Notes from the Medical Director

How bad can the flu get?

Flu season is challenging. First, we need a new flu vaccine every year because the flu virus is always changing.  Before each flu season, a new flu vaccine is developed to match the flu strain that scientists expect will be dominant during the upcoming season. Then, vaccine producers start manufacturing the vaccine and distribute it all over the world. Finally, local public health professionals like us here in Philadelphia work hard to remind everybody to get a flu vaccine as early as September to make sure everyone is protected before flu arrives.

From vaccine development to vaccine delivery, it is a large amount of work. But it is important work because flu is serious, every year. During the height of a bad flu season, up to 8% of all emergency room visits in the USA – 1 out of every 12 – is somebody who’s sick with the flu and hundreds of thousands of people are hospitalized with illness caused by the flu. Last year’s flu season killed an estimated 80,000 people in the USA.

Despite flu’s severity every year, too few people get the flu vaccine – immunization rates hover around 40% in the USA. Why? Often, I think we underestimate how bad flu can be. We call lots of things ‘the flu,’ including milder infections like the common cold. That can lead us to think that the flu does not really make you very sick. But influenza can invade your lungs and make you feel horrible. In severe cases, your lungs can get so inflamed that they stop working.

The worst example of how bad the flu can get was the 1918 flu pandemic. It was so bad that “cities ran out of wood for coffins” as the virus killed 3 to 5 percent of the world’s population – an estimated 50 to 100 million people. The 1918 pandemic was caused by a new strain of influenza. We have had pandemics since that time and will probably have more the future. And we will continue to have flu epidemics every season. While we now have more tools to prevent and treat influenza, we need to keep being prepared and keep working to reduce the toll that the seasonal flu takes on our population.

To help, we’ve got a Flu Toolkit that health care providers can use to boost flu vaccination rates at their clinics this fall and winter – and, of course, resources for Philadelphia residents to Get Your Annual Flu Shot.

Notes from the Medical Director

The historical impact of vaccines

It can be so easy to lose sight of the incredible impact that vaccines have had on our society. Mike Bostock, a data visualization specialist, reminds us of the history of the measles vaccine with the data visualization below.

Measles used to be incredibly common, but when the vaccine was introduced to the US in 1963, cases plummeted. Bostock’s visualization shows this clearly: moving from left to right, the darker colors begin to fade, just as the number of cases in each state decline immediately following the introduction of the vaccine.

If there are so few measles cases in the U.S., do we still need to maintain high immunization rates? Yes. The dramatic impact of measles vaccine introduction is testament to both the individual and community effects with immunizations.  Vaccinated children were no longer getting infected themselves, and they could no longer spread measles to others.  But to see the community effects of measles vaccines, we do need high vaccination rates.  Measles is one of the most contagious vaccine-preventable disease out there so almost everyone needs to be protected to stop transmission.  When we keep our measles vaccination rates above at least 92%, we eliminate measles outbreaks.

Measles still affects about 20 million people per year worldwide.  No other vaccine-preventable illness causes as many deaths.  Most cases occur in developing areas of Africa and Asia but there are also tens of thousands of cases in several European countries due to decreasing immunization rates. In fact, the Centers for Disease Control and Prevention has issued travel advisories for places from which many of us may receive visitors or visit ourselves.  So the likelihood of being exposed to measles is very real.  If communities do not maintain high immunization rates, outbreaks can happen here as well.

Here at the Philadelphia Department of Public Health, we’ve done similar work to highlight the history of vaccines and their important public health impact. The history of vaccine-preventable diseases in Philadelphia shows how these diseases used to kill nearly 3,000 Philadelphians per year. As more vaccines were licensed and distributed, this death toll fell steadily until the modern era, when vaccine-preventable diseases only kill 11 Philadelphians per year.  Let’s work together to make sure these trends don’t change.

Measles in the USA

Notes from the Medical Director

Is it time for a Lyme vaccine?

The New York Times recently reported what we’ve seen for several years now: that Lyme disease and other tick-borne diseases are spreading.

The US Centers for Disease Control and Prevention (CDC) and the Environmental Protection Agency (EPA) have both observed that Lyme disease has been rising. In fact, since 1990, Lyme disease cases in the USA have tripled.

So what’s going on? Well, climate change is probably a factor. Lyme disease is spread by blacklegged ticks, which are commonly found on deer and white-footed mice. Because of changes in weather patterns, their habitat is expanding – and, milder winters mean that fewer ticks die off each winter.

Health officials are pretty sure that this is only going to get worse. Whether you spend time in city parks or live in wooded areas, it is possible to find blacklegged ticks – and there are things we can do to prevent getting bitten by ticks.

What about a Lyme vaccine?

In 1998, a vaccine for Lyme disease was released. Four years later, the company that made it took it off the market: it just didn’t sell very well. There were concerns that the vaccine could be linked to autoimmune diseases, even though all of the studies about the vaccine found that it was safe. Plus, a lot of health care providers were unclear about who should get the vaccine.

That was several years ago. Now, with Lyme disease on the rise – and expected to continue rising – there are initiatives to develop a new vaccine to prevent Lyme disease and to also potentially prevent other infections spread by ticks. If a vaccine comes to market, then the US Advisory Committee on Immunization Practices (ACIP) would review the evidence and make recommendations about who should get the vaccine, and when.

