical care in the region scalable if cases explode? There are many such questions, with decisions proposed and agencies assigned. Appendices describe such entities as the Pentagon's Military Aeromedical Evacuation team, which can be assembled to transport patients. Health and Human Services can call upon a Disaster Mortuary Operational Response Team, which includes medical examiners, pathologists, and dental assistants.

The Trump Administration jettisoned the Obama playbook. In 2019, H.H.S. conducted Crimson Contagion, a simulation examining the government's ability to contain a pandemic. Among the participants were the Pentagon, the N.S.C., hospitals, local and regional health-care departments, the American Red Cross, and twelve state governments. The scenario envisioned an international group of tourists visiting China who become infected with a novel influenza and spread it worldwide. There's no vaccine; antiviral drugs are ineffective.

The Crimson Contagion exercise inspired little confidence that the government was prepared to handle such a crisis. Federal agencies couldn't tell who was in charge; states grew frustrated in their attempts to secure enough resources. During the simulation, some cities defied a C.D.C. recommendation to close schools. Government policies, the report concluded, were inadequate and "often in conflict." The Public Health Emergency Fund and the Strategic National Stockpile were dangerously depleted; N95 masks and other medical essentials were in short supply, and domestic manufacturing capacity was insufficient. Congress was briefed on the findings but they were never made public. By the time COVID arrived, no meaningful changes had been made to address these shortcomings.

"I just love infectious diseases," John Brooks, the chief medical officer of the COVID response team at the C.D.C., admitted to me. "I know diseases are terrible-they kill people. But something about them just grabs me."

Each generation has its own struggle with disease. In 1939, Brooks's mother, Joan Bertrand Brooks, developed polio. Her legs were covered with surgical scars, and her right leg was noticeably shorter than her left. "She spoke about that experience often-how she was teased, stigmatized, or blatantly discriminated against," Brooks recalled.

For Brooks, who is gay, the disease of his generation was H.I.V./AIDS. He grew up near the Dupont Circle neighborhood of Washington, D.C., which had a large gay population, and watched men he knew disappear: "Guys would get thin and develop lesions and then be gone. It was scary." Science offered no solution, and that was on Brooks's mind when he decided to become a doctor. The day he was accepted at Harvard Medical School, he and his mother went to lunch to celebrate. "Afterward, we dropped into a ten-dollar palm reader, who said she saw me marrying a tall Swedish woman and owning a jet with which I flew around the world with our three children," he told me. "We had a good laugh. I should have asked for a refund."

In 2015, Brooks became the chief medical officer of the H.I.V./ AIDS division at the C.D.C. Every H.I.V. researcher has been humbled by the various manifestations of this disease. "At every turn, there was something different," Brooks said. "All these opportunistic infections show up. What in the world is this all about? Very cool." The experience of studying H.I.V. helped prepare him for the myriad tricks that COVID would present.

The C.D.C. was founded in 1946, as the Communicable Disease Center. Atlanta was chosen as its home because the city was in the heart of what was called "the malaria zone." Five years later, America was declared malaria-free. The C.D.C.'s mission expanded to attack other diseases: typhus, polio, rabies. In 1981, the organization, by then renamed the Centers for Disease Control, reported the first known cases of AIDS, in Los Angeles. Until this year, the C.D.C. maintained a reputation as the gold standard for public health, operating above politics and proving repeatedly the value of enlightened government and the necessity of science for the furthering of civilization. During the twentieth century, the life span of Americans increased by thirty years, largely because of advances in public health, especially vaccination.

The C.D.C. campus now resembles a midsize college, with more buildings under construction, including a high-containment facility for the world's most dangerous diseases. Lab animals-mice, ferrets, monkeys-inhabit cages inside Biosafety Level 4 chambers. Humans move around them like deep-sea divers in inflated suits, tethered to an overhead airflow system.

The Emergency Operations Center is a large, bright room, with serried rows of wooden desks facing a wall of video screens. The place exudes a mixture of urgency and professional calm. On one side of the room, operators triage incoming phone calls. In 2014, during the Ebola crisis, Brooks received a call from Clay Jenkins, a county judge in Dallas. A Liberian citizen visiting the city, Thomas Eric Duncan, had contracted the disease. Jenkins wanted advice about how to safely approach Duncan's fiancée and her family members. On a monitor, Brooks could see the fiancée's apartment complex, shot from above by cameras on helicopters. Brooks told Jenkins that he could safely enter the apartment as long as the family had no symptoms: it would be an important public gesture for him to choose compassion over fear. Brooks watched footage of Jenkins escorting the family out of the complex. (Thomas Duncan eventually died; two nurses who had cared for him were infected but survived.)

Brooks was working on the COVID response team with Greg Armstrong, a fellow-epidemiologist. Armstrong oversaw the Advanced Molecular Detection program, which is part of the C.D.C.'s center for emerging and zoonotic infectious diseases. (Zoonotic diseases come from animals, as coronaviruses typically do.) Humanity's encroachment into formerly wild regions, coupled with climate change, which has forced animals out of traditional habitats, has engendered many new diseases in humans, including Ebola and Zika. At first, SARS-CoV-2-as the new virus was being called-presented itself as a less mortal coronavirus, like the common cold, spreading rapidly and sometimes asymptomatically. In fact, SARS-CoV-2 was more like polio. Most polio infections are asymptomatic or very mild-fever and headaches. But some are deadly. The polio cases that doctors actually see are about one in every two hundred infections. Stealth transmission is why polio has been so hard to eradicate.

Armstrong was in Salt Lake City, conducting a training session, when he noticed an article on the Web site of The New England Journal of Medicine: " Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia." The article was one of the first to describe the virus's spread among humans, a development that didn't surprise Armstrong: "Anybody with any epidemiology experience could tell you it was human-to-human transmission." Then he noticed Table 1, "Characteristics of Patients," which noted the original source of their infection. Of the Chinese known to have contracted the virus before January 1st, twenty-six per cent had no exposure either to the Wuhan wet market or to people with apparent respiratory symptoms. In subsequent weeks, the number of people with no obvious source of infection surpassed seventy per cent. Armstrong realized that, unlike with sars or mers-other coronavirus diseases-many infections of SARS-CoV-2 were probably asymptomatic or mild. Contact tracing, isolation, and quarantine would likely not be enough. These details were buried in Table 1.

Other reports began to emerge about possible asymptomatic spread. Although SARS-CoV-2 was genetically related to the sars and MERS viruses, it was apparently unlike them in two key ways: people could be contagious before developing symptoms, and some infected people would never manifest illness. In late February, University of Texas scientists, led by Lauren Ancel Meyers, reported that it could have a "negative serial interval," meaning that some infected people showed symptoms before the person who had given it to them.

The C.D.C.'s early guidance documents didn't mention that possibility, because the evidence of asymptomatic spread was deemed insufficient. "In the beginning, for every mathematical analysis that indicated a shorter serial interval than incubation period, others reported no difference," Brooks said. "When the science changed, we changed. And our recommendations changed, too." But, by that time, the C.D.C. had been muzzled by the Trump Administration.

"There are three things this virus is doing that blow me away," Brooks told me. "The first is that it directly infects the endothelial cells that line our blood vessels. I'm not aware of any other human respiratory viruses that do this. This causes a lot of havoc." Endothelial cells normally help protect the body from infection. When SARS-CoV-2 invades them, their powerful chemical contents get dumped into the bloodstream, resulting in inflammation elsewhere in the body. The rupture of individual endothelial cells coarsens the lining in the blood vessels, creating breaks and rough spots that cause turbulent blood flow.

The second surprise was hypercoagulability-patients had a pronounced tendency to develop blood clots. This reminded Brooks of Michael Crichton's 1969 novel, " The Andromeda Strain," in which a pathogen causes instant clotting, striking down victims in mid-stride. "This is different," Brooks said. "You're getting these things called pulmonary embolisms, which are nasty. A clot forms-it travels to the lung, damaging the tissues, blocking blood flow, and creating pressures that can lead to heart problems." More puzzling was evidence that clots sometimes formed in the lungs, leading to acute respiratory distress. Brooks referred to an early report documenting autopsies of victims. Nearly all had pulmonary thromboses; until the autopsy, nobody had suspected that the clots were even present, let alone the probable cause of death.

"The last one is this hyperimmune response," Brooks said. Most infectious diseases kill people by triggering an excessive immune-system response; COVID, like pneumonia, can unleash white blood cells that flood the lungs with fluid, putting the patient at risk of drowning. But COVID is unusual in the variety of ways that it causes the body to malfunction. Some patients require kidney dialysis or suffer liver damage. The disease can affect the brain and other parts of the nervous system, causing delirium, strokes, and lasting nerve damage. COVID could also do strange things to the heart. Hospitals began admitting patients with symptoms of heart attack-chest pains, trouble breathing-and preparing emergency coronary catheterizations. "But their coronary vessels are clean," Brooks said. "There's no blockage." Instead, an immune reaction had inflamed the heart muscle, a condition called myocarditis. "There's not a lot you can do but hope they get through it." A German study of a hundred recovered COVID patients with the average age of forty-nine found that twenty-two had lasting cardiac problems, including scarring of the heart muscle.

Even after Brooks thought that COVID had no more tricks to play, another aftereffect confounded him: "You get over the illness, you're feeling better, and it comes back to bite you again." In adults, it might just be a rash. But some children develop a multi-organ inflammatory syndrome. Brooks said, "They have conjunctivitis, their eyes get real red, they have abdominal pain, and then they can go on to experience cardiovascular collapse."

3. Spike

When I was around six, I woke up one morning and couldn't get out of bed: I was paralyzed from the waist down. It was during the polio era, in the early fifties, before there was a cure. I remember the alarm in my mother's eyes. Our family doctor made a house call. He sat on the edge of the bed, and took my temperature and pulse; there was little else he could do. The terror of polio haunted children and parents everywhere.

I was lucky. After a day or so, I could move my legs again. I was never certain what had caused my brief paralysis, but the memory was searing. Soon after the polio vaccine, invented by Jonas Salk, became available, in 1955, I was inoculated, along with millions of other children.

So I had a personal interest when I entered Building 40 of the main campus of the National Institutes of Health, in Bethesda, Maryland, which houses the National Institute of Allergy and Infectious Diseases. Dr. Barney S. Graham, the deputy director of the Vaccine Research Center and the chief of the Viral Pathogenesis Laboratory and Translational Science Core, works on the second floor. He studies how viruses cause disease, and he designs vaccines.

The first thing you notice about Graham is that there's a lot of him: he's six feet five, with a gray goatee and a laconic manner. Graham's boss at niaid, Anthony Fauci, told me, "He understands vaccinology better than anybody I know."

Bookshelves in Graham's office hold colorful 3-D printouts of viruses that he has worked with, including Ebola, Zika, and influenza. While I was researching " The End of October," a novel that I published earlier this year, about a deadly pandemic, Graham helped me design a fictional virus, and then concocted a vaccine for it. As we collaborated, I came to understand that researchers like Graham are essentially puzzle solvers. This past year, he solved one of the most consequential puzzles in modern science. He is the chief architect of the first COVID vaccines authorized for emergency use. Manufactured by Moderna and Pfizer, they differ only in their delivery systems.

On Graham's wall is a map of Kansas, where he grew up. His father was a dentist and his mother was a teacher. For part of his childhood, they lived on a hog farm. Barney and his brother did much of the farming. Working with the animals, he learned a lot about veterinary medicine. At Rice University, he majored in biology. He earned a medical degree at the University of Kansas, where he met his wife, Cynthia Turner-Graham, a psychiatrist. In 1978, on an infectious-disease rotation in medical school, he spent time at the N.I.H., where he first encountered Fauci. "Cynthia noticed when I came back how excited I was," Graham recalled. "People were willing to battle each other's ideas. She thought I would end up here."

First, he and Cynthia had to complete residencies. They wanted to be in the same town, a problem many professional couples face, but additionally complicated in their case because Cynthia is Black. She suggested Nashville: he could apply to Vanderbilt School of Medicine and she to Meharry Medical College, a historically Black institution. Tennessee had only recently repealed a ban on interracial marriage.

Driving back to Kansas from Maryland on Christmas Eve, Graham stopped in at Vanderbilt. To his surprise, the director of the residency program, Thomas Brittingham, was in his office and willing to meet with him immediately. When the interview was over, Graham told Brittingham, "I know this is the South. I'm going to marry a Black woman, and if that makes a difference I can't come here." Brittingham said, "Close the door." He welcomed Graham on the spot. Cynthia was accepted at Meharry, and so they moved to Nashville.

By 1982, Graham had become the chief resident at Nashville General Hospital. That year, he saw a patient suffering from five simultaneous infections, including cryptococcal meningitis and herpes simplex. It was a mystery: most infections are solitary events. The medical staff was terrified. Graham realized that he was treating Tennessee's first AIDS patient. "We kept him alive for three weeks," he said.

Millions of lives would be changed, and so many ended, by this remorseless, elusive disease. Immunology, then a fledgling field, was transformed by the battle. "It took us a couple years just to figure out that H.I.V. was a virus," Graham said. He started running vaccine trials. "It was not till the mid-nineties that we had decent treatments. There were some really hard years. Almost everyone died."

In 2000, the N.I.H. recruited Graham to create a vaccine-evaluation clinic. He insisted on keeping a research lab. With space for two dozen scientists, his lab focusses on vaccines for three categories of respiratory viruses: influenza, coronaviruses, and a highly contagious virus called respiratory syncytial virus (RSV), which ended up playing a key role in the development of a COVID vaccine.

RSV causes wheezing pneumonia in children, and sends more kids under five years old to the hospital than any other disease. One of the last childhood infectious diseases without a vaccine, RSV also kills about as many of the elderly as seasonal influenza. It's wildly infectious. In order to stop its spread in a hospital pediatric ward, staff must wear gloves, masks, and goggles; if any of these items is omitted, RSV will surge. Like COVID, it is dispersed through particle droplets and contaminated surfaces. In the nineteen-sixties, a clinical trial of a potential RSV vaccine made children sicker and led to two deaths-a syndrome called vaccine-enhanced disease. Graham spent much of two decades trying to solve the riddle of what causes RSV, but the technology he needed was still being developed.

In 2008, he had a stroke of luck. Jason McLellan, a postdoc studying H.I.V., had been squeezed out of a structural-biology lab upstairs. H.I.V. has proved invulnerable to a vaccine solution, despite extraordinary technological advances and elegant new theories for designing one. "I thought, Let's try things out on a more tractable virus," McLellan recalled. "Barney thought RSV would be perfect for a structure-based vaccine."

A vaccine trains the immune system to recognize a virus in order to counter it. Using imaging technology, structural biologists can intuit the contours of a virus and its proteins, then reproduce those structures to make more effective vaccines. McLellan said of his field, "From the structure, we can determine function-it's similar to how seeing a car, with four wheels and doors, implies something about its function to transport people."

The surface of an RSV particle features a protein, designated F. On the top of the protein, a spot called an epitope serves as a landing pad for antibodies, allowing the virus to be neutralized. But something extraordinary happens when the virus invades a cell. The F protein swells like an erection, burying the epitope and effectively hiding it from antibodies. Somehow, McLellan had to keep the F protein from getting an erection.

Until recently, one of the main imaging tools used by vaccinologists, the cryogenic electron microscope, wasn't powerful enough to visualize viral proteins, which are incredibly tiny. "The whole field was referred to as blobology," McLellan said. As a work-around, he developed expertise in X-ray crystallography. With this method, a virus, or even just a protein on a virus, is crystallized, then hit with an X-ray beam that creates a scatter pattern, like a shotgun blast; the structure of the crystallized object can be determined from the distribution of electrons. McLellan showed me an "atomistic interpretation" of the F protein on the RSV virus-the visualization looked like a pile of Cheetos. It required a leap of imagination, but inside that murky world Graham and McLellan and their team manipulated the F protein, essentially by cloning it and inserting mutations that kept it strapped down. McLellan said, "There's a lot of art to it."

In 2013, Graham and McLellan published " Structure-Based Design of a Fusion Glycoprotein Vaccine for Respiratory Syncytial Virus," in Science, demonstrating how they had stabilized the F protein in order to use it as an antigen-the part of a vaccine that sparks an immune response. Antibodies could now attack the F protein, vanquishing the virus. Graham and McLellan calculated that their vaccine could be given to a pregnant woman and provide enough antibodies to her baby to last for its first six months-the critical period. The paper opened a new front in the war against infectious disease. In a subsequent paper in Science, the team declared that it had established "clinical proof of concept for structure-based vaccine design," portending "an era of precision vaccinology." The RSV vaccine is now in Phase III human trials.

In 2012, the mers coronavirus emerged in Saudi Arabia. It was extremely dangerous to work with: a third of infected people died. Ominously, it was the second novel coronavirus in ten years. Coronaviruses have been infecting humans for as long as eight centuries, but before sars and mers they caused only the common cold. It's possible that, in the distant past, cold viruses were as deadly as COVID, and that humans developed resistance over time.

Like RSV, coronaviruses have a protein that elongates when invading a cell. "It looks like a spike, so we just call it Spike," Graham said. Spike was large, flexible, and encased in sugars, which made it difficult to crystallize, so X-ray crystallography wasn't an option. Fortunately, around 2013, what McLellan calls a "resolution revolution" in cryogenic electron microscopy allowed scientists to visualize microbes down to one ten-billionth of a metre. Finally, vaccinologists could truly see what they were doing.

Using these high-powered lenses, Graham and McLellan modified the mers spike protein, creating a vaccine. It worked well in mice. They were on the way to making a version for humans, but, after mers had killed hundreds of people, it petered out as an immediate threat to humans-and the research funding petered out, too. Graham was dismayed, realizing that such a reaction was shortsighted, but he knew that his energies hadn't been wasted. About two dozen virus families are known to infect humans, and the weapon that Graham's lab had developed to conquer RSV and mers might be transferrable to many of them.

What was the best way to deliver a modified protein? Graham knew that Moderna, a biotech startup in Cambridge, Massachusetts, had encoded a modified protein on strips of genetic material known as messenger RNA. The company had never brought a vaccine to market, concentrating instead on providing treatments for rare disorders that aren't profitable enough to interest Big Pharma. But Moderna's messenger-RNA platform was potent.

In mice, Graham had proved the effectiveness of a structure-based vaccine for mers and also for Nipah, a particularly fatal virus. In 2017, Graham arranged a demonstration project for pandemic preparedness, with mers and Nipah serving as prototypes for a human vaccine using Moderna's messenger-RNA platform. Almost three years later, as he was preparing to begin human trials for the Nipah vaccine, he heard the news from Wuhan.

Graham called McLellan, who happened to be in Park City, Utah, getting snowboard boots heat-molded to his feet. McLellan had become a star in structural biology, and was recruited to the University of Texas at Austin, where he had access to cryogenic electron microscopes. It took someone who knew Graham well to detect the urgency in his voice. He suspected that China's cases of atypical pneumonia were caused by a new coronavirus, and he was trying to obtain the genomic sequence. It was a chance to test their concept in a real-world situation. Would McLellan and his team like to get "back in the saddle" and help him create a vaccine?

"Of course," McLellan said.

"We got the sequences Friday night, the tenth of January," Graham told me. They had been posted online by the Chinese. "We woke up on the eleventh and started designing proteins."

Nine days later, the coronavirus officially arrived in America.

Within a day after Graham and McLellan downloaded the sequence for SARS-CoV-2, they had designed the modified proteins. The key accelerating factor was that they already knew how to alter the spike proteins of other coronaviruses. On January 13th, they turned their scheme over to Moderna, for manufacturing. Six weeks later, Moderna began shipping vials of vaccine for clinical trials. The development process was "an all-time record," Graham told me. Typically, it takes years, if not decades, to go from formulating a vaccine to making a product ready to be tested: the process privileges safety and cost over speed.

Graham had to make several crucial decisions while designing the vaccine, including where to start encoding the spike-protein sequence on the messenger RNA. Making bad choices could render the vaccine less effective-or worthless. He solicited advice from colleagues. Everyone said that the final decisions were up to him-nobody had more experience in designing vaccines. He made his choices. Then, after Moderna had already begun the manufacturing process, the company sent back some preliminary data that made him fear he'd botched the job.

Graham panicked. Given his usual composure, Cynthia, his wife, was alarmed. "It was a crisis of confidence that I just never see in him," she said. So much depended on the prompt development of a safe and effective vaccine. Graham's lab was off to a fast start. If his vaccine worked, millions of lives might be spared. If it failed or was delayed, it would be Graham's fault.

After the vaccine was tested in animals, it became clear that Graham's design choices had been sound. The first human trial began on March 16th. A week later, Moderna began scaling up production to a million doses per month.

4. "It's more like 1918"

Since 2016, Dr. Rick Bright has run the Biomedical Advanced Research and Development Authority. A division of H.H.S., the authority is responsible for medical countermeasures in the event of bioterrorism or a pandemic. According to a whistle-blower complaint, on January 22nd Bright received an e-mail from Mike Bowen, an executive at the Texas-based firm Prestige Ameritech, the country's largest maker of surgical masks. Bowen wrote that he had four "like new" N95 manufacturing lines, which weren't in use. He added, "Reactivating these machines would be very difficult and very expensive but could be achieved in a dire situation and with government help." In another message, Bowen wrote, "We are the last major domestic mask company. . . . My phones are ringing now, so I don't 'need' government business. I'm just letting you know that I can help you preserve our infrastructure if things ever get really bad. I'm a patriot first, businessman second."

Bright had already been worried about the likely shortage of personal protective equipment in the Strategic National Stockpile. He also felt that not enough was being done to develop diagnostics for the virus from Wuhan. On January 23rd, at an H.H.S. leadership meeting with Secretary Alex Azar, he warned that the "virus might already be here-we just don't have the tests to know." Many Trump Administration officials seemed determined to ignore scientists who shared bad news.

On January 25th, Bowen wrote Bright again, saying that his company was getting "lots of requests from China and Hong Kong" for masks-a stunning piece of intelligence. About half the masks used in the U.S. come from China; if that supply stopped, Bowen said, American hospitals would run out. Bright continued pushing for immediate action on masks, but he found H.H.S. to be unresponsive. On January 27th, Bowen wrote, "I think we're in deep shit. The world."

The same day, at the White House, Matt Pottinger convened an interagency meeting of Cabinet officers and deputies. Attendees fell into four camps. There was the public-health establishment-Redfield, Fauci, Azar-data-driven people who, at the moment, had no data. Another group-the acting White House chief of staff, Mick Mulvaney, along with officials from the Office of Management and Budget and the Transportation Department-was preoccupied with the economic damage that would result if drastic steps were taken. A State Department faction was concerned mainly with logistical issues, such as extracting Americans from Wuhan. Finally, there was Pottinger, who saw the virus not just as a medical and economic challenge but also as a national-security threat. He wanted dramatic action now.

For three weeks, the U.S. had been trying unsuccessfully to send medical experts to China. The public-health contingent didn't want to make decisions about quarantines or travel bans without definitive intelligence, but the Chinese wouldn't supply it. When Pottinger presented a proposal to curtail travel from China, the economic advisers derided it as overkill. Travel bans upended trade-a serious consideration with China, which, in addition to P.P.E., manufactured much of the vital medicine that the U.S. relied on. Predictably, the public-health representatives were resistant, too: travel bans slowed down emergency assistance, and viruses found ways to propagate no matter what. Moreover, at least fourteen thousand passengers from China were arriving in the U.S. every day: there was no way to quarantine them all. These arguments would join other public-health verities that were eventually overturned by the pandemic. Countries that imposed travel bans with strict quarantines, such as Vietnam and New Zealand, kept the contagion at a manageable level.

The State Department's evacuation of Americans, particularly diplomatic staff in Wuhan, outraged the Chinese; Tedros Adhanom Ghebreyesus, the director-general of the W.H.O., said that the U.S. was overreacting. In part to placate the Chinese, the 747s that were sent to collect Americans were filled with eighteen tons of P.P.E., including masks, gowns, and gauze. It was a decision that many came to regret-especially when inferior substitutes were later sold back to the U.S., at colossal markups.

The morning after the meeting, Pottinger spoke to a doctor in China who was treating patients. People were getting infected and there was no way to know how and where it happened-a stage of contagion called community spread.

Pottinger asked, "Is this going to be as bad as sars?"

"Don't think 2003-it's more like 1918," the doctor said. That flu lasted two years, and killed between forty and a hundred million people.

On January 28th, the national-security adviser, Robert O'Brien, brought Pottinger into the Oval Office, where the President was getting his daily intelligence briefing. According to contemporaneous notes from someone present at this meeting, the briefer mentioned the virus, but didn't present it as the top threat. O'Brien warned the President, "This will be the biggest national-security threat you will face." Trump asked if the outbreak posed as big a danger as sars, and the briefer responded that it wasn't clear yet.

Pottinger leaped to his feet and recounted what he'd heard from his sources-most shockingly, that more than half the disease's spread was attributed to asymptomatic carriers. Yet, every day, thousands of people were flying from China to the U.S.

"Should we shut down travel?" Trump asked.

"Yes," Pottinger advised.

Pottinger left the Oval Office and walked to the Situation Room, where a newly formed Coronavirus Task Force was meeting. People were annoyed with him. "It would be unusual for an asymptomatic person to drive the epidemic in a respiratory disorder," Fauci said. That certainly had been true of sars. He still wanted U.S. scientists to report from China, in order to get more data. Redfield, of the C.D.C., considered it too early for disruptive actions. He said that there were only a handful of cases outside China, and that in the U.S. the pathogen wasn't moving that fast. The public-health contingent was united. "Let the data guide us," they advised.

Pottinger pointed out that the Chinese continued to block such efforts: "We're not getting data that's dependable!"

The economic advisers, meanwhile, were frantic-a travel ban would kill the airline industry and shut down the global supply chain. Larry Kudlow, the President's chief economic adviser, had been questioning the seriousness of the situation. He couldn't square the apocalyptic forecasts with the stock market. "Is all the money dumb?" he wondered. "Everyone's asleep at the switch? I just have a hard time believing that." (Kudlow doesn't recall making this statement.)

Pottinger, sensing that he'd need backup, had brought along Peter Navarro, an abrasive economic adviser who had been part of the trade negotiations with China. Many White House officials considered Navarro to be a crackpot, but he was known to be one of the President's favorites because he advocated tariff wars and other nationalist measures. Navarro warned the group, "We have got to seal the borders now. This is a black-swan event, and you're rolling the dice with your gradualist approach."

Within minutes, Navarro was at odds with everyone in the room. He pointed out that the new virus was spreading faster than the seasonal flu or sars. The possible economic costs and loss of life were staggering. Azar argued that a travel ban would be an overreaction. No progress was made in that meeting, but Navarro was so strident that Mulvaney barred him from future sessions.

Then data surfaced that shifted the argument. In mid-January, a Chicago woman returned from a trip to China. Within a week, she was hospitalized with COVID. On January 30th, her husband, who hadn't been to China, tested positive. Fauci, Redfield, and others in the public-health contingent changed their minds: human-to-human transmission was clearly happening in America.

Trump was told the news. The timing couldn't have been worse for him. The bitter trade war he had initiated with China had reached a tentative pause. Since then, he had been praising Xi Jinping's handling of the contagion, despite evidence of a coverup. A travel ban would reopen wounds. Nevertheless, Trump agreed to announce one the next day.

It was a bold gesture, but incomplete. The Administration blocked non-Americans coming from China, but U.S. citizens, residents, and their family members were free to enter. A two-week quarantine was imposed on travellers coming from the Wuhan region, but, unlike Taiwan, Australia, Hong Kong, and New Zealand, which rigidly enforced quarantines, the U.S. did little to enforce its rules, and the leaks soon became apparent.

5. Flattening the Curve

In 1989, Dr. Howard Markel was in graduate school at Johns Hopkins, specializing in both pediatrics and the history of medicine. He had just lost his wife to cancer, a month after their first anniversary. Markel began volunteering at a local AIDS clinic. He found that helping men his own age who were facing their mortality, or their partner's, was immensely consoling-"the most spiritually uplifting work I did in my entire clinical career."

Markel's patients often asked him, "Doc, do you think I'll be quarantined because I have H.I.V.?" He'd reply that it wasn't appropriate for the disease. But, realizing that these men feared being shut away, like victims of leprosy, he began studying "the uses and misuses of quarantine." His first book was about two epidemics in New York City in 1892, one of typhus and one of cholera, in which Jewish immigrants were blamed for the outbreak and many were sent to quarantine islands.

In the early two-thousands, Markel studied "escape" communities that had essentially closed their doors during the 1918 flu pandemic-among them Gunnison, Colorado, and a school for the blind in Pittsburgh. All had survived the contagion virtually unscathed. In 2006, Markel continued his work on the 1918 flu with Martin Cetron, who now directs the Division of Global Migration and Quarantine, at the C.D.C. For an initiative undertaken by the George W. Bush Administration, Cetron and Markel were asked to help identify the best way to manage the early waves of a pandemic that had no vaccine or treatments. They considered school closures, public-gathering bans, business shutdowns-traditional tools of public health. Markel assembled a dozen researchers-"the Manhattan Project for historians," he jokes-who combed through more than a hundred archives.

In 1918, Americans faced the same confounding choices as today. Twenty-five cities closed their schools once; fourteen did so twice, and Kansas City three times. More than half the cities were "double-humped"-suffering two waves of the flu. "They raised the bar too early because the natives got restless," Markel, who is now a professor at the University of Michigan, told me. "They each acted as their own control group. When the measures were on, the cases went down. When the measures were off, the cases went up." After Philadelphia permitted a Liberty Loans parade, there was a huge uptick in cases. St. Louis, by contrast, cancelled all parades, and local officials broadcast a unified message. The city's health commissioner published an op-ed alerting citizens to the threat, immediately closing entertainment venues and banning public gatherings. St. Louis's death rate was half of Philadelphia's. By quickly imposing several nonpharmaceutical interventions, a city could dramatically lower the peak of infection-on a graph, it would look more like a rainbow than like a skyscraper. Markel compared each intervention to a slice of Swiss cheese; one layer by itself was too riddled with holes to be effective, but multiple layers made a profound difference. "Early, layered, and long" was the formula.

JAMA published the study in 2007. The authors declared, "We found no example of a city that had a second peak of influenza while the first set of nonpharmaceutical interventions were still in effect." In the century since 1918, technology has transformed so much, but the tools for curbing a novel pandemic haven't changed. Masks, social distancing, and frequent hand washing remain the only reliable ways to limit contagion until treatments or vaccines emerge.

One night, Markel and Cetron were in Atlanta, talking over their study, and they ordered Thai food. When their dinner arrived, Markel opened his Styrofoam container: instead of a fluffy mound of noodles, he gazed on a level, gelatinous mass. "Look," Markel said. "They've flattened the curve, just like we're trying to do." A slogan was born.

6. The Lost February

By January 20th, ten days after the Chinese posted the genetic sequence of SARS-CoV-2, the C.D.C. had created a diagnostic test for it. Secretary Azar reportedly boasted to Trump that it was "the fastest we've ever created a test" and promised to have more than a million tests ready within weeks. (Azar denies this.) But the F.D.A. couldn't authorize it until February 4th. And then everything really went to pieces.

The testing fiasco marked the second failed opportunity America had to control the contagion. The C.D.C. decided to manufacture test kits and distribute them to public-health labs, under the Food and Drug Administration's Emergency Use Authorization provision. According to Redfield, the C.D.C. published the blueprint for its test, and encouraged the labs to ask the F.D.A. for permission to create their own tests. But Scott Becker, the C.E.O. of the Association of Public Health Laboratories, told me that the labs weren't made aware of any change in protocol. They kept waiting for the C.D.C. to supply tests, as it had done previously.

At a Coronavirus Task Force meeting, Redfield announced that the C.D.C. would send a limited number of test kits to five "sentinel cities." Pottinger was stunned: why not send them everywhere? He learned that the C.D.C. makes tests, but not at scale. For that, you have to go to a company like Roche or Abbott-molecular-testing powerhouses that have the experience and the capacity to manufacture millions of tests a month. The C.D.C., Pottinger realized, was "like a microbrewery-they're not Anheuser-Busch."

At the time, Azar, a former top executive at the pharmaceutical firm Eli Lilly, led the Coronavirus Task Force. He agreed with Pottinger that test kits needed to be broadly distributed, yet nothing changed. Everyone on the task force understood the magnitude of the crisis; they attended meetings every weekday, with conference calls on weekends. North Korea and Iran didn't receive such concentrated attention. Yet the Administration was simply not accomplishing tasks crucial to limiting the pandemic. There was a telling disparity between what Azar said in private, or in the task-force meetings, and what he told the President. He was hammering Redfield and the C.D.C. on testing delays while assuring Trump that the crisis was under control.

A bottleneck of constraints imposed by the C.D.C. meant that testing was initially limited to symptomatic patients who had come from China or had been in close contact with an infected person. Even health-care workers who'd developed COVID-like symptoms while treating patients had trouble getting tests, because the C.D.C.'s capacity was so limited.

Pottinger kept in frequent touch with his brother, Paul, the infectious-disease doctor in Seattle.

"You getting enough test kits?" Matt asked him.

"We use none of the C.D.C. kits," Paul responded. "They have been way too slow in coming." They also hadn't been approved for screening asymptomatic patients. Seattle doctors had instead devised a "homemade" diagnostic platform, but their testing capacity was "way less than demand." Paul was frantically setting up triage procedures-guessing which cases were COVID, and trying to sequester those patients, in order to prevent them from infecting everyone at the hospital.

But there was an even bigger problem.

Microbiologists are acutely aware of the danger of contamination. Viral DNA can linger for hours or days on surfaces, adulterating testing materials. C.D.C. scientists wipe down their instruments every day. Chin-Yih Ou, a Taiwanese microbiologist who retired from the C.D.C. in 2014, told me that while he was creating a test for H.I.V. in infants he refused to let janitors into his lab, mopping the floor himself. In some labs, the last person to leave at night turns on ultraviolet lamps, to kill DNA that might be on the floor or a lab bench. A new pathogen is like an improvised bomb: one wrong decision can be fatal.

The development of the C.D.C.'s test kits was overseen by Stephen Lindstrom, a microbiologist from Saskatchewan, who was known for his ability to function under pressure. C.D.C. scientists began working sixteen-hour days. The C.D.C.'s Biotechnology Core Facility is in charge of producing the components used to detect such pathogens as flu, H.I.V., and sars. To save time, Lindstrom asked the Core Facility to produce both the components and a template of a coronavirus fragment, which would be used to generate the positive control for the C.D.C. test. But, just as the kits were being boxed up to be mailed, a last-minute quality-control procedure found a problem that could cause the tests to fail thirty-three per cent of the time. A decision was made-perhaps by Lindstrom, perhaps by his superiors-to send the kits anyway. According to ProPublica, Lindstrom told colleagues, "This is either going to make me or break me." (The C.D.C. did not make Lindstrom available for comment.)

Almost immediately, public-health labs realized that something was wrong with the kits. The labs are required to do a negative control on the test-for instance, using sterile water-and the tests kept showing false positives.

The C.D.C. test kit had three sets of primers and probes, which are tiny bits of nucleic acid that find a segment of RNA in the virus and replicate it until it gets to a detectable level. Two were aimed at SARS-CoV-2 and a third would detect any coronavirus, in case the virus mutated. The third component failed. Public-health labs figured this out quickly. On their behalf, Scott Becker communicated with the C.D.C. on February 9th, seeking permission to use the test without the third component. "I got radio silence," he told me. Later, he learned that an internal C.D.C. review showed that it hadn't passed the quality-control check before the test kit was sent out. "That was a gut punch," Becker said.

In 2009, Matt Pottinger was in Kabul, in his final deployment as a marine. While walking through a tunnel connected to the U.S. Embassy, he passed a young woman, and then suddenly wheeled around. Her name was Yen Duong. She was working with the Afghan government on improving its H.I.V. testing. "It was, like, seven o'clock at night," Yen remembers. "He came up to me and asked if I knew where so-and-so's office was. I was thinking that I'm pretty sure so-and-so's office is closed right now. It was just a ploy to talk." Matt and Yen married in 2014.

They have lived very different American lives. He grew up in Massachusetts. His parents divorced when he was young, and he lived mostly with his mother and stepfather. His father, J. Stanley Pottinger, was a lawyer in the Nixon Administration. Matt had an ear for languages, and majored in Mandarin and Japanese at the University of Massachusetts, Amherst, and that is how he found his way to China as a reporter.

Yen was six months old when her family left Vietnam, in 1979, in a boat that her father had secretly built in his sugar factory. At sea, the Duong family-sixty-eight in all-were shot at. A storm nearly capsized the vessel. Pirates robbed them. Finally, the family reached a refugee camp in Indonesia. Six months later, the Duongs were sponsored by four American churches on Long Island, and ended up living in the Hamptons. Yen's mother cleaned houses and took in sewing, and then found a job in a bakery. Her father painted houses and worked in construction. Eventually, they saved enough money to send Yen to boarding school.

Yen, drawn to science, fell in love with studying viruses. She got a doctorate in pharmacology at the University of California, Davis. In 2007, she became a virologist at the C.D.C., where she developed the global-standard test to measure H.I.V. incidence. None of this would have happened if the family had stayed in Vietnam, if the boat had sunk in the storm, if the pirates had murdered them, or if they hadn't been taken in by Americans who wanted to help them achieve the opportunities that freedom allowed.

Yen Pottinger, who is now a senior laboratory adviser at Columbia University, told her husband what she thought had gone awry with the test kits. Once the Chinese had posted online the genetic sequence for the virus, Yen explained to Matt, primers would have been easy to design. "It's a pretty standard task," she told him. But SARS-CoV-2 is an RNA virus, which is "sticky"-tending to cling to any surface. Contamination was the only plausible explanation for the test kit's failure. Perhaps a trace amount of the virus template had found its way into the primers and probes. "Contamination has felled many a great scientist," she said, which is why a pristine lab environment is essential.

On February 10th, the F.D.A. learned that ten labs working with C.D.C. test kits were reporting failures. The C.D.C. assured the F.D.A. that it could quickly fix the problem with the third component. The Trump Administration-in particular, Azar-insisted on continuing with the C.D.C. test kits. Although F.D.A. rules generally require that any procedure granted an Emergency Use Authorization be used exactly as designed, the agency could have allowed public-health labs to use the C.D.C. test kits without the third component, as they were pleading for. The test kits largely worked, even without it, but the F.D.A. says that it didn't have the data from the C.D.C. to justify that simple solution. The C.D.C. wanted to stick with its original design. Moreover, university scientists, hospital researchers, and commercial labs were eager to develop their own tests, but they were hampered by the bureaucratic challenge of obtaining an Emergency Use Authorization.

