Hawaii’s new Health Director Libby Char is urging the public to remain vigilant during the upcoming flu season that health experts predict could be the worst in years due to the prevalence of COVID-19 in the community.

In her most challenging role to date, Char, an emergency physician who previously served as the state EMS district medical director for Oahu, joined the Department of Health on Sept. 16, ahead of a potential third wave of coronavirus infections that could be even more devastating with influenza in the mix.

Throughout the nation, health experts are worried the collision of the two potentially deadly viruses might result in a surge in hospitalizations and mortality. Getting a flu shot is even more critical this year to prevent hospitals from becoming overwhelmed with both flu and COVID-19 patients, she said.

“What I’m hearing is this year is going to be a particularly bad flu season,” said Char, who managed the City and County of Honolulu’s EMS system for years. “When you couple a bad flu season with COVID-19, that just compounds it. It’s entirely possible we could see another wave of COVID-19. I would tell people to be prepared for … another spike. If we’re in that mindset, maybe it will help us to be diligent and help us to prepare.”

The coronavirus has killed 131 people and sickened more than 12,000 since it reached the islands earlier this year. The DOH estimates the upcoming flu season may result in as many as 1,000 Hawaii deaths due to pneumonia and influenza and about 10,000 cases.

That compares with 686 deaths from pneumonia and influenza in the 2019-2020 flu season that ended Saturday, according to the department’s Influenza/Respiratory Disease Surveillance Report for the week ending Sept. 5.

Both viruses have almost the exact same symptoms and are transmitted the same way — through airborne droplets from coughing or sneezing. Flu and pneumonia were among the state’s top five causes of death from 2014 to 2017, according to the Centers for Disease Control and Prevention.

“COVID-19 is bad and flu is bad, and if you get both of them you’re going to be in real trouble,” said Dr. DeWolfe Miller, a University of Hawaii professor and fellow in the American College of Epidemiology, adding that the mortality rate could increase exponentially with dual infections. “It absolutely could be a devastating thing. If we get a co-infection with either one of these viruses it’s going to be deadly,” he said.

While it’s uncommon to contract two viruses at the same time, co-infection is possible — and both respiratory viruses target the lungs and can cause viral pneumonia.

“Even if it’s just an ordinary flu season, it’s going to be worse,” Miller added. “And if people don’t get their flu vaccine, it’s definitely going to be worse. This is part of a disaster that we can avert if we take our flu shots.”

Miller contends the public must be cautious and should stay inside, for the most part, and avoid crowds during flu season. While the flu can be particularly serious in younger children, COVID-19 has mostly affected older adults and those with underlying medical conditions.

Char replaced Bruce Anderson, the former health director who was criticized for failing to build a robust COVID-19 response. She is now on a mission to restore public trust and persuade Hawaii residents to heed the warnings of public health experts to get their flu shots, continue mask wearing and good hygiene, and practice social distancing during the holidays despite quarantine fatigue.

“She does have an issue of having to play catch-up with public trust or getting people who are weary of this (on board),” Miller said. “It’s a very serious situation we’re looking at.”

With flu season, the reopening of businesses and trans-Pacific travel quarantine exemptions, and blended in-person and online school programs starting next month, officials are closely monitoring signs of another wave of coronavirus infections depleting the state’s health care resources.

“At least for many, many months we’re still going to be dealing with COVID-19. I can’t tell you when it will end,” Char said. “What makes me worried is that flu season is around the corner. The best thing we can do is to work on the prevention side so we never get sick in the first place.”

Hawaii’s “very social” culture makes it even more critical “to convince each other and convince our friends and family that everybody’s got to do their part, and at some point, hopefully, we get buy-in and we as a community change our behaviors,” she said.

Hawaii hospitals have already begun seeing the first patients of the fall flu season, with case numbers typically continuing through March, said Jill Hoggard Green, president and CEO of the Queen’s Health Systems.

“The combination of coronavirus being spread and flu at the same time could dramatically increase the number of people who are ill,” she said. “Flu on top of coronavirus could amplify the pandemic and make it much worse. For me, that’s just too much pain and suffering that we can prevent.”

On the flip side, if as much as 80% of the population gets the flu vaccine, the community could actually see a better-than-normal flu season and create a broader reduction of transmission, according to Hoggard Green.

Lt. Gov. Josh Green, an emergency room doctor on Hawaii island, said he expects that because people are wearing masks and socially distancing for COVID-19, there will be fewer flu cases, “but you never know how strong a flu strain is going to be.”

He added that he gets a flu shot annually and has contracted the virus only once in the past 20 years. “You can tell that COVID-19 is more severe for us and we have no immunity, so that’s why we’re trying to prevent it,” he said.

Hawaii has had 787 total coronavirus hospitalizations out of 12,018 cases, a rate of 6.5%. Nationally, there’s been roughly 600,000 hospitalizations from 45 million flu cases, a rate of about 1.3%.

“People have been hospitalized (for COVID-19) at five times higher rates … and the mortality rates are 15 times higher,” Green said, adding that the state is working to put into place additional safeguards to ensure any future COVID-19 vaccine is safe and voluntary in Hawaii.

“We need to get herd immunity. If people don’t get it, they are going to be very vulnerable to getting the coronavirus and will impact us opening up the state.”

Honolulu family doctor Jennifer Frank said the flu vaccine is “flying off the shelves” this year and even people who ordinarily don’t get it are asking for the shot. Although last year’s flu vaccine was only 30% effective, none of her patients who caught the virus ended up in the hospital or dying, so it may have prevented complications, she said.

While there’s no cross-­protection from the flu vaccine, “one of the best things you can do to prevent COVID-19 for yourself and everybody around you is take a flu shot” to stay healthy, she said.