Flu, RSV, or COVID-19? Convergence of Three Viruses Creates Risk of Diagnostic Errors

By DEBRA KANE HILL, MBA, RN

As we transition into colder weather, it is possible that healthcare practitioners will again see a spike in influenza (flu), respiratory syncytial virus (RSV), and COVID-19 cases—particularly with the circulation of newer Omicron subvariants. Last year, RSV infection peaked unusually early, flooding primary care offices and hospital emergency departments while creating severe shortages of pediatric hospital beds.

Public health officials declared the three viruses as a public health “triple threat” in 2022/2023, but this year we have reason for good news: Vaccines are now readily available for all three viruses—flu, RSV, and COVID-19. In 2023, the FDA approved RSV vaccines for adults ages 60 and over and pregnant women during weeks 32 through 36 gestational age, providing protection for infants from birth through six months of age.

Diagnosis

For unvaccinated patients manifesting illness, the bad news is that all three viruses have similar symptoms, and testing must be performed for each to effectively confirm a correct diagnosis. Understanding the differences between the flu, RSV, and COVID-19 will help prevent misdiagnosis or delayed diagnosis when patients present with respiratory symptoms.

The American Academy of Pediatrics offers information on differential diagnosis between the three viruses, and the CDC provides specific guidance on distinguishing between the flu and COVID. General information for practitioners about each virus is available from the CDC as follows: flu, RSV, and COVID-19. The CDC addresses signs and symptoms, incubation periods, length of time for spreading the viruses, how the viruses spread, individuals at higher risk for severe illness, potential complications, and approved treatments.

Prevention

During flu season, it is possible that all three of the viruses may spread at the same time and patients could become infected with one or all three of the diseases. To counter this possibility, it is important to continue offering appropriate screening, testing, and vaccinations. Refer to the CDC’s guidance on “Frequently Asked Influenza (Flu) Questions: 2022-2023 Season.” Note that according to the CDC, both flu and COVID vaccines may be given on the same day if patients are eligible and vaccines follow the appropriate administration schedule. Some infectious disease experts recommend, however, that the RSV vaccine be given separately.

Patient Safety Strategies

Enhance patient safety by taking the following actions:

Patient Care

Follow testing guidelines. Testing is the best method for determining which virus the patient may have while guiding your decisions about the appropriate treatment.
Review the CDC’s “Information for Clinicians on Influenza Virus Testing” for patients with acute respiratory illness symptoms.
Educate staff and patients on the new vaccine for RSV: See ABRYSVO information by Pfizer and the CDC’s RSV Vaccine Information Statement.
Encourage your patients to get appropriate age-related vaccines.
Ensure that the patient’s health record includes standard documentation about the possibility of contracting the flu, RSV, and/or COVID-19—including vaccination informed consent and informed refusal discussions.
Adopt a shared decision-making approach for patients at high risk for flu, RSV, or COVID-19 who are reluctant to get vaccines. Ensure that patients understand the risks of not being vaccinated. Learn more about this process with the Agency for Healthcare Research and Quality’s “The SHARE Approach.” The shared decision-making/consent discussion should be well documented in the patient’s record. For additional information, see our articles “Reduce Patient Safety Risks With Vaccinations, Including COVID-19” and “Communicating with COVID-19 Vaccine-Hesitant Patients: Top Tips.”
Prescribe antivirals as necessary to prevent complications. See the CDC’s “What You Should Know About Flu Antiviral Drugs” and “COVID-19 Treatments and Medications.” From the American Academy of Pediatrics, see “Updated Guidance: Use of Palivizumab Prophylaxis to Prevent Hospitalization From Severe Respiratory Syncytial Virus Infection During the 2022-2023 RSV Season.”

Office Measures

Encourage all staff members to get vaccinated for the flu. Offering it at no cost to employees increases vaccination rates.
Follow the CDC’s “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic.”
Appoint someone in the office to maintain all policies and procedures related to flu, RSV, and COVID-19 in a central location.
Maintain, date, and document all changes in office policies related to personal protective equipment or other infection control protocol.
Ensure that all vaccinations stored in the office are current.

Patient Education

Distribute or display the American Heart Association infographic “Flu Shot 411.” Flu shots reduce the risk of death for people with heart disease.
Use other infographics and print resources in your office for the flu, RSV, and COVID-19.
Offer a free video in your waiting area to educate patients about getting vaccinated. For an example, see the Mayo Clinic Minute: “Why getting vaccinated for the flu is doubly important this season.”
Educate patients to stop the spread of germs:

Wash hands frequently.
Maintain respiratory etiquette (including masking when possible).
Avoid touching eyes, nose, and mouth.
Avoid close contact, particularly with those who are sick.
Disinfect frequently touched surfaces and objects.
Encourage self-isolation if sick.

Community Monitoring

Adhere to local government or public health department recommendations for additional precautions. Check transmission levels in your community: “Weekly U.S. Influenza Surveillance Report,” “RSV Surveillance,” and “COVID-19 by County.”

For additional assistance, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.

Debra Kane Hill, MBA, RN, is a Senior Patient Safety Risk Manager for The Doctors Company.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.