It's Never Too Late to Get a Flu Shot ... Or Is It?

The cheery reminder of “It’s never too late to get that flu shot!” has been popping up on the media lately. Is it correct?

Well… yes and no. From a medical standpoint, it’s true. While an eleventh-hour flu vaccine given to you or your child after influenza has already hit your community won’t protect you as well as if you had received it months ago, it will still give you a measure of protection. How much protection simply depends on the interval between when you got the vaccine and when you personally are finally exposed to the flu. That’s fairly impossible to predict without knowing a lot of other variables. So yes, if you can get a vaccine this late in the season, it is still totally worth doing so. While we are finally experiencing intense flu activity here in Oregon, we haven’t been inundated with it the way the East Coast has, and if you are careful about your exposures and your handwashing, your flu vaccine still has a good chance that it can protect you before flu crosses your path (unless you are a health care worker or a teacher, in which case you have almost certainly been exposed already multiple times).

But there’s a big ‘if’ in that statement. IF you can get a vaccine, it will still help.

Why the ‘if’? Well, it’s January, and many medical offices have either used up their stock of vaccine — and are unable/unlikely to get more — or will soon be running out. As I write this, we still have some vaccine but we aren’t sure how long it will last or how much more we will be able to get. Eventually we too will run out. We might be able to get more, we might not; if we do keep ordering more, we also run the risk that the flu shot frenzy will die down before our supplies run out. That leaves us with unused vaccine, and that’s an expensive proposition.

This article from the FDA is a nice explanation of the science and technology that’s involved in making the flu vaccine every year. I think it’s all rather exciting: the idea of the world’s infectious disease experts getting out their Magic Eight-Balls and making trips to Hong Kong to try to predict which strains will strike us sets my nerdy little heart thumping. I’d love to be a fly on the wall for that. But what the FDA summary doesn’t mention, and what most news stories about flu vaccine leave out, is the rest of the guesswork that’s involved.

How many people will queue up to get the flu vaccine? And when? Will the public flock obediently to their doctors’ offices in early fall, the way we always urge them to? Or, lulled into a sense of false security by a couple of mild flu seasons, will they keep putting it off? If they don’t bother to get the vaccine one year and there isn’t widespread disease, will they be even less likely to bare their arms for a poke the following season?

And when the news media starts showing footage of overwhelmed emergency departments in the big cities, will the public suddenly feel motivated to get vaccinated?

These aren’t questions that can be answered easily by the use of science… at least, not by the kind of science that involves going to the Far East and getting samples from pigs and chickens. Now we’re dealing not with virology and epidemiology, but sociology — human nature — and economics. Human beings, in their own way, are more maddeningly unpredictable than viruses any day.

So after the big brains at the CDC and elsewhere have consulted the stars, tossed the bones, and sacrificed the chickens to study the entrails (okay, not really… after they have Done Their Research) and told the world which strains should be included, then the manufacturers of the vaccine have to make their best predictions of vaccine demand for the coming season. What a lot of people don’t realize is that in this country, the flu vaccine — and routine childhood vaccines — aren’t made by the government, but by for-profit businesses. They want to keep their production of the vaccine high enough to meet the demand, so as not to miss out on sales of vaccine, but they don’t want to overshoot and end up with a lot of unused product. Since the flu vaccine is different every year, leftovers from this season aren’t something that the manufacturers can just keep on ice for next year.

The same process happens on a smaller scale in your doctor’s office. Every year, months in advance, we place our orders. Usually we base the numbers on how much vaccine we were able to give out the previous season. It’s especially complicated for pediatric offices, because there are different vaccine doses for the youngest children versus the older kids. In offices like ours that see both commercially insured kids as well as clients on the Oregon Health Plan, we have to order both from the commercial suppliers and the federal Vaccines for Children program. And then there’s the option of FluMist, the intranasal live vaccine, as well. Somehow, in a process that I don’t even begin to understand, our nursing staff makes their best guess and places the initial orders.

Vaccine usually arrives in late August, and as soon as we have vaccine in all of the necessary categories we put out the call and start vaccinating like crazy. I’m proud of our patients: every year you seem to come in earlier and every year we are able to vaccinate more children (and their parents, when desired) against the flu. It’s wonderful. But it could be better, and this year illustrates exactly why.

Remember the H1N1 influenza epidemic of the 2009-2010 season? That was the year when the novel strain of flu hit first in April 2009, then went underground for a few months only to re-emerge in the fall with a fury that most of us in the healthcare world had never seen before. Usually February is the busiest month of the year for us, but October 2009 broke all previous records for us for the sheer number of patients seen. (Because of what may possible have been the best vacation timing of my career, I ended up spending the very worst week of the season on a working cattle ranch in eastern Idaho; after up to ten hours a day in the saddle for a week a nice flu epidemic back home didn’t sound so bad.) Vaccine production was thrown for a loop and we had two different vaccines to worry about, in addition to all the other variables. First we got the seasonal vaccine the experts had already recommended, then the H1N1-specific vaccine. Or maybe it was the other way around; it’s all a blur now.

