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August 2022, Volume 72, Issue 8

Student's Corner

Twindemic — An emerging concern in Pakistan

Sareema Eman Akhtar  ( 4th Year MBBS Student, Ziauddin Medical College, Karachi, Pakistan. )
Sareema Eman Akhtar  ( 4th Year MBBS Student, Ziauddin Medical College, Karachi, Pakistan. )
Azhar Chachar  ( Fourth Year MBBS Student, Ziauddin Medical College, Karachi, Pakistan. )



Madam, as winter approaches, people succumb to a myriad of winter illnesses. Seasonal Influenza (Flu) is predominantly prevalent in the USA and Pakistan. CDC reported 20,000 deaths and 380,000 hospitalizations from flu in 2019 till 2020.1 According to Dr Ebell, we are likely less immune, since we are not exposed to flu for twenty months or even more. There is uncertainty regarding flu strains since it can undergo antigenic shifts and antigenic drift that can cause the evolution of new strains.2 Therefore, CDC estimates that approximately seven hundred thousand people would  get hospitalized in the upcoming flu-season.3

Flu season paired with Covid-19 classically presents as "Twindemic". Although influenza (Flu) and Covid share similar clinical symptoms, both can have severe, mild or moderate effects, mode of transmission and preventive strategies, but they still differ in their treatment modalities and vaccines. Therefore, during the covid era it has become challenging to report influenza cases as both diseases present with similar symptoms making clinical diagnosis difficult. However, some studies suggest that preventive measures used for Covid were also effective against the prevention of flu. Hence, the number of flu cases were reported to be lower than expected for the year 2020-2021. People infected with Covid and Influenza at the same time, are more prone to develop severe illness. To keep the pressure off healthcare systems, vaccination programmes are imperative. CDC has issued new guidelines for this potential twindemic this winter, stating that flu vaccines must protect against all4 influenza virus strains that were not  the recommendation in prior years. However, in Pakistan Flu shots are not prioritized. Even though CDC recommends a flu shot annually, there is no national influenza vaccination policy in Pakistan. Low levels of vaccination are due to little knowledge regarding the importance of influenza prevention, misinformation about its side effects and lack of public awareness,4 due to which the death toll of influenza was reported to be 42.03 per 100,000 of population as per 2018 data.5

Despite the serious health and economic consequences faced due to influenza, vaccination rates remain low. Pakistan Government must play a pivotal role to include influenza vaccination in its EPI schedule in order to make it available for the citizens at low costs. The risk of co-infection is estimated to be higher as the season changes. With Covid immunization making progress, it is crucial to focus on flu shots as a preventive measure to ease the burden of healthcare systems across the country. A step forward would be to raise awareness about the dangers of influenza and its consequences of co-infection with Covid-19.


Disclaimer: None to declare.


Conflict of Interest: None to declare.


Funding Disclosure: None to declare.




1.      Lafond KE, Nair H, Rasooly MH, Valente F, Booy R, Rahman M, et al. Global Role and Burden of Influenza in Pediatric Respiratory Hospitalizations, 1982-2012: A Systematic Analysis. PLoS Med. 2016; 13:e1001977.

2.      Twindemic meaning 2021 | This is why it is more likely | [Online] [Cited 2021 November 7]. Available from: URL:

3.      Is a "twindemic" of flu and COVID-19 about to hit the U.S.? [Online] [Cited 2021 November 6]. Available from: URL:

4.      Farrukh MJ, Ming LC, Zaidi STR, Khan TM. Barriers and strategies to improve influenza vaccination in Pakistan. J Infect Public Health. 2017; 10:881-3.

5.      Influenza and Pneumonia in Pakistan [Online] [Cited 2021 November 07]. Available from: URL: Pakistan-influenza-pneumonia.

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