The Combat Medic’s Guide to Answering Flu and Vaccine Questions from Patients

It’s that time of the year again.

No, not for pumpkin spice frappamochachialattamericana.

It’s time for mandated flu vaccines.

This is all in accordance with the Assistant Secretary of Defense for Health Affairs direction outline in the aptly-named “Interim Procedures Memorandum 17-005, 2017-2018 Seasonal Influenza Vaccination Program (IVP)”.  For the vast majority of Soldiers, this is just another annual wait-in-a-line-to-get-a-shot event.  For some, however, this provides the opportunity for a renewed argument over why they have to do this.  For medics, it’s a great opportunity to educate.

First, an important disclaimer: individuals are entitled to their own opinions on vaccines, to their own religious beliefs regarding vaccines, and their right to disagree with getting vaccines or other medical care in general.  This is not meant to be a piece to encourage a superiority complex, medical, moral, or otherwise, in medics administering a vaccination.  For those Soldiers who are legitimately interested in why they must get the annual influenza vaccination, this is meant as a simple review to answer some common questions.

What is influenza?

In short, the influenza virus, more broadly known as “the flu”, is a small snippet of ribose-nucleic acid (RNA) that is spread through aerosolized respiratory droplets during close contact with an infected person or animal can infect cells of the upper respiratory tract (nose, throat, upper bronchi), stimulating an inflammatory response leading to the all-too-familiar symptoms of stuffy/runny nose, throat pain/discomfort, coughing, headache, body aches, fevers, chills, and fatigue.

Influenza has two primary types, easily classified as A and B.  The classification for influenza A is based according to the types of hemagglutinin (H) and neuraminidase (N) (H1N1). Influenza B does not have multiple subtypes. The hemagglutinin is a surface receptor that binds to sialic acid particles on human cells.   The neuraminidase works by aiding in separating from cell surfaces and dissolving mucus to help the virus spread. The tricky part about this virus is that it is constantly mutating.  Yes, mutating, very much like those expensive CGI sequences you see in all the superhero movies, except there isn’t some cool techno music to amp it up.

A single RNA sequence contains thousands of sub-units, and the number of combinations is pretty much infinite.  These mutations can come through a number of ways as the virus exists and replicates in a host.  More information on the history of the influenza virus, its outbreaks, and medical attempts to help the population with vaccinations is well-explained over at Havok Journal.

If getting the flu mainly causes me to have a stuffy nose and cough, then why do I need a vaccination?

Woah!  Slow down there high-speed.  Influenza indeed does cause the symptoms listed above, but those are usually just the milder cases that are found in most healthy individuals. Part of the reason we vaccinate everyone is the mechanism of the flu virus can weaken the immune system and allow for a subsequent bacterial invasion and pneumonia to set in.  This is one of the main reasons of why and how people die from the flu.  The culprit may not be the virus itself, but rather a secondary invasion of bacteria such as Staphylococcus aureus that sets up shop after the flu already damages your respiratory tract.  However, in some cases, it is influenza itself that does that damage and could be fatal.

Yes, but right now I AM healthy now!

Yes, and we’re glad you’re staying healthy.  However, the issue is that an influenza strain doesn’t really care if you are healthy or not, hence the “most” above.  You may be too young to remember, but in early 2009 there was an outbreak of H1N1 influenza (originally called “swine flu” because it was believed to have originated from pigs, although was later disproved).  Initial cases were found to be resistant to antiviral medications, and with numbers quickly climbing, the World Health Organization (WHO) declared a Public Health Emergency of International Concern in late April 2009.  Cases peaked in June 2009 when H1N1 had been documented in patients from 70 countries and all 50 states.  When the final numbers were compiled, there were over 270,000 hospitalizations in the United States and over 12,000 deaths due to H1N1 influenza.  To put that in perspective, the number of individuals hospitalized due to “the flu” in a 6-month period in the United States was equal in number to over HALF of the active duty Army force strength.

Going back 100 years, there was also this little thing called the 1918 Influenza Pandemic, caused by an H5N1 strain, which is estimated to have infected up to one-third of the world’s population at the time, and overall killed approximately 50 million people, although some estimates state up to 100 million people.  In the midst of World War I, conservative estimates are that at least 26% of the U.S. Army was stricken with influenza, killing nearly 30,000 before they even arrived at the European theater.

So then how does this vaccine how work, especially if it didn’t work so well before during the Swine Flu?

