Equal Opportunity Flu in an Ageist World

| Fri May 1, 2009 2:48 AM EDT

One of the unusual things about the current swine flu virus, compared with the strains that cause our yearly seasonal flu outbreaks, is that it doesn’t seem to discriminate on the basis of age. That may change as the pandemic develops, but it may not: The massive 1918 Spanish Flu pandemic is also known for killing across all age groups.

There is, nonetheless, an age angle to this story, and it has to do with those garden-variety annual influenza outbreaks, and how the medical, political, and media establishments have handled them. The great majority of deaths caused each and every year by these “ordinary” flu viruses--some 36,000 on average in the United States alone, according to the CDC--are of people over 65 years old.  Some years it’s more, and some years it’s fewer: During the 1990s, the number of deaths ranged from 17,000 to 54,000. But every year, tens of thousands of old folk succumb, with little fanfare and minimal media attention, to flu-related deaths.

One major public health initiative has been launched in response to these deaths, and that is to promote the flu vaccine for older Americans. The percentage of elders who are vaccinated annually has grown about four-fold in the last 30 years. But there’s just one problem with this approach: The vaccine apparently doesn’t work too well for us old folks, if at all.

For decades, the conventional wisdom was that the vaccine cut flu-related deaths in the elderly by anywhere from 25 to 75 percent. But as the New York Times reported last fall, ”a growing number of immunologists and epidemiologists say the vaccine probably does not work very well for people over 70, the group that accounts for three-fourths of all flu deaths.”A study published last year in Britain’s most respected medical journal, the Lancet, found no correlation at all between flu vaccination and a reduced risk of illness and death.

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An analysis on the American Medical Association’s AMNews site outlines some possible reasons for the skewed results. Placebo-controlled studies of the vaccine’s effectiveness, it says, ”have been carried out in young and middle-aged adults rather than those older than 65--the demographic that makes up the biggest target of vaccination efforts and suffers the greatest ill effects from this respiratory infection. A trial focused on this age group would be considered unethical.” In other words, you can’t very well give a fake shot to a bunch of old geezers at risk for a life-threatening disease, and then wait to see how many of them die that winter.

But the ”observational studies ” that researchers have relied on instead “may be confounded by other factors.” For example, “The seniors who are healthy and are able to go get a flu shot are less likely to get pneumonia or die. The benefits are probably real but rather small,” said the lead author of the Lancet study, Michael L. Jackson.

Part of the reason for the vaccine's ineffectiveness, as AMNews notes, is ”the nature of influenza vaccine, which aims at a constantly moving target. The viral strains it includes change every year. Circulating viruses shift constantly. And every season is different in regard to severity and spread.”

But it appears there’s another problem with the vaccine, as well, when it comes to older people. Yet another recent study found that people over 65 might need a larger dose of the vaccine--as much as four times the usual dose. As Reuters reported, researchers concluded that “this is likely because their immune systems are not as active as those of younger people”:

Dr. Ann Falsey of the University of Rochester School of Medicine and Dentistry and colleagues tried giving a much bigger dose of flu vaccine to see if that might help. They tested the idea on 3,800 volunteers aged 65 and older and found their bodies produced up to twice as many antibodies--the immune system proteins that help attack invaders such as viruses--compared to seniors given the usual vaccine dose….

“The goal is to increase immune response in older adults, since this is one of the populations most at risk for becoming seriously ill or dying from influenza,” Falsey said in a statement.

Like so many other studies, this one was paid for by the company that wants to manufacture the new product--in this case Sanofi Pasteur, which hopes to get approval for a new, high-dose vaccine. But it wouldn’t be the first time that a dosage developed for and tested on younger people proved to be the wrong dosage for elders.

The excellent public health blog Effect Measure had some other ideas on how to protect older people, since the vaccine seems to be proving ineffective for them. But this would involve shifting the focus of national public health efforts.

The data present a serious challenge to the CDC program which concentrates on blanket coverage of the 65 plus age group. Both epidemiological and biological data suggest that immune response declines with age. Us older folks just don’t respond as well to the vaccines. This in turn suggests that instead of blind faith in the current program, alternative ideas should be explored, including shifting the target to younger age groups responsible for transmitting the virus in the population.

It makes perfect sense, when you think about it: Young people are more likely to infect their elders than vice versa, and since the vaccine apparently works better on them, why not push them to have it? But frankly, I can’t see this working. I can’t see young people, who know they aren’t likely to die from the flu, going out and getting vaccinated just to protect older people.

I can’t see this, any more than I can see the newspapers running headlines every winter proclaiming: “30,000 Geezers Dead in Seasonal Flu Outbreak,” or the president going on TV to say that the government would stop at nothing to protect granny from this dangerous virus. And the fact that these things don’t happen, I think, is proof that the older we get, the less our lives are worth in this society.

Of course, I’m not saying that the only reason for the furor over the swine flu is the fact that it kills the young and the middle aged, as well as old. But I do believe that if this weren’t the case, the reaction would be quite different. A lot of younger people would probably react the same way they do when an older person dies from an ordinary, run-of-the-mill case of the flu: They would shrug their shoulders and think, “Well, they’ve got to die from something.”

This post also appears on Unsilent Generation, James Ridgeway's blog on the politics of aging.

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