February 16, 2005: Flu
Shots and Manipulative Reporting
By Ahchie
Yet
another study has been released on the effectiveness of the influenza vaccine.
The study, led by researchers from the National Institutes of Health, reveals
that flu shots do not seem to be effective in reducing the number of deaths
in the elderly. Researchers also indicate that an alternative plan could be
to vaccinate all school-age children. While the BMTG finds fault with the
numbers used and the conclusions made in the study, a point about misleading
and manipulative reporting shall be made first.
Questionable Reporting
A comparison between two articles on the study reveal a drastic difference
in how it was presented, serving to illustrate how the same subject can be
slanted to emphasize what the author wants, as opposed to simply reporting
the findings. The articles in question, in the February 15th edition of the
Sacramento Bee and in the February 14th edition of the
Denver Post, paint two very different pictures. While
the Bee article contains a glaring inaccuracy that taints the entire article,
the Post article seems to be much more even handed in its reporting.
The
Sacramento Bee misses the mark on two major points. First, the Bee’s
primary emphasis is on the idea that all school-age children should be given
flu shots in order to protect the elderly. Second, the Bee misstates by a
huge margin the number of elderly that die because of influenza, reporting
that more than a half million people 65 or older die each year. The Post,
meanwhile, reports the more commonly used number of 36,000. These numbers
are analyzed in more detail below. After reading the article in the Bee, one
does not come away with an accurate view of what the study revealed. Reading
only the Bee article would lead one to think that influenza is a huge problem
among the elderly and that children are a major cause of influenza related
deaths among the elderly.
While the idea to vaccinate children is mentioned as a possible way to better protect the elderly, the Denver Post takes on a completely different tone, making clear that the main point of the study is that, based on three decades of research, flu vaccines do not seem to be effective in reducing the number of influenza related deaths in the elderly. The Post also clarified that there is a separate report that advocates a shift to vaccinating schoolchildren, since they are the most likely to spread the flu virus. The Post emphasizes the point that for most of the elderly the chance of dying from the flu is low and that they should not panic if they are unable to get a vaccine.
Blame it on the Children
Before delving into the details of the study, it is necessary to address the
tendency to always blame the children on the spread of the flu. The reality
is that one can catch a cold in a veritable plethora of ways. Do you: Go grocery
shopping? Work in an office? Shake the hands of people you meet? Use the ATM
machine? Pick up things with your hands? Rent movies? Go to the post office?
Go to the bank? Breathe air? Go anywhere out of your house where you may have
the opportunity to interact with people? If you answered yes to any of the
above, then you are probably at risk for catching a cold during the flu season.
No matter how careful you are, catching a cold is something that will probably
happen to you at least once a season.
But, despite the multitude of ways to come down with the flu, the children are always the ones that catch the most blame for the spreading of disease. It is true that schools are one of the places where colds spread among families, and children unwittingly do spread their fair share of germs. But to place all the blame on their shoulders is to miss the larger point, which is that colds will spread amongst everyone, young and old, and this has been the way for a very, very long time.
To
solve the problem of the young infecting the old, scientists have discovered
that the Malagasy Giant Jumping Rat, found only in the Menabe region of Madagascar,
actually eat their diseased young before the baby rats infect the entire colony.
Those rats that ate diseased babies were even found to have higher levels
of immunity. Perhaps we should follow that model. However, since the proposal
to eat our own diseased young would be met with much resistance, the recommendation
now is that all school-age children should receive flu shots every year. The
concept is that fewer diseased children will translate to fewer diseased elderly,
which will translate to fewer elderly deaths at the hands of influenza.
The Study
Whatever newspaper is consulted, in the end the studies are flawed, first
in the numbers reported, and second in their conclusions. They offer a recommendation
(vaccinate all school-age children with a flu shot) that will cost much, while
providing questionable benefits. The studies ignore simple truths and ignore
the idea that perhaps it is the actual flu shot that is a much bigger threat
than the children.
