What’s with the fear of the flu vaccine?

We’re right smack in the middle of flu season. The number of reported cases, hospitalizations, and deaths from influenza this season seems to be at its peak, meaning that we have about 6-8 more weeks of heavy influenza activity before it all ends. Those are just the reported cases. Not all cases get reported, and deaths associated with influenza in adults are not as closely observed as deaths associated with influenza in children. Many get classified as deaths from natural causes because a flu test is not done, though, many times, the person may have been complaining of flu-like illness.

The best thing we have against influenza is the flu vaccine. It’s not as good as it could be, but it’s the best thing we have. Short of the vaccine, we can also focus on washing our hands constantly, and staying away from sick people (or, if we’re sick, keeping away from people). But all those other things require us to make a conscious effort day in and day out during the yearly epidemic. If you sit and watch people, we’re quite nasty. We scratch our face, wipe our nose or mouth, and we touch things with unwashed hands all the time.

Even before the 2009 influenza pandemic, there were plenty of people who were afraid of the influenza vaccine. They saw a list of side-effects reported during the clinical trials of the vaccine and thought that all of those side-effects occurred at rates higher than stated. They were also convinced by anti-vaccine and anti-science activists that the vaccine was nothing but pure poison. They were told that the vaccine kills when, in fact, the vaccine saves lives.

Then the 2009 influenza pandemic happened and the anti-vaccine crowd had a collective orgasm (allegedly) when it was announced that the vaccine for that strain was going to be “experimental” or approved by FDA under an “experimental” protocol. They went nuts saying that we were being “experimented” on or that we were taking a risk by taking a vaccine that was not “fully tested” before it was given. Those and other statements just made it clearer that they didn’t know what they were talking about, even if they should know better.

A friend of mine gave me the example of pies as vaccine. We know what goes in an apple pie. We know what goes in a cherry pie. The difference in the two is the filling. Likewise, the difference in a flu vaccine is the strains it contains. For the 2009 vaccine, all they did was change the strain. Everything else about the vaccines was the same. It’s not like they went and created a new way of delivering the vaccine or a new way of growing the virus strains. That came later, and those vaccines underwent extensive testing, more than the testing that goes into a vaccine when strains are changed.

The anti-vaccine cultists will say that the flu vaccine has thimerosal. When you tell them that there is a thimerosal-free version, they’ll say that the vaccine has aluminum. (SEE COMMENT BELOW ON ALUMINUM.) When you tell them that aluminum covers the whole world, they say it has formaldehyde. Then you tell them that a pear has more formaldehyde than a vaccine, they’ll come up with some sort of bullshit like “it’s not natural formaldehyde like the formaldehyde in a pear.” Right. Because the body can tell the difference of where the formaldehyde came from.

I really wish that anti-vaccine cult members just stopped lying. That’s all. Stop lying and don’t get vaccinated if you don’t want to. But to lie and misinform so openly and so happily, associating vaccines with just about anything that happens to anyone at any time? That right there will earn you a special place in whatever hell you believe in. And, if you don’t believe in hell, we’ll still laugh at you in decades to come as yet another deluded person who thinks they know more than they do. (I’m looking at you, Sherry Tenpenny.)

What worries me the most is that there are a number of groups of nurses who are trying to stop mandates for them to get the influenza vaccine at their place of employment. On its face, it seems ridiculous that they wouldn’t want to do what they need to do to protect their patients. But, like so many other people around the world, they’ve been convinced of monsters under their beds by anti-vaccine activists. Either that’s the case, or their nursing schools really, really suck.

Either way, fears of the influenza vaccine are founded in lies and misinformation from anti-vaccine groups. Many of those fears are founded on fantasies about toxins and inexistent injuries. While some people do react badly to the vaccine, their numbers and proportions are astronomical tiny compared to the toll that influenza exacts on humanity year after year. Chances are that these people would have had a similar, if not worse, reaction to getting the actual disease.

But I’m preaching to the choir, aren’t I?

One physician comes back from the dark side, sort of, while another goes over, kinda

Remember that “pediatrician to the stars” that I mentioned to you a while back? The one that has his doubts about vaccines and has even used “The Brady Bunch” as his basis for the severity of mumps? He’s (probably) coming back from the dark side. He posted this summary on his blog of a study on the safety of vaccines. Is he coming back? Is he going to stop it with the questioning of the evidence of the safety of vaccines?

