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IN the midst of this year’s unusually long influenza season, high number of confirmed cases and media attention on the spate of influenza-related deaths in residential aged care centres, the President of the Australian Medical Association Dr Michael Gannon proclaimed that it was “utterly irresponsible” for aged care workers not to be vaccinated against flu. Moreover, Health Minister Greg Hunt has promised their mandatory vaccination from next season.
In my opinion, calls for flu vaccination of people who are fit and healthy are horribly misguided.
There is no conclusive evidence that vaccinating health care workers meaningfully benefits patients, with one recent review suggesting that up to 32 000 health care workers would need to be vaccinated to prevent a single death in health care facilities generally, and another finding no benefit in the number of cases, complications, or all-cause mortality in patients of long term aged care facilities specifically.
Influenza is highly infectious before the carrier even feels sick, and the virus can survive on doorknobs for up to 48 hours. Should facilities be requiring all visitors and patients to be vaccinated before entering? Do we really think that outbreaks in health care settings could otherwise be prevented or contained when there is no herd immunity in the general population?
The influenza vaccine has serious problems that have (rightly) kept it off the normal vaccination schedule. It is funded for, and targeted to, the most medically vulnerable people because that is when the benefits specific to those vaccinated clearly outweigh the risks.
However, the flu vaccine is not great at preventing influenza infection. The choice of which flu virus strains to cover each season sometimes turns out to be wrong, while vaccine effectiveness is typically less than 50%, with a waning protection that lasts for far less than a year, often for only a few months (here and here).
This season, early indications are that the vaccine’s effectiveness could be as low as 15% in Australia, due in part to antigenic drift of the predominant H3N2 strain since it was selected for the formula early in the year. As a result, we have had an unusually high number of influenza A cases even among those who had been vaccinated.
How would any (future) herd immunity not be as fleeting as vaccine effectiveness?
Getting the flu vaccine regularly simply postpones susceptibility to the covered strains and may even further reduce vaccine effectiveness, while actually coming down with the flu when healthy results in decades’ (often lifelong) protection. Getting the flu infection also results in further protection against dozens, potentially hundreds of related strains (as in the case of the 2009 influenza H1N1 pandemic), while vaccination has been only sporadically and inconsistently found to confer a much weaker, short term cross-immunity. Indeed, prior infection with related influenza A strains decades earlier is believed to be the reason that the elderly were not at highrisk to the 2009 strain in the first place (here, here, here, here, and here).
Moreover, there is a poor understanding of the risks of mass vaccination on influenza strain selection, virility, and vaccine resistance — which may be compared with the resurgence of whooping cough in the general population, and its association with waning immunity to the new predominant pertussis strains increasingly seen in vaccinated people, since the switch to acellular formulas in the 1990s (here and here).
The expected outcome of regular flu vaccination in healthy people is therefore increased morbidity later in life, when protection is needed the most (ie, after not having had many of the “common” influenza infections for decades, there is little resistance to them or their relatives once people are old and frail), with unknown risks to future vaccine effectiveness and from induced strain selection in a highly mutating class of viruses.
Forced medication should have a clear and significant expected net benefit. Influenza vaccination simply does not fit the bill. For long term health care facilities such as nursing homes, it makes sense to improve vaccine responsiveness in the patients themselves (eg, through improved rates, timing, dosage and adjuvant formulation), not to coerce an increased risk of morbidity onto health care workers.
Dr Randal Pittelli is a full-time rural generalist locum with a special interest in aeromedical retrieval. Before medicine he conducted research in behavioral toxicology following a BA in mathematics.
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The H3N2 strain that wreaked havoc this year in Australia has continued to mutate as it hits the US, with vaccine now only 10% effective at the start of its flu season:
http://www.dailymail.co.uk/health/article-5148911/This-years-flu-set-one-worst-ever.html
Thanks for the article.
Your thorough and succinct summary of the evidence is timely, to say the least.
However while we strive to practice evidence based medicine, I believe that the phenomenon of “evidence based politics” would take us all by surprise- more so than a talking duck!
More seriously though, as already pointed out, health dollars are scarce, and the evidence is not there for this intervention.
