Elderly may overrate shots
At 67, Helen Wong hasn’t missed her annual flu shot in years. She also hasn’t been seriously sick in years. Wong is pretty sure there’s a connection between those two facts, and she’ll be sharing that conviction this fall with fellow members of her fitness club at the Glassell Park Senior Center, five miles north of downtown Los Angeles.
When it comes to flu vaccination, there are always doubters, says Wong, a resident of Glassell Park and a regular at its senior center. But on Nov. 1, when the center holds its annual flu immunization clinic, Wong expects that many of her peers will line up for the shot.
“I’m finding confidence growing,” she says, in the long-advertised benefits of the vaccine for older people -- that it drives down the odds of catching the flu, of developing complications from the illness such as pneumonia, of dying.
Among medical researchers and health professionals, however, confidence in those benefits has turned in the opposite direction. After six decades of steadily expanded use among the elderly, flu vaccination for seniors has come under critical scrutiny in several studies. Collectively, they suggest that for those over 65, flu vaccination may confer fewer benefits than have been widely advertised.
Researchers like Lone Simonsen of George Washington University say that the new skepticism is overdue. The medical profession’s wariness should have been piqued by a simple but glaring disconnect, says Simonsen, a former epidemiologist for the National Institute of Allergy and Infectious Diseases: Flu vaccination rates among American seniors have risen more than fourfold over 25 years -- to 65% in 2007. During the same period, however, hospitalization for, and death due to, flu and pneumonia appear to have declined only marginally in the nation’s 65-and-over population. It just doesn’t add up, she says.
“If I could have it my way, we would start by going back and looking at the basic premise for flu vaccination of seniors,” says Simonsen, the author of one of the first studies to question the vaccine’s benefits for seniors.
Studies on the effectiveness of flu vaccine in older populations have had a wide range of methodological problems, says Simonsen. But although their weaknesses are varied, their effect is almost invariably skewed in one direction, she says: The studies have produced a view of vaccination that is “is far too rosy.”
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Evidence disputed
Since the late 1950s, when flu vaccine became widely available to Americans, a belief in the vaccine’s lifesaving benefits for older people has been the cornerstone of the nation’s immunization policy, a perennial conclusion of published medical studies and an article of popular faith. Not surprisingly, then, the studies that cast doubt on those benefits have been met with concern and hostility.
“These studies are acknowledged to be less specific. More specific studies show clear evidence of effectiveness in individuals and subpopulations,” says Dr. William Schaffner, chairman of Vanderbilt University Medical School’s department of preventive medicine and an executive board member of the Infectious Diseases Society of America. Schaffner acknowledges that among those over 70, flu vaccine often produces a weak response. “If we wait for something much better, we are missing the opportunity to provide some protection for people who need it.”
Helen Wong says she recognizes that for some fellow seniors, the flu vaccine does not appear to provide the kind of robust protection she believes she has enjoyed.
“I cannot say that it will help everyone in the same way it has helped me,” Wong says. Other people her age, she adds, “should also be cautious” and understand that the vaccine will not ward off all sickness. “But I would tell them it has helped me.”
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Flawed fatality count?
The centers for Disease Control and Prevention estimate that flu kills about 36,000 Americans annually. But while that shocking figure seems straightforward enough, calculating the totals of death by flu is anything but. For most of those counted as flu fatalities, pneumonia -- a frequent complication of flu -- is listed as the cause of death.
For those 65 and older, the lesson is clear: A dose of pneumococcal vaccine is a good way to bolster protection among those at risk of suffering complications of flu. A single dose, says the U.S. Department of Health and Human Services, can protect against 23 types of Streptococcus pneumonia bacteria thought responsible for causing more than 90% of pneumonia cases.
The latest of the critical studies, published in the Aug. 2 issue of the Lancet, followed the cases of 3,519 patients over age 65 -- all admitted to the hospital with pneumonia either during or just before the flu seasons of 2000-2002. After separating those who had been vaccinated against flu from those who had not, and accounting for other health factors, the study found that the group that had been immunized against flu appeared no less likely to develop pneumonia requiring hospitalization than those who had not.
