January 11th, 2013

How to Make the Flu Vaccine More Popular, Warts and All

In a week that saw both our hospital’s influenza-induced bed crunch make the New York Times, and my son, mother-in-law, and me succumb to this seasonal plague despite our receiving flu shots, I have been highly attuned to all things influenza.

But the focus here will be on that perennial whipping boy of preventive Infectious Diseases, the flu vaccine. Let me get it out of the way that I unequivocally believe that it’s our best way of preventing flu, and that I would never skip it. Nonetheless, it’s far from perfect, which is why in the court of public opinion, it just can’t win.

Why do most universal flu vaccine campaigns seemed doomed from the outset? Let me list the ways, some of them the fault of the vaccine, some just human nature:

  1. It has to be repeated yearly. Like magazine subscriptions renewals, membership dues, car inspections, and taxes, the flu vaccine comes round every year and induces the same feelings of nauseating weariness. Again? You mean I need that shot already? Didn’t I just do it? And will it even work this year? All right, go ahead. Medically savvy patients note that we’re not making them repeat any of the other shots yearly, which must imply to them a serious weakness in our vaccine.
  2. It doesn’t always work. Estimates of flu vaccine effectiveness vary widely, so I like to cite the 70% figure from this study rather than the more discouraging CDC’s aggregate data of 60%. And then I add some motivating language such as, “but it works better in some people than others, so let’s be on the optimistic side.” Plus I mention that all doctors and nurses get the vaccine, which though a bit of a lie, is at least true about ID docs/nurses.
  3. Many people think it works even less well than it does. Flu season just happens to coincide with the seasonal increase in all kinds of other respiratory tract infections, and it’s inevitable that patients with bad colds will blame that on the failure of the flu vaccine. Plus, approximately 32.56% of the population use the term “stomach flu” to describe various short-term gastrointestinal ailments, and regardless of what that term actually means, it’s 100% certain that the flu vaccine does nothing to prevent them. More failure! Even the above-mentioned Times article compounds this confusion by starting the piece on influenza, yet including several paragraphs on norovirus — just because, um, it’s sort of related, I guess. (It’s not.)
  4. “It gives me the flu.” I find it truly mystifying why so many people believe that the flu vaccine gives them the flu, but regardless, it’s either the top reason cited by vaccine refuseniks or a close second to, “I never get the flu, so I don’t need it.” My hunch is that people believe the flu vaccine gives them the flu because 1) colds are common and 2) they once got a bad cold (the “flu”) shortly after getting the vaccine. QED.
  5. It has to be matched each year with the predicted circulating influenza viruses. Sometimes the match is a good one (this year it is), sometimes less so. Unfortunately, in the absence of an all-knowing, popular Nate Silver-like projection guru — someone who updates his/her predictions on a regular basis for the public to see, and does it in plain language — the process of matching the vaccine to the circulating viruses is not for the faint of heart. (I dare you to read this all the way through.) This stuff is rough going even for most doctors, hence it’s no wonder that the public is skeptical on an annual basis. For the record, this is what’s in this year’s vaccine (in case you want to make one at home): an A/California/7/2009 (H1N1)pdm09-like virus, an A/Victoria/361/2011 (H3N2)-like virus, and a B/Wisconsin/1/2010-like virus (from the B/Yamagata lineage of viruses). Piece of cake.
  6. Weird stuff happens. Just like no vaccine is 100% effective, none is 100% safe either. The sheer volume of flu vaccines given every single year means that bad stuff is numerically more likely to happen with the flu vaccine than with others, at least in adults. Some of these linked events will be little more than anecdotes — do you really think your golf game was worse this week is because you just got a flu shot? — but some will be real, e.g. the 1976 swine flu vaccine and Guillain-Barré syndrome. These associations are hard to shake, and not a year passes where I’m not asked about the flu vaccine and Guillain-Barré, along with much more tenuous (really nonexistent) links such as flares of multiple sclerosis, transplant rejection, arthritis, and inflammatory bowel disease.

Given the above challenges, what can we do about it?

Seems what we need is a truly trustworthy spokesperson for the flu vaccine, someone who will take on what Magic Johnson did for HIV. He or she will calmly recommend the vaccine, reassure people about its safety, acknowledge fears and misconceptions — perhaps even mention that even if the vaccine doesn’t work, it probably makes the breakthrough case of flu milder — how many people know that?