Ok, a two-parter:

Vaccines were discovered over two-hundred years ago by Dr. Edward Jenner, who found that people who were exposed to Cow Pox were able to avoid getting the much-worse smallpox virus.  Dr. Jenner later tested intentionally inoculating individuals with Variolae vaccinae, and found that these vaccines (derived from the “vaccinae” in the Cow Pox virus) largely protected individuals from smallpox altogether.  In short, these vaccines work by exposing the body to a mimic, weakened, or inactive version of a virus or bacteria, allowing the body to better recognize the antigens (think: viral/bacterial fingerprints) and thus have a more alert immune response to be better prepared to respond if a person is exposed again later on.  For some vaccines, such as polio, a person receives lifelong immunity after vaccination.  For other vaccinations, such as for tetanus (a bacterium found in soil which you are often re-vaccinated for if you get seen for a dirty wound), you may get more frequently.  As the influenza virus is prone to mutation, organizations like the WHO and the Centers for Disease Control and Prevention (CDC) constantly sample the global population and produce a vaccine each year that best covers the spread of those strains found.

Now, as anyone who has ever bet on anything knows, there is no such thing as a “guarantee”, and this is especially true with an ever-changing virus like influenza.  In 2009, H1N1 was not predicted to be one of the main strains.  However, once it came into the spotlight, the WHO and CDC supported a recommendation from the Advisory Committee on Immunization Practices (ACIP) that as many individuals be vaccinated against H1N1 as quickly as possible.

Similarly, data over the past 10 years have shown largely varying rates of vaccine efficacy (effectiveness).  Studies have shown that the influenza vaccine was anywhere from 10-60% effective at preventing influenza illness.  So, then why get a vaccine if some years it has only been 10% effective?  Because, quite frankly, 10% effectiveness is better than 0% effectiveness without a vaccine.   If you were about to crash your car, would you rather have an airbag that worked 10% of the time, or 0% of the time?  Granted, 10% is not huge, but it has not always been 10% and is definitely greater than 0%.

But why does the influenza virus “mutate?”

RNA viruses do not consistently replicate they are supposed to.  As such, they tend to accumulate very small mutations over time which can change the viral antigens (fingerprints), and the way our body recognizes it.  This is called an antigenic drift. When multiple influenza strains infect a single cell, due to the segmented nature of their genome, recombination of segments of the genome can occur.  This is called an antigenic shift.  Antigenic shifts are largely responsible for pandemic influenza, such as the episode in 1918 note above.

But, I know that this vaccination will make me sick!

This is very important: an influenza vaccine does not “give you the flu.”  The most common side effects of a flu shot are redness and soreness at the injection site.  Similarly, common side effects of the intranasal vaccination are nasal congestion and a runny nose.  This is not “getting the flu”.  In fact, studies where subjects were randomized to get a shot of either influenza vaccination or sterile saline have shown no difference in significant “flu-like” reactions, and an overwhelming majority of subjects could not tell if they were given the actual vaccine or the sterile saline.

The usual minor side effects of a vaccination that most people see, if any, are the result of your immune system responding to the vaccination. Redness and soreness are not a person “getting sick”, but rather increased blood flow to the vaccination area to allow the body to identify and respond to the vaccination.

Ok, fine, but don’t vaccines cause autism since they have lots of bad stuff in them? Jenny McCarthy says so!

This is a larger answer but can be simplified by one word: NO.

The primary concern centers around vaccine additives that enhance the vaccine, referring primarily to adjuvants and preservatives.  An adjuvant is added to a vaccination to help make the vaccination last longer and create a better immune response for better overall effectiveness.  This can be found in numerous vaccines besides influenza, including hepatitis, tetanus, diphtheria, and meningococcus.  Adjuvant itself is derived from the Latin adjuvare, meaning “to help”.  The primary adjuvant used in influenza vaccination is an aluminum compound (“alum” for short), which is largely believed to stimulate a more robust immune response, allowing smaller doses of vaccine to be used, and a slower release of the vaccination from the site, which helps to induce a stronger response to the vaccine.  This is needed because, with most inactivated vaccinations, the viral or bacterial dose given is so weak that it would not normally induce an immune response.

