American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, January 14, 2015

The flu vaccine takes a drubbing from its flubbing

This year's flu vaccine, as you likely know, is taking a drubbing. The contention is that Centers for Disease Control and Prevention (CDC) flubbed, and didn't get quite the right flu strains in the mix. That is apparently true, although more the “fault” of the influenza virus and its natively wily ways, than of the CDC. Either way, the drubbing is disproportionate to any flubbing.

The drubbing occurs in the context of a strong, New Age, anti-vaccine sentiment. How populous that movement truly is, it's hard to say. Those in it tend to be quite vocal, so they may be few yet sound like many. However, enough families forego vaccination, and enough cases of vaccine-preventable illnesses such as measles occur, for us to know the movement is far from inconsequential.

Those who know of my clinical activities, directing a holistic, integrative medicine center in close collaboration with naturopathic colleagues for the past 15 years, might expect my sympathies to align with the anti-vaccine crowd. But they certainly do not. I favor kinder, gentler treatment whenever possible; but I never drank of the “nature is benevolent and science is malicious” Kool-Aid. Nature spawned smallpox; science devised the vaccine. Botulinum toxin is natural; effective anesthesia is a product of science.

Both nature and science can do good and harm, and which is friend and which foe depends entirely on context and circumstance. Ideology tends to obscure that. So I will take epidemiology over ideology every time.

Epidemiology tells us what we need to know about vaccines. Yes, of course, they can do unintended harm. But they have eradicated smallpox, and done the same to polio in most of the world. They have spared our children mumps and measles, and the potential for lifelong sequelae, including sterility.

The bottom line is that anti-vaccine sentiment and associated conspiracy theories are a luxury accessible only to societies largely spared the historical toll of dreadful, vaccine-preventable diseases. If our children were still prone to polio, any anti-vaccine evangelists would be trampled by the mob rushing to the immunization clinic.

Now, back to the flu. As noted, it is a singularly wily virus, the very reason there is a new vaccine for it every year, unlike any other bug. The flu virus strains routinely mix with one another, particularly as they migrate among different species (e.g., human, duck, pig) living in close proximity, especially in parts of Asia. The virus strains trade genes, and surface proteins.

The surface proteins, or antigens, are what each year's vaccine targets. Unfortunately, they are prone to both drift, and shift. Drift is relatively modest, annual change. Shift is a major rearrangement of flu surface proteins that historically presages a pandemic, because these fundamentally altered flu strains encounter human immune systems unfamiliar with them, and relatively undefended against them.

Global surveillance of the flu is more elaborate than for perhaps any other infectious disease. Those data inform the preparation of each year's vaccine, which is an attempt to stay a step ahead of the germ and put into the preparation all of the likely antigens for a given year.

The enterprise does, inescapably, involve some informed guessing, because there is lead time required to prepare millions upon millions of vaccine doses. During that time, the virus can be prone to further drift. This year, that appears to be the case.

What does it mean? There are some suggestions that this year's flu strain may be especially nasty, which has nothing to do with the vaccine. It does mean if we get the flu, it won't be very pleasant. It also means the vaccine will protect us less reliably. There is a good chance, though, that if infection does occur in the vaccinated, it will be less severe and protracted than in the unvaccinated due to that partial protection.

Vaccine protection against flu is never 100%. Even when the vaccine and virus are well matched, there can be a mix of flu strains in circulation, with some less like the vaccine strains than others. The vaccine depends on the host's immune system response, and often those most in need of protection, the elderly, the very young, the chronically ill, have the weakest immune system responses. And then there is simply the fact that no defense against anything is ever 100%. A given bullet from a given gun can pierce a bulletproof vest. That doesn't make the vest useless; just imperfect.

The use of flu vaccine imperfections as an argument against immunization is not only misguided, but a classic instance of making an elusive perfect the enemy of attainable good. The fact that people can still die in car crashes is scarcely an argument against seat belts and airbags. Those not saved in no way obviate the merit of those who are. Were we to treat seat belts like vaccines, there would be websites devoted to deaths among those wearing seat belts; arguments that seat belts were to blame for those deaths; the insinuation, or overt accusation, that seat belts are in fact a genocidal tactic of some government agency; and a patina of “back to nature” virtue painted over the anti-seat belt movement.

The flu vaccine will not provide perfect defense against the flu, not in any year. It may, alas, provide less than average protection this year, although that remains to be seen. But seat belts cannot guarantee we won't be killed in a car crash, either. We are well advised to wear them just the same; to drive carefully; and not to drink, text, or use an abacus while doing so.

Any flu vaccine flubbing this year was minor, and of the unavoidable kind. The attendant drubbing is misguided, and misleading. I had my vaccine, and I am glad I did. I plan to keep wearing my seat belt, too.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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