Lyme disease can be serious – people with the disease can have symptoms that range from a rash to joint swelling to neurologic symptoms. No matter how it presents, Lyme disease is treatable and responds well to antibiotics, but it can sometimes take time for symptoms to go away completely. And while the CDC counts about 30,000 people per year in the USA getting Lyme disease, they’re pretty sure that the actual figure is much higher – up to ten times higher – due to cases not getting properly diagnosed or reported.

This is the time to build up our prevention tool box for Lyme disease. Preventing its spread will take a lot of different strategies: teaching the public to prevent tick bites, developing better insect repellents, and reducing tick habitat around people’s homes. But adding a vaccine to our prevention options could be another powerful tool.

Notes from the Medical Director

The return of the flu spray: what changed?

For the 2018-19 flu season, the Advisory Committee on Immunization Practices (ACIP) added the intranasal live-attenuated influenza vaccine (LAIV) back to the list of recommended flu vaccines for children and adults. The LAIV is a flu vaccine given as a nasal spray instead of as a shot – which a lot of patients liked.

LAIV, the flu spray, was fist introduced in 2003. It initially appeared to work really well in children, so in 2014, the ACIP made a recommendation to prefer it. But 2 years later, they changed their minds, recommending against it for the past few seasons because of LAIV’s poor effectiveness.

So what changed? Why is it being reintroduced now? Let’s take a deeper dive.

How is LAIV different from other flu vaccines?

Most flu vaccines are “inactived influenza vaccines,” or IIVs. These are made by growing the flu virus in eggs, purifying it, and then inactivating the virus – killing it. It’s then given as a shot that teaches our immune system how to respond to an actual live flu virus – even though the IIV can’t reproduce to cause a flu infection.

We’ve been using this method to make flu vaccines since the 1940s. Since the flu virus changes each year, we have to make a new vaccine each year so that the vaccine matches up with the flu strain that’s likely to emerge most strongly each year.

• IIV: inactivated virus, given with a shot
• LAIV: weakened virus, given with a nasal spray

Unlike the IIV, the LAIV (live attenuated influenza vaccine) is made by growing the flu virus in egg cells, and then just weakening it instead of inactivating the virus. It’s then given as a nasal spray instead of a shot – and the weakened virus can reproduce just enough to spark an immune response in a patient’s body. Though the virus is live, it’s too weak to cause infection; and since it’s administered in the nose – which is how a lot of people are exposed to the flu – it can be an especially effective way to provide protection: following the same path the disease would follow.

So why was the LAIV removed from the list of recommended vaccines in 2016?

When LAIV was first introduced, it did appear to work a little better, especially in children. So in 2014, the ACIP gave LAIV a preferential recommendation – preferring the spray over the shot.

Shortly after that – once the spray was used more widely – the ACIP’s research showed that the spray stopped working as well as it initially did. For 3 years in a row, the spray didn’t perform any better than the shot. In fact, it was less effective. So, while the CDC worked to understand what happened, the ACIP removed their recommendation for the spray (LAIV).

So what happened?

Every flu vaccine protects against 3 to 4 strains of the flu. And, the CDC found that one of the flu strains in the spray didn’t reproduce well enough to spark a good immune response in patients. Since the spray relies on weakened but live virus to reproduce in order to trigger protection in a patient, this was a problem.

This flu strain was H1N1. We had several seasons where a lot of the flu disease was due to H1N1 – so the spray just didn’t provide as much protection as originally hoped.

Okay – so now the spray is back?

Yes. Once the CDC figured out the problem with the spray, the vaccine manufacturer replaced the H1N1 strain – which wasn’t reproducing well – with another strain that works better. They also checked to make sure that there’s a good immune response to the new LAIV.

The ACIP reviewed all of the changes and felt that the problem was addressed – so the spray was added back to the list of recommended flu vaccines for anyone between age 2 and 49.

Even though the ACIP recommends the spray, the American Academy of Pediatrics recommends the shot. Why do they disagree?

When the ACIP reviewed information about the new version of the spray – including studies on the spray’s effectiveness from other countries that continued to use it – they felt that the strong immune response was a good sign that the spray should work at least as well as the shot.

The AAP was also reassured, but they wanted to see more information on protection against the actual disease before they strongly recommended it. So, they decided to recommend the inactivated vaccine (the shot) over LAIV (the spray) until we learn more about the spray’s effectiveness once it’s used more broadly.

So what should I do?

Offer both vaccines.

The effectiveness of the flu vaccine always varies from year to year as researchers try to match the vaccine to the flu virus that they expect to dominate the flu season. Despite varying effectiveness, vaccination is our best method of protection against this virus that kills tens of thousands of people in the USA each year. Since some people decline the flu vaccine because of a fear of injections, having the spray available may increase the likelihood that patients will accept the vaccine.

Patients look to us – health care providers – to listen to their concerns and make recommendations that will keep them healthy. So let’s offer them choices that can help protect them, and let’s remind them that we get our flu vaccines to protect ourselves, our children, our patients, and our community too.