Issue 19 / 27 May 2013

LIKE many people, I have had a somewhat lackadaisical approach to getting an annual influenza shot.

If it’s been offered free at my workplace, I’ve tended to do it. Otherwise, I mostly haven’t bothered.

As anybody who reads this blog regularly will know, I’m a strong supporter of immunisation, but that doesn’t mean I believe all vaccines are equal.

Whooping cough in children: absolutely. Influenza in healthy adults: not so sure.

The picture may be different in children or in adults with other risk factors (respiratory disease, for example), but Cochrane reviews don’t offer strong support for general influenza immunisation programs such as those offered by many employers.

A 2010 review of influenza vaccination in healthy adults found it had only a modest effect in reducing symptoms and working days lost, and no effect on transmission of disease or on complications such as pneumonia.

In Australia, the flu vaccine is recommended for all people over 65, although a 2009 Cochrane review found the evidence on immunisation in that age group was of poor quality and not capable of providing guidance on safety, efficacy or effectiveness.

A feature article published by the BMJ this month further questions the evidence for widespread influenza immunisation.

Dr Peter Doshi, a researcher at the medical school at Johns Hopkins University in the US, argues public health officials may have exaggerated the risks associated with the disease and overstated the benefits of the vaccine.

In fact, he describes the official rhetoric on influenza in his own country as an example of “disease-mongering”, comparing it with drug companies that try to convince us “we have underdiagnosed epidemics of erectile dysfunction, social anxiety disorder, and female sexual dysfunction, each with their own convenient acronym and an approved medication at the ready”.

Dr Doshi isn’t saying influenza is a figment of the imagination, or that immunisation against it is entirely without benefit, but he is asking for more rigour in assessing the risks and benefits of vaccinating.

One of the problems is that most studies of influenza immunisation have been observational, which obviously makes their findings less reliable.

If healthier people are more likely to immunise, it wouldn’t necessarily be surprising if studies found lower all-cause mortality rates in those who’d had the vaccine.

In fact, some studies have found reductions in all-cause mortality of up to 50% associated with influenza immunisation, prompting Dr Doshi to ask how flu shots could be preventing half of all deaths when the disease itself is only estimated to cause around 5% of deaths during the flu season.

It’s a reasonable question and the only way to answer it would be a properly designed randomised controlled trial conducted in a large enough population to provide reliable mortality data.

There may be other benefits from widespread immunisation, of course. It’s possible this has played a role in preventing flu pandemics: fewer circulating viruses in humans might mean less risk of recombination with animal viruses.

But the real problem is that we don’t have a clear picture of the risks and benefits of influenza immunisation in the general community.

And that’s what an evidence-based approach requires.

And while on the subject of immunisation, congratulations to SBS on their documentary, Jabbed, which aired last night. It was an intelligent look at the issues surrounding childhood immunisation.

Jane McCredie is a Sydney-based science and medicine writer.

18 thoughts on “Jane McCredie: Flu shot doubts

  1. Pamela Wilson says:

    Great piece, Jane. I am a healthy adult and have been having the flu vax for years after my doctor advised that it would help prevent flu transmission to my husband, who suffers with an autoimmune disease. This information will make me think again.

  2. Judy says:

    Interesting & informative info…thank you Jane. As an adult with an autoimmune disease (RA) my GP has decided that all vaccinations in my case can not be done. I had Hep A/B recently for a proposed trip to Vietnam later in the year whereby shortly afterward I developed severe Viral Bronchitis resulting in a hospital stay. So it was decided that due to my condition it would be wise to forgo ALL vaccinations including Typhoid & flu. My partner can fortunately have the lot…therefore, hopefully enabling me to have a better chance of not contracting them.

  3. Robert Hall says:

    I have to say I have changed my mind three times about influenza immunisation over the last 20 years. I am now not so sure about how much it should be used. I am not convinced that there is evidence that influenza immunisation will stop transmission, and I think its effectiveness in preventing symptoms is weak and of short duration. I am convinced, despite the weakness of effectiveness, that there is a worthwhile gain in saving lives and preventing hospitalisations in vulnerable groups. I think the vaccine should be offered yearly to vulnerable groups and not offered to health care workers.

  4. Ron Law says:

    Jane, you say, “It’s possible this has played a role in preventing flu pandemics: fewer circulating viruses in humans might mean less risk of recombination with animal viruses.”

    But what evidence exists that the flu vax reduces the number of circulating viruses… I’m not aware of any…

  5. Jane McCredie says:

    Thanks for the feedback Anonymous, but do please talk to your doctor about your particular situation before making a decision not to immunise. Although the article raises questions about influenza immunisation in the general population, it is not intended to provide clinical advice and particularly not in a situation such as yours where special considerations may apply. With best wishes, Jane.

