The Flu Shot: Myths and Mysteries in the 2020/2021 season

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I have been receiving a lot of questions lately about the 2020/2021 seasonal flu shot. This is because the call has gone out to the public that having a flu shot is one of the steps that can be taken to combat COVID-19.

“Everyone above the age of 6 months should be getting the flu vaccine,” said Dr. Uchenna Ikediobi, an assistant professor of general internal medicine and infectious diseases at Yale University. According to the The New York Times: “Growing concern over the combined impact of the two viruses [flu and COVID-19] has even led some to mandate the vaccine. The University of California system announced this month that it would require all its employees and students to get a flu shot by Nov. 1. And Massachusetts is requiring all students between 6 months and 30 years old to get the flu shot by the end of the year.”

Personally, I’m not a proponent of mandating vaccination unless you are in the military and face the potential of biologic warfare. Moreover, it seems that mandates cause an unintended backlash insofar that those with strong feelings about being told what to do (but who may otherwise be ambivalent about vaccination itself) find themselves in a position of refusing to be vaccinated.

Additionally, flu vaccine efficacy hasn’t been all that great in recent years (Figure 1) below. In fact, for the 2017/2018 season it was less that 20% effective for all age groups. Of course, we will not know the effectiveness of the 2020/2021 vaccine until the season has ended. Nevertheless, mandating a vaccine with 90-95% effectiveness seems like an easier task than mandating one with at 20-40%.

Each year, we take early cues of flu season severity from Australia. Unsurprisingly, with COVID-19 mitigation efforts in full swing, the Australia Department of Health reports “Following a high start to the 2020 interseasonal period, currently, influenza and influenza-like illness (ILI) activity are lower than average across all systems for this time of year. At the national level, notifications of laboratory-confirmed influenza have substantially decreased since mid-March and remain low.” They conclude, ” it is likely that there is minimal impact on society due to influenza circulation in the 2020 season.” There have been 36 deaths attributed to influenza in Australia this season.

As noted above, US public health officials are concerned about the potential dual effect of Covid-19 and influenza (so called “twindemic”) that will further overburden hospitals and testing locations. For me, being able to distinguish between COVID-19 and influenza became of primary concern – given the significant overlap of symptoms and that we have effective treatment for influenza. To this end, we have point-of-care testing both for COVID-19 and influenza available in the office.

Timing of the flu shot is important as well. Many retailers such as retail pharmacies already have flu shots in stock and are advertising its availability. Here at Santa Monica Primary Care, we don’t purchase in quite such large volumes so receive our flu shots a bit later in the year – but expect to have them in stock in the next week or so.

Buried in the CDC guidelines (now I’ve bashed the CDC response to COVID-19 but they have a good track record when it comes to influenza) is a short statement on timing. “Make plans to get vaccinated early in fall, before flu season begins. CDC recommends that people get a flu vaccine by the end of October. However, getting vaccinated early (for example, in July or August) is likely to be associated with reduced protection against flu infection later in the flu season, particularly among older adults.”

Each year, Columbia University School of Public Health runs a predictive model of influenza by major US metropolitan area. I have been using this resource in clinical planning for the last several years and have found it to be spot on. This year, in Los Angeles, they predict flu cases to peak the week of December 22nd (https://cpid.iri.columbia.edu/). Cases are at a very low level in September and October and begin to risk in mid-November. I would expect a much lower volume of flu cases given significant decrease in travel, closed schools as well as widespread COVID-19 mitigation efforts.

Additional CDC fine print pertains to the “high dose” Fluzone Quadrivalent flu vaccine approved for people 65 years and older. While there are studies suggesting that this formulation may reduce flu-related hospitalization, “The CDC and its Advisory Committee on Immunization Practices have not expressed a preference for any flu vaccine indicated for people 65 years and older.” Some adverse events were reported more frequently after vaccination with trivalent Fluzone High-Dose than after standard-dose inactivated flu vaccines. But most people had minimal or no adverse events after receiving the Fluzone High-Dose vaccine. We do not stock the high-dose vaccine in our clinic, but retail pharmacies do routinely carry this formulation.

So, to sum up, what do I recommend?

1. Get a flu shot – whether it is mandated or not. Hopefully it works more like 2016/2017 than 2017/2018.

2. Have your kids get a flu shot – the vaccine has worked better in ages 2-17 in every year.

3. Get one before October – but remember the month of September tends to go by very quickly.

4. If you are over 65 – get a flu shot. Either the Fluzone Quadrivalent or the standard-dose.

5. Buckle up for peak flu season in Los Angeles to be in late December / early January

6. If you have fever, chills, or any symptoms that could be flu or COVID-19, call our office – we can distinguish between the two.

references:

https://cpid.iri.columbia.edu

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