More than 40% of Americans may not get a flu shot this year. That could spell trouble during COVID.

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More than 4 in 10 Americans aren't sure about or aren't planning on getting a flu shot this year, a new survey found, in a worrying trend public health experts say could exacerbate a worse-than-average flu season.

Last year's worries around a "twindemic" of influenza and COVID-19 overwhelming hospitals around the nation luckily went unfounded after a historically mild flu season.

But with COVID-19 vaccinations affording many people a return to more "normal" lives of socialization and in-person work during flu season, hospitals and health systems could be strained in parts of the country where vaccination against both viruses remains low, doctors say.

"We're particularly concerned because COIVD is out there," said Dr. William Schaffner, medical director for the National Foundation for Infectious Diseases. "Flu will come back this year. And we don't want to further stress our already very stressed health care system."

And while COVID-19 cases are declining nationally, there are parts of the country "where a large proportion of the population is undervaccinated against COVID," Schaffner said. "COVID is going to remain active in those parts of the country. And then if you add influenza to that, I think in parts of the country, we could have a tough winter."

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Dr. Lilian Abbo, center, receives a flu vaccine from Nicholas Torres, left, and a Pfizer COVID-19 booster shot from Douglas Houghton, right, at Jackson Memorial Hospital Tuesday, Oct. 5, 2021, in Miami. According to the Centers for Disease Control and Prevention it is safe to get your COVID-19 vaccine and flu vaccine at the same time. The COVID-19 booster is now available to those over 65 and to workers whose jobs put them at high risk of exposure.
Dr. Lilian Abbo, center, receives a flu vaccine from Nicholas Torres, left, and a Pfizer COVID-19 booster shot from Douglas Houghton, right, at Jackson Memorial Hospital Tuesday, Oct. 5, 2021, in Miami. According to the Centers for Disease Control and Prevention it is safe to get your COVID-19 vaccine and flu vaccine at the same time. The COVID-19 booster is now available to those over 65 and to workers whose jobs put them at high risk of exposure.

A survey of more than 1,000 U.S. adults commissioned by the National Foundation for Infectious Diseases found that while more than 60% of Americans agreed the flu shot was the best way to prevent flu deaths and hospitalizations, 44% said they were unsure about or not planning to get a flu vaccine this year.

The causes of flu vaccine hesitancy may be less political than the divides driving COVID-19 vaccine skepticism, Schaffner said. They're a yearly practice, and unlike vaccines for polio or measles, which have virtually eradicated those diseases in the United States, the flu sticks around.

The top reason cited for flu vaccine hesitancy by surveyed adults was that it doesn't work very well.

Schaffner said while the flu vaccine is by no means perfect, it still provides significant protection against hospitalization and death.

"It would be great if we had a vaccine that was even more effective than what we have," said Dr. Thomas Holland, an infectious diseases specialist at Duke University Hospital. "But the fact remains that the most effective way, the best tool that we have to prevent influenza infections and hospitalizations and deaths is still the annual vaccine."

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Survey respondents also said they wouldn't get a flu shot because they never get the flu, were worried about side effects, did not consider flu to be a serious illness, or were worried about getting flu from the vaccine.

The flu vaccine cannot give people the flu, and side effects indicate a proper immune response in the body. It also can be received at the same time as a COVID-19 vaccine, according to the Centers for Disease Control and Prevention.

Holland said about half of Americans get a flu shot in a typical year. But immunity wanes much more quickly compared with COVID-19 vaccines, and flu viruses change yearly, requiring annual shots. 

However, with so few people exposed to the influenza virus last season, people won't have the potential added defense against illness that natural immunity can bring, he said.

The 2020-2021 flu season was practically nonexistent. Public health and clinical laboratories reported 2,038 flu cases during the season from Sept. 27, 2020, to April 24, according to the CDC. 

Schaffner said much of that decline was due to social distancing and mask-wearing practiced around the country to prevent the spread of COVID-19. With many of those restrictions eased, Schaffner expects flu to return.

The return of many children to classrooms poses a significant threat of transmission, he added, given children shed flu virus much more and for longer periods than adults.

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One potential benefit of the pandemic has been an increased willingness of people to stay home when sick rather than powering through an illness and potentially spreading it to others, Holland said.

The survey found 45% of Americans said they were more likely to stay home from work or school when ill because of the pandemic. A majority also said they would wear a mask at least sometimes during this flu season.

To boost vaccination numbers, Schaffner said physicians need to make the flu shot a priority in their messaging. Often, it is an afterthought at the end of a visit.

"Health care providers of all kinds have to be not just influenza vaccine recommenders, they have to be influenza vaccine insisters," Schaffner said.

Contributing: Adrianna Rodriguez

This article originally appeared on USA TODAY: Flu shot: 40% of Americans may not get flu vaccine amid COVID: survey