First flu season with no COVID-19 requirements: Answer patient FAQs

Editor’s note: This article was updated in October to reflect the CDC’s decision to expand the use of bivalent COVID-19 vaccines to children 5 or older. The move followed the Food and Drug Administration’s authorization of updated vaccines from Pfizer-BioNTech for children 5–11, and from Moderna for those 6–17 years old.

It is the third autumn and will be the third winter with COVID-19 in the United States, but this year looks different. With limited COVID-19 requirements on masking or physical distancing in place, many Americans have taken on the mindset that the pandemic is a thing of the past. But COVID-19 is still very much with us, as a look at Centers for Disease Control and Prevention (CDC) data illustrates.

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At the time of publication, the CDC reports that based on the current daily average:

• About 40,000 cases of COVID-19 are being reported, likely a significant undercount due to the many patients who test at home and don’t report positive results to their physicians or health officials.
• Nearly 3,300 patients are being admitted to U.S. hospital beds.
• More than 335 people in the U.S. are dying—about the same number as would die in a fatal commercial airline crash.

As the temperatures dip and with few public health mitigation measures in place—no required masking in schools or on public transportation, and no limits on indoor gatherings to offer added protection against SARS-CoV-2 infection—patients have questions on how best to protect themselves against COVID-19 while searching for a new normal.

As patients navigate the fall season and move into winter months, AMA member Christopher Garofalo, MD, a family physician in Attleboro, Massachusetts and an AMA delegate for the Massachusetts Medical Society, took time to answer questions patients might have about COVID-19.

“There are other people out there who you’re coming into contact with that you may not realize are at higher risk, such as those who are immunocompromised or have other underlying medical conditions that are often not visible to the rest of us. These people are at higher risk of worsening their illnesses or ending up hospitalized,” Dr. Garofalo said, noting that with the BA.5 subvariant of the COVID-19 Omicron variant, “shows an excess death rate in Massachusetts, compared with Delta.”

Additionally, “there is still long COVID,” he said. “There are children and adults who have long COVID—and that’s not an easy place to be in. It’s challenging to treat those symptoms.”

“It’s not just about ending up in the hospital and dying. It’s about having consequences down the road that are other symptoms,” Dr. Garofalo said, adding that “several studies demonstrate that long COVID is preventing several million people in the United States from returning to the workforce.”

It is estimated that as many as 23 million Americans have been affected by long COVID.

“Anytime that you are indoors in a more crowded environment, especially if you’re going to be talking or really interacting up close with people, you should mask up,” said Dr. Garofalo. This means “religious services, concerts and the airport—you would benefit from wearing a mask.”

It is also important to note that wearing a mask protects those around you too. So, mask up for yourself and for others around you.

“If you are at higher risk, it is also important to mask almost anytime you are indoors, including museums, sporting events, children’s school events, and work meetings.  You need to understand you are at higher risk and you need to protect yourself because one of the things that we have seen—for better or for worse—is most people aren’t going to mask to protect other people.

“In other words, those who are going to a concert aren’t going to think the person next to them may have something that they need to be protected from,” Dr. Garofalo added, noting that “if you are immunocompromised, if you have lung issues, heart problems or cancer, those are the people who definitely need to make sure that they are masking up, even if they're just going to the grocery store or going out shopping someplace because you are the one at this point who needs to protect yourself.”

“People need to be making sure that they’re protecting themselves,” he emphasized.

“During summer, almost all the patients who called us and said they got COVID, they would say they just got back from traveling,” Dr. Garofalo said. “And it’s hard to know if they got it in the airport, from sitting on a plane or from whatever their location is.

“It probably wasn’t the location so much because most places people travel to [during summer] are outdoors,” so SARS-CoV-2 may have been acquired during travel, Dr. Garofalo said. “If you are traveling, wear a mask in the airport and on the airplane.”

“Those enclosed environments are the places to keep wearing a mask,” he emphasized. “So, wear a mask on trains, buses, and ride sharing. Any sort of enclosed environment is a good place to wear a mask.”

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“People are going to concerts and those can have tens of thousands of people. There are people attending college football games now with some of those stadiums holding 100,000 people,” said Dr. Garofalo, noting that there are no longer certain precautions in place to limit the spread during large events, especially “events where you’re too close together or too intimate.” 

“That is when masking and physical distancing—if possible—can help,” he said. “For example, , I know a patient who has medical issues that increase their risk of COVID complications who has an indoor event for their parents’ anniversary coming up. I recommended wearing a well-fitting N95 or KN95 mask when attending and limit attendance time.”

“So, it gets back to how much cumulative exposure you have to the people near you at the event,” Dr. Garofalo said.

“If you have any respiratory symptoms—such as a fever, cough, runny or stuffy nose, sore throat, congestion, then you should test for COVID-19,” said Dr. Garofalo. “There are other viruses with similar symptoms that are going around right now and flu will be here soon so you may have one of those, but you need to test yourself so that you can make sure that it’s not COVID.”

“The reason for that is just like most other things we do in medicine. You should be testing if it’s going to change your management,” he said, noting that “if you test positive for COVID that makes you think differently about the treatment options.”

“If you test negative for COVID-19 and you have the flu, you’re going to treat the flu differently than you’re going to treat COVID-19,” Dr. Garofalo said.