According to the Sacramento Bee influenza kills more than a half-million people 65 or older each year, despite the high number of elderly folk getting flu shots. The numbers are so far off that if actually used in the study, the study ought to be disregarded due to glaring inaccuracy. More likely is that the Bee is using a grossly inflated number to advance its own agenda. In 2001, the Centers for Disease Control and Prevention (CDC) estimated that during an average flu season, up to 20,000 Americans die as a result of influenza-related complications, and that number would likely double in a severe season. 40,000 Americans is a far cry from the half-million elderly cited by the Bee. The Denver Post uses 36,000 as the number and that number includes all ages, not just the elderly. Even 36,000 seems greatly exaggerated when you look at the actual numbers. In 2001, according to the CDC records, only 257 people died from the flu, and of those 257 people, 173 were 65 or older. To justify the 20 to 40 thousand numbers, the CDC says that a number of pneumonia caused deaths were really deaths caused by the flu because the flu led to the pneumonia.
According to the Bee, the experts in the study state that the vaccine system is failing because not enough of the frailest, sickest elderly patients who need vaccine get it, and the way to fix it is to give the vaccine to schoolchildren. If one only looks at the article in the Bee, the first thought is that if not enough of the frailest and sickest elderly are getting the vaccine, then an effort should be made to get it to them, instead of diverting it to the children, especially since the chances are that the number of schoolchildren is greater than the number of the frailest and sickest elderly. What the Bee does not mention is the much bigger point that the flu vaccine does not seem to be as effective in older people, which prompted the idea of vaccinating children.
The point that seems to be missed by the study, however, is that the frailest and sickest elderly patients are generally not in contact with schoolchildren. The frailest and sickest are already teetering on the brink of death due to their advanced age and whatever conditions they are already facing. If the flu doesn’t get them, something else soon will. The frailest and sickest elderly are more apt to catch a death-threatening cold just by sitting near an open window on a mild winter day. The vast number of elderly people that do interact with children are those elderly that are not the frailest and sickest. While their recovery time may be longer, they will not fall over dead after catching a cold.
According to the Sacramento Bee, the study says that giving the vaccines to the elderly does not prevent enough deaths, intimating that it at least prevents some deaths. The Denver Post states that the study shows that giving flu shots to the elderly does not reduce the number of deaths. While the wording may be suttel (BMTG official spelling), the implication is very different. One makes it sound like the vaccine helps, just not enough, while the other makes it sound like the vaccine does not help at all.
The bigger point should be to ask how big of a problem are influenza caused deaths in the elderly? According to the U.S. Census Bureau, there were 33 million people 65 or older in 1994, up from just 3 million in 1900. Projections are that the number of elderly would more than double, by the middle of this century, to 80 million. In 1994, about 1 in 8 Americans were elderly. In the year 2030, the projection is that about 1 in 5 will be elderly. The oldest old, described as those 85 or older, are a rapidly growing group and are projected to be the fastest growing part of the elderly population. In 1980, 3 out of 4 deaths among the elderly were from heart disease, cancer, or stroke. In 1991, the number was still high at 7 out of 10. If there were really more than 500,000 elderly dying every year from influenza, then perhaps we would have a real issue to consider. But if we consider the actual number, we quickly see that influenza is the least of their problems. Besides, despite our sadness at their death, at some point the elderly do have to pass on to make room for the next wave of elderly.
The Real Villain
What the study does not show is why the flu seems to get stronger and the
flu season seems to last longer each year. Every year that flu shots have
been in vogue, the outbreaks and intensity of influenza have gotten worse
and have lasted longer, making them harder to recover from and perpetuating
the spread. Perhaps this is not discussed because there is a strong possibility
that the flu vaccine itself is actually paving the way for more virulent strains
of influenza. As the vaccines fight off the viruses that cause influenza,
the strains are mutating and getting stronger. The flu vaccines are creating
a super flu that will only get stronger with each passing year. Eventually
the flu shots will become completely useless and influenza will cause whole
markets to close down due to the high number of incapacitated workers.
A Bit of Irony
On the same day of the release of the study, accused child abuser Michael
Jackson was admitted to the hospital with a severe case of the flu. Perhaps
if the plan to vaccinate all schoolchildren had been implemented, Mr. Nasty
himself would not have come down with the dreaded influenza.
