Recently the Centers For Disease Control released an advisory about cases of influenza that appear to have genetically drifted—enough to reduce the effectiveness of the vaccine. If true, why is the CDC still recommending unvaccinated people get a flu shot? What good is the vaccine this year and why does this happen? The obvious self-serving question is “Why should I get an annual flu vaccine if it is not going to protect me?”
What does this development mean for public health both this year and long term? What does this complication really say about the benefit of the annual influenza vaccine?
Most people tend to think of any medical treatment in binary ways. Either it works or it doesn’t; and the treatment is safe or it isn’t. That’s a misrepresentation of vaccines and of medical treatments more generally. The vast majority of medical treatments are actually nuanced and complicated by risks and benefits. Medical treatments need to be explained, complications vetted, and benefits reviewed. Public health is even trickier than personal health because it affects everyone, not just the individual. A heart attack won’t spread to others, but the measles will. The risks and benefits of the individual versus society need to be considered. Public health risks and benefits require an intricate balance between individual and public health needs.
Influenza’s occasional genetic drift is a well-known limitation of the vaccine and it gets a lot of play in the anti-vaccine community. That group has a systematic and ideological need to magnify the deficits and minimize the benefits of vaccines. When a vaccine provides less than perfect coverage, anti-vaccine advocates are eager to point out the problem. Unfortunately, this has become a headline for the general media as well. Complicated discussions about medical treatment are vulnerable to ideology and over-simplification. Ideologues prefer binary answers because it makes arguments easier for them to present and harder for others to defend. Ideological standpoints have the luxury of demanding binary answers because they don’t have to operate in the real world. Unfortunately, the general public also likes binary answers.
Influenza vaccines are the poster child for ideological attacks. Influenza can be deadly, but due to a variety of factors it often is not. Still, approximately 50,000 people die annually from influenza. Deaths related to the flu often result from complications associated with the disease. Bacterial pneumonia is closely linked as a complication associated with fatality. Seasonal flu is commonly deadly to the weakest members of our society, the old, the infirm, and the very young.
Most people consider getting the flu vaccine as a personal health decision: Do I want to protect myself or do I want to gamble? That thought process ignores the public health benefit of the flu vaccine. The vaccine is not just a binary set of choices—good for me/bad for me. There is a societal benefit. Its greatest benefit is in protecting those whole can’t receive it or respond poorly to the vaccine. Realistically, healthcare workers are asking you to take a shot in the arm so that you protect not just yourself, but also grandma, little cousin Jeffy, and the guy in the wheelchair on line at the coffee shop. Yes, there is a benefit. And even if you are young and healthy and not vulnerable to the more serious dangers associate with flu, the disease will make you miserable. All too often, people look at this issue through the myopic selfish view. If you focus on the flaws and limitations of the vaccine you can easily use that to prop up a desire to avoid a shot. Ignorance, misunderstanding, anti-vaccine propaganda are the biggest problems in promoting the flu vaccine.
Anti-vaccination proponents look for flaws, focus on complications, and ignore benefits. The most reasonable end of the anti-vaccine movement contends that the risks of vaccination are gigantic and the benefits minuscule. The radical, crazy end of the anti-vaccine movement feels that all vaccines are an inherent danger foisted on the public by greedy corporations, backed up with governmental force. Vaccines are accused of causing brain damage, death, and all sorts of mystery illnesses, and such claims are promoted with the narrative that they’re making a small elite very rich. It’s a passionate if discordant viewpoint, and it’s completely disconnected from reality. For example: flu vaccine is not profitable. Most vaccines are, in fact, government subsidized, since a healthy public is beneficial to the whole nation and vaccines are expensive to develop but yield little to no profit. I am personally amused by the cognitive dissonance in the Big Pharma conspiracies. In one conspiracy, pharmaceutical companies want to make you take a cure like the measles vaccine because it is profitable, while other conspiracies focus on suppressing patent medicines or herbal curatives because they are not profitable.
Dark, money-driven conspiracies and post hoc hypotheses about how Big Pharma is out to get us are just part and parcel of anti-vaccine rhetoric, so it is unsurprising that when a real issue pops up they flock to discredit the vaccine. This year we are suffering from one of the vaccine limitations. Due to antigenic drift a widely circulating strain of flu has mutated just enough that the current vaccine is proving to be less effective than expected. The CDC’s alert last month released, indicating that one strain has changed just enough to make influenza cases serious in the vaccinated, was a boon for anti-vaccine advocates. But, as I stated earlier, the reasons for this problem are clearly known.
Dr. Joseph Albietz MD, at Science-Based Medicine, writes:
Influenza A is a versatile virus with many distinct serotypes. Most people are familiar with human, bird, and swine influenza, but influenza is in fact able to infect a large number of avian and mammalian species on the planet. It is important to realize that these viruses are not, despite their name, truly species specific. Random mutations and natural selection frequently create new strains of influenza capable of infecting other species; in its ability to mutate influenza is unparalleled.
Influenza is an RNA virus encoded by just 11 genes on 8 separate RNA segments. With only 11 genes, you can see that influenza is a relatively simple virus. […] This means that it makes more transcription errors, a lot more. One in every 1000-10,000 nucleotides is mis-transcribed by influenza, giving it one of the highest mutation rates known. Some of these errors are neutral and have no effect on the virus. Some are detrimental and will result in a defective virus. But some of them are beneficial. […] Every so often a transcription error will change the [virus] just enough so that it cannot be recognized by the immune system. Voilà, we have a new strain of influenza, and your immune system has to start from scratch. This is the concept of “antigenic drift,” and it is responsible for the variation in influenza strains we see every year.