About 230 million Americans are eligible for a bivalent COVID-19 vaccine booster. Pfizer's bivalent booster is authorized for those 5 or older, while Moderna’s authorization is for patients 6 or older. Patients must complete a primary COVID-19 vaccine series before getting the booster. Additionally, the recommendation is that people should wait at least two months from their last COVID-19 vaccine dose or booster to get a bivalent booster.

Most people eligible for a booster are at least six months from their last dose, so “get it as soon as you can,” Dr. Garofalo said, noting that he recently got his bivalent vaccine booster.

“The virus that we have circulating right now, this bivalent vaccine booster was made particularly to match up with what we’re seeing, so it’s going to be protective,” he said. “It does take a little bit of time to ramp up that protection inside the body, so it doesn’t make sense to wait.”

The Centers for Disease Control and Prevention says it is safe to get a flu shot at the same time as any SARS-CoV-2 vaccine because the two viruses will be circulating at the same time. It’s also acceptable to get a COVID-19 vaccine or booster with other needed vaccines, but there is one exception—monkeypox.

“If you would rather get your flu shot and the bivalent COVID-19 vaccine booster at the same time, that is recommended if you are eligible and the timing coincides,” said Dr. Garofalo. “What is important is that if you are eligible for the bivalent booster, to get it as soon as you can.”

People who received a flu vaccine and an mRNA COVID-19 vaccine booster at the same time were slightly more likely to report systemic reactions including fatigue, headache and muscle ache than people who only received a COVID-19 mRNA booster vaccine, but these reactions were mostly mild and resolved quickly.

“The side effects are similar, especially the fatigue and the fever,” said Dr. Garofalo. “Your immune system is going to be ramped up in responding to both vaccines, so you will just feel that.”

“As this bivalent vaccine is a little bit different, you may have some side effects that you didn’t necessarily have before,” he said. “Everyone is different, but some of the typical side effects include fatigue, headache, muscle and joint aches, chills, nausea, vomiting and fever.”

Before the end of October is the ideal time for getting your flu shot. But, since the flu season is unpredictable, you can get the vaccine as long as flu is still circulating.

“The protection from the flu shot usually lasts about five or six months” and is also dependent on age and how quickly waning occurs, said Dr. Garofalo. “At least in the northern part of the country, we see the flu into March or even early April.

“We don’t know what it’s going to be like because we’ve had lower flu numbers because a lot of people were masking and got vaccinated, so that cut down on cases,” he added. “If you're getting the flu shot in October or even if you get it in  the beginning of November, that is OK because we don’t tend to see flu until around December.”

“It takes about two weeks to really kick in, but if you are someone who is at higher risk, you may want to get your flu shot in early October rather than waiting until November,” Dr. Garofalo said.

“One thing COVID has made us realize is that going to work or school when you have a fever, are sniffling, sneezing, or coughing, was not the healthiest thing to do.”

“But one of the difficulties is that workplace policies don’t always make it easy to stay home,” he said, noting “many businesses don’t provide paid sick leave and if they do they require you to have a doctor’s note, or you have to fill out multiple pages of paperwork to take those days off.

“What we should begin doing is normalizing better self-care and if you’re sick, stay home” Dr. Garofalo added, “but if you must go out, wear a mask. It will be helping to protect other people and that’s the right thing to do,” he said.

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“If you test positive for COVID-19, you should be isolating yourself,” said Dr. Garofalo, noting “it’s always a tricky thing because if you live in a house with four people and you all went to the same event and now, you’re isolating yourself, you may not necessarily be extra protecting them.

“But, again, it is a small price to pay to try to prevent other people from getting sick, even within your own household,” he added. “So, if you come down with COVID, you need to isolate. You don’t necessarily need to do it while you’re waiting for your test result, but when you have symptoms, it is best to stay away from others.”

“One of the things that's going to make it a little more difficult this year is: Do you have flu, do you have COVID-19, or do you have neither?” said Dr. Garofalo. “Flu, COVID-19 and the common cold have similar symptoms. You should not have a fever with allergies, so that would definitely be a differentiating symptom.”

“What to look out for is fever, coughing, shortness of breath and fatigue. Those are the ones that we tell people to look for,” he said. “Although it is interesting because we still have some remnants of the previous variants around.

“I just had a patient who had the usual symptoms and lost her sense of taste and smell, which we haven’t seen for eight or nine months,” Dr. Garofalo added. “So, symptoms tied to previous variants still happen.”

“Because people are going to be indoors more and aren’t masking as much, we could possibly see an increase in the number of people who are sick with COVID-19 or the flu,” said Dr. Garofalo. “But we hope that we don’t see a spike in people who end up in the intensive care unit or dying.”

“They still will be there, but we hope that those numbers don’t go up,” he added, noting “we do have Paxlovid to treat COVID-19, and that has done a wonderful job. Even though it doesn’t necessarily shorten your symptoms, it does a great job of keeping people from getting sicker and that’s important.”  

“The sooner you can, the better because you can make sure that you’re getting tested and Paxlovid has to be given within the first five days,” said Dr. Garofalo. “So, if you do qualify for Paxlovid, you want to make sure that you can get started on that sooner rather than later.”

“If you have symptoms and think that you have COVID-19, please reach out to your physician,” he said, noting that “if you do test positive, we can talk about treatment options and get that taken care of right away” because there are other treatments that need to be started within the first few days of symptoms.