On the heels of that study came a second, conducted by Canadian researchers, that looked at the death rates of elderly hospitalized patients with pneumonia. About 8% of the patients vaccinated for flu died, compared with 15% of the nonvaccinated patients.
But when researchers paired patients of similar age and health status and then looked at their comparative likelihood of dying, they found that age and frailty -- not flu vaccination -- seemed to account for which patients were most likely to die of pneumonia during flu season. At the same time, they noted, seniors who were younger, more active and generally in better health were more likely to be vaccinated.
The study’s lead author, Dean T. Eurich of the University of Alberta School of Public Health, concluded that past studies likely attributed to vaccination the benefits that actually come from what he called the “healthy user effect”: Seniors who get vaccinated against flu -- like Helen Wong -- tend to be younger, healthier, more active and better able to take better care of themselves. For those reasons -- not flu immunization -- they are less likely to succumb to pneumonia, Eurich said.
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Shots recommended
Both Simonsen and Schaffner agree that the current dispute among experts should not sway seniors inclined to get the shot from doing so. With a vaccine that is safe and easy to get -- this year at least -- some protection against flu is better than none at all, they say. (Many people don’t seem to know that a dose of pneumococcal would benefit them as well.)
“No one is saying don’t vaccinate seniors. It would be imprudent to do that,” Simonsen says. Indeed, several studies have pointed to the need for community groups, hospitals and nursing homes to step up their efforts to vaccinate frail and elderly patients at highest risk of dying if they contract the flu.
But clinging to inflated measures of effectiveness discourages public health officials from exploring and encouraging better vaccines, more effective ways of administering them, and improved vaccination policies to protect the elderly, Simonsen says.
The decision to recommend the widespread vaccination of schoolchildren is one way to protect seniors from flu, with its complications of secondary infections, hospitalization and death. Meanwhile, the poor response that many older patients have to the vaccine -- a function of their immune system’s decline -- suggests other improvements that could be made.
New vaccines, higher doses of existing vaccines and vaccine formulations with additives designed to jump-start the immune system -- have been tested and have shown promise in boosting seniors’ immune response, Simonsen says. But they are moving slowly toward adoption by government officials and the medical profession.
“We’re not limited by technology. We’re limited by studies that say everything is fine,” Simonsen says. “If the system is broken, we can fix it. But if we don’t know it’s broken, we can’t.”
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Facts and figures
5% to 20% -- Portion of U.S. population that gets the flu each year
200,000 -- On average, Americans hospitalized with flu complications each year
36,000 -- On average, Americans of all ages who die of flu complications each year
83 -- Children who died of flu complications in the 2007-08 flu season
261 million -- Number of Americans for whom the flu vaccine is currently recommended
22.1% -- Children ages 6 to 23 months who were fully vaccinated last year
16.5% -- Children ages 24 to 59 months who were fully vaccinated last year
42.0% -- Adults ages 50 to 64 who were vaccinated in 2006-07
72.1% -- Adults age 65 and older who were vaccinated in 2006-07
146 million -- Doses of flu vaccine that will be manufactured this year; an all-time high
Source: Centers for Disease Control and Prevention. Data reflect most recent years for which statistics are available.
About the vaccine
This year’s vaccine contains A/Brisbane/59/2007(H1N1)-like virus; A/Brisbane/10/2007 (H3N2)-like virus and B/Florida/4/2006-like virus
Resources
For more information on influenza and protecting yourself from the disease, see the CDC’s flu page at www .cdc.gov/flu/.
To find a flu clinic, see the American Lung Assn.’s clinic locator at www.fluclinic locator.org. Also, Maxim Health Systems holds 25,000 flu clinics nationwide; locations can be found at www.findaflushot.com.
