Advice on Flu Vaccination from NHS Direct site

[Ivor the Engineer]

I don't think there's much controversy over the effectiveness of a well-matched flu vaccination in healthy adults.

The hotly debated question is how effective the vaccine is in the elderly and the very young.

 

[Furcifer]

I'm sure that available supply is a very large factor.

For example, recently here in the US there was a shortage of the flu shot and it was offered first and foremost to those with an actual medical need. Several clinics local to myself actually ran out and had to send patients elsewhere.

I don't really think that "you shouldn't get it unless you actually need it" is an unreasonable stance to take on medical care. Especially when the situation is such that if you provide an item to someone who doesn't need it, someone who does need it may have to go without, and going without may result in a long (and expensive) hospital stay, or even death.

Last year, or the year before, I was in Vancouver and I seem to recall Seattle Physicians were sending at risk patients North for the shot. I never understood how Canadians could anticipate the number of at risk patients better than the Americans? I thought it was just a case of us being more sensible than or impressionable Southern counterparts. From the looks of the posts here the consensus is in favour of the shot. I don't find myself in one of the identified at risk groups so I never considered getting the shot. I'm surprised at the number of people here, not at risk, considering the shot. Is this a correct observation?

 

[Skeptic Ginger]

It is an issue with flu vaccine supply. Those at risk should get it first.
If you want it, go ahead.
Since I work in healthcare, I already got it a week ago.

There is an abundance of vaccine this year in the US so I assume there is plenty to go around elsewhere. Prioritizing should not be an issue.

This is probably information that was already covered in this thread but I haven't had time to read all the posts yet.

First, a little history. In 1976 when the first mass flu vaccine campaign was initiated and there was concern a serious side effect was occurring, the risk/benefit ratio was estimated to favor giving the vaccine to high risk persons but not low risk persons. Later it was found to be an extremely rare side effect and only occurred in a couple years of the 30+ years the vaccine has since been given. Now the risk/benefit ratio favors giving the vaccine to everyone. Even people with no known risk factors die from influenza and its complications every year. People with risk factors die in the thousands.

Ivor likes to assess cost/benefit rather than strictly risk/benefit. The NHS may very well feel that not enough lives are saved per doses given in healthy populations.

But the CDC in the US has taken a different approach. They have examined studies which showed health care workers were a significant source of influenza in hospitalized patients. Thus the recommendation to vaccinate all health care workers has been stressed in this country.

With an increase in vaccine supply, that was expanded to include all care givers or household members of persons with risk factors.

This year they have, based on evidence, taken that concept even further. Some studies indicate that children are a big reservoir and amplifier of influenza disease in the community. So this year all children under the age of 18 are on the recommenced list for flu shots.

So, the US list of people who should get flu shots now includes all children, all pregnant women, all people over age 50, all people with significant health problems and all people who have substantial contact with people who have significant health problems and healthy people over age 50.

Those who are left out of those groups are listed as, "all persons who want to reduce the risk of becoming ill with influenza or of transmitting it to others".

Target Groups for Vaccination

Influenza vaccine should be provided to all persons who want to reduce the risk of becoming ill with influenza or of transmitting it to others. However, emphasis on providing routine vaccination annually to certain groups at higher risk for influenza infection or complications is advised, including all children aged 6 months--18 years, all persons aged >50 years, and other adults at risk for medical complications from influenza or more likely to require medical care should receive influenza vaccine annually. In addition, all persons who live with or care for persons at high risk for influenza-related complications, including contacts of children aged <6 months, should receive influenza vaccine annually (Boxes 1 and 2). Approximately 83% of the United States population is included in one or more of these target groups; however, <40% of the U.S. population received an influenza vaccination during 2007--2008.

Then there is this matter of increasing risk of MRSA following influenza:

Deaths among children that have been attributed to co-infection with influenza and Staphylococcus aureus, particularly methicillin resistant S. aureus (MRSA), have increased during the preceding four influenza seasons (70; CDC, unpublished data, 2008). The reason for this increase is not established but might reflect an increasing prevalence within the general population of colonization with MRSA strains, some of which carry certain virulence factors (71,72).

Severe Methicillin-Resistant Staphylococcus aureus Community-Acquired Pneumonia Associated with Influenza --- Louisiana and Georgia, December 2006--January 2007

 

[Skeptic Ginger]

Last year, or the year before, I was in Vancouver and I seem to recall Seattle Physicians were sending at risk patients North for the shot. I never understood how Canadians could anticipate the number of at risk patients better than the Americans? ...

This is a false assumption. The reason Canada had vaccine in the 2006-07 flu season and the US had a shortage was each drug company produces vaccine specifically approved for the country by that country's FDA. Half our vaccine supply was spoiled by contaminants in the vaccine production cutting the supply in half. It had nothing to do with anticipating need.

The shortages prior to 2006 were because many manufacturers left the market. Last year the vaccine took longer to make but eventually there was enough and in fact millions of doses were wasted. This year there is plenty of vaccine and new manufacturers are in the market.

