Can Clinicians Influence Influenza Vaccination Rates?

Myths Abound, but Clinicians Can Overcome Patient Objections

Cynthia Green


September 22, 2017

The Influenza Vaccine: Getting Patients to Yes

Every year, the Centers for Disease Control and Prevention (CDC) comes out with its recommendations for the influenza vaccine, using the latest data to advise on who should get the shot, especially those at greatest risk for complications should they become infected. Typically, the CDC urges most people to get vaccinated.

Despite a long record of vaccine efficacy, myths persist and their believers are hesitant to get vaccinated against influenza, if not downright and adamantly opposed to it. Convincing the diehard anti-vaxers might be a stretch, but many patients simply need a brief overview and some coaxing from a trusted clinician.

"There is abundant evidence supporting the safety of the flu vaccine as well as its effectiveness in reducing illness and death in vulnerable populations, infants, and the elderly in particular," said Gary Stadtmauer, MD, a private-practice allergist, internist, and immunologist. Dr Stadtmauer is also an assistant professor of medicine and clinical immunology at Mount Sinai School of Medicine, New York, New York, and serves on the advisory board for Medscape's Allergy & Clinical Immunology site. "Despite an abundance of proof, there is a widespread and utterly false belief that flu shots can give people the flu, which is absolutely not the case."

Clinicians have heard plenty of concerns from reluctant patients, ranging from the prudent to the absurd, but patients rarely sit down with data to analyze short- and long-term risks of influenza infection.

"Many times, people underestimate the health risks of the flu. Influenza and pneumonia are two of the top 10 causes of death in the United States, and this can be preventable," says Shital M. Patel, MD, assistant professor of medicine and molecular virology & microbiology at Baylor College of Medicine, Dallas, Texas. "Many people also have health conditions that put them at a higher risk for serious complications, hospitalization, and death secondary to influenza. The flu shot is the primary way to prevent influenza and its serious complications [and] hospitalization."

"The vaccine is made from an inactivated virus that can't transmit infection," Dr Stadtmauer reiterated. Yet, there are people who still widely believe this myth. "Those who get sick after receiving a flu shot were likely going to get sick anyway. It takes a week or two to get protection from the vaccine." Still, there are patients who make an incorrect assumption that there is a correlation between their symptoms and the vaccine.

Dr Patel is familiar with this belief. "I frequently hear my patients say that they get the flu from the flu shot. I tell them that the influenza vaccine does not have live virus in it so you cannot get the flu from it. However, you can get some common side effects as your body responds to the ingredients. The most common side effects are mild and typically last 1-2 days. These can be headache, feeling tired, low-grade fever, and a sore arm. Let's compare that to the actual flu, which sometimes keeps people in bed for 5-7 days."

"Statistically, there is some chance that you might acquire a cold at about the same time that you get the vaccine," Paul Auwaerter, MD, MBA, stressed. Dr Auwaerter is a clinical director in the Division of Infectious Diseases at Johns Hopkins University School of Medicine and serves on the advisory board for Medscape's Infectious Diseases site.

"I hear my patients say, 'The flu vaccine doesn't work. Last time I took it, I still got the flu,'" says Dr Patel. "I tell them that although flu vaccines may not protect you 100%, they can reduce your risk of getting the flu." People may still get sick this winter, but the symptoms may not be as severe. "During the fall-winter season, lots of viruses cause colds and flu-like illnesses that are not the flu, but rather another virus that we cannot protect you against."

It is also false that a person can only catch influenza from someone who is already symptomatic. The influenza virus is detectable in the upper airway and nasopharynx of influenza-infected persons for several days before symptom onset. In addition, it can be helpful to remind patients that having had a flu shot once before offers little to no protection, as the strains are constantly changing.

Another common refrain that clinicians might hear is that a patient is in such good health that he or she doesn't need the vaccine. The truth is that anyone can be infected with influenza, Dr Auwaerter stresses. "The influenza vaccine appears to help keep people healthy during the winter so that school or work is not missed," he adds. But even if a robust patient manages to skirt the infection, "receiving the flu vaccine reduces the chance that you will spread the infection to family members and other people." The more people who get vaccinated, the safer our entire population is. "The vaccine is particularly helpful in people who have chronic health conditions that may predispose to influenza," says Dr Auwaerter. Patients should consider what happens when a vulnerable patient, such as a child or grandparent, does get the flu despite vaccination, and gets sick because a "healthy" person passed on the virus without getting sick themselves. This is why the CDC is so adamant about treating this as a leading public health issue. CDC guidelines suggest that healthy individuals—children aged 6 months and up, and adults (particularly older adults)—be vaccinated each year. They also urge the general public to get vaccinated in order to contain the virus at the population level.

Dr Patel is familiar with the healthy-patient argument. "When patients are not keen on getting the flu shot, I ask why they feel that way. Some say, 'I do not need the flu vaccine. I never get the flu.' I respond by saying that flu can affect anyone, regardless of age or health conditions. It can affect healthy individuals, as well as those with chronic illnesses, and cause complications. Each year, thousands of people die from flu."

Sometimes people think that because the flu is so common and familiar, it's harmless. Most people who have suffered through it would disagree. As reported in an earlier Medscape article, epidemiologic data show that influenza infection is not harmless. In recent years, influenza has been associated with as many as 56,000 deaths[1] and 310,000 hospitalizations[2] each year. Influenza can cause significant disease in children, as seen by annual hospitalizations ranging from 7000 to 26,000 in children under 5 years of age alone. An estimated 37-171 children have died each year since 2005, depending on the severity of the season and strain.[3] The good news is that for the 2015-2016 influenza season, the CDC estimates that influenza vaccination prevented approximately 5.1 million flu illnesses, 2.5 million influenza-associated medical visits, and 71,000 influenza-associated hospitalizations.[4] "Receiving the vaccine reduces [a person's] chances of getting a severe case of influenza that would put [them] in the hospital," says Dr Auwaerter. Clinicians can influence patients to stack the odds in their favor.

Among the Most Vulnerable: Patients With Chronic Conditions

Although everyone should be vaccinated, it is especially important to address those patients with chronic medical conditions.

The elderly may be especially high-risk because of a weakening immune system and the likelihood of chronic health conditions that can exacerbate the flu, leading to serious complications, according to Tom Skinner, senior public affairs officer for the CDC.

For those with asthma, the symptoms of infection can be far more serious. In the lungs, the virus can trigger an attack and lead to pneumonia or other acute respiratory diseases. In those with cardiovascular disease, there is a higher risk for complications. According to the CDC, 41% of adults who were hospitalized due to influenza infection during the 2015-2016 season had a diagnosis of heart disease. Last but not least, patients with type 1 or 2 diabetes are at much greater risk for serious flu complications such as bronchitis, pneumonia, and sinus or ear infections. The virus can also worsen outcomes because diabetes itself often weakens the immune system, and it is even more vulnerable during periods of infection because of escalating blood sugars prompted by that very infection.

With an open ear, patient education, dispelling of myths, and professional reassurance, clinicians have the power to influence patients who might otherwise refuse an influenza vaccination.


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