On February 12th, the C.D.C. estimated that it would take a week to remanufacture the third component. Six days later, Redfield informed Azar that doing so might take until mid-March. By February 21st, only seven labs in the country could verify that the test worked. Redfield admitted that he had no idea when new test kits might be ready.

On Saturday, February 22nd, the F.D.A. sent Dr. Timothy Stenzel, the director of the Office of In Vitro Diagnostics and Radiological Health, to the C.D.C. to investigate what had gone wrong with the test. When he arrived, there was no one there to receive him, and he was turned away. The next day, he was allowed in the building but forbidden to enter any labs. It was still the weekend. Stenzel made some calls. After he was finally permitted to visit the labs where the test kits were manufactured, he spotted a problem: in one lab, researchers were analyzing patient samples in the same room where testing ingredients were assembled. The tests are so sensitive that even a person walking into the room without changing her lab coat might carry viral material on her clothing that would confound the test. According to the Wall Street Journal, an F.D.A. official described the C.D.C. lab as "filthy." It was the lowest point in the history of a proud institution.

According to an internal F.D.A. account, C.D.C. staff "indicated to Dr. Stenzel that Dr. Stephen Lindstrom-who oversaw a different lab in the manufacturing process-directed them to allow positive and negative control materials to occupy the same physical space of the lab, even though this is a violation of their written protocols." The clear remedy was to hand over part of the test's manufacture to two outside contractors. Within a week, tens of thousands of tests were available. But America never made up for the lost February.

I recently asked Redfield, a round-faced man with a white Amish-style beard, how the contamination had occurred and if anyone had been held accountable for the corrupted kits. He replied, vaguely, "One of the newer individuals hadn't followed protocol." It also could have been a design flaw that mangled results. Both mistakes might have happened, he conceded. "I wasn't happy when we did our own internal review," he said, and acknowledged that the C.D.C. shouldn't have mass-produced the test kits: "We're not a manufacturing facility." He insisted, "At no moment in time was a COVID test not available to public-health labs. You just had to send it to C.D.C." But the C.D.C. couldn't process tens of thousands of tests.

The C.D.C. wasn't entirely responsible for the delay. The F.D.A. might have authorized a version of the test kit without the problematic third component, and loosened the reins on tests developed by other labs. Not until February 26th did the F.D.A. permit public-health labs to use the C.D.C. test kit without the third component. Only on February 29th could other labs proceed with their own tests.

Secretary Azar held the F.D.A. responsible for the absence of alternative tests. A senior Administration official told me, "Instead of being more flexible, the F.D.A. became more regulatory. The F.D.A. effectively outlawed every other COVID test in America." Stephen Hahn, the F.D.A.'s commissioner, says, "That's just not correct," and notes that more than three hundred tests are currently authorized. But there was only one other test by the end of February. Whether the delay was caused mainly by the C.D.C. or the F.D.A., Azar oversaw both agencies.

Without the test kits, contact tracing was stymied; without contact tracing, there was no obstacle in the contagion's path. America never once had enough reliable tests distributed across the nation, with results available within two days. By contrast, South Korea, thanks to universal public insurance and lessons learned from a 2015 outbreak of MERS, provided free, rapid testing and invested heavily in contact tracing, which was instrumental in shutting down chains of infection. The country has recorded some fifty thousand cases of COVID. The U.S. now reports more than four times that number per day.

7. "This is Coming to You"

"One day, it's like a miracle, it will disappear," the President told the American people on February 27th. At the time, there were only fifteen known cases of COVID in the U.S., and nearly all involved travellers or people close to them.

As Trump made his promise, a hundred and seventy-five employees of the biotech firm Biogen were heading home from a conference held at a Marriott in Boston. The attendees, many of whom had travelled from other states or foreign countries, had gathered for two days in banquet rooms, shared crowded elevators, and worked out in the gym. Soon, many fell ill.

Researchers affiliated with Massachusetts General Hospital and the Broad Institute of M.I.T. and Harvard believe that sars-CoV-2 was probably introduced to the conference by a single individual. About a hundred people associated with the conference eventually tested positive. The viral strain that they contracted had unusual mutations, allowing researchers to track its spread. In a recent study published in Science, the researchers reported that the Biogen outbreak may have been responsible for three hundred thousand cases in the U.S. alone.

During the study's initial stages, in February and March, the researchers were discomfited by the implications of their data. "The rapidity and degree of spread suggested it wasn't a series of one-to-one-to-one transmissions," Dr. Jacob Lemieux, a lead author, told me. Rather, it was "one-to- many transmission events." That raised the question of airborne transmission. "At the time, the idea was heretical," Lemieux said. "We were afraid to consider it, because it implied a whole different approach to infection control"-one in which masks played a central role, especially indoors. But the W.H.O. had repeatedly proclaimed that large respiratory droplets-as from a sneeze or a cough-drove the spread. This wasn't based on data about the new virus, Lemieux said: "It was received wisdom based on how previous respiratory viruses had behaved. The global public-health infrastructure has egg on its face. There's a component of human nature that, until you get burned, you don't know how hot the fire is."

Vaccines were in development around the world, but Pottinger was hearing that they wouldn't be available for eighteen months at the earliest. Even that would be a record. A vaccine must be subjected to three trials of increasing size, to determine safety, effectiveness, and proper dosage. Pharmaceutical companies then invest in production, ramping up from thousands of doses to millions.

Pottinger and Navarro, the China-trade adviser, advocated for a way to radically shorten the time frame: companies would be paid to manufacture vaccine candidates that were still in trials and might never be used. If any ended up being successful, Americans could be inoculated in less than a year.

At the end of February, Navarro wrote a memo proposing a three-billion-dollar supplemental budget appropriation to cover the cost of an accelerated vaccine process, P.P.E. for frontline workers, and effective therapeutics. Azar recognized the need for a major budget supplement, but after he met with Mulvaney, Trump's acting chief of staff, he declared that eight hundred million dollars was enough for now.

Pottinger was apoplectic. The Administration was in denial. There were now more cases outside China than within. Italy and Iran were exploding. And yet Mulvaney and the Office of Management and Budget insisted on viewing the contagion as a kind of nasty influenza that could only be endured. At home, Pottinger fumed to Yen that eight hundred million dollars was half the sum needed just to support vaccine development through Phase III trials.

"Call Debi," Yen suggested.

Debi was Deborah Birx, the U.S. global AIDS coördinator. In the mid-eighties, as an Army doctor, Birx studied immunology and AIDS at Fauci's clinic. They walked the hallways together, watching their patients die. Birx then moved to Walter Reed Army Medical Center, where she worked on an H.I.V./ AIDS vaccine. At Walter Reed, Birx worked with Redfield. From 2005 to 2014, she led the C.D.C.'s Division of Global H.I.V./ AIDS (making her Yen Pottinger's boss). Birx was known to be effective and data-driven, but also autocratic. Yen described her as "super dedicated," adding, "She has stamina and she's demanding, and that pisses people off." That's exactly the person Pottinger was looking for.

Birx was in Johannesburg when Pottinger called and asked her to join the Coronavirus Task Force, as its coördinator. She was ambivalent. When she had started her job at the C.D.C., some African countries had H.I.V.-infection rates as high as forty per cent. Through the steady application of public-health measures and the committed collaboration of African governments, the virus's spread had been vastly reduced. What if she turned her attention and the numbers skyrocketed? Then again, COVID would likely run rampant through the same immune-compromised population she was devoted to protecting. She went to Washington.

As March approached, Secretary Azar had to defend his supplemental budget request before a Senate appropriations subcommittee. Earlier, the senators had been briefed that a grave coronavirus outbreak in the U.S. was likely. Patty Murray, the Democrat from Washington State, was on the committee. "You've had a month now to prepare," she said. "Is our country ready?"

"Our country is preparing every day," Azar responded.

"You sent over a supplemental that wasn't clear to me at all," Murray said. She listed actions that Azar had said were necessary. None were listed in the budget on the table. "Did you stockpile any of these critical supplies that we are told we need-masks, protective suits, ventilators, anything?"

"We do have in the Strategic National Stockpile ventilators, we have masks, we have-"

"Enough?"

"Of course not, or we wouldn't be asking for a supplemental," Azar said.

"I didn't see any numbers in your request," Murray said.

Azar said that the details were being worked out. Murray persisted: "I'm very concerned about this Administration's attitude. We're not stockpiling those things right now that we know we might possibly need." She concluded, "We are way behind the eight ball."

On February 27th, the C.D.C. began allowing tests for people who hadn't been to China or in close contact with someone known to be infected. The next day, doctors in Washington State tested two people from a nursing home, in the Seattle suburb of Kirkland, that was overrun with pneumonia. Both tested positive. America's blindfold was finally coming off.

Trump, however, continued offering false assurances. "We're testing everybody that we need to test," he proclaimed. "We're finding very little problem."

On February 29th, Washington's governor, Jay Inslee, reported that someone in his state had died of COVID. It was the first official death from the disease in the U.S., although it was later established that two Californians had died from it weeks earlier. Many others may have as well.

Inslee declared a state of emergency. One of Senator Murray's relatives had been in the Kirkland facility a few years earlier. "I knew how many people came in and out of it, visitors and staff," she told me. She said to herself, "Wow, this contagious virus, it can't have just stayed in a nursing home." Soon, friends of Murray's got sick. She urged them to get tested, but they said, "I've asked my doctor, I've asked the public-health people in the county, I've called the state health people- nobody has these tests." Her state was in turmoil. In Senate hearings and briefings, though, she sensed a lack of coördination and urgency.

The Democratic caucus went on a retreat in Baltimore. Murray received a text from her daughter, whose children attended school near the nursing home. "They closed the schools," her daughter said. She added, "Kids are sick, teachers are sick. This is really frightening."

Murray told her colleagues, "My daughter's school closed. This is coming to you."

8. "Just Stay Calm"

While this was happening, I was in Houston, in rehearsals for a play I'd written about the 1978 Camp David summit. Oskar Eustis, of New York's Public Theatre, was directing. I have a memory of the preview performances which later came back to me, charged with significance. The actors were performing in the round, and slanted lighting illuminated their faces against the shadowy figures of audience members across the way. When one actor expostulated, bursts of saliva flew from his mouth. Some droplets arced and tumbled, but evanescent particles lingered, forming a dim cloud. At the time, I found this dramatic, adding to the forcefulness of the character. Later, I thought, This is what a superspreader looks like.

I have no idea how Eustis got sick. But when he abruptly flew back to New York and missed opening night, on February 20th, I knew that something was wrong. Texas was thought to be outside the danger zone that month, but retrospective modelling suggested that the virus likely had been infecting at least ten people a day since the middle of the month. The same was true for New York, California, Washington, Illinois, and Florida. By the end of February, there was probable local transmission in thirty-eight states.

The virus continued hitchhiking with passengers coming from other hot spots. Between December and March, there were thirty-two hundred direct flights from China to the U.S., many of them landing in New York. More consequentially, sixty per cent of flights from Italy to the U.S. landed in the New York area. Some of these passengers carried a more contagious mutation of SARS-CoV-2. On March 10th, Italy entered lockdown, and the next day the W.H.O. finally declared a pandemic. By that time, there were more than a hundred thousand cases in a hundred and fourteen countries.

"Just stay calm," Trump remarked. "It will go away."

Weeks had passed from the point when containment was possible. On February 25th, Nancy Messonnier, a senior director at the C.D.C., warned, "We will see community spread in this country. It's not so much a question of if this will happen anymore but rather more a question of exactly when." Without vaccines or treatments, communities needed to rely on such measures as school closures, social distancing, teleworking, and delaying elective surgeries. People should expect missed work and loss of income. Parents needed a child-care plan. "I understand this whole situation may seem overwhelming," she said. "But these are things that people need to start thinking about now."

A steep drop in the stock market followed Messonnier's blunt assessment. The President, who had encouraged Americans to judge his performance by market indicators, was enraged. The next time Messonnier spoke in public, she was quick to praise Trump, saying that the country had acted "incredibly quickly."

Amy Klobuchar dropped out of the Presidential race on March 2nd and flew to Dallas to endorse Joe Biden. The stage was filled with supporters. As the crowd cried, "Let's go, Joe!," she embraced Biden. But as she did so she said to herself, "Joe Biden shouldn't get COVID." She warned his advisers to begin taking greater precautions.

On the first Friday in March, she attended a Biden rally in Detroit. That night, employees in the Wayne County sheriff's office gathered for an annual party at Bert's, a soul-food and jazz venue. Most of the officers were Black; some had retired. At the time, there were no known cases of COVID in Michigan. Three weeks later, seven of the attendees had COVID, and dozens more in the sheriff's office were ill. By the end of March, three law-enforcement officials had died.

At the rally, Klobuchar noticed that people had become more careful. "I put on gloves," she said. "We didn't know about masks at the time."

Democratic rallies soon came to a halt.

Bellevue Hospital, on First Avenue in Manhattan, is "the grande dame of America's public hospitals," the historian David Oshinsky told me. Since it opened, as an almshouse, in the eighteenth century, nobody has been turned away, whether the patient can afford treatment or not. Bellevue has endured epidemics of cholera and yellow fever, diseases that sent untold thousands to their graves in the potters' fields that are now Washington Square and Bryant Park. In the nineteen-eighties, Bellevue treated more AIDS patients than any other American hospital.

In 1983, Nate Link began an internship at Bellevue, and almost immediately pricked himself, by accident, with a contaminated needle. He thought it was a death sentence, but he escaped infection. The work was both harrowing and thrilling. "I felt like I was in the epicenter of the universe," he told me. He is now Bellevue's chief medical officer.

During the 2014 Ebola outbreak in Africa, Link and his colleagues knew that, if Ebola spread to New York, the patients would end up at Bellevue. The hospital built an Ebola unit and a dedicated laboratory, training hundreds of staff and storing additional personal protective equipment. The instant they finished their preparations, a patient appeared. He survived. Bellevue then sent emissaries across the country to help hospitals prepare special facilities, develop protocols, and train their staffs for novel infections. Had it not been for the foresight of Link and his colleagues, America would be far less prepared for the COVID onslaught.

Once the coronavirus emerged, Bellevue's special-pathogens team began preparing a protocol. "We thought we'd get one or two cases, just like Ebola," Link recalled. But by early March the hospital was admitting a stream of patients with fever and unexplained respiratory problems. They were labelled P.U.I.: patients under investigation. Tests weren't available. "We had this sense that there was this invisible force out there," Link recalled. He believes that the city already had tens of thousands of cases, but, "without testing, there was just no way to know-it was a sneak attack." When the city reported its first positive case, on March 1st, only thirty-two tests had been conducted. Asymptomatic carriers and people with mild symptoms slipped through the nets. The testing guidelines almost seemed designed to undercount the spread.

On March 10th, Eustis, the theatre director, walked half a mile from his home, in Brooklyn, to an emergency clinic on Amity Street. His muscles ached. Twice he had to stop and catch his breath, sitting for a while on a fire hydrant. He was too exhausted to be afraid.

His vital signs showed dangerously low potassium levels, and his heart kept skipping beats. An ambulance ferried him to a Brooklyn hospital. An antibody test eventually showed that he had the coronavirus. Despite his condition, there was no room for Eustis. He was placed on a gurney with an I.V. potassium drip and left in a corridor overnight. He soiled himself, but nobody came to change him. He was given no food for thirty-six hours. The COVID surge had begun.

On March 11th, Dr. Barron Lerner was at his office in Bellevue. The hospital had begun implementing triage at the front desk for patients with respiratory problems. That morning, at a staff conference, doctors were told, "If you're talking to a patient you think might have COVID, you excuse yourself from the room. You say, 'O.K., I need to leave now. A nurse is going to come in and give you a mask.' "

Lerner met with a regular patient, an Asian immigrant who didn't speak English. Bellevue maintains a staff of a hundred translators, and one of them connected to a dual telephone system. "About ten days ago, she had a fever," the translator told Lerner. "Then she was coughing, and she's been really short of breath since then."

"I thought, I can't believe this just happened," Lerner recalled. "I was probably the first staff member to be exposed." He was sent home and told to monitor his temperature. He and his wife began sleeping in separate bedrooms. Five days later, the fever struck.

Meanwhile, Eustis was released after four days, still shaky. Upon returning home, he immediately went to bed. He turned out to have "long haul" COVID. "It comes in waves," he told me. "I'm struggling with extreme fatigue and continued muscle pain." Working wasn't an option in any case: every theatre in New York had gone dark.

9. The Doom Loop

Vice-President Mike Pence was now in charge of the task force, but Azar remained a member. Meetings were often full of acrimony. Olivia Troye, a former homeland-security adviser to Pence, told me, "I can't even begin to describe all these insane factions in the White House. I often thought, If these people could focus more on doing what's right for the country rather than trying to take each other down, we'd be in a much different place." Fauci, she recalled, was considered too "outspoken and blunt" with the media, which led such Trump Administration officials as Jared Kushner and Peter Navarro to complain that he was "out of control." Troye summed up the Administration's prevailing view of Birx crisply: "They hate her." At task-force briefings, Birx typically presented a slide deck, and Troye once caught White House staff members rolling their eyes. Marc Short, Pence's chief of staff, remarked, "How long is she going to instill fear in America?"

On March 11th, members of the Coronavirus Task Force crowded into the Oval Office, where they were joined by Kushner, Ivanka Trump, Secretary of State Mike Pompeo, and a dozen others. According to the official who kept contemporaneous notes, Birx and Fauci pushed for shutting down European travel. "Every seed case you prevent is a cluster of cases you prevent," Birx explained. Redfield and Azar had swung around to the idea that cutting off European travel might buy time, but Steven Mnuchin, the Treasury Secretary, heatedly insisted that doing so would cripple the U.S. economy and trigger a global depression. The markets would crater. "Forget about ballgames!" he said, pointedly adding, "Forget about campaign rallies!"

After an hour, the President had another obligation, and he asked Pence to keep the discussion going. The group adjourned to the Cabinet Room. Mnuchin argued that there must be ways to curb viral spread without banning travel. The elderly were at high risk-why not sequester the most vulnerable?

"It's twenty-five per cent of the population!" Robert O'Brien, the national-security adviser, observed. "You're not going to be able to stick them all in hotels."

Fauci had recently warned the group that the outbreak was going to get far worse, saying, "There's no place in America where it's business as usual. By the time you mitigate today, we're three weeks late." Colleges were sending students home, further contributing to the spread.

Another member of the task force noted that, in a bad flu season, sixty thousand Americans might die. What was the difference?

"This is twenty times that," Pottinger argued. "This is two per cent dead, where the flu is .1 per cent."

"If we just let this thing ride, there could be two million dead," Birx said. "If we take action, we can keep the death toll at a hundred and fifty to two hundred and fifty thousand." It was surreal hearing such numbers laid out so nakedly.

Mnuchin demanded data. He felt that the U.S. just had to live with the virus. It wasn't worth sacrificing the airlines, the cruise ships, the hotels. "This is going to bankrupt everyone," he said. "Boeing won't sell a single jet."

"You keep asking me for my data," Birx said, sharply. "What data do you have? Does it take into account hundreds of thousands of dead Americans?" In the end, her side won.

That evening, in an unusually formal speech from the White House, the President announced that he was suspending travel from Europe for the next month. "We are marshalling the full power of the federal government and the private sector to protect the American people," he promised. He had also signed a bill providing $8.3 billion to help the C.D.C. and other government agencies fight the virus. He highlighted the danger the elderly faced and urged nursing homes to suspend unnecessary visits. He advised social distancing and not shaking hands-practices that he hadn't yet adopted himself.

Trump's speech included his usual distortions. He claimed that insurance companies had agreed to "waive all co-payments for coronavirus treatments," though they'd agreed only to waive fees for tests. But, for perhaps the first time, he was presenting himself as a unifier-as a take-charge Consoler-in-Chief. If he had continued playing that role, America would have had a different experience with the contagion.

Glenn Hubbard is a conservative economist who served as the chairman of President George W. Bush 's Council of Economic Advisers. Soon after the pandemic began, he became involved in discussions in Washington about how to handle the financial impact. Hubbard told me, "I and other economists had been worried about a doom loop"-a cycle of negative economic feedback. When the pandemic hit, the world suffered a supply shock: trade was disrupted, factories and stores closed. If workers didn't start earning again soon, the supply shock could turn into a demand shock, and that would further weaken supply, which would increase unemployment and further diminish demand. A doom loop.

In mid-March, Hubbard spoke with the Republican senators Marco Rubio, of Florida; Susan Collins, of Maine; and Roy Blunt, of Missouri. The N.B.A. had just suspended its season. Economic forecasts were terrifying. The senators were getting panicked reports from business owners back home.

Only Collins had been in office during the 2008 financial crisis, when Congress had passed a seven-hundred-billion-dollar bill to bail out troubled assets-the outer limit of what these conservatives had ever imagined spending. Now they were talking about trillions. Enlarging the deficit and expanding the federal government's reach were anathema to the Republican caucus; to some members, it smacked of socialism. Rubio indicated that he would never support such spending in normal times.

"You need to do something," Hubbard warned. "We've been having a debate for decades now about the size of government. The more interesting debate is the scope of government." He spoke of the first Republican President, Abraham Lincoln: "He decided to do the Homestead Act, land-grant colleges, and to lay the foundation for the transcontinental railroad. If Lincoln, in the middle of the Civil War, had the idea of using government as a battering ram for opportunity, why can't we do that today? Instead of focussing on how big government is, think about what you want it to do."

Rubio, who is the chairman of the Small Business Committee, thought about the restaurants, the travel companies, the hair salons-all of them service businesses "with the least ability to survive." The action that Congress was contemplating was heresy from a fiscal-conservative perspective, but the alternative-failing businesses, deepening poverty, boundless unemployment-was worse.

Action was necessary, the senators agreed. As it turned out, there was a surprising logistical problem: the Treasury Department had previously bailed out corporations and given checks to individuals, but it wasn't clear how to give assistance to small businesses. Collins was working on a loan-forgiveness program, and Rubio was trying to figure out how to create a new loan program through the Small Business Administration's existing network of lenders. "That's when the Paycheck Protection Program arose as an idea," Rubio told me. Loans taken out to keep people on the payroll could be forgiven, offering employees assurance that their jobs would still be there when the clouds cleared.

The Democrats were fully on board, and Congress soon approved three hundred and fifty billion dollars' worth of forgivable loans to small businesses. The over-all relief package was even larger. Chris Coons, a Democratic senator from Delaware, told me, "We went from 'We don't know what to do' to nine hundred pages and $2.2 trillion in about ten days. I've never seen anything like it."

Hubbard said, "Nothing like a big shock to help people become more bipartisan."

10. Reinforcements Arrive

On March 12th, Amy Klobuchar was back in Minnesota. Her husband, John Bessler, who teaches law at the University of Baltimore, remained in Washington. He awoke that morning feeling ill. "He was going to take my place at my constituent breakfast in D.C.," Klobuchar recalled. "It was when he would have been most contagious, as we now know. There would have been around fifty people, in a small room. And then he was going to a faculty meeting-about sixty people, in a small room. Then he was going to get on an airplane and fly to Minnesota, with a bunch of people packed in. I was having some minor surgery at Mayo, and he was going to come there! He really would have had quite a day of infecting people." They had no idea how he'd caught the virus. He was fifty-two and, until then, in excellent health.

Bessler stayed home, and steadily grew worse. For more than a week, Klobuchar kept calling, anxiously asking what his temperature was. Their only thermometer was in centigrade, so Klobuchar had to Google the conversion. Each time, it exceeded a hundred degrees. Hearing that he was short of breath, she urged him to see a doctor, worrying that "it was one of those cases where people are underestimating how sick they are, and then they die the next day." After Bessler coughed up blood, he went to the hospital to get tested. He had severe pneumonia. Doctors kept telling Klobuchar, "The oxygen is getting worse." She couldn't visit him, making the ordeal even more frightening.

Bessler spent five days in the hospital. He recuperated, and was back in the couple's D.C. apartment when his test finally came back positive.

Dr. Lerner's COVID case was mild. He returned to work at Bellevue after twelve days, on March 23rd. The city had become weirdly quiet: First Avenue resembled an abandoned set on a studio back lot. During his absence, a tent had been erected in the courtyard, for screening patients. Everyone now wore a mask.

Non- COVID patients in intensive care were shuttled to the postoperative surgical unit, which was available because all surgeries had been cancelled. This freed up fifty-six I.C.U. beds. Workers installed hepa filters in each room, creating negative pressure that prevented infected air from escaping. Offices were turned into more patient units; as soon as carpenters walked out of a converted room, a patient was wheeled in. Twenty-five more spaces for ventilator patients were added in the E.R. When all the beds filled, the I.C.U. cubicles were doubled up. Lerner, still recovering, tended to his patients through televisits, taking hour-long naps as Bellevue whirled around him.

In mid-March, Bellevue had its first COVID death: a middle-aged patient with no preëxisting conditions, who had been hospitalized for two weeks. Dr. Amit Uppal, the director of critical care, recalled, "Among our staff, we just looked at each other and said, 'O.K., here we go.' And from there it just exponentially ramped up."

Uppal, the son of Indian immigrants, grew up in Northern California and did his medical training at Ohio State. He was drawn to Bellevue because he wanted to serve the disadvantaged, but also because of the staff-"people that could work anywhere in the country and chose to defend this population." Uppal wanted to specialize in critical care so that he could handle the most extreme diseases. He was prepared to face the knotty ethical dilemmas at the limits of medical knowledge.

Part of the mission at Bellevue is helping patients die well. "It provides you a rare perspective on your own life," Uppal said. "Many laypeople who don't do medicine, and aren't exposed to end-of-life issues, may not have the opportunity to reflect on what's really important to them until the end of their own life." But COVID seemed cruelly designed to frustrate the rituals of death.

Just as Bellevue's first patients began dying, the hospital was flooded with new admissions. The I.C.U.'s typical mortality rate was far lower than COVID's, so even critical-care staff like Uppal were unsettled. Such doctors knew how to click into emergency mode. Before COVID, that might last thirty or forty minutes-say, with a heart-attack patient. After a bus wreck or a mass-casualty event, emergency mode could last a full day. With COVID, it lasted weeks on end.

During rounds, Uppal passed each of the I.C.U.'s fifty-six cubicles. The patients were all on ventilators, the distinctive gasping sound unvaried. I.V. lines extended outside each cubicle, so attendants didn't have to enter to administer medication. In the antiseptic gloom, the patients appeared identical. It was too easy to overlook their humanity. Uppal forced himself to examine their charts. He needed to recapture "what made them unique."

Overwhelmed hospitals in New York's outer boroughs transferred more than six hundred patients to Bellevue, knowing that nobody would be turned away. The E.R. became a hot zone where many people coming off the street required immediate intubation. Before COVID, the E.R. was always jammed, and nobody wore P.P.E. Nate Link told me, "When COVID hit, we made a promise to ourselves that we would not let the emergency rooms back up, and that we would keep them pristine." Staffers had to remain swathed in P.P.E., Link said, adding, "In the end, only fifteen per cent of the staff in the emergency department tested positive. That's lower than the hospital in general. It's even a bit less than the city average. The message is that P.P.E. works."

Some doctors needed new roles to play. Orthopedic surgeons began devoting their shifts to turning patients-"proning"-to facilitate breathing. Ophthalmologists helped in the I.C.U.; general surgeons treated non- COVID patients. "Everybody found a niche," Link said. "We were a completely different hospital for three months."

More than twenty thousand New Yorkers died from COVID in the spring. As the numbers mounted, Link noticed that employees were practicing "psychological distancing." He said, "Our staff had never seen so much death. Normally, a patient dying would be such a big deal, but, when you start having a dozen patients die in a day, you have to get numb to that, or you can't really cope." This emotional remove was shattered when the first staff member died: a popular nurse, Ernesto (Audie) De Leon, who'd worked at Bellevue for thirty-three years. Link said, "His death was followed by a COVID-style 'wake,' as many of his colleagues approached his I.C.U. cubicle in full P.P.E., put their hands on the glass door, and read Scripture, prayed, and wept. Because of the infection-control restrictions, staff consoled each other without touching or hugging. It was very unnatural."

When Bellevue's doctors were at their lowest ebb, reinforcements arrived: hospital workers from other states flooded into New York to help. According to Governor Andrew Cuomo, thirty thousand people responded to the city's call for aid. It was a rare glimpse of national unity. "Half the people in the I.C.U. had Southern accents," Link told me. "That's what saved us."

11. The No-Plan Plan

In mid-March, America began shutting down. The Coronavirus Task Force urged Americans to work from home. Education would be virtual. Travel and shopping would stop. Restaurants and bars would close. The goal was to break the transmission of the virus for fifteen days and "flatten the curve." Trump's impatience flared. At a press briefing, he said of the virus, "It's something we have tremendous control over." Fauci corrected him, observing that the worst was ahead, and noting, "It is how we respond to that challenge that's going to determine what the ultimate end point is."

Trump held a conference call with governors. "We're backing you a hundred per cent," he said. Then he said, "Also, though, respirators, ventilators, all the equipment-try getting it yourselves."

Most governors had assumed that, as in the event of a hurricane or a forest fire, the federal government would rush to help. Storehouses of emergency equipment would be opened. The governors, faced with perilous shortages of ventilators, N95 masks, and nasal swabs, expected Trump to invoke the Defense Production Act, forcing private industry to produce whatever was needed. Surely, there was a national plan.

Governor Inslee, of Washington, was flabbergasted when he realized that Trump didn't intend to mobilize the federal government. Inslee told him, "That would be equivalent to Franklin Delano Roosevelt, on December 8, 1941, saying, 'Good luck, Connecticut, you go build the battleships.' "

Trump responded, "We're just the backup."

"I don't want you to be the backup quarterback," Inslee said. "We need you to be Tom Brady here."

Larry Hogan, the Republican governor of Maryland, was incensed. "You're actively setting us up!" he told Trump.

Matt Pottinger's brother, Paul, kept sending desperate e-mails from Seattle. He had heard about medical workers fashioning P.P.E. out of materials from the Home Depot. Industrial tape and marine-grade vinyl were being turned into face shields. Garbage bags were serving as surgical gowns. A local health official wrote him, "We are currently drafting up guidelines for how to make homemade masks from cloth and I've asked other innovators in the community to see if they can figure out if we can do ANYTHING that would be better than nothing." Matt wrote to Paul, "Help is on the way, but it probably won't be in time-so start tearing up bedsheets and turning them into lab coats, raid the Salvation Army for garments, wrap bras around your faces in place of facemasks if you have to."

The Strategic National Stockpile existed for such emergencies, but Secretary Azar had recently testified to the Senate that it had only twelve million N95 masks-a fraction of what was needed. The storehouse had once held more than a hundred million masks, but many were used during the 2009 H1N1 flu pandemic, and the supply wasn't replenished.

After Trump made clear that the states were on their own, Ned Lamont, the gregarious governor of Connecticut, called other governors in his region: Phil Murphy, of New Jersey; Charlie Baker, of Massachusetts; Gina Raimondo, of Rhode Island; and Cuomo. The states needed to act together, Lamont said. "If I close down bars and Andrew keeps them open, that doesn't solve any problems," he said. "Everybody's going to go down there to drink, and bring back the infection."

The governors were daunted by the task facing them. Lamont imagined furious constituents: "You're going to close down the schools? My God!" Acting in concert provided political cover and a sense of solidarity.

The governors closed gyms, restaurants, and bars at the same time. Lamont, Murphy, and Cuomo prohibited gatherings exceeding fifty people. Baker and Raimondo limited them to twenty-five. Cuomo announced, "If you were hoping to have a graduation party, you can't do it in the state of New York, you can't go do it in the state of New Jersey, and you can't do it in the state of Connecticut."

Governors discovered that the Trump Administration was sabotaging their efforts to protect citizens. Charlie Baker arranged to buy three million N95 masks from China, but federal authorities seized them at the Port of New York, paying the supplier a premium. In another group call with Trump, Baker, a Republican, complained, "We took seriously the push you made not to rely on the stockpile. I got to tell you, we lost to the Feds. . . . I've got a feeling that, if somebody has to sell to you or me, I'm going to lose every one of those."

"Price is always a component," Trump replied coldly.

Baker quietly secured a cache of 1.2 million masks from China, and enlisted the help of Robert Kraft, the owner of the New England Patriots, who used the team plane to fly the shipment to Logan Airport, where it was received by the Massachusetts National Guard and spirited away.

At a briefing, Cuomo fumed, "You have fifty states competing to buy the same item. We all wind up bidding up each other." He threw up his hands. "What sense does this make? The federal government- fema -should have been the purchasing agent."

Gina Raimondo pressed FEMA, saying, "Can we tap into our national stockpile?" After days of giving her the runaround, the agency promised that a truckful of P.P.E. was on its way. At 9 P.M., she got a text saying that the truck had arrived. Raimondo told Politico, "I called my director of health. 'Great news, the truck is finally here!' She says, 'Governor, it's an empty truck.' They sent an empty truck."

Inslee told me, "Only eleven per cent of the P.P.E. we've obtained has come from the federal government."

Governors who got more had to show obeisance to Trump. Gavin Newsom, of California, praised the President fulsomely after being promised a shipment of swabs. Around this time, a reporter asked Trump, "You've suggested that some of these governors are not doing everything they need to do. What more, in this time of a national emergency, should these governors be doing?"

"Simple," Trump said. "I want them to be appreciative."

In the spring, Trump pressed the F.D.A. to fast-track authorization of a malaria treatment, hydroxychloroquine, for COVID patients. Fox News touted the drug as a "game changer." Tucker Carlson and Laura Ingraham aired breathless interviews with Gregory Rigano, who had co-written a "paper"-a self-published Google Doc-calling the drug an effective treatment. Rigano, a lawyer, had recently started blockchain funds that aimed to "cheat death" and "end Alzheimer's." Between March 23rd and April 6th, hydroxychloroquine was mentioned on Fox News nearly three hundred times. White House officials, including Peter Navarro, heavily promoted it.

At a task-force briefing, Fauci was asked if hydroxychloroquine curbed the coronavirus. "The answer is no," he said.

The President glowered and stepped toward the mike. "I'm a big fan," he said.

Three months later, the F.D.A. withdrew its authorization. The drug was ineffective and caused "serious cardiac adverse events" and other side effects, including kidney disorders and death. When hydroxychloroquine was paired with azithromycin-a combination that Trump had publicly championed-patients were twice as likely to suffer cardiac arrest as those who took neither drug.

Fox News stopped hyping hydroxychloroquine, but Trump still wanted a quick fix. While cases in New York were doubling every three days, and doctors were treating patients in tents in Central Park, he declared that he wanted America "raring to go" by Easter.

Over all, the case fatality rate for COVID is two per cent. But for people over seventy-five the risk of death is hundreds of times greater than it is for those under thirty. The devaluation of elderly lives was evident in the low standard of care in many nursing homes, where forty per cent of U.S. deaths have occurred, despite accounting for only eight per cent of cases. In March, two hundred and thirty-five military veterans were living at the Soldiers' Home in Holyoke, Massachusetts. Some had served in the Second World War. Now they were captives to a system that was failing to protect them.

According to an independent investigation commissioned by the state, family members and workers had long complained about understaffing, in part because of a 2015 hiring freeze ordered by Governor Baker. On March 17th, a veteran who had been showing symptoms for weeks was tested for COVID. He lived in one of two dementia units; he wasn't isolated, not even after his test came back positive, four days later. Contagion took hold, and overburdened employees made the fateful decision to combine the two units, with beds placed in tight rows. Many disoriented veterans climbed into the wrong beds, accelerating the spread. A recreational therapist said that she felt as if she were leading her patients "to their death."

On Friday, March 20th, Michael Miller, who is retired from the Army National Guard, got a call from his two sisters, Linda McKee and Susan Perez. "They're not thinking Dad's gonna make it through the night," they said. Their father, James L. Miller, was ninety-six, and had been at the Soldiers' Home since 2015. The siblings drove to the facility. Only one family member could enter at a time. Mike went in while his sisters waited in the car. His father "looked like a corpse," he recalled. "He had been in that state of decay for a week, and nobody called us."

Jim Miller had landed at Normandy Beach on D Day. He had helped liberate a concentration camp near Nordhausen, Germany. After mustering out, he became a postal worker and a firefighter. He was a taciturn man who had rarely discussed his military service with his children.

Now this quiet old veteran was dying in the midst of bedlam. "Men were just wandering around," Mike said. "They were in various states of dress. There was a curtain drawn for my dad-other veterans would open the curtain and stand there. And these gentlemen I knew. They meant no disrespect." A man on a nearby bed was "just moaning-he couldn't breathe. He ended up passing away that night."

Staffers couldn't offer the dying residents anything but "comfort measures"-morphine under the tongue. Jim was so dehydrated that he couldn't swallow. "Give him an I.V.!" Mike pleaded. But staffers weren't authorized to do this; nor could they transport him to a hospital. Mike moistened his dad's mouth with a foam swab. Nurses broke down, Mike recalled: "They loved my dad. But they couldn't do anything." He never saw any administrators.

Mike returned each day as his sisters kept vigil in the parking lot. On Saturday, they witnessed the arrival of a refrigerated truck that had been sent to store bodies. On Monday, Jim Miller passed away. Before it was all over, at least seventy-five other veterans had died.

12. Little Africa

In the COVID world, everyone is in disguise. When Dr. Ebony Hilton enters a room, patients see wide-set, lively eyes above her surgical mask. Her hair and body are hidden by a bonnet and a gown. Her accent marks her as a Southerner. She calls herself a "country girl," which is at odds with her assured manner. When the call comes to intubate a COVID patient, "it's already a situation where somebody is dying," she told me. "The only reason I'm placing this breathing tube is because your body is shutting down, so if I don't touch you you're dead." She added, "If I do touch you, I could die."

Hilton, who is thirty-eight, is a professor and an anesthesiologist at the University of Virginia School of Medicine, in Charlottesville. U.Va.'s hospital has some six hundred beds, but at night Hilton often works alone: "I'm literally the only anesthesiologist attending for the entire hospital. At that moment, I can't shut down, I can't go to my room and let fear stop me." She continued, "I don't think any of us have slowed down to think that this could be the one that gets me sick. You don't have time to consider options A, B, C, and D. You've got to gown up and go."

One day in early March, Hilton got a page. A patient was septic, meaning that an infection had entered her bloodstream and was raging through her body. Her kidneys were starting to fail. Ordinarily, doctors would suspect bacteria as the cause, but the infection's spread had been alarmingly rapid, and the symptoms matched what doctors were reporting about COVID patients in China and Italy. Many health-care workers had noted the speed with which the infection killed when it made its move.

