January 28th, 2015

Quick Question: Should We Still Be Recommending This Year’s Flu Vaccine?

From a football-obsessed primary care provider, written to me on one very snowy day in New England:

Hi Paul,
I’ve been reading about this year’s flu vaccine, and how ineffective it is. Not surprisingly, my patients have been hearing this too, and it has only increased their reluctance to go through with it. Should I just cut my losses and stop recommending it this year? Seems we have much more important things to worry about, such as measles in Disney and deflated footballs.
Go Pats!
p.s. I think the Pats are really geniuses. And they realized that if they pump the balls to 11.5 PSI right before the game, then heat them (microwave? hair dryer? ) to get up to 12.8 PSI, then hand to the refs who measure at at least 12.5 PSI, then let them cool down for a while. And, as with taxes, if it doesn’t say you can’t do it, then you can do it. Genius.

Dear Kerry,

The quick answer is yes, we should still be recommending it, but I share your pain. (I mean about the flu vaccine, not about Deflategate.) My experience this year is that when I suggest a flu vaccine, my reluctant patients not only decline, but look at me as if I’ve recommended that they undergo a colonoscopy without sedation. You must be kidding me, everyone knows this year’s vaccine is a dog.

kid with fluSo why recommend it? First, it still works some of the time, even if the H3N2 match isn’t good (there are influenza B strains as well that are included in the vaccine). 23% effective is better than nothing, which means that these 23% not only won’t get sick with flu themselves, but they won’t spread it to the people who are the most vulnerable (the very young, the elderly, and pregnant women).

Second, there’s really nothing else out there that works, unless you want to take oseltamivir continuously, all flu season — this is not recommended, and would be very expensive. I suppose our patients could seal themselves off in a polyurethane bubble until Spring — which would be particularly difficult if they like to ski.

Third, there’s at least a little evidence that even if the flu vaccine doesn’t work, it might attenuate the severity of clinical influenza, reducing the risk of pneumonia and hospitalization. As an optimist, I plan to believe this last item until someone proves it’s not true.

Your email also gives me a chance to link a truly outstanding review over on Medscape called, Why is Influenza So Difficult to Prevent and Treat? It’s an interview with two experts in the field, Drs. Andrew Pavia and Gregory Poland, and really the title should have been expanded to “Why is Influenza So Difficult to Predict, Prevent, and Treat?” I always get asked about the upcoming flu season by my friends, and the honest answer is — WE HAVE NO CLUE.

The Medscape piece is top-notch, a very readable update on these issues. I learned a lot about this tricky infection, including the key fact that if we delayed choosing the strain for next year’s vaccine for a few months, we’d probably have a better vaccine match from year-to-year. Plus I was introduced to the seat belts analogy, which goes like this:  “Seat belts may not protect from high-speed crashes all the time, but some protection is better than none.” Exactly!

So go ahead and continue to recommend it. I find that if my patients balk, I don’t push it, but better to have a uniform medical position on flu vaccine than to waffle.

And about that game on Sunday — 20 days until pitchers and catchers report for Spring Training.

5 Responses to “Quick Question: Should We Still Be Recommending This Year’s Flu Vaccine?”

  1. Hossain Jabbari says:

    Dear Paul,
    Thank you so much for this interesting discussion.

    I would like to make some comments on the discussed issue:
    I think from the mass aspect, “23% effective is better than nothing” could not be suggested for all population group and is not cost- effective. As you know CDC recommended mass vaccination in new guideline, but when the efficacy of the new vaccine would be as low as 23%, then maybe recommending it just to high risk people (and not all people who search it as a shield and are not in fact in danger of complications) would be justifiable. We know that 23% efficacy is also far more nehind the around 70% efficacy which could have protective efficacy like herd immunity! Again, from this point of view, maybe it would be wise to recommend vaccination to close contacts of those who have high risk people (like cardio pulmonary problems) in their families rather than a mass vaccination.
    For the second point, the price of chemical prophylaxis v.s. vaccination, again, maybe the economic burden of mass vaccination surpluses the real number of those who really will take chemoprophylaxis.
    For the last point, attenuation of clinical severity, you clearly mentioned that there is not enough evidence to support it. I’m going to add another point: If partially immune people for measles develope atypical (less severe and shorter form) mealses, its because the mechanisms like “lack of proof reading” (leading to antigenic drift) and “Reassortment or swap”(leading to antigenic shift), aswe see in influenza, are not considerations in measles, and so the patient’s immune system is not confronting to a less or more different virus, and so the expectation for a milder (atypical!) form of influenza in vaccinated people with this weakly immunogen vaccine is less plausible.
    I agree with you that “Seat belts may not protect from high-speed crashes all the time, but some protection is better than none”, but I wonder if the people seat their belts if we ask them every year buy a new one!! 🙂
    Thanks again for sharing this interesting discussion.

  2. Sandeep Saluja says:

    There is reasonable ground to say that Andrographis has antiviral activity against influenza as also could attenuate secondary harmful inflammatory response.
    True,there are no clinical trials so far but is definitely safe.
    I would at least prefer to take that as prophylaxis rather than vaccine. I would also not hesitate telling that to my patients.

  3. Erynn says:

    I’m going to start getting vaccinated because I was shocked to hear about how bad last year’s flu cases were. It’s definitely something I have declined before but now I’m putting it at the top of my priority list.

  4. Santiago says:

    Dear Paul,
    Thank you for your marvelous post (as they always are always). I personally recommend Flu vaccination every year to all my patients… and to everyone. I disagree with vaccinating only the high risk group since we are at some point all in contact with someone from that group: most certainly during the holidays when families (all ages mixed up) get together… In my hospital it is always the non-vaccinated that come in with Flu.

    Great video comparing football and Baseball! What about Rugby?

  5. Interesting. So year-round oseltamivir comes to mind (?!) but getting your patients’ 1,25(OH)-vitamin D levels above 50 ng/mL does not. Curious. {shaking head}

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