COVID-19 and influenza co-infection

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Main article: COVID-19

For COVID-19 frequently asked inpatient questions, click here

For COVID-19 frequently asked outpatient questions, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Zaida Obeidat, M.D.[2]

Synonyms and keywords:

Historical Perspective

• COVID-19, also called Sever Acute Respiratory Distress Syndrome Coronavirus 2 (SARS-CoV-2) originated in Wuhan, China in late December 2019.
• It has been declared a global pandemic by the WHO after being caused a significant morbidity and mortality worldwide.
• Influenza is a highly contagious respiratory virus, it causes an acute respiratory infection, occurs mainly during the winter, it causes significant morbidity and mortality worldwide.
• It can be mild or sever, which may result in hospitalization or death.
• People at high risk of serious complications are young children, elderly, and people with underlying medical conditions.
• The total number of morbidity and mortality has been declining significantly after the seasonal Influenza vaccine.

Classification

• There is no established system for the classification of COVID-19 and Influenza co-infection.

Pathophysiology

• The exact pathogenesis of co-infection with SARS-CoV-2 and Influenza viruses is not fully understood.

Causes

• Coronavirus disease 2019 (COVID-19) and Influenza co-infection are caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and influenza (A or B) viruses.

Differentiating COVID-19 and Influenza co-infection from other Diseases

• Influenza and COVID-19 are both contagious respiratory illnesses, but they are caused by different viruses. Influenza is caused by infection with influenza viruses and COVID-19 is caused by infection with the coronavirus2 (SARS-CoV-2). Testing may be needed to help confirm a diagnosis because some of the symptoms of flu and COVID-19 are similar. Influenza and COVID-19 share many characteristics, but there are some key differences between the two.

• This table compares the Influenza and COVID-19: "Similarities and Differences between Flu and COVID-19 | CDC".

	Similarities	Differences
Signs and symptoms	- It can be vary from asymptotic disease to sever symptoms. Common symptoms include: - Fever/chills, cough, shortness of breath, fatigue, sore throat, runny nose, muscle aches, headache, and gastrointestinal symptoms (vomiting and diarrhea).	- Change in or loss of taste or smell can be a sign of COVID-19.
Incubation period	- It takes one or more days for a person to get infected and develop symptoms after the exposure.	- It takes longer to develop symptoms in COVID-19 than Influenza. - The time range can be vary in COVID-19, symptoms can appear early in 2 days or late in 14 days. - In Influenza, symptoms may develop 2 to 4 days after infection.
Period of Contagiousness	- A person can spread the virus for 1 day before the appearance of any symptoms.	- The period of contagiousness is longer in COVID-19, a person can spread the virus for about 2 days before having any symptoms and remain contagious for at least 10 days after experience any signs or symptoms. - Asymptotic or after the symptoms disappeared, It can be contagious for 10 days after testing positive for COVID-19. - In Influenza, it can be contagious for about 1 day before appear any symptoms. - Older children and adults can be most contagious during the first 3-4 days, but many remain contagious for 7 days of their illness. - Infants and immunocompromised patients can be contagious for longer.
How does it spread	- Both can spread from person-to-person, people in close contact (within 6 feet) with one another. - Mainly by droplets from sick people when cough, sneeze, or talk. - Physical contact or touching their own face, mouth, nose or eye after touching contaminated surfaces or objects. - Asymptotic or people with very mild symptoms.	- COVID-19 is very contagious among certain populations and age groups than Influenza. - [[SARS-CoV-2 virus can cause quickly and easily spread to a lot of people, COVID-19 has been observed to have more superspreading events than Influenza.
High risk groups	Highest risk groups to develop severe illness and complications in both COVID-19 and Influenza includes: - Elderly. - People with underlying medical conditions. - Pregnant[ women.	- School-aged children infected with COVID-19 are at higher risk of Multisystem Inflammatory Syndrome in Children (MIS-C) which is rare but sever complication. - The risk of complications in Influenza for young healthy children are higher compared to COVID-19. - Infants and children with underlying medical conditions are at the highest risk for both Influenza and COVID-19.
Complications	Complications in both can include: - Pneumonia. - Respiratory failure. - Acute respiratory distress syndrome (ARDS). - Sepsis. - Heart attacks or myocardial infarction (MI). - Multiple organ failure (renal failure, respiratory failure, shock). - Worsening of chronic medical conditions. - Heart, muscle, or brain tissues inflammations.	COVID-19 can associate with: - Blood clots in heart, lungs or brain blood vessels. - Multisystem Inflammatory Syndrome in Children (MIS-C).
Treatment	- Supportive medical care to relieve symptoms and complications.	COVID-19: - The National Institute of Health (NIH) has developed guidance on treatment, which will be updated regularly as new evidence on safety and efficacy of drugs come out. - There are no drugs approved by the FDA to prevent or treat COVID-19. - Remdesivir (antiviral agent) is available under Emergency Use Authorization (EUA), and being explored as a treatment for COVID-19. Influenza: - Hospitalized patients with Influenza or high risk group are recommended to be treated with antiviral drugs.
Vaccine	- Vaccines for COVID-19 and Influenza must be approved by the FDA.	- There are multiple vaccines to protect against 3 or 4 viruses that cause the Influenza produced annually and approved by the FDA. - There is no Vaccine to COVID-19 yet but researchers and vaccine developers are working on developing a vaccine to prevent COVID-19.

