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Apple a Day

COVID and Influenza Season – A Panel Discussion with Local Health Experts

Dr. Josh Overgaard, Dr. Angela Folstad, Public Health Nurse Jessica Metzger and Infection Preventionist Sarah Brunn
September 15, 2020
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We've gathered a panel of local experts to discuss the many questions surrounding the convergence of flu season with COVID-19. How can you tell the difference in symptoms, when should you get tested, is it safe to get a flu shot…..they'll answer all these questions and more in this special edition of Apple a Day featuring Dr. Josh Overgaard, Dr. Angela Folstad, Public Health Nurse Jessica Metzger and Infection Preventionist Sarah Brunn.


Katie Johnson: Good morning and welcome to this special Apple A Day Podcast and education session focused on the convergence of COVID and our influenza season. I am Katie Johnson your host, and I have a panel of local experts with me to address this topic and the many questions that we're hearing around this topic today.

Along with me, via Zoom, we have Jessica Metzger with Otter Tail County Public Health. We have Dr.Josh Overgaard, Internal Medicine Physician at Lake Region Healthcare. We have Dr. Angela Folstad, a pediatrician at Lake Region Healthcare, and Infection Prevention Coordinator, Sarah Brunn, from Lake Region Healthcare joining us as well. Thank you all for making time to be with us this morning and to address this topic. As I said, there are so many questions about COVID alone, and often times many questions about the influenza season as it approaches, and the two of them happening at the same time brings all kinds of uncertainty.

Add to that, all of the misinformation, all of the confusing information that people don't know who to turn to or who to trust, and we felt it was important that we establish a voice of reason. Local experts in health care in our community come together and answer these questions for our community and for our staff members. So, we're going to try and cover a lot in a relatively short period of time, and we're going to be managing this through technology, so bear with us as we do that as well. But I'd like to start by talking about the comparisons between the coronavirus and influenza, both in terms of symptoms and how they're spread, and total number of cases, and just set the stage with that. So, considering what we know about both of these illnesses today, how do the signs and the symptoms of each of these compare with each other?

Dr. Josh Overga: So, with coronavirus and influenza at the same time, it's going to be very difficult. And I think that's something that most of us recognize whether we're medical persons or not. There is quite a lot of symptom overlap. Obviously, the hallmark symptoms of influenza are fever, cough, other cold symptoms, you feel really tired, and we see a lot of the same with COVID, especially in the cases of [inaudible 00:02:33] disease, it can look like a cold or a bad cold.

I anticipate that in most people, or if not all, who have symptoms of either, we're going to have some level of suspicion for both. And I anticipate that a lot of our patients that wind up getting tested for COVID will get tested for flu and vice versa. There are some distinguishing characteristics, but I don't think they're reliable enough that we really could say, "Oh, based on how this person's feeling or what I hear on their exam or things like that." I don't know that we're reasonably going to be able to differentiate without testing. And that we anticipate that being a major challenge and we're hoping that we have the testing supplies to do what we need to.

Katie Johnson: What's unique about one over the other? Are there any telltale signs that if you have this symptom and not that symptom, then you probably have COVID or you probably have influenza or is there no such clarity whatsoever?

Dr. Josh Overga: We certainly see more GI symptoms, people [inaudible 00:03:38] with nausea and diarrhea and COVID then with influenza. And I think in adults, that might tip the scale a little bit for us. I'd like to hear Dr. Folstad's take on this too, but I know, in kids, when they get sick, they throw up and they get diarrhea. They don't even have to be sick, quite frankly. But again, I don't think that's specific enough necessarily that we'll know, even in adults. Dr. Folstad.

Dr. Angela Fols: Yes. Thanks, Josh. I would agree. And in kids, the presentation is so variable with COVID. It can be from absolutely no symptoms at all to multi-system inflammatory disease where it's very vascular, to just a sniffle or a sore throat all the way to vomiting, diarrhea, and dehydration. So, it's so variable and there's a lot of overlap even with just seasonal allergies. So I think that when influenza season comes, it's just another bag of worms that's going to complicate this big stew we're entering into right now.