Hilton entered the room, wearing an N95 mask. The patient had no blood pressure; without intervention, her oxygen-starved brain would start dying within seconds. The procedure for intubation requires a pillow to be placed under the patient's shoulder blades, so that the head is tilted back in the "sniffing position." Hilton made sure that the patient was oxygenated and given a sedative and a muscle relaxant; then she pried her mouth open, pushed her tongue aside, and inserted a laryngoscope-a curved blade attached to a handle, which looks like the head of a walking cane. The device lifts the epiglottis, exposing the vocal cords. If the vocal cords don't readily appear, pressure on the larynx can bring them into view. Hilton slowly inserted a plastic tube through the narrow portal between the vocal cords, down into the trachea. Once the tube was secured, the patient was connected to a ventilator.

That was probably Hilton's first COVID patient, but there was no way to know. Virginia had barely any tests in early March.

Hilton comes from a community near Spartanburg, South Carolina, called Little Africa. After the Civil War, Simpson Foster, a formerly enslaved man, and a Cherokee named Emanuel Waddell founded the community as an agrarian refuge. "It's tiny," Hilton said. "We don't have a red light. We only have my great uncle Hobbs's store-he keeps snacks and stuff for us."

Little Africa is in the foothills of the Blue Ridge Mountains. "When you're sitting on the porch, you can see the skyline of the peaks," Ebony's mother, Mary Hilton, told me. "We have doctors, lawyers, judges-we have so many professions coming out of the Little Africa community, because we put so much emphasis on education, taking care of each other," she said. "Eb is coming from a very powerful place."

When Ebony was eight, her little sister asked Mary if they could have a brother. Mary was caught by surprise but answered honestly: her first child had been a boy. "I was seventeen," she recalled. "I had never heard of an ob-gyn. We always went to the clinic." She went alone; her mother was picking cotton. Mary suspects that, during a pregnancy exam, a technician punctured her amniotic sac. The boy was born prematurely and died after three days. "I told Eb that story, not knowing it would change her life," Mary said. The moment Ebony heard it, she announced that she was going into medicine. Her resolve must have been evident: right then, Mary began calling her Dr. Hilton.

Not long ago, Ebony and her sisters, Brandi and Kyndran, placed a tombstone for the brother they never knew. They erected it in the churchyard of the New Bedford Baptist Church, in Little Africa. "He was a fighter," Ebony told me. "He tried to beat the odds. So I try to finish out that mission for him."

Hilton's image of her future was formed by watching "Dr. Quinn, Medicine Woman." She attended the Medical University of South Carolina, intending to become an obstetrician-gynecologist. "One night, when I was on my OB rotation, there was a lady having a seizure-she actually had eclampsia-and this guy ran into the room and started shouting orders, like, 'I'm going to do the A-line,' 'You start a magnesium.' I leaned over and asked, 'Who is that guy?' One of the OBs said, 'Oh, that's the anesthesia resident.' " Hilton told herself, "I want to be the person that, when there's utter chaos, you know what to do."

In 2013, she became the first Black female anesthesiologist to be hired by the Medical University of South Carolina, which opened in 1824. U.Va. hired her in 2018. "Growing up in medicine, what I've come to realize is that, should I have a child, it would actually be at more risk of dying than my mom's child was," she said. She cited a Duke University study that correlated race and education levels: "If you look at white women with my same level of degrees, my child is five to seven times more likely to die before his first birthday than theirs. It's been that way historically for Black women. Our numbers haven't really changed, as far as health outcomes, since slavery times."

Many minorities suffer from co-morbidities. "That's where the social determinants of health kick in," Hilton said. Asthma and chronic respiratory disease can be the result of air pollution-say, from an industrial plant in a low-income neighborhood. "If you're in a gated community, you don't see smoke billowing out of these industries, because you have the money and power to influence the policymakers to say, 'You can't put that here.' " Heart failure, obesity, and diabetes are tied to whether or not there are nearby restaurants and grocery stores with healthy options. She pointed out that, in South Carolina, one in every five counties doesn't have a hospital; eleven counties don't have any ob-gyns.

The moment the first American COVID death was announced, in February, Hilton said, she "started doing a tweetstorm to C.D.C. and W.H.O., saying, 'We know racial health disparities exist, and they existed before COVID-and we know where this will end up.' " She demanded, "Tell us who you're testing and who you're not." The C.D.C. didn't release comprehensive data until July, after the Times sued for it. The country, it turned out, was experiencing wildly different pandemics. For every ten thousand Americans, there were thirty-eight coronavirus cases. But, for whites, the number was twenty-three; for Blacks, it was sixty-two; for Hispanics, it was seventy-three. At Hilton's hospital, seven of the first ten COVID fatalities were people of color.

Hilton and her colleagues went to minority communities in and around Charlottesville to provide testing at churches and shopping centers. "Minorities are less likely to be tested, which means they might go back home, where they have the capability to infect their entire community," she said. People of color are more likely to be exposed because so many are essential workers. "Only one in five African-Americans can work remotely," she said. "Only one in six Hispanics can."

Staffers at U.Va.'s hospital prepared their wills. Hilton realized that she would be spending long hours away from her dog, Barkley, so she bought a puppy-"a dog for my dog"-that she named Bentley. "They barely get along," she admitted. Hilton's neighbor, a nurse in the COVID unit, has two children, and feared exposing them. The woman began living in her basement.

One of the hardest moments at Hilton's hospital came when Lorna Breen, a forty-nine-year-old doctor, was admitted to the psych unit. Her father, Philip Breen, is a retired trauma surgeon; her mother, Rosemary Breen, had been a nurse on the ward where Lorna was admitted. Lorna had been living in Manhattan, overseeing the E.R. at NewYork-Presbyterian Allen Hospital.

When COVID inundated New York, she worked twelve-hour shifts that often blurred into eighteen. She barely slept. Within a week, Breen caught COVID herself. She sweated it out in her apartment while managing her department remotely. After her fever broke, she returned to work, on April 1st.

Breen was defined by her vitality. She was a salsa dancer and a cellist in an amateur orchestra. She ran marathons; she drove a Porsche convertible; in her spare time, she was pursuing an M.B.A. "She never left the party," her sister, Jennifer Feist, told me.

Breen told Feist that a trauma nurse was walking through the E.R. triaging patients based on how blue their faces were. So many doctors in New York fell ill that, at one point, Breen supervised the E.R.s in two hospitals simultaneously. It became too much. As her father put it later, Breen was "like a horse that had pulled too heavy a load and couldn't go a step further and just went down."

Breen called her sister one morning and said that she couldn't get out of a chair. "She was catatonic," Feist told me. " COVID broke her brain."

Feist and her husband, Corey, decided that Breen needed to come home to Virginia. A friend in Connecticut drove Lorna to Philadelphia; another friend took her to Baltimore. Feist was waiting on the side of the road to drive her to Charlottesville.

During the eleven days that Breen spent in U.Va.'s hospital, she was terrified that her career was over. Licensing boards, she knew, might flag evidence of mental illness. Before COVID, Breen had never had a trace of instability. Feist and her husband, both attorneys, assured her that she wouldn't lose her license. Breen seemed to improve: she even tried to do her M.B.A. homework on her phone. Feist took Breen home with her on the last Saturday in April. The next day, Breen killed herself.

The pandemic has added immeasurable stress to a public-health workforce already suffering from burnout. Feist told me, "She got crushed because she was trying to help other people. She got crushed by a nation that was not ready for this. We should have been prepared for this. We should have had some sort of plan."

13. The Mission of Wall Street

Goldman Sachs is a controversial name in high finance. Its influence pervades American economic policy. Three of the twelve presidents of the Federal Reserve have worked there. Steven Mnuchin, the Treasury Secretary, is a Goldman alum. The company's many critics see it as the pinnacle of avarice. They hold it responsible for contributing to the vast income disparities in America and see its alumni as manipulating government policy to further enrich the wealthy. But, in the upper chambers of power, Goldman's culture of success is revered.

In the first quarter of 2020, the Goldman view of the economy was exuberant. Jan Hatzius, its chief economist, told me, "We had come fully out of the deep downturn post-2008." Unemployment was near historically low levels; wages were creeping up. Sure, median incomes hadn't risen substantially since the seventies; the gap between the rich and the poor appeared unbridgeable. But those weren't Goldman problems. The company exists to make wealthy clients wealthier.

When the Wuhan outbreak began, the economic risk to America seemed low. Previous pandemics, such as H1N1 and SARS, had negligible economic impact on the U.S. On February 12th, with COVID already rooted in this country, the Dow Jones closed at 29,551-a record high at the time. Three weeks later, Hatzius said, "we began the deepest contraction in the global economy on record."

Hatzius compiled data for quarterly Goldman G.D.P. forecasts. Normally, he said, "you estimate the ups and downs of a business cycle by, say, relating people's propensity to spend on consumer goods to their labor income or tax changes, or the effect of interest-rate changes on the willingness or ability to buy homes." This situation was different. "It wasn't the case that people didn't have the money to go to restaurants-they couldn't go to restaurants." Airlines stopped flying. Car production ceased. Entire sectors had to be subtracted from the economy: "It was more arithmetic than econometrics."

On March 27th, the Times ran an apocalyptic headline: " job losses soar; u.s. virus cases top world." Curiously, by that time, the Dow had reversed its plunge and begun a long climb that was strikingly at odds with the actual economy. In November, it once again reached record highs.

Steve Strongin is a senior adviser at Goldman. Sixty-two, he wears rimless glasses that lend him the aspect of a nineteenth-century European intellectual: Ibsen without the sideburns. "Markets very often get talked about as though they're some kind of giant casino," he told me. "But they actually have a deep economic function, which is to move capital, both equity and debt, from businesses that no longer serve a purpose to businesses we need today."

The market's initial reaction, Strongin said, was "Somehow we are going to freeze in place, the virus will pass, and then we'll unfreeze." During that phase, Wall Street's function was to provide liquidity as clients turned to preservation strategies-raising cash, drawing on lines of credit-while waiting out the contagion. But the pandemic settled in like a dinner guest who wouldn't leave and was eating everything in the pantry.

"The moment when everybody was forced to reassess the severity and longevity of the crisis is when people realized that asymptomatic carriers were important," Strongin said. "That meant that all the prior controls were going to fail." Thousands of businesses would close. Nobody alive had seen a catastrophe of such scale. The rules had to change. The pandemic was a historic disrupter, forcing a shift from short-term to long-term thinking. Strongin, who once wrote a paper called "The Survivor's Guide to Disruption," said, "Once that realization came into place, you saw the rush to opportunity."

Investors pivoted to a consolidation phase: going with the winners. The market recovery was led by five stocks- Facebook, Apple, Microsoft, Google, and Amazon-accounting for more than twenty per cent of the S. & P. However, "the Darwinian reality of capitalism is not about this brilliant insight into the five winners," Strongin said. "It's about taking money away from the fifty thousand losers. It's the core of the economic system-we don't prop up failures."

The most useful thing the government can do, he said, is help people start new small businesses: "The current split between the stock market and the employment numbers is a flashing warning that the economy and the people are not the same. If we don't spend real money, the pain will be very real, and the political consequences dangerous at best."

14. The Man without a Mask

The third and final chance to contain the infection-masks-was the easiest, the cheapest, and perhaps the most effective. But the Administration, and the country, failed to meet the challenge.

On March 4th, as Matt Pottinger was driving to the White House, he was on the phone with a doctor in China. Taking notes on the back of an envelope while navigating traffic, he was hearing valuable new information about how the virus was being contained in China. The doctor mentioned the antiviral drug remdesivir-which was just emerging as a possible therapy in the U.S.-and emphasized that masks were extremely effective with COVID, more so than with influenza. "It's great to carry around your own hand sanitizer," the doctor said. "But masks are going to win the day."

Still on the phone when he parked his stick-shift Audi, on West Executive Avenue, next to the West Wing, Pottinger forgot to put on the parking brake. As he rushed toward his office, the car rolled backward, narrowly missing the Vice-President's limo, before coming to rest against a tree.

While the Secret Service examined the errant Audi, Pottinger kept thinking about masks. America's pandemic response had already been handicapped by China's withholding of information about human-to-human and asymptomatic transmission. The testing imbroglio would set the country back for months. But masks offered a ready solution.

Deborah Birx had told Pottinger that, whereas mask wearing is part of Asian culture, Americans couldn't be counted on to comply. Pottinger began to see America's public-health establishment as an impediment. The Surgeon General, Jerome Adams, had tweeted, " STOP BUYING MASKS! They are NOT effective in preventing general public from catching #Coronavirus." Such messages were partly aimed at preventing the hoarding of hospital-grade masks, but they dissuaded people from adopting all forms of face covering. In those early days, the U.S. medical establishment looked at SARS-CoV-2 and flatly applied the algorithm for sars: sick people should wear masks, but for others they weren't necessary. Redfield, of the C.D.C., told me, "We didn't understand until mid-March that many people with COVID weren't symptomatic but were highly infectious."

Pottinger, however, thought it was evident that, wherever a large majority of people wore masks, contagion was stopped "dead in its tracks." Hong Kong was one of the world's densest cities, but there was no community spread of the virus there, because nearly everyone wore masks. Taiwan, which was manufacturing ten million masks per day for a population of twenty-three million, was almost untouched. Both places neighbored China, the epicenter. Pottinger's views stirred up surprisingly rigid responses from the public-health contingent. In Pottinger's opinion, when Redfield, Fauci, Birx, and Hahn spoke, it could sound like groupthink, echoing the way that their public messaging was strictly coördinated.

Nobody in the White House wore a mask until Pottinger donned one, in mid-March. Entering the West Wing, he felt as if he were wearing a clown nose. People gawked. Trump asked if he was ill. Pottinger replied, "I just don't want to be a footnote in history-the guy who knocked off a President with COVID."

Many N.S.C. staffers work in the Situation Room, monitoring news and global developments. They are crammed together like workers in a call center. Pottinger asked the staff virologist to teach everyone how to mask up. Some people were annoyed. Masks had become a political litmus test, with many conservatives condemning mask mandates as infringements on liberty, and to wear one in Trump's White House seemed borderline treasonous. Pottinger was shocked to learn that, in any case, the White House had no ready supply of masks.

He called an official in Taiwan and asked for guidance about controlling the virus. Masks, he was told again. Soon after that call, Taiwan's President donated half a million masks to the U.S., via diplomatic pouch. Pottinger took thirty-six hundred, for the N.S.C. staff and the White House medical unit, and sent the rest to the national stockpile.

In early April, new studies showed substantial reductions in transmission when masks were worn. Pottinger put copies of the studies into binders for key task-force members. A Chinese study reported on an infected traveller who took two long bus rides. He began coughing on the first ride, then bought a face mask before boarding a minibus. Five passengers on the first ride were infected, and no one on the second. Another study failed to detect any viral particles in aerosol or droplets from subjects wearing surgical masks.

On April 3rd, the C.D.C. finally proclaimed that masks were vital weapons. It was the last opportunity to do something meaningful to curb the pandemic.

The C.D.C.'s sudden reversal, Redfield admitted to me, was awkward: "When you have to change the message, the second message doesn't always stick." Worse, when the President announced the new mask advisory, he stressed, "This is voluntary," adding, "I don't think I'm going to be doing it."

Trump is a notorious germophobe. He hates shaking hands and recoils when anyone near him sneezes. He once chastised Mick Mulvaney, on camera in the Oval Office, "If you're going to cough, please leave the room." Years before COVID, Trump told Howard Stern that he had a hand-washing obsession, which "could be a psychological problem." It's one of the only frailties he acknowledges. He seems fascinated by his horror of contamination.

How could such a man refuse to wear a mask in a pandemic? It wasn't just Trump, of course; the people around him followed his example. Pence visited the Mayo Clinic without a mask, violating hospital policy. Many Republican legislators shunned masks even after members of their caucus became infected. It wasn't just Republicans, but Democrats were twice as likely to say that masks should always be worn. It wasn't just men, but women were more in favor of masks. It wasn't just white people, but they were much more averse to mask wearing than Blacks and Latinos were. If you name each of the groups least likely to wear a mask, the result roughly correlates with the average Trump voter.

Some anti-maskers called the coronavirus a hoax; others believed that it wasn't all that dangerous. But the image of the maskless President spoke to people, especially his base. He appeared defiant, masculine, invulnerable. He knew that the virus was dangerous-"more deadly than even your strenuous flus," as he told Bob Woodward, in a February interview that surfaced months later. Yet he dared the virus to touch him, like Lear raging against the storm.

Tens of millions of Americans emulated the President's bravado, and the unchecked virus prolonged unemployment, upended efforts to reopen the economy, and caused many more fatalities. "I'm not buying a fucking mask," Richard Rose, a thirty-seven-year-old Army veteran from Ohio, posted on Facebook. "I've made it this far by not buying into that damn hype." He tested positive on July 1st and died three days later. There are many similar stories.

It's dispiriting to think that, had such a simple precaution been broadly implemented from the start, America could have avoided so much suffering, death, impoverishment, and grief. The starkest example occurred in Kansas, when the governor issued an executive order to wear masks in public but allowed counties to opt out. It was as if Kansas were performing a clinical trial on itself. Within two months, infections in mask-wearing counties had fallen by six per cent; elsewhere, infections rose a hundred per cent.

Of course, wearing a mask was a much smaller burden than self-isolating. Although CNN repeatedly ran alarming footage of people who refused to stop going to bars or malls, a far greater number of Americans had listened to the experts, sequestering themselves for months, at tremendous financial and emotional cost. My wife and I live in Austin, and, as the quarantine dragged on, we forced ourselves to take an occasional drive, partly to keep our car battery alive. We'd snake through vacant streets downtown, grimly taking note of which businesses had boarded up since the previous drive.

One April afternoon, I went for a jog on a school track near my home. A group of young women were running time trials in the hundred-metre dash. They were the fastest people I had ever seen. Occasionally, as I came around a curve, I'd pull even with one of the women just as she was taking off. It was like Wile E. Coyote eating the Road Runner's dust.

"What school do you guys run for?" I asked one of them, who was cooling off.

"Oh, it's not a school," she said. "We're Olympians."

Instead of competing in Tokyo, here they were, on a middle-school track in Austin, isolating together and trying to maintain peak condition as they waited for the rescheduled Games. So many dreams have been deferred or abandoned.

15. "I Can't Breathe"

The corpse on the autopsy bench was a middle-aged Black man with COVID-19. Six feet four and two hundred and twenty-three pounds, he had suffered from many of the co-morbidities that Ebony Hilton had described to me. The medical examiner identified signs of heart disease and hypertension. The autopsy noted the presence of fentanyl and methamphetamine, which could be considered co-morbidities, although they didn't really factor into this case. The cause of death was a police officer's knee on the neck. The victim was George Floyd.

On a video seen worldwide, four Minneapolis policemen killed Floyd as he was handcuffed and lying face down in the street. It was Memorial Day. One cop stood watch as two knelt on Floyd's back and held his legs while the fourth, Derek Michael Chauvin, pressed his knee into Floyd's neck for more than nine minutes.

At a time when health officials were begging people to stay home and avoid groups, protests arose in Minneapolis, then spread across America. They called to mind the Liberty Loans parades in 1918-the ones that had served as potent vectors for the killer flu. Nevertheless, thirteen hundred public-health officials signed a letter supporting the demonstrations.

Hilton joined a protest in Charlottesville on June 7th. Hundreds of people marched to the rotunda at the University of Virginia, carrying Black Lives Matter signs and placards saying "Let My People Breathe." I asked Hilton if she was worried about the mass gatherings. She said that she expected a rise in infections. Then she added, "For Black men, one in every thousand is at risk of dying in his lifetime from an encounter with a police officer. If you think about that number, that's what leads Black people to say it's worth me dying and going out to this protest and saying enough is enough. Police brutality is almost like a pandemic, a generational pandemic. It's a feeling-I'm going to die anyway, so I might as well risk this virus that I can't see, to speak about the virus of systemic racism that I can see."

Surprisingly, the marches did not appear to be significant drivers of transmission. "We tested thousands of people," Michael Osterholm, the director of the Center for Infectious Disease Research and Policy, at the University of Minnesota, said. "We saw no appreciable impact." One study found lower rates of infection among marchers than in their surrounding communities. Epidemiologists concluded that mask wearing and being outdoors protected the protesters. Moreover, demonstrators were on the move. Osterholm said that people in stationary crowds are more likely to become infected. In other words, joining a protest march is inherently less dangerous than attending a political rally.

16. Thelma and Louise

The President hadn't gathered with supporters since March, and was eager to dive back into the pool of adulation. An event was scheduled for June 20th. "It's going to be a hell of a night," he promised. He tweeted, "Almost One Million people request tickets for the Saturday Night Rally in Tulsa, Oklahoma!"

Only sixty-two hundred showed up. Trump was enraged by the dismal turnout but delivered his usual blustery speech. Because Oklahoma had just seen a record increase in COVID cases, attendees were required to release the Trump campaign from responsibility for any exposure. Just before Trump went onstage, two Secret Service officers and six campaign staffers tested positive.

In the audience was Herman Cain, the former C.E.O. of Godfather's Pizza and an erstwhile Presidential candidate, who had become one of Trump's most prominent Black supporters. Like nearly everyone else, he was unmasked. He flew home to Atlanta the next day, feeling exhausted-"from his travels," his daughter, Melanie Cain Gallo, believed. It was Father's Day, and she stopped by to give him a gift. They embraced. She had seen a photograph of him at the rally and wondered why he hadn't worn a mask. Cain had preached the virtue of social distancing and hand washing on "The Herman Cain Show," a Web series that he hosted, and he had usually worn a mask in public. He told her that everyone entering the Tulsa auditorium had passed a fever check-an insufficient gauge.

Gallo worked with her dad all week on his show. By Friday, they were both feeling ill, but Cain filmed another episode. Flanked by the American flag and a painting of Ronald Reagan, he looked wan, his eyes rheumy. He quoted a newspaper headline: " U.S. DEATH RATE FALLS FOR THIRD DAY IN A ROW." Other newscasts had hyped rising case counts, he complained, adding, "They never get to the death rate is falling."

On Monday, both were sick enough to go to a clinic for a test. Cain was feeling weak, so he waited by the car while Gallo stood in a long line. Suddenly, he passed out. An E.M.S. truck took him to the E.R. "They checked him out and said he was fine," Gallo recalled. They returned to the testing clinic. Both were positive.

Her case was mild. On July 1st, Cain was hospitalized. That day, he tweeted an article about a forthcoming Trump rally at Mt. Rushmore. "Masks will not be mandatory," Cain tweeted, adding approvingly, " PEOPLE ARE FED UP!" It was a defiant nod to Trump's base. Cain died on July 30th. He was seventy-four.

For some public-health officials, Deborah Birx had become an object of scorn. "She's been a disaster," a former head of the C.D.C. told me. The Yale epidemiologist Gregg Gonsalves tweeted, "Dr. Birx, what the hell are you doing? What happened to you? Your HIV colleagues are ashamed." Birx was accused of enabling an incompetent and mendacious President. The mortified look on her face at the press briefing when he suggested injecting disinfectant or using powerful light-"inside the body, which you can do either through the skin or in some other way"-became a meme, underscoring how much Trump had compromised scientists. The public didn't know what she was saying in private.

Birx confided to colleagues that she'd lost confidence in the C.D.C. She disparaged the agency's hospital reports on COVID, which relied on models, not hard data. A C.D.C. staffer told Science that compiling precise totals daily in a pandemic was impossible. But hospitals quickly complied after Birx said that supplies of remdesivir could be portioned out only to hospitals that provided inpatient COVID data.

In August, Dr. Scott Atlas, a neuroradiologist, a fellow at Stanford University's Hoover Institution, and a Fox News regular, joined the task force. He was adamant that children should return to school-as was the American Academy of Pediatrics, which urged a "safe return" to schools in the fall, warning of learning deficits, physical or sexual abuse at home, and depression. That was a debate worth having, but most of Atlas's views on COVID seemed reckless. He insisted that masks did little to stop the spread, and he advocated creating "herd immunity" by allowing the virus to be passed freely among people at lower risk. Herd immunity is gained when roughly seventy per cent of a population has effective antibodies to the disease, through either infection or vaccination.

Once Atlas got to the White House, Trump stopped speaking to other health advisers. Herd immunity could be achieved by doing nothing at all, which became the President's unspoken policy. Atlas encouraged Trump and others to believe that the pandemic was waning. "His voice is really very welcome combatting some of the nonsense that comes out of Fauci," Stephen Moore, a White House economic adviser, reportedly said. (The White House denies that "the President, the White House, or anyone in the Administration has pursued or advocated for a strategy of achieving herd immunity.")

Birx and Atlas had it out in the Oval Office, in front of Trump. Birx accused Atlas of costing American lives with his unfounded theories. Atlas cursed her. Birx, who spent twenty-eight years in the Army, gave it right back. Atlas said that young, asymptomatic people shouldn't be tested, adding, "She just wants to lock them down and not let them live their lives." They kept shouting at each other, but Trump was undisturbed and didn't take either side. "It's all reality TV to him," one of Birx's colleagues said.

After the confrontation, Birx demanded that Pence remove Atlas, but Pence declined. The task force began to dissolve after Atlas took a seat.

When Birx was working in Africa, she and her chief epidemiologist, Irum Zaidi, had met with Presidents and village elders across the continent, learning the value of personal diplomacy. The two scientists decided to take an American road trip together. The contagion had moved from the coasts to the heartland. In June, when the virus suddenly gripped Texas, Birx and Zaidi travelled to Dallas to meet with Governor Greg Abbott. Abbott's dithering response to the pandemic had led to attacks by Democrats-who noted that the death rate soared when he lifted restrictions too soon-and by Republicans, who called him a tyrant for imposing any restrictions at all. At a press conference, Birx urged Texans to mask up, especially young people. "If they're interacting with their parents and grandparents, they should wear a mask," she said. "No one wants to pass the virus to others." She praised Abbott for closing bars, knowing that he was being pressured to fully open the economy. Abbott soon issued a mask mandate.

Zaidi grew up in Atlanta, and her father was a C.D.C. statistician. On vacations, they took long car trips, a passion passed along to Zaidi. She loves to drive-fast. As they were leaving Dallas, a state trooper pulled her over. She'd been doing a hundred and ten.

"Little lady, what's the hurry?" he asked.

Zaidi explained that they'd just met Governor Abbott, and New Mexico's governor was next. "Surely you recognize Dr. Birx," she said.

The trooper let them off.

Soon after their visit to New Mexico, Governor Michelle Lujan Grisham announced a hundred-dollar fine for going maskless in public. Birx and Zaidi proceeded to Arizona and met with Governor Doug Ducey. Birx explained that even a small increase in the percentage of positivity-going from 3.5 to five per cent-could spark an unmanageable crisis. Ducey soon declared, "If you want to participate in any good or service in Arizona, you're going to wear a mask."

Birx and Zaidi racked up twenty-five thousand miles as they crossed the country eight times, visiting forty-three states, many more than once. They saw the rural areas and the cities, red America and blue America. They drove past cotton farms and soybean fields, but they also saw derelict oil rigs and abandoned factories, remnants of a vanishing industrial age. There were gleaming cities, bold and glassy, with construction cranes crowning the skyline, and broken towns, tumbling in decay, with all the promise bled out of them.

The women, who got regular COVID tests, established their own protocols. They cleaned rental cars and motel rooms with Clorox Wipes. In the morning, early, they'd pick up coffee and pastries at Starbucks. Lunch was often peanut butter spread on bread with a plastic knife. Dinner was served at a drive-through window. Baristas and gas-station attendants were useful informants of community outbreaks and served as indicators of local mask compliance. Birx and Zaidi met mayors and community organizers; they visited hospitals and nursing homes; they turned H.I.V. activists into COVID activists. In Atlanta, they urged officials to test migrants working on chicken farms. They visited more than thirty universities. Those which conducted mandatory weekly testing of students had positivity rates below one per cent; at schools where only symptomatic people were tested, positivity rates were twelve to fifteen per cent. Republican and Democratic governors made the same complaint: many people wouldn't listen as long as Trump refused to set an example.

One of the most effective governors Birx and Zaidi encountered was Jim Justice, of West Virginia. He issued a mask mandate, and in press briefings he read out the names of West Virginians who had died of COVID. He urged residents to "be great, loving neighbors." The state developed a plan to safely reopen schools by constantly assessing the level of risk in every county and presenting these data on a color-coded map. "It's something that every county and every state can do," Birx said. "West Virginia represents exactly what we want to see across the country-a commonsense approach based on the data."

A pandemic lays bare a society's frailties. Birx and Zaidi saw a nation that was suffering from ill health even before COVID attacked, where forty per cent of adults are obese, nearly half have cardiovascular disease, and one in thirteen has asthma. They visited reservations and met with Native Americans, who have been particularly ravaged by COVID. The Salt River Pima-Maricopa Indian Community, in Arizona, gave Birx a mask inscribed with the Salt River tribe's shield. When North Dakota recorded the nation's highest rate of infection, Birx met with the governor, Doug Burgum, and with local, state, and tribal officials. Birx scolded them: "This is the least use of masks that we have seen in retail establishments of any place we have been." She added, "It starts with the community, and the community deciding that it's important for their children to be in school, the community deciding that it's important not to infect the nursing-home staff who are caring for their residents." Burgum eventually agreed to a mask mandate. In South Dakota, Governor Kristi Noem couldn't find the time to meet with Birx.

For nearly six months, Birx corralled politicians, hospital executives, and public-health officials, often bringing such leaders together for the first time. She took charts and slides from state to state, promoting a simple, consistent message about masks, social distancing, transparency, and responsible leadership. She was the only federal official doing so.

One day in October, Birx and Zaidi were eating lunch at a roadside stop in Utah, beside the Bonneville Salt Flats, where land speed records are often set. The salt stretched out like a frozen sea.

They'd rented a blue Jeep Wrangler. "We have to go off-road, for just a minute," Zaidi said. Birx gazed at the great white emptiness. "As long as you don't hit anybody," she said.

17. Dark Shadows

I asked Dr. Fauci about the global-preparedness study calling America the nation best prepared for a pandemic. What happened? He emitted a despairing laugh and said, "We never got back to baseline"-the point when the contagion had been reduced enough to allow contact tracing to minimize spread. "It could be the fact that we didn't have a uniform strategy," he went on. "It could be our own culture right now, of people not wanting to be told what to do. The guidelines say 'Don't go to bars. Wear a mask.' And you look at the pictures in the newspaper and on TV and you see large crowds of mostly young people, not wearing masks."

Fauci, who has led niaid through six Administrations, has never seen this level of distrust and anger in the country. "Political divisiveness doesn't lend itself to having a coördinated, coöperative, collaborative response against a common enemy," he said. "There is also this pushback in society against anything authoritative, and scientists are perceived as being authority, so that's the reason I believe we have an anti-science trend, which leads to an anti-vaccine trend." Even with an effective vaccine-or several of them-social resistance could delay the longed-for herd immunity.

I asked Fauci if he'd been threatened. "Oh, my goodness," he said. "Harassing my wife and my children. It's really despicable. It's this dark-Web group of people who are ultra-ultra-ultra-far-right crazies. They somehow got the phone numbers of my children, they've tracked them where they work, they've harassed them with texts, some threatening, some obscene. We have gotten multiple death threats, my wife and I." He sighed and said, "It is what it is."

"Buy ammunition, ladies and gentlemen, because it's going to be hard to get," Michael Caputo warned, in a rambling Facebook Live event on September 13th. Caputo is an Assistant Secretary of Health and Human Services, and focusses on public affairs. He controls the flow of information from America's public-health establishment: the C.D.C., the F.D.A., and the N.I.H. Trump appointed Caputo to the post in April, when COVID was out of control; competence and transparency were needed to restore public trust. Caputo had no public-health expertise, and he claimed that his best friend was the notorious political operative Roger Stone.

Evidently, all the President wanted Caputo to do was reinforce his message that the virus wasn't as dangerous as scientists claimed, and that the crisis was under control. Caputo presided over interventions by H.H.S. that meddled with the C.D.C.'s guidelines-apparently, to get case numbers down and stanch the flow of bad news. Trump asked Caputo to lead a campaign to "defeat despair," which encouraged celebrities to endorse the Administration's laissez-faire approach. To fund the campaign, Caputo snatched three hundred million dollars from the C.D.C.'s budget.

Meanwhile, his science adviser, Paul Alexander, a part-time professor at a Canadian university, pushed an alternative plan: herd immunity. "It only comes about allowing the non-high risk groups to expose themselves to the virus," Alexander wrote to Caputo, in an e-mail obtained by Politico. "We want them infected."

Caputo's efforts met with resistance from Fauci and others, and he felt under siege. In the Facebook video, he was unshaven, sitting outside his house in Buffalo. "There are scientists working for this government who do not want America to get better," he said. "It must be all bad news from now until the election." He stared into space. "This is war. Joe Biden is not going to concede. The Antifa attacks, the murders that have happened, the rallies that have turned into violence-this is all practice."

Such embattled thoughts were shared by Adam Fox. A powerfully built man with a trim brown beard and a square face, he helped lead a militia called the Michigan Three Percenters-a reference to their belief that only three per cent of American colonists took up arms against Britain in the Revolutionary War.

In a strip mall in Grand Rapids, a shop called the Vac Shack sells and services vacuum cleaners. Fox, a former employee, had been kicked out of his girlfriend's house and was homeless. The shop's owner let Fox sleep in the basement. That's where he allegedly began plotting to kidnap Gretchen Whitmer, Michigan's governor, who had enforced tough lockdown measures.

In June, at a gun-rights rally in Lansing, Fox met with members of a militia, the Wolverine Watchmen, who planned to kill police officers. They were infuriated by Whitmer's COVID restrictions, but, even before the pandemic, they'd been prone to anger. "I'm sick of being robbed and enslaved by the state," one of the conspirators complained, after receiving a ticket for driving without a license.

Fox allegedly told the Watchmen that he was recruiting for an operation targeting the state capitol. He needed two hundred men to storm the building and abduct politicians, including Whitmer, whom Fox called a "tyrant bitch." Although the plotters were mostly unemployed or in low-paying jobs, they spent thousands of dollars on a Taser and night-vision goggles, and were planning to spend thousands more on explosives. They were plainly inspired by Trump's disparaging of Whitmer for shutting down her state. " liberate michigan!" the President had once tweeted.

The F.B.I. learned of the scheme, and arrested the conspirators in October. In a statement, Whitmer singled out Trump, who, in a recent debate with Biden, had refused to explicitly condemn right-wing, white-supremacist violence. "Words matter," she said. "When our leaders meet with and encourage domestic terrorists, they legitimize their actions and they are complicit."

Trump tweeted that "My Justice Department and Federal Law Enforcement" had foiled the plot, adding, "Rather than say thank you, she calls me a White Supremacist." He commanded Whitmer, "Open up your state."

On Michael Caputo's Facebook video, he sighed deeply. "I don't like being alone in Washington," he said. "The shadows on the ceiling in my apartment, there alone, those shadows are so long."

Soon afterward, he went on medical leave.

18. The Rose Garden Cluster

On September 26th, eight days after the death of Supreme Court Justice Ruth Bader Ginsburg, Trump nominated her successor, Amy Coney Barrett, in a White House ceremony. The Reverend John Jenkins, the president of the University of Notre Dame, where Barrett had taught law, recalled, "We were required to wear a mask at entry and, after going through security, were immediately taken to a room and administered a nasal swab for a COVID test." Once a negative result came back, guests could remove their masks. "I assumed that we could trust the White House health protocols," Jenkins said. He regretted his decision: "I unwittingly allowed myself to be swept up very publicly into the image of a White House that sometimes seemed to disregard scientific evidence and minimize the threat of the pandemic."

Guests were ushered to the Rose Garden, where there were two hundred assigned seats. Barrett spoke briefly. "Movement conservatives were very happy," Mike Lee, the Republican senator from Utah, recalled. Friends who hadn't seen one another for months reunited, he said, which "added to the jovial atmosphere." Afterward, dozens gathered in the Diplomatic Reception Room to meet the Barrett family.

That day, seven hundred and sixty-nine American deaths from COVID were recorded-down from the spring peak, on April 15th, of twenty-seven hundred and fifty-two. Despite the absence of miracle drugs, the death rate for hospitalized patients had fallen significantly. In part, this was because the average age of patients was lower, but the improved chances of survival were also the result of flattening the curve, which gave doctors and scientists the time to devise more effective treatments, such as proning. The infection rate, however, was harder to slow. The number of cases per day, which had topped seventy-five thousand in mid-July, had faded a bit in the late summer, but it was again rounding upward. After months of being more careful, Americans had apparently let down their guard.

The White House refused to say when the President had last been tested before the Rose Garden event. He had just made multiple campaign stops, in Florida, Georgia, and Virginia. More than a dozen guests-including Reverend Jenkins, Senator Lee, the former New Jersey governor Chris Christie, and the former Presidential adviser Kellyanne Conway -soon tested positive. Without knowing Trump's testing history, no one can say when he contracted the disease or how many people he might have infected. The full extent of the Rose Garden cluster will never be known. Fauci labelled it a superspreader event.

Despite his germophobia, Trump is proud of his immune system, boasting on multiple occasions that he never gets the flu. But COVID hit him hard. According to New York, he told a confidant, "I could be one of the diers." A friend from the real-estate world, Stanley Chera, had died from it. "He went to the hospital, he calls me up," Trump recounted after Chera's death. "He goes, 'I tested positive.' I said, 'Well, what are you going to do?' He said, 'I'm going to the hospital. I'll call you tomorrow.' He didn't call." Vanity Fair reported that Trump developed heart palpitations. He asked aides, "Am I going out like Stan Chera?"

Hospitals are often portals to the graveyard, and that has been especially true during the pandemic. But Trump, who received a series of cutting-edge therapies, including monoclonal antibodies, was ready to return to the White House after three days. According to the Times, he considered hobbling out of the hospital and then yanking open his shirt to reveal a Superman logo. In the event, he saved his drama for the moment he stood again on the Truman Balcony and ripped off his surgical mask.

"Don't be afraid of COVID," he tweeted afterward. "Don't let it dominate your life."

19. Survivors

After Amy Klobuchar dropped out of the Presidential race, she was on Biden's shortlist for his running mate. George Floyd's death put an end to that. She had begun her career twenty years earlier as the district attorney in Minneapolis, earning a reputation for being tough on crime but light on police misconduct. On June 18th, she asked Biden to take her name off his list and urged him to select a woman of color as his running mate.