But that is only part of the story. Do you remember the 8 separate RNA segments? If a cell is infected with a single strain of influenza this is an inconsequential factoid. However, if two dissimilar strains of influenza co-infect the same cell, those 8 RNA segments become exceedingly important. Up to 256 unique combinations can result from that one pairing. Instead of a slow drift in the surface markers of the circulating influenza strains, suddenly we have a major re-assortment, and a brand-new strain is created. This is “antigenic shift,” and this is how the 2009 (H1N1) strain was born.
Influenza is not a single virus that changes over time, but is instead a family of viruses that to a greater or lesser extent co-exist and are constantly changing. Were it stable, your immune system would be able to establish meaningful immunity. Until we discover a way to make your immune system target a stable section of influenza, our best hope is to constantly redesign our vaccines against a moving target.
Dr. Albietz’s synopsis is very thorough. Sometimes it happens that the “moving target” gets away from us. This year, one circulating strain of the flu has mutated just enough to make the CDC recommend that healthcare providers still treat the vaccinated like the un-vaccinated, meaning that they aggressively treat at-risk patients with antivirals if the patient is flu positive.
The anti-vaccine response is, as expected, ecstatically pointing out this problem. Worse, the regular news media has run with fear-mongering headlines, such as one by Time Magazine, telling us that the flu vaccine has no effect this year. This is a double blast of misinformation. Public vaccination programs are a constant battle. This sort of hysterical misunderstanding is the worst kind of setback, especially to health departments who are promoting public vaccination in peak season.
The reason why anti-vaccine rhetoric sounds so plausible to under-informed people is because patients like simple, definite, results. Actually, that is an infinitesimally small part of medical knowledge and treatment. Still, it is the public’s perception that good medicine is precise and predictable. It can be frustrating to providers. Personally, I like to call it “penicillin syndrome.” My imaginary syndrome is an impossibly high expectation about medical care that we develop in childhood. It is a personal experience that carries over to our adult attitude about medical care. For example: 37% of children get strep throat at some point. From a child’s perspective, they take ill and suffer with throat pain, fever, etc. Then they see a pediatrician he gives them a pill or liquid. In a day they begin to feel better, in 72 hours most are completely recovered. From their perspective, the medicine fixes the problem like it never occurred. That experience can happen multiple times over our childhood. Those enduring experiences tend to remain our gold standard for medical care going forward. It commonly set an impossibly high expectation for infectious disease treatment, and all medical treatment. Hence my moniker Penicillin Syndrome.
Conversely we can have an equally negative experience related to vaccines. Children who get vaccinated receive a semi-traumatic shot that makes them feel slightly sick for awhile. Parents and doctors tell them that there is a future benefit, although in a vague sort of way. That is hardly the positive experience of the anti-biotic treatment.
Anecdotally, as a provider, I have no problems convincing people to take antibiotics, yet struggle getting 50% of my patients to get vaccinated. This expectation is difficult to overcome. The vaccine narrative is complex for seasonal flu and the benefits are less concrete than a tetanus shot. For many people influenza, and its vaccine, is where their experience is at odds with medical advice.
Combining these two issues—lofty expectations for medical care with a nuanced and complicated treatment—makes promoting flu vaccines hard work. Panicked headlines and sound bites telling people it doesn’t work is not helpful and probably harmful. Education becomes a nightmare, and as a provider it can tend to wear you down after awhile.
The influenza vaccine is not a single treatment—it is a methodically derived public health plan. That plan has overlapping effects. If you remove one part of the structure it hangs together. That is how it is meant to work. The influenza vaccine is not simply a personal treatment with only personal risks and personal rewards. The plan is structured to accommodate the shortcomings of the vaccine when given to a community. You do have to treat sick individuals who were vaccinated more seriously, maybe even with anti-virals, which is a controversial decision.
That does not mean that there is no benefit to the influenza vaccine, even for an individual. There are other circulating strains that you are well protected from. If you’ve been vaccinated and still catch the mutated strain, the infection will be less severe and it is harder to pass to those that can’t vaccinate. Flu shots also have a cumulative benefit: every year you are teaching your immune system, and it doesn’t easily forget. A vaccine you received 10 years ago may help protect you from this strain. People who systematically get the vaccine every year seem to be better protected from this strain than those who don’t. The public health benefits are hard to perceive for the individual, especially since absence of illness is not as obvious as its presence. But vaccines protect typically the individual, and (perhaps more importantly) they protect others through herd immunity. Herd immunity can seriously inhibit the spread of a virus before it can reach those that cannot be vaccinated due to allergies, health issues, or age (under 6 months). Those benefits all decline precipitously with declining numbers of vaccinated individuals.
That is the real rub about the superficial nature of spurious news reports. Instead of informing people they perpetuate misunderstanding by narrowly focusing on the individual’s benefit. If everyone, I mean everyone, got the vaccine every year, in a few decades you would see a large decline in flu deaths and epidemics. We would have taught all our immune systems a good lesson to help them fight new strains. That’s a win-win for public health, rather than a social failure. Superficial discussions never broach the long-term or societal benefits.
Questions like “Do I want it or not?” or “Why get it if it doesn’t work?” are not the real questions. Those are the questions that anti-vaccination people want you to ask. You are now armed with the knowledge that the vaccine is not all about one shot-one person—it’s about public health. You know that even if the flu mutates you are better protected than the unvaccinated. If you get the flu vaccine every year you are even better protected than the intermittent vaccine recipient. The lesson is simple, get the flu shot every year.
The flu vaccine is not a useless treatment and it is not a personal treatment choice; it is a choice that affects the health of everyone. So refuse to be selfish and don’t make decisions based solely on your own self benefit: get the vaccine and get it every year and Gram Gram and little Jeffy will thank you.