We’ll see. We’ll see.

On the other hand, we have this article from this physician about mandatory influenza vaccination of healthcare workers. Unfortunately, she hits a lot of the anti-vaccine talking points in her disagreement with hospitals’ policies on having their employees vaccinated against the flu:

“But I choose to take the flu vaccine realizing that the vaccine won’t necessarily protect me against all the different strains of the flu virus, and knowing too that I could suffer severe side effects.”

Ah, the “severe” side effects of the flu. You’ve probably heard about them and how “common” they are. (They’re not that common, and they’re not that severe.) The worst side effect from a flu vaccine in terms of mortality is Guillain-Barré Syndrome. It can be very severe and life-threatening, but you can also get it from a viral infection alone. This leads us to believe that it’s not the vaccine, per se, but the immune response to viral infection.

The article continues:

“I’ve always agreed with the general recommendation that people who work in health care should be vaccinated against the flu, but that still needs to be a personal decision, not a government mandate. Each person has individual responsibility to make decisions about safety issues of all kinds — whether or not to smoke, to eat that second piece of cake, to get the tires checked on the car before the road trip. While we acknowledge that bad decisions may put others at risk to a greater or lesser degree, in America we still believe that personal decisions are just that: personal.”

This is the “freedom gambit.” On its face, it makes sense that it’s up to us whether or not to make the decision to be safe. In this case, we’re not making a decision to be safe for ourselves. This is a decision that also affects the safety of others, i.e. the patients. Equate this to washing your hands. It’s your decision, but woe be unto you if you don’t wash your hands in a healthcare setting. You’re placing in jeopardy your safety and that of your patients. I’d say to Dr. Sibert that people who work in healthcare chose to be in a profession where their “freedom” can very well kill people. If she, or others in healthcare, cannot deal with that, they’re more than welcome to exercise their freedom in other professions.

She adds:

“If I should become ill with a strain of influenza that hasn’t been covered by this year’s vaccine, since I’ve been vaccinated I don’t have to wear a mask though I could be quite contagious for at least a day before I develop overt symptoms.”

Well, now we have a quadrivalent vaccine, Dr. Seibert, so you can take that to further reduce this theoretical situation of yours from happening. I mean, the odds of it happening are pretty low already because the way we select the strains to go into the vaccine have been very good for the Type A (and more severe) strains. The type B selection was tricky, I’ll admit it, but the quadrivalent vaccine takes care of it.

Issues of vaccine effectiveness aside, this argument of hers that there maybe, possibly, probably, in some weird situation be a strain that is not covered is hogwash. If there was some big problem with the vaccine not covering a strain, we epidemiologists would make it known to her and her colleagues so that everyone exercises the proper precautions at all times.

And then this:

“No hospital (to my knowledge) is requiring patients’ visitors and families to provide evidence of flu vaccination or wear masks, though they go in and out of patient care areas at will. If we are really to be logical and scientific about flu transmission, either we all should wear masks or none of us should bother.”

Wow! Just, wow! Replace masks with “hand washing” and see where she goes off the deep end on her argument. “None of us should bother?” Excuse me, doc, with all due respect, YOU CHOSE THIS PROFESSION. You also come into contact in a more direct way with a lot more patients that a visitor. And, if you look into isolation precautions, you’ll note that visitors to patient areas where there are severely sick and immune-compromised people are required to wear masks and gowns and gloves. You should have really consulted with your facility’s infection preventionist. You really should have.

Finally:

“Many of us in clinical health care have good reason to resent the obvious HIPAA violation that is taking place when health care workers are required to divulge whether or not they’ve been vaccinated against this year’s most likely influenza strains. Apparently, HIPAA only applies to some patients, not to all.”

