Whether and with what vaccine to get vaccinated against the flu – Winter Edition 2020-2021

(And what is swine flu? And can the vaccine cause the disease? And what does it have to do with Corona? And why did the neighbor tell my grandmother's aunt that he did not get vaccinated last year that he got sick two years ago? And many more questions)

The corona is celebrating, winter is approaching and with it mostly approaches The talk about the flu. Ha, and the flu is approaching.

There seems to be no vaccine more controversial than this vaccine, and it seems that even in this case the people of Israel are divided into two – those who are piously vaccinated every year and those who are never vaccinated.

So a little about the flu, about the flu vaccine and my recommendation to you and your family at the end.

What exactly is a flu virus? And what are the different types of flu virus?

The flu is a disease caused by a common virus called Influenza which is divided into three groups called A / B / C.

Viruses from the first two groups (A and B) are the most common pathogens in humans and cause epidemics (local epidemics).

The viruses from the different groups are divided into other subtypes according to two sugary proteins that are on the virus shell and they determine the specific serotype (type) of the virus and are responsible for its degree of violence.

Proteins are called glutinin (marked H and there are about 15 types) and neuraminides (marked N, there are 9 types).

There is even a further subdivision of the strains, even within the same type of virus. Do not think these resolutions should be dropped, although they may have clinical significance.

But why do I keep babbling about these types?

Since the influenza A virus has a complicated epidemiology involving many mammals and birds that serve as a reservoir for subspecies with the potential to infect humans. And since the influenza virus tends to undergo many mutations and genetic substitutions between the virus found in animals and those in humans, then potentially each of the many H and N antigenic groups found in animals have infectious potential in humans.

Small changes in the virus are called antigenic drifts while large changes are called significant antigenic shifts.

This is why the flu virus is attracting global interest because beyond the known seasonal epidemics it has the potential to cause a pandemic (global epidemic).

This will happen if after a significant antigenic change, a new virus that is unfamiliar to humans enters the circulation.

Indeed many plagues in the past have taught us about this deadly potential.

An example of a flu pandemic that has occurred in the world

The deadliest flu pandemic of all occurred between 1918 and 1920 and is called the "Spanish flu".

It is estimated that this flu has affected between twenty and forty percent of the world’s population and killed more than 20 million people.

It is clear that poor hygiene conditions and the lack of supportive care for patients also contributed to the high mortality rates at the time, but this is a classic example of a new strain of influenza virus that struck the world with great intensity.

What do I mean by the expression swine flu?

If one understands the issue of the different types of flu virus then one can understand that every few years a new strain of flu virus appears.

This breed is named after its source, usually in animals.

The A / H1N1 influenza virus, which originated in the genetic replacement of the human, swine and bird flu virus, went into circulation in 2009 and became known as swine flu.

Does it really matter what the specific type of flu virus is called?

The name of course does not matter, and it is clear to us today that the virus that causes swine flu does not necessarily make a disease more severe than the flu virus that has not been given that name.

The fear was (and still is) of the introduction of a new type of virus that the population is not properly vaccinated against and that could therefore cause more significant morbidity. The coming winter specifically the concern is double because of the combination of the corona and the flu.

How can we predict which types of flu viruses are expected to reach our country this coming winter (2020-2021)?

The World Health Organization monitors morbidity and type of flu strains in the southern hemisphere of the world, where influenza precedes the northern hemisphere.

How do you get the flu?

Infection with the flu is tricky. I mean flushes from a patient’s respiratory tract pass to another person’s lining (mouth, nose or eyes).

Even contact with surfaces or hands that have saliva on them is highly contagious.

Practically I can say from experience that in the vast majority of homes where diagnosed the flu (I do a quick checkup for the flu in the clinic in appropriate cases during the winter season) there was more than one patient in the family.

Which indicates the high infection rates of this virus as well.

What disease does the flu virus cause?

Real infection of Influenza virus causes significant and unpleasant disease.

I repeat the sentence because it is important – real infection with the flu virus causes a significant and unpleasant disease.

Why did I emphasize the word real? Because everyone thinks they know whether or not they have the flu while this is usually not the case.

Many people who catch a cold with or without a fever during the winter are sure they have the flu.