That day, she learned that her ninety-two-year-old father, Jim Klobuchar, had COVID. He was a retired newspaper columnist, and known to everyone in Minneapolis, especially cops and bartenders. Full of adventure, he was also often full of alcohol. When Amy was a young lawyer, her father was arrested for drunk driving. In a closed hearing, she encouraged him to take responsibility and plead guilty. He did so, and finally got sober. Now this vigorous old man, so troubled and so beloved, had COVID -and Alzheimer's. When Klobuchar visited him, at an assisted-living facility, they were separated by a window, and she believed that it would be her final glimpse of him alive. He recognized her, but couldn't understand why they had to remain separated. He sang to her: "Happy Days Are Here Again." He has since recovered.

Among the many awful legacies that COVID will leave, one blessing is that our understanding of coronaviruses, and the tools to counter them, has been transformed. Much of that progress will be because of Barney Graham, Jason McLellan, and other scientists who have spent their careers building to this moment.

There has never been such an enormous, worldwide scientific effort so intently focussed on a single disease. More than two hundred vaccines are in various stages of development. On December 11th, the F.D.A. granted its first Emergency Use Authorization for a COVID vaccine. Created by Pfizer, in partnership with the German firm BioNTech, it uses the modified protein that Graham and McLellan designed. In its third and final human trial, it was deemed ninety-five per cent effective. Giant quantities of the vaccine had been prepared in advance of F.D.A. approval. "Our goal is more than a billion doses by the end of 2021," Philip Dormitzer, Pfizer's chief scientific officer for viral vaccines, told me. The first employee at U.Va.'s hospital to get the Pfizer inoculation was Ebony Hilton.

Operation Warp Speed, the government initiative to accelerate vaccine development, may prove to be the Administration's most notable success in the pandemic.

Moderna's vaccine secured approval next. Its formulation proved to be 94.1 per cent effective in preventing infection and, so far, it has been a hundred per cent effective in preventing serious disease. Graham is happy that he chose to work with Moderna. In 2016, his lab developed a vaccine for Zika, a new virus that caused birth defects. His department did everything itself: "We developed the construct, we made the DNA, we did Phase I clinical trials, and then we developed the regulatory apparatus to take it into Central and South America and the Caribbean, to test it for efficacy." The effort nearly broke the staff. Moderna was an ideal partner for the COVID project, Graham told me. Its messenger-RNA vector was far more potent than the DNA vaccine that Graham's lab had been using.

In another major development, Eli Lilly recently received an Emergency Use Authorization for a monoclonal antibody that is also based on the spike protein that Graham and McLellan designed. It is similar to the treatment that President Trump received when he contracted COVID.

Graham had been in his home office, in Rockville, Maryland, when he got a call telling him that the Pfizer vaccine was breathtakingly effective-far better than could have been hoped for. "It was just hard to imagine," he told me. He walked into the kitchen to share the news with his wife. Their son and grandchildren were visiting. "I told Cynthia, 'It's working.' I could barely get the words out. Then I just had to go back into my study, because I had this major relief. All that had been built up over those ten months just came out." He sat at his desk and wept. His family gathered around him. He hadn't cried that hard since his father died.

Graham and his colleagues will not become rich from their creation: intellectual-property royalties will go to the federal government. Yet he feels amply rewarded. "Almost every aspect of my life has come together in this outbreak," he told me. "The work on enhanced disease, the work on RSV structure, the work on coronavirus and pandemic preparedness, along with all the things I learned and experienced about racial issues in this country. It feels like some kind of destiny."

More than a thousand health-care workers have died while taking care of COVID patients. Nurses are the most likely to perish, as they spend the most time with patients. On June 29th, Bellevue held a ceremony to memorialize lost comrades. Staff members gathered in a garden facing First Avenue to plant seven cherry trees in their honor.

As the coronavirus withdrew from Bellevue, it left perplexity behind. Why did death rates decline? Had face masks diminished the viral loads transmitted to infected people? Nate Link thinks that therapeutic treatments such as remdesivir have been helpful. Remdesivir cuts mortality by seventy per cent in patients on low levels of oxygen, though it has no impact on people on ventilators. Amit Uppal told me that the hospital has improved at managing COVID. "We now understand the potential courses of the disease," he said. Doctors have become more skilled at assessing who requires a ventilator, who might be stabilized with oxygen, who needs blood-thinning medication. Then again, the main factor behind superior outcomes may be that patients now tend to be younger.

When a patient is discharged, the event offers a rare moment for the staff to celebrate. On August 4th, a beaming Chris Rogan, twenty-nine years old, was wheeled by his wife, Crystal, through a gantlet of cheering health-care workers, in scrubs and masks. There were balloons and bouquets. After so much death, a miracle had occurred.

Rogan was an account manager for a health-insurance firm in midtown. Crystal was a teaching assistant. In late March, he developed a low-grade fever and stomach discomfort, but he wasn't coughing. His doctor said that he probably had the flu. Rogan grew increasingly lethargic. He developed pneumonia. An ambulance took him to Metropolitan Hospital, on the Upper East Side. He still felt O.K., even when his oxygen level fell to sixty-four per cent. An hour after he checked in, he couldn't breathe. He was placed in a medically induced coma and intubated for nine days. During that time, the ventilator clogged and Rogan's heart stopped for three minutes. When he was brought back to consciousness, a doctor asked, "Did you see anything while you were dead?"

"No," Rogan said. "I don't even remember being resuscitated."

He began experiencing what hospital staffers told him was I.C.U. psychosis. He told Crystal that he'd been stabbed as a child. He began conversing with God. Just before he was intubated again, on April 15th, he felt certain that he would die in the hospital. He didn't wake up for sixty-one days.

During that time, he was transferred to Bellevue, which was better equipped to handle him.

It's a mistake to think that a patient in a coma is totally unaware. Rogan swam in and out of near-consciousness. When his doctor came in, he tried to talk to him: "Why am I awake? Why can't I move?" He couldn't sleep, because his eyes were partly open. "It's like being buried alive," he told me.

His tenth wedding anniversary passed. Sometimes he heard Crystal's voice on video chat. "I hear you," he'd say, but she couldn't hear him. "I feel the tube down my throat, tell them to take me off the vent." A machine kept pumping oxygen into his lungs: psht! psht! psht! The sound pounded in his head. He would dream that he had left the hospital, then wake to find himself still there, the ventilator pumping away. "It was fucking torture," he said.

He developed internal bleeding. Clots formed in his legs. He told God that he didn't want to die-that he had too much left to do. God assured him that he was going to make it.

Crystal was charged with making choices for Rogan's care. The hardest one was the decision to amputate his right leg. It took three days to get him stable enough to perform the operation, which had to be done at his bedside, because he was too fragile to move. The doctors performed a guillotine amputation, just below the knee. Eight days later, they had to take off the knee.

Rogan doesn't remember any of that. Some days, he is elated to be alive; other times, he asks himself, "What kind of quality of life is this?" Whether or not it was I.C.U. psychosis, he's clung to the experience of talking with God.

When he emerged from the coma, he couldn't move his arms, but now his right hand is functional. After several weeks of rehab, he can walk a bit with a prosthetic leg.

When he fell ill, there were only a hundred and fifty thousand cases in the U.S. When he left the hospital, there were more than four million.

The death toll kept mounting, surpassing three hundred thousand at year's end. Some victims were famous. The playwright Terrence McNally was one of the first. The virus also killed Charley Pride, the first Black singer in the Country Music Hall of Fame, and Tom Seaver, one of the greatest pitchers in baseball history. Eighty per cent of fatalities have been in people aged sixty-five or older, and most victims are male. It's been strange to find myself in the vulnerable population. I'm a year younger than Trump, so his adventure with COVID was of considerable interest to me. If I get ill, I'm not likely to receive the kind of treatment the President did, but I'm in better physical condition, despite a bout of cancer. My wife, though, has compromised lungs. Even before the coronavirus put a target on our age group, mortality was much on my mind. Sometimes I'm dumbstruck by how long I've lived; when I'm filling out a form on the Internet, and I come to a drop-down menu for year of birth, the years fly by, past the loss of parents and friends, past wars and assassinations, past Presidential Administrations.

On September 9th, our grandchild Gioia was born. She is the dearest creature. We stare into each other's eyes in wonder. Even in this intimate moment, though, the menace of contagion is present: we are more likely to infect the people we love than anyone else. Deborah Birx has recalled that, in 1918, her grandmother, aged eleven, brought the flu home from school to her mother, who died of it. "I can tell you, my grandmother lived with that for eighty-eight years," she said.

Even before the election, Matt and Yen Pottinger had decided that they were tired of Washington. He was burned out on the task force, which had drifted into irrelevance as the Administration embraced magical thinking. They drove west, looking for a new place to live, and settled on a ski town in Utah. Matt will join Yen there once he wraps up his job in Washington.

Pottinger's White House experience has made him acutely aware of what he calls "the fading art of leadership." It's not a failure of one party or another; it's more of a generational decline of good judgment. "The élites think it's all about expertise," he said. It's important to have experts, but they aren't always right: they can be "hampered by their own orthodoxies, their own egos, their own narrow approach to the world." Pottinger went on, "You need broad-minded leaders who know how to hold people accountable, who know how to delegate, who know a good chain of command, and know how to make hard judgments."

At the end of October, before returning to D.C., Pottinger went on a trail ride in the Wasatch Range. As it happened, Birx was in Salt Lake City. Utah had just hit a record number of new cases. On the ride, an alarm sounded on Pottinger's cell phone in the saddlebag. It was an alert: "Almost every single county is a high transmission area. Hospitals are nearly overwhelmed. By public health order, masks are required in high transmission areas."

Pottinger said to himself, "Debi must have met with the governor."

C ovid has been hard on Little Africa. "Some of our church members have passed, and quite a few of our friends," Mary Hilton, Ebony's mother, told me recently. "We just buried one yesterday. They're dropping everywhere. It's so scary." A cousin is in the hospital.

"One out of eight hundred Black Americans who were alive in January is now dead," Hilton told me. "There would be another twenty thousand alive if they died at the same rate as Caucasians." She added, "If I can just get my immediate family through this year alive, we will have succeeded." She and two colleagues have written a letter to the Congressional Black Caucus proposing the creation of a federal Department of Equity, to address the practices that have led to such disparate health outcomes.

Infected people keep showing up at U.Va.'s hospital at a dismaying pace. Hilton recently attended the hospital's first lung transplant for a COVID patient. He survived. Lately, more young people, including children, have populated the COVID wards. Hospitals and clinics all over the country have been struggling financially, and many health-care workers, including Hilton, have taken pay cuts.

Thanksgiving in Little Africa is usually a giant family reunion. Everyone comes home. There's one street where practically every house belongs to someone in Hilton's family; people eat turkey in one house and dessert in another. Hilton hasn't seen her family for ten months. She spent Thanksgiving alone in Charlottesville, with her dogs.

Thanksgiving was Deborah Birx's first day off in months. She and her husband have a house in Washington, D.C., and her daughter's family lives in nearby Potomac, Maryland. During the pandemic, they have been a pod. Recently, Birx bought another house, in Delaware, and after Thanksgiving she, her husband, and her daughter's family spent the weekend there.

Her access to the President had been cut off since the summer, and, with that, her ability to influence policy. She had become a lightning rod for the Administration's policies. Then, in December, a news report revealed that she had travelled over the Thanksgiving weekend, counter to the C.D.C.'s recommendation. She was plunged into a cold bath of Schadenfreude. Old photographs resurfaced online, making it look as if she were currently attending Christmas parties.

Birx indicated that she might soon leave government service.

20. Surrender

Austin bills itself as the "Live Music Capital of the World," but the bars and dance halls are largely closed. Threadgill's, the roadhouse where Janis Joplin got her start, is being torn down. The clubs on Sixth Street, Austin's answer to Bourbon Street, haven't been open for months. A band I play in has performed in many of them, but for the past several years we had a regular gig at the Skylark Lounge, a shack tucked behind an auto-body shop. Johnny LaTouf runs the place with his ex-wife, Mary. It's been shut since March 15th.

"All small businesses have been affected, but music venues around the country were already in a struggle," Johnny told me. He's had to let go his ten employees-including three family members. That's only part of the damage. "When the musicians get laid off and the bands disperse and go their separate ways, then you've actually broken up their business." He added, " COVID killed off more than people with preëxisting conditions. Lots of businesses have preëxisting conditions."

Lavelle White, born in 1929, was still singing the blues at Skylark until the doors closed. "Some of our greater musicians are older, because it takes a lifetime to master the craft," Johnny said. Skylark was a mixing bowl where younger musicians learned from their elders. "Now that pathway is broken."

When Congress passed the CARES Act, which included money to support small businesses, local bars were not a priority. "There's no money," Johnny said Wells Fargo told him. He helps several older musicians with groceries, but he doesn't know how many in that crowd will ever return. Some have died from COVID.

Two qualities determine success or failure in dealing with the COVID contagion. One is experience. Some places that had been seared by past diseases applied those lessons to the current pandemic. Vietnam, Taiwan, and Hong Kong had been touched by sars. Saudi Arabia has done better than many countries, perhaps because of its history with mers (and the fact that many women routinely wear facial coverings). Africa has a surprisingly low infection rate. The continent's younger demographic has helped, but it is also likely that South Africa's experience with H.I.V./ AIDS, and the struggle of other African countries with Ebola, have schooled the continent in the mortal danger of ignoring medical advice.

The other quality is leadership. Nations and states that have done relatively well during this crisis have been led by strong, compassionate, decisive leaders who speak candidly with their constituents. In Vermont, Governor Phil Scott, a Republican, closed the state early, and reopened cautiously, keeping the number of cases and the death toll low. "This should be the model for the country," Fauci told state leaders, in September. If the national fatality rate were the same as Vermont's, some two hundred and fifty thousand Americans would still be alive. Granted, Vermont has fewer than a million people, but so does South Dakota, which was topping a thousand cases a day in November. Scott ordered a statewide shutdown in March, which caused an immediate economic contraction. Governor Noem opposed mandates of any sort, betting that South Dakotans would act in their best interests while keeping the economy afloat. Vermont's economy has recovered, with an unemployment rate of 3.2 per cent-nearly the same as South Dakota's. But South Dakota has seen twelve times as many deaths.

In Michigan, the state's chief medical officer, Joneigh Khaldun, is a Black emergency-room doctor. "She was one of the first to look at the demographics of COVID and highlight that we have a real racial disparity here," Governor Whitmer told me. "Fourteen per cent of our population is Black, as were forty per cent of the early deaths." The state launched an aggressive outreach to Black communities. By August, the rates of both cases and fatalities for Blacks were the same as-or lower than-those for whites. The vast differences in outcomes among the states underscore the absence of a national plan. The U.S. accounts for a fifth of the world's COVID deaths, despite having only four per cent of the population.

In August, the Pew Research Center surveyed people from fourteen advanced countries to see how they viewed the world during the pandemic. Ninety-five per cent of Danish respondents said that their country had handled the crisis capably. In Australia, the figure was ninety-four per cent. The U.S. and the U.K. were the only countries where a majority believed otherwise. In Denmark, seventy-two per cent said that the country has become more unified since the contagion emerged. Eighteen per cent of Americans felt this way.

On March 16th, Trump issued nationwide guidelines for closing schools, shutting down bars and restaurants, and limiting unnecessary travel and social gatherings. But that day marked a turning point. In his conversation with governors, he abandoned any effort to coalesce a national plan, and his Administration began undercutting governors' attempts to acquire P.P.E. Then, on April 3rd, Trump undermined the C.D.C.'s guidance on wearing masks: "You don't have to do it. I'm choosing not to do it. But some people may want to do it."

Trump, by his words and his example, became not a leader but a saboteur. He subverted his health agencies by installing political operatives who meddled with the science and suppressed the truth. His crowded, unmasked political rallies were reckless acts of effrontery. In his Tulsa speech, he said that he'd asked his health officials to "slow the testing down"-impeding data collection just to make his Administration look better. When the inevitable happened, and he contracted the disease, he almost certainly spread it. Every guest at the Barrett reception tested negative for the virus before entering. Trump may well have been the superspreader at the Rose Garden event.

The President could have tried to bring the country together. In the press conference where he said that he wouldn't wear a mask, he praised the efforts of the Democratic governors of New York and New Jersey; he expressed sympathy for Michiganders, who were "getting hit very, very hard." He announced federal efforts to aid New York City. "America is engaged in a historic battle to safeguard the lives of our citizens," he said. "Our greatest weapon is the discipline and determination of every citizen to stay at home and stay healthy." The man who said those words might have been the President the country needed. But he was not that man.

He campaigned against Biden, but mainly he campaigned against the disease. "When the year started, he appeared unbeatable," Senator Lee told me. "My Democratic colleagues were discouraged about their chances. By the end of the impeachment trial, when we began hearing about the virus, we were not sure it would be a big deal. But it put an end to one of the things the President is best at-those big rallies." When Trump finally resumed them, defying medical advice, his fury was volcanic. "People are tired of hearing Fauci and all these idiots," he grumbled on October 19th, when the number of new cases exceeded sixty-five thousand. " COVID, COVID, COVID, COVID, COVID, COVID!" he said at a rally in North Carolina, five days later. "We're doing great. Our numbers are incredible." That day, nearly eighty thousand new cases were reported, overshadowing the highest levels of the summer. In Omaha, on October 27th, he said of COVID, "I'm here, right? . . . I had it." Hospitalizations were up forty-six per cent that month. He ignored the fever sweeping through the Mountain West and the Great Plains-Trump country. His slogan was both cynical and fatuous: "If I can get better, anybody can get better."

Infections often rose in counties where Trump held a rally. The surge in infections and deaths mocked his assertions that we were "rounding the turn." The disease stalked him; it encircled him. On October 25th, Trump's chief of staff, Mark Meadows, declared, "We are not going to control the pandemic." The Administration had given up.

COVID couldn't kill Donald Trump, but it could defeat him.

Five days before the election, Biden spoke at a drive-in rally in Tampa. "So much suffering, so much loss," he said. "Donald Trump has waved the white flag, abandoned our families, and surrendered to the virus." Honking cars punctuated his remarks. That day, new confirmed cases topped ninety thousand.

The next day, Fauci said, "All the stars are aligned in the wrong place as you go into the fall and winter season, with people congregating at home indoors. You could not possibly be positioned more poorly."

Halloween night in Austin was beautiful, graced with a blue moon. My wife and I set out a bowl of chocolate bars and Dum Dums, but there were scarcely any trick-or-treaters. As dusk settled over the city, when our neighborhood would normally be filled with fairies and vampires, a deer galloped down the street.

21. "GET HERE NOW"

America is full of strivers whose dreams seem just out of reach. Iris Meda was one of them. She had a big smile but sad eyes. She grew up in Harlem, the oldest of six children. Her mother was a domestic who was home only one day a week; her stepfather was a longshoreman. Meda's first bed was an ironing board.

For most of her childhood, she was the family caretaker, walking her siblings to school before she went herself. Like many of her high-school friends, she dropped out after a bout of depression. She married and had two daughters. Meda eventually got a G.E.D. and surprised herself by graduating at the top of her class from Bronx Community College. In 1984, she earned a nursing degree from City College. Medicine fascinated her. She would go home and talk about watching a surgeon massage a patient's heart. She was drawn to those who were wounded or hurting-people who felt that the world wasn't big enough for them. For years, she was a nurse at the Rikers Island jail. She cared about the prisoners, and they knew it. When her husband was transferred to Dallas, she gave notice, and on her last day the inmates clapped her out. "She was always looking for an underdog to pull up, because she was an underdog," her daughter, Selene Meda-Schlamel, said.

Meda retired in January, after two years in the North Texas Job Corps. She had been in charge of on-site care, meaning that she was on call nights and weekends, and when she turned seventy she decided that she'd had enough. She and Selene had big plans. Meda wanted to travel; she wanted to ride in a convertible for the first time; she talked about writing a book. "In March, it all came to a screeching halt," Selene told me. Her mother was still a proud New Yorker, so she spent a lot of time in front of the TV watching Dr. Fauci and Governor Cuomo. "Her knowledge of science kept her ahead of the news reports," Selene said. Meda, having worked in nursing homes, hospitals, and jails, knew that COVID would be devastating for people who were confined, and for those who took care of them.

Meda couldn't stand being idle during the crisis. "She wanted to teach," Selene said. "She wanted to encourage younger nurses to continue their education. She wanted them to reach their full potential in a way she almost didn't." Meda successfully applied for a job at Collin College, in Allen, Texas. At the time, courses were being offered virtually, and Meda imagined that she would be teaching online in the fall. When the semester began, she learned that many classes were in-person. According to the local NPR station, the college's president, H. Neil Matkin, had made his views of the virus known in an e-mail to trustees: "The effects of this pandemic have been blown utterly out of proportion across our nation."

Meda hoped to be in a large classroom where students could be widely spaced, but she was assigned to teach a lab for a nurse's-aide course. There was no social distancing. On October 2nd, a student was coughing and sneezing, complaining of allergies. That day, Trump announced that he had COVID. Meda was repulsed when he insisted on taking a car ride to wave at his supporters outside the hospital, with Secret Service agents in the car with him. Meda texted Selene, "He's putting all those people at risk just for a photo."

On October 7th, Meda learned that the student had tested positive. The college chose to continue in-person classes even after one student died. By this time, Trump was out of the hospital, saying he felt "better than twenty years ago."

Meda became feverish on October 12th. Two days later, she tested positive and went to the E.R., but her oxygen level was not low enough for her to be admitted. On October 17th, Selene took her mom back to the hospital. Meda was seriously ill, but the staff, worried about COVID, kept her waiting outside, slumped over on a bench in the E.R. drive-through. When the triage nurse finally waved Meda in, Selene wasn't permitted to join her, because she had been exposed. Meda's oxygen level was now so low that she couldn't speak. Selene didn't see her again for thirty days.

During that period, Meda was able to speak only once on the phone. Most days, she texted with Selene. One day, she asked Selene to call a nurse who she thought was doing an excellent job. "She's having a hard day," Meda texted. She worried about her students and wondered if anyone else had caught the virus. (None showed symptoms.)

The disease progressed inexorably. Selene could tell that doctors were doing everything they could, but her mother's lungs wouldn't rebound. Selene wondered if things would be turning out differently had her mother received treatment earlier.

On November 14th, Selene got a call advising that her mother's blood pressure was plummeting. "Based on how she's declining, how long do we have?" Selene asked, thinking that she would pick up her father, so that he could say goodbye. "A couple hours," the doctor said. Ten minutes later, a nurse called and said, "Get here now."

"They put me in a helmet," Selene recalled. "There was a plastic flap that closed around my neck. Inside the helmet there was a fan at the top that blew air down, so that any air that got in would be flushed away. And they put a gown on me, and double gloves, and they let me go in and say goodbye to her. That was the biggest shock, to see her, and to see how she looked. She was twice her size, because she was swollen from steroids. Her tongue was swollen and hanging out the side of her mouth because she was on the ventilator-she'd been intubated. They had to brace her head to keep it straight on the pillow, and they had tape around her mouth to keep the tube in. I'll never forget it. But I think the thing that will haunt me is the smell. It's like the smell of decay, like she had already started to die.

"The thing that made it so hard to see that was to juxtapose it against President Trump out there, saying he felt like he was twenty-eight years old again and he never felt better. So how could the same thing that did this to her, how could someone ever take it for granted that this was nothing, you have nothing to be afraid of?"

Selene gathered her mother in her arms as the machines went silent.

My wife and I voted early, in a drop-off location in Travis County, where ninety-seven per cent of eligible voters were registered. It was a new way of voting-swift, efficient, and rather exhilarating. And yet the vote came amid a crescendo of bad news. The week before November 3rd, the country added half a million new COVID cases, reaching record highs in half the states. The stock market had its worst week since the swan dive in March. Eight million Americans had fallen into poverty since the summer. At least five members of Vice-President Pence's staff had been infected with COVID, as the virus continued to roam the White House.

In Texas, as in many Republican states, there were naked attempts to suppress the vote. Governor Abbott restricted the number of drop-off sites to one per county, including in Harris County, which has more than four million people. The attorney general, Ken Paxton, went to court to block the enforcement of a mask requirement at the polls, endangering voters as well as poll workers, who tend to be older. For the election, Abbott readied a thousand National Guard troops in major Texas cities, in anticipation of violence. Store owners in Dallas boarded up their windows, like beach communities awaiting a hurricane.

But there was no violence in Texas on Election Day. Voting is a simple act, and an act of faith. It is a pledge of allegiance to the future of the country. Across America, people waited in long lines to vote-despite the disease, despite attempts to discredit or invalidate their vote, despite postal delays, despite Russian or Iranian meddling, despite warnings from the White House that the President would not go quietly if he lost. They voted as if their country depended on it. ♦

An earlier version of this piece mischaracterized the cardiac symptoms doctors were seeing in COVID patients.

More on the Coronavirus

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1. "An Evolving Situation" There are three moments in the yearlong catastrophe of the COVID-19 pandemic when events might have turned out differently. The first occurred on January 3, 2020, when Robert Redfield, the director of the Centers for Disease Control and Prevention, spoke with George Fu Gao, the head of the Chinese Center for Disease Control and Prevention, which was modelled on the American institution.

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Can those eligible for a COVID booster shot also get a flu shot?

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With COVID-19 booster shots now on the way and flu season right around the corner, many are wondering if it’s ok to get protection from both illnesses at the same time. "You could get your flu shot with your booster, you can get your flu shot with your first dose, you could get your flu shot with your second dose.

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(Health.com) -- Nobody wants to get the flu this year. The dreaded, head-pounding, body-aching, feverish, nauseating, cough-fest packs equal parts misery and inconvenience.

But nobody wants to get a shot that might be unnecessary or ineffective, either. So, while some experts worry aloud about a 1918-like flu pandemic, most of us -- well aware of the risks of getting the virus, from being sneezed on at the office to living with a toddler -- are not lining up to get the shot. In fact, only a third of us even bother.

The truth is, while the U.S. Centers for Disease Control and Prevention and most mainstream docs are pushing the flu vaccine, the latest science suggests it just doesn't work very well. So, should you or shouldn't you? Here, the answers to your flu-shot questions.

How effective is the shot?
The flu shot is only as good as the educated guesses of a group of vaccine researchers across the globe. Every February, they try to predict which flu viruses will work their evil during the next fall and winter. Their three top choices are put into the vaccine. The CDC claims that vaccine will be 70 to 90 percent effective against just those strains of flu.

"We hope that these smart scientists who get together with the vaccine producers make the right call," says immunologist Dr. Randy Horwitz, medical director of the University of Arizona's School for Integrative Medicine. But sometimes they don't, partly because the virus mutates from year to year. In 2003-2004, the CDC admitted that it completely missed the virulent Fujian flu strain that hit hard that winter.

In the 2005-2006 season, in which the CDC said the match between the vaccine and the virus was good, a strain not included in the vaccine hospitalized 31 children in Houston. Also, two recent studies found that the shot may be less effective for people with weaker immune systems, so its effectiveness can depend on how well your body responds to the vaccine.

Will it make me sick?
Even if it doesn't work, it can't hurt to get the shot, right? For most people that may be true. Millions of vaccinations are administered each year, but since 1991, only about 26,000 adverse events have been reported to the Vaccine Adverse Events Reporting System (VAERS). Most of those were fever, rash, headaches, hives, or, very rarely, seizures. The most common side effect is swelling at the injection site on your arm.

And any bad reactions, thought to be your immune system's way of gearing up after the exposure to dead virus particles in the vaccine, typically ease after a few days. (Manufacturers are required to verify that each batch of vaccine used for injections contains no live flu viruses. But people with egg allergies shouldn't get the shot because the vaccine is manufactured using eggs.)

Still, some researchers aren't comfortable with the safety data. Dr. Tom Jefferson, coordinator of the Vaccines Field for the Cochrane Collaborative, an international group of researchers, reported last year in the British Medical Journal that he had found only six limited studies on safety after reviewing 206 studies on the vaccine. That, he says, is a surprisingly small number considering the widespread use of the vaccine and its mixed bag of ingredients.

Osteopathic doctor Sherri Tenpenny, author of "Vaccines -- The Risks, the Benefits, the Choices: A Resource Guide for Parents," cautions that only small populations and short-term info are used to measure safety. Adverse-events reporting, for instance, is done for only 2 to 14 days after an injection and it's voluntary.

Here's another concern: Except for about 8 million doses, the flu vaccine contains a preservative, thimerosal, that is 49 percent mercury, a known neurotoxin. While the latest research seems to disprove any link between thimerosal vaccines and autism in children, the debate still rages, and several states have prohibited the use of thimerosal in children's vaccines. Yet supplies of mercury-free flu vaccine are limited due to manufacturing capacity. If you want to avoid thimerosal, you may have to make a special request to your health-care provider in advance.

Is the nasal vaccine better than the typical shot?
Hard to say, but the latest news on FluMist may leave you skeptical. Earlier this year the manufacturer, MedImmune, had trouble getting an OK to market the vaccine for kids under 5. The U.S. Food and Drug Administration found ongoing problems at the company's plant in Great Britain -- bacterial and fungal contamination as well as the use of a disinfectant banned by the European Union. Eventually, the company fixed the problems and, in September, received approval for the under-5 set.

Unlike the shot, this vaccine contains live but weakened viruses. When inhaled, these viruses can survive in the nose and throat long enough to trigger the immune reaction that fights off flu, but will be killed by the higher temperatures in your lower respiratory tract. The CDC does not believe these viruses can mutate into a form that can survive. The nasal vaccine is only approved for healthy children ages 2 to 17 and adults ages 18 to 49 who aren't pregnant. (Pregnant women and people with chronic conditions can get the shot.) The nasal vaccine does not have any thimerosal. Federal guidelines on who should -- and shouldn't -- get vaccinated "

Who really needs a shot?
The flu kills. Each year nearly 40,000 people in the United States die from flu complications like pneumonia and heart failure. And more than 200,000 are hospitalized due to flu. The people at highest risk have lowered defenses: children ages 6 months to 5 years, pregnant women, people older than 50, and anyone with a chronic condition like asthma, diabetes, and heart or blood disorders. The CDC recommends they all get vaccinated.

But what if you're healthy and are not in a high-risk group? Should you get vaccinated as a charitable act to help prevent spreading the flu to those who're less healthy? Or to prevent a few weeks of potential misery? If you live or work with high-risk people, maybe you'll decide that the shot is worth it.

You can also gauge your other lifestyle risks. We all know that spending a lot of time in busy public places -- like the subway or a gym -- boosts your risk of catching the flu. Anyone walking around with the virus can breathe it in your direction. And kids in day care or school are more likely to be exposed to the flu than anyone else. Just the simple act of living with them heightens your risk.

Is there a shot shortage?
You may remember the panic over vaccine shortages in 2004, when a major flu-vaccine manufacturer, Chiron, was unable to deliver 50 million doses of the vaccine due to bacterial contamination. Some experts speculate that the shortage encouraged people to stay away from the vaccine in the following years.

But Curtis Allen, spokesperson for the CDC, says a shortage is unlikely this year. Manufacturers are promising a record number of doses (132 million), although they won't all be available at once.

When's the best time of year to get vaccinated?
Now, before the flu season really kicks in from December to March, experts say. It takes about two weeks after vaccination for your body to build up enough antibodies to protect you.

Aren't I more likely to catch a cold than the flu?
For sure. There are more than 200 cold viruses, they mutate a lot, and virtually everybody comes down with one from time to time. Although the worst colds might feel like the flu, lots of people say they have the flu when they really don't. Two years ago, only 13 percent of people who were tested after reporting flu-like illnesses actually had the real thing.

Should I really worry about a flu epidemic?
Nobody really knows. The 1918 pandemic seemed to start like any old flu season, but within a few months the virus had mutated into a monster that killed healthy adults within a day. Like most flus, it may have originated in birds. That's why experts worry that today's avian flu may turn into a global epidemic. But, unlike the 1918 strain, it hasn't spread readily from person to person. And while the regular flu shot won't protect you against avian flu (it's a different strain of the virus), consider this: Researchers are finding that millions of people have been infected with avian flu without suffering serious complications. E-mail to a friend

All About Influenza * Contagious and Infectious Diseases * Vaccines

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centers for disease control and prevention

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(Health.com) -- Nobody wants to get the flu this year. The dreaded, head-pounding, body-aching, feverish, nauseating, cough-fest packs equal parts misery and inconvenience. But nobody wants to get a shot that might be unnecessary or ineffective, either.

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Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: mmwrq@cdc.gov. Type 508 Accommodation and the title of the report in the subject line of e-mail.

The National Immunization Survey (NIS) provides vaccination coverage estimates among children aged 19--35 months for each of the 50 states and selected urban areas.* This report describes the results of the 2007 NIS, which provided coverage estimates among children born during January 2004--July 2006. Healthy People 2010 established vaccination coverage targets of 90% for each of the vaccines included in the combined 4:3:1:3:3:1 † vaccine series and a target of 80% for the combined series ( 1). Findings from the 2007 NIS indicated that>90% coverage was achieved for most of the routinely recommended vaccines ( 2). The majority of parents were vaccinating their children, with less than 1% of children receiving no vaccines by age 19--35 months. The coverage level for the 4:3:1:3:3:1 series remained steady at 77.4%, compared with 76.9% in 2006. Among states and local areas, substantial variability continued, with estimated vaccination coverage ranging from 63.1% to 91.3%. Coverage remained high across all racial/ethnic groups and was not significantly different among racial/ethnic groups after adjusting for poverty status. However, for some vaccines, coverage remained lower among children living below the poverty level compared with children living at or above the poverty level. Maintaining high vaccination coverage and continued attention to reducing current poverty disparities is needed to limit the spread -preventable diseases and ensure that children are protected.

To collect vaccination information on age-eligible children (i.e., those aged 19--35 months), NIS uses a quarterly, random-digit--dialing sample of telephone numbers for each survey area. When respondents grant permission to contact providers, the telephone interview is followed by a mail survey of the children's vaccination providers to validate immunization information. NIS methodology, including how the responses are weighted to represent the population of children aged 19--35 months, has been described previously ( 3). During 2007, the household response rate ( 4) was 64.9%; a total of 17,017 children with provider-verified vaccination records were included in this report, representing 68.6% of all children with completed household interviews. Statistical analyses were conducted using t-tests. Differences were considered statistically significant at p<0.05. A poverty status variable § was added to the logistic regression models to control for racial/ethnic differences among children living at or above the poverty level and children living below the poverty level. This report describes coverage levels for vaccines that have been included in the routine childhood vaccination schedule recommended by the Advisory Committee on Immunization Practices (ACIP) since 2000 or before ( 2).

In 2007, national coverage with the 4:3:1:3:3:1 series was 77.4%; this coverage has been stable since 2004. Coverage with the combined 4:3:1:3:3:1:4 vaccine series (i.e., the 4:3:1:3:3:1 series plus >4 doses of 7-valent pneumococcal conjugate vaccine [PCV7]) is being reported for the first time and was 66.5%. National coverage was>90% for each of the vaccines included in the 4:3:1:3:3:1 series except for>4 doses of DTaP (84.5%); coverage with>3 doses of DTaP was 95.5% ( Table 1). Coverage with>1 dose of varicella vaccine (VAR) reached 90% for the first time. VAR coverage among American Indian/Alaska Native (AI/AN) ¶ children increased significantly, from 85.4% in 2006 to 94.9% in 2007. National vaccination coverage estimates for PCV7 continued to increase, from 86.9% in 2006 to 90.0% in 2007 for>3 doses and from 68.4% to 75.3% for> 4 doses. Among AI/AN children, coverage with the fourth dose of PCV7 increased significantly, from 62.7% to 80.4%.

Substantial differences were observed in vaccination coverage among states and local areas ( Table 2). Estimated coverage for the 4:3:1:3:3:1 series ranged from 91.3% in Maryland to 63.1% in Nevada. Among the 14 local areas included in the 2007 NIS, coverage with the 4:3:1:3:3:1 series ranged from 82.2% in Philadelphia, Pennsylvania, to 69.6% in San Bernardino, California.

Vaccination coverage levels were higher among AI/ANs compared with whites for measles, mumps, and rubella (MMR) vaccine, hepatitis B (HepB) vaccine, and VAR ( Table 3). Coverage with the fourth dose of DTaP and the fourth dose of PCV7 among black children was not significantly lower than white children after controlling for poverty status. Vaccination coverage with the fourth dose of DTaP and the fourth dose of PCV7 was lower among children living below the poverty level compared with children living at or above the poverty level, but this difference declined from 6.1% in 2006 to 4.8% in 2007 for>4 doses of DTaP and from 9.4% in 2006 to 3.5% in 2007 for> 4 doses of PCV7. Vaccination coverage levels were similar across all racial/ethnic groups for the 4:3:1:3:3:1 series. Coverage differed for this series among children living at or above the poverty level compared with children living below the poverty level, but this difference declined from 4.9% in 2006 to 3.2% in 2007. Coverage between white and black children with the 4:3:1:3:3:1:4 series was not significantly different after controlling for poverty status.

Reported by: N Darling, MPH, M Kolasa, MPH, KG Wooten, MA, Immunization Svcs Div, National Center for Immunization and Respiratory Diseases, CDC.

Editorial Note:

NIS is the only population-based, provider-verified survey to provide national, state, and local area estimates of vaccination coverage among children aged 19--35 months. The results of the 2007 survey indicate that vaccination coverage for vaccines recommended routinely by ACIP since 2000 and before ( 2) reached record high levels. Improvements in vaccination coverage for VAR meant that national coverage estimates for all individual vaccines in the 4:3:1:3:3:1 series were>90%, except coverage with>4 doses of DTaP. Coverage with>4 doses of PCV7 also was <90%. However, 3-dose coverage for both DTaP and PCV7 remained high. Coverage with>4 doses of PCV7 increased significantly to 75.3% in 2007, a substantial increase since PCV7 was first recommended in 2000 (5). However, coverage with >4 doses of DTaP has not changed during the past 5 years. Increasing coverage for the fourth dose of DTaP and the fourth dose of PCV7 would improve national coverage for the 4:3:1:3:3:1 series and the 4:3:1:3:3:1:4 series, which will be used to monitor the Healthy People 2010 immunization objectives beginning with 2009 NIS data. The vaccine shortage that ended in September 2004 (6) might have reduced coverage with the fourth dose of PCV7 among children in the 2007 NIS cohort (i.e., those born during January 2004--July 2006). Use of effective interventions, such as parent and provider reminder/recall, reducing out-of-pocket costs, increasing access to vaccination, and multicomponent interventions that include education might further improve overall coverage in areas where coverage is low ( 7). In addition, closing the coverage gap between areas with the highest and lowest coverage remains a priority. To achieve this, further collaborative efforts among CDC, state immunization coordinators, immunization programs, and other entities are essential.