What? Yeah, so her whole argument is that her private and protected medical information is being divulged to the public when she is required to either wear a badge that states she’s been vaccinated or wear a mask if she refuses to be vaccinated. You’ve probably seen this anti-vaccine argument before. It stems from the “sacred and impenetrable” relationship between a provider and their patient. However, there are two things at work here. Number one, she is not a patient. Whether or not she is vaccinated is not between her an a healthcare provider. It’s between her and her employer. And, number two, exclusions to HIPAA are allowed in matters of public health (as this so obviously is) and when the information needs to be divulged in order to operate the hospital in a better way. What do you think we, the public, think when we see someone with a cast over their arm? We think that they broke it. No HIPAA violation there. Why is it a HIPAA violation if we see your badge (if you got vaccinated) or your mask (if you’re not)?

If you feel like it, go read the article yourself, but, if you want to keep your sanity, stay away from the comments section. There’s even more anti-vaccine insanity there.

Another one for Dr. Peter Doshi

It’s been a while since I’ve written to you about Peter Doshi, PhD, the guy who thinks that the flu is not a big deal and who may very well be an HIV-AIDS denialist. He is probably not as prominent now in the anti-science media because he’s busy being the associate editor of the British Medical Journal and calling on drug companies to be more transparent with their data. (Big Pharma is the big fish everyone wants to take down nowadays.) Nevertheless, his work against the stockpile and use of neuraminidase inhibitors (NI) like oseltamivir (aka “Tamiflu”) is still out there. It still gets quoted.

The Lancet put out an article recently about the effectiveness of NIs and their effect on mortality in hospitalized patients. It is a meta analysis. This means that they took together a whole bunch of studies and looked at them in the aggregate. I don’t generally like these studies because it is easy to be biased in the analysis by discounting or ignoring some studies while favoring others. Still, when done well, these studies have more power because they’re looking at more subjects and more outcomes. This particular study took 78 studies done between 2009 and 2011 and looked at the outcomes for treatment while hospitalized. This is what they found:

“We included data for 29 234 patients from 78 studies of patients admitted to hospital between Jan 2, 2009, and March 14, 2011. Compared with no treatment, neuraminidase inhibitor treatment (irrespective of timing) was associated with a reduction in mortality risk (adjusted odds ratio [OR] 0·81; 95% CI 0·70—0·93; p=0·0024). Compared with later treatment, early treatment (within 2 days of symptom onset) was associated with a reduction in mortality risk (adjusted OR 0·48; 95% CI 0·41—0·56; p<0·0001). Early treatment versus no treatment was also associated with a reduction in mortality (adjusted OR 0·50; 95% CI 0·37—0·67; p<0·0001). These associations with reduced mortality risk were less pronounced and not significant in children. There was an increase in the mortality hazard rate with each day’s delay in initiation of treatment up to day 5 as compared with treatment initiated within 2 days of symptom onset (adjusted hazard ratio [HR 1·23] [95% CI 1·18—1·28]; p<0·0001 for the increasing HR with each day’s delay).”

In other words, giving an NI early in the course of the disease is associated with lower mortality, and giving it versus not giving it was also associated with a reduction in mortality risk. Note this: “These associations with reduced mortality risk were less pronounced and not significant in children.” That’s “clutch” right there and something that infectious disease doctors and pediatricians should keep in mind.

NIs are not a magic bullet against influenza. Nothing is, not even the influenza vaccine. But something is better than nothing, and something backed up by evidence is best. Contrary to Dr. Peter Doshi’s assertions about NIs, evidence keeps coming in that it is better to give them than to not give them, and that they actually reduce the risk of death from influenza in some groups. There is both observational and experimental evidence of this.

But you don’t have to just take my word for it.

Influenza is here, it’s bad, and it’s killing people

Contrary to the opinions of people like Peter Doshi, PhD, and others that influenza is not that bad, influenza is pretty bad. Just ask the family of this woman in Texas how bad it is. Or ask the family of this girl. Influenza is being reported from all over the lower 48, Canada, and Mexico. Many public health agencies are now recommending the influenza vaccine as a countermeasure to the increase in cases. As an epidemiologist, I join other epidemiologists in saying that the vaccine is not a good countermeasure, and it shouldn’t be used as the lone countermeasure. It takes a while for it to confer immunity, so it may be too late now that the season is fully underway.

