The psychology of flu shots

When it comes to flu shots, why does cool indifference sometimes give way to white hot demand?


TORONTO – Influenza is notoriously mercurial, forcing even the experts to guess at which strain will dominate from one year to the next. As Canada is learning this winter, almost as unpredictable as the virus itself is whether the public will be willing to embrace flu vaccination.

Public Health officials regularly plead and cajole, but most years the majority of people pass on getting a shot. Canadian flu vaccination rates sit pretty squarely in the one-quarter to one-third range, Statistics Canada data show.

But occasionally we experience a phenomenon such as what has been happening in Western Canada where, undeterred by frigid temperatures, people embarked on sometimes desperate searches for flu shots — something they should have done weeks ago to get optimal protection.

While public health authorities are delighted people want to be vaccinated, they are puzzled by the unexpected clamour for flu shots. Going by the numbers, this year’s flu season is active, but not overly severe.

So what the heck is going on? When it comes to flu shots, why does cool indifference sometimes give way to white hot demand?

“The psychology of influenza vaccination uptake is sometimes almost as complex as the disease itself,” says Michael Osterholm, director of the Center for Infectious Diseases Research and Policy at the University of Minnesota.

“We want everyone to be vaccinated. But the question is: Why do we sometimes have these runs?”

So far this year the data collected by the Public Health Agency of Canada and the U.S. Centers for Disease Control suggest North America is experiencing a normal sort of flu season.

Hospitalization rates for influenza, for instance, are lower than those of some recent years. And where 171 children died from flu infections last winter in the United States, so far this year there have been 10 pediatric deaths there.

“I think that this year will assuredly end up less — as far as sheer numbers — than the 2009 pandemic,” says Dr. Michael Jhung, a medical epidemiologist in the CDC’s influenza division.

“And it looks like it will have had less activity than last year, but that I’m not so sure about until we get all the data in.”

But Jhung and others say the overall picture may be masking a shift that the public is actually picking up on. It’s not that more people are getting admitted to hospitals or dying from flu. The concern stems from who is getting severely ill and who is dying.

For years, flu saved its biggest wallop for the elderly. But since the new H1N1 strain emerged in the 2009 pandemic, you can’t assume that grandma and grandpa are the folks most likely to end up in ICUs with flu.

As was seen in the pandemic, the elderly aren’t as susceptible to this H1N1 as they are to H3N2, the virus that dominated last season. Younger people are more likely to get infected with this virus, and some of those infections lead to serious illness.

“We’re used to our parents being the ones who end up in ICU or dying, sadly…. But now it’s us, right?” says Dr. Perry Kendall, chief medical officer of health for British Columbia.

“So if you’re a 50-year-old, you would be sad if your father or your mother went into ICU. But when it’s your spouse or your brother, it’s different. The risk is a lot more proximal.”

By flu terms, the numbers of deaths being reported this year are still small. Two deaths here, 10 there. Each is a tragedy. Still, the reality is lots of people die from flu every year; the Public Health Agency of Canada estimates the toll to be about 3,500 Canadians a year.

But those smaller numbers actually mean something to people, where the larger estimate is an abstraction, suggests Dr. Kumanan Wilson, a senior scientist at the Ottawa Hospital Research Institute.

“A few stories that are particularly vivid and clear can start to create a perception of risk that’s much greater than the actual number of deaths,” he says.

“There’s a big difference between an individual story of a young person who was healthy, got the flu and then died than at the end of the flu season someone saying ‘Actually, X thousand people died from the flu.'”

Jhung says as of last week the U.S. had seen 2,622 hospitalizations. Of those, 61 per cent were in the 18-to-64 demographic. “When we think about who gets hospitalized for flu, it’s usually 60 per cent of those hospitalizations are in people 65 or older.”

In both Canada and the U.S., there are reports of really sick young and middle-aged adults in ICUs. That was the pattern during the H1N1 pandemic, so public health folks who know influenza aren’t surprised. That’s the way this virus rolls.

But it’s not something the public — or even some doctors — expect from flu, Jhung says, admitting this could be making influenza more noticeable this year.

“I do get the sense — and this is not substantiated by any data — that clinicians are being maybe taken aback a little bit by the number of severe illnesses they’re seeing in younger adults.”

The perception something unusual is happening fuels demand for vaccine and supplies start to tighten. Suddenly that shot you didn’t think you needed is something you desperately want, something you and your children need to be safe.

It’s happened before.

In 2004, the U.S. lost about 40 per cent of its vaccine order when one of its suppliers had to jettison its entire output because of a contamination problem. Word that supplies would be tight sent demand soaring. Americans were crossing the border to get a flu shot in Canada. Canada had plenty of vaccine that year, but media coverage of the U.S. shortage spiked demand here too.

And just as Canadian vaccination clinics were poised to open in the 2009 pandemic, a young boy died from the new flu in Ontario. Lines for vaccine were enormous.