New ideas in fighting flu
Sacramento Bee, Lisa Rapaport, February 15, 2005
Giving
flu shots to every school-age kid in the United States may be the best way
to prevent influenza deaths among the elderly, according to a study released
today by a team of researchers at the National Institutes of Health.
The study, published in the Archives of Internal Medicine, confirmed what many of the nation's top scientists, doctors and public health experts already knew: More than half of elderly patients in the U.S. today get flu shots, but influenza still kills more than a half-million people over age 65 every year.
"Vaccinating the elderly does not prevent enough deaths. We need to do better," said study author Lone Simonsen, senior epidemiologist with the National Institute of Allergy and Infectious Diseases. She recommended that every child ages 5 to 18 get an annual flu shot to help reduce the spread of flu.
The nation's vaccination system has failed because not nearly enough of the frailest, sickest elderly patients who need vaccine get it, Simonsen said Monday.
"We fix this by focusing more of our vaccination effort on the schoolchildren who will catch flu and transmit it to the elderly," she said.
One study is not enough to prompt the U.S. Centers for Disease Control and Prevention to advise otherwise healthy school-age children to get flu shots, federal officials told the Associated Press.
Currently, the CDC recommends vaccination for three groups of patients: infants under age 2, adults over age 50, and people with chronic health problems.
Dr.
Howard Backer, chief of the immunization branch of the California Department
of Health Services, said the idea of vaccinating healthy kids to prevent them
from contracting a disease they can pass to frail elderly people is not new.
But it is "an idea whose time has come," Backer said. However, state health officials have no plans at this time to recommend flu shots for healthy school-age children, he said.
"It is not feasible right now because we have a very limited vaccine supply."
This year, the nation's expected flu vaccine supply of 100 million doses was abruptly cut in half when manufacturing problems at a foreign plant prevented one U.S. supplier from delivering a shipment of 48 million doses. In response, federal, state and local health officials advised only the sickest elderly patients to get vaccinated.
Seniors waited for hours in long lines outside flu clinics. One California woman died while waiting for her shot.
After widespread panic about supplies running out, though, this season has turned out to be just like every other year in one respect: Clinics in California and around the country still have excess vaccine that will have to be thrown out if it's not used by the end of flu season in March.
"Every year for the last several years, we have had some sort of vaccine shortage and we have also had vaccine left over at the end of flu season," said Stuart Cohen, clinical director of infection control and epidemiology at UC Davis Medical Center in Sacramento.
"Given that some elderly people who need vaccine have no enthusiasm for getting it, I think it is legitimate to try and help those elderly patients indirectly by vaccinating children who might catch the flu and pass it on."
That approach, known as "herd immunity" has worked before, Cohen said.
Rates of measles, mumps and polio cases in adults dropped as an indirect result of widespread childhood vaccination programs. It could also work with flu, many in the medical community believe.
Sacramento County already is testing the approach, said Glennah Trochet, the county's chief health officer.
After three Sacramento-area schools closed for several days in 2003 due to high absenteeism during a severe flu season, county health officials got a vaccine donation from MedImmune, a California drug maker, to give free doses of the inhaled vaccine FluMist to students. A total of 378 kids this flu season got vaccinated at Washington Elementary School, Woodlake Elementary School and Noralto Elementary School, Trochet said.
While these and other efforts may well help prevent flu in the elderly, it would be a mistake to ignore the proven value of vaccine, said Steven Black, director of the vaccine study center for Kaiser Permanente.
The study just released, while a good impetus for debate, did not explain whether or not the elderly patients who died from flu had been vaccinated. It would be a mistake, Black said, to assume from this study that flu shots cannot prevent elderly deaths.
Study: Flu shots for elderly don't
save lives
Denver Post, Carla K. Johnson, The Associated Press, February 16, 2005
Chicago
- A new study based on more than three decades of U.S. data suggests that
giving flu shots to the elderly does not reduce deaths.
Led by National Institutes of Health researchers, the study challenges standard government dogma and is bound to confuse senior citizens.
During last fall's flu vaccine shortage, thousands of older Americans, heeding the government's public health message, stood in long lines to get their shots.