Vaccination coverage among AI/AN children for VAR, MMR vaccine, and the fourth dose of PCV7 increased significantly in 2007 compared with 2006; in 2007, coverage levels among AI/AN children were higher for two of these vaccines (VAR and MMR vaccine) compared with white children. Improved exchange of data between the Indian Health Service information system and state immunization information systems and implementation of evidence-based strategies such as reminder/recall at Indian Health Service and tribal facilities, might have contributed to these increases in vaccination coverage (A. Groom, CDC, personal communication, August 2008). However, further monitoring is needed to determine whether these levels will be sustained.

As in 2006, the results of the 2007 NIS indicate that differences in poverty status accounted for the observed differences in coverage between white and black children for the fourth dose of DTaP and fourth dose of PCV7. In 2007, these differences in coverage between children living at or above the poverty level compared with children living below the poverty level were reduced by one percentage point for DTaP and by nearly six percentage points for PCV7. Continued efforts are needed to improve vaccination coverage among children of all racial and ethnic groups living below the poverty level.

The 2007 NIS results confirm that the majority of parents are vaccinating their children, with less than 1% of children receiving no vaccines by age 19--35 months. Although vaccination coverage in this age group remains high, recent outbreaks of measles have occurred in certain communities (8). Several factors might explain this apparent paradox. Despite record high coverage with MMR vaccine, nearly 8% of children aged 19--35 months surveyed for the 2007 NIS remained unvaccinated. Measles is highly contagious, and clustering of unimmunized children within geographic areas can increase risk for measles and other vaccine-preventable disease transmission. Clusters of unimmunized children might not be detected by NIS methods and might not be visible in national and state rates. Furthermore, any changes in vaccination behaviors among parents of children born after July 2006 would not have been detected by the 2007 survey. Increased attention to parental concerns about vaccine safety has become apparent in recent years ( 9). The 2008 NIS is collecting information on parental concerns about vaccine safety to better assess parental attitudes and beliefs about vaccines. In addition, CDC and its partners are developing new educational materials that can assist parents in making fully informed decisions about immunizing their children.**

The findings in this report are subject to at least three limitations. First, NIS is a telephone survey, and statistical adjustments might not compensate fully for nonresponse and households without landline telephones. Second, underestimates of vaccination coverage might have resulted from the exclusive use of provider-verified vaccination histories because completeness of these records is unknown. Finally, although national coverage estimates are precise, annual estimates and trends for state and local areas should be interpreted with caution because of smaller sample sizes and wider confidence intervals.

Achieving and maintaining high vaccination coverage levels is important to further reduce the burden of vaccine-preventable diseases and prevent a resurgence of measles and other diseases that have been eliminated in the United States (10). Although vaccination coverage estimates were at record highs and above the Healthy People 2010 target for most of the routinely recommended vaccines in 2007, ongoing efforts through partnerships among national, state, local, private, and public entities are needed to sustain these levels and ensure that vaccination programs in the United States remain strong.

Acknowledgments

The findings in this report are based, in part, on contributions by PJ Smith, PhD, Immunization Svcs Div, and BP Bell, MD, Office of the Director, National Center for Immunization and Respiratory Diseases, CDC.

References

1. US Department of Health and Human Services. Healthy people 2010 (conference ed, in 2 vols). Washington, DC: US Department of Health and Human Services; 2000. Available at http://www.healthypeople.gov/document/html/objectives/14-24.htm.

2. CDC. Recommendations and guidelines: 2008 child & adolescent immunization schedules for persons aged 0--6 years, 7--18 years, and catch-up schedule. Atlanta, GA: US Department of Health and Human Services, CDC; 2008. Available at http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm.

3. CDC. Statistical methodology of the National Immunization Survey, 1994--2002. Vital Health Stat 2005;2(138). Available at http://www.cdc.gov/nchs/data/series/sr_02/sr02_138.pdf.

4. Ezzati-Rice TM, Frankel MR, Hoaglin DC, Loft JD, Coronado VG, Wright RA. An alternative measure of response rate in random-digit-dialing surveys that screen for eligible subpopulations. J Econ Soc Meas 2000;26:99--109.

5. CDC. Preventing pneumococcal disease among infants and young children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2000;49(No. RR-9).

6. CDC. Pneumococcal conjugate vaccine shortage resolved. MMWR 2004; 53:851--2.

7. Briss PA, Rodewald LE, Hinman AR, et al. Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. The Task Force on Community Preventive Services. Am J Prev Med 2000;18:97--140.

8. CDC. Update: measles---United States, January--July 2008. MMWR 2008;57:893--6.

9. Cooper LZ, Larsen HJ, Katz SL. Protecting public trust in immunization. Pediatrics 2008;122:149--53.

10. CDC. Measles---United States, January 1--April 25, 2008. MMWR 2008; 57:494--8.

* Fourteen local areas were sampled separately for the 2007 NIS. These included six areas that receive federal immunization grant funds and are included in the NIS sample every year (District of Columbia; Chicago, Illinois; New York, New York; Philadelphia County, Pennsylvania; Bexar County, Texas; and Houston, Texas); seven previously sampled areas (Alameda County, California; Los Angeles County, California; San Bernardino County, California; Miami-Dade County, Florida; Marion County, Indiana; Dallas County, Texas; and El Paso County, Texas); and one area sampled for the first time (western Washington). Local areas sampled in the NIS might change yearly as state immunization programs target local assessments where they are most needed.

† >4 doses of diphtheria, tetanus toxoid, and any acellular pertussis vaccine, which can include diphtheria and tetanus toxoid vaccine or diphtheria, tetanus toxoid, and pertussis vaccine (DTaP);>3 doses of poliovirus vaccine;>1 dose of measles, mumps, and rubella vaccine;>3 doses of Haemophilus influenzae type b vaccine; >3 doses of hepatitis B vaccine; and> 1 dose of varicella vaccine).

§ Poverty status was based on 2006 U.S. Census poverty thresholds (available at http://www.census.gov/hhes/www/poverty.html).

¶ For this report, persons identified as white, black, Asian, or American Indian/Alaska Native are all non-Hispanic. Persons identified as Hispanic might be of any race.

** Additional information available at http://www.cdc.gov/vaccines.

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All MMWR HTML versions of articles are electronic conversions from typeset documents. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version (http://www.cdc.gov/mmwr) and/or the originalMMWR paper copy for printable versions of official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices. **Questions or messages regarding errors in formatting should be addressed to mmwrq@cdc.gov.
Date last reviewed: 9/4/2008

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National, State, and Local Area Vaccination Coverage Among Children Aged 19--35 Months --- United States, 2007

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Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: mmwrq@cdc.gov. Type 508 Accommodation and the title of the report in the subject line of e-mail.

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https://www.cdc.gov/nchs/data/hus/2014/074.pdf
https://www.chop.edu/centers-programs/vaccine-education-center/vaccine-history/developments-by-year
https://www.cnn.com/2003/HEALTH/12/13/sprj.flu03.flu/

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https://usafacts.org/articles/how-many-americans-get-flu-shots-vaccine-cdc/?utm_source=google&utm_medium=cpc&utm_campaign=ND-Healthcare&gclid=Cj0KCQjwsZKJBhC0ARIsAJ96n3XUJtQ0PywjlqrOq6KmxXcLneg6VJ7eWwDP_t3vQtK06W77QKbg0TIaAq02EALw_wcB

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How many Americans get flu shots? - USAFacts

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Historically, children have been more likely to be vaccinated than adults.

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https://www.theguardian.com/science/2007/jan/18/birdflu.medicineandhealth

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The victims of the deadliest flu pandemic in history were killed when their bodies unleashed an uncontrolled immune reaction as a protective mechanism, say scientists. Patients' lungs rapidly became inflamed and filled with blood and other fluids which eventually drowned them.

The discovery could help emergency authorities prepare for flu pandemics caused by the H5N1 avian flu virus, which appears to kill in a similar way. It may also give scientists ideas for making flu vaccines.

In 1918 a strain of influenza ravaged populations around the world, killing an estimated 50 million people before it eventually died out. In a bid to understand why this strain, called the Spanish flu, was so dangerous, American scientists re-constructed the virus in 2005.

In the latest experiment scientists used the re-constructed virus to infect macaque monkeys. They found that the over-reaction of the immune system destroyed the monkeys' lungs within a week.

There are strong parallels between this reaction and the one that almost killed six volunteers who were given the experimental antibody drug TGN1412 at London's Northwick Park hospital in March last year. Both the virus and the drug caused a surge of cytokines, the molecules in the blood that activate immune cells. When this "cytokine storm" occurs in the lungs, body fluids and immune cells can accumulate and block the airways, quickly leading to death.

"Essentially, people are drowned by themselves," said Yoshihiro Kawaoka, a virologist at the University of Wisconsin and a co-author of the study published today in Nature.

In the trials seven macaques were infected with the reconstructed 1918 virus. The experiment was supposed to last 21 days but after eight days the monkeys were so sick with fever, pain and breathing difficulties the researchers, following laboratory guidelines, killed the animals.

Scientists believe the 1918 virus had the same effect on humans. "There was some surprise that it was that nasty. It was the robustness of the immune system that helped victimise them," said Michael Katze, a microbiologist at the University of Washington in Seattle, who took part in the research. "That breaks the paradigm as always thinking of the host response as protective."

It might also explain why the 1918 flu virus killed so many healthy adults in their 20s and 30s; conventional influenza preys mostly on babies, the elderly or sick.

Darwyn Kobasa, of the Public Health Agency of Canada in Winnipeg, said the experiment was highly topical for researchers preparing for a possible flu pandemic from the avian H5N1 virus. "This can also cause very serious disease and it appears to do this in a way that appears quite similar to the 1918 virus. Although no one can predict if the H5 virus will cause a pandemic, the threat posed by the virus is significant."

Professor Kawaoka said that no flu virus other than the 1918 strain had been found to be deadly to monkeys. The speed that it spread and the overwhelming immune system response was only similar to those for the H5N1 avian flu. The only thing preventing a human flu outbreak from H5N1 was that the virus would need to mutate or combine with another strain. The 161 people killed by H5N1 since 2003 had had direct contact with infected birds.

"A greater understanding of the viruses that caused past pandemics will help us predict what to expect to reduce the impact of a new pandemic," said Professor Kobasa.

Professor Katze said: "Our analysis revealed potential mechanisms of virulence, which we hope will help us develop novel anti-viral strategies to both outwit the virus and moderate the host immune response. It's best to be prepared for a pathogenic virus by studying a pathogenic virus." He added that if a new virus were to cause a similar immune response to the 1918 flu authorities could prepare frontline staff in hospitals by treating them with a combination of anti-viral drugs, such as Tamiflu, and medicines to control inflammation.

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Scientists reveal how world's worst flu killed victims

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The victims of the deadliest flu pandemic in history were killed when their bodies unleashed an uncontrolled immune reaction as a protective mechanism, say scientists. Patients' lungs rapidly became inflamed and filled with blood and other fluids which eventually drowned them.

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Historical Reference of Seasonal Influenza Vaccine Doses Distributed | CDC

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Seasonal flu vaccine: total doses distributed provides a cumulative weekly total of the number of doses of flu vaccine distributed - CDC

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ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/Health_US/hus09tables/table084.xls

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How many Americans get flu shots? - USAFacts

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Historically, children have been more likely to be vaccinated than adults.

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Abstract

During the 1989-90 influenza season, 98% of all influenza viruses isolated in the United States and reported to CDC were influenza A. Almost all those that were antigenically characterized were similar to influenza A/Shanghai/11/87(H3N2), a component of the 1989-90 influenza vaccine. Regional and widespread influenza activity began to be reported in late December 1989, peaked in mid-January 1990, and declined rapidly through early April 1990. Most of the outbreaks reported to CDC were among nursing-home residents. Considerable influenza-associated mortality was reflected in the percentage of deaths due to pneumonia and influenza (P&I) reported through the CDC 121 Cities Surveillance System from early January through early April. More than 80% of all reported P&I deaths were among persons greater than or equal to 65 years. In contrast to the predominance of influenza A during 1989-90, during the 1990-91 influenza season 86% of all influenza virus isolations reported were influenza B. Widespread influenza activity was reported from mid-January through April 1991, with regional activity extending into May. Outbreaks were reported primarily among schoolchildren, and no evidence of excess influenza-associated mortality was found. Almost all the influenza B isolates tested were related to influenza B/Yamagata/16/88, a component of the 1990-91 influenza vaccine, but were antigenically closer to B/Panama/45/90, a minor variant.

Comparative age distribution of influenza morbidity and mortality during seasonal influenza epidemics and the 2009 H1N1 pandemic.

Lemaitre M, Carrat F. Lemaitre M, et al. BMC Infect Dis. 2010 Jun 9;10:162. doi: 10.1186/1471-2334-10-162. BMC Infect Dis. 2010. PMID: 20534113 Free PMC article.

Influenza excess mortality from 1950-2000 in tropical Singapore.

Lee VJ, Yap J, Ong JB, Chan KP, Lin RT, Chan SP, Goh KT, Leo YS, Chen MI. Lee VJ, et al. PLoS One. 2009 Dec 1;4(12):e8096. doi: 10.1371/journal.pone.0008096. PLoS One. 2009. PMID: 19956611 Free PMC article.

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national center for biotechnology information

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Influenza--United States, 1989-90 and 1990-91 seasons - PubMed

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During the 1989-90 influenza season, 98% of all influenza viruses isolated in the United States and reported to CDC were influenza A. Almost all those that were antigenically characterized were similar to influenza A/Shanghai/11/87(H3N2), a component of the 1989-90 influenza vaccine. Regional and wi ...

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Feb 20, 2007 (CIDRAP News) - Because of changes in the influenza viruses now in circulation, the World Health Organization (WHO) has recommended changing one of the three viral strains to be used in flu vaccines in the Northern Hemisphere next fall and winter.

The WHO is recommending changing the influenza A/H1N1 strain in the vaccine for the first time since the 2000-01 season. The agency recommends a Solomon Islands strain of H1N1, replacing a New Caledonia strain. The New Caledonia strain of H1N1 had been recommended for the previous 7 years.

The other two recommended strains remain the same as last year. They are a Wisconsin strain of influenza A/H3N2 and a Malaysia strain of influenza B. The WHO had changed the H3N2 strain the past 3 years and changed the B strain last year.

Each February the WHO assesses the flu virus strains in circulation before picking the strains for the next Northern Hemisphere flu season. It takes about 6 months for vaccine manufacturers to grow the viruses in chicken eggs and formulate them into trivalent (three-strain) vaccines. In many years the WHO picks one new strain and some years selects two, as was the case a year ago.

The WHO report on its recommendations, published last week, says H1N1 viruses have predominated in the United States so far this season (September to January), while H3N2 viruses have been more prominent in Canada and Europe. Type B viruses have been circulating at low levels in most countries.

Analysis of the circulating H1N1 viruses has shown that many "were antigenically similar to the current reference virus, A/New Caledonia/20/99, but an increasing proportion of recent viruses was more closely related to A/Solomon Islands/3/2006," the WHO said. Tests in ferrets immunized with the current vaccine showed that the Solomon Islands strain generated a lower antibody response than the New Caledonia strain did, which prompted the decision to recommend using the Solomon Islands variant.

Concerning the H3N2 viruses in circulation, the WHO said tests have shown many samples were similar to the current vaccine virus, called A/Wisconsin/67/2005, but a growing proportion of recent isolates have varied. However, the differences have not emerged clearly enough to warrant changing the recommended vaccine strain.

"While there was genetic variation, the absence of a sufficiently well characterized antigenically variant group including the lack of corresponding egg isolates precluded the selection of a new vaccine candidate in time for the 2007-2008 influenza season," the report said.

In other comments, the WHO report says that H3N2 viruses worldwide continue to show high resistance to the two older antiviral drugs used for flu-amantadine and rimantadine. Some H1N1 viruses also are resistant to the drugs, but the proportion varies by country. The US Centers for Disease Control and Prevention (CDC) has been recommending against using the two drugs in seasonal flu cases since January 2006.

The US Food and Drug Administration and the CDC normally issue their own recommendations about strains for flu vaccines in the United States shortly after the WHO and typically match the WHO advice.

Jennifer Armstrong, a spokeswoman for GlaxoSmithKline, a flu vaccine manufacturer, said the company waits for the CDC recommendations before starting the process of making vaccines for the US market.
See also:
Full WHO report on strain selection
http://www.who.int/influenza/vaccines/20078anorthreport.pdf

WHO page with list of past vaccine strains
http://www.who.int/influenza/vaccines/vaccinerecommendations1/en/index.html

Mar 1, 2006, CIDRAP News story "Two new strains to be used in 2006-07 flu vaccine"
http://www.cidrap.umn.edu/cidrap/content/influenza/general/news/mar0106vaccine.html

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WHO picks one new strain for 2007-08 flu vaccine

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Feb 20, 2007 (CIDRAP News) - Because of changes in the influenza viruses now in circulation, the World Health Organization (WHO) has recommended changing one of the three viral strains to be used in flu vaccines in the Northern Hemisphere next fall and winter.

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Social media users have been sharing an image online that questions the possibility of creating a vaccine for COVID-19 in six months because there are no vaccines for influenza and RSV and no cures for cancer. This claim is partly false.

Examples can be seen here and here .

The posts read: "Can't make a vaccine that works for influenza. No vaccine for RSV. Can't cure cancer. But they sure as heck can make a vaccine in 6 months for an illness that they still don't understand. How's that Kool-Aid taste."

The claim assumes that finding a vaccine for COVID will be equally hard for scientists, but these viruses and diseases are all different in their makeup and paths for a cure.

INFLUENZA

While there is no single vaccine for the flu as there is for measles or mumps, the seasonal flu shot does provide care and prevention among the population.

Although the effectiveness can vary because of seasons, strains and who is being vaccinated, the influenza vaccine does work. The U.S. Centers for Disease Control and Prevention (CDC) explains on its website that vaccination "reduces the risk of flu illness by between 40% and 60% among the overall population during seasons when most circulating flu viruses are well-matched to the flu vaccine." ( here )

The influenza vaccination can prevent catching the flu, reduce flu-associated hospitalization and reduce severe illness. More information can be found here .

RSV

It is true that no vaccine exists for Respiratory Syncytial Virus (RSV). Initial symptoms are like the common cold. Infants, premature babies, older adults and those with some chronic conditions or weakened immune systems are most at risk ( here ).

While a vaccine is not yet available, a medicine called palivizumab can be given in the form of shots during peak seasons to infants and young children at higher risk to protect them from the virus. Personal prevention methods are like those of the novel coronavirus ( here ).

CANCER

Cancer is not one single illness, there are more than 100 types of cancer and a variety of treatments available ( www.cancer.gov/types , here ). The American Cancer Society explains on its website that "Many cancers can be cured, but not all of them and not always". ( here )

The statement in these claims lacks context for the different kinds of cancer that can be cured with various treatments. For example, the average 5-year survival rate for women diagnosed with non-invasive breast cancer is 91% ( here ). The death rate of women from breast cancer decreased by 40% between 1989 and 2007 due to early detection and treatment developments ( here ). In contrast, the 5-year survival rate for those with lung cancer is 19% ( here ).

COVID-19 VACCINE EFFORTS

The statement about a COVID-19 vaccine being developed in 6 months is inaccurate. As of this check's publication in September 2020, it has been eight months since the first case of novel coronavirus was detected in the United States in January ( here ) and a COVID-19 vaccine is yet to have been approved in the U.S.

Vaccines announced by China and Russia over the summer have been met with caution and, at times, suspicion in the United States and Europe ( here , here , here ) Scientists casted doubt on their effectiveness because of their design based on viruses similar to the common cold ( here ).

Generally, the development and approval process for a vaccine is complicated and lengthy ( here ). According to Boston Children's Hospital, the fastest vaccine to date was for mumps and took four years to be completed ( here )

A Reuters vaccine tracker for COVID-19 can be seen here .

According to the New York Times, as of Sept. 11, 2020, there are 38 vaccines being clinically tested on humans and at least 93 vaccines being tested on animals, with 3 vaccines "approved for early or limited use." Their vaccine tracker can be found here .

VERDICT

Misleading. While there is indeed no vaccine for RSV, the seasonal flu shot provides some immunization for influenza and there is effective treatment for some of the many forms of cancer. It has been more than six months since COVID-19 appeared in the United States and no vaccine has been approved.

This article was produced by the Reuters Fact Check team. Read more about our fact-checking work  here   .

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Fact check: Comparing vaccine efforts for COVID-19 to influenza, RSV and cancer lacks context

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Social media users have been sharing an image online that questions the possibility of creating a vaccine for COVID-19 in six months because there are no vaccines for influenza and RSV and no cures for cancer. This claim is partly false.

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The US Food and Drug Administration's Vaccines and Related Biological Products Advisory Committee (VRBPAC)...

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fda selection of flu vaccine for the 2021-2022 season

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FDA selection of flu vaccine for the 2021-2022 season

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The US Food and Drug Administration's Vaccines and Related Biological Products Advisory Committee (VRBPAC)... To continue reading The Pharma Letter please login, subscribe or claim a 7 day free trial subscription and access exclusive features, interviews, round-ups and commentary from the sharpest minds in the pharmaceutical and biotechnology space.

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Each year from October to mid-May, Georgia's Department of Public Health tracks flu activity throughout the State and reports the findings in the Georgia Weekly Influenza Report. Along with other surveillance components, influenza-like illness is tracked with the help of volunteer sentinel providers (private providers, occupational health providers, student health clinics and emergency departments) as part of CDC's ILINet program. While each individual case of influenza is not reportable to health authorities, we monitor flu activity by watching the percent of doctors' visits that are for "influenza-like illness" (fever >100º F and cough and/or sore throat). When these doctors' visits for "influenza-like illnesses" begin to increase compared to baseline levels, we suspect that influenza is active in an area. Baseline levels are considered to be 0-3%.

For archived Weekly Flu Reports visit this page.

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Each year from October to mid-May, Georgia's Department of Public Health tracks flu activity throughout the State and reports the findings in the Georgia Weekly Influenza Report. Along with other surveillance components, influenza-like illness is tracked with the help of volunteer sentinel providers (private providers, occupational health providers, student health clinics and emergency departments) as part of CDC's ILINet program.

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https://www.cdc.gov/flu/season/faq-flu-season-2020-2021.htm

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Centers for Disease Control and Prevention

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What you need to know about the upcoming 2020-2021 influenza season in the United States.

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Flu vaccine is produced by private manufacturers. For the 2020-2021 season, manufacturers have projected they will provide as many as 194 to 198 million doses of influenza vaccine for the U.S. market.

Additional information is available.

Figure 1. Weekly Cumulative Doses (in Millions) of Influenza Vaccines Distributed,* United States, 2016-2021, Data Source: CDC, Data are current through week ending Feb 26, 2021 - View and Download Data

View and Download Data * Due to missing data, data for the following weeks have been imputed using a linear interpolation imputation approach: 2016-2017: Dec week 3; 2017-2018: Sep week 4, Nov week 3, Dec week 3; 2018-2019: Sep week 4, Nov week 3, Dec week 3, Dec week 4; 2019-2020: Sep week 4, Nov week 4, Dec week 4. The estimate for October week 1, 2016-17 is being reviewed.

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Influenza Vaccine Doses Distributed, United States

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Flu vaccine is produced by private manufacturers. For the 2020-2021 season, manufacturers have projected they will provide as many as 194 to 198 million doses of influenza vaccine for the U.S. market. Additional information is available. Figure 1.

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Flu shots may fail to offer sufficient protection this year and cause many more people to fall ill, after coronavirus emergency measures hindered research on influenza.

Scientists said they feared that the reduction in research on dominant variants, notably a 62 per cent drop in the international transportation of flu samples, could lead to a medicine mismatch.

In February, the World Health Organisation recommended the ingredients to be used in vaccines administered in the Northern Hemisphere.

But vaccine makers say that globally, the genetic sequencing of flu variants had fallen by up to 94 per cent before the ruling was made.

"We saw quite a big reduction in the labs supplying the genetic sequence data to WHO, and around September last year, we saw a 94 per cent drop in the genetic sequence data that was reported into the database. So this has had a massive impact in the reporting," said Dr Beverly Taylor, at vaccine maker Seqirus, which provides Britain with seasonal flu vaccines.

"We could have reduced the opportunity to identify viruses as they emerge. We certainly have reduced the opportunity to look at which viruses would give the best overall protection and the best coverage of all the circulating viruses.

"What we're actually seeing is influenza in geographical pockets, so it's very difficult for us to tell which one is going to be the winner. We could potentially see a mismatch for at least one of the subtypes. And so that's cause for concern.

"This winter, it's going to be over 18 months since most of us have seen influenza and there is concern that we'll see a lower level of population immunity."

Thousands of deaths

Since the pandemic began, many laboratories that usually provide flu data have switched to researching Covid-19.

The Academy of Medical Sciences said it estimated that between 15,000 and 60,000 people in the UK could die of flu this winter. A mismatched vaccine could make the situation worse, it said.

"In years with mismatch, [vaccine] effectiveness against both infection and severe disease can be markedly reduced, resulting in more severe epidemics," the authors wrote.

"Given the global decrease in influenza circulation, there has been much less information available on which to base predictions about which influenza strains will circulate this winter.

"As such, there is an increased likelihood that there will be influenza vaccine mismatch this winter, which could result in more infections and disease."

Public Health England said the failure to provide an effective flu vaccine during the winter of 2014 to 2015 may have contributed towards a spike in deaths.

Figures on fatalities of all causes published by the Office for National Statistics showed 28,189 more people died in England and Wales in 2015 than in the previous year, the largest percentage increase since 1968.

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Flu vaccines may be less effective this winter

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Flu shots may fail to offer sufficient protection this year and cause many more people to fall ill, after coronavirus emergency measures hindered research on influenza. Scientists said they feared that the reduction in research on dominant variants, notably a 62 per cent drop in the international transportation of flu samples, could lead to a medicine mismatch.

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FORT WAYNE, Ind. (WANE) - The height of flu season is still a few months away, but health experts are urging the public to get their flu shots in the coming weeks.

Leslie Lake, a pharmacy practice coordinator for Kroger, says the peak of flu season is not until the late fall or early winter. She adds that patients who get a flu shot will need to wait some time before getting full protection from the vaccine.

"The flu shot takes about two weeks to build up to maximum effectiveness, so you want to get it before the flu really starts circulating so that you have an immune response," Lake said.

Flu shots are starting to roll out at a time when local, state and national health officials are trying to convince millions of Americans to get the COVID-19 vaccine. Lake believes there is a window of people who have not gotten the COVID-19 vaccine, but are willing to get the flu shot. When these patients come in for their flu shot, that is also an opportunity to address any concerns about the COVID-19 vaccine.

"I think it definitely opens up a nice space to have those conversations because if the person's coming in for their flu vaccine, you know they're vaccine receptive for the most part," Lake said. "But then, okay let's talk the COVID vaccine and let's clear up some misconceptions. So I think it flows naturally."

Lake also confirmed that patients can receive the COVID-19 and flu vaccines on the same day.

Watch these videos below as Lake answers other frequently asked questions about the flu shot:

Does the flu shot change every year?

I feel more sick from the flu shot than the actual flu. Why is that?

Appointments are available to schedule a flu shot at various pharmacies, including Kroger. To schedule a free flu shot, visit Kroger's website.

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Health experts encouraging others to get flu shots sooner than later

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FORT WAYNE, Ind. (WANE) - The height of flu season is still a few months away, but health experts are urging the public to get their flu shots in the coming weeks. Leslie Lake, a pharmacy practice coordinator for Kroger, says the peak of flu season is not until the late fall or early winter.

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by: Chris Melore/StudyFinds.org via Nexstar Media Wire

Posted: / Updated:

(GettyImages)

(StudyFinds.org) - A new study reveals the annual influenza vaccine may provide significant protection against some of the most serious complications from a coronavirus infection.

Researchers from the University of Miami Miller School of Medicine say the largest study of its kind to date has discovered that the basic flu shot lowers the risk of stroke, sepsis, and blood clots in patients with COVID-19. Moreover, COVID patients who have been vaccinated against the flu are also less likely to need hospitalization or enter the intensive care unit.

Study authors note their findings are particularly important since much of the world is still waiting to receive their COVID vaccinations. Hesitancy due to distrust of vaccines or unfounded claims about side effects have also kept countries from reaching their goals for herd immunity.

"Only a small fraction of the world has been fully vaccinated against COVID-19 to date, and with all the devastation that has occurred due to the pandemic, the global community still needs to find solutions to reduce morbidity and mortality," says senior study author Devinder Singh, M.D., chief of plastic surgery and professor of clinical surgery at the Miller School, in a university release.

"Having access to the real-time data of millions of patients is an incredibly powerful research tool," adds Dr. Singh. "Together with asking important questions, my team has been able to observe an association between the flu vaccine and reduced morbidity in COVID-19 patients."

A flu shot may keep COVID patients out of the hospital

Researchers examined the electronic health records from a database of more than 70 million anonymous patients in the U.S., United Kingdom, Germany, Italy, Israel, and Singapore. From that pool, the team selected nearly 75,000 patients, which they split into two equal groups.

The first group of 37,377 COVID patients received a flu shot between two weeks and six months prior to their diagnosis. The second group tested positive for the virus but did not receive an annual flu vaccine. The team compared these groups, looking at rates of 15 severe complications due to coronavirus within 30, 60, 90, and 120 days of infection.

Those conditions included sepsis, strokes, deep vein thrombosis or DVT blood clots, pulmonary embolism (a blood clot in the lungs), acute respiratory failure, acute respiratory distress syndrome (ARDS), joint pain, kidney failure, anorexia, heart attack, pneumonia, emergency room visits, hospital admission, ICU admission, and death.

In comparison to patients getting their flu shots, unvaccinated COVID patients were up to 20 percent more likely to enter a hospital ICU due to coronavirus. People who did not get a flu shot were nearly 60 percent more likely to need hospitalization and 45 percent more likely to develop sepsis. They were also 58 percent more likely to suffer a stroke and up to 40 percent more likely to develop DVT blood clots while dealing with COVID-19.

Study authors note the risk of death did not noticeably decrease among patients getting their annual flu vaccine.

A flu shot is not a substitute for the COVID vaccine

The Miami team says it's unclear what exactly makes a flu shot so protective for COVID patients. However, the team theorizes that the influenza vaccine boosts the body's innate immune system - strengthening the defenses that protect against all forms of illness.

Despite these findings, researchers say opting for a flu shot this fall is no substitute for the coronavirus vaccine. They urge people to receive both shots in order to avoid both the coronavirus and a potential resurgence of the flu after public safety measures end.

"Continued promotion of the influenza vaccine also has the potential help the global population avoid a possible 'twindemic' - a simultaneous outbreak of both influenza and coronavirus," concludes lead author and medical student Susan Taghioff. "Regardless of the degree of protection afforded by the influenza vaccine against adverse outcomes associated with COVID-19, simply being able to conserve global health care resources by keeping the number of influenza cases under control is reason enough to champion continued efforts to promote influenza vaccination worldwide."

The findings appear in the journal .

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flu shots may protect against severe complications from covid-19

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Flu shots may protect against severe complications from COVID-19

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by: Chris Melore/StudyFinds.org via Nexstar Media Wire Posted: / Updated: (StudyFinds.org) - A new study reveals the annual influenza vaccine may provide significant protection against some of the most serious complications from a coronavirus infection.

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Influenza Actvy and Composition of the 1992-93 Flu Vaccine (cdc.gov)

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This online archive of the CDC Prevention Guidelines Database is being maintained for historical purposes, and has had no new entries since October 1998. To find more recent guidelines, please visit the following:

Composition of the 1992-93 Influenza Vaccine

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Article
During the 11 influenza seasons from 1977 through 1988, more than 10,000 excess deaths attributed to pneumonia and influenza (P&I) were reported during each of seven seasons, and approximately 45,000 deaths were reported during each of two seasons (CDC, unpublished data, 1992). The most important strategy for preventing influenza-associated morbidity and mortality is vaccination of persons in high-risk groups with vaccine closely matched to circulating strains. In collaboration with state and local health departments, CDC conducts surveillance to monitor influenza activity and to detect antigenic changes in the circulating strains of influenza virus. This report summarizes surveillance for influenza in the United States and worldwide during the 1991-92 season and describes the composition of the 1992-93 influenza vaccine.
United States
During the 1991-92 influenza season, substantial influenza activity began in October and peaked from December 1 through January 18 when 11-20 states reported widespread activity * each week. From January 19 through March 21, activity steadily declined; for the week ending March 21, no states reported widespread activity, and three states reported regional activity.
Before mid-December, outbreaks were reported primarily in schools; subsequently, outbreaks were reported in schools, nursing homes, and other institutional settings. Based on data from death certificates provided by CDC's 121 U.S. Cities Mortality Surveillance System, excess mortality was associated with P&I. The proportion of deaths attributable to P&I exceeded the epidemic threshold for 7 consecutive weeks (from the weeks ending December 28 through February 8) and peaked at 7.9% of all deaths during the week ending January 18.

Of the 5861 influenza virus isolates reported to CDC, more than 99% were influenza A. Of the influenza A virus isolates subtyped, 81% were influenza A(H3N2), and 19% were influenza A(H1N1). As of April 10, 179 (99%) of the 180 influenza A(H3N2) viruses characterized at CDC resembled A/Beijing/353/89, the A(H3N2) component included in the 1991-92 influenza vaccine. Influenza A(H1N1) viruses were isolated most frequently in the mid-Atlantic and South Atlantic regions and accounted for 30% and 52% of influenza A isolates, respectively. Influenza A(H1N1) viruses were characterized by moderate antigenic heterogeneity.

Worldwide
Influenza activity worldwide occurred at moderate levels during the 1991-92 influenza season. Although most activity was associated with influenza A(H3N2), influenza A(H1N1) viruses were isolated in 17 countries; influenza B viruses were isolated rarely. Most countries reported that influenza activity began in December and peaked in late January or early February.
In Europe, influenza A(H3N2) virus was the predominant isolate in the Commonwealth of Independent States, Czechoslovakia, Denmark, Finland, France, Greece, Hungary, Italy, the Netherlands, Norway, Portugal, Romania, Spain, Sweden, Switzerland, and the United Kingdom; in some of these countries, it was associated with localized outbreaks. In Asia, outbreaks of influenza A(H3N2) were reported in Japan, Korea, and the People's Republic of China.

Although influenza A(H1N1) viruses were isolated less frequently worldwide, Belgium and Japan reported that A(H1N1) viruses constituted the majority of isolates and were isolated from outbreaks. France, Germany, the Netherlands, and the United Kingdom reported that approximately 20% of the influenza A viruses isolated were A(H1N1). In these countries, the proportion of influenza A(H1N1) viruses isolated increased during the latter part of the season as influenza A(H3N2) activity declined. Bulgaria, Canada, the Commonwealth of Independent States, Croatia, Finland, Norway, Spain, Switzerland, and Yugoslavia reported only sporadic cases of influenza A(H1N1).

Outbreaks caused by influenza B viruses were reported in Greece, Korea, the People's Republic of China, Taiwan, Tunisia, and Yugoslavia. Sporadic cases were reported from Canada, the Commonwealth of Independent States, Finland, France, Norway, Poland, Sweden, the United Kingdom, and the United States.

Composition of the 1992-93 Influenza Vaccine
For the 1992-93 influenza season, the Food and Drug Administration (FDA) Vaccines and Related Biologicals Advisory Committee (VRBAC) has recommended that the trivalent influenza vaccine contain A/Texas/36/91-like(H1N1), A/Beijing/353/89-like(H3N2), and B/Panama/45/90-like viruses. This recommendation was based on the antigenic analyses of recent isolates and studies of the antibody response of persons previously vaccinated with the 1991-92 influenza vaccine.
Antigenic analyses of influenza A(H1N1) isolates from North America and Europe indicate that antigenic heterogeneity exists among recent isolates (1,2). Approximately 40% of isolates, represented by the A/Texas/36/91 strain, exhibit drift from the A/Taiwan/1/86 vaccine strain. Antibody induced by the A/Taiwan/1/86 vaccine component reacted at lower titers with the A/Texas/36/91 virus and other representative 1991-92 A(H1N1) viruses than with A/Taiwan/1/86 in several vaccine studies (Table 1). Therefore, the VRBAC recommended changing the influenza A(H1N1) vaccine component to an A/Texas/36/91-like strain for the 1992-93 vaccine.

Although some antigenic heterogeneity exists among influenza A(H3N2) isolates, most viruses isolated throughout the world were antigenically related to the A/Beijing/353/89 vaccine strain (2). Antibody induced by this vaccine component reacted similarly with recent isolates, such as the A/Washington/15/91 virus, in serum from all age groups, and postvaccination geometric mean titers (GMTs) of antibody to the recent isolates were approximately 50%-100% of those to the vaccine virus. Thus, the World Health Organization and the VRBAC recommended retaining the A/Beijing/353/89 vaccine strain.

Two distinct strains of influenza B virus, related to either the B/Victoria/2/87 or the B/Yamagata/16/88 and B/Panama/45/90 reference strains, have cocirculated in the world since 1988. Since October 1991, only two strains related to the B/Victoria/2/87 reference strain have been identified worldwide. Although relatively few influenza B viruses related to the B/Yamagata/16/88 and B/Panama/45/90 reference strains have been isolated, antigenic heterogeneity has been observed among them. Postvaccination serum specimens obtained from vaccinees of all age groups reacted well with the vaccine virus B/Panama/45/90, and except for serum from the youngest children, also reacted well with B/Victoria/2/87. In all age groups, the postvaccination GMTs to recent influenza B isolates were approximately 50%-100% of those for the vaccine virus. Therefore, for the 1992-93 vaccine, the VRBAC recommended retaining the B/Panama/45/90 vaccine strain.

Reported by: K Nerome, PhD, National Institute of Health, Tokyo, Japan. M Chakraverty, PhD, Central Public Health Laboratory; J Skehel, PhD, National Institute for Medical Research, London; G Schild, PhD, J Wood, PhD, National Institute for Biological Standards and Control, Hertfordshire, England. I Gust, MD, Commonwealth Serum Laboratories, Parkville, Australia. J Groothuis, MD, Univ of Colorado School of Medicine and The Children's Hospital; P Graves, G Meiklejohn, MD, Univ of Colorado Medical Center, Denver. A Biache, MSN, Goodwin House, Inc., Alexandria, Virginia. WHO National Influenza Centers, Microbiology and Immunology Support Svcs, World Health Organization, Geneva. Participating state and territorial health department epidemiologists and state public health laboratory directors. Div of Virology, Center for Biologics Evaluation and Research, Food and Drug Administration. Epidemiology Activity and WHO Collaborating Center for Influenza, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC.