Where is the Minister taking his advice/receiving his instructions from?
Thankyou. This article also is in step with scientific studies that have found the same results. Eg – “Moreover, there is a poor understanding of the risks of mass vaccination on influenza strain selection, virility, and vaccine resistance” See Cowling’s study – https://academic.oup.com/cid/article/54/12/1778/455098/Increased-Risk-of-Noninfluenza-Respiratory-Virus
Thanks, Prof Del Mar — I just read and enjoyed your BMJ Opinion.
Geoffrey, I’m puzzled by your comment, as I wouldn’t think risk analysis has anything to do with God. A fundamental criterion to justify forced or coerced medication, based on the ‘cautionary principle’, is that it have known net benefit (at the very least) to the population, additionally with minimal risk to the individual.
Flu vaccine is not part of the normal vaccine schedule in no small part because it is not understood whether there would be net benefit to healthy people, given that it is well-established that getting the flu is more protective than getting flu shots (and there is some evidence to suggest that getting the vaccine even a couple years in a row makes the vaccine less effective, further increasing risk later in life…what about after 20 years of vaccination?). It has also not been established whether those *unvaccinated* get any cross-proteciton, some justifiable degree of herd immunity being part of the cost-beneft calculus (I should note that there is some evidence of short-term cross-protection to the unvaccinated using *live attenuated* flu vaccine, e.g., from a Russian study conducted on school children decades ago, but even there, and assuming the increased side-effect profile of attenuated vaccine is acceptable, no risk analysis of net benefit/harm over the longterm, given there is evidence of longterm harm).
I tend to find the argument, “What’s your qualification?” rather specious, akin to an ad hominem — the readily available evidence and the rationale supplied to make the arguments are either convincing, or they are not. Either way, inquiry/debate about scientific research and public policy, like anything else invites counter-argumentation through…a critique of the evidence and the rationale, not an interrogation of the messenger. I.e., if you take issue with my arguments, point out where, and I shall rebut or concede.
I would question the writer’s qualifications in this matter. Is he playing God?
I have been told that a mother should be vaccinated against whooping cough in late pregnancy and that is the most effective protection tfor young bubs
could anyone comment not the fact that any family member who comes in contact with new babies at home have to be vaccinated against whooping cough – what happens if child is taken shopping? or is the child deprived of all other human contact until it begins its vaccination journey?
What is the scientific status of herd immunity? everyone throws this around as a fact.
Can anyone write a concise article – – but not a public health ‘expert’ they push their barrow continually on TV.
Yes indeed. I thought that nowadays even the AMA shared the commitment to advocating for evidence-based health policy: health dollars are always scarce, let’s spend them where they will do most good.
And at risk of being shot down, I will pose the question many must be too scared to ask.
How many of us doctors want to have our lives prolonged in “God’s Waiting Rooms”, should we be unfortunate enough to live so long as to become aged and debilitated to the extent we have to be put away there?
pneumonia, and the influenza which preceded it, used to be “the old person’s friend”. Now it is an opportunity for a transfer to hospital and IV antibiotics.
do we have to have blanket prescriptions of influenza vaccine for all? Or could we have a considered decision, by nursing home residents themselves when possible, as to whether extraordinary life prolonging and preserving measures should be instituted.
No, I am not seeking to play god and make the decision for others. On the contrary I hope to die with dignity, preferably allowing nature to take its course BEFORE losing all my faculties and control of my bodily functions, and I would like that opportunity to be available to all.
Now if only I can remember where I stashed the escape kit when I need it…..
Thank you Dr. Pitelli for some common sense.
I find it hilarious (in a dark way) whenever I read an article on this year’s horror flu season, that reports the massive number of flu cases, a huge number of which occurred in people who had received the flu vaccine….and then at the end emphasises “it’s not too late to get your flu vaccine!”
The authors of these articles seem completely oblivious to reality.
Quite agree: we have commented on this issue here:
http://blogs.bmj.com/bmj/2017/10/04/chris-del-mar-and-peter-collignon-another-seasonal-influenza-epidemic/
It’s hard to understand why public health experts — and others — promote influenza vaccine so hard.