"There is a sense that we're all going to die if we don't get the flu shot," said the study's lead author, Lone Simonsen, a senior epidemiologist at the National Institute of Allergy and Infectious Diseases in Bethesda, Md. "Maybe that's a little much."
The study should influence the nation's flu prevention strategy, Simonsen said, perhaps by expanding vaccination to schoolchildren, the biggest spreaders of the virus.
However, the U.S. Centers for Disease Control and Prevention in Atlanta plans
no change in its advice on who should get flu shots, saying the NIH research
isn't enough to shift gears.
"We think the best way to help the elderly is to vaccinate them,"
said CDC epidemiologist William Thompson. "These results don't contribute
to changing vaccine policy."
The CDC currently recommends flu shots for people age 50 and over, nursing home residents, children 6-23 months, pregnant women, people with chronic health problems and certain health care and day care workers. When vaccine was scarce a few months ago, healthy people under 65 were urged to forgo the shot.
Although the study, published today in the Archives of Internal Medicine, looks at data from the whole U.S. elderly population over time, it doesn't directly compare vaccinated vs. unvaccinated elderly, Thompson said. Previous studies that made that comparison found the vaccine decreased the rate of all winter deaths.
It's also unlikely that a single study would trigger a change in policy, said CDC spokesman Glen Nowak.
But the former head of the nation's vaccine strategy, Dr. Walter Orenstein, said Simonsen's work "should make us think twice about our current strategy and (about) potentially enhancing it."
Orenstein is former director of the CDC's National Immunization Program and now leads a program for vaccine policy development at Emory University.
A shift to vaccinating schoolchildren, the age group most likely to spread the flu virus, is advocated by colleagues of Orenstein's at Emory in a separate report to be published Tuesday in the American Journal of Epidemiology.
The NIH and Emory papers, one a highly technical statistical analysis of death data and the other a commentary based on field studies and mathematical modeling, come during a season that focused the nation's attention on vaccine supplies.
As a vaccine shortage loomed last fall, the CDC urged shots only for the
highest-risk groups. Most of the 36,000 people who die each year of flu-related
causes are elderly and the nation's strategy has focused on getting shots
to them, as well as other high-risk groups.
Last week the CDC reported that about 59 percent of older Americans got shots
in 2004, down from 65 percent in 2003.
Based on her research, Simonsen doesn't expect to see a corresponding increase in flu-related deaths this year, something that "can be seen as good news."
The flu vaccine is less effective in the elderly than in younger people. It works, but not very well, said Ira Longini, a biostatistics professor at Emory University's Rollins School of Public Health and a proponent of vaccinating schoolchildren.
While it's smart for senior citizens to get their yearly flu shots because it can decrease their risk of getting sick, he said, a smarter government strategy would emphasize shots for children, ages 5 to 18. His statistical models show that strategy could save more elderly Americans from hospital visits and death.
"If we really want to make a difference and control influenza, we simply have to change the policy. We have to vaccinate large numbers of children," Longini said.
He and his colleague Dr. Elizabeth Halloran write that if 70 percent of schoolchildren were vaccinated, the elderly would be protected without flu shots. The strategy would require 42 million doses of flu vaccine. Even during this season's shortage, there were 57 million doses available, their report says.
Yearly flu shots have been recommended for people 65 and older since the 1960s and for those 50 and older since 2000. Vaccination rates have risen among seniors from 20 percent before 1980 to 65 percent in 2001, according to the NIH study.
Simonsen and her team of researchers could find no corresponding decrease in death rates. Their analysis took into account the fact that people are living longer and that more virulent strains of flu dominated the 1990s.
The CDC's Thompson said Simonsen didn't take into account the effect of a gradual lengthening of the average flu season over the decades. But Simonsen said that no matter what model she used to define a flu season, she came to the same result.
Older Americans should keep their risk in perspective, said Dr. Lisa Schwartz and Dr. Steven Woloshin, senior researchers at the VA Outcomes Group, a small group of researchers trying to promote the straightforward presentation of medical information.
For the average senior citizen, the annual risk of dying from the flu is low: about 1 in 1,000. They said senior citizens still should try to get flu shots, but shouldn't panic if vaccine isn't available.