I had the flu last week. Here’s the e-lament I managed to tap out on my phone in a shameless plea for sympathy: “I am so sick it hurts to pee or breathe or think or move my eyes. Whaaaaa whaaaaa whaaaaaa!” The sage advice I received from my BFF in response? Swing a chicken over your head.
I decided against taking her suggestion; I was too achy to swing a chicken over my head. But the worst of the flu moved through in about five days. Yes, I’m still blowing my nose and I’m tired but otherwise okay.
And no, I didn’t get vaccinated. I’ve never gotten vaccinated for the flu. And I don’t recommend it to my patients, but I don’t tell them not to get it, either. Personally, I tend to lean toward the conservative side for vaccines, erring on the side of less-is-more. (There may be reason for concern around excess vaccination in terms of increased risk for allergies, autoimmunity and other complex, chronic conditions.1,2) But should I get it? Should I recommend it? Will it benefit?
In 2010 the CDC, but not the World Health Organization, decided healthy adults needed to be vaccinated. And by 2020, the CDC will want the lot of us (except those six months or younger) getting our annual jab.3 No other country is recommending influenza vaccination to healthy adults.
But here in the US, the urgency to be vaccinated for seasonal influenza has reached such a fevered pitch that some health care workers who choose against vaccination risk being fired or laid off. No longer will wearing a mask and washing hands — both of which effectively interrupt transmission — suffice in some settings.4
SO, armed with the experience of being a full-on participant in the 2012-2013 influenza epidemic, I dived into the research on the state-of-the-state of influenza vaccines. Yup. As I lay in bed, achy and chilled, I tapped out little search queries between cool sips of water….
Here’s what I found: If we all believe the CDC regarding the influenza vaccine, will it become true?“The flu vaccine is the best way to protect against flu.” Nancy Cox, PhD, Center for Disease Control Influenza Division chief.5
“Results for the 2012–13 season indicate that vaccination has reduced the risk for influenza-associated medical visits by approximately 60%, demonstrating the benefits of influenza vaccination during the current season.”6
But, “In the relatively uncommon circumstance of vaccine matching the viral circulating strain and high circulation, 4% of unvaccinated people versus 1% of vaccinated people developed influenza symptoms…. The corresponding figures for poor vaccine matching were 2% and 1%…. These differences were not likely to be due to chance. Vaccination had a modest effect on time off work and had no effect on hospital admissions or complication rates.”7
Commentary: We’re promoting the vaccine as our main-line intervention, and the early data coming out for the 2012-2013 flu season suggest there is a 60% reduction in medical visits. (This doesn’t mean you won’t get the flu, it just might be less virulent. And the jury is still out on who will benefit from this reduction, healthy adults like myself who would otherwise whiz through the flu without issue, or people with chronic disease who won’t whiz though.)
However, in 2010 a massive meta-analysis by the highly respected Cochrane Collaboration that I quoted above (looking at vaccine efficacy between the years 1966 and 2010 in 70,000 people), suggested that overall, the vaccine was woefully ineffective. At best, it reduced flu symptoms by 4%, and most likely it was more like 2%. They concluded that with the vaccine, you might get back to work a little bit sooner, but it wouldn’t reduce the risk for hospitalizations or developing complications like pneumonia. Thus, it seems healthy adults do better with the vaccine, rather than those who need it.7
Further, The Cochrane Collaboration included a warning label on the abstract. (I have NEVER seen a warning label on a research abstract. What’s next, the black box?)
“WARNING: This review includes 15 out of 36 trials funded by industry. (Four had no funding declaration.) An earlier systematic review of 274 influenza vaccine studies published up to 2007 found industry funded studies were published in more prestigious journals and cited more than other studies independently from methodological quality and size. Studies funded from public sources were significantly less likely to report conclusions favorable to the vaccines. The review showed that reliable evidence on influenza vaccines is thin, but there is evidence of widespread manipulation of conclusions and spurious notoriety of the studies. The content and conclusions of this review should be interpreted in light of this finding.”7
Commentary: Cochrane thinks their relatively puny, but statistically significant findings, might actually be inflated! This is because some of the studies Cochrane used were completed by the same folks who make the vaccines, who obviously have a financial investment in their studies being favorable.
But could Cochrane be biased? Some people think so. Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy (CIDRAP), also released an exhaustive 160 page mega-meta-analysis just last year.8,9 (Download the full text free.)
He thinks The Cochrane Collaboration’s meta-analysis eliminated some studies from their analysis that should have been included. Apparently, Cochrane’s results would be more favorable toward the vaccine with these additions. Dr. Osterholm’s group’s research was supported by grants rather than industry, so their work should be relatively non-biased.