  6. Jan Sheringham says:

    Jane, while I can’t quote the research document, I am aware that some large employers did studies in Victoria (Ford was one I believe) on their own workers after offering immunization against influenza some years back, using the un-immunized as the control group. The results showed at least 2 interesting findings, both achieving statistical significance.
    – 1. Sick days from reported influenza reduced, and
    – 2. Sick days from ALL respiratory illnesses were also reduced!
    I would infer 2 things from this, and I believe quite safely, that the immune systems of the immunized workers were stimulated, improving their responses to respiratory (at least) pathogens AND that their (admittedly presumed) bouts of influenza were reduced in numbers due to the vaccine. While not a true double-blind trial, since some of those who chose to immunize may have also been in risk categories and would likely benefit in any case, this study has always helped me to convince many of my working patients of the possible benefits of “the jab”.

  7. Gary M. Levin MD says:

    In my experience influenza outbreaks are sporadic, difficult to predict annually, and the antigen profile is labile. So making an accurate vaccine becomes a bit of a cr-p shoot. As you say the cohort should be limited to those whose risks are greatest. Aged, SNF patients, maybe health care professionals,

  8. Alan Hampson says:

    The recent article by Peter Doshi contributes more heat than light to the discussion of influenza and influenza vaccines. With respect to vaccinating older adults, the lack of RCT evidence of protection does not equate to absence of protection and one should not dismiss observational studies out of hand. If you really wish to gain a balanced appreciation of the protective efficacy of influenza vaccines, and make properly informed decisions, I suggest that you read the excellent meta-analysis by Michael Osterholm particularly the concluding paragraphs of the discussion [M. T. Osterholm et al. Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis. Lancet Infect.Dis. 12 (1):36-44, 2012.] and, in addition, the commentary which follows this particularly that by Caplan [A. L. Caplan. Quantifying the efficacy of influenza vaccines Lancet Infect.Dis. 12 (9):656-657, 2012.] which concludes that “Misinterpretation of the study ought not to fuel inappropriate indifference to influenza vaccination.” Those among you who feel that vaccination of health care professionals is unwarranted might like to consult a recent Australian study – N. Macesic, T. C. Kotsimbos, P. Kelly, and A. C. Cheng. Hospital-acquired influenza in an Australian sentinel surveillance system. Med J Aust. 198 (7):370-372, 2013.

  9. Department of Health Victoria Clinicians Health Channel says:

    As the risk of Guillain Barre Syndrome is increased by influenza vaccination, though different authors vary on how great this risk is, it would be interesting to know how many employers are warning their workers of this risk before advertising and promoting influenza vaccinations. It does not seem ethical to promote an intervention without warning of the risk of flu-like symptoms (common) but also of rare but life-changing complications like Guillain Barre syndrome (rare).

  10. Dr Kirsten Baulch says:

    I just hope that the doctors and nurses reading this understand that while the Influenza vaccine is not perfect, it is the best we have available at the moment and that healthy health care workers need to have it annually to help protect their vulnerable patients: newborns, ICU patients, patients with chronic diseases (who only have access to an imperfect vaccine), the immunocompromised. The list goes on. I believe it is our duty of care as health care workers to do what we can to avoid passing on diseases that can be lethal to our patients.

  11. jorge h romero says:

    I think your position is prudent and that mass vaccination can only be addressed after very well controlled studies and not on viruses that are in the process of mutation, as its effects are uncontrollable. if I vaccinate my child against polio I would not doubt it, but if I am forced to vaccinate against influenza I would reject this since the results are very uncertain. Very simple hygiene measures prove more effective than the vaccine and fear has been generated by some producers – their market strategy is perverse or simply reckless by declaring a pandemic. These errors are not allowed when what is at stake is the lives of our children and human beings should never be treated as laboratory guinea pigs.

    [This comment has been translated from the following original comment in Spanish – Editor]

    me parece que su posición es prudente y que la vacunación masiva, solo debe abordarse tras estudios muy bien controlados y no con virus que están en proceso de mutación ,sus efectos son incontrolables si debo vacunar a mi hijo contra la polio no lo dudaría pero si me veo obligado a vacunarlo contra la influenza lo rechazaría puesto que los resultados son muy inciertos y medidas de higiene muy simples demostraron ser más efectivas que la dichosa vacuna preparada a la carrera ante el temor generado por los mismos laboratorios productores – estrategia de mercado perversa o simple imprudencia al declararla como pandemia . esos errores no se permiten cuando lo que está en juego es la vida de nuestros hijos y la tranquilidad de los seres humanos que no deben ser nunca tratados como conejillos de laboratorio cordialmente jh

  12. bruni brewin says:

    Thank you for the article. There was a good documentary on television last night on vaccinations, which also showed the possibilities of adverse affects to some of the population. I had one flue injection because the doctor thought it would benefit someone of my age to have one. I have a fairly good immune system, but this vaccine gave me the worst flue symptoms ever experienced. Haven’t had one since and no flu. A few weeks ago, I got bitten by something which turned into cellulites in my ankle and lower leg. three lots of antibiotics and it looks like it is on the mend but still red and swollen, wearing pull on stockings with leg elevated when I can (not easy). Following this, has brought on flue symptoms with coughing, either due to a reaction to the antibiotics or low immune system. Hopefully with a little TLC and some earlier nights, this will be short lived.