 

[Skeptic Ginger]

I don't think there's much controversy over the effectiveness of a well-matched flu vaccination in healthy adults.

The hotly debated question is how effective the vaccine is in the elderly and the very young.

Except you are leaving out the benefit of disrupting the spread, thus protecting more people regardless of how effective the vaccine is in every individual.

 

[Eos of the Eons]

http://www.cbc.ca/canada/british-columbia/story/2008/10/22/bc-fku-shot-paralysis.html

This one is making the rounds in emails.

Although the disease is in remission, he is not expected to make a full recovery, and the chronic condition could return at any point in the future.

What exactly puts people at risk for Guillain-Barré? Can the risk be tested for?

 

[Skeptic Ginger]

http://www.cbc.ca/canada/british-columbia/story/2008/10/22/bc-fku-shot-paralysis.html

This one is making the rounds in emails.



What exactly puts people at risk for Guillain-Barré? Can the risk be tested for?

This rare condition appears to follow a number of viral infections and is suspected to be an autoimmune reaction. It is not certain that an infection always precedes the initial onset. Flu vaccine is only rarely implicated. Other vaccines may also precipitate the reaction but that isn't sure yet either. There is no test for risk factors.

The myelin sheath of the nerve is damaged or destroyed and nerve impulses cannot transmit in their normal speed.


As for the article in your link, lots of people blame their flu shot even when it clearly is unrelated. There are websites promoting the shot as the cause and people like to have someone or something to blame and/or give them a cause to fight against in response to their personal tragedy. The man in the story fits a possible link between vaccine simply because it occurred with a couple weeks of his getting the shot. But studies looking at background rates of GBS and rates after flu shots show less than 1 excess case of GBS for every million vaccine doses and then only in some years.

 

[Ivor the Engineer]

Except you are leaving out the benefit of disrupting the spread, thus protecting more people regardless of how effective the vaccine is in every individual.

Which is why I suggested a few seasons with near-universal influenza vaccination would indicate how effective the vaccine is. With the recommendations from the CDC each year becoming ever more inclusive, this should be possible within a few years in the US.

 

[Capsid]

Which is why I suggested a few seasons with near-universal influenza vaccination would indicate how effective the vaccine is. With the recommendations from the CDC each year becoming ever more inclusive, this should be possible within a few years in the US.

Which near-universal vaccine are you thinking of? I didn't think there was one.

ETA: aah, you mean vaccinate everyone, so you meant global not universal.

The hotly debated question is how effective the vaccine is in the elderly and the very young.

I thought it is well understood that it is not as effective in those groups.

 

[Ivor the Engineer]

Which near-universal vaccine are you thinking of? I didn't think there was one.

ETA: aah, you mean vaccinate everyone, so you meant global not universal.

Not necessarily global, but certainly everyone (ETA: 90%+) in the US.

I thought it is well understood that it is not as effective in those groups.

'Not as effective' *may* be an understatement.

http://ajrccm.atsjournals.org/cgi/content/abstract/178/5/527

Rationale: Observational studies suggest a 50% mortality reduction for older patients receiving influenza vaccination; some deem this magnitude of benefit implausible and invoke confounding by the "healthy user effect" as an alternate explanation.

Objectives: To evaluate unrecognized confounding by hypothesizing the presence of a 50% mortality reduction with vaccination for patients with pneumonia outside of influenza season.

Methods: Clinical, laboratory, and functional data were prospectively collected on 1,813 adults with community-acquired pneumonia admitted to six hospitals outside of influenza season in the Capital Health region (AB, Canada). Vaccination status was ascertained by interview and chart review. Outcome was in-hospital mortality. Influenza-vaccinated patients were matched to a nonvaccinated control using propensity scores, and then multivariable regression was used to determine the independent association between vaccination and mortality.

Measurements and Main Results: The cohort consisted of 352 vaccine recipients and 352 matched control subjects. Most (85%) patients were 65 years or older, 29% had severe pneumonia, and 12% died. Influenza vaccination was associated with a 51% mortality reduction (28 of 352 [8%] died vs. 53 of 352 [15%] control subjects; unadjusted odds ratio [OR], 0.49; 95% confidence interval [CI], 0.30–0.79; P = 0.004) outside influenza season. Adjustment for age, sex, and comorbidities did not alter these findings (adjusted OR, 0.45; 95% CI, 0.27–0.76). More complete adjustment for confounding (e.g., functional and socioeconomic status) markedly attenuated these benefits and their statistical significance (adjusted OR, 0.81; 95% CI, 0.35–1.85; P = 0.61).

Conclusions: The 51% reduction in mortality with vaccination initially observed in patients with pneumonia who did not have influenza was most likely a result of confounding. Previous observational studies may have overestimated mortality benefits of influenza vaccination.