“Every time a child or a youth dies, demand goes soaring up,” says Kendall.

The frustrating thing for public health officials is that these periodic runs on flu vaccine do not seem to translate into long-term increases in demand for flu shots. It’s quite probable that many of the people who lined up this week will not bother getting a flu shot next fall.

“It’s a shame that this psychological effect also tends to wane over time,” says Jhung.

“You would think that if they’d never been vaccinated, once they go through the process and recognize that it’s really not that bad, that they may continue to do it. But I don’t know what’s going to make the message stick. We haven’t figured that out yet.”

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The psychology of flu shots

  1. The media starts hyping it up with the backing of the pharmaceutical companies. People get scared even though the number of the deaths is lower than from other causes. I am an RN who has to wear a mask because I don’t get the flu shot. Coworkers found the mask so uncomfortable they got the shot and they still call in with the flu. It is handwashing!

    • They call in with the influenza? Or are they confusing it with Rhinovirus or Norovirus (Often misnamed a flu)? Or maybe they had parainfluenza?

      While the vaccine isn’t 100% effective, it has been shown to be exceptionally effective. It reduces the likelihood of catching and transmitting the flu; it does not increase it.

      Please, for the sake of the people in your care, read the research. Lot’s of it is out there from reputable, independent sources. Or at the very least, read this list of flu myths from Harvard,

      Your training should have included an in depth course on disease control and epidemiology, but unfortunately it didn’t. It likely barely scratched the surface and now you get to be the one putting the final nail in patients’ coffins. Not only that, you come online and spread myths pretending to be an expert in the field.

      Oh, you are right about one thing. Hand washing is key. It’s too bad most health care practitioners don’t wash their hands properly, or at all.

      • There should also be either copper or silver door handles on hospitals and medical facilities, instead of the stainless steel ones, which not only have surface pits which trap microorganisms, but do not kill what they trap.

        Trouble is, your sickness is more profitable to others than your health.

    • I find it pretty amazing that an RN wouldn’t get the flu shot. Isn’t the scientific evidence pretty much overwhelming and the risk very low?

    • So glad you’re not my nurse, Typhoid Judith. Flu spreads through airborne droplets.

  2. “But occasionally we experience a phenomenon such as what has been
    happening in Western Canada where, undeterred by frigid temperatures,
    people embarked on sometimes desperate searches for flu shots —”
    Well no wonder, the fear mongering brought on by the media government and medical personnel regarding the flu (a relatively benign illness in most people) was beyond ridiculous.

      • Read this: A comprehensive of the flu research by the Cochrane Collaboration in healthy adults aged 18-65 from 1960 to the present including over 40 clinical trials with over 70,000 people found no evidence of benefit for the flu vaccine. Only the best 50 studies were included in the final analysis. The studies that showed any benefit were industry funded. There are different 200+ strains of flu and viruses that infect people every year. The vaccine covers only about 10 percent of the virus strains that make people sick. They also found cases of severe harm and inadequate reporting of adverse effects of the flu vaccine. There was also NO evidence that the vaccine reduced transmission of the flu (a major rationale for mass vaccination) or complications such as pneumonia (another major justification).

        • Do you have a reference for that?

          Because all of these are from Cochrane and they refute what you say. Any other sources you want to check?

          Not getting a flu shot is selfish, because you might be fine, but others you give it to will not.

          Jefferson T, Del Mar CB, Dooley L, et al. (2011). “Physical interventions to interrupt or reduce the spread of respiratory viruses”. Cochrane Database Syst Rev (7): CD006207. doi:10.1002/14651858.CD006207.pub4. PMID 21735402.

          Jefferson T, Di Pietrantonj C, Rivetti A, Bawazeer GA, Al-Ansary LA, Ferroni E (2010). “Vaccines for preventing influenza in healthy adults”. Cochrane Database Syst Rev (7): CD001269. doi:10.1002/14651858.CD001269.pub4. PMID 20614424.

          Jefferson T, Rivetti A, Di Pietrantonj C, Demicheli V, Ferroni E (2012). “Vaccines for preventing influenza in healthy children”. Cochrane Database Syst Rev 8: CD004879.doi:10.1002/14651858.CD004879.pub4. PMID 22895945.

          Poole PJ, Chacko E, Wood-Baker RW, Cates CJ (2006). “Influenza vaccine for patients with chronic obstructive pulmonary disease”. Cochrane Database Syst Rev(1): CD002733. doi:10.1002/14651858.CD002733.pub2. PMID 16437444.

          Cates, CJ; Rowe, BH (Feb 28, 2013). “Vaccines for preventing influenza in people with asthma.”. The Cochrane database of systematic reviews 2: CD000364.doi:10.1002/14651858.CD000364.pub4. PMID 23450529.

