What are the risks associated with the current low levels of influenza awareness and low (no) circulating influenza viruses?

#TogetherAgainstFlu - 29/04/21

An interview with Dr. Arnold Monto from the University of Michigan School of Public Health  

  • Influenza is still a danger and if there are not continued immunization efforts, it’s going to return as the major threat.   
  • Since the amount of influenza virus in circulation was low last winter, there are going to be questions about what is going to happen in the future. 
  • The difficulty is trying to remind people that flu is a continued threat because there’s been so much emphasis on covid and absence of an influenza season. 
  • We don’t know need to reinvent our messaging approaches; we just need to strengthen them and to change the message based on current experience. 
  • It has to be done very carefully; telling the truth, saying what you know and what you don’t know is very important.   

With low levels of influenza virus circulating and low levels of influenza awareness, Dr. Arnold Monto talks about questions about what might happen in the future, why he believes there is no need to reinvent messaging approaches and the importance of being transparent.    

Dr. Arnold Monto is Professor of Epidemiology and Professor of Global Public Health at the University of Michigan School of Public Health and Acting Chair of the FDA’s Vaccines and Related Biological Products Advisory Committee. He has been working on influenza vaccines for many years, most recently involved in studies evaluating how well influenza vaccines protect and in figuring out how to improve influenza vaccines. He’s also involved in working towards a universal influenza vaccine.  

We have seen concerns from the medical community that the current low influenza awareness and also the low exposure might affect the how the population will be affected by influenza in the future. How is this influenza consciousness making a difference during the pandemic? 

Dr. Arnold Monto: Given that we didn’t know what was going to happen this past winter, we were afraid initially that we would see both covid and influenza circulating at the same time, and there was a discussion about a twindemic. Given that we didn’t yet have a covid vaccine in the United States, the influenza vaccine was vigorously pushed as something that might be necessary. 

Since we did not have any influenza at all, then there are going to be questions about what is going to happen in the future. Is this something that is going to continue since covid will probably continue to be circulating? Or is this something that was temporary? And do we need to keep up our influenza vaccination programs?  

I see that as our first challenge. The problem is that even though we may get answers during our summer from the Southern Hemisphere; it may not be sufficient to answer the questions that will arise in our autumn when we get into the influenza season. Many of us are concerned that we will have a severe influenza season unless we do keep up our vaccination frequency. And that is going to be the challenge.  

There’s also a new challenge because of the covid situation: the fact that we have not seen any flu. And in parts of the world that are still doing mitigation strategies, the question is whether this is going to interrupt flu transmission and whether it’s necessary to get influenza vaccines. It’s going to be different in different places. Europe has been much more hesitant about influenza vaccination than the US.  

How can we make a difference so that people are aware of how flu and covid vaccination can help? 

Dr. Arnold Monto: I think there’s been a lot of experience in Europe on this. I was a board member of the ESWI for a number of years, and they’ve done very well at this. The ESWI organization has solicited funds for many of the manufacturers to do this with a unified, non-branded message. So, there’s a good deal of experience with his group. 

So, there’s been a lot of experience here, and I don’t know that we need to reinvent the approaches. We just need to strengthen them and to change the message based on how covid is impacting the current levels of flu virus in circulation and try to convince people that both are a threat. Because now they’re talking about for those who are vaccinated initially with covid, you are going to need revaccination and making the program similar, but convincing the public that you need both. 

Would there be actions that you would recommend to help with this? 

Dr. Arnold Monto: To show that influenza is still a danger, that it is an infection that has been here for a long time, that mortality is present but it is not as likely because of past immunization efforts – but if there are not continued immunization efforts, it’s going to return as the major threat. 

A lot will be dependent on what is going on in a particular country because European vaccine recommendations are very different. One of the key differences between covid and flu is that young children are at risk from influenza, but not necessarily from covid except with some of the variants. Many European countries are ignoring childhood vaccination with influenza. This varies from country to country. Finland, for example, is very concerned about it, whereas the Netherlands is not. I would focus on harmonizing recommendations across Europe, which is harder to do than you might think. The recommendations, the updates for flu across Europe are enormously different.  

Do you think this setup made a difference when the pandemic started? 

Dr. Arnold Monto: I think it did because the flu people were experienced and the covid people were trying to catch up – and that continues. So, I see the problem is trying to remind people that flu is a continued threat because there’s been so much emphasis on covid, and in the absence of an influenza season, people may say, “Well, is it important to continue?”  

Social media is a big problem. I divide hesitancy between people who have a rational idea of why they’re hesitant, which you can address, and the anti-vaxxers, which you might as well forget about. Nothing you do is going to change them.  

I’ve seen some opinions of these people who are maybe just hesitant, and then they would mention, “We had covid, and we focused on that, but then I didn’t get the flu this year at all.”  

Dr. Arnold Monto: We had recommendations, a push to get the flu vaccine, and then there wasn’t any flu. And is it going to happen again once we start recommending flu vaccine?  

The only way we may be saved on this is if there is a significant flu season in the Southern Hemisphere during our summer. And that remains to be seen because the countries in the Southern Hemisphere are either dealing with covid still, such as South Africa or are still somewhat isolated from the rest of the world, such as Australia, New Zealand.  

How do you think that this consciousness, the fact that we’re talking about this, will prevent flu in the future? 

Dr. Arnold Monto: I think we’re going to have to be flexible in our approach because I think there are new issues that have come up. We still will have to deal with the problem of explaining that we have a burden of influenza, high burden of influenza, and our vaccines may not be 94% effective as the covid vaccines, but they still prevent severe disease. And that’s going to be the real challenge because, for example, if we start having vaccine effectiveness studies, if we have an AH3N2 and we’re 40% effective, what does that mean? Why should I get vaccinated when it’s not even 50% effective? And that has to be handled.  

How would you address that? 

Dr. Arnold Monto: I think the CDC’s addressed it by showing how many cases are averted. It’s been done before. All of this has been done before. It’s a question of putting it all together and modifying it based on what’s happened with covid. There’s no magic here. It’s just redoing the same kinds of things we’ve been doing before and updating. And there are new drivers. Social media has become the main new driver.  

If we have a vaccine that’s 94% effective against flu, then we would be able to talk about that. And I think it is basically saying we have a good vaccine, we don’t have a great vaccine, but we’re doing a lot of good with this vaccine, and we’re working to make it better. That’s the basic message. 

I think we have to watch and see what happens because everything is really unknown in terms of what we’re going to be seeing this winter 21/22, that’s the big question. We are concerned that it will be a bad year simply because there is so little immunity in the population since we didn’t have influenza for a whole year.  

So, we have to watch out, but the trouble is if you make the message too strong and we’re wrong, and then you’re in trouble afterward. It has to be done very carefully. Telling the truth, saying what you know and what you don’t know is very important. 

Finding the right balance is always difficult because certain media want stories that are highly impactful. Giving a balanced approach is not exciting to them. Getting space in the media sometimes is hard if it’s going to be a balanced message. 

As Dr. Arnold Monto highlights, transparency and agility will be key to preventing a flu epidemic once physical restrictions are lifted. Only by being open and honest about the effectiveness and importance of vaccines will we be able to ensure people – particularly the vaccine-hesitant – get their flu shots needed to keep the flu virus under control..

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