Patients packed EDs and office waiting rooms. Lines for the vaccine wrapped around the block. Many offices, including ours, removed toys and books from the waiting rooms and exam rooms to help stop the spread of the flu. Schools closed entirely in some places due to the disease burden. Masks were handed out at the front desk when appropriate. Everyone wanted both the vaccine and antiviral medications if they did get sick. It was, in short, a feeding frenzy, a perfect storm.

We survived, and saw increased interest in the flu vaccine the following year. Everyone remembered H1N1 and most wanted their children to be vaccinated. We had a mild flu season that year, the 2010-2011 season. And the following year, we had another mild season. Memories of the fall of 2009 began to fade.

This year, the country as a whole is having a bad year. Flu is more widespread and more severe and more people are dying from it. The result? Those who didn’t get themselves and their families vaccinated in the fall are now desperately seeking the vaccine. Some are finding it; some aren’t. It’s just so late in the vaccination season.

It might help to think of flu vaccine supplies as being a little bit like breastfeeding. If you’ve breastfed an infant, you know that as the infant feeds for longer periods and more frequently the amount of milk produced increases. It’s supply and demand: baby demands and mama supplies. Baby has a growth spurt and wants to eat every hour? Mama’s milk-producing glands start working extra shifts and paying overtime to get the milk out. It’s the same way with flu vaccine: If we vaccinate like crazy in the early fall and blow through all the doses we’ve ordered by, say, late October, we can order more, no problem. We’ll be able to get more because it’s early in the season and the manufacturers still have stock. If that’s happening everywhere and the manufacturers start to run out, they’ll make more because they know they can still sell it if it’s early in the season. It’s a feedback loop, with more demand creating more supply.

But when demand is lackluster in the fall and then suddenly peaks in January, everyone is caught with their pants down (and not in the sense of waiting expectantly for a shot in the gluteus maximus). Medical offices are reluctant to order more, because no one wants to be stuck with a fridge full of unusable and expensive vaccine. And they might not be able to get more even if they decide to take that risk, as the manufacturers may have called it quits for the season so that they don’t end up with a warehouse of leftovers. This is like the baby who has had a poor appetite for weeks and then suddenly starts eating like crazy; mama’s milk production isn’t going to come back overnight (thankfully, breastfeeding is not a for-profit industry).

The take-home lesson from all of this is predictable, even if the flu virus and the vaccine supply isn’t. Get your flu vaccine every year, for you and your children. Get it early, as soon as the vaccine becomes available. Give your doctor’s office a chance to protect you before the virus hits. The more people we can vaccinate in September and October, the better we are able to get more supplies and vaccinate the folks who will inevitably procrastinate.

Consider it your civic duty.

HPV Vaccine and Your Adolescent

I think it’s safe to say that no new vaccine has ever generated quite as many questions from parents or quite as much discussion on the media as the Human Papillomavirus Vaccine. That’s not surprising. It’s a vaccine designed to prevent the recipient from a sexually transmitted infection, and from the cancer that can result from infection. For best effectiveness it should be given several years before the onset of sexual activity. We usually target our 11- and 12-year olds for this vaccine, although it can be given at a younger age. The combination of talking about an STI and middle-schoolers in the same breath is bound to make any parent uncomfortable.

But we at Childhood Health Associates of Salem — and other pediatricians around the country — believe passionately in this vaccine. While the vaccine for hepatiis B vaccine does help prevent cases of liver cancer caused by the effects of the hepatitis B virus, this is the first time we’ve had a vaccine whose primary purpose is to save young people from a deadly cancer.  Cervical cancer in young women can result in painful tests and procedures, loss of fertility, the need for hysterectomy at a terribly young age, and death. The same strains of HPV are also responsible for many cases of oral cancer in both sexes. We can prevent this, and can also prevent the corresponding disfiguring and infectious genital warts in both females and males, by a simple three-dose vaccine.

When I talk with parents about this vaccine, I get a variety of responses. Many want their children to have it ASAP, and don’t even have questions. Others have questions about efficacy (it works, the cervical cancer rates are already decreasing nationally) and safety (after-market research continues, as it does on every vaccine, and safety data continues to show no increased incidence of adverse events). Some want their adolescents to have the vaccine but want to wait a year or two more. Others tell me that they don’t want their young people to have the vaccine, because they believe that it isn’t necessary for their children or that it will somehow encourage their children to become sexually active at a young age. I want to gently suggest some reasons why that isn’t true.