But most of the time in such a mild illness it was not a real flu but another respiratory virus.

On the other hand, many of the sick people with high fever and cough who are diagnosed with bacterial pneumonia after five days are sure they had bacterial pneumonia, but actually the whole disease was flu without any bacterial complication.

Only by testing in a qualified laboratory (usually in an inpatient / emergency set-up) or a fast antigen (done in individual clinics) can you really be diagnosed with the flu.

See episode 59 in the mythological series "Ma Pitom?" (Kishkashta).

You can learn manners from this video and also that Kishkashta diagnoses himself as having the flu (I must admit that he really does look ‘sloping’).

But the flu is a serious illness and usually includes a fever of 38 degrees or more, sometimes chills and muscle aches, colds, sore throats, a troublesome cough, a headache and shortness of breath. The disease lasts about 3 to 7 days. I define flu as a ‘decomposing’ disease.

The disease is more severe in frail people including infants and young children, the elderly and people suffering from significant background illnesses.

Pregnant women and obese people are also at risk for serious illness.

Among the common complications of the flu are bacterial infections such as pneumonia, sinusitis or otitis media. There are other complications including neurological and cardiac complications but they are uncommon.

this year add to this equation also the corona mainly the fact that it will be difficult to differentiate this year between these two infections and we will come to an unequivocal conclusion together – If flu can be prevented, we must do so.

Is there a cure for the flu?

Around 2009, the Ministry of Health, in accordance with other circulars published around the world, issued a recommendation for the treatment of antiviral drugs in certain patients.

According to the guidelines of the Ministry of Health, one of the two conditions must be treated: the first – a patient who belongs to a risk group for a serious illness and the second – a patient who suffers from severe disease symptoms.

It should be noted that according to the guidelines of the Ministry of Health (which have not changed since then and many experts know they are too sweeping) should be treated on suspicion of disease and there is no need to isolate the virus for treatment.

In practice there are several drugs against the flu virus but the most common of them is oslatamibir (Tamiflu) whose mechanism of action includes inhibition of neuraminides and is effective against viruses from group A or B.

Infectious disease experts disagree about the true effectiveness of this drug and what is clear is that in order for the drug to do something and shorten the disease a bit, there is room to start treatment early during the disease.

Personally I would not trust any of the flu medications to make a significant difference.

As mentioned, it should be remembered that not only is the flu disease a serious illness but in light of the weakness of the body and the involvement of the respiratory system, bacterial complications can be seen after a flu infection.

Infections can be severe including bacterial pneumonia, sepsis and more.

In young children, bacterial ear infections secondary to influenza can also be seen.

Antibiotic treatment does not change the course of the flu and should be reserved for those cases of actual suspicion or diagnosis of secondary bacterial infection.

Since it is very difficult to differentiate between the symptoms of the flu and the symptoms of sinusitis or bacterial pneumonia for example, many people who actually only suffer from the flu, get antibiotics unnecessarily.

Is there a prevention against the flu?

Yes. Vaccine.

Seasonal flu vaccine is given at the beginning of each winter season. The composition of strains varies from year to year according to the decision of the World Health Organization and on the basis of data from the southern hemisphere. In the last flu season (winter 2019-2020), about 25% of the Israeli population was vaccinated, despite a delay in the arrival of vaccines in the country. It is interesting to note that the group of adults over the age of 65 were vaccinated at nice rates of about 60%.

In the coming season in Israel (2020-2021), a number of different vaccines for influenza are expected to arrive in Israel.

Killed vaccines against three strains (Influvac).

Killed vaccines against four strains (Influvac-Tetra or Vaxifrip-Tetra or Fluarix-Tetra).

High-dose killed vaccine against 4 strains for 65 years and older (Fluzone).

Live attenuated vaccine against 4 strains given as a nasal spray (Flumist).

Note, last year life was much simpler because the only vaccine available was a killed vaccine against 4 strains. This year, the subject is a bit confusing.

What strains will be in the vaccine this year?

According to the decision of the World Health Organization, the four strains that will be in the various vaccines will be:

  • A / H1N1
  • A / H3N2
  • strain B Washington
  • Strain B Phuket – will only be in vaccines of the four strains.

Why should flu be vaccinated every year?

Because they have not yet invented a universal vaccine that is suitable for all strains and which causes immune memory over time.

Who can and should get the flu vaccine?

Vaccinated vaccines Theoretically any person over the age of six months. But there are two exceptions:

A. The Influvac-Tetra vaccine is currently only available for those aged 18 and over. It is not clear to me why.

B. The high-dose killed vaccine called Fluzone is currently registered for those aged 65 and over out of a desire to prioritize it for this population.

Attenuated live vaccine (Flomist) – Registered only for ages two to 50 years. Note below, beyond age there are other populations that must not receive the attenuated live vaccine.

Who can not get vaccinated with the killed vaccines for influenza?

  • People with a severe allergic reaction to egg protein in the past should only be vaccinated in a medical facility where they can be given appropriate treatment if a severe reaction develops.
  • People who have experienced a severe allergic reaction after a previous flu vaccine cannot be vaccinated.
  • In people (adults or children) who have a moderate to severe illness accompanied by fever, it is best to wait until recovery to get vaccinated. At this point I would like to expand a bit because I hear a lot from parents who wanted to vaccinate their children but in practice did not vaccinate because the child was dehydrated and coughed without fever. Anyone who postpones the flu vaccine because of a cold can miss the flu season. Mention that in the winter season some children catch a cold and cough throughout the season and therefore recommend postponing a vaccine only during a fever.
  • Warning – People who have had Gillian-Barre Syndrome within 6 weeks of a flu vaccine in the past.

All other people over the age of six months can be vaccinated. Immunosuppressants can also be vaccinated. The vaccine response of immunocompromised people may be less good but there is no real way to "quantify" it and there is no prevention from getting vaccinated.

Who can not get the attenuated live vaccine for the flu (plumist)?

  • Children under 2 years of age or adults over 50 years of age.
  • Pregnant women.
  • People who have experienced a severe allergic reaction after a previous flu vaccine.
  • People with a defect or suspicion of any defect, congenital or acquired, in the immune system.
  • Beeping three days before receiving the vaccine or receiving steroids orally or people who needed to be hospitalized in intensive care due to exacerbation of asthma. People who receive steroid inhaler treatment at any dose can be vaccinated.
  • People aged 2-17 years who take drugs from the salicylate group (aspirin for example) for an extended period of time.
  • People in any health condition that may cause aspiration or impair the ability of the respiratory system to deal with secretions such as spinal cord injury and more.
  • People with a leak of cerebrospinal fluid or people with a cochlear implant.
  • People (adults or children) who have moderate to severe disease with or without fever, including people with severe rhinitis – it is best to wait until recovery to get vaccinated.
  • People who received antiviral drugs for the flu two days before the vaccine. Taking the same medication is not recommended for those receiving a live attenuated vaccine even in the two weeks after the vaccine as it can impair the effectiveness of the vaccine.
  • Warning – People who have had Gillian-Barre Syndrome within 6 weeks of a flu vaccine in the past.
  • Warning – People who are in the risk group for complications due to influenza infection including chronic lung disease (not asthma), cardiovascular disease, kidney / liver disease, neurological, hematological or metabolic diseases including diabetes.

In order to shorten it can be written that the live attenuated vaccine is only suitable for people who have a healthy background and aged 2-50 years.

Important Important Important – It is recommended that a person who has received a live attenuated vaccine in the past week does not come in contact with people who have severe suppression in the immune system who need a pathogen-protected environment.

What are the side effects of inactivated flu vaccines?

The most common side effect is a local reaction at the vaccine site, ie sensitivity at the injection site that lasts up to 24/48 hours after vaccination.

Mild systemic symptoms including drowsiness, some muscle aches, cough, etc. – can last up to 24/48 hours after vaccination.

I’ve heard a lot in the past about people swearing they got the flu after the vaccine. It is possible that the flu hatched in them when they were vaccinated, but most of the time it expresses a lack of understanding of what a real flu is.

Sharp and smooth, the killed vaccine can not cause disease or flu.

What are the side effects of the live vaccine attenuated by the flu

The most common side effects include runny nose, nasal congestion, nosebleeds and sore throat. Lasts 1-3 days after vaccination. Systemic side effects such as fever, headache, muscle and abdominal pain and more – less common but may also last 1-3 days after vaccination.