So, with influenza too, the duration's a little bit shorter. So, if you're looking at four or five days of illness, for pediatrics anyway, that tends to be probably by, the data seems to be more associated with COVID. So, the length of illness. And you certainly can have both at the same time too, which is going to be even more problematic, I think.

But I agree with Dr. Overgaard, we're going to rely so much on testing. And there's so much controversy right now with testing, which tests. And I think some states are getting one that tests for both influenza and for COVID, but it's only going to the state labs. And so, it's going to be a work in progress I think throughout the entire season. So, just staying abreast of information, being open to new suggestions, and relying on local health experts, public health, hospitals, ID, and your physicians and nurses.

Katie Johnson: I think that's a really good point that this information will be ever changing. Jessica, did you have something to add there?

Jessica Metzger: Yeah, something I just wanted to add. Just from doing a lot of, I've been doing a lot of case investigations since the first part of April. And the loss of taste and smell seems to be very common with COVID. It's not something that I've seen typically with influenza now, as a provider, I bet you guys have probably seen it, maybe you've seen it, but I just think the loss of taste and smell for no other reason, no stuffiness, no other cold symptoms, but just that loss of taste and smell. That's not in everybody, but we do see that as a piece of being very unique to COVID.

Dr. Josh Overga: One of the other differences between this and flu we think, and there's some debate around this, but it seems like it hangs around in the air for a longer period of time. Influenza, pretty clearly, if you cough the little droplets of spit or whatever fly out into the air, and if they land on you in the course of their travels to the ground, you can get sick.

It appears that the coronavirus can exist in much smaller particles that can spin in the air and hang out. You don't have to cough right on someone. You can breathe or speak loudly or sing and aerosolize those particles and they can float around. And that's part of the reasons that the masking becomes important. It would work for flu too, but it's even that much more important I think in COVID if that's a concern of ours, that level of contagiousness is going to be amplified by that means and so, the masking is just that much more useful.

Katie Johnson: That's a good factor to bring up. I've heard lots of people say they expect the influenza season to be of lesser severity this year because of the masking and social distancing measures that we're taking. And we can only hope that that will be one of the results of the COVID precautions that we're taking. What about in terms of how both of these viruses spread? My understanding is that COVID is much more contagious than influenza. Is that a misperception or is that actually true?

Sarah Brunn: I don't think that's a misperception. It does appear that COVID is potentially more contagious, or that you have the potential to infect more individuals if you turn positive than with influenza. So, I don't know that we have that number with COVID drilled down super tightly. With an emerging illness, there's just so much that isn't known yet, but it does appear to spread more easily.

Katie Johnson: And I would imagine that the fact that so many COVID positive individuals seem to be asymptomatic would also lend to that inadvertently spreading the virus.

Dr. Angela Fols: I agree 100%. And I think our testing for COVID versus influenza too, skews our perception of how contagious is this, who has it, because if a member of the family has influenza, we don't typically test everybody else in the family for influenza, but we treat them if they started having symptoms. So, our data on numbers and contagious illness and asymptomatic carriers, it's apples and oranges.

Katie Johnson: That's a really good point. We know that the elderly and the very young are most at risk for influenza. Do the at-risk categories differ any between COVID and influenza?

Sarah Brunn: There does seem to be variability between influenza and COVID in terms of those risk factors. So, in influenza, yes, you're looking at the very young, the very old, those with underlying health conditions that would lead them to get sicker, especially respiratory illness or cardiac illness, but with COVID, your youngest population tends to be a little bit more protected, in that they just don't get as sick, it doesn't appear, for the most part. We do have some young people who have gotten very sick and have secondary problems from COVID, but for the most part, it tends to be deadliest in our oldest population. So, when you look at numbers of those who have died from COVID, it's definitely our most elderly.

Katie Johnson: Dr. Folstad, you mentioned this a little bit earlier, that it is possible for someone to have both COVID and influenza at the same time, which is a thought that had never occurred to me until I started researching this, which sounds absolutely horrible. So, the question that it leads me to ask is, what should I do if I start having symptoms, or my child has symptoms that lead me to believe it might be one or the other? What's the first step I should take? And I'm sure that varies based on what those symptoms are, but what's our guidance for where to look for information, who to call, and when to get tested. When and how do you decide that a COVID test is your best next step?