          Thomas, RE; Jefferson, T; Lasserson, TJ (Jul 22, 2013). “Influenza vaccination for healthcare workers who care for people aged 60 or older living in long-term care institutions.”. The Cochrane database of systematic reviews 7: CD005187.doi:10.1002/14651858.CD005187.pub4. PMID 23881655.

        • Source?

      • And read this:

        Influenza: marketing vaccine by marketing disease – Peter Doshi

        Promotion of influenza vaccines is one of the most visible and aggressive public health policies today.

        Closer examination of influenza vaccine policies shows that although
        proponents employ the rhetoric of science, the studies underlying the
        policy are often of low quality, and do not substantiate officials’
        claims. The vaccine might be less beneficial and less safe than has been
        claimed, and the threat of influenza appears overstated.

          • Hey idiot! We are talking about the flu vaccine; not the polio vaccine, or the small pox vaccine. So, don’t give me that conspiracy crap nonsense!

            “EVIDENCE REFUTES the claims that the flu vaccine prevents the flu;

            the EVIDENCE REFUTES the claim that it prevents viral
            transmission in healthy adults;

            and the EVIDENCE REFUTES the claim that the
            vaccine prevents complications and “saves lives.”

          • Thanks for refuting yourself. Your quote above is not from a study, but from a website which references a study. That study could only conclude that the flu shot reduces missed work days. It didn’t have enough evidence to conclude on anything else. Given that there are thousands of studies with different parameters, and this only looked at 50, it’s no surprise.

            Plenty of studies show a serious benefit from the flu vaccine.

          • “For the past two decades, I have been involved in the writing and periodic updating of Cochrane reviews on influenza vaccines in children,healthy adults, the elderly, and healthcare workers who care for sick people. My group and I also carried out a review on 270 influenza vaccines studies on all types of populations published from the 1940s up to 2007 and found near universal poor methodological quality. We also found that pharma-funded studies were more likely to be published in the top journals and be more often quoted than their non pharma counterparts, but the quality and size of the studies were the same as the others. Their conclusions were not surprisingly far more optimistic on the vaccines’ performance. Their publication on top journals was probably a result of the fatal attraction of pharma sponsorship for big journals and their publishers.”

            Tom Jefferson, Cochrane Collaboration

            Read more:

          • That quote says nothing about flu vaccinations not working, just that the industry pushes the more pro-vaccination studies. He says that the vaccines did not perform as well as suggested, but by no means does he say that they were ineffective. I’m starting to really doubt you, Huyie.

          • Wait! Is he saying that biologists are doing research on the products they produce?

            Maybe the accountants should do scientific research. What could possibly go wrong?

          • Could you please link a source to some article that defends what you are saying?

  3. Cochrane Collaboration: Flu Vaccines of No Benefit

    “Specifically, the EVIDENCE REFUTES the claims that the flu vaccine
    prevents the flu;

    the EVIDENCE REFUTES the claim that it prevents viral
    transmission in healthy adults;

    and the EVIDENCE REFUTES the claim that the
    vaccine prevents complications and “saves lives.”

      • Read the note above. Your reference refutes what you say. The website takes the study out of context and the study refutes you.

  4. People need to stop being like a heard of cattle and be more like the bull… other words use your brains that god gave you and think for yourself, dont let people or the media scare you….

    • Soooo…get the flu shot because its so obvious that its a good idea?

  5. What PANDEMIC? How many people died in Canada during that “pandemic” 2009? Hundred thousand? Ten thousand? And how many die from flu in a “non-pandemic” year? This was the best pharma marketing ever. Plus, the “pandemic” label allowed the vaccine to skip the regular protocol …

    • The 2009 outbreak was indeed a pandemic. This refers to how widespread the disease is rather than to how many people died of it.

    • 428 people in Canada died of H1N1 in 2009. Much less than the 3500 to 8000 quoted in this news piece.

  6. The reason for the panicked long line ups is because of all the exaggerated hyper media reports.

    Only 428 Canadians died in the H1N1 pandemic of 2009, according to vital statistics. It was a year where flu swabs were actually taken and lab analyzed, unlike most years when no real flu lab testing is done. That is far less than 3500 to 8000 people dying of flu, because those estimates are based on computer models, not reality.

    For the record, the H1N1 vaccine only became available AFTER H1N1 had struck that year (2009). Worse, people who had received the regular 2008-2009 flu vaccine were more susceptible and more sick with H1N1 than people who did not get the regular flu shot.


    My family did receive just the H1N1 vaccine in 2009, but that was after my kids’ school mates had already been stricken with flu. I assume that we still have some protection from that vaccine. If not, then flu vaccines are not very effective.

    I do know people who did get this year’s flu shot back in October and November, but they still got sick with a flu (fever/aches/head-ache/ respiratory) over the holidays. The flu shot is no guarantee when there are about 200 other viruses to get infected with.