Non-epidemiologist tries to do epidemiology, feeds anti-vaccine activists

One of the rules of this blog has been to not name any names, but it’s going to be broken for this post because it’s hard not to break it in this case. The person I’m going to write about is putting himself out there, sometimes vociferously, to say some things that, as an epidemiologist, I find frustrating. First, a little background. A few months ago, a friend of this blog wrote this post about influenza vaccines. In that post’s comments, the name of one Peter Doshi, PhD, came up. Dr. Doshi wrote this article in the British Medical Journal and delivered this presentation (PDF) at the “Selling Sickness 2013” conference in Washington, DC. In his article and his presentation, Dr. Doshi, who is not an epidemiologist, makes some clear mistakes about the nature of the yearly flu epidemics that we see, the deaths from influenza, and the benefits/risks of the influenza vaccine.

Five things you need to know about the flu right now

Today, January 9, 2013, we are the peak of influenza activity in the United States. Places like Boston, Chicago, and North Dakota are seeing a surge in cases of influenza. The Centers for Disease Control and Prevention (CDC) is reporting that flu activity is widespread and intense in most of the nation.

WIDESPREAD!

INTENSE!

So here are five things you need to know about the flu right now:

1. The flu likes unvaccinated people. While there are some people who will get the flu eventhough they’re vaccinated, comparing apples to apples, people who are not vaccinated have a higher risk of getting the flu. There is an injectable vaccine and a nasal spray vaccine. The evidence seems to point to the spray being better for children and the injection being better for adults, while older adults need the high-dose vaccine. So get your flu vaccine, and get it each year. The flu likes to mutate, a lot. And, no, you can’t get the flu from a vaccine. If you do, you would be the first person in the world to do so, and scientists would like to talk to you.

2. The flu likes dirty people. The flu vaccine makes it harder for the virus to make you sick if it infects you. It doesn’t act as a magical barrier that keeps the virus off of you. To do that, you need to wash your hands, and wash them well. A simple rinse and go will not do. By washing your hands often, you minimize the chances of catching the flu from all the surfaces you touch during the day. When you touch a surface with the virus on it and then you touch your nose, mouth, or eyes, you have a good chance of getting infected. If you’re a food handler, you have a good chance of making a lot of other people sick if you don’t wash your hands well. That would be embarrassing.

3. The flu is deadly. Most of us will get through the flu just fine because most of us are otherwise healthy. We’ll feel bad for a few days and then recover with no lingering problems. This is not the case for people who have underlying medical conditions, and there are more of us with those underlying conditions out and about nowadays. What are those conditions? They include diabetes, pregnancy, asthma, cancer, heart conditions, lung conditions, even neurological conditions. This is why it is important for people who can be vaccinated to get vaccinated, and for everyone to wash their hands. Doing this protects people who are too weak or too sick to protect themselves. To date, according to CDC, there have been 18 deaths in children. That’s 18 too many, especially in an era where the flu is completely preventable with vaccination, hand hygiene, and social distancing.

4. The flu likes friendly people. Ever wonder why the flu is so active in the winter? One of the reasons is that people tend to pack into tight spaces in the winter. We do this almost automatically to get away from the cold weather. (The cold, dry air also helps the flu survive longer in the environment, so that’s a double whammy.) We pack ourselves into movie theaters, malls, schools, and at work, and we share the virus with everyone. So, if you are sick, stay away from crowds. If you want to increase your chances of not being sick, vaccinate, wash your hands, and stay away from crowds. (I don’t mean for you not to shop, but do it as off peak hours, online, or in places that are not too crowded.) If you must take the train in a crowded car, stay away from people who look ill and wash your hands as soon as you get to your destination.

5. The flu is inside you long before you know it. It takes between one to two days for you to feel the signs and symptoms of the flu once you’ve been infected. But here’s the kicker: You’re infectious one to two days before symptoms as well. That means that you can be completely healthy and be spreading the flu around. This is why quarantines generally fail when it comes to the flu if you base those quarantines on signs and symptoms. A perfectly healthy-looking person can make it through a checkpoint and be infectious. So, if you know you’ve been exposed, stay away from people who are susceptible to serious complications form the flu, complications like pneumonia and death.

Now that you’re armed with knowledge, you’ll be more likely to make it through the flu season, no colloidal silver or magic required. Good luck. I’ll see you on the other side.

