A Call to Action
Fouad Atallah, MD1
Howard Minkoff, MD1,2
1Department of Obstetrics and Gynecology, Maimonides
Medical Center, Brooklyn, New York
2Department of Obstetrics and Gynecology, SUNY
Downstate Medical Center, Brooklyn, New York
Corresponding author:
Fouad Atallah, MD
Department of Obstetrics and Gynecology
Maimonides Medical Center
967 48th Street, Brooklyn, NY 11219
E-mail:
fatallah@maimonidesmed.org
Phone: 718.283.7663
Fax: 718.635.7172
Disclosure: no conflict of interest
Word count: 990
Having lived through the havoc of COVID-19 in a hospital situated in one
of the hardest hit zip codes in the United States, the thought that
another wave could loom in the fall is bracing. Obstetricians at our
institution have cared for well over 200 COVID-19-infected pregnant
women, and are acutely aware of the herculean effort it took to
reorganize the service to accommodate the needs of women infected with
this new pathogen.1 Many institutions, including ours,
modified the frequency of prenatal visits, among other measures, to
minimize in-person contacts, in an effort to reduce the likelihood of
viral spread. However, it is those changes, along with our prior
experience of treating women unimmunized against influenza that leads to
our concern that a singular focus on COVID-19 could leave pregnant women
at risk from a more familiar threat.
While COVID-19 is a threat to the health of individuals and society, its
effect on pregnancy is less clear. Thus far, few COVID-19-infected
pregnant women have required ICU care, and to date three maternal deaths
has been reported in the United States.2-4 The toll of
influenza in pregnancy is more clearly documented and is more
severe.5
Now that the first wave is ebbing in New York, we are seeing fewer and
fewer cases but still diagnose about 15 infections per week in our
hospital. That pattern is the converse of what is being seen in large
swaths of the country. Despite the higher prevalence seen earlier in the
epidemic in New York, and the fact that many of those women needed
respiratory support, only two women in our hospital required admission
to the intensive care unit (ICU), and only one needed ventilator
support. Mercifully, none died. During the preceding influenza season,
whose end overlapped with the start of the COVID-19 pandemic, we treated
six women with influenza who required admission to the ICU, only one of
whom had been vaccinated against influenza. As opposed to our COVID-19
cases (putting aside the more rigorous application of social
distancing), there were clearly missed opportunities to have prevented
some of the morbid events caused by influenza.
Admittedly, the higher admission rate to the ICU may be misleading. It
is certainly possible that criteria for admission to ICUs, like almost
all other aspects of care, evolved during the COVID-19 crisis. There was
such a rapid and dramatic increase in the need for ICU beds in our
hospital (from a baseline of 40 mid-March, 2020 to a peak of 140
mid-April; 2020, internal data) that more stringent criteria for
admission may have been applied and some of our COVID-19 patients that
were cared for on the wards, may have been cared for in an ICU in less
harrowing times. But even given that possibility, the fact that a
similar number of women were extremely ill with influenza raises grave
concerns going forward.
In the first instance, co-infection with COVID-19 and influenza, as well
as other viruses, has been reported.6 Co-infection
events will make diagnosis of either entity more difficult, and could
potentially increase morbidity. Thus, both because of the risks of
co-infection, and the known risks of influenza in pregnancy, providers
can’t afford to take their “eye off the ball,” and become less
vigilant about vaccinating patients, even if some of the new protocols
for fewer visits or telehealth visits remain in place. With fewer visits
comes the risk of missing both the vaccination “window” and the
opportunity to incorporate vaccination as an essential component of
health maintenance. In addition, obstetricians’ performance as
vaccinators has been less than ideal as only approximately half of
pregnant women get influenza vaccines.7
In addition to vaccination, obstetricians must remain vigilant in order
to prevent progression of disease among those who get infected.
Oseltamivir provides the opportunity for secondary
prevention.8 It has been shown to reduce maternal ICU
admission and mortality.9 Yet, as with vaccination,
even before the COVID-19 epidemic, it was
underutilized.10
Beyond committing to better use of medical interventions for influenza,
obstetricians have to assure that just because they have lived through
COVID-19, and the world’s attention remains fixed on COVID-19, they
don’t become so COVID-19-focused, that they fail to include influenza in
the differential diagnosis of women reporting respiratory symptoms in
the fall. Every fever and ache will not be COVID-19. If we delay
consideration of the diagnosis of influenza, we will lose the
opportunity to use Oseltamivir before the window of eligibility closes.
In the post-pandemic world, it will be hard to avoid cognitive biases,
such as the availability heuristic (a strategy for making judgments
about likelihood of occurrence based on the salience of the information)
and confirmation bias (the tendency to gather evidence that confirms
preexisting expectations, typically by emphasizing or pursuing
supporting evidence while dismissing or failing to seek contradictory
evidence). These can result in physicians being hammers and every
respiratory symptom, a COVID-19 nail; especially when rapid COVID-19
tests are not uniformly available and don’t yet have uniformly high
quality. This is the reverse of one of the most cited examples of the
availability heuristic, “In influenza season, it is tempting to
consider all patients with fever and myalgias as having
influenza.”11 An enhanced situational awareness,
i.e., recognizing the influence of recent diagnoses on your diagnostic
proclivities, will become an ever more crucial antidote to the hard
earned reflex response to fevers and aches that developed during the
first wave of COVID-19.
We know from history that influenza recurs both in epidemic and pandemic
forms, and that an initial wave can be a “herald wave” for the
following one.12 Hence, it is our responsibility not
to let the current COVID pandemic prevent us from properly dealing with
the possibility of overlapping epidemics (seasonal influenza and COVID)
in the fall. Vaccination, rapid recourse to antivirals (e.g.,
Oseltamivir), and community mitigation measures will be more important
than ever. COVID-19 can kill, but so can influenza, and if we do our
jobs, we can reduce that toll.