  13. Mark Flynn says:

    This article is timely.
    There is limited evidence for effectiveness of the Influenza Vaccination in the over 65 age group. There is no evidence to suggest that it reduces the rates of hospital admission or serious complications in this group, which is after all the reason we vaccinate in the first place.
    Interventions will need to be justified on the basis of efficacy as we see our health budget stretched. We will also find out position on childhood vaccination undermined if it is seen that we pursue other programs on the basis of limited evidence. The fluvax debacle legacy is alive and well, and may reflect an increasing vaccination recidivism.

  14. Matthew Harvey says:

    Its great to be a fit and healthy adult with no medical problems, isn’t it Jane? Why think about anyone else as long as you’re well, right? We don’t really need to think looking after the wellbeing of anyone else as long as we’re well!! Let them look after themselves, let them have the vaccination or maybe just let have the illness the vaccine is trying to prevent, and deal with the consequences of that; because we’re healthy adults and nothing bad like that will ever happen to us or to anyone we care about.

    What a selfish piece of journalism, Jane. Selfish, short sighted, and dangerous. Right there in the comments you can see why. “I don’t have to get the vaccine to help protect my immune compromised husband,” thinks one. I hope that respondent was trolling, but I know that there are people out there who really only think about themselves and don’t consider any moral social obligations they might have.

    Sure, you may or may not catch influenza, and if you do, then it may not be the death of you. But what about the people you pass it on to? What about the frail elderly and the very young, what about people with genuine medical contraindications to vaccination, and yes, what about those sadly misguided people who believe vaccines are all part of the great evil Big Pharma conspiracy (or some such thing) and refuse to vaccinate themselves or their children as a result?

    Yes, there are clear social benefits (and economic benefits, as another poster pointed out), even if the direct benefit to yourself is not immediately obvious. So, can I kindly suggest you take a little more care in advice/opinions you disseminate? You might just be helping some one else!

  15. Andy Wellwood says:

    Wow, attach and destroy previous reader, that was harsh!!! I don’t believe Jane was saying for everyone not to immunise but she clearly doesn’t believe that it’s been studied enough, which I agree. The hardest part is how do we study the effects of not immunising sick people when that is perhaps what’s keeping them alive through the flu season and that is what you would have to do, amongst other things, to get a true picture. You need a conrol group of sick elderly giving them a placebo to see if it does work, once again amongst other things, or if it doesnt’t. Who wants to do that to our elderly and sick/immune compromised? Certainly not me. I get immunised every year just in case it works and therefore I don’t pass it onto my elderly parents, my kids or work collegues and friends. If it doesn’t work I’ve wasted my money, if it does I may have saved someone’s life, perhaps even my own.

  16. Joe Kosterich says:

    In any other industry the claims made about the benefits of a flu vaccine would be need to be backed up by some evidence or else could not be made. When the evidence is dispassionately examined the flu vaccine does not save lives”nor reduce hospitalisation or even days lost from work. If naturopaths made comparable claims for what they offer we would say “where is the science?”
    In promoting flu vaccine in the way it is promoted we are no better than snake oil salespeople

  17. Sue Ieraci says:

    Jane is right about the good quality evidence, but two important factors need to be recognised. First, it’s not possible to do the type of testing one might do on other pharmaceuticals, because the influenza viral strain changes seasonally. SO, efficacy is often measured by the demonstration of a level of specific antibodies rather than clinical outcomes. Secondly, we need to think differently about “ordinary” seasonal flu vs pandemics. We can anticipate pandemics because of what happens in the northern hemisphere – so limiting transmission by widespread immunisation might be effective in limiting the size of a pandemic, even if it makes little difference to the overall health of well young adults and older children. Finally, we might consider the position of the public health specialists trying to work out what to do when the next pandemic looms – they are held accountable for their actions in a very public way.

  18. Alison says:

    I’ve heard many doctors interviewed who refuse to get the flu vaccine because it is not as effective as it is made out to be.  Dr Oz (the famous tv doctor) when interviewed was promoting the fly vaccine, however when he was asked about his own family he admitted that his wife and children were not going to receive the vaccine.  Simple hygiene measures and people staying home when they are sick instead of ‘going to work like a trooper’ would go a long way in preventing the spread of flu.  I myself developed erythema multiforme all over my body, followed by bacterial infections from the broken skin, after I received a vaccine as a teenager (my parents thought it was a good idea) and have had this recurring constantly for the past 6 years after vaccination.  If I had my time again I wouldn’t get the vaccine as I am constantly suffering now.

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