One error that every anti-vaccine activist jumps all over (UPDATED)

There is this book called “Your Baby’s Best Shot“. It’s a book about childhood vaccines and their benefits versus their perceived dangers. It’s pretty good, but it’s not perfect. In one of their pages, the word “free” is missing from a statement. The statement reads like the authors are recommending “aspirin” instead of “aspirin free” fever reducers. We’ve known for a while that aspirin and kids with fevers don’t get along because there is an increased risk of a condition called “Reye’s Syndrome“. It’s a serious condition that can be seen with viral infections and the administration of aspirin. The aspirin doesn’t cause it, necessarily. It does increase the risk of it.

UPDATE: The authors have issued a correction on their Facebook page. I made the mistake of saying that “free” was left out. It wasn’t. As you can see in the correction, it was something else entirely:

“It has been brought to our attention that a typo exists on page 71 of the book. The sentence that reads: ‘A mild vaccine reaction is easily treatable with a few aspirin’ should have read ‘A mild vaccine reaction is easily treatable with a few Tylenol.’ Children should not be given aspirin due to the possibility of developing Reye’s Syndrome, a rare but serious illness. We apologize for the typo, and are grateful for your continued support of the book!”

Yes. I make mistakes too. We all do. Unlike anti-vaccine people, and other unsavory characters, I try to spread out my mistakes throughout my lifetime, not concentrate them in one single anti-vaccine blog post.

I knew a girl in high school who had it when she was ten years old. She had a lot of trouble walking after it. Very bad.

The book has that one flaw, that one little thing. The authors are aware, and they are working on issuing an erratum to amend that mistake. But that has not stopped the anti-vaccine people from relentlessly attacking it, calling for a banning of the book:

“Vaccine Skeptic Society” is the online, Facebook-only pseudonym of a woman who has gone by “Stacy” in the past. Stacy has openly claimed that she is a healthcare worker, but she’s also clarified that her work in healthcare goes as far as working as a medical transcriptionist/coder out of her home. Her science degree diploma must be enormous. Yet she’s not the only one getting all bent out of shape over that one error in the book:

Her followers may very well be frothing at the mouth. To please them even further, Stacy went and created a whole new Facebook page aimed at the book and its authors. Medical coders have so much time on their hands.

The worst thing is that a person who is reasonably pro-vaccine decided to attack the book on her Facebook page. I hate Facebook. I’m hardly on it anymore. Here is what she wrote:

The way you look at the timeline of events, the only reason Stacy learned of the error was from “Informed” writing about it, all the while “Informed” is just writing about it out of concern.

What a mess.

The same rule does not apply to all the lies and misinformation in anti-vaccine books and publications, of course.

Flu Vaccine Not As Effective As We Thought: Ring The Alarm?

Science is a funny thing. Just when you think you have it all figured out, something comes along that challenges the status quo, and we scientists end up going back to the drawing board. It happened to Einstein, believe it or not. When Edwin Hubble came along with observations that stated that the universe was expanding, Einstein didn’t quite want to believe it. When those observations were shown to be true, Einstein didn’t hold fast to his own views. He analyzed the evidence and judged it for what it was. Then he changed his mind.

Likewise, when we are talking about vaccines with an anti-vax person — and most discussions are not really about “talking” — the accusation comes up that we, the people who support and encourage the use of vaccines to prevent some horrible epidemics, somehow belong to a “cult” or a “religion” that worships vaccines. Nothing could be further from the truth. What we do is take in the evidence that has shown that vaccines — the licensed ones — are safe and effective against some nasty diseases. We weigh that evidence against what we know, and then we render judgment on that evidence.

Once in a while, like it happened with Einstein, something will come along to change our view about vaccines, or a vaccine, and we do change our view. Again, we weigh the evidence. (Can you see a recurring theme here?)

The National Association of County and City Health Officials (NACCHO) did an extensive study of the influenza vaccine in the United States. Guess what? It’s not as good as we thought it was.

Let that sink in for a minute or two.

Did you catch your breath? Well, you shouldn’t be out of breath to begin with because this is not earth-shattering news. It’s not to us epidemiologists, anyway. We’ve been noticing that, despite some pretty good vaccine coverages in different populations, we were still seeing some gnarly flu outbreaks each year. We were lacking the evidence on why this was occurring, but now we have it.

Here is the full report.

