Thursday November 22 2012
The UK flu vaccine programme has prevented deaths
As flu season approaches, claims that the flu vaccine is a 'waste of money' are being widely reported. The Daily Telegraph declares that 'flu vaccine effectiveness [is] exaggerated,' while the Daily Mail claims that 'flu jabs are a 'waste' of taxpayer's money.'
Both headlines are exaggerations based loosely on a new report from researchers at the University of Minnesota.
While the news stories go on to offer measured coverage of the report, the suggestion that the vaccine is of limited effectiveness in older people and a 'waste of money' is spurious and misleading when read out of context in the headlines.
The report by a team of researchers at the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota covers multiple aspects of the flu vaccine in the US. It includes evidence of the vaccine's effectiveness, research and development efforts, vaccine production, and policy surrounding who gets the vaccine.
While the flu vaccine is not 100% effective, the flu vaccination programme in the UK has proven effective at preventing deaths. Claims that the flu vaccine is in some way over-hyped are based on the report's finding that the perceived level of effectiveness may be putting vaccine manufacturers off investing in research into new types of flu vaccine.
Multiple strains of the flu virus may be circulating in any given year. Current efforts to prepare for and combat flu epidemics include the widespread production and use of a yearly flu vaccine. This vaccine is developed to protect against three strains of the virus that experts predict will circulate during the upcoming winter flu season.
How effective is the flu vaccine?
The UK Department of Health (DH) reports that the current trivalent inactivated influenza vaccine (the seasonal flu jab) has an overall efficacy, or success rate, of 59% among adults aged 18 to 65 years. Protection may be lower in the elderly. The type of flu vaccine recommended for children (a 'live' vaccine as opposed to an inactivated vaccine) is thought to be more effective, with a reported efficacy of 83% for children. The DH figures correspond with those reported in the current CIDRAP report.
Who produced the report?
The report was produced by the Center for Infectious Disease Research and Policy (CIDRAP). CIDRAP is a research unit based at the University of Minnesota in the US, which says it aims to "prevent illness and death from infectious diseases through epidemiological research".
CIDRAP carried out an extensive review of flu vaccine efforts. The report authors reviewed studies published between 1967 and 2012 that looked into the effectiveness of flu vaccination. This report covers:
- the scientific basis of the vaccine, including research and development, and the safety and effectiveness of the annual vaccine
- the implementation of annual vaccination programmes, including the financing, manufacturing and distribution of the flu jab
- policy and communication regarding the annual flu jab, including details on public education programmes, acceptance of the jab among patients, and public policy surrounding the vaccine
What were the main findings of the report?
The CIDRAP review reports 10 key findings, only some of which feature in current media coverage.
The report says that the current flu vaccine offers "substantially lower" protection than that offered by most routinely recommended vaccines. However, the report has concluded that during some flu seasons, the jab offers substantially more protection for most people compared with not being vaccinated at all.
It says that for one form of the vaccine (trivalent inactivated influenza vaccine, or TIV) the evidence surrounding protection varied:
- among children aged of 2-17, they found inconsistent evidence of vaccine protection
- among healthy adults (aged 18-64), the vaccine offered moderate protection (approximately 59%).
- there was limited evidence of TIV effectiveness for people over the age of 65
For the other type of vaccine (live attenuated influenza vaccine, or LAIV), CIDRAP found:
- evidence of high protection (approximately 83%) among children aged six months to seven years
- a lack of evidence for protection among people aged 8-59
- limited evidence among adults over the age of 60
The review found that commonly cited figures regarding flu vaccine effectiveness are largely based on studies with poor methodology, and studies employing better methods have not reported protection levels as high. The authors suggest that this perception of vaccine effectiveness prevents research into the development of highly effective vaccines.
Over the last 50 years in the US the groups of people recommended to receive the annual flu jab have expanded beyond those at high risk of complication. The study authors report that these recommendations were often based on professional judgement and not scientific evidence.
New approaches to flu vaccine development may offer increased protection against seasonal flu, but more research support is needed to determine whether these approaches could result in "game-changing vaccines".
The media did not cover the report findings concerning vaccine policy, financing, production and distribution.
What recommendations did the report make?
The CIDRAP report recommends:
- Research efforts should focus on developing new "game-changing" vaccines that offer high levels of protection against both seasonal and pandemic flu. These vaccines should show increased effectiveness for populations at high risk of severe illness or death, while maintaining at least the same levels of safety as current vaccines.
- Estimates of current flu jab effectiveness based on methodologically strong research should be used in all vaccine policy. The authors recommend that international standards for determining vaccine effectiveness are developed so that all policy is based on the same quality level of evidence.
- Vaccines against pandemic flu should achieve high levels of protection, be based on new international standards of effectiveness, and be available in the quantity necessary to protect populations around the world either before or during the early stages of a new pandemic.
- New regulatory, investment and production strategies should be developed to support the development of highly effective flu vaccines.
- The US should take on a leadership role in developing new vaccines, and the World Health Organisation (WHO) and other international agencies and governments should support this US-led effort.
- New international standards of evaluating vaccine effectiveness should be used to assess whether vaccines offer good value for money.
These are broad recommendations and it is unclear at this point how and whether they will be implemented.
How accurate was the media's coverage of the report?
The media coverage of this report in the UK was poor for two main reasons:
- there was no acknowledgment that this report was primarily aimed at a US readership and is based on the situation in that country
- all of the report's claims were taken at face value, with no attempt made at subjecting the claims to any kind of critical analysis
Due to both of these facts, there are a number of important points that need to be stressed:
- According to the CIDRAP, in the US the current recommendations for flu vaccination are that everyone over the age of six months is vaccinated. The same is not true in the UK, where only high-risk groups, such as pregnant women, are recommended that they receive the vaccine. These two different approaches to flu vaccination programmes may reflect different value for money, given the moderate effectiveness of the flu vaccine.
- The report states that the medical and health policy communities in the US tend to believe that the current flu vaccine is largely effective. They speculate that such beliefs could lead to "overselling" of the vaccine, despite evidence regarding its moderate effectiveness. The risk of such overselling may be lessened in the UK, as the Department of Health is entirely transparent about the effectiveness of the flu vaccine and actually quote many of the statistics included in the CIDRAP report.
- The report makes repeated reference to the need to produce a "game-changing vaccine" – that is, a vaccine that can adapt to the flu virus' ability to mutate. But as yet there is no evidence that the production of such a vaccine is feasible, or whether such a vaccine would be safe and effective.
- The media makes repeated claims that the flu vaccine is "far less effective in the elderly". This is not actually an appropriate reflection of the review's findings. The review says that there is "limited evidence" surrounding the effectiveness of the vaccine in the elderly – this is not the same as "limited effectiveness" in this group. Absence of evidence is not the same as evidence of absence.
Overall, the report found that while the protection offered by the current annual flu jab is less than ideal when compared to other vaccines, for most people it is still better than not being vaccinated.
The report certainly does not conclude that flu vaccination be abandoned, or is a "waste of taxpayer's money".
But it does suggest that a new approach be taken to the development of the annual vaccine by both drug companies and governments, so that the protection it offers can be brought up to the standards we see with jabs for other diseases.
The report also recommends that more resources need to be put aside so that in the event of a future flu pandemic an appropriate vaccine can be produced quickly and distributed to the public.
Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on twitter.