And before Skeptigirl has a go at me, this may mean it is more important for those at low-risk of complications to get vaccinated so they do not spread it to those for whom the vaccine does not provide effective protection.

 

[Skeptic Ginger]

...
And before Skeptigirl has a go at me, this may mean it is more important for those at low-risk of complications to get vaccinated so they do not spread it to those for whom the vaccine does not provide effective protection.

Both need the vaccine. I didn't want to get into this because I don't have time to dig up all the studies that showed positive benefit from flu vaccine in high risk populations. The studies with positive results overwhelm the studies which found no clear benefit. I am tired of arguing this issue with people who cherry pick the handful of studies that failed to show a benefit from flu vaccine. (yes that means you)

In patients in whom the vaccine is not effective enough to prevent infection, the evidence is clear they have milder disease. So the best practice at the moment until further research says otherwise is to vaccinate both the high risk populations and the spreader populations.

And that still leaves my recommendation the remainder get vaccinated. While risk of deadly outcome from flu is rare in low risk populations, it is not zero and it is higher than the risk from complications from the vaccine. So if you don't consider dollars spent per lives saved, the flu vaccine benefit outweighs the flu vaccine risk for everyone.

 

[Ivor the Engineer]

No doubt you will be able to prove your point when the number of deaths in the US from seasonal flu plummets because enough people have been vaccinated to provide heard immunity.

 

[Skeptic Ginger]

When the levels of vaccine coverage rise, yes, I am confident the data will support the hypothesis. Why wouldn't it?

 

[Ivor the Engineer]

When the levels of vaccine coverage rise, yes, I am confident the data will support the hypothesis. Why wouldn't it?

Because many of the current studies of effectiveness are contaminated by a "healthy user effect"?

If the data does not support the hypothesis would you change your mind?

 

[Skeptic Ginger]

Because many of the current studies of effectiveness are contaminated by a "healthy user effect"?

If the data does not support the hypothesis would you change your mind?

I am an evidence based believer. But the problem with your prediction is that I have already been down this road and came back to my original position. When some of these "flu shots don't work" articles began surfacing, I read them all. And I continue to do so.

But they were counterintuitive so I didn't just look at those studies. I looked at many others which did show the clear benefit of flu vaccinations. I have posted links to many of them as have others in this forum.

It is you, Ivor, who continues to ignore the preponderance of the evidence as it currently stands.

 

[Beth]

For what it's worth, conversations like these are helpful in just reminding us all about the option of getting vaccinated. I went ahead and got the flu vaccine a couple of days ago - primarily because I currently have a heavy work load and having to take several days off if I become ill would cause problems I'd rather avoid than deal with. It may be a selfish reason, but I'm glad the option is available to me. My arm is still sore though - ouch.

 

[Rolfe]

I'm going to get mine tomorrow.

I sort of sneak into the DoH recommendations list (quoted by Ivor)

iv).... those who are the main carer of an elderly or disabled person whose welfare may be at risk if the carer falls ill. This should be given on an individual basis at the GP’s discretion in the context of other clinical risk groups in their practice.

Last year I phoned the practice to arrange a flu jag for my mother. I remarked that my employer has a habit of announcing that I should have one myself due to the fact that I'm involved with avian influenza screening, but they often don't get round to that until the main vaccination avaliability is past. So did they want to do me too while they were at it?

I was asked, was I my mother's carer? I said that was maybe pushing it a bit, she manages most things for herself and usually makes the evening meal for both of us. I was then asked, does your mother live with you? I said yes. I was then left in no doubt that they believed anyone who had their 92-year-old mother living with them should be vaccinated anyway, regardless of which of them did the cooking. "We don't want you bringing flu home and giving it to your mother," were the exact words.

So tomorrow I intend to trot Mum up to the vaccine clinic, and let them do me while they're at it.

Rolfe.

 

[Physiotherapist]

For what it's worth, conversations like these are helpful in just reminding us all about the option of getting vaccinated. I went ahead and got the flu vaccine a couple of days ago - primarily because I currently have a heavy work load and having to take several days off if I become ill would cause problems I'd rather avoid than deal with. It may be a selfish reason, but I'm glad the option is available to me. My arm is still sore though - ouch.

I agree that conversations such as these are good for reminding everyone of their options. However, having weighed up all the evidence, I have decided not to have the vaccine, not being in the at risk category.

 

[Ivor the Engineer]

Resistance is futile. You will be inoculated.

 

[Eos of the Eons]

I agree that conversations such as these are good for reminding everyone of their options. However, having weighed up all the evidence, I have decided not to have the vaccine, not being in the at risk category.

In your work, are you around anyone in the at risk category? Would you consider getting the shot to prevent the spread to those in the at the risk category? Herd immunity would be nice, but would that ever be possible?

These are the questions I've had since my hubby, who works around children and seniors in a customer service setting, declined a free flu shot at work on the grounds that "he never gets the flu anyways". So, if he never gets sick, is he going to spread it? What are the chances he's a carrier?