Dr. Angela Fols: Oh, they are all such great questions. Especially, in pediatrics, our dreaded winter-time disease is RSV, so that adds into the mix as well. So, I would say respiratory illnesses are scary for us as pediatricians, so if your child is showing any sort of respiratory distress, I think you need to be seen immediately. So either contact your child's primary care provider, and then be directed that way.

Fevers can be addressed at home, but dehydration too can be very worrisome. And again, COVID can do that, some influenza, and then just the stomach virus that we saw so much last year could be back. So, dehydration is going to get us into trouble and respiratory issues. Fevers can be managed at home just as well as we manage them any other place, but those are the big systems that I tend to worry about. I'm sure Dr. Overgaard has... I don't have as many cardiac patients as he does, so I'm sure that he has some other indications for contacting your health care provider, but those are the two big ones that we tend to lose sleep over in pediatrics.

Another thing to keep in mind is people tend to rely on treatment for influenza with Tamiflu and think, "Oh, I'm not going to get a vaccine for it because there's Tamiflu in that exists." Tamiflu is definitely worthwhile in some populations. It does tend to decrease the symptoms by 24 hours, but there are GI side effects. So, if you are also exposed to COVID or there's another illness going around, that could really compound the treatment. Albeit, your influenza or primary illness, and then give you symptoms, which are going to compound the symptoms of a secondary illness. So many chests pieces in move here this winter.

Katie Johnson: Sarah, maybe you could answer the question about when and how you decide whether or not you should be tested, and if so, what that looks like. Where can you seek out testing and what does that look like?

Sarah Brunn: Yeah, so we're recommending that patients that have symptoms, basically, that they be tested. On the Lake Region side, you can call the main number for Lake Region, 218-736-8000, and the operator will get you in touch with our COVID nurse line, who will go through a series of questions just to help us guide where you should be seen, and then also if you should be tested. So, we have a drive through process for people who need to be swabbed, that maybe aren't significantly ill and don't need to see a provider. We do have appointments set up at our walk-in clinic at Lake Region. So, you can call the walk-in clinic to get set up for an appointment if you are having respiratory symptoms and don't need to seek emergency care, or our emergency department is also an option.

So, any of those locations, we can do testing for both influenza, in the near future, we're going to add that into our screening process and for COVID. On the Prairie Ridge side, again, if you call the main number for Prairie Ridge and get in contact with them, they will set you up to get swabbed, and again if you need to be seen by a provider, they will also make arrangements for that in a safe location.

We're trying to keep our respiratory patients, as much as possible in one location, to just attempt to decrease exposure to our really vulnerable other patients and to our providers as much as possible. So, we're just trying to make sure that we're taking the best care of people possible in the right location. So if you call our main number, both at Prairie Ridge or at Lake Region, and asked to talk to a nurse about getting tested for COVID or you're having respiratory symptoms, they will get you to the right location.

Katie Johnson: Awesome. Jessica, how about from a County-wide perspective? What kind of guidance do you give to folks? Obviously, we're hearing from people throughout the County and offering guidance to people at all corners and of all ages. Anything different or additional to add about guidance regarding testing?

Jessica Metzger: No, I would just reiterate what Sarah said. Honestly, we just really encourage people to get tested as they can. On the East side of the County, of course, we recommend that they go into their healthcare provider. First of all call, and then get tested appropriately.

Katie Johnson: As far as managing symptoms, there's a lot of guidance from the Department of Health and the CDC about how to manage your symptoms at home. So, I think we can point people to those websites, but any other or additional topics you would really want to call out about doing that and maybe at the same time about if you're managing symptoms and waiting for a test result, so you have the anxiety on top of all of this. Any tips on any of those areas, of managing symptoms and waiting for test results and what to do in that interim timeframe?

Dr. Josh Overga: I think the first thing to remember is that if you're getting tested for COVID, there's a reasonable enough suspicion that you could have it, that you need to exercise precaution with what you do and where you go. If it were me, I would try to stay away from my kids and my wife for a while. I mean, I might hunker down in my room and just wait to see what happen. Certainly avoiding public places, any kind of other gatherings that you can while you wait for your test. This thing spreads in a very sneaky way. And as you alluded to earlier, that fact that you can be asymptomatic and carry it makes it more difficult to track down those people that are affected. And so, each chance we have to limit someone else coming in contact with it and taking it somewhere else is important.