The long and short of it is that the flu vaccine is not as effective as public relations campaigns will have you believe. Were they lying? No. They were making those statements based on sub-par scientific evidence. (That’s why we weigh evidence before we render judgment, though it doesn’t always happen that way.) Also, the Advisory Committee on Immunization Practices (ACIP) has been making some of the flu vaccine recommendations based on expert opinion and not hard data. So the NACCHO report suggests that better vaccines be developed, that current vaccine recommendations be based on hard data, and that we don’t stop vaccinating in light of this evidence.

Why not? Because the flu vaccine is still the best thing we have against a disease that kills thousands of Americans each year and millions worldwide. So, while we work on the next best thing — and we must — we must also continue to use what we have.

It’s kind of hard to think about this from a scientific point of view, so it will not surprise me at all if the anti-vax crowd twists and bends what is in the report to fit their views. I’ll bet you $5 that they will.

Nevertheless, this report tells us that there are dedicated public health officials looking at these things and not being afraid to criticize them. If Edwin had been afraid to tell Albert that his general theory of relativity was a bit off, our GPS systems would be off. (They really would.) So, while the anti-vax crowd will raise this report as a failure of vaccine policy in this country, I raise it here as a success.

Now that we know what is going on with the flu vaccine, we can make a better, more efficacious one. And that is not a bad thing at all.

Let’s play with numbers, and your head, just a little bit

From this site:

“New research brought to us by The Lancet shows some startling news regarding the true effectiveness of the flu vaccination. The study involved a control group of 13,095 adults who were not vaccinated. The group were watched to see if they caught the influenza virus, but 97 percent of them did not. Only 2.7 percent, or 357 people, of the non-vaccinated group ended up catching the virus. Another group of adults whom were vaccinated with a trivalent inactivated influenza vaccine ended up with 1.2 percent of them not catching the flu. The difference between the two outcomes is 1.5 people out of 100 which shows that the flu vaccine only prevents the flu in 1.5 out of every 100 adults injected with the flu vaccine.”
 
Emphasis so totally not mine.

But the person then explains their own misunderstanding:

“While the media runs around “spreading the rumor” that flu shots are 60 percent effective, one would assume that 60 out of 100 people receive the flu based on those claims. The problem with this claim is that it’s wrong. Anyone who takes a crash course in college statistics knows how to skew data. Methods for exaggerating data range from manipulating the graph to using complex statistical algorithms to eventually reach the desired conclusion. In this case, the 60 percent effectiveness claim births from an ongoing equation which transforms the numbers properly. First, 2.73% is taken for the people who got the flu in the control group. That number is then divided into 1.18% which stands for the percentage of people who got the flu in the treatment group. The answer comes out  to be 0.43. You are now able to say that 0.43 is 43% of 2.73 (control group people who got the flu) and make the claim 57% are protected by the flu vaccine.”

Well, yes, that’s how it works. This is what we epidemiologists call a “case-control” study, and it is very robust in terms of determining whether or not things happen by chance. In short, that reduction in influenza was not by chance, and it was significant, and it was by more than a half. But let me explain it differently.

The problem with looking at things in terms of percentages is that you lose sight of the magnitude of what you are looking at. If I tell you that 1% of the population of the United States has an ailment, you might think that’s not worth it to try and find a cure or prevention for it. But that 1% translates into roughly 3 million people. That’s a large city!

In the study cited by this particular anti-vaxer, you had a reduction in cases from 2.73% to 1.18%. Using our example of the US population, this would translate into helping 4.65 million people avoid the flu. In this person’s mind, going from 8.19 million to 4.65 million is meaningless. This person seems to be playing mind games to try and convince you that this is not a significant finding. It is, very much. It just seems small because, again, you’re looking at percentages.

So don’t just look at the percentages. Look a the whole picture. Even a reduction in disease burden of 1% or 2% is huge when it comes to saving lives and maintaining productivity.

Related articles elsewhere online (via Zemanta):

• Universal flu vaccine?
• The Flu: A Guide For Parents
• Canada researchers find clues to a universal flu vaccine
• More Than 690,000 Americans Have Already Been Vaccinated Against The Flu This Season, SDI Reports – Cdc Supports Expanded Access To Flu Vaccination
• Flu Shots and Flu Vaccines: It’s Not Too Late