• COVID-19 and Influenza co-infection should be differentiated from other diseases presenting with cough, fever, shortness of breath, and tachypnea.

• To read more about COVID-19 differential diagnosis, Click here

Epidemiology and Demographics

• All age groups can get affected.
• It is a pandemic, the countries that got affected most are:
  • China
  • Italy
  • India
  • The United States
  • Brazil

Risk Factors

• The risk factors are:
  • Immunocompromised ( e.g. chronic infections or cancer patients).
  • It's more common among the workers who works in close contact.
  • It's common among the population who doesn't maintain proper social distancing.
• To view the COVID-19 risk factors, click here.

Screening

• There is insufficient evidence to recommend routine screening for COVID-19 and Influenza co-infection.
• For the prevention and control of infection, on January 24th 2020 Taiwan Centers for Disease Control started testing of SARS-CoV-2 for people suspected with COVID-19. Until February 28th, 2015 cases were screened and 34 of them were diagnosed of COVID-19. During this time, 43 flu-like symptomatic patients were screened in China Medical University Hospital and 2 of them were confirmed to be positive for SARS-CoV-2.
• To establish the diagnostic protocol for the co-infection of COVID-19 and other respiratory infections like Influenza A and B, they comparatively analyzed the clinical presentations, laboratory data, radiologic findings, and travel and exposure contact histories, of COVID-19 patients who suspected to have other respiratory infections.
• SARS-CoV-2 detection by real-time reverse transcription polymerase chain reaction (rRT-PCR) and Respiratory pathogens detection by FilmArray™ Respiratory Panel were used for screening.

Natural History, Complications, and Prognosis

• SARS-CoV-2 and Influenza co-infection has a wide range of clinical presentation, most of the symptoms are similar, the symptoms can be vary from asymptomatic to severe disease (ARDS) which require the ICU admission.

• The main complications for the patients according to a study conducted in Wuhan, China, were acute respiratory distress syndrome, acute liver injury, and diarrhea.

• SARS-CoV-2 and Influenza co-infection did not significantly worsen the symptoms and outcomes.

Diagnosis

Diagnostic Study of Choice

• The diagnosis of COVID-19 and Influenza co-infection can be established by the following investigations:
  • SARS-CoV-2 detection by real-time reverse transcription polymerase chain reaction (rRT-PCR) from nasopharyngeal swab sample or bronchoalveolar lavage fluid.
  • Respiratory pathogens detection by FilmArray™ Respiratory Panel.
  • Rapid nucleic acid amplification test for influenza A and B.
  • Chest Tomography images showing peripheral and bilateral multiple plaques or nodular ground-glass opacities.

Symptoms

• According to a study conducted in Wuhan, China, common symptoms at onset of illness included:
  • Fever
  • Cough
  • Shortness of breath
  • Sore throat
  • Myalgia
  • Fatigue
  • Headache
  • Expectoration

Laboratory Findings

• Lymphocytopenia (80% of patients)
• Thrombocytopenia
• Elevated liver functions AST, ALT (40%)
• Elevated CRP (80%)
• Elevated ESR (30%)
• Elevated BUN (30%)
• Elevated Creatinine (70%)
• Elevated ferritin (70%)
• Elevated fibrinogen
• Elevated D-dimer
• Elevated interleukin-6
• Elevated lactic acid
• Elevated LDH
• Elevated creatine kinase

Imaging studies

• Chest X-ray images showing bilateral/peripheral opacities with lower lobes predominant.
• Chest Tomography images showing peripheral and bilateral ground-glass consolidation peripherally.

Treatment

Surgery

• Surgical intervention is not recommended for the management of COVID-19 and Influenza co-infection.

Primary Prevention

• The CDC recommends getting the Influenza vaccine, there are multiple FDA-licensed influenza vaccines produced annually to protect against the 3 or 4 influenza viruses.
• There is currently no vaccine to prevent COVID-19. The best way to prevent infection is to avoid being exposed to the virus by:
  • Washing hands regularly with soap and water for at least 20 seconds or using a hand sanitizer with 60% alcohol.
  • Wearing a cloth face mask and avoid touching eyes, nose, and mouth with unwashed hands.
  • Covering mouth and nose when cough or sneeze.
  • Maintaining 6 feet distance from other people and avoiding close contact.
  • Refraining smoking and other activities that weaken the lungs.
  • Clean and disinfect frequently touched surfaces and objects.

Secondary prevention

• There are no secondary prevention measures of COVID-19 and Influenza co-infection.
• The secondary prevention measures of COVID-19 include measures to make sure that an infected individual does not transfer the disease to others.
• WHO recommends for patients with suspected or confirmed COVID-19 with mild symptoms to stay home and self isolation from other family members at home.
• To read more about COVID-19 secondary prevention, Click here.