Editorial Note
Editorial Note: Strains to be included in the influenza vaccine for the United States are selected from late January through March each year to meet the production schedule required for the manufacture, quality control, and distribution of more than 30 million doses of vaccine before the next influenza season. Specific recommendations for the use of the newly constituted influenza vaccine will be made by the Immunization Practices Advisory Committee of the Public Health Service and published in the MMWR Recommendations and Reports dated May 15, 1992.
* Levels of activity are: 1) sporadic -- sporadically occurring influenza-like illness (ILI) or culture-confirmed influenza, with no outbreaks detected; 2) regional--outbreaks of ILI or culture-confirmed influenza in counties having a combined population of less than 50% of the state\'s population; 3) widespread -- outbreaks of ILI or culture-confirmed influenza in counties having a combined population of 50% or more of the state's total population.

References

1. CDC. Update: influenza activity -- United States, 1991-92 season. MMWR 1992;41:63-5.

2. World Health Organization. Recommended composition of influenza virus vaccines for use in the 1992-1993 season. Wkly Epidemiol Rec 1992;9:57-60.

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Influenza Actvy and Composition of the 1992-93 Flu Vaccine

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This online archive of the CDC Prevention Guidelines Database is being maintained for historical purposes, and has had no new entries since October 1998.

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Percentages of people who received the flu vaccine during the years of 1989 and 2004.

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Flu Season Summary (September 30, 2007 - May 17, 2008)**

When did the 2007-2008 flu season start, peak and end?

From October through early December, low levels of flu activity were reported in the United States. The first report of regional flu activity came from the West South Central region of the United States (Texas) during the first week of December. (Regional flu activity is defined as increased flu-like activity or flu outbreaks in at least two - but fewer than half - of the regions in a state with recent laboratory evidence of flu in those regions.) Activity increased slowly from mid-December through the end of the year with more rapid increases during January and through the week ending February 16. Flu activity peaked in mid-February and then decreased through the end of the flu season on May 17.

How severe was the 2007-2008 flu season?

A greater proportion of deaths associated with influenza illness and slightly higher rates of influenza-related hospitalizations in children 0-4 years occurred during the 2007-2008 U.S. flu season than was measured during each of the previous three seasons. When compared with the previous three seasons, the 2007-2008 season was similar in severity to the 2004-2005 flu season in terms of the percentage of deaths due to pneumonia and flu, pediatric hospitalization rates, and the percentage of visits to outpatient clinics for flu-like illness.

What determines the severity of a flu season?

The overall health impact (e.g., infections, hospitalizations and deaths) of a flu season varies from year to year. Based on available data from U.S. influenza surveillance systems monitored and reported by CDC, the severity of a flu season can be judged according to a variety of criteria, including:

The level of reported activity within each state;

The proportion of influenza laboratory tests that are positive;

The proportion of visits to physicians for influenza-like illness;

The proportion of all deaths that are caused by pneumonia and flu;

The number of influenza-associated deaths among children; and

The influenza-associated hospitalization rate among children

A season's severity is determined by comparing these measures with previous seasons.

Was the peak of the 2007-2008 flu season typical in terms of timing?

Flu activity for the 2007-2008 U.S. flu season peaked in mid-February. Flu activity in the United States typically peaks between December and March, and the timing of peak activity changes from year to year. In 16 of the past 26 years, the U.S. flu season has peaked in February or later, making this year pretty typical in terms of the timing of the peak.

Where did most flu activity occur in the United States this season?

Flu viruses were identified in all states. In February, when the flu season peaked, widespread* flu activity was reported in all 50 states across all regions of the country.

* Widespread flu activity is defined as increased flu-like activity or flu outbreaks in at least half of the regions in a state with recent laboratory evidence of flu in the state.

How many people died from flu during the 2007-2008 season?

Exact numbers of how many people died from flu this season cannot be determined. Flu-associated deaths (which have laboratory confirmed influenza), are only a nationally notifiable condition among children; however not all pediatric influenza deaths may be detected and reported and there is no requirement to report adult deaths from influenza. In addition, many people who die from flu complications are not tested, or they seek medical care later in their illness when flu can no longer be detected from respiratory samples. However, CDC tracks pneumonia and influenza (P&I) deaths through the 122 Cities Mortality Reporting System. This system collects information each week on the total number of death certificates filed in each of the 122 participating cities and the number of death certificates with pneumonia or influenza listed as a cause of death. The 122 Cities Mortality Reporting system helps gauge the severity of a flu season compared with other years. However, only a proportion of all P&I deaths are influenza-related and, as noted, most flu deaths are not lab confirmed. Thus, this system does not allow for an estimation of the number of deaths, only the relative severity among different influenza seasons. For the 2007-2008 season, the proportion of deaths due to pneumonia and influenza was higher than the previous two years, but was similar to the 2004-2005 season.

What flu viruses circulated this season?

In the United States, influenza A (H1N1), A (H3N2) and B viruses co-circulated throughout the season. Influenza A viruses accounted for 71% of the specimens testing positive for flu by public health laboratories while influenza B viruses accounted for 29%.

Early in the season, influenza A (H1N1) viruses predominated, however, as the season progressed, an increasing proportion of sub-typed* influenza A viruses were influenza A (H3N2) viruses. Late in the season, when overall influenza activity was declining, influenza B viruses were more commonly reported than influenza A viruses. Overall, for the 2007-2008 U.S. flu season, influenza A (H3N2) viruses were most commonly reported.

* Subtyping is the process of identifying an influenza A virus by its genetic and antigenic (biological) properties to determine if it is an influenza A (H3N2) or influenza A (H1N1) virus. Flu A viruses are subtyped in public health laboratories, such as state department of health laboratories and CDC Influenza Division laboratories.

How well did circulating viruses match the vaccine strains during the 2007-2008 season?

The majority (66%) of influenza A (H1N1) viruses were found to be similar to the vaccine strain. However, 77% of influenza A (H3N2) and 98% of B viruses sent to CDC for further testing were not optimally matched to the 2007-2008 influenza vaccine strains.

Why were two of the three strains in this season's flu vaccine less than optimally matched to circulating viruses?

Flu viruses are always changing. They can change from the time the vaccine is recommended and the beginning of the flu season, or they can even change during a flu season. Each year, experts study thousands of flu virus samples from around the world to figure out which viruses are making people sick and how these viruses are changing. With this information, they forecast which three viruses are most likely to make the most people sick during the next flu season. Each year, the seasonal influenza vaccine contains three influenza virus strains - one influenza A (H3N2) virus, one influenza A (H1N1) virus, and one influenza B virus. The selection of which viruses to include in the vaccine must be made in February of the prior year in order for vaccine to be produced in time for distribution the following season. For this reason, there is always the possibility of a less than optimal match between viruses in the vaccine and circulating viruses. For more information about the vaccine strain selection process, visit Selecting the Viruses in the Influenza (Flu) Vaccine.

In terms of the influenza A (H3N2) virus strain selection for the 2007-2008 vaccine, in February of 2007, there were few influenza A (H3N2) virus samples available to guide the selection of the H3N2 vaccine component. While the H3N2 A/Brisbane-like virus that became the predominant virus in the U.S. this season first emerged in Australia in 2007, there was no clear indication that this virus would become the predominant virus causing illness. In addition, there were very few influenza A (H3N2) samples and nothing suitable as a strain for vaccine production. For this reason, the World Health Organization and the Vaccines and Related Biologicals Advisory Committee in the U.S. Food and Drug Administration recommended that the influenza A (H3N2) component of the 2007-2008 influenza vaccine would remain the same as the previous season because influenza A (H3N2) viruses similar to the vaccine strain were still circulating and no other candidate reference strains were available. CDC continued to monitor this situation closely and frequently updated information on circulating strains and public health and public education guidance based on this information throughout the season.

In terms of the selection of the B/Yamagata lineage for inclusion in the 2007-2008 vaccine, in February 2007, both B/Yamagata and B/Victoria viruses were co-circulating, however the B/Victoria lineage was predominant at the time. B/Victoria and B/Yamagata viruses are antigenically and genetically far apart. With two co-circulating B lineages, it's more difficult to forecast which B lineage will predominate for the next season. At the time the vaccine virus selection decision was made, is was not yet clear that B/Yamagata viruses would become the predominant B viruses circulating in the United States this season.

Can the vaccine provide protection even if the vaccine is not a "good" match?

Yes, antibodies made in response to vaccination with one strain of influenza viruses can provide protection against different, but related strains. A less than ideal match may result in reduced vaccine effectiveness against the variant viruses, but it can still provide enough protection to prevent or lessen illness severity and prevent flu-related complications. In addition, it's important to remember that the influenza vaccine contains three virus strains so that even when there is a less than ideal match or lower effectiveness against one strain, the vaccine may protect against the other two viruses. For these reasons, even during seasons when there is a less than ideal match, CDC continues to recommend influenza vaccination. This is particularly important for people at high risk for serious flu complications and their close contacts.

How often are the vaccine and circulating virus strains well matched?

In recent years the match between the vaccine viruses and those identified during the flu season has usually been good. In 16 of the last 20 U.S. influenza seasons, including the 2007-2008 season, the viruses in the influenza vaccine have been well matched to the predominant circulating viruses. Since 1988, there has only been one season (1997-1998) when there was very low cross-reaction between the viruses in the vaccine and the predominate circulating virus and three seasons (1992-1993, 2003-2004, and 2007-2008) when there was low cross-reaction.

What did we see during the 2007-2008 season in terms of antiviral resistance monitoring or surveillance in the United States?

During the 2007-2008 flu season, a small increase in the number of flu viruses resistant to the neuraminidase inhibitor oseltamivir was observed. Among specimens collected since October 1, 2007, 111 (10.9%) of the 1,020 influenza A (H1N1) viruses tested were found to be resistant to oseltamivir, an increase from four (0.7%) of 588 influenza A (H1N1) viruses tested during the 2006-2007 season. No resistance to oseltamivir was identified among the 444 influenza A (H3N2) or the 305 influenza B viruses tested.

CDC laboratory surveillance has indicated continued high resistance among influenza virus isolates to the adamantanes (amantadine and rimantadine) in the United States. Among specimens collected since October 1, 2007, 99.8% of influenza A (H3N2) viruses tested were resistant to the adamantanes. Adamantane resistance among influenza A (H1N1) viruses has been detected at a lower level with 10.8% of influenza A (H1N1) viruses resistant to adamantanes.

Did CDC recommend any changes to the guidance on the use of antivirals for the 2007-2008 influenza season?

No, CDC did not recommending any changes to the guidance on the use of influenza antivirals. CDC and the Advisory Committee on Immunization Practices (ACIP) recommended that oseltamivir (brand name Tamiflu®) or zanamivir (brand name Relenza®) be used for the treatment and prevention of flu in the United States during the 2007-2008 season. Although amantadine and rimantadine (two other influenza antiviral drugs) also are FDA-approved for treatment or prevention of influenza, these two drugs were NOT recommended for use in the United States during the 2007-2008 flu season because many recent flu viruses are resistant to these drugs. This guidance can be found in Prevention & Control of Influenza - Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2007 Jul 13;56(RR06):1-54.

What was this season like in terms of bacterial co-infections, including Staphylococcus aureus, with flu?

Bacterial infections can occur as co-infections with influenza or occur following influenza infection. In 2006-2007, CDC noted an increase in flu and Staphylococcus aureus (S. aureus) co-infections among children who had died or were hospitalized with influenza infection. Some of those infections were with methicillin-resistant S. aureus (MRSA). CDC is working with state and local public health authorities to monitor and investigate flu- S. aureus co-infections, including pneumonias and other types of S. aureus infections. On January 30, 2008 CDC issued a Health Advisory on Influenza-Associated Pediatric Mortality and Staphylococcus aureus co-infection. For more information about flu and staph infections visit Seasonal Flu and Staph Infection.

Flu Deaths in Children

Flu-associated deaths in children (defined as persons aged 18 years and younger) first became a nationally notifiable condition during the 2004-2005 flu season and are reported through the National Notifiable Diseases Surveillance System (NNDSS). The number of flu-associated deaths among children reported during the 2007-2008 flu season can be found at Flu Activity & Surveillance.

How many children have died from flu-associated complications during previous flu seasons?

During the 2003-2004 season, 153 flu-associated deaths in children were reported to CDC. (This data was collected by CDC.)

During the 2004-2005 season, 47 deaths in children were reported to CDC. (This is the first year that influenza mortality in children became a nationally reportable condition.)

During the 2005-2006 season, 46 deaths in children were reported to CDC.

During the 2006-2007 season, 76 deaths in children were reported to CDC.

As of June 14, 2008, 83 deaths in children occurring during the 2007-2008 season have been reported to CDC.

(Note: The counts above are of flu-associated deaths among children according to the flu season the deaths occur, not when they are reported to CDC.)

What can be done to protect children from flu-associated illness and death?

Vaccination remains the best method for preventing flu and its potentially severe complications in children. There are two types of vaccines that protect against the flu. The "flu shot" is an inactivated vaccine (containing killed virus) approved for use among people 6 months of age or older, including healthy people and those with chronic medical conditions (such as asthma, diabetes, or heart disease). The nasal-spray flu vaccine (sometimes referred to as LAIV for Live Attenuated Influenza Vaccine or FluMist®) contains attenuated (weakened) live viruses, and is administered by nasal sprayer. It is approved for use only among healthy* people 2-49 years of age who are not pregnant. Children under 6 months old can become very sick from the flu, but they are too young to get a flu vaccine. The best way to protect young children is to make sure that their household members and their caregivers are vaccinated.

Children 6 months to 9 years of age getting a flu shot for the first time will need two doses of vaccine the first year they are vaccinated, with the first dose ideally being given in September. The second dose should be given 28 or more days after the first dose. The first dose "primes" the immune system; the second dose provides immune protection. Keep this in mind if your child needs the two doses-begin the process early. It usually takes about two weeks after the second dose for protection to begin.

Vaccination should begin in September or as soon as vaccine is available. Though it varies, the flu season can last as late as May and sporadic cases of flu occur year round. For more information, see Children, the Flu, and the Flu Vaccine.

* "Healthy" indicates persons who do not have an underlying medical condition that predisposes them to influenza complications.

**The most up-to-date influenza surveillance summaries can be found at Flu Activity & Surveillance.

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Summary of the 2007-2008 Influenza Season

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From October through early December, low levels of flu activity were reported in the United States. The first report of regional flu activity came from the West South Central region of the United States (Texas) during the first week of December.

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https://www.cdc.gov/flu/prevent/vaccine-supply-historical.htm

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Historical Reference of Seasonal Influenza Vaccine Doses Distributed | CDC

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Seasonal flu vaccine: total doses distributed provides a cumulative weekly total of the number of doses of flu vaccine distributed - CDC

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See How Vaccinations Are Going in Your County and State

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See where doses have gone, and who is eligible for a shot in each state.

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Flu shots will be available soon in the United States, and health experts hope people will get vaccinated early. Luis Alvarez/Getty Images

Health experts are expressing concerns that this fall's flu season in the United States is coinciding with another surge in COVID-19 cases.

They say they hope vaccine hesitancy and fatigue won't carry over from COVID-19 into the flu season.

Flu shots will begin to be distributed in August and will continue through November.

After influenza was nearly nonexistent in 2020, health authorities in the United States are gearing up for a flu season that coincides with the circulation of the Delta strain of COVID-19.

Experts say that having both influenza and the Delta variant active could pose some challenges this fall.

"We infectious disease people and public health folks are very concerned. We're anxious because COVID-19, Delta, or the other strains, and influenza are certainly in their clinical presentation initially, indistinguishable. We will be doing, I anticipate, a great deal of testing to try and distinguish flu from COVID-19," Dr. William Schaffner, an infectious disease expert at Vanderbilt University in Tennessee, told Healthline.

Last year, the number of influenza cases in the United States was historically low. Experts say this was likely due to the public health measures put in place to mitigate COVID-19.

"That first flu season during COVID-19... was a non-flu season. The lowest rate of flu that any of us can remember. That was because, of course, we were all social distancing, remaining at home and avoiding large groups, working many of us virtually from home and, most importantly from my point of view, children were studying virtually at home. They were not interacting with each other whether at school or on the playground," Schaffner said.

The 2021 flu season in Australia has seen similarly low rates of influenza circulating. There have been only 419 confirmed cases of influenza in Australia this year.

Schaffner says this is surprising.

"I would have anticipated at least some influenza during (the Australian) typical influenza season. I'm very surprised. I'm still concerned that we will have influenza here. To what degree... I don't know," he said.

This year, with schools returning to in-person learning, businesses reopening, and people interacting, health authorities anticipate an increase in influenza.

"The environment to have influenza be introduced, spread, and cause disease is there. So, we're all really quite anticipating we will have some sort of influenza season this fall and winter," Schaffner said. "How severe it will be, we don't know, but nonetheless we expect flu, and we're already starting to promote influenza vaccination here in the states, just alerting people that COVID-19 vaccine is not the only vaccine that ought to be on their minds."

The U.S. Centers for Disease Control and Prevention (CDC) flu vaccine distribution in the United States will begin in August and continue through November.

They say that manufacturers are expected to produce between 188 million and 200 million doses.

The CDC 50 to 55 percent of adults in the United States got a flu vaccination last year, up from 48 percent the previous season.

But Schaffner worries people have become tired of vaccine campaigns and are less likely to opt for a flu shot this year.

"Our influenza vaccine campaign will be in some sense competing with COVID-19. Even among people who've received the COVID-19 vaccine, there is a kind of vaccine weariness. We have been speaking about vaccination so much I think some of our messaging will fall on deaf ears, ears that in previous years would have been more receptive to the message to get vaccinated against flu," he said.

Recent research suggests that the flu vaccine may also protect against stroke, sepsis, and deep vein thrombosis in people with COVID-19.

However, despite the benefits, Schaffner says persuading the segment of the population who are hesitant to get the flu shot will be as difficult as persuading them to get the COVID-19 vaccination.

"That's an overlapping population, very much so, and if they're reluctant to come forward for vaccination against COVID-19, they will trivialize the potential risk of influenza, I think, and will not present themselves for flu vaccine either," he said.

"I'm looking forward with trepidation to see how much messaging about influenza vaccine will be able to be effective this year. I'm becoming more pessimistic as I see the rather stubborn reluctance of people to get vaccinated against COVID-19," Schaffner said.

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flu season vaccinations fall winter covid19 immunity illness

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How Vaccine Hesitancy Could Impact 2021 Flu Season

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Health experts are expressing concerns that this fall's flu season in the United States is coinciding with another surge in COVID-19 cases. They say they hope vaccine hesitancy and fatigue won't carry over from COVID-19 into the flu season. Flu shots will begin to be distributed in August and will continue through November.

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u.s. flu vaccine effectiveness (ve) network

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CDC Seasonal Flu Vaccine Effectiveness Studies | CDC

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Seasonal Influenza Vaccine Effectiveness, 2005-2016 - CDC

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However, even among children with high rates of interaction with the health care system-those with high-risk conditions that can make them especially vulnerable to influenza-vaccination rates are low. Existing literature suggests 33%-59% of hospitalized children have the flu vaccine, despite the CDC's recommendation that such children receive the vaccine while in hospital.

Corresponding author Evan W. Orenstein, MD, of the Emory University School of Medicine, and colleagues, wanted to find out whether implementing a CDS strategy might help providers achieve higher rates of vaccination among hospitalized children. Writing in JAMA Network Open, they explained that existing studies evaluating using CDS to boost compliance with health care maintenance objectives are inconsistent, and other studies have shown that health-record-embedded CDS tools only work if they deliver the right messages to the right providers at the right time.

Orenstein and colleagues devised a study which took place at a tertiary pediatric health system comprising 3 hospitals. A CDS tool was developed that included 3 main components, a default vaccine order for eligible patients, a script to offer the vaccine, and just-in-time education for clinicians with links to reference material.

The intervention was rolled out in the health system for the 2019-2020 flu season. Eligible children who were hospitalized during that time span were split into 2 groups, an intervention group and a control group. A second control group, based on patients who sought care in the 2018-2019 influenza season, was also evaluated.

The study population was mostly boys (52%) with a median age of 8; 50% were Black and 43% were White. Nearly two-thirds (64%) were on a public insurance plan.

The hospitals in the study reported 10,997 eligible hospitalizations during the 2019-2020 flu season. Those patients were divided on a 1:1 basis, with half receiving the CDS intervention. Among those in the intervention group, 31% received the vaccine. Among the concurrent control group, the vaccination rate was 19%. Of the 6743 patients in the 2018-2019 control group, the vaccination rate was 14%.

Orenstein and colleagues said the CDS is built around making the vaccine the default action, rather than framing it as an "addition" to routine care.

"These interventions stress the use of defaults as a behavioral economic strategy to influence behavior, including targeted defaults for clinicians to order the influenza vaccine as well as a nursing staff script emphasizing a default option for families of patients receiving the influenza vaccine during the hospitalization," they wrote.

However, the study also showed that while both vaccine orders and administration increased, the former increased more than the latter, suggesting vaccine refusal or other barriers remain an issue.

"Additional work to understand persistent reasons for low uptake and the potential effect of combining CDS with other behavioral economic and implementation science interventions would likely reduce the burden of influenza in a vulnerable population and provide lessons to improve vaccine coverage for other diseases, such as COVID-19," the authors concluded.
Reference
Orenstein EW, ElSayed-Ali O, Kandaswamy S, et al. Evaluation of a clinical decision support strategy to increase seasonal influenza vaccination among hospitalized children before inpatient discharge. JAMA Netw Open. Published online July 1, 2021. doi:10.1001/jamanetworkopen.2021.17809

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Clinical Decision Support Tool Raises Flu Vaccination Rates in Hospitalized Children

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However, even among children with high rates of interaction with the health care system-those with high-risk conditions that can make them especially vulnerable to influenza-vaccination rates are low. Existing literature suggests 33%-59% of hospitalized children have the flu vaccine, despite the CDC's recommendation that such children receive the vaccine while in hospital.

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https://www.cdc.gov/flu/prevent/vaccine-supply-historical.htm

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Historical Reference of Seasonal Influenza Vaccine Doses Distributed | CDC

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Seasonal flu vaccine: total doses distributed provides a cumulative weekly total of the number of doses of flu vaccine distributed - CDC

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LANDOVER, Md., Aug. 24, 2021 /PRNewswire/ -- Giant Food, the leading greater Washington D.C. regional grocery chain, today announces that seasonal flu vaccinations are once again available at all 152 of its in-store pharmacies for both adults and children* with no appointment required. The vaccinations are administered by Giant's certified in-store pharmacists and are often covered in-full by most insurance plans.

"The health of our community is of utmost importance to Giant, and we welcome everyone to come and meet with one of our specially trained, dedicated pharmacists about flu shots and other immunizations," said Paul Zvaleny, Giant Food Director of Pharmacy Operations. "As COVID-19 cases continue to rise, it is of vital importance that individuals take preventative measures and receive immunizations to reduce risk of infection of both the seasonal flu and COVID-19 to keep themselves and communities healthy. Our Giant pharmacists go one step further and are able to travel for immunization clinics, which can be held at businesses, schools, universities, gyms, places of worship, local parks, or other regional locations."

New this year, COVID-19 vaccines and other flu and non-flu vaccines including tetanus, shingles, pneumonia, meningitis, hepatitis and many more, can be administered together as the 14-day waiting period between COVID-19 and other vaccines is no longer recommended by health experts. Giant is also currently offering a third dose of Moderna and Pfizer mRNA COVID-19 vaccinations for immunocompromised individuals as defined by the CDC.

To help customers stay healthy throughout the flu season, Giant has made getting vaccinations simple and easy with no appointment needed. Insurance companies, including Medicare, are billed directly, often at $0 copays. The flu vaccines offered this season will cover four strains of the flu virus and Giant will again offer high dose flu vaccines for adults aged 65 and older. Pharmacists can recommend and administer the appropriate immunizations based on specific patient needs and all customers receiving flu shots will be offered a complimentary short questionnaire designed to identify any missing vaccinations.

Giant is also bringing back its signature Airstream this season for mobile flu clinics at locations throughout the region to provide as many individuals and families as possible the opportunity to receive the recommended flu and other necessary vaccines.

For more information, or to schedule an on-site flu clinic, please call 1-888-469-4426. To find a local Giant pharmacy, please visit giantfood.com/store-locator and to learn more about the COVID-19 vaccinations, visit www.giantfood.com/pages/covid-info.

*Age restrictions on flu shots apply per state. Ask your pharmacist for details.

About Giant Food
This year, Giant Food is celebrating 85 years as a community grocery store. Since opening its first location on Georgia Ave. in Washington, DC in 1936, Giant has been an integral part of our customers' lives and the communities it serves. Giant is committed to being a Better Neighbor and has designated four main giving pillars that address local Food Insecurity, Military Support, Pediatric Cancer Research, and Social Equality. Giant is headquartered in Landover, Md. and operates 164 supermarkets in Virginia, Maryland, Delaware, and the District of Columbia with approximately 20,000 associates. Included within the 164 stores are 152 full-service pharmacies, 82 full-service PNC Banks and 24 Starbucks locations. Giant fits all the ways today's busy customers want to shop - whether in store or online. With 152 Giant Pickup locations and Giant Delivery available to all our market areas in DC, MD, VA and DE, customers have even more convenient options right at their fingertips to get the best product and prices, whenever and however they want it. For more information on Giant, visit: www.giantfood.com.

View original content to download multimedia: https://www.prnewswire.com/news-releases/seasonal-flu-vaccinations-now-available-at-giant-food-pharmacies-301360897.html

SOURCE Giant Food

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Seasonal Flu Vaccinations Now Available at Giant Food Pharmacies

# data[].attributes.attachment_link.description
Giant Food, the leading greater Washington D.C. regional grocery chain, today announces that seasonal flu vaccinations are once again available at all 152 of its in-store pharmacies for both adults and children* with no appointment required. The vaccinations are administered by Giant's certified in-store pharmacists and are often covered in-full by most insurance plans.

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Lambda and B.1.621: New COVID variants could be the worst yet, doctor warns

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At least two new COVID-19 variants have hit the United States and they could be worse than the delta variant in their infectiousness and ability to stand up to vaccines, according to a top medical authority. The lambda variant, along with another one so new it doesn't even have a Greek letter name yet, are [...]

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Colin Ochs

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PITTSBURGH (KDKA) - We've been hearing about them for months, and it's finally time for COVID-19 booster shots.

Doctors recommend getting the booster eight months after the second shot, and for many - that falls smack dab in flu shot season.

READ MORE: COVID-19 In Pittsburgh: Allegheny County Health Department Reports 263 New Cases

KDKA's Meghan Schiller asked the experts what people need to know about mixing the two.

"I think ideally it might be two shots this year, but to get them both at the same time would certainly be efficient," said Dr. Amy Crawford-Faucher, family doctor and Vice Chair of Allegheny Health Network's Primary Care Institute.

KDKA's cameras were rolling as people lined up for another dose of protection at Allegheny General Hospital.

"I feel much safer because I don't want to lose my kidney," said Esperanza Bier.

Bier just received a new kidney and said she's vaccinated to honor her donor. She's one of many immunocompromised people now eligible for a COVID-19 booster shot.

"I was in dialysis close to three or four years," said Bier.

Schiller: How are you feeling now?

Bier: Oh, it's wonderful.

The CDC just announced we'll need booster shots for maximum protection, but for many - the third shot overlaps with flu season.

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"When the COVID vaccines first came out, we said no other vaccines within two weeks of a COVID vaccine. So that recommendation changed a few months ago," said Dr. Crawford- Faucher

But doctors now say people can now get their flu shot and COVID booster shot around the same time. Turns out, people always could, but scientists didn't want overlap for one reason.

"Because we were just rolling this out to lots of people, we really wanted to be pure in knowing that if you had a reaction, it was due to the COVID vaccine and not from something else you got in your body," said Dr. Crawford- Faucher.

Top researchers already started discussing a combo shot that covers both the coronavirus and the flu. UPMC's Dr. Graham Snyder told KDKA expect two shots for now.

"It's plausible that we could every winter get a combo influenza vaccine and COVID vaccine, but it's way too early to say that's going to happen. But that plausibly could happen," said Dr. Snyder, UPMC's medical director of infection prevention and hospital epidemiology.

People in line for the booster shot at AGH didn't seem to mind that another shot is in their not-so-distant future.

"I would get the flu shot. I get it every year," said Marie Geubtner, nurse and booster shot recipient.

"So, I did that booster too, I get all my boosters, all my shots all the time," said Mary Louise Pastorok, Allegheny Health Network's booster shot recipient and senior executive assistant.

Doctors warn against skipping the flu shot, saying we won't see a repeat winter with low flu cases for these reasons:

"A major contributor to the reason we saw no flu virus was because many of us were staying at home, we're working from home, we're doing school from home, we were limiting the number of contacts we all had and we were masking," said Dr. Snyder. "Now, obviously, that has changed and will probably remain changed going into this winter."

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That's why doctors say schedule both, in whatever order works out best for your schedule.

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Doctors Say It Is Safe To Get Flu Shot And COVID-19 Booster Shot Around Same Time

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PITTSBURGH (KDKA) - We've been hearing about them for months, and it's finally time for COVID-19 booster shots. Doctors recommend getting the booster eight months after the second shot, and for many - that falls smack dab in flu shot season.

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The flu season of 1989-90 has been a bad one, killing tens of thousands of people and preying especially on the elderly, federal flu specialists reported Thursday.

To make matters worse, flu vaccination levels among older people may be little more than four in 10, another new survey shows.The national Centers for Disease Control reported that the 1989-90 flu season, now winding to a close, has been marked by a flu type especially troublesome for older people: what researchers know as A-H3N2.

The CDC estimates that in the average influenza season, about 20,000 Americans are killed by the flu. But in 1984-85, the last year in which A-H3N2 was so predominant, an estimated 57,000 people died.

``This year looks to me like the worst year since '84-85,' said Dr. Walter Gunn, a CDC flu specialist. Final figures aren't in; his estimate was based on the death rate so far.

The U.S. flu season, which peaked in late January and early February, was characterized almost exclusively by a type A-H3N2 flu strain dubbed the ``Shanghai flu.' That was one of the three components in the current winter's flu vaccine, which is recommended chiefly for people over 65 or patients with ailments such as diabetes or kidney disease.

But a survey of Medicare beneficiaries found that only 43 percent had received flu vaccinations for the 1988-89 winter flu season, the CDC reported. And 91 percent of the Medicare participants who didn't get their flu shots were people who should have, such as the elderly.

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The flu season of 1989-90 has been a bad one, killing tens of thousands of people and preying especially on the elderly, federal flu specialists reported Thursday.

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https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjBoOvjhsryAhXEhOAKHX1KDJ8QFnoECA0QAQ&url=ftp%3A%2F%2Fftp.cdc.gov%2Fpub%2FHealth_Statistics%2FNCHS%2FPublications%2FHealth_US%2Fhus09tables%2Ftable084.xls&usg=AOvVaw09tTKzdOENbgZyqPKUjrTe

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Influenza vaccine distribution information for the 2020-2021 season is posted here as CDC receives it, typically on Fridays. Please continue to check this page for the most up-to-date information.

Flu vaccine is produced by private manufacturers, so supply depends on manufacturers. For the 2020-2021 season, manufacturers have projected they will provide as many as 194 to 198 million doses of influenza vaccine for the U.S. market. (Projections may change as the season progresses.) As noted below, manufacturers are already distributing flu vaccine with no significant delays reported (Additional information on vaccine supply and distribution for the 2020-2021 influenza season is available). However, because of the record number of doses being produced this season, production and distribution will occur over a longer period.

Table of 2020-21 Seasonal Influenza Vaccine-Total Doses Distributed

*This number has been corrected from 197.4M doses, which was incorrectly reported for the week of November 20, 2020.

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2020-2021 Seasonal Influenza Vaccine Total Doses Distributed

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Influenza vaccine distribution information for the 2020-2021 season is posted here as CDC receives it, typically on Fridays. Please continue to check this page for the most up-to-date information. Flu vaccine is produced by private manufacturers, so supply depends on manufacturers.

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How crucial is the booster with the delta varient

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Here's what you need to know about booster shots and the United States' plans.

Frequently Asked Questions

Why is the U.S. planning to offer booster shots?

Who qualifies for a booster shot in the U.S., and when?

Why are booster shots recommended after eight months?

How will booster shots be distributed in the U.S.?

What other countries are offering boosters?

What about approval by health agencies?

Why is the U.S. planning to offer booster shots?

Booster shots are extra doses of vaccine beyond a normal regimen. For the two-dose Moderna and Pfizer-BioNTech vaccines, that means a third shot. Health officials say a growing body of data suggests the boosters will counteract waning immunity. But officials said that administering of boosters won't go forward without the approval of the Food and Drug Administration and the Centers for Disease Control and Prevention.

They also said they want to stave off any potential decline in the vaccines' ability to prevent hospitalizations and deaths. "You want to stay ahead of the virus. ... You don't want to find yourself behind, playing catch-up," said White House medical adviser Anthony S. Fauci.

Officials said they were also persuaded by evidence that boosters can significantly increase people's immunity after it declines. The results were "striking," Fauci said.

President Biden said on Aug. 18 that after Sept. 20, vaccinated Americans can get booster shots against coronavirus eight months after their second injection. (The Washington Post)

If the Biden administration's plan is approved,Americans will be eligible for a third dose eight months after the date on which they received their second dose, officials said. That means that while the broad booster rollout begins the week ofSept. 20, the first people to get the extra doses will be the first populations that were vaccinated - higher-risk groups such as health-care workers, residents of long-term-care facilities and the elderly.

Those who got the Johnson & Johnson vaccine probably will also need a booster, officials said, but they are awaiting more data. Use of the J&J shots in the United States did not begin until March, they noted.

There is "nothing magical" about the eight-month mark, Surgeon General Vivek H. Murthy said Wednesday. But that is what health experts landed on after observing increases in infection over time among the vaccinated.

"Around the six-month mark in the data, you start to see increases in mild to moderate infection," Murthy said Wednesday.

Health officials emphasized that vaccines remain highly protective. Murthy said that "the most important purpose of the vaccine is to keep us out of the hospital and to save our life. ... And, fortunately, we are seeing that still holding at a high level, which is good news."

"But our anticipation is that if the trajectory that we are seeing continues ... we will likely see in the future an increase in breakthrough hospitalizations and breakthrough deaths" without boosters, Murthy said.

White House coronavirus coordinator Jeff Zients promised Wednesday that it will be "just as easy and convenient to get a booster shot as it is to get a first shot." About 80,000 sites nationwide, including 40,000 local pharmacies, will offer third doses, he said.

Boosters will be free to everyone regardless of their health insurance or immigration status, he said, adding: "No ID or insurance required."

"The bottom line is that we are prepared for boosters and we will hit the ground running in the weeks ahead," Zients said.

France also plans to make certain groups - residents of nursing homes, those over age 75 and people with severe health conditions - eligible for boosters in September.

Hungarian Prime Minister Viktor Orban has announced plans to offer third doses widely, and officials in Spain and Italy have suggested that boosters are likely to be needed. British health officials also are preparing to administer booster shots, starting in September.

Standard practice is for the Food and Drug Administration to assess the safety and efficacy of vaccines and for the Centers for Disease Control and Prevention's outside advisers - the Advisory Committee on Immunization Practices (ACIP) - to recommend what vaccines Americans should get and when. After ACIP makes its recommendations, the CDC director decides whether to accept them.

Administration officials stressed in Wednesday's coronavirus briefing and in subsequent interviews that a booster-shot campaign will not proceed without a go-ahead from the FDA and the ACIP. One official conceded that the process is "going to be a little messy" for a while but added that the administration has little choice but to act, given the fast spread of the delta variant.

"We are not skipping the very important FDA and ACIP process here," Murthy said at Wednesday's briefing. "They have an incredibly important role to play in evaluating safety and making recommendations for vaccines."

Asked why the Biden administration is announcing its intentions before those groups weigh in, Murthy said leaders want to be transparent and give the public as well as state and local governments time to plan.

"We have told the public [that] when we see a signal in the data, we will tell them when we are concerned." he said.

"We are fulfilling that promise today," Murthy said.

Jesse Goodman, a former chief scientist at the FDA and now a professor of medicine and infectious diseases at Georgetown University School of Medicine, said he thinks that boosters will be needed. "Being prepared for a booster campaign makes sense," he added.

But Goodman also said it was important for the Biden administration to avoid putting "the cart before the horse."

He added that it was repeatedly said in the coronavirus briefing that normal processes would prevail, "but I think it puts that process under a date-certain kind of pressure."

As new coronavirus variants emerge and the longevity of vaccine protection remains unknown, scientists are researching how booster shots could work. (John Farrell/The Washington Post)

Some in the global public health community have criticized wealthy countries' moves to offer booster shots while poorer nations struggle to provide even their most vulnerable citizens with first vaccine doses.

On Wednesday, WHO officials decried "vaccine nationalism" and said that allowing the virus to spread among unvaccinated populations also could lead to the emergence of dangerous new variants.

Mike Ryan, executive director of the WHO's Health Emergencies Program, likened booster shots to giving out extra life jackets to people who already have them. Joachim Hombach, executive secretary of the WHO's Strategic Advisory Group of Experts on Immunization, said that vaccines may become less protective over time but that scientists have not seen a decline in protection against severe disease.

Paul Offit, director of the Vaccine Education Center at Children's Hospital of Philadelphia, also questioned a premise of the U.S. decision on booster shots - that an already occurring decline in vaccine immunity against mild or moderate illness was likely to be followed by a decline in protection against severe disease and hospitalization. He says he thinks protection against serious disease might last a few years.

Wednesday, Biden administration officials said the United States remains committed to distributing vaccine doses around the globe and noted that the United States has donated more vaccine than all other nations combined.

Frances Stead Sellers, Brittany Shammas, Adela Suliman and Bryan Pietsch contributed to this report.

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What to know about coronavirus booster shots in the U.S.

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Here's what you need to know about booster shots and the United States' plans. Why is the U.S. planning to offer booster shots? Who qualifies for a booster shot in the U.S., and when? Why are booster shots recommended after eight months? How will booster shots be distributed in the U.S.?

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PITTSBURGH (KDKA) - We've been hearing about them for months, and it's finally time for COVID-19 booster shots.

Doctors recommend getting the booster eight months after the second shot, and for many - that falls smack dab in flu shot season.

READ MORE: COVID-19 In Pittsburgh: Allegheny County Health Department Reports 263 New Cases

KDKA's Meghan Schiller asked the experts what people need to know about mixing the two.

"I think ideally it might be two shots this year, but to get them both at the same time would certainly be efficient," said Dr. Amy Crawford-Faucher, family doctor and Vice Chair of Allegheny Health Network's Primary Care Institute.

