80,000 died in 2017-18 flu epidemic in US

The recent CDC estimate is that 80,000 Americans died from the flu last year. This is way above the usual 12,000 to 56,000, and is the single highest toll in the past 4 decades, per the CDC (see https://apnews.com/818b5360eb7d472480ebde13da5c72b5 ); [they do not have exact counts on the numbers of deaths, just statistical models]. a few points:

--CDC reports of the last year flu epidemic (see https://www.cdc.gov/flu/about/season/flu-season-2017-2018.htm ):
    --the increase in morbidity and mortality was general: more kids died (180, the highest number ever), 80% in kids who were not immunized; and hospitalizations were the highest ever (58% of them in those >65yo)
    --last year, the vaccine did not work so well (estimated overall effectiveness of 40%, though the flu vaccine was a good match for the majority of flu viruses that season)
    --and, in terms of viral susceptibility to antivirals: the "CDC tested 1,147 influenza A(H1N1)pdm09, 2,354 influenza A(H3N2), and 1,118 influenza B viruses for resistance to antiviral medications (i.e., oseltamivir, zanamivir, or peramivir). While the majority of the tested viruses showed susceptibility to the antiviral drugs, 11 (1.0%) H1N1pdm09 viruses were resistant to both oseltamivir and peramivir, but were sensitive to zanamivir".
--the above findings of huge morbidity and mortality by a virus well-covered by the vaccine does raise the very serious question of “are we giving a useful vaccine too early to work when the flu actually strikes???” one newish entry into the vaccination field is the retail pharmacies (and I have had patients get the vaccine in early September, perhaps even before), and the vaccine in Massachusetts is available increasingly early (with the concept that we need to increase the number vaccinated). But the outbreak peaks most typically in February or sometimes later. A  prior blog http://gmodestmedblogs.blogspot.com/2017/08/should-we-delay-giving-flu-vaccine.html reviewed several studies of the timing of vaccine, suggesting that the vaccine should be given at most 3 months prior to flu outbreaks; and for some of the influenza species, they really begin losing apparent effectiveness rapidly, with peak immunity about 14 days after the shot)
    --the flu season last year peaked in February; though it began in November. It may be useful to track the flu to figure out when is optimal timing for vaccination, especially in more vulnerable populations, for example at https://gis.cdc.gov/grasp/fluview/fluportaldashboard.html 

--see http://gmodestmedblogs.blogspot.com/2018/01/flu-vaccine-in-older-people-decreased.html which found that older people getting the flu vaccine did find improved effectiveness if people got annual shots
--see http://gmodestmedblogs.blogspot.com/2018/01/influenza-spread-by-breathing-flu.html finding that flu can be spread just by breathing (no need for the cough)
--and, in a more global perspective, the Lancet reported that deaths from influenza are likely much higher than previously thought: http://gmodestmedblogs.blogspot.com/2017/12/global-deaths-from-influenza.html 
-- http://gmodestmedblogs.blogspot.com/2017/11/herd-immunity-epidemics-and.html reviews the mathematics of herd immunity, epidemics and vaccinations, emphasizing the social imperative for individuals to be vaccinated (and arguing that we clinicians should reinforce the social good of doing so even in patients who "never get the flu" and "don't need to be vaccinated".
-- and, the imperative for vaccination will only increase as more people are living longer (and are more vulnerable to flu-based mortality)
--some good news:  vaccination coverage among health care personnel increased to 78.4% (15 points above 2010-11, but similar to the past 4 seasons), likely from workplace vaccination requirements (94.8% vaccinated); this number dipped to 47.6% in those workplaces where there was neither an employer-mandate nor on-site vaccination or promotion. (see https://www.cdc.gov/mmwr/volumes/67/wr/mm6738a2.htm )

--a few questions/thoughts:
    --is there a difference in the decay in immunity or in the morbidity/mortality if those older than 65 if they received the high-dose vaccine? Perhaps it is okay to give that shot earlier in the season given the higher antibody response…
    --perhaps flu shots should be a double process: one shot in October and another in late December or January???? Might be worth studying, given the large worldwide toll of influenza
    --and we should explore more effective ways to get the message across about the importance of the vaccine (most of the kids who died were unimmunized). Requiring health workers to be immunized works. Perhaps home health aides and others taking care of the elderly or young (daycare workers…)?? Perhaps stressing the social importance of getting lower-risk people immunized as a way to protect the very young and the elderly (and widely advertising that)?

So, at this point, I do think it makes sense to delay giving the vaccine. Which means trying to regulate or at least undercut the message to get the vaccine in the late summer/early fall, which means undercutting the retail pharmacies advertising the availability and stressing the utility of early vaccination. And there should be flu clinics more in December than in mid-October (these clinics could be moved up if the virus is hitting the US earlier than usual). The huge morbidity/mortality last year, I think, should be a wake-up call that we should look at our processes and see if there are ways to optimize protection (and do the studies to see)…

geoff​

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