In that waning period, distancing and isolating yourself is just really crucial. Symptom wise, it's similar to how we try to treat other similar viral illnesses, like influenza. If it's otherwise safe for you to use Tylenol, it's fine to use Tylenol for your fevers and the body aches and those kinds of things, that I just got hit by a bus feeling. Tylenol or ibuprofen. Again, if it's safe for you or if it's okayed by your doctor, those in this situation, will be effective therapies too. But the age old, get lots of rest, drink plenty of water, lay low, that stuff all works. Beyond that, we don't have disease specific things that we think would be effective. We just don't have that knowledge yet, but those are the main things from my perspective.

Katie Johnson: One of the things that I find confusing is the number of days from when you were exposed to when it's safe to be... Or a number of days since you had onset of symptoms, and which one do you go by. I feel like it's a much shorter timeframe for influenza, and it's not emphasized as much, but could anyone speak to giving some clarity to that? When is it okay for me to break free again?

Jessica Metzger: I think it gets super complex. Katie, I do. I think it gets really hard to navigate. So, as you're of course waiting for a test, if you are asymptomatic and you have been tested, we would want you to stay home for 10 days. If your tests come back positive, we want you to stay home for 10 days from your date of your test. If you're symptomatic, regardless, if you test positive or negative, if you have COVID symptoms, the recommendation is to still stay home for 10 days from your onset of symptoms.

There is a difference between isolation and quarantine. And even when I talk to people, I talk so much that it gets complex and you get them mixed up sometimes. So what I try to explain is that, isolation is for the people who are sick. The quarantine are for the people who are well, but have been exposed to sick. And the quarantine people don't understand why the quarantine is longer than the isolation for the people who are sick. And that can be hard to explain to people, but we can... The 14 days for someone who has been exposed and they now have to quarantine for 14 days, regardless if they get a negative test or not, they really need to wait that 14 days, because it can take up to 14 days to start showing symptoms or to actually get a positive test. So, I think it's taking so long for some people to actually start showing symptoms.

I've gotten a few phone calls where they've been asymptomatic. They've had point prevalence testing done at their work. Now a week later, they're starting to show symptoms. So now they have to stay home for an additional 10 days from their onset of symptoms. And they were tested eight days prior. So they were almost to the end of their 10 days, but now they started symptoms. Now it starts over.

Katie Johnson: That's really helpful.

Dr. Josh Overga: Yeah. If it helps to make sense out of this, for anybody, just consider that those people that are symptomatic were exposed several days before, right? Like a five days before or a week before. And that virus has been slowly….or not slowly, but it's been gradually building in its concentration in their body, and initially during that period, you don't have symptoms. So the reason it's different is that when you pick up those symptomatic people, presumably they've were exposed several days ago. Four or five, seven days ago. So, that's why there's a difference. It does make sense, even though it sounds crazy.

So, if I have symptoms, I have to isolate for less time, but that's the reason. Presumably we're probably isolating people until the same duration from their exposure.

Katie Johnson: One of the really underlying themes that we want to communicate today is in relation to the influenza vaccine and why it is important in any year to get the influenza vaccine and why it's particularly important this year. The underlying reason is if nothing else has been clear of our conversation so far, it's that the convergence of all of these things is really going to be messy. And if we can do anything to prevent or potentially rule out one of those many contributing messy factors, we should do it. And the influenza vaccine gives us the opportunity to do that. I'd be curious to hear some more perspectives about why the influenza vaccine is important in any year and why more important this year then than typically.

Sarah Brunn: I'll start. Because you know, I'm a huge advocate for the influenza vaccine. So influenza is deadly, and it can cause really significant illness. So even in just a regular year, we're looking at Lake Region last year, we had over 30 hospitalizations that were related to influenza. We're not that big of a hospital and we have 30 hospitalizations. 31 last year. That's a lot of people that were affected. And you're looking at an illness that is definitely deadly in the elderly. And I don't know about you, but I have a lot of elderly people in my life that I come in contact with. And if I can prevent the spread of influenza to those people in my life, I'm going to do everything that I can to protect them. And part of that is getting my flu shot.