KDKA's cameras were rolling as people lined up for another dose of protection at Allegheny General Hospital.

"I feel much safer because I don't want to lose my kidney," said Esperanza Bier.

Bier just received a new kidney and said she's vaccinated to honor her donor. She's one of many immunocompromised people now eligible for a COVID-19 booster shot.

"I was in dialysis close to three or four years," said Bier.

Schiller: How are you feeling now?

Bier: Oh, it's wonderful.

The CDC just announced we'll need booster shots for maximum protection, but for many - the third shot overlaps with flu season.

READ MORE: Pennsylvania Redistricting Panel Considers Where To Count State Prisoners

"When the COVID vaccines first came out, we said no other vaccines within two weeks of a COVID vaccine. So that recommendation changed a few months ago," said Dr. Crawford- Faucher

But doctors now say people can now get their flu shot and COVID booster shot around the same time. Turns out, people always could, but scientists didn't want overlap for one reason.

"Because we were just rolling this out to lots of people, we really wanted to be pure in knowing that if you had a reaction, it was due to the COVID vaccine and not from something else you got in your body," said Dr. Crawford- Faucher.

Top researchers already started discussing a combo shot that covers both the coronavirus and the flu. UPMC's Dr. Graham Snyder told KDKA expect two shots for now.

"It's plausible that we could every winter get a combo influenza vaccine and COVID vaccine, but it's way too early to say that's going to happen. But that plausibly could happen," said Dr. Snyder, UPMC's medical director of infection prevention and hospital epidemiology.

People in line for the booster shot at AGH didn't seem to mind that another shot is in their not-so-distant future.

"I would get the flu shot. I get it every year," said Marie Geubtner, nurse and booster shot recipient.

"So, I did that booster too, I get all my boosters, all my shots all the time," said Mary Louise Pastorok, Allegheny Health Network's booster shot recipient and senior executive assistant.

Doctors warn against skipping the flu shot, saying we won't see a repeat winter with low flu cases for these reasons:

"A major contributor to the reason we saw no flu virus was because many of us were staying at home, we're working from home, we're doing school from home, we were limiting the number of contacts we all had and we were masking," said Dr. Snyder. "Now, obviously, that has changed and will probably remain changed going into this winter."

MORE NEWS: Registration Opens For PedalPGH

That's why doctors say schedule both, in whatever order works out best for your schedule.

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Doctors Say It Is Safe To Get Flu Shot And COVID-19 Booster Shot Around Same Time

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PITTSBURGH (KDKA) - We've been hearing about them for months, and it's finally time for COVID-19 booster shots. Doctors recommend getting the booster eight months after the second shot, and for many - that falls smack dab in flu shot season.

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https://www.contagionlive.com/view/is-there-risk-of-flu-outbreaks-2021-22-season

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COVID-19 was as rampant in the US as it had ever been in the very first days of 2021.

In the early January weeks following the winter holiday season-a time of mass indoor gathering and socializing-and just weeks before newly authorized vaccines from Pfizer-BioNTech and Moderna would begin reaching greater adult populations, the pandemic virus began its greatest climb in US daily cases.

The very peak of new daily COVID-19 cases, as of this writing in July 2021, came on January 12: more than 210,000 reported cases in a single day, per the Centers for Disease Control and Prevention (CDC).

At the very same time, influenza was a non-factor. There were just 273 total positive cases of the flu reported in the US for the week ending January 16, according CDC FluView data. Just a year before, positive flu cases in the same week had exceeded 3000.

After months of speculation that legitimate risk of a "twindemic" in the 2020-21 flu season could overwhelm already exhausted hospital systems, flu was a sparse infection risk in the US while another respiratory virus was uncontrolled at unprecedented rates.

The explanations for contrasting confirmed COVID-19 and flu cases in the US during the 2020-21 season are simply understood and widely accepted by clinicians; what such factors mean for the forecast of the next season remains unclear. As the 2021-22 flu season approaches during a critical period of evolving COVID-19 mitigation strategies, public health experts are utilizing recent history to interpret future outbreak risks.

A Quiet 2020-21 Season

It helps to first understand the influences of the minimal 2020-21 flu season.

Wary of COVID-19 spread risk during the fall and winter months, experts stressed the importance of annual flu vaccination access and administration. The approximate 194 million flu vaccine doses distributed in the US last season were the most ever-an 11% increase from total distribution the season before (174.5 million).

Even with record supply and heightened messaging, flu vaccination coverage actually dipped among key populations. The 58.2% vaccination rate among children in mid-April was 4.1 percentage points fewer than the year prior; among pregnant women, the drop was 4.2 percentage points (61.3% vs 65.5%).

All race ethnicity groups additionally reported decreased flu vaccination coverage rates last year; Black and non-Hispanic persons rates decreased from 43.5% in 2019-20, to 36.5% to 2020-21.

However, overall coverage among adults had improved. Per a CDC survey in early February, 55% of all US adults had already received a flu vaccine, versus the 48% reported at the end of the 2019-20 season.

Rates were greatest among the age groups at greatest risk of COVID-19 and flu severity: 60% of people aged 50-64 years were vaccinated against the flu last year, as were 80% of those aged ≥65 years old.

The next contributing factors were those which had primarily sought to mitigate COVID-19 spread, but experts believe ultimately helped limit the flu through the winter. Tim Uyeki, MD, MPH, MPP, Chief Medical Officer of the CDC's Influenza Division, National Center for Immunization and Respiratory Diseases, told Contagion® a litany of COVID-19 measures may have reduced flu spread in often highly susceptible areas:

Reduced traveling and limited international travel options

Significant increases in remote work for adults and remote schooling for children

Social distancing measures and regional/state mask mandates

"It's possible that higher influenza vaccine coverage may have also contributed, but collectively all of these mitigation measures probably contributed," Uyeki said. "How much one measure such as facemask wearing contributed to all of that, I think is impossible to really discern.

"It's what local governments and local public health recommended or required, and then it's people's behaviors and interactions," he explained.

Pandemic-driven public health guidance and collective behavior may have indeed contributed equally to the minimal flu spread thus far, but both factors are currently evolving. Just this week, the CDC announced updated recommendations advising that Americans vaccinated for COVID-19 should begin wearing masks again when in indoor areas of high transmission risk.

With the Delta variant of SARS-CoV-2 now lifting 7-day averages for new daily US cases back above 50,000 for the first time since April, federal health authorities are reconsidering the immunity and prevention assured by available COVID-19 vaccines.

Approximately half the country's population is now fully vaccinated against COVID-19. Though mRNA vaccines BNT162b2 and mRNA-1273 remain significantly able to prevent symptomatic and severe cases driven by the Delta variant, breakthrough infection risk and the reported greater transmissibility of the dominant variant has driven the call for continued mask-wearing.

High flu transmission-risk areas such as schools will again be aided by masks; included in the CDC's guidance this week was recommendation that all teachers, staff, students and visitors wear mask indoors when classrooms reopen this year-regardless of vaccination status.

Epidemic Risks

The fear of recession in flu prevention is justified, particularly in an era when most common COVID-19 mitigation strategies are subject to dichotomized debate. But there is already a stable base of acceptance in flu vaccination and treatment that experts hope keeps the seasonal virus at bay.

Leslie Kantor, PhD, MPH, Chair and Professor of the Department of Urban-Global Public Health at the Rutgers School of Public Health, told Contagion there's a greater acceptance of regular flu vaccination-one which adults generally pass down to their children and future generations as common practice.

"We're all kind of in agreement on the flu. And I hope that that stays," Kantor said. "My fear is that some of the same problems that have emerged and gotten stronger during COVID will cross the street and affect the flu response."

Of greater concern is that the population is straying further away from virus infection-induced immunity from influenza strains. As Uyeki noted, flu virus circulation was not only limited in the 2020-21 season-it had been circulating at a significantly reduced rate since at least March 2020.

From season to season, he explained, the most severe flu epidemics have been associated with influenza type A (H3N2) variant virus. Such viruses have not circulated much at all in the US since 2018-19.

"The bottom line is we could be at risk on a population basis of a rather severe influenza epidemic with type A (H3N2) viruses, depending upon how antigenically similar the viruses are compared to what people have been exposed to in the past, and how well the H2N3 vaccine strain has been mapped to it," Uyeki said.

The 'anti-vax' misinformation movement, and even the greater public hesitancy surrounding vaccines, has been exacerbated by the pandemic, Kantor noted. Whether that would apply to discourse around annual flu vaccine doses is inconclusive-if not disproven by last year's record rate of distribution in the US.

But were last year's flu vaccination rates actually just a byproduct of significantresourcing? Kantor described the US' healthcare emergency funding as a reactive process: a crisis like COVID-19 begins, it overwhelms, resources and tools are expedited and provided, then the funding stops short.

"When ideally, if you wanted to avoid public health crises, you would have strong infrastructure, strong funding, strong coordination all the time," she explained.

Given the emphasis on risk of twin respiratory virus outbreaks last flu season, the US set a new precedent for vaccination rollout. Would continuing to contain the flu during COVID-19 outbreaks be reliant on such resourcing?

Tools in Place

The US healthcare system is only as strong as its weakest links. And for some time-at least since the 2008 economic recession-its local health departments have been exceptionally weakened, Kantor said. The cracks of local care team understaffing and overburden were fully exposed when COVID-19 outbreaks began.

The US healthcare system is lauded for its world-leading advances in clinical and scientific innovation, and ability to prioritize top-down guidance for care teams. None of that matters if execution is lacking at the patient level.

"The only way to [contain COVID-19] is with testing and contact tracing," Kantor said. "And in so many of these towns across America, you're lucky if you have one full time person doing that."

The flu season, in theory, adds another risk factor to be monitored in a system that already cannot keep up with the pandemic. Kantor called it "fortunate" that last season's flu circulation was minimal; what could easily occur this season is millions more needing testing for overlapping COVID-19, flu, and other respiratory virus symptoms.

The US industry's delivery of dozens of PCR and antigen assays for COVID-19, as well as multiplex tests differentiating SARS-CoV-2 from flu and respiratory virus strains, have stocked local pharmacies, clinician offices, and even online consumer marketplaces. Pharmacies and community centers have become better-resourced vaccination sites during the pandemic; adding flu vaccine doses to their offerings is a simplistic strategy.

Supply meets demand-yet, as Kantor noted, testing utility has never been streamlined.

She prosed, for example, why there aren't relatively cheap antigen testing stations established in COVID-19 outbreak-risk areas, such as schools or public transportation hubs? If local systems cannot prioritize testing standards for something as severe as the pandemic virus, there's little hope they'd put stress on testing for and mitigating flu spread.

"I do think there will be a lot of people who will have to rule out one or the other," Kantor said about this upcoming flu season. "But I'm always going to lean on, wouldn't it be better to avoid this in the first place? We have been a country that has tolerated tens of thousands of deaths every from the flu, year after year.

"We've absorbed it, and we've absorbed these COVID-19 deaths," Kantor said.

Though monitoring and spread prevention remain lackluster, reactive care has been bolstered for some time. Uyeki spoke to the availability and proven efficacy of flu antiviral therapy-a treatment option which has been generally linked to reduced risk of even household spread among patients with the flu.

The pandemic also required most primary care settings begin providing telemedicine options. In the event a patient tests positive for the flu, they could be prescribed antiviral therapy remotely by their physician, further reducing the risk of community spread.

Equipped with antiviral options for the flu, as well as monoclonal antibody options for high-risk patients with COVID-19, frontline physicians have a critical role to play in distinguishing either respiratory virus and making a timely treatment decision this season, Uyeki said.

"Clinicians really are going to depend upon knowing what's the level of SARS-CoV-2 circulation in the community at that moment, whether there's influenza virus circulation-and if yes, how much?" Uyeki said. "It's really a reliance upon local surveillance data, and that will help inform clinical management and testing for SARS-CoV-2 and influenza."

Timely diagnosis is also vital to the potential efficacy of prescribed flu treatment. Being able to initiate therapy with 1-2 days of symptoms being present for influenza could reduce disease duration, complications, and risk of spread.

It will be real-time monitoring of circulating viruses that inform ideal mitigation measures, Uyeki explained. While vaccination should continue to be prioritized, it has risk to be a sometimes ineffective practice.

Limited Measures

As influenza strains annually fluctuate in circulation-first in the Southern Hemisphere, then in the Northern Hemisphere-available vaccine doses are often an imperfect, educated prediction of necessary immunity.

In the 2019-20 season alone, flu vaccine effectiveness varied from 37% to 50% in all persons aged ≥6 months old, depending on the virus strain, according to CDC data.

Everyone of such age should be annually vaccinated for the flu, Uyeki stressed. But that guidance comes with an understanding of possible limitations. Though the vaccines' benefits in reducing hospitalization, severe flu progression, and even death are generally consistent attributes, overall symptomatic disease prevention is not assured due to the moving target of circulating strains.

Kantor noted that Northern Hemisphere flu vaccine development and rollout is often informed by trends observed in the Southern Hemisphere's flu season. Given that the latter similarly saw little of the flu in the last season, the former's vaccine "guessing game" is a bit greater than usual.

"There seems to be a reasonable scientific argument that we should go with the same strains that were around [last year] because they didn't have a chance to mutate," Kantor said. "That should be a pretty good bet. But we might have a slightly less effective vaccine."

Vaccination timing is also a concern for this flu season. Kantor prosed whether reported waning efficacy of COVID-19 mRNA vaccines over time, as well as against the dominant Delta variant, may hinder the general public's drive to upkeep record vaccination rates from last year.

She also suggested that timing of a possible COVID-19 vaccine booster dose authorization-if it were to occur in the fall season-may reduce flu vaccination rates if the processes are not streamlined.

"Can we get this set up so that we're doing boosters and flu at the same time?" Kantor suggested. "Or does this become two separate things that people need to do, which we know would really cut down on the likelihood that people would do it, just because the logistics get complicated?"

Uyeki added there is concern as to whether the 2021-22 flu season could begin earlier than usual this fall. Though such an event is unpredictable, the reopening of school systems, resumption of international travel, and possible resurgence of the type A (H3N2) virus could spell flu outbreaks occurring before the general vaccination push.

"If this occurred in September or early October before a lot of people were vaccinated, then there would be a lot of susceptible people-and in particular, if the viruses were also not well matched by the vaccine strains," he explained.

Finally Prioritizing the Flu

There is no crystal ball gazing into upcoming flu seasons. There is only understanding of what constitutes greater risk of viral outbreaks, and what could reduce the effect of such factors. For that reason, Uyeki concludes that there is likely to be more flu activity in 2021-22 than was observed in the past season. For that reason, he stressed the need for clinicians to get their flu shot by late October, and to impress the same need to their patients as well.

Kantor added that, along with getting vaccinated, clinicians and patients need to keep perspective on the dangers of the flu. Especially at a time when great stress is put upon the severe risks of COVID-19, a more familiar but nonetheless potentially deadly virus like the flu can't be discounted.

"Because it comes around every year, that doesn't mean that it's not serious, right?" she said.

The history of familiarity with the flu, contrasted against the heightened concern of COVID-19, and combined with greater leniency in public health measures among a more vaccinated population could spell significant risks for the 2021-22 flu season.

The pandemic response, almost coincidentally, provided a blueprint to reducing flu spread and severity in the US. But now the public must embrace it regularly, regardless the status of COVID-19.

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Is There Risk of Flu Outbreaks in the 2021-22 Season?

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COVID-19 was as rampant in the US as it had ever been in the very first days of 2021. In the early January weeks following the winter holiday season-a time of mass indoor gathering and socializing-and just weeks before newly authorized vaccines from Pfizer-BioNTech and Moderna would begin reaching greater adult populations, the pandemic virus began its greatest climb in US daily cases.

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Historical Reference of Seasonal Influenza Vaccine Doses Distributed | CDC

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Seasonal flu vaccine: total doses distributed provides a cumulative weekly total of the number of doses of flu vaccine distributed - CDC

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Historical Reference of Seasonal Influenza Vaccine Doses Distributed | CDC

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Seasonal flu vaccine: total doses distributed provides a cumulative weekly total of the number of doses of flu vaccine distributed - CDC

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Centers for Disease Control and Prevention

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All data are preliminary and may change as more reports are received. A description of the CDC influenza surveillance system, including methodology and detailed descriptions of each data component is available on the surveillance methods page. Additional information on the current and previous influenza seasons for each surveillance component are available on FluView Interactive.

The percent of specimens testing positive for influenza remains stable, indicating that influenza virus circulation has remained at similar levels during the past two weeks, even while overall levels of respiratory illness have declined.

All data are preliminary and may change as more reports are received. A description of the CDC influenza surveillance system, including methodology and detailed descriptions of each data component is available on the surveillance methods page. Additional information on the current and previous influenza seasons for each surveillance component are available on FluView Interactive.
Key Points

The percent of specimens testing positive for influenza remains stable, indicating that influenza virus circulation has remained at similar levels during the past two weeks, even while overall levels of respiratory illness have declined. While influenza activity is difficult to predict, it is expected to continue for several more weeks.

The majority of influenza viruses detected are A(H3N2). Most of the H3N2 viruses identified so far this season are genetically closely related to the vaccine virus, but there are some antigenic differences that have developed as H3N2 viruses have continued to evolve.

The percentage of outpatient visits due to respiratory illness decreased nationally again this week but remains above baseline. Influenza is contributing to levels of respiratory illness, but other respiratory viruses are also circulating. The relative contribution of influenza varies by location.

The number of hospital admissions reported to HHS Protect declined slightly again this week.

The cumulative hospitalization rate in the FluSurv-NET system is higher than the rate for the entire 2020-2021 season, but lower than the rate seen at this time during the four seasons preceding the COVID-19 pandemic.

CDC estimates that so far this season there have been at least 2 million flu illnesses, 20,000 hospitalizations, and 1,200 deaths from flu.

There's still time to get vaccinated. An annual flu vaccine is the best way to protect against flu and its potentially serious complications. CDC recommends everyone 6 months and older get a flu vaccine.

Flu vaccination coverage so far is lower this season compared to last.

Flu vaccines are available at many different locations, including pharmacies and health departments. Visit www.vaccines.gov to find a flu vaccine near you.

There are also flu antiviral drugs that can be used to treat flu illness.

Influenza A(H3N2) viruses have been the most frequently detected influenza viruses this season. For regional and state level data and age group distribution, please visit FluView Interactive. Viruses known to be associated with recent live attenuated influenza vaccine (LAIV) receipt or found upon further testing to be a vaccine virus are not included as they are not circulating influenza viruses.

Clinical Laboratories

The results of tests performed by clinical laboratories nationwide are summarized below. Data from clinical laboratories (the percentage of specimens tested that are positive for influenza) are used to monitor whether influenza activity is increasing or decreasing.

Week 3

Data Cumulative since
October 3, 2021
(Week 40)

No. of specimens tested
79,667

1,360,940

No. of positive specimens (%)
1,543 (1.9%)

35,913 (2.6%)

Positive specimens by type

Influenza A
1,503 (97.4%)

35,104 (97.7%)

Influenza B
40 (2.6%)

809 (2.3%)

View Chart Data | View Full Screen

Public Health Laboratories

The results of tests performed by public health laboratories nationwide are summarized below. Data from public health laboratories are used to monitor the proportion of circulating viruses that belong to each influenza subtype/lineage.

Week 3

Data Cumulative since
October 3, 2021
(Week 40)
Positive specimens by type/subtype

View Chart Data | View Full Screen

Additional virologic surveillance information for current and past seasons:
Surveillance Methods | FluView Interactive: National, Regional, and State Data or Age Data

CDC performs genetic and antigenic characterization of U.S. viruses submitted from state and local public health laboratories using the Right Size Roadmap submission guidance. These data are used to compare how similar the currently circulating influenza viruses are to the reference viruses representing viruses contained in the current influenza vaccines. The data are also used to monitor evolutionary changes that continually occur in influenza viruses circulating in humans. CDC also tests susceptibility of circulating influenza viruses to antiviral medications including the neuraminidase inhibitors (oseltamivir, zanamivir, and peramivir) and the PA endonuclease inhibitor baloxavir.

CDC has genetically characterized 460 influenza viruses collected since October 3, 2021. Most of the H3N2 viruses so far are genetically closely related to the vaccine virus, but there are some antigenic differences that have developed as H3N2 viruses have continued to evolve. Virus antigenic data will be reported later this season when a sufficient number of specimens have been tested.

Virus Subtype or Lineage

Genetic Characterization

Total No. of
Subtype/Lineage
Tested

HA
Clade

Number (% of
subtype/lineage
tested)

HA
Subclade

Number (% of
subtype/lineage
tested)

6B.1A

3 (100%)

5a.1

2 (66.7%)

5a.2

1 (33.3%)

3C.2a 1b

437(100%)

1a

1 (0.2%)

3C.3a

0

3a

0

V1A

20 (100%)

V1A

0

Y3

0

CDC assesses susceptibility of influenza viruses to the antiviral medications including the neuraminidase inhibitors (oseltamivir, zanamivir, and peramivir) and the PA endonuclease inhibitor baloxavir using next generation sequence analysis supplemented by laboratory assays. Information about antiviral susceptibility test methods can be found at U.S. Influenza Surveillance: Purpose and Methods | CDC.

Viruses collected in the United States since October 3, 2021, were tested for antiviral susceptibility as follows:

High levels of resistance to the adamantanes (amantadine and rimantadine) persist among influenza A(H1N1)pdm09 and influenza A(H3N2) viruses (the adamantanes are not effective against influenza B viruses). Therefore, use of these antivirals for treatment and prevention of influenza A virus infection is not recommended and data from adamantane resistance testing are not presented.

The U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet) monitors outpatient visits for influenza-like illness [ILI (fever plus cough or sore throat)], not laboratory-confirmed influenza, and will therefore capture respiratory illness visits due to infection with any pathogen that can present with similar symptoms, including influenza, SARS-CoV-2, and RSV. Due to the COVID-19 pandemic, health care-seeking behaviors have changed, and people may be accessing the health care system in alternative settings not captured as a part of ILINet or at a different point in their illness than they might have before the pandemic. Therefore, it is important to evaluate syndromic surveillance data, including that from ILINet, in the context of other sources of surveillance data to obtain a complete and accurate picture of influenza, SARS-CoV-2, and other respiratory virus activity. CDC is tracking the COVID-19 pandemic in a weekly publication called COVID Data Tracker Weekly Review. Information about other respiratory virus activity can be found on CDC's National Respiratory and Enteric Virus Surveillance System (NREVSS) website.

Outpatient Respiratory Illness Visits

Nationwide, during week 3, 2.8% of patient visits reported through ILINet were due to respiratory illness that included fever plus a cough or sore throat, also referred to as ILI. This percentage is above the national baseline. Five of the 10 HHS regions are above their region-specific baselines (Regions 3,4,6,7, and 10), and the remaining regions are below their baselines. Multiple respiratory viruses are co-circulating, and the relative contribution of influenza virus infection to ILI varies by location.

* Effective October 3, 2021 (week 40), the ILI definition (fever plus cough or sore throat) no longer includes "without a known cause other than influenza."

View Chart Data (current season only) | View Full Screen

Outpatient Respiratory Illness Visits by Age Group

More than 70% of ILINet participants provide both the number of patient visits for respiratory illness and the total number of patient visits for the week broken out by age group. Data from this subset of providers are used to calculate the percentages of patient visits for respiratory illness by age group.

The percentage of visits for respiratory illness reported in ILINet are trending downward for all age groups (0-4 years, 5-24 years, 25-49 years, 50-64 years, and 65+ years).

* Effective October 3, 2021 (week 40), the ILI definition (fever plus cough or sore throat) no longer includes "without a known cause other than influenza."

View Chart Data | View Full Screen

Outpatient Respiratory Illness Activity Map

Data collected in ILINet are used to produce a measure of ILI activity* by state/jurisdiction and Core Based Statistical Areas (CBSA).

Activity Level

Number of Jurisdictions

Number of CBSAs

*Data collected in ILINet may disproportionally represent certain populations within a jurisdiction or CBSA, and therefore, may not accurately depict the full picture of influenza activity for the entire jurisdiction or CBSA. Differences in the data presented here by CDC and independently by some health departments likely represent differing levels of data completeness with data presented by the health department likely being the more complete.

Additional information about medically attended visits for ILI for current and past seasons:
Surveillance Methods | FluView Interactive: National, Regional, and State Data or ILI Activity Map

FluSurv-NET

The Influenza Hospitalization Surveillance Network (FluSurv-NET) conducts population-based surveillance for laboratory-confirmed influenza-related hospitalizations in select counties in 14 states and represents approximately 9% of the U.S. population. FluSurv-NET hospitalization data are preliminary. As data are received each week, prior case counts and rates are updated accordingly.

A total of 1,250 laboratory-confirmed influenza-associated hospitalizations were reported by FluSurv-NET sites between October 1, 2021, and January 22, 2022. The overall cumulative hospitalization rate is 4.3 per 100,000 population. This cumulative hospitalization rate is higher than the cumulative in-season hospitalization rate observed for week 3 during the 2020-2021 season (0.5 per 100,000), but lower than the in-season rates observed for week 3 during the 4 seasons preceding the COVID-19 pandemic (these ranged from 14.8 to 41.9 per 100,000 during the 2016-17 through 2019-20 seasons).

When examining rates by age, the highest rate of hospitalization per 100,000 population was among adults aged ≥65 years (11.3); within this group, rates were highest among adults aged ≥85 years (24.0). Among persons aged <65 years, hospitalization rates per 100,000 population were highest among children aged 0-4 years (6.2) followed by adults aged 50-64 years (4.0). When examining rates by race and ethnicity, the highest rate of hospitalization per 100,000 population was among non-Hispanic American Indian or Alaska Native persons (5.4) followed by non-Hispanic Black persons (5.0).

Among 1,250 hospitalizations, 1,178 (94.2%) were associated with influenza A virus, 62 (5.0%) with influenza B virus, 5 (0.4%) with influenza A virus and influenza B virus co-infection, and 5 (0.4%) with influenza virus for which the type was not determined. Among 295 hospitalizations with influenza A subtype information, 292 (99.0%) were A(H3N2) and 3 (1.0%) were A(H1N1)pdm09. Based on preliminary data, of the 1,250 laboratory-confirmed influenza-associated hospitalizations, 1.9% also tested positive for SARS-CoV-2.

Among 444 hospitalized adults with information on underlying medical conditions, 89.6% had at least one reported underlying medical condition. Among 52 hospitalized children with information on underlying medical conditions, 55.8% had at least one reported underlying medical condition; the most commonly reported was asthma.

View Full Screen

Additional FluSurv-NET hospitalization surveillance information for current and past seasons and additional age groups:
Surveillance Methods |FluView Interactive: Rates by Age, Sex, and Race/Ethnicity or Data on Patient Characteristics

FluSurv-Net data are used to generate national estimates of the total numbers of influenza cases, medical visits, hospitalizations, and deaths. This season, CDC is reporting preliminary cumulative in-season estimates, which are available at https://www.cdc.gov/flu/about/burden/preliminary-in-season-estimates.htm

National Center for Health Statistics (NCHS) Mortality Surveillance

Based on NCHS mortality surveillance data available on January 27, 2022, 28.4% of the deaths that occurred during the week ending January 22, 2022 (week 3), were due to pneumonia, influenza, and/or COVID-19 (PIC). This percentage is above the epidemic threshold of 7.1% for this week. Among the 5,940 PIC deaths reported for this week, 5,160 had COVID-19 listed as an underlying or contributing cause of death on the death certificate, and 27 listed influenza, indicating that current PIC mortality is due primarily to COVID-19 and not influenza. The data presented are preliminary and may change as more data are received and processed.

View Chart Dataexcel icon | View Full Screen

Additional pneumonia, influenza and COVID-19 mortality surveillance information for current and past seasons:
Surveillance Methods | FluView Interactive

Influenza-Associated Pediatric Mortality

No influenza-associated pediatric deaths were reported to CDC during week 3.

A total of five influenza-associated pediatric deaths occurring during the 2021-2022 season have been reported to CDC.

View Full Screen

Additional pediatric mortality surveillance information for current and past seasons:
Surveillance Methods | FluView Interactive

Additional National and International Influenza Surveillance Information

FluView Interactive: FluView includes enhanced web-based interactive applications that can provide dynamic visuals of the influenza data collected and analyzed by CDC. These FluView Interactive applications allow people to create customized, visual interpretations of influenza data, as well as make comparisons across flu seasons, regions, age groups and a variety of other demographics.

National Institute for Occupational Safety and Health: Monthly surveillance data on the prevalence of health-related workplace absenteeism among full-time workers in the United States are available from NIOSH.

U.S. State and local influenza surveillance: Select a jurisdiction below to access the latest local influenza information.

World Health Organization:
Additional influenza surveillance information from participating WHO member nations is available through
FluNetexternal icon and the Global Epidemiology Reports.external icon

WHO Collaborating Centers for Influenza:
Australiaexternal icon , Chinaexternal icon , Japanexternal icon , the United Kingdomexternal icon , and the United States (CDC in Atlanta, Georgia)

Europe:
The most up-to-date influenza information from Europe is available from WHO/Europe and the European Centre for Disease Prevention and Controlexternal icon .

Public Health Agency of Canada:
The most up-to-date influenza information from Canada is available in Canada's weekly FluWatch reportexternal icon .

Public Health England:
The most up-to-date influenza information from the United Kingdom is available from Public Health Englandexternal icon .
Any links provided to non-Federal organizations are provided solely as a service to our users. These links do not constitute an endorsement of these organizations or their programs by CDC or the Federal Government, and none should be inferred. CDC is not responsible for the content of the individual organization web pages found at these links.
A description of the CDC influenza surveillance system, including methodology and detailed descriptions of each data component is available on the surveillance methods page.

Page last reviewed:

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Weekly U.S. Influenza Surveillance Report

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All data are preliminary and may change as more reports are received. A description of the CDC influenza surveillance system, including methodology and detailed descriptions of each data component is available on the surveillance methods page. Additional information on the current and previous influenza seasons for each surveillance component are available on FluView Interactive.

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Some scientists are worried that the upcoming flu season could be very bad - after a year when it seemed to virtually disappear - and are urging people to get their flu vaccine by late October, ahead of the winter season.

But there's some good news.

One health survey, commissioned by CVS and released Wednesday, found that 71% of Americans intend to get their flu shot this year, a 5 percentage point increase from last year. And according to a study, getting both COVID-19 and flu vaccines appears safe and effective.

Worries about the flu come as the state's top doctor said she had advised Gov. Gretchen Whitmer that a mask mandate is needed for K-12 schools to keep children safe when they return to classrooms soon; the governor has yet to take action on that recommendation.

"Getting your flu shot is a great way to be proactive about your health and the health of your community," said Angela Patterson, chief nurse practitioner officer of MinuteClinic. "It's an easy way to protect yourself and those around you."

How a new vaccine might interact with other vaccines usually is looked at before it is approved for use, but that didn't happen with the COVID-19 vaccines, which were authorized because of the pandemic.

A study published in June, however, suggested it was safe to take both vaccines.

Last year, the CDC reported a significant decline in flu cases, likely because of masking, social distancing and other precautions taken to prevent coronavirus spread.

Moreover, Michiganders were urged to get the flu vaccine because officials said it would help improve the health and safety of everyone, especially as the coronavirus ravaged the United States and overwhelmed many hospitals.

This season, however, could be much worse for the flu.
Read more: Michigan's top doctor asks Gov. Whitmer for school mask mandate Tiny Romeo church forced to leave historic building after nearly 2 centuries
The CDC recommends a flu vaccine before flu viruses begin spreading in the community, since it takes about two weeks after vaccination for antibodies to develop in the body and provide adequate protection.

About 45% of the people who participated in the CVS-commissioned survey said they would get a flu shot at a retail pharmacy, followed by 25% at a doctor's office.

Patients with either the seasonal flu, certain respiratory illnesses or COVID-19 can present similar symptoms: fever, cough and body aches.
Contact Frank Witsil: 313-222-5022 or fwitsil@freepress.com.

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Survey reveals how Americans feel about getting flu shot this year

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Some scientists are worried that the upcoming flu season could be very bad - after a year when it seemed to virtually disappear - and are urging people to get their flu vaccine by late October, ahead of the winter season. But there's some good news.

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Historical Reference of Seasonal Influenza Vaccine Doses Distributed | CDC

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Seasonal flu vaccine: total doses distributed provides a cumulative weekly total of the number of doses of flu vaccine distributed - CDC

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ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/Health_US/hus08figures/fig24.xls

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https://www.freep.com/story/news/health/2021/08/18/flu-shot-vaccine-cvs-covid-19/8181974002/

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Some scientists are worried that the upcoming flu season could be very bad - after a year when it seemed to virtually disappear - and are urging people to get their flu vaccine by late October, ahead of the winter season.

But there's some good news.

One health survey, commissioned by CVS and released Wednesday, found that 71% of Americans intend to get their flu shot this year, a 5 percentage point increase from last year. And according to a study, getting both COVID-19 and flu vaccines appears safe and effective.

Worries about the flu come as the state's top doctor said she had advised Gov. Gretchen Whitmer that a mask mandate is needed for K-12 schools to keep children safe when they return to classrooms soon; the governor has yet to take action on that recommendation.

"Getting your flu shot is a great way to be proactive about your health and the health of your community," said Angela Patterson, chief nurse practitioner officer of MinuteClinic. "It's an easy way to protect yourself and those around you."

How a new vaccine might interact with other vaccines usually is looked at before it is approved for use, but that didn't happen with the COVID-19 vaccines, which were authorized because of the pandemic.

A study published in June, however, suggested it was safe to take both vaccines.

Last year, the CDC reported a significant decline in flu cases, likely because of masking, social distancing and other precautions taken to prevent coronavirus spread.

Moreover, Michiganders were urged to get the flu vaccine because officials said it would help improve the health and safety of everyone, especially as the coronavirus ravaged the United States and overwhelmed many hospitals.

This season, however, could be much worse for the flu.
Read more: Michigan's top doctor asks Gov. Whitmer for school mask mandate Tiny Romeo church forced to leave historic building after nearly 2 centuries
The CDC recommends a flu vaccine before flu viruses begin spreading in the community, since it takes about two weeks after vaccination for antibodies to develop in the body and provide adequate protection.

About 45% of the people who participated in the CVS-commissioned survey said they would get a flu shot at a retail pharmacy, followed by 25% at a doctor's office.

Patients with either the seasonal flu, certain respiratory illnesses or COVID-19 can present similar symptoms: fever, cough and body aches.
Contact Frank Witsil: 313-222-5022 or fwitsil@freepress.com.

# data[].attributes.attachment_link.title
Survey reveals how Americans feel about getting flu shot this year

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Some scientists are worried that the upcoming flu season could be very bad - after a year when it seemed to virtually disappear - and are urging people to get their flu vaccine by late October, ahead of the winter season. But there's some good news.

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PITTSBURGH (KDKA) - We've been hearing about them for months, and it's finally time for COVID-19 booster shots.

Doctors recommend getting the booster eight months after the second shot, and for many - that falls smack dab in flu shot season.

READ MORE: COVID-19 In Pittsburgh: Allegheny County Health Department Reports 263 New Cases

KDKA's Meghan Schiller asked the experts what people need to know about mixing the two.

"I think ideally it might be two shots this year, but to get them both at the same time would certainly be efficient," said Dr. Amy Crawford-Faucher, family doctor and Vice Chair of Allegheny Health Network's Primary Care Institute.

KDKA's cameras were rolling as people lined up for another dose of protection at Allegheny General Hospital.

"I feel much safer because I don't want to lose my kidney," said Esperanza Bier.

Bier just received a new kidney and said she's vaccinated to honor her donor. She's one of many immunocompromised people now eligible for a COVID-19 booster shot.

"I was in dialysis close to three or four years," said Bier.

Schiller: How are you feeling now?

Bier: Oh, it's wonderful.

The CDC just announced we'll need booster shots for maximum protection, but for many - the third shot overlaps with flu season.

READ MORE: Pennsylvania Redistricting Panel Considers Where To Count State Prisoners

"When the COVID vaccines first came out, we said no other vaccines within two weeks of a COVID vaccine. So that recommendation changed a few months ago," said Dr. Crawford- Faucher

But doctors now say people can now get their flu shot and COVID booster shot around the same time. Turns out, people always could, but scientists didn't want overlap for one reason.

"Because we were just rolling this out to lots of people, we really wanted to be pure in knowing that if you had a reaction, it was due to the COVID vaccine and not from something else you got in your body," said Dr. Crawford- Faucher.

Top researchers already started discussing a combo shot that covers both the coronavirus and the flu. UPMC's Dr. Graham Snyder told KDKA expect two shots for now.

"It's plausible that we could every winter get a combo influenza vaccine and COVID vaccine, but it's way too early to say that's going to happen. But that plausibly could happen," said Dr. Snyder, UPMC's medical director of infection prevention and hospital epidemiology.

People in line for the booster shot at AGH didn't seem to mind that another shot is in their not-so-distant future.

"I would get the flu shot. I get it every year," said Marie Geubtner, nurse and booster shot recipient.

"So, I did that booster too, I get all my boosters, all my shots all the time," said Mary Louise Pastorok, Allegheny Health Network's booster shot recipient and senior executive assistant.

Doctors warn against skipping the flu shot, saying we won't see a repeat winter with low flu cases for these reasons:

"A major contributor to the reason we saw no flu virus was because many of us were staying at home, we're working from home, we're doing school from home, we were limiting the number of contacts we all had and we were masking," said Dr. Snyder. "Now, obviously, that has changed and will probably remain changed going into this winter."

MORE NEWS: Registration Opens For PedalPGH

That's why doctors say schedule both, in whatever order works out best for your schedule.

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Doctors Say It Is Safe To Get Flu Shot And COVID-19 Booster Shot Around Same Time

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PITTSBURGH (KDKA) - We've been hearing about them for months, and it's finally time for COVID-19 booster shots. Doctors recommend getting the booster eight months after the second shot, and for many - that falls smack dab in flu shot season.

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https://greensboro.com/1989-90-flu-season-one-of-worst-ever/article_5eba93cf-0af5-5067-949f-c39a43f72356.html

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The flu season of 1989-90 has been a bad one, killing tens of thousands of people and preying especially on the elderly, federal flu specialists reported Thursday.

To make matters worse, flu vaccination levels among older people may be little more than four in 10, another new survey shows.The national Centers for Disease Control reported that the 1989-90 flu season, now winding to a close, has been marked by a flu type especially troublesome for older people: what researchers know as A-H3N2.

The CDC estimates that in the average influenza season, about 20,000 Americans are killed by the flu. But in 1984-85, the last year in which A-H3N2 was so predominant, an estimated 57,000 people died.

