In this last post of the dots series, we shall try to explain why influenza vaccines have played a prominent role in the previous two decades.

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None of them are sure, just probable or possible. What is certain is that the role of influenza has been massively overplayed to the benefit of certain sectors of “the industry”: public health, big pharma, and mainstream media. Politicians have also benefited from the public's distraction.

First, influenza vaccine trials funded by industry are more prominent than those not sponsored by industry.  This has nothing to do with methodological quality or study size.  By “prominent”, we mean being published in journals with the highest impact factor.  We will return to this aspect, but first, let us explain how we know this.

In 2009, Tom and his then-Cochrane group looked at 259 randomised and observational influenza vaccine studies of all designs. The included studies that tested the effects of influenza vaccines against placebo, symptomatic interventions or sit on your hands. Yes, that’s a lot of work, and Tom is still recovering. However, it was worth it as the work allowed the group to see what no one else before had seen: not just prominence. The results of non-industry-funded studies were significantly more conservative; they gave lower effectiveness estimates than pharma-funded studies. That’s when you could still tell the difference between big pharma and government.

Second, the Cochrane review was published in early 2009, and any public servant with financial probity in mind would have started asking questions. The 2009 Swine Flu pandemic swept it under the carpet, folks. It was so severe that few will probably have a lasting memory of its effects. To be clear, There is no connection between the publication and Dr Margaret Chan, the WHO chief's declaration of a pandemic.

However, it is significant that the findings did not move the policy tanker one inch. Everything unfolded exactly as all the pandemic planning wanted: emergency registration of untested influenza vaccines, indiscriminate prescription of antivirals and additions to essential medicine lists, and an apocalyptic forecast that never happened—a failed dress rehearsal for what would follow. 

Third, It was WHO policy. In 2006, WHO produced the following policy document: Global pandemic influenza action plan to increase vaccine supply. The message was clear to increase demand: 

“4. Major approaches to increasing supplies of pandemic influenza vaccine 

4.1 Develop an immunization policy to increase demand for seasonal vaccines.

Objective:

Increase use of seasonal influenza vaccine. This will reduce burden of seasonal influenza infections, contribute towards the preparedness of countries to respond to an eventual pandemic and motivate industry to develop greater capacity for manufacturing vaccines.”

Fourth, the WHO is still working on the demand side of the problem. In the updated pandemic plan (note the emphasis on a single agent) 2019-2023, WHO wrote: 

“However, the current global use of antiviral drugs for seasonal influenza is low, thus limiting the current supplies and surge capacity given manufacturers match production with demand. As evidenced during the 2009 pandemic when WHO initiated the dispatch of 2.4 million antiviral drugs to 72 countries within a month of the declaration of the pandemic (48), antiviral drugs will have a prominent role during a pandemic, especially during the early months, because vaccines will be unavailable initially. Countries should properly account for antiviral drugs in pandemic preparedness efforts since they are feasible to stockpile”.

So vaccines and antivirals continue to be recommended to keep the production lines open despite their lack of effectiveness. However, the WHO asks for an evidence-base:

"Action 3C: Design and implement evidence-based treatment policies and programmes to reduce morbidity and mortality

Supporting components:

i. Promote the appropriate, evidence-based and effective use of currently available antiviral drugs, and integration of antiviral drugs into treatment programmes.

ii. Strengthen countries’ capacities for triage, clinical management and treatment of patients with severe influenza.”

Fifth, the "magic bullet” syndrome. The idea is that of a hypothetical medical treatment that targets and destroys diseased cells without harming healthy ones. German Nobel laureate Paul Ehrlich coined “magic bullet” in 1907. Ironically Ehrlich's discovered Salvarsan in 1909. This was the first effective drug for syphilis, and considered the first “magic bullet”.

Sixth, DO SOMETHING, ANYTHING!!!!

And the prestigious journal thing. Why would pharma influenza trials appear in prestigious journals and have more traction despite having inflated conclusions and the same quality as their pedestrian counterparts? Might it have something to do with the subscription, reprints and publicity businesses?  

Influenza vaccines and antivirals have an evidence base beset by poor-quality evidence, ghosting and a lack of effectiveness.  But no worries—WHO is “making the world safer”—at our expense.

This post was written by an old geezer who’s been working on this for three decades and hopes that the content of posts like these will be his legacy. The other old geezer just shakes his head. Both thank RonL for his prompts.

We will publish a summary post of the dots series.

Readings 

Jefferson T et al. Relation of study quality, concordance, take home message, funding, and impact in studies of influenza vaccines: systematic review BMJ  2009; 338 :b354 doi:10.1136/bmj.b354

Jefferson T. Influenza vaccination: policy versus evidence BMJ  2006;  333 :912 doi:10.1136/bmj.38995.531701.80

Jefferson T,  et al. Inactivated influenza vaccines: methods, policies, and politics. J Clin Epidemiol. 2009 Jul;62(7):677-86. doi: 10.1016/j.jclinepi.2008.07.001. Epub 2009 Jan 4. PMID: 19124222.

Global influenza strategy 2019-2030. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.