So, what then did Dr. O’s analysis have to say about the state-of-the-state of the influenza vaccine? CDC Megaphone
“The perception that current vaccines are already highly effective in preventing influenza is a major barrier to game-changing alternatives. Indeed, hundreds of influenza vaccine efficacy and effectiveness studies have been conducted since the 1940s, and vaccine efficacy in healthy adults of 70% to 90% is frequently cited. However, the preponderance of the available influenza vaccine efficacy and effectiveness data is from studies with suboptimal methodology, poorly defined end points, or end points not proven to be associated with influenza infection.”9
Ouch! So even though he challenges Cochrane, Dr. O obviously has some HUGE concerns around the current vaccines. Here’s what he had to say to the New York Times in November, 2012:
“We have overpromoted and overhyped this vaccine,” said Michael T. Osterholm, director of the Center for Infectious Disease Research and Policy, as well as its Center of Excellence for Influenza Research and Surveillance. “It does not protect as promoted. It’s all a sales job: it’s all public relations.” 5
Zing!
Why can’t you swing a chicken without hitting an advertisement for the flu vaccine? They’re on every gas station, residence, warehouse, farmhouse, henhouse, outhouse and doghouse (and medical practice).
Well, for starters, there is some fear here. The flu could become serious business. In the 2009 influenza pandemic, the average age of death was 40 — comparable to the 1918 pandemic. In all other pandemics, with the exception of 1918, the mean age of death was in the 60s and 70s, close to the life expectancy. In 2009 there were about 12,500 fatalities in the US — much lower than all previous pandemics. The most vulnerable were obese individuals, children, pregnant women and those with asthma. (Attention integrative clinicians: we can assist these populations, can we not?).
Scientists expect, for a number of reasons, that there will be another serious pandemic. If we’re not ready, we’ll likely see very high death rates. Dr. O is pro-vaccine. When he mentions “game-changing alternatives,” as he does in the above quote, he’s talking about the current vaccine being insufficient, and wanting a new “universal” vaccine.
But something more insidious is going on: a highly intractable refusal to acknowledge the limitations of our current interventions. I turn to two quotes included in Dr. O’s paper:9
“The greatest obstacle to discovering the shape of the earth, the continents, and the oceans was not ignorance but the illusion of knowledge.”
– Daniel Boorstin, 12th Librarian of the United States Congress from 1975 until 1987.
“For a successful technology, reality must take precedence over public relations, for Nature
cannot be fooled.”
– Richard Feynman, 1965 Nobel Prize laureate in physics.
Science, like the truth, is a delicate thing: To the significant detriment of humanity, it can be squashed by fear, politics, policy, opinion and greed.
– Dr. Kara Fitzgerald, 01-22-2013
Epilogue: I would be remiss in my duty as an integrative physician if I didn’t mention there are a plethora of tools to support the immune system before, during and after influenza. In fact, the integrative approach is urgently needed, given the likelihood of a major pandemic. In 2007 with the H5N1 scare, I published an in-house document for Metametrix Laboratory, addressing interventions for the bird flu that are generally useful, which I will link here. Also, for clinicians: The Institute for Functional Medicine’s 2011 annual Symposium was devoted to emerging infectious disease. Access The Challenge of Emerging Infections in the 21st Century. For everyone else, as I always say, talk to your neighborhood integrative doctor. They’ll help you! As you can imagine from this blog, my position on the vaccine hasn’t really shifted…
1. Kondrashova A, Seiskari T, Ilonen J, Knip M, Hyoty H. The ‘Hygiene hypothesis’ and the sharp gradient in the incidence of autoimmune and allergic diseases between Russian Karelia and Finland. Apmis. Nov 6 2012.
2. Okada H, Kuhn C, Feillet H, Bach JF. The ‘hygiene hypothesis’ for autoimmune and allergic diseases: an update. Clin Exp Immunol. Apr 2010;160(1):1-9.
3. Control CfD. 2020 Topics and objectives: immunization and infectious diseases. Accessed 01-23-13, 2013.
4. Daniels TL, Talbot TR. Unmasking the confusion of respiratory protection to prevent influenza-like illness in crowded community settings. J Infect Dis. Feb 15 2010;201(4):483-485.
5. Pope. Reassessing the flu shot as the season draws near. 2012; http://well.blogs.nytimes.com/2012/11/05/reassessing-flu-shots-as-the-season-draws-near, 2013.
6. Early estimates of seasonal influenza vaccine effectiveness – United States, january 2013. MMWR Morb Mortal Wkly Rep. Jan 18 2013;62:32-35.
7. Jefferson T, Di Pietrantonj C, Rivetti A, Bawazeer GA, Al-Ansary LA, Ferroni E. Vaccines for preventing influenza in healthy adults. Cochrane Database Syst Rev. 2010(7):CD001269.
8. Osterholm ea. Influenza Vaccine Efficacy and Effectiveness: A Comprehensive Review. 2009; http://www.preventinfluenza.org/newsletters/101512_osterholm.pdf.
9. Osterholm ea. The Compelling Need for Game Changing Influenza Vaccines. 2012; http://www.cidrap.umn.edu/cidrap/files/80/ccivi%20report.pdf.
Photo credits: flickr.com, William Brawley, kazamatsuri