``This year looks to me like the worst year since '84-85,' said Dr. Walter Gunn, a CDC flu specialist. Final figures aren't in; his estimate was based on the death rate so far.

The U.S. flu season, which peaked in late January and early February, was characterized almost exclusively by a type A-H3N2 flu strain dubbed the ``Shanghai flu.' That was one of the three components in the current winter's flu vaccine, which is recommended chiefly for people over 65 or patients with ailments such as diabetes or kidney disease.

But a survey of Medicare beneficiaries found that only 43 percent had received flu vaccinations for the 1988-89 winter flu season, the CDC reported. And 91 percent of the Medicare participants who didn't get their flu shots were people who should have, such as the elderly.

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The flu season of 1989-90 has been a bad one, killing tens of thousands of people and preying especially on the elderly, federal flu specialists reported Thursday.

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2021 flu season: what we should expect as flu shots begin to roll out in a few weeks

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As the debate over the COVID-19 vaccine continues to spark conversations across the valley, soon another shot will be hitting headlines and pharmacies. The flu shot is only a few weeks away from rolling out and rolling sleeves up.

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Centers for Disease Control and Prevention

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What you need to know about the upcoming 2020-2021 influenza season in the United States.

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ORLANDO, Fla. - With COVID booster shots on the way and flu season right around the corner, many are wondering if it's OK to get protection from both illnesses at the same time.

AdventHealth epidemiologist Dr. Vincent Hsu said Thursday that he expects a more active flu season than last year.

"As masks come off, we are going to see a resurgence of the flu," Hsu said.

He said that COVID and the flu could infect the same person.

"Get your flu shot, just like the COVID vaccine," said Hsu, adding that someone could get both shots at the same time. "One in each arm."

Pharmacies, like those at Walmart, are alreadypromoting low-cost flu shots now available at most Central Florida stores.

"We want to keep everyone safe," Dr. Shasly Ulysse from Walmart Pharmacy said. "I believe if people understand the why and the how the vaccine works in our body, then it's a no brainer. Let's go ahead and protect ourselves."

Pharmacists say to call ahead to make sure a store has the flu vaccine, but at most locations no appointment is necessary.

Family Medicine Specialist Dr. Thomas Kelley from Orlando Health said he's encouraging his patients to get both shots too, He's also working to set the record straight when it comes to misinformation about the vaccines for those who may be hesitant.

"The vaccines just simply do not cause the illness that it's meant to prevent," Kelley said. "The biggest thing to dispel is that taking either of these vaccines is going to make you horribly ill and that's just not the case. There are certainly potential for some limited side effects with either vaccine."

Dr. Kelley said people who are hesitant should talk to their doctor.

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Should I get the flu shot and the COVID vaccine/booster?

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ORLANDO, Fla. - With COVID booster shots on the way and flu season right around the corner, many are wondering if it's OK to get protection from both illnesses at the same time. AdventHealth epidemiologist Dr. Vincent Hsu said Thursday that he expects a more active flu season than last year.

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Historical Reference of Seasonal Influenza Vaccine Doses Distributed | CDC

# data[].attributes.attachment_link.description
Seasonal flu vaccine: total doses distributed provides a cumulative weekly total of the number of doses of flu vaccine distributed - CDC

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Some scientists are worried that the upcoming flu season could be very bad - after a year when it seemed to virtually disappear - and are urging people to get their flu vaccine by late October, ahead of the winter season.

But there's some good news.

One health survey, commissioned by CVS and released Wednesday, found that 71% of Americans intend to get their flu shot this year, a 5 percentage point increase from last year. And according to a study, getting both COVID-19 and flu vaccines appears safe and effective.

Worries about the flu come as the state's top doctor said she had advised Gov. Gretchen Whitmer that a mask mandate is needed for K-12 schools to keep children safe when they return to classrooms soon; the governor has yet to take action on that recommendation.

"Getting your flu shot is a great way to be proactive about your health and the health of your community," said Angela Patterson, chief nurse practitioner officer of MinuteClinic. "It's an easy way to protect yourself and those around you."

How a new vaccine might interact with other vaccines usually is looked at before it is approved for use, but that didn't happen with the COVID-19 vaccines, which were authorized because of the pandemic.

A study published in June, however, suggested it was safe to take both vaccines.

Last year, the CDC reported a significant decline in flu cases, likely because of masking, social distancing and other precautions taken to prevent coronavirus spread.

Moreover, Michiganders were urged to get the flu vaccine because officials said it would help improve the health and safety of everyone, especially as the coronavirus ravaged the United States and overwhelmed many hospitals.

This season, however, could be much worse for the flu.
Read more: Michigan's top doctor asks Gov. Whitmer for school mask mandate Tiny Romeo church forced to leave historic building after nearly 2 centuries
The CDC recommends a flu vaccine before flu viruses begin spreading in the community, since it takes about two weeks after vaccination for antibodies to develop in the body and provide adequate protection.

About 45% of the people who participated in the CVS-commissioned survey said they would get a flu shot at a retail pharmacy, followed by 25% at a doctor's office.

Patients with either the seasonal flu, certain respiratory illnesses or COVID-19 can present similar symptoms: fever, cough and body aches.
Contact Frank Witsil: 313-222-5022 or fwitsil@freepress.com.

# data[].attributes.attachment_link.title
Survey reveals how Americans feel about getting flu shot this year

# data[].attributes.attachment_link.description
Some scientists are worried that the upcoming flu season could be very bad - after a year when it seemed to virtually disappear - and are urging people to get their flu vaccine by late October, ahead of the winter season. But there's some good news.

# data[].attributes.attachment_link.readable_text
Some scientists are worried that the upcoming flu season could be very bad - after a year when it seemed to virtually disappear - and are urging people to get their flu vaccine by late October, ahead of the winter season.

But there's some good news.

One health survey, commissioned by CVS and released Wednesday, found that 71% of Americans intend to get their flu shot this year, a 5 percentage point increase from last year. And according to a study, getting both COVID-19 and flu vaccines appears safe and effective.

Worries about the flu come as the state's top doctor said she had advised Gov. Gretchen Whitmer that a mask mandate is needed for K-12 schools to keep children safe when they return to classrooms soon; the governor has yet to take action on that recommendation.

"Getting your flu shot is a great way to be proactive about your health and the health of your community," said Angela Patterson, chief nurse practitioner officer of MinuteClinic. "It's an easy way to protect yourself and those around you."

How a new vaccine might interact with other vaccines usually is looked at before it is approved for use, but that didn't happen with the COVID-19 vaccines, which were authorized because of the pandemic.

A study published in June, however, suggested it was safe to take both vaccines.

Last year, the CDC reported a significant decline in flu cases, likely because of masking, social distancing and other precautions taken to prevent coronavirus spread.

Moreover, Michiganders were urged to get the flu vaccine because officials said it would help improve the health and safety of everyone, especially as the coronavirus ravaged the United States and overwhelmed many hospitals.

This season, however, could be much worse for the flu.
Read more: Michigan's top doctor asks Gov. Whitmer for school mask mandate Tiny Romeo church forced to leave historic building after nearly 2 centuries
The CDC recommends a flu vaccine before flu viruses begin spreading in the community, since it takes about two weeks after vaccination for antibodies to develop in the body and provide adequate protection.

About 45% of the people who participated in the CVS-commissioned survey said they would get a flu shot at a retail pharmacy, followed by 25% at a doctor's office.

Patients with either the seasonal flu, certain respiratory illnesses or COVID-19 can present similar symptoms: fever, cough and body aches.
Contact Frank Witsil: 313-222-5022 or fwitsil@freepress.com.

# data[].attributes.attachment_link.title
Survey reveals how Americans feel about getting flu shot this year

# data[].attributes.attachment_link.description
Some scientists are worried that the upcoming flu season could be very bad - after a year when it seemed to virtually disappear - and are urging people to get their flu vaccine by late October, ahead of the winter season. But there's some good news.

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https://abcnews.go.com/Health/flu-numbers-year-due-higher-vaccination-rates-amid/story?id=74783195

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Experts say mask use and social distancing have also helped keep numbers low.

Hospitals across the U.S. are nearing critical capacity due to the rise in COVID-19 cases just as the winter flu season begins to threaten the country. Public officials and doctors worry that the worst is yet to come, but increased rates of flu vaccinations this year may help us avoid a further catastrophic stress on our health care system.

The Centers for Disease Control and Prevention's tracking of flu vaccine distribution over the years shows that so far in the 2020-2021 flu season, 189.4 million flu vaccines have been distributed in the U.S., compared to 174 million in the 2019-2020 season.

This, paired with stay-at-home orders, masking and social distancing, means there are fewer cases of the flu this year than ever before. Doctors are noticing less clinic visits and hospital admissions for the flu and pharmacies are filling fewer prescriptions for the antiviral medications physicians prescribe for influenza. Data analysts at Walgreens have tracked sales of antiviral medications for flu over the past seven years to estimate flu activity across the U.S. and 2020 has had significantly lower sales than in 2019.

Flu activity, or incidence of flu cases, in November 2020 was approximately 91% lower than in November 2019, according to the data.

Analysts mapped the data, which they call the Walgreens Flu Index, to show via color coordination how heavily each state has been affected by the flu. A time-lapse of the map from the 2019-2020 flu season to the 2020-2021 season shows a dramatic shift from mostly red-colored states (which means high flu activity) to mostly green-colored states (which means low flu activity).

"I've definitely seen less flu this year," Dr. Simone Wildes, an infectious disease physician at South Shore Health, told ABC News. "Masks are key for this change, but another reason [for decreased flu] is ... we really pushed for a really big campaign this year to get people out to get vaccinated [against the flu] and I think people really heeded our recommendation to take the flu shot this year."

"I think it is probably because of the precautions we are taking for COVID-19 and also because of flu shots," Dr. Krutika Kuppalli, vice chair of the Infectious Disease Society of America, said.

Walgreens has also seen an "unprecedented demand ... for flu shots this season," Dr. Kevin Ban, the chief medical officer at Walgreens, said in a written statement to ABC News. "We've seen double-digit growth in demand for flu shots this year."

But even as the CDC reports that " flu vaccine coverage has increased for both children and adults over the past flu season," a great part of the U.S. population has yet to be vaccinated.

"Especially in communities of color, there has been a lot of vaccine hesitancy, so a lot of them don't get the flu vaccine," Wildes said.

But together as a nation, we are moving to address health disparities highlighted during the pandemic.

Clinicians "try to engage different disenfranchised communities and patients that we know are at higher risk," Kuppalli said. "We work on engaging them to understand their concerns when it comes to vaccines."

This year, Walgreens also "implemented the safety precautions needed to administer vaccines in a COVID environment, and rolled out off-site clinics in churches and community centers to ensure access to care for underserved communities," Ban said.

Remember, it's not too late to get your flu shot this year. And even as the COVID-19 vaccines start rolling out across the country, Wildes said we "absolutely have to continue all of the safety measures" implemented during the pandemic to continue protecting ourselves from both the flu and the novel coronavirus.
Shiela Beroukhim Afrahimi, M.D., is an internal medicine resident at Harbor-UCLA Medical Center in Torrance, California, and a contributor to the ABC News Medical Unit.

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Flu numbers are down this year due to higher vaccination rates amid COVID pandemic

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Experts say mask use and social distancing have also helped keep numbers low. Hospitals across the U.S. are nearing critical capacity due to the rise in COVID-19 cases just as the winter flu season begins to threaten the country.

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https://www.cdc.gov/flu/prevent/vaccine-supply-historical.htm

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Historical Reference of Seasonal Influenza Vaccine Doses Distributed | CDC

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Seasonal flu vaccine: total doses distributed provides a cumulative weekly total of the number of doses of flu vaccine distributed - CDC

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During the 1989-90 influenza season, 98% of all influenza viruses isolated in the United States and reported to CDC were influenza A. Almost all those that were antigenically characterized were similar to influenza A/Shanghai/11/87(H3N2), a component of the 1989-90 influenza vaccine. Regional and widespread influenza activity began to be reported in late December 1989, peaked in mid-January 1990, and declined rapidly through early April 1990. Most of the outbreaks reported to CDC were among nursing-home residents. Considerable influenza-associated mortality was reflected in the percentage of deaths due to pneumonia and influenza (P&I) reported through the CDC 121 Cities Surveillance System from early January through early April. More than 80% of all reported P&I deaths were among persons ≥65 years. In contrast to the predominance of influenza A during 1989-90, during the 1990-91 influenza season 86% of all influenza virus isolations reported were influenza B. Widespread influenza activity was reported from mid-January through April 1991, with regional activity extending into May. Outbreaks were reported primarily among schoolchildren, and no evidence of excess influenza-associated mortality was found. Almost all the influenza B isolates tested were related to influenza B/Yamagata/16/88, a component of the 1990-91 influenza vaccine, but were antigenically closer to B/Panama/45/90, a minor variant.

Journal Information

The CDC Surveillance Summaries provide a means for CDC programs to disseminate surveillance findings, permitting detailed interpretation of trends and patterns based on those findings.

Publisher Information

Collaborating to create the expertise, information, and tools that people and communities need to protect their health - through health promotion, prevention of disease, injury and disability, and preparedness for new health threats. CDC seeks to accomplish its mission by working with partners throughout the nation and the world to * monitor health, * detect and investigate health problems, * conduct research to enhance prevention, * develop and advocate sound public health policies, * implement prevention strategies, * promote healthy behaviors, * foster safe and healthful environments, * provide leadership and training. Those functions are the backbone of CDC′s mission. Each of CDC′s component organizations undertakes these activities in conducting its specific programs. The steps needed to accomplish this mission are also based on scientific excellence, requiring well-trained public health practitioners and leaders dedicated to high standards of quality and ethical practice.

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Influenza - United States, 1989-90 and 1990-91 Seasons on JSTOR

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During the 1989-90 influenza season, 98% of all influenza viruses isolated in the United States and reported to CDC were influenza A. Almost all those that were antigenically characterized were similar to influenza A/Shanghai/11/87(H3N2), a component of the 1989-90 influenza vaccine.

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Store photos and docs online. Access them from any PC, Mac or phone. Create and work together on Word, Excel or PowerPoint documents.

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ALBANY, N.Y. ( NEWS10) - Worried about getting the flu shot alongside a COVID booster? According to some experts, there's nothing to worry about.

The CDC said COVID vaccines can be given with other routine vaccinations, including the flu shot. They also said people do not have to wait in between the shots. COVID vaccines can be given the same day as other vaccinations.

"You could get both vaccines simultaneously, or if you're worried about local effects or side effects-local effects or low-grade fever are common with both vaccines-then you could split them up by a week or two," said Dr. Arthur Gran, an infectious disease specialist with Samaritan Hospitals.

Because it's recommended people get the flu shot in early fall-like September or October-getting both inoculations at once may not be an issue, either. Many will have to wait for another two to three months before they are eligible to get a COVID booster. Experts are recommending a booster for people eight months after getting fully vaccinated which would make a large portion of people eligible for a booster sometime between November and December.

Children can also get the COVID vaccine with their routine immunizations as well. "A COVID-19 vaccine could be authorized for ages 5 to 11 as soon as September or October. So right around the time your child gets their annual flu shot, they could become eligible for the COVID-19 vaccine. If that happens, they won't need to wait between vaccines," reads a post from Dr. Juan C. Salazar, a pediatrician at Connecticut Children's Medical Center.

What will the 2021-2022 flu season look like? It's still too early to tell, said Dr. Gran. The U.S. usually looks to the southern hemisphere to try to get a glimpse of the upcoming flu season. He said that, so far, cases in Australia have been low. But that doesn't necessarily mean the same will hold true for the U.S.

Last year, cases of flu in the U.S. were minute compared to the previous three flu seasons. In the 2020 to 2021 flu season, the rate of infection was .2%. That season, 1,675 out of 818,939 people tested were positive for the flu. Averaging the three previous flu seasons-from 2017 to 2020-the CDC clocked an infection rate between 26.2% and 30.3%.

"An average flu season-when flu season peaks-the clinical labs that report to the CDC [reported on average] about 20,000 cases a week during the height of flu season. Last year, there were maybe 150. It was considerably lower than it was the previous year, and that presumably is because of public health [initiatives] to try and contain COVID," Dr. Gran said.

How effective will this year's flu shot be? That is also difficult sometimes to forecast, Dr. Gran said. Through research, scientists are able to predict roughly which flu virus will be the most prevalent, but it's not always completely accurate.

Like COVID vaccines, flu shots take about two weeks before a person builds antibodies. It's why experts recommend people get the shot early in the fall, well in advance of flu season, which generally starts in December.

Most flu vaccines in the U.S. offer protection against four strains: influenza A (H1N1), influenza A (H3N2), and two influenza B viruses, the CDC said. Flu shots work similarly to COVID vaccines by helping the body recognize the virus in order to produce an immune response. Just like breakthrough cases of COVID occur in vaccinated people, flu variants can also cause people who have gotten their seasonal shot to get sick.

As COVID vaccines keep a high majority of people with breakthrough cases out of the hospital, Dr. Gran said the same is true of flu shots. Even if there is a strain outside of what's included in the vaccine, the shot will still protect a majority of people from serious illness if they become infected.

Season to season changes in the flu virus are also the reason why the CDC said it's important to get one before each flu season:

A flu vaccine is needed every season for two reasons. First, a person's immune protection from vaccination declines over time, so an annual vaccine is needed for optimal protection. Second, because flu viruses are constantly changing, flu vaccines may be updated from one season to the next to protect against the viruses that research suggests may be most common during the upcoming flu season. For the best protection, everyone 6 months and older should get vaccinated annually.

"There's evidence to support that even if it does not prevent you from getting the flu, it can prevent you from having a severe case of the flu. And we see that with the COVID vaccination as well," said Dr. Gran.

Is it a good idea to wear a face mask in order to prevent a flu infection? The CDC doesn't recommend it but Dr. Gran said there is much more research that supports the use of a mask can prevent flu transmission, as it's been studied over a longer period than COVID.

What if someone had to choose between the flu shot or the COVID vaccine? Dr. Gran said the more imminent danger is COVID: "COVID-19 is the more transmissible disease. It is the more dangerous disease. It's more important to be vaccinated against COVID-19 than it is to be vaccinated against the flu, if you had to choose one."

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What will the 2021-2022 flu season look like?

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ALBANY, N.Y. (NEWS10) - Worried about getting the flu shot alongside a COVID booster? According to some experts, there's nothing to worry about. The CDC said COVID vaccines can be given with other routine vaccinations, including the flu shot. They also said people do not have to wait in between the shots.

# data[].attributes.attachment_link.readable_text
Some scientists are worried that the upcoming flu season could be very bad - after a year when it seemed to virtually disappear - and are urging people to get their flu vaccine by late October, ahead of the winter season.

But there's some good news.

One health survey, commissioned by CVS and released Wednesday, found that 71% of Americans intend to get their flu shot this year, a 5 percentage point increase from last year. And according to a study, getting both COVID-19 and flu vaccines appears safe and effective.

Worries about the flu come as the state's top doctor said she had advised Gov. Gretchen Whitmer that a mask mandate is needed for K-12 schools to keep children safe when they return to classrooms soon; the governor has yet to take action on that recommendation.

"Getting your flu shot is a great way to be proactive about your health and the health of your community," said Angela Patterson, chief nurse practitioner officer of MinuteClinic. "It's an easy way to protect yourself and those around you."

How a new vaccine might interact with other vaccines usually is looked at before it is approved for use, but that didn't happen with the COVID-19 vaccines, which were authorized because of the pandemic.

A study published in June, however, suggested it was safe to take both vaccines.

Last year, the CDC reported a significant decline in flu cases, likely because of masking, social distancing and other precautions taken to prevent coronavirus spread.

Moreover, Michiganders were urged to get the flu vaccine because officials said it would help improve the health and safety of everyone, especially as the coronavirus ravaged the United States and overwhelmed many hospitals.

This season, however, could be much worse for the flu.
Read more: Michigan's top doctor asks Gov. Whitmer for school mask mandate Tiny Romeo church forced to leave historic building after nearly 2 centuries
The CDC recommends a flu vaccine before flu viruses begin spreading in the community, since it takes about two weeks after vaccination for antibodies to develop in the body and provide adequate protection.

About 45% of the people who participated in the CVS-commissioned survey said they would get a flu shot at a retail pharmacy, followed by 25% at a doctor's office.

Patients with either the seasonal flu, certain respiratory illnesses or COVID-19 can present similar symptoms: fever, cough and body aches.
Contact Frank Witsil: 313-222-5022 or fwitsil@freepress.com.

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Survey reveals how Americans feel about getting flu shot this year

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Some scientists are worried that the upcoming flu season could be very bad - after a year when it seemed to virtually disappear - and are urging people to get their flu vaccine by late October, ahead of the winter season. But there's some good news.

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https://www.wivb.com/health/coronavirus/what-will-the-2021-2022-flu-season-look-like/

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ALBANY, N.Y. ( NEWS10) - Worried about getting the flu shot alongside a COVID booster? According to some experts, there's nothing to worry about.

The CDC said COVID vaccines can be given with other routine vaccinations, including the flu shot. They also said people do not have to wait in between the shots. COVID vaccines can be given the same day as other vaccinations.

"You could get both vaccines simultaneously, or if you're worried about local effects or side effects-local effects or low-grade fever are common with both vaccines-then you could split them up by a week or two," said Dr. Arthur Gran, an infectious disease specialist with Samaritan Hospitals.

Because it's recommended people get the flu shot in early fall-like September or October-getting both inoculations at once may not be an issue, either. Many will have to wait for another two to three months before they are eligible to get a COVID booster. Experts are recommending a booster for people eight months after getting fully vaccinated which would make a large portion of people eligible for a booster sometime between November and December.

Children can also get the COVID vaccine with their routine immunizations as well. "A COVID-19 vaccine could be authorized for ages 5 to 11 as soon as September or October. So right around the time your child gets their annual flu shot, they could become eligible for the COVID-19 vaccine. If that happens, they won't need to wait between vaccines," reads a post from Dr. Juan C. Salazar, a pediatrician at Connecticut Children's Medical Center.

What will the 2021-2022 flu season look like? It's still too early to tell, said Dr. Gran. The U.S. usually looks to the southern hemisphere to try to get a glimpse of the upcoming flu season. He said that, so far, cases in Australia have been low. But that doesn't necessarily mean the same will hold true for the U.S.

Last year, cases of flu in the U.S. were minute compared to the previous three flu seasons. In the 2020 to 2021 flu season, the rate of infection was .2%. That season, 1,675 out of 818,939 people tested were positive for the flu. Averaging the three previous flu seasons-from 2017 to 2020-the CDC clocked an infection rate between 26.2% and 30.3%.

"An average flu season-when flu season peaks-the clinical labs that report to the CDC [reported on average] about 20,000 cases a week during the height of flu season. Last year, there were maybe 150. It was considerably lower than it was the previous year, and that presumably is because of public health [initiatives] to try and contain COVID," Dr. Gran said.

How effective will this year's flu shot be? That is also difficult sometimes to forecast, Dr. Gran said. Through research, scientists are able to predict roughly which flu virus will be the most prevalent, but it's not always completely accurate.

Like COVID vaccines, flu shots take about two weeks before a person builds antibodies. It's why experts recommend people get the shot early in the fall, well in advance of flu season, which generally starts in December.

Most flu vaccines in the U.S. offer protection against four strains: influenza A (H1N1), influenza A (H3N2), and two influenza B viruses, the CDC said. Flu shots work similarly to COVID vaccines by helping the body recognize the virus in order to produce an immune response. Just like breakthrough cases of COVID occur in vaccinated people, flu variants can also cause people who have gotten their seasonal shot to get sick.

As COVID vaccines keep a high majority of people with breakthrough cases out of the hospital, Dr. Gran said the same is true of flu shots. Even if there is a strain outside of what's included in the vaccine, the shot will still protect a majority of people from serious illness if they become infected.

Season to season changes in the flu virus are also the reason why the CDC said it's important to get one before each flu season:

A flu vaccine is needed every season for two reasons. First, a person's immune protection from vaccination declines over time, so an annual vaccine is needed for optimal protection. Second, because flu viruses are constantly changing, flu vaccines may be updated from one season to the next to protect against the viruses that research suggests may be most common during the upcoming flu season. For the best protection, everyone 6 months and older should get vaccinated annually.

"There's evidence to support that even if it does not prevent you from getting the flu, it can prevent you from having a severe case of the flu. And we see that with the COVID vaccination as well," said Dr. Gran.

Is it a good idea to wear a face mask in order to prevent a flu infection? The CDC doesn't recommend it but Dr. Gran said there is much more research that supports the use of a mask can prevent flu transmission, as it's been studied over a longer period than COVID.

What if someone had to choose between the flu shot or the COVID vaccine? Dr. Gran said the more imminent danger is COVID: "COVID-19 is the more transmissible disease. It is the more dangerous disease. It's more important to be vaccinated against COVID-19 than it is to be vaccinated against the flu, if you had to choose one."

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What will the 2021-2022 flu season look like?

# data[].attributes.attachment_link.description
ALBANY, N.Y. (NEWS10) - Worried about getting the flu shot alongside a COVID booster? According to some experts, there's nothing to worry about. The CDC said COVID vaccines can be given with other routine vaccinations, including the flu shot. They also said people do not have to wait in between the shots.

# data[].attributes.attachment_link.readable_text
UGA research also uncovers disparities in ethnic acceptance of vaccine

More U.S. adults reported receiving or planning to receive an influenza vaccination during the 2020-2021 flu season than ever before, according to findings from a December 2020 national survey.

The survey of 1,027 adults, conducted by the University of Georgia, found that 43.5% of respondents reported having already received a flu vaccination with an additional 13.5% stating they "definitely will get one" and 9.3% stating they "probably will get one." Combined, 66.3% have received or intend to receive an influenza vaccination.

By comparison, 48.4% of adults 18 and older received the vaccine during the 2019-2020 flu season, according to the Centers for Disease Control and Prevention, an increase of 3.1 percentage points from 2018-2019.

The survey was led by professor Glen Nowak, director of UGA's Center for Health and Risk Communication in the Grady College of Journalism and Mass Communication, and associate professor Michael Cacciatore, CHRC research director. The respondents came from the National Opinion Research Center's AmeriSpeak panel, which uses a prescreened, nationally representative pool of participants to obtain rapid and projectable survey findings.

"Our survey shows that most Americans have or planned to act on the advice to get a flu vaccination this season," said Nowak. "Further, these results strongly suggest the U.S. will be crossing an important threshold this flu season, which is over half of U.S. adults getting a flu vaccination."

The survey results indicate much of the increase in flu vaccine uptake is being driven by people 60 years old and older. A total of 61.5% said they had already received the influenza vaccine in December, with another 12% stating they "would definitely get it" and 5.8% stating they "would probably get it."

Demographic differences

The survey results also indicated many demographic differences when it came to having received a flu vaccination. Forty-eight percent of white respondents reported having a flu vaccination by December, compared to 35.1% of Hispanic respondents and 30.1% of Black respondents. Having already received a flu vaccination was also much higher for respondents with a college or higher education and those with annual household incomes of $75,000 a year or more.

Conversely, flu vaccination uptake and plans to get a flu vaccination were lowest for those 18-29 years old, those with some college or a high school education, and those with annual incomes less than $25,000. The survey found that 50.7% of those making more than $75,000 had already been vaccinated for the flu, while only 35% of those making less than $25,000 had been vaccinated.

"It was disappointing to see that significant differences by race, age, education and income persisted during a flu vaccination season that took place during a COVID pandemic," Cacciatore said. "It's important that we continue to learn more about why these disparities exist so we can take steps that will reduce them."

"Overall, it is good news to find that many people, particularly those at highest risk for serious flu or COVID-19 illness, followed the advice to get the flu vaccine. Hopefully, we can sustain that level of success in the years ahead," Nowak said. "It also remains worrisome to find much lower flu vaccination rates and intentions in so many groups. We continue to have much work to do among Hispanic and Black adults and those with lower income and years of formal education when it comes to flu vaccination."

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Flu vaccination this season likely to be highest ever

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UGA research also uncovers disparities in ethnic acceptance of vaccine More U.S. adults reported receiving or planning to receive an influenza vaccination during the 2020-2021 flu season than ever before, according to findings from a December 2020 national survey.

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Historical Reference of Seasonal Influenza Vaccine Doses Distributed | CDC

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Seasonal flu vaccine: total doses distributed provides a cumulative weekly total of the number of doses of flu vaccine distributed - CDC

# data[].attributes.attachment_link.title
Historical Reference of Seasonal Influenza Vaccine Doses Distributed | CDC

# data[].attributes.attachment_link.description
Seasonal flu vaccine: total doses distributed provides a cumulative weekly total of the number of doses of flu vaccine distributed - CDC

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Health experts worry as flu season approaches

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Health experts worry as flu season approaches

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Flu season is right around the corner in the midst of our country dealing with the delta variant. A year ago, doctors said the number of flu infections decreased globally because of the precautions we took against COVID-19.

This is because a year ago we were still wearing masks, social distancing and staying at home. Now that many of those restrictions have been lifted, Dr. Rebekah Bernard believes this flu season will be different.

Avoiding the "twindemic" is the messaging from doctors again this year. This is as COVID-19 cases continue to rise and hospitals are filling up. Not to mention that flu season is just around the corner.

"If we're still in our increase in cases and still in the spike with the delta wave and we see influenza start to creep in as well, then I think that's going to be stressful for our health care system," Bernard said.

Bernard is with Gulf Coast Primary Care and says that with more people traveling, the likelihood that America could see a spike in flu cases will increase.

And the beginning of flu season is coming at a critical point in our fight against COVID-19. Over the next few months, people will begin rolling up their sleeves to receive the coronavirus booster shot.

Others will roll up their sleeves as well but for their yearly flu shot. But is this safe? Dr. Bernard believes the CDC will say that people can have both in such a short timeframe.

"They're probably going to want to prioritize making sure patients get their flu shots. And not wanting anyone to wait too long and increase the chances of them getting the flu," she said.

To prevent even more strain on hospitals, Dr. Bernard wants to urge everyone to stay safe as the delta variant continues to wreak havoc. "We're a high-risk area right now in Southwest Florida based on the numbers. So, my advice would be, follow those CDC guidelines and continue to practice physical distancing, mask up when indoors," Bernard said.

Officials expect that the FDA will give full approval for the Pfizer vaccine on Monday, August 23. Dr. Bernard hopes that will result in more people getting vaccinated.

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Health experts worry as flu season approaches

# data[].attributes.attachment_link.description
Flu season is right around the corner in the midst of our country dealing with the delta variant. A year ago, doctors said the number of flu infections decreased globally because of the precautions we took against COVID-19. This is because a year ago we were still wearing masks, social distancing and staying at home.

# data[].attributes.attachment_link.readable_text
FluSurge is a spreadsheet-based model which provides hospital administrators and public health officials estimates of the surge in demand for hospital-based services during the next influenza pandemic. FluSurge estimates the number of hospitalizations and deaths of an influenza pandemic (whose length and virulence are determined by the user) and compares the number of persons hospitalized, the number of persons requiring ICU care, and the number of persons requiring ventilator support during a pandemic with existing hospital capacity.

FluSurge 2.0 is a new version of FluSurge 1.0, which was originally released in July, 2004. With FluSurge 2.0, users can now change variables that impact estimates of the number and duration of influenza-related hospitalizations. Variables that can be altered by the user include the assumed average length of hospital stay for an influenza-related illness, and the percentage of influenza-related hospital admits that will require a bed in an Intensive Care Unit (ICU). The user can also change the total number of persons requiring hospitalization.

FluSurge and FluAid Questions and Answers
Can FluSurge and FluAid be used to estimate impact on a pediatric facility?
You can use FluSurge to consider plans for pediatric facilities. You may wish to alter the rates of health outcomes. In FluSurge and FluAid, the rates of health outcomes for children are averaged over the entire 0-18 years of age. Please see instructions on how to use FluAid and FluSurge to estimate the impact of next pandemic by using 1968 and 1918 scenarios Cdc-pdf [467 KB, 42 pages] . The instructions also explain how to alter the rate of outcomes in FluSurge and FluAid.
Can FluSurge and FluAid be used to accurately estimate the impact of H5N1?
Estimates from FluSurge are really illustrations: for a given scenario; therefore, accuracy cannot be guaranteed. FluSurge should be used as a starting point for planning. Given the large number of unknowns for a possible pandemic, any plan has to be flexible.

As of mid May 2006, there is not a human-adapted strain of H5N1. The reported human cases of H5N1 have not been associated with sustained human-to-human transmission, and most of the cases appear to be the result of direct infection from bird to human. Therefore, we do not have any data regarding any aspect related to the potential impact of such a strain in humans. However, you can follow the instructions on how to alter FluSurge and FluAid outputs to reflect different rates of health outcomes Cdc-word [1.2 MB, 42 pages] .

System Requirements

Windows* operating system (MS Windows 2000 or newer)

Microsoft Excel (MS Office 2000 or newer)

486 Pentium processor and at least 128MB RAM

2 MB of hard drive storage space

* MS Windows and Office is a copyrighted product produced by Microsoft Corporation, WA. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

Instructions for Downloading

Before loading and starting FluSurge, you must change Excel's security level. You must first do the following steps:

1. Open a blank Excel spreadsheet.

2. Click Tools and then click Macro, choose Security.

3. Set Security Level to Medium.

4. Click OK.

5. Double-click and open FluSurge file.

6. When asked to Disable Macros or Enable Macros, click Enable Macros.

Downloading the Files

*We recommend downloading and saving the FluSurge Spreadsheet to your computer, then open the spreadsheet from your computer. This will allow the spreadsheet to open in Excel instead of your web browser.

# data[].attributes.attachment_link.description
FluSurge is a spreadsheet-based model which provides hospital administrators and public health officials estimates of the surge in demand for hospital-based services during the next influenza pandemic.

# data[].attributes.attachment_link.title
Historical Reference of Seasonal Influenza Vaccine Doses Distributed | CDC

# data[].attributes.attachment_link.description
Seasonal flu vaccine: total doses distributed provides a cumulative weekly total of the number of doses of flu vaccine distributed - CDC

# data[].attributes.attachment_link.readable_text
Some scientists are worried that the upcoming flu season could be very bad - after a year when it seemed to virtually disappear - and are urging people to get their flu vaccine by late October, ahead of the winter season.

But there's some good news.

One health survey, commissioned by CVS and released Wednesday, found that 71% of Americans intend to get their flu shot this year, a 5 percentage point increase from last year. And according to a study, getting both COVID-19 and flu vaccines appears safe and effective.

Worries about the flu come as the state's top doctor said she had advised Gov. Gretchen Whitmer that a mask mandate is needed for K-12 schools to keep children safe when they return to classrooms soon; the governor has yet to take action on that recommendation.

"Getting your flu shot is a great way to be proactive about your health and the health of your community," said Angela Patterson, chief nurse practitioner officer of MinuteClinic. "It's an easy way to protect yourself and those around you."

How a new vaccine might interact with other vaccines usually is looked at before it is approved for use, but that didn't happen with the COVID-19 vaccines, which were authorized because of the pandemic.

A study published in June, however, suggested it was safe to take both vaccines.

Last year, the CDC reported a significant decline in flu cases, likely because of masking, social distancing and other precautions taken to prevent coronavirus spread.

Moreover, Michiganders were urged to get the flu vaccine because officials said it would help improve the health and safety of everyone, especially as the coronavirus ravaged the United States and overwhelmed many hospitals.

This season, however, could be much worse for the flu.
Read more: Michigan's top doctor asks Gov. Whitmer for school mask mandate Tiny Romeo church forced to leave historic building after nearly 2 centuries
The CDC recommends a flu vaccine before flu viruses begin spreading in the community, since it takes about two weeks after vaccination for antibodies to develop in the body and provide adequate protection.

About 45% of the people who participated in the CVS-commissioned survey said they would get a flu shot at a retail pharmacy, followed by 25% at a doctor's office.

Patients with either the seasonal flu, certain respiratory illnesses or COVID-19 can present similar symptoms: fever, cough and body aches.
Contact Frank Witsil: 313-222-5022 or fwitsil@freepress.com.

# data[].attributes.attachment_link.title
Survey reveals how Americans feel about getting flu shot this year

# data[].attributes.attachment_link.description
Some scientists are worried that the upcoming flu season could be very bad - after a year when it seemed to virtually disappear - and are urging people to get their flu vaccine by late October, ahead of the winter season. But there's some good news.

# data[].attributes.body
https://www.contagionlive.com/view/the-unpredictable-factors-of-the-2021-22-flu-season

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Following a minimal influenza season amid rampant COVID-19 outbreak during 2020-21, US experts are beginning to speculate the risk of a worse 2021-22 flu season.

As many are indicating, though, the factors influencing flu outbreak risk are varied-and sometimes linked to COVID-19 response.

In the next segment of an interview with Contagion, Jason C. Gallagher, PharmD, FCCP, FIDP, FIDSA, BCPS, Clinical Professor at Temple University School of Pharmacy, discussed the unknown expectations of the upcoming flu season. One major influence, Gallagher noted, is the evolving strategies of classroom settings.

"Unlike for COVID, kids are what spread influenza, and those kids were not together in the same way," Gallagher said. "Some of them were remote learning, others were together in the classrooms with masks or social distancing."

Gallagher also noted that parental anxiety surrounding COVID-19 may influence likelihood of flu spread among children this year. He expressed overall concern for what a quieter 2020-21 season may indicate for future seasons as well.

"I also am curious as to whether our vaccine will be matched well against the strains that emerge," he said. "I don't think we have a reason to think it won't, just because there's been less influenza overall and less chance for it to mutate."

Again, how such evolving factors and responses to another respiratory virus outbreak influence the flu season are difficult to project.

"Those kind of things are all pretty hard to quantify but all come into this equation," Gallagher said. "Coming into this year, it's obviously going to be different."

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The Unpredictable Factors of the 2021-22 Flu Season

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Following a minimal influenza season amid rampant COVID-19 outbreak during 2020-21, US experts are beginning to speculate the risk of a worse 2021-22 flu season. As many are indicating, though, the factors influencing flu outbreak risk are varied-and sometimes linked to COVID-19 response. In the next segment of an interview with Contagion, Jason C.

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Seasonal Influenza Vaccine and Increased Risk of Pandemic A/H1N1-Related Illness: First Detection of the Association in British Columbia, Canada

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made on 3 May 2009, and the school was closed the following week. Because pH1N1 was first recognized in mid-April as a novel virus, and to learn more about its characteristics, risk factors, and impact, an outbreak investigation was undertaken by public health through a school-based telephone survey conducted between 15 May and 5 June 2009 [ 3].