Although opposition to vaccines has been around in the United States for more than 100 years, it has been much more recently that there has been a popular belief that there is a vaccine-autism link.  This is primarily thanks to Andrew Wakefield, a British physician who published papers in 1998 and 2001 that suggested a possible relationship between the vaccine for measles, mumps, and rubella (MMR).  In the 1998 paper, Dr. Wakefield took 12 cases referred to pediatric gastroenterology specialist, stating that 8 of them had an onset of “behavioral symptoms” associated with the MMR vaccine and that 9 of the 12 cases were diagnosed with autism.  It is important to point out that, although the paper’s discussion did state blatantly that “we did not prove an association between measles, mumps, and rubella vaccine and the syndrome described,” it also boldly declared without substantial evidence that “If there is a causal link between measles, mumps, and rubella vaccine and this syndrome, a rising incidence might be anticipated after the introduction of this vaccine in the UK in 1988.”  So, while in one sentence Dr. Wakefield stated there is no link, he then kinda-sorta stated that there might be one, and indirectly told the UK to watch out for a rise autism in the wake of the large-scale MMR vaccine.  His later work in a 2001 paper similarly declared that “the foundations to claims of MMR safety have failed.”  Even though the other original author’s of Wakefield’s 1998 paper stated in 2004 that it shouldn’t have published the work, and formally retracted the paper in 2010, AND later Dr. Wakefield was struck from the medical register in Great Britain, thereby terminating his ability to legally practice medicine, AND subsequent research proved that the research was largely fraudulent, the idea of an MMR-vaccine autism link, and thus a suspicion of all vaccines, continued.

And thus, false legitimacy helped breed a new generation of vaccine opponents.  These “anti-vaxxers”, led by former celebrity Jenny McCarthy, brought Wakefield’s work to the forefront, stating that he had been unfairly vilified and was a victim of a corporate conspiracy.  Much of this conspiracy was directed at a vaccine preservative, thimerosal, which contained mercury.  Despite multiple reviews and reports over the years that there was no firm evidence to link thimerosal additives and autism or other behavioral developmental issues, this compound is largely absent in vaccines, with the exception of some multi-use vials of… yup, wait for it…. the influenza vaccine.

Now, while this may seem to lend credibility to someone attempting to get out of the flu vaccine, it is important to note that the belief of autism and other disorders to vaccination compounds are developmental disorders, which are not likely to affect your largely fully-developed active duty population.

And, there you have it.

You now have substantial history and answers to respond to most influenza questions.

And, if all else fails, here is the list of contraindications to receiving the influenza vaccination shot, directly taken from the CDC website here.

For the inactivated influenza vaccine (IIV):

• Infants younger than 6 months of age
• People who have experienced a severe (life-threatening) allergy to a prior dose of a seasonal influenza vaccine
• People who have a severe allergy to a component of the IIV

For the Live, Attenuated Influenza Vaccine (LAIV)

• Children aged <2 years of age
• Adults aged >50 years of age
• Individuals with a history of severe allergic reaction to any component of the vaccine or to a previous dose of any influenza vaccine
• People who are allergic to eggs.
• Children or adolescents ages 2 through 7 years of age receiving aspirin or other salicylates (because of association of Reye syndrome with wild-type influenza virus infection).
• Pregnant women.
• Individuals with known or suspected immunodeficiency diseases or immunosuppressed states (including those caused by HIV).
• Children 2 through 4 years of age who have asthma or who have had a wheezing episode in their medical record within the past 12 months, or for whom parents report that a health care provider stated that they had wheezing or asthma within the past 12 months.
• Individuals who have taken influenza antiviral medications within the past 48 hours.
• Persons who care for severely immunosuppressed persons who require a protective environment or these individuals should avoid contact with such persons for 7 days after receipt.

In short, a review:

• Influenza vaccines are part of a Department of Defense mandate (as stated in the beginning) to maintain the health of the force.
• The issues come when influenza strains mutate or drift, which means last year’s immunization doesn’t work well against this year’s most likely virus. Prior rates of effectiveness have been up to 60% in the past decade, but even the lowest estimates of 10% effectiveness are better than 0% if you don’t get the vaccine.
• The flu shot will not “get me sick”, as studies have shown no difference in reactions between a sterile saline injection and the actual influenza vaccination.
• Vaccine opposition has existed for a long time. Adjuvants, such as alum, and preservatives, such as thimerosal, are additives that have largely disproven to have any significant adverse effects. Previous work suggesting a link of the MMR vaccine to autism was disproven, redacted, and the author banned from practicing medicine. Plus, these concerns are developmental issues, meaning unlikely to affect your (mostly) fully-developed active duty Soldiers, Sailors, Airmen, and Marines.

Any questions?

The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the US Government.

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References:

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Bridges CB, Thompson WW, Meltzer MI. Effectiveness and cost-benefit of influenza vaccination of healthy working adults: a randomized controlled trial.  JAMA.  2000;284(13):1655-1663.

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