When the flu virus begins mixing with the coronavirus this fall, the resulting double whammy of respiratory disease threatens to overwhelm doctors and hospitals, officials fear.

“Each can fill up emergency rooms on its own,” said Dr. Kathleen Neuzil, director of the University of Maryland School of Medicine’s Center for Vaccine Development and Global Health. “That’s why we’re really encouraging people this year to get the influenza vaccine.”

Neuzil and other public health officials say the upcoming flu season could be more mild, at least to start, because of the wide adoption of COVID-19-related precautions. Many people also remain at home because schools and office buildings are closed.

There are fewer flu cases now in the Southern Hemisphere during its flu season because “people are behaving and social distancing and wearing masks,” she said.

But she and others worry those benefits could wane as cities and states lift restrictions, people tire of precautions and colder weather pushes more activities indoors.

There also will be fewer mass influenza vaccination opportunities because fewer people are going to work or school. People also may continue avoiding doctors’ offices. Already, routine inoculations for children have dropped during the pandemic, sparking a push by the U.S. Department of Health and Human Services to catch up.

Dr. Lisa Maragakis, senior director of infection prevention for the Johns Hopkins Health System, said taking steps to prevent one virus prevents others, and she hopes such vigilance continues. She also hopes people get the flu vaccine.

“Raising awareness of the flu vaccine is even more important this year,” she said. “The more we can do to prevent the viruses the better off we’ll be.”

The flu vaccine is the only option, she said, since vaccines to prevent COVID-19 remain in development and aren’t expected to be widely available until next year at the earliest.

Maragakis also said that doctors won’t know which respiratory infection someone has without testing because flu and COVID-19 share symptoms, including fever, cough and aches. Other respiratory diseases also begin circulating in the fall, such as RSV.

The nation’s testing system already is bogged down with COVID-19 for a variety of reasons, including a lack of supplies and scarce lab capacity. Tests, though, are being developed to could screen for multiple viruses at the same time.

Maragakis said scientists and doctors are looking to the Southern Hemisphere, which is in the midst of its flu season, for some information to guide their response and should have data in the coming weeks and months.

International health officials say such information may not be as helpful this season, however. Some countries may not collect as much flu data because they are devoting all of their public health resources to COVID-19. If health officials can’t figure out, as a result, which strains of flu are most prevalent, that could even lead to the development of a less effective flu vaccine in the future.

Officials also worry about how few people actually get a flu vaccine. It’s rarely required outside of U.S. health care settings, and, even though it’s recommended for everyone, particularly older people, children and pregnant women, surveys show that no more than half the population normally seeks a shot.

Local public health officials say they’ve heard all the excuses: Some believe falsely that the shot makes them sick, but others see little threat from the flu or don’t see value in a vaccine that is protective for only several months at a time and is less effective than other vaccines.

The U.S. Centers for Disease Control and Prevention reported that the last flu vaccine was effective 45% of the time, below average, but it also can lessen the severity of illness. The vaccine’s effectiveness varies because it’s formulated based on a best guess of what strains of the constantly evolving influenza virus will be circulating each season.

Most people recover from the flu at home, and reporting of suspected cases is voluntary, making it hard to know just how many people are infected. The CDC estimates last season there were up to 56 million cases and up to 62,000 deaths.

Hopkins data shows COVID-19 deaths now exceed 170,000, making it more deadly.

Maryland’s emergency departments reported visits for more than 100,000 suspected flu cases and 67 deaths last season. There have been more than 3,400 COVID-19 deaths in Maryland since March.

Scientists agree that people can catch both viruses at once, and each can be miserable and deadly on their own.

“We don’t have a lot of experience because we didn’t have huge overlap last flu season, but the cases we did have of both appeared to be particularly severe,” the University of Maryland’s Neuzil said.

Dr. Letitia Dzirasa, Baltimore City’s health commissioner, fears a lot of flu or COVID-19 cases could mean a shortage of hospital staff or beds.

“Both viruses together could really be a challenge for the health care system, and the more we can reduce one virus, in this case the flu, the better,” Dzirasa said.

World Health Organization officials recently warned the number of flu cases could rise globally, even if they get off to a slow start, creating a threat to a host of health care systems.

“In all nations the threat of pandemic influenza, which could emerge any moment anywhere, remains real,” the group said in a statement.

Calls for vaccination are echoed by national and international health leaders. The CDC recommends vaccination for anyone over 6 months old.

CDC officials report manufacturers planned to make up to 198 million doses of flu vaccine for the 2020-2021 flu season, up from 175 million doses from last season, with most containing four strains of the virus.

Shipments have begun and vaccines are starting to become available at doctors’ offices, pharmacies and elsewhere.

Baltimore City and area counties say they are considering how to safely and effectively distribute the vaccine.

For example, Della Leister, Baltimore County’s deputy health officer, said seasonal clinics will look different than in past years. Most likely the clinics will require appointments and be held in large, open spaces. She expects paperwork to be done online during scheduling. Drive-through clinics also are being considered.

Elin Jones, a spokeswoman for the Anne Arundel County Health Department said officials plan a campaign about “the importance of county residents getting the flu vaccine, particularly with seasonal flu having symptoms similar to COVID-19.”

In Baltimore City, Dzirasa said the health department is encouraging people to contact their doctor about a vaccine for themselves and children.

The department was working with other city agencies and health care providers to target its limited number of doses to vulnerable residents without easy access to a doctor’s office, such as those in congregate housing, older adults with underlying health conditions, children and pregnant women.

Dzirasa said she hopes the department’s campaign helps counter any resistance to vaccination.

“My biggest message is: Get the flu shot,” she said. “If no other year, get it this year.”

How the public will respond to such appeals remains uncertain, though a recent UnitedHealthcare survey found that 30% of Americans said they were more likely to get the seasonal flu shot this fall.

The health insurance provider also found people were taking better care of themselves and trying to avoid infections. One in five people said the pandemic encouraged better eating habits. A third planned to stop shaking hands.

For their part, vaccine makers say they will encourage preventive measures.

Pharmaceutical giant AstraZeneca reports that its Gaithersburg-based subsidiary MedImmune has increased production of FluMist by 25% to almost 8 million doses. The nasal spray vaccine popular with needle-averse children will again be offered after a hiatus due to questions about its effectiveness.

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