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Flu Guide: What to Know This Season

Early Flu Treatment May Be Critical

What to know about the new combination flu/COVID-19 test — and the importance of antivirals

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En español | As flu season ramps up with the start of fall, experts say that treating it in the time of coronavirus will present its own complications. 

“At the present time, we do not know whether people with the flu or people with COVID-19 are at an increased risk of getting the other infection. What we do know is that both flu and COVID-19 can present in a patient in a similar manner, and a patient can benefit from earlier treatment with both,” says Bruce Farber, M.D., chief of the Infectious Diseases Division at Northwell Health, New York State’s largest health care provider. 


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Since the two viruses may coexist, and also share symptoms, Pritish Tosh, M.D., an infectious disease physician and researcher at the Mayo Clinic in Rochester, Minnesota, says testing will be needed to determine who has which virus. 

The Centers for Disease Control and Prevention (CDC) recently came out with a new combined test for both viruses, called the Influenza SARS-CoV-2 (Flu SC2) Multiplex Assay. This test is currently being used by local and state public health laboratories for public health surveillance of the viruses, and may soon be available in doctor’s offices. Other combination tests have also recently received an emergency use authorization by the U.S. Food and Drug Administration (FDA). 

Farber says patients should ask their health care provider if a combined test is available. 

Treating flu early with antivirals 

For those who test positive for the flu, doctors say early treatment with antivirals is important, especially if you are at high risk for flu complications because you have heart, lung, liver or kidney disease, are immunocompromised or are over 65. A type of prescription medicine that fights flu viruses by reducing viral replication, antivirals should be taken within 48 hours of the first sign of flu to lessen fever and other symptoms, and shorten how long the virus lasts, Farber says. 

Red Flag Symptoms

If you’re sick with the flu and experiencing any of these symptoms, the CDC recommends getting immediate medical attention:

  • Difficulty breathing or shortness of breath
  • Persistent pain or pressure in the chest or abdomen
  • Persistent dizziness or confusion; seeming unresponsive
  • Seizures
  • Not urinating
  • Severe muscle pain
  • Severe weakness or unsteadiness
  • Fever or cough that improve, but then return or worsen
  • Worsening of chronic medical conditions

While not ideal, starting antivirals more than two days after the onset of flu symptoms can still be beneficial, especially if you’re at high risk for serious complications, says Elena Govorkova, M.D., laboratory director in the Department of Infectious Diseases at St. Jude Children’s Research Hospital in Memphis, Tennessee.

In recent years, the CDC estimates that between 70 to 85 percent of seasonal flu-related deaths have occurred in people 65 years and older, and between 50 to 70 percent of seasonal flu-related hospitalizations have occurred among individuals in this age group. 

One of the oldest antivirals on the market is the pill or liquid suspension oseltamivir (Tamiflu), which is also available as an equally effective, and often cheaper, generic medicine. Clinical trials have proven that this drug works to relieve flu symptoms, and is well absorbed as well as “pretty well tolerated,” says Tosh. As with any antiviral, Govorkova notes, it’s important to finish all the prescribed medicine instead of stopping once you feel better.

Other antivirals on the market include zanamivir (Relenza), which is taken by an inhaler device. It is not recommended for people with breathing problems such as chronic obstructive pulmonary disease (COPD) or asthma. The antiviral peramivir (Rapivab) is given intravenously and is used for hospitalized patients. 

One of the newest antivirals on the market is baloxavir marboxil (Xofluza), which can be taken as a single dose (as opposed to Tamiflu, which is taken over several days). However, given its side effects, this medication is not recommended for those with other illnesses, or those who are severely immunocompromised. Govorkova notes that this antiviral should not be taken with oral supplements such as iron, magnesium, selenium or zinc, because those will decrease the effectiveness of the medication. It should also not be taken with laxatives and antacids. 

As for whether we’ll see shortages of antivirals as flu season gets going, experts say it’s possible. “We still have to be judicious in how we give out Tamiflu,” Tosh says.

Over-the-counter RX options

For uncomplicated cases of the flu, Peter Ellis, M.D., associate professor of internal medicine at the Yale University School of Medicine, says patients can rely on over-the-counter nonsteroidal anti-inflammatories — such as Advil, Motrin and Aleve — to relieve muscle aches and lower fever. However, these medicines should be used only in the short term since they can harm the stomach and kidneys, sometimes causing internal bleeding. Tylenol, he notes, is safer.

If your fever doesn’t improve in two to three days, or you get a deepening and worsening cough, you should call your health care provider immediately. Flu is a common cause of pneumonia, especially in the elderly. 

Nasal sprays — like ipratropium bromide (Atrovent) — can help relieve nasal congestion, Ellis notes. Other sprays, such as Afrin or Neosynephrine, shouldn’t be used for more than two to three days, however, as they can cause rebound congestion.

For cough and congestion, doctors say a combination decongestant and antihistamine found in Alka-Seltzer Plus Cold & Flu can also help. However, expectorants, such as Mucinex, “don’t cause harm, but they don’t do much,” Ellis notes. 

Why you need rest — and fluids

Beyond medications, the standard advice to get enough rest still applies. Being up and around too much “will probably impair your ability to fight [the flu],” Ellis says.

And, yes, be sure to get enough fluids. Not only do you want to fend off dehydration, you also “need [enough] circulating blood volume to treat infection,” says Ellis, who believes a good bowl of chicken soup can’t hurt, because fever causes you to lose water as well as salt. 

Finally, doctors recommend staying away from herbs such as elderberry and echinacea, because they have not been shown to help fight the flu and may contain contaminants. Vitamin C and zinc have also not been proven to treat the flu.  


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Good News About the Common Cold

A Yale University study shows it might fight the flu

There may be a silver lining to getting a cold this fall. A team of researchers from Yale School of Medicine found that the rhinovirus, the most common cause of the common cold, can block flu infection for up to five days.

Ellen Foxman, M.D., assistant professor of laboratory medicine and immunobiology at Yale and a member of a team that studied three years of clinical data from more than 13,000 adult patients seen at Yale-New Haven Hospital with symptoms of a respiratory virus, found that during months when the common cold virus was present, the flu virus was not. 

For the new analysis, published in the September 2020 issue of the Lancet Microbe, the study team found that 989 patients had rhinovirus and 922 had the flu. Only 12 patients had both. 

“We would have expected to see 67 people with both viruses,” Foxman says. 

The team developed an experimental model to test and figure out why this might be so. It used stem cells to create human airway tissue that is the main target of respiratory viruses. They found that tissue exposed to rhinovirus triggered the production of the antiviral agent interferon, which apparently blocks the flu virus.   

Researchers say it’s possible that the common cold virus could also offer protection from COVID-19, though more research would be needed to test that hypothesis.

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