So with the help of this nice list of the most Trustworthy Celebrities, plus some of my regional/personal biases, I ask you to help choose our Flu Vaccine Celebrity Spokesperson. I am 100% sure that after hearing of their nomination, they will quickly drop whatever project they are doing and volunteer their time for this important public health effort.

Who should be our national Flu Vaccine Celebrity Spokesperson?

View Results

24 Responses to “How to Make the Flu Vaccine More Popular, Warts and All”

  1. Sarag says:

    Ooooh, all very good celeb choices. I vote for Matt Damon. But maybe you should consider someone from Downton Abbey? How about Elizabeth McGovern? Her character came down with the 1918 Spanish Flu in Season 2 episode 8 and recovered. . ..

  2. Carlos del Rio says:

    Great posting. I take the flu vaccine every year yet have gotten culture confirmed influenza teice in tne past so I must be like the “cannary in the coal mine” to know when the vaccine is not as effective. Nevertheless, I still consider getting the flu shot a yearly routine like paying taxes or celebrating New Year.

  3. Ingrid says:

    I was glad I was in the majority with Betty White! BTW – on point #4 – I heard this as a reason to not get a flu vaccine from nurses working on a pod at a certain hospital in the greater northeast where I happen to be on an inpatient service this week! OY!

  4. All the six reasons why people dont follow the flu-camüaigns are mentioned very often by the patients. For America it would be a great idea to have a spokesperson (I would prefer Matt Damon). In Germany we had such a campaign for coloscopy in prevetion of colon cancer. It failed! Good luck for your flu-campaign!

  5. SB says:

    Definitely not Betty White. She’s likely to die within a few years, and that wouldn’t exactly help your cause. (“See, she got the vaccine and look what happened to her.”) Maybe Lindsay Lohan. Although she’s likely to die within a few years too.

  6. Ringer Lactate says:

    I voted for JB. Because he has lay public name and face recognition. Oh. Never mind. Well, I still think he’d be good. Him or Conan. Yeah. That.

  7. Loretta S says:

    Who is John Bartlett?? Last week, we had a stampede for flu vaccine in our office, all because the local news broadcast images of a hospital in the general region that had a triage tent outside for all the patients with flu and flu-like illnesses. That sure got people’s attention. Maybe we can have a yearly (harmless) scare campaign? 🙂 “It gives me the flu” is the one that makes me the craziest. I have taken to saying, “One of three things happened: (1) You got a bad cold right after getting the vaccine; (2) You caught the flu while your body was still building immunity to the virus; or (3) you felt flu-like symptoms while your body was creating its immune response to the DEAD VIRUS”. I know, I am wasting my breath. But it does make me crazy. I never say, of course, “You got the flu because the vaccine is only about 60-70% effective.” 🙂

  8. John Bartlett says:

    Great review. I didn’t vote due to bias. I have a Conflict of Interest! I also get the vaccine every year and haven’t had flu for decades. Hopkins healthcare workers had 99.9% compliance with the mandate to be vaccinated. I don’t know who the holdout is but it might be that nurse in a space suit.

    Professor of Medicine
    Johns Hopkins University School of Medicine

  9. Sheldon Ball says:

    I have yet to see a viable mechanism of action for the influenza virus vaccine. IM or SQ injections should elicit IgG against the antigen(s) in the vaccine (hemagglutinin,; also neuraminidase ?). However, influenza A & B are spread by aerosolized respiratory secretions or contaminated hands and the viruses replicate in ciliated columnar epithelial cells of the respiratory tract. I was taught that IgA is needed for protection from respiratory infections. In the case of Pneumovax, the vaccine protects against Streptococcal septicemia (not alveolar infection by Streptococcal pneumonia) [PMID: 16983612, PMID: 19124790, PMID: 19124781]. Is there a septicemic phase of influenza where IgG might be effective?

  10. J. Horowitz says:

    Another reason that some people reject the flu vaccine is that it contains mercury. I’ve seen this discussed back and forth for some time, and would much appreciate knowing the current medical thinking regarding its safety.

  11. Alyssa says:

    The lastet addition to the anti-vaccine campaign is a book educating children about the ineffectiveness of vaccines:


    This scares me.


  12. Rizwan says:

    “Last month,, in a step tantamount to heresy in the public health world, scientists at the Center for Infectious Disease Research and Policy at the University of Minnesota released a report saying that influenza vaccinations provide only modest protection for healthy young and middle-age adults, and little if any protection for those 65 and older, who are most likely to succumb to the illness or its complications. Moreover, the report’s authors concluded, federal vaccination recommendations, which have expanded in recent years, are based on inadequate evidence and poorly executed studies.