How can babies under the age of six months be vaccinated?

It is not possible to vaccinate babies under the age of six months, but it is possible to protect babies under the age of six months with the help of:

  • Breastfeeding – Partial or complete breastfeeding from a mother who has been vaccinated and passively passes antibodies to the baby. It is permissible to vaccinate if breastfeeding with any flu vaccine, including the attenuated live vaccine.
  • Vaccinate all the rest of the family – so that the virus ‘does not enter the house’.

Are there different types of vaccines that are preferred in different populations?

Really confusing this year. Beyond the different populations that may or may not receive this or that vaccine, this year, perhaps in a precedent-setting manner, the Ministry of Health prioritizes different vaccines (brands) in different populations:

High-dose killed vaccine (Pelvon) – only registered for those aged 65 and over. From studies that have demonstrated that this population needs more significant antigenic stimulation to generate antibodies.

Attenuated live vaccine – From the point of view of the Ministry of Health, between the lines, it is recommended to vaccinate children from the age of two to sixth grade in this vaccine. More clearly:

2 to 6 year olds who have not yet advanced to first grade – will be vaccinated at the HMO, preferably an attenuated live vaccine.

Second, third and fourth graders will be vaccinated at school with the attenuated live vaccine.

First-, fifth-, and sixth-graders will be vaccinated with a attenuated live vaccine.

I mention experience from previous years: even in previous years these or other vaccines were launched as a great promise. The four strains for influenza (compared to the three strains), the attenuated live vaccine (compared to the killed) and this year also the phallus. Is the difference really so significant that one has to "commit suicide" to get this or that specific vaccine?

For the Ministry of Health, this is important. Mainly on the subject of prioritizing vaccines for appropriate populations. As far as we are concerned, in the field, if you have a flu vaccine and you are on indications – just get vaccinated.

Who is recommended (in my opinion must) get the flu vaccine?

In my humble opinion everyone. Why not actually?

However, the Ministry of Health has compiled a ‘target list’ of the population that it is recommended to focus on, in order to prioritize vaccines.

For the Ministry of Health, the flu vaccine was initially to be given only to those people on the list of target groups. On 12/11/20 it was announced that the four HMOs will no longer consider this list and will give vaccine to anyone who requests it. Is it because the HMOs have realized that they are expected to be left with a stockpile of vaccines? interesting.

Who was on the Ministry of Health’s original “target groups” list?

  • Virtually all people over the age of six months suffer from this or that chronic disease, including lung disease (including asthma), metabolic diseases (including diabetes), neurological, hematological diseases, immune system suppression, morbid obesity or basically any chronic condition / disease in the background.
  • All children up to the age of 5 years (from the age of six months of course).
  • Adults aged 55 and over (note the slight change from last year when the threshold was 50 years).
  • People who are in closed or semi-closed institutions or people who suffer from severe mental illness.
  • Pregnant women and women 3 months after giving birth.
  • All health system workers including caregivers and volunteers who make home visits to people at risk or over the age of 65. Please note, this is only the primary caregiver of the person in need.
  • Second-, third-, and fourth-grade school students will be vaccinated this year in one dose of attenuated live vaccine. Students who for one reason or another are unable to receive the attenuated live vaccine will be referred to the HMO for another available vaccine.

How many vaccine doses should I get?

All vaccinators over the age of 9 should be vaccinated in one dose.

Children up to the age of 9 who have been vaccinated against influenza in the past in two or more doses (in one season or in several seasons) should be vaccinated in only one dose.

Children up to the age of 9 who have not been vaccinated at all in the past or who have been vaccinated with one dose in the past, are entitled to two doses that should be given at least 4 weeks apart.

When it is necessary to give a second dose to a child, it is advisable to give it from the same manufacturer and the same vaccine given for the first dose. However, if this vaccine is not available, any flu vaccine can be vaccinated in the absence of a contraindication.

Where is the flu vaccine given?

The killed vaccines are given intramuscularly to the thigh or arm depending on the age of the vaccinated person.

The attenuated live vaccine is given as a spray for the nostrils.