We all know that the efficacy is not 100%. Not everybody. Some people that get the flu shot are still going to get influenza, but we do know that it is going to likely decrease your length of illness and your severity of symptoms if you've had an influenza vaccine, and it definitely decreases your risk of death if you get the vaccine. So, there's definitely evidence out there that it's beneficial. So even if it doesn't prevent influenza in me, I'm still less likely to die from it. So I just want to protect my community. I want to protect my friends and my coworkers and my mom and dad who are in their 70s. I just want to take care of my community. And part of that for me is getting an influenza vaccine.

Dr. Josh Overga: I think too, just limiting the amount of... The first thing is we don't want anybody to get sick. We'd like it if all of our community could just stay healthy and feel well and do the things they want to do all day long. And we see this as a good chance to make that more likely, but also, I think about just how our healthcare system is going to work in function if we do see a huge volume of each disease.

If we have a flu season like we did last year or in another busy season and we have COVID on top of it, that can be overwhelming. And it's not a matter of, "Oh gosh, shoot. Now I have a busy day at work." It's a matter of we don't have places to put patients. We don't have enough nurses to take care of them. We don't have enough supplies and things like that. So, that gets to be an important factor too. And I think anything that we can do to take down the [inaudible 00:25:41] general level of disease in town, is going to make that less likely to be a problem. Just you know, there's some evidence out there that giving your flu shot makes it less likely that you'll get a cold in the next couple of months. Ramps up your immune system a little bit, so it might even help you there.

Dr. Angela Fols: I also think right now, we're finally back in school. That was such a big deal [inaudible 00:26:04]. We didn't know when the schools are... I'll put so much time and effort into getting a plan together to monitor for illnesses and a plan to identify anybody who was sick and triage them appropriately back to the home. And so, if you can get a flu shot and live with the spread of a viral febrile illness in your household, your household can remain functional for a month out of the winter that otherwise you would be at home when you're taking care of the sick child with the flu. And so I just think if you have a healthy family, and y'all take vitamins and you all sleep well and you wash hands and that's all great, but one little sneeze from a colleague in school who didn't get vaccinated onto your child, who's also not vaccinated could destroy your household.

And you just do that throughout the community. The whole town is really going to suffer. And I really haven't seen any bad side effects from the flu shot. And I know the resistance I've received from giving the flu shot in my patients is just thinking, "Oh, it's not going to be that. It's only so, so effective. And my child's otherwise healthy. No they'll navigate and fine." But right now you're not just navigating an illness, you're navigating your community.

Katie Johnson: Excellent point. Anything we can do to keep the kids in school this year is going to be worth the effort. As far as who the flu shot is recommended for, it's really very few people that we don't recommend the flu shot for, right? Anybody want to maybe just highlight who those rare exceptions are?

Sarah Brunn: If you've had a very severe allergic reaction to the flu shot in the past, then we would not recommend the flu shot. Otherwise the majority of even the health conditions that previously we would have excluded you from, we have variants of vaccines now that we can get a flu shot to almost anybody.

Dr. Josh Overga: What about the eggs?

Sarah Brunn: We do have egg-free vaccines now. So there are some vaccines that use egg as a base for their culture, but we have some now that are completely egg-free. So again, we have a flu shot for you if you have an egg allergy.

Katie Johnson: That's awesome. I also heard that this year's vaccine, there might be other things to call out about it this year, but there are a couple of new facets to this year's vaccine in terms of quadrivalents. Anyone want to speak to this year's vaccine in particular, what we know about it, what it's aiming for and any differences that we want to call out for certain populations and their flu shots?

Jessica Metzger: Well, I will just say the one, because we just received some, but the high dose vaccine, which is for the 65 and older has gone to a quadrivalent vaccine. So it's a four strain versus the three strain that has been in the past.

Katie Johnson: So that's a good advancement.

Jessica Metzger: It's great.

