Australia saw a record number of cases of the flu in 2017.It was a busy flu year with H1N1 strains and different strains of flu B all circulating, sometimes in the same person at the same time.One strainmutatedafter it was chosenas a vaccine strain, and another vaccine virus strainchangedduring vaccine production, so the vaccine no longer matched what was out there.Australia has recorded 221,853 flu infections so far in 2017,more than any other year. As theflu seasoncomes toan end, were beginning to understand why it was so bad. And it wasnt because of increased, or more sensitive, testing.A better vaccine could have reduced the rates, but not the high-dose Fluzone vaccinedoctors were toutingat the start of the week.This years flu virusesMultiple flu viruses circulate each year and are broadly grouped into two types: A and B.Influenza B viruses have two main strains, while the influenza A viruses are more variable. The influenza As you get each year are usually A/H3N2the main player so far this seasonor A/H1N1, which lingers on from its 2009 swine flu pandemic.This was a busy flu year with H1N1 strains and different strains of flu B all circulating, sometimes in the same person at the same time.How vaccines are formulatedThe formulation for a vaccine to immunise against all four flu viruses was decided back inSeptember 2016and the final product released seven months later.Commonly, each virus is amplified by injecting well-growing seed virus into vast numbers of fertilised (embryonated) hens eggs. Fluid containing lots of new virus is removed, the virus isinactivatedand the new vaccine is manufactured.Todays flu vaccines remainmediocrecompared to those formeaslesorhuman papilloma virus, which offer 97% and 90% protection respectively. Its normal forless than 60%of those vaccinated against the flu to develop a protective immune response.Inone study of the 2017 flu seasona paltry 27% of Australians were vaccinated (73% werent), including just 6% of children. Among those vaccinated, 33% were effectively protected, though rates differed between the strains. The vaccine was 5-19% effective at protecting against H3N2 and 37% effective at protecting against H1N1 or flu B infections.Flu vaccination doesnt produce the same degree of immunity to flu viruses that wild infection does. But vaccine protection is much safer than getting the flu, and vaccinationcannot give you the flu.What went wrong in 2017Its difficult to predict what strains will dominate months later. Viruses within each flu type also change over time so H3N2 from years ago differs from H3N2 in 2017. These mutationsreduce the effectivenessof flu vaccines.Over the past year, H3N2 mutatedafter it was chosenas a vaccine strain. Additionally, the egg-grown H3N2 vaccine virus strainchangedduring vaccine production. For both these reasons, the vaccine no longer matched what we faced.Would Fluzone have helped'This week, media stories implied that if Australia had purchased a different vaccine, Sanofi Pasteurs egg-grown inactivated Fluzone, the massive flu epidemic would not have happened. Rubbish.The Fluzone product being discussed is a high-dose flu vaccine licensed in the United States (2009) and Canada (2016) for those aged 65 years or older, but not for other age groups. Its not available in Australia because Sanofihasnt appliedto register it here.This vaccine contains four times more antibody-inducing active ingredient, hemagglutinin (60g rather than the usual 15g) than a standard-dose vaccine. But it remains susceptible to problems discussed earlierthough thishasnt been well studied.High-dose Fluzone is a trivalent formulation (meaning it protects against three strains of flu), not quadrivalent (four-strain protection) asrecommended in Australiathis year.No current vaccine could have prevented 2017s flu epidemic.How to better protect the elderlyH3N2 viruses cause more harm among the elderly than the young, whereas flu B strains tend to impact children more.Flu virus infection directly damages cells and paves the way for bacterial infections. The elderly are particularly affected by the flu because an older immune system struggles to defend against infections; specialised immune cells are less effective, less able to respond to new viruses and prefer reminiscing about past viral battles which confuse new skirmishes.An ageing immune system also loses vaccine-induced antibody protectionfasterthan a younger one.To better protect the elderly, some rapid response options include moving immunisation closer to the start of flu season, adding an additional substance to boost the immune response to the vaccine, or increasing the amount of the virus active ingredient to produce a stronger defence against infection.Is a high-dose vaccine safe and more effective than the standard-dose vaccines in the elderly'Sanofis own researchfound its more expensive vaccine better protected older people from lab-confirmed flu, producing higher antibody levels than a standard-dose vaccine. High-dose Fluzoneshowed benefitover standard-dose vaccines across two seasons.Other researchers found the elderly hadfewer doctor visits and hospitalisationsand thatdeaths were prevented.But temporary, mild injection-site reactions weremore commonafter high-dose vaccines because more active ingredient was injected.However, absolute effectiveness is not clear as studies to date usually compare Fluzone to another vaccine.Stopping a repeat in 2018The Fluzone high-dose vaccines can reduce disease and death in the elderly but wont halt spread of an efficiently transmitting flu virus.Stopping flu viruses requires vaccines that are effective in those who most efficiently carry and spread the virus pre-schoolandschool-agedchildren, in whom rates are highest. It also needs higher uptake by the community.The promise of a universal flu vaccine has been dangled since at least1980. We need focused research to commercialise and license vaccines that effectively protect us from seasonal influenza.SEE ALSO:Inside the market for dead humans, where 'donated' bodies from low-income families sell for millionsJoin the conversation about this storyNOW WATCH: What it's like to fly on North Korea's one-star airline
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