  1. The odds are against you. Most teens experiment with some kind sexual activity during their school years. We know this from anonymous surveys, from experts who study adolescent sexual behavior, and from teen pregnancy rates. My own very conservative high school church youth group saw (in the 1-3 years after high school graduation, back in the 80’s) at least five unintended pregnancies amongst those who were about my age or a little older. None were still in high school, but none of those pregnancies were intended. If these young people, (all of whom had publicly and earnestly embraced the concept of chastity) were having sex, then you’d better believe that today’s teens are doing so. The average age of first sexual intercourse in this country is age 16.9. That’s just the average, so for every teen who is waiting until 18 or 19 there is one becoming active at 14 or 15… or younger.
  2. You can’t foresee the future. The girl or boy who follows their parents’ rules at age 12 and shows little interest in their developing sexuality may present a completely different picture at 16. Or 18. Or 22. You don’t know who they will meet, when they will leave home, where and if they will attend college, and what pitfalls they will encounter. Maybe they will travel, maybe they will join the military, maybe they will have friends who are a great influence, maybe they will have friends who terrify you. You can’t predict exactly what kind of person they will be over the coming years, and what part of your careful parental instructions will ‘stick’. And you will be unlikely to be able to drag that 18 year old or that 20 year old in for a vaccine, which will now be less effective than if it had been given earlier.
  3. There may be special risks that you don’t yet realize. The adolescent with ADHD, for example, will always be more prone to impulsive actions. In elementary school that may be limited to building catapults out of their desk supplies or jumping off of the garage roof, but as they get older, these impulsive actions may take the form of sexual risk-taking. Children with developmental disabiities are also at risk; they may head into their teenage years with a rapidly maturing body but a mind that isn’t ready to cope with sexual attraction and that can’t discern good intentions from seduction and predation. Mental illnesses such as schizophrenia and bipolar disorder typically present during the teen and young adult years, often with no signs during childhood, and those young people can place themselves at considerable risk with unwise sexual behaviors before their illness is recognized and controlled.
  4. Not all adolescent sexual contact is consensual, especially the first time. Date rape is an ugly thing, yet it happens every day to someone. Your teen may have every intention of saying ‘no’, but may find themselves either physically or emotionally overpowered or given substances to ensure their cooperation.
  5. Not everyone tells the truth to their eventual spouse, and many don’t know they are infected. Even if you’ve got one of those rare young people who can delay gratification and can pick their way through the minefield of teenage sexuality unscathed, they still aren’t safe from HPV. They can still get infected by that one special man or woman with whom they have chosen to spend their life. Maybe that person isn’t honest with them, or maybe they simply don’t realize that those illicit moments behind the bleachers in the 9th grade with their ‘crush’ gave them an invisible STD.

These are all sobering thoughts. Our goal is to help your adolescent get through these difficult years and end up happy and healthy at the end of them. Even if you consider your youngster to be relatively low-risk for HPV, we’d recommend that you have them receive this vaccine, for all of the reasons listed above. They can get this vaccine at any office visit or you can make a ‘nurse visit only’ appointment for shots. And if after reading this, you still have questions, please ask any of our nurses or providers.

HPV (human papillomavirus) Vaccine For Boys

We’ve been giving HPV vaccine to girls for several years now, but recently the AAP’s immunization experts have recommended that boys also start to receive it. HPV is the name for a group of viruses that cause dangerous and unsightly genital warts; the warts are a known cause of cancer. We usually start offering this vaccine at the 11 year checkup visit. It is a three-shot series. While OHP and most insurances are covering it, we advise you to verify coverage with your own insurance company before the vaccine is given. We charge $143 for each dose and the cost does become patient responsibility if not covered by insurance.

Whooping cough is on the rise

Pertussis is bacteria that causes whooping cough. It is prevented through vaccination begun at two months of age. Until recently the last booster was given around time of entry to kindergarten. In 2005 a new booster (TdaP) was made available that can be given for middle schoolers and up, including adults.

Some areas of the country have noticed large increases in the number cases, especially in areas of decreased use of vaccination. This has been most striking in the last year in areas of Northern California and Southern Oregon. Marion County data for last year was just released and we are seeing an increase as well. In 2010 there were about 30 confirmed cases which is double 2009 numbers.

Pertussis vaccine is recommended at 2 months, 4 months, 6 months and 12-18 months old. There is a booster given at 4-5 years old. Middle school pertussis booster (TdaP) is routinely recommended at age 11 years old and then repeated every 10 years. Call our office to confirm that your child is up to date on recommended vaccines.

One group we sometimes forget about is parents of young children. Adults get pertussis very easily and then spread it to young children. It is young children who are most likely to be hospitalized or die from pertussis so close contacts should get vaccinated. Discuss with your doctor if you are unsure if you have been protected against pertussis.

To learn more visit CDC Pertussis page.