Katie Johnson: And for kids under a certain age is it? That required a series of two?

Jessica Metzger: Go ahead Dr. Folstad

Dr. Angela Fols: Yeah. Okay. Up until eight to six months, you're eligible for that first flu shot. Definitely, if you need two flu shots, you're given there ASAP when we start, so you can be fully protected then a month later, but at six months you can start and after eight you'll need to. And if you've got one last year, you still need to this year. So that one doesn't really carry over and count.

Katie Johnson: So considering the precautions that are in place due to COVID. Flu shots are probably going to look a little bit different this year. We've decided they need to look a little bit different this year. We used to set up a few days that we'd have hundreds of people come through and just get up a bunch of people vaccinated in one day. So we're doing some things this year to make it more feasible, to keep the social distance and to make sure that we are being safe for COVID precautions while ensuring that you can safely get your flu shots. Somebody, Sarah, maybe you have the high level details of what Lake Region Healthcare and Prairie Ridge are doing. And then Jessica, maybe you can speak to some other opportunities for flu shots and how they're being done throughout the community as well.

Sarah Brunn: Right? So probably the biggest difference from our previous years is that as opposed to just showing up for your flu shot, we're asking that you make an appointment for that flu shot. And that is really just so that we can control the volume of people that are coming into the facility at one time. So at Lake Region appointments, your flu shots will be done in clinic. I know we've had some talk about trying to figure out a drive through that process has not been figured out yet, as far as I'm aware, but we're still working on that. For Prairie Ridge. They are doing it also by appointment. At Prairie Ridge there'll be drive up appointments so you won't have to get out of your car, which is great.

Jessica Metzger: So throughout the community, and from what we do here at Otter Tail County Public Health is, we are going to try to utilize, we ordered some outdoor tents, privacy tents that we're going to try to actually utilize outside, starting some next week for some of our facilities that we've held flu shots for in the past. The weather looks to be good next week, so that's why we really wanted to try to look at that.

So we always go to all of the school districts in the past, things will look differently. We still want it to try to service our school community because it's super important, but we also are utilizing a scheduling base for flu shots this year. So it might be, we'll be in different districts, a couple different times. It's just going to look different. So not all of the plans are solidified yet, but we're getting there.

Katie Johnson: Perfect. So for Lake Region Healthcare and Prairie Ridge, flu shots will start in October and be available at the clinic in Fergus really every weekday during October. We have a couple of evenings schedules that we're opening up. Prairie Ridge has some specific days that they're opening up their clinics for flu shots. But again, by appointment only. All of the outreach clinics are going to have special flu shot clinic days. And all of those schedules can be found on our website at and Jessica, do you have a place you want to direct people to find out more information about a flu shot developments from a public health standpoint?

Jessica Metzger: Absolutely. Go ahead and go to the Otter Tail County website and there's a link for public health and we should have all of our schedules and what's going on and where we're at. Also the link to the scheduling point will be there as well.

Katie Johnson: Well, we've covered a lot. I'm not sure if, if we've missed any high points, but I know there are so many questions there. I hope we've been able to address a lot of them for you today. And again, I just can't tell you how much I appreciate all of you gathering together today to be that voice of reason to be the local community experts here answering those difficult questions, we navigate the potential of influenza and COVID and like you mentioned, RSV and all the other respiratory illnesses that come with the weather that we experience this time of year in our region, but I'm grateful for each one of you. Thank you for the time that you have spent with us this morning. Again, we remind everyone getting your flu shot is one thing that you can do to help mitigate the effects of the upcoming seasons. And we encourage you to check out the information about flu shots.

Also our COVID-19 resource page. I know the County also has great resources on their website for navigating COVID-19 and answering your questions about some of those things we talked about today, quarantine and isolation, masking, social distancing, all of those components that are up to each one of us to do as was mentioned before, to navigate as a community, our community health. So Jessica Metzger Otter Tail County, public health, Sarah Brunn infection prevention at Lake region healthcare, Dr. Angela Folstad our pediatrician and Dr. Josh Overgaard Internal Medicine Physician here. Thank you each for joining me today and sharing your expertise with us and for everything that you're doing to help improve the health of each of us as individuals and as a community.