    “We have overpromoted and overhyped this vaccine,” said Michael T. Osterholm, director of the Center for Infectious Disease Research and Policy, as well as its Center of Excellence for Influenza Research and Surveillance. “It does not protect as promoted. It’s all a sales job: it’s all public relations.”


  13. Larraine says:

    Morgan Freeman is great choice—a Saturday Night Life skit coined a phrase that captures the essence of this father figure’s firm encouragement to be actively engaged in our life journey

    “Get busy living or get busy dieing”

  14. Ann says:

    I saw stupidity in suggesting celebrities for flu vaccine campaign. Flu vaccine does make a lot of people feel sick, just like flu virus does. The vaccine industry is getting stronger and stronger.

  15. Karen says:

    I think that a video should be made of President Obama and his family each getting the flu Vaccine.

  16. NursingDept says:

    Who should be our national Flu Vaccine Celebrity Spokesperson?

    Have you thought about nominating a government leader – such as President Obama?

    People follow what the leaders find safe to do. Get the folks at the White House on board for flu vaccines and the American people will follow.

  17. John Loder says:

    I like Morgan Freeman but feel an actor/actress with MD on his CV like George Clooney or Eriq LaSalle might have clouds of medical authority swirling about him. Any thought of having two so you could use their banter to sell to the naysayers (like my niece-in-law)?

  18. Bill says:

    Well so much for John Bartlett.
    I’d prefer a multiple personality campaign with various comedians heaping ridicule on the rationales of vaccine refuseniks.
    How about Chris Rock, Will Ferrel, push flu vaccine on SNL, Make them look ridiculous on “Portlandia”.

  19. Todd ellerin says:

    I’d vote for Matt Damon since he can guilt anyone into doing something (see Entourage).

    Even in 1976 when flu vaccine was linked to GBS, there was 1 additional case per 100,000 vaccinations (450 cases/45 million doses) so rare during that season and unique to that season since that incidence of GBS has not been reproduced with flu vaccine. Given 10-20 percent risk of acquiring flu in any season and tens of thousands of deaths every season in the US, seems like the benefits outweigh the risks for this moderately effective vaccine. The lower efficacy in the elderly is true (and not unique to flu shot) but mortality is highest in this group so even a 20 percent reduction in mortality is worthwhile given a very safe vaccine

    One disturbing anecdote was when I was rounding in the ICU on a pt with severe flu and discussing the case with the ICU attending and we focused on the fact that this pt had not received the flu vaccine. The intensivist then aske pd me if I received my flu shot. I looked at him incredulously and said of course, but was dismayed to hear he hadn’t it was because one of his mentors in residency or fellowship had told him that he didn’t believe in it and felt that building up natural immunity made more sense. I guess if the critical flu pt didn’t motivate him to get a shot, not sure ther’s anything that will work short of mndatory program linked to employment,.


  20. Preethi says:

    The most well known advocate for the flu would be the flu! Now with almost every state seeing cases & the flu getting notorious recognition on almost every news show, column & website this is the time to highlight & debunk common myths! In the era of “reality tv” real life cases with influenza as the unfortunate star is hopefully going to raise public awareness & increase popularity for the less than perfect vaccine.

  21. Lisa P says:

    I think we need more aggressive public health campaigns. It made me crazy recently when someone who I went to college with posted on Facebook that getting a flu shot is tantamount to ‘shooting mercury into your veins’ and that this is a sure way to develop Alzheimer’s. Arrrrrrgh. Could we have more public information about thimerosal, or make it more obvious that most vaccine manufacturers don’t use thimerosal anymore anyway??

  22. One of the challenges any science communicator faces when speaking to a skeptical public, is proper image use. All too often images on articles about vaccination are stock photo of cool-blue and white backgrounds with shiny syringes. Or worse.

    This scares people. Happy healthy, smiling kids and families might seem a bit sales-y, but in the long run it shows the effect of the vaccine: not the momentary pinch of a needle: but the continued health and ease of mind of vaccinated people.

  23. Ashraf says:

    Bette Midler

  24. Loretta S says:

    I am mortified to note that at the time of my original comment, I did not know who John Bartlett is! How embarrassing. My apologies to Dr. Bartlett, a giant in the world of ID!

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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