Is it possible to reduce the pain when injecting this vaccine (or any other vaccine)?

Definitely yes!
As I have written in other chapters on vaccines, pain can be reduced with any vaccine or injection by distracting the vaccinated child.
The age from which this trick works depends on the character of the child and the parents and the patience of the vaccinator.
I use a technique I call "funny coughs".

I ask the child to look the other way and cough 7 times (or 10 or 13, whichever comes first).

If the child is calm and cooperates with me then he can be vaccinated along with one of the coughs and many times the child will not feel vaccinated.

This technique can be used with all routine vaccines given by injection in children over a certain age who cooperate.

Is it possible to give a flu vaccine together with other vaccines?

Inactivated component – In general, the flu vaccine can be given at the same time as any other vaccine, except for a 3-day wait between the flu vaccine and the meningococcal B vaccine in children under one year of age. You can read about the new vaccine for meningococcus B. At the following link.

Attenuated live vaccine – can be given with any other vaccine at the same time, including other attenuated live vaccines. If it is not possible to vaccinate on the same day with two attenuated live vaccines, wait 4 weeks between two attenuated live vaccines (for example, the measles / mumps / rubella vaccine with or without chickenpox).

What is the effectiveness of the flu vaccine?

This is the main Achilles heel of flu vaccines.
If because flu strains change from year to year and the vaccine is not always accurate in predicting the strains, and perhaps because pre-flu vaccines are not the most effective vaccines available, then the effectiveness of the flu vaccine is low and insufficient by all accounts.

The effectiveness of disease prevention in all age groups in the United States in the 2018-2019 season for example was only 47%.

There are populations where the efficiency was higher (children from the age of six months to a year and a half, efficiency 61%) or lower (adults over the age of 50 years, efficiency of only 24%).

So why bother bothering about a flu vaccine at all, and why get vaccinated at all when the effectiveness is clearly insufficient?
A. The efficiency varies from year to year, there are years when the efficiency is higher and reaches 70%.
B. People who get the flu and who are vaccinated that season, suffer less severely than those who are not vaccinated (which is also something).

See the following link – The work quoted in the area dedicated to scientific articles on this site demonstrates the effectiveness of influenza vaccination in Israel in children under 9 years of age. Well, the vaccine has brought down over 50% of hospitalizations due to the flu.

Therefore, the main reason for getting vaccinated against the flu is that we have no other means of protecting against the disease and that if I were to suggest that you get a 50% incidence or intensity of a disease that is clearly unpleasant and has the potential for complications, I think it would be right to take this offer.

I hope that in the future someone will find a universal vaccine for all strains, a vaccine that only needs to be given once in a lifetime.

What happens to the timing of the vaccine this year?

Traditionally every year flu vaccines arrive in Israel during the month of October. This year the vaccines are likely to arrive late.

Since we do not know when the flu activity will begin this year, and since it takes time (days for those who have been vaccinated or ill in the recent past, about two weeks for those who have not been vaccinated or recently ill) to produce good amounts of antibodies, I recommend everyone get vaccinated as soon as possible.

The Ministry of Health emphasized this year that a flu vaccination campaign should end no later than 31/12/20. However, the vaccines will be given as long as the flu activity continues, deep into March-April 2021.

Mention that there are children who need two doses at least 4 weeks apart, so it is advisable to give the first dose as early as possible in order to be vaccinated in the second dose before the onset of the disease.

The absolute end

There are families that I vaccinate at the beginning of the flu season and at the end of the season thank me for not being sick at all in the winter. That’s great, but I always explain that it’s just luck. The flu vaccine lowers the incidence of flu, certainly not the rest of the viruses that go around in the winter.

Some people I vaccinated with my own hands and got the flu. frustrating. To my delight in most cases it is a milder disease than it would have been without the vaccine.

And yet an emphasis on children. In light of the fact that children are at greater risk for infection and disease I think we all, as parents, have a very important role in strictly adhering to and recommending vaccination of children against seasonal flu, including healthy children.

In addition, the Corona has forfeited the cards and we do not know if we are planning a harder (or maybe easier) winter than the previous ones. But the flu, we do not want.

I wish us all an easy and usual winter ‘that we will always stay on the right side of the stethoscope’.