To put the current ecosystem of respiratory viruses and, specifically, the flu situation in context, Gaceta Médica has interviewed Alberto Perez Rubiomedical director of the Health Service of Castilla y León (SACYL), who has shared his vision on the possible future scenarios that arise in influenza and COVID-19 vaccination.
Ask. What is the current situation of respiratory viruses in Spain?
Answer. The multiple respiratory viruses, in general, have a different behavior depending on the season and depending on the cocirculation of the viruses that exist. In recent seasons, COVID-19 has devastated everything and has been monovalent. This season there has once again been a normal circulation of what are respiratory viruses and among which, fundamentally, the flu falls. Because the flu, although it tries to normalize, is still one of the infectious diseases that cause the highest morbidity and mortality in the world and in Europe. This morbidity and mortality is concentrated in advanced ages: due to characteristics of the immune system, it produces greater affectation and mortality. That is why it is so important to protect these groups using vaccines that offer a greater immune response to this group: immunogenic vaccines, including adjuvanted ones, which have shown great effectiveness and have greatly reduced the level of infections.
Q. Is there enough evidence around the flu? How important is the Real World Evidence?
A. More evidence is needed. Different studies are needed, clinical results of influenza that show whether infections and hospitalizations due to influenza are avoided and not only the mortality variable. Because the flu is not only a respiratory infection, but also a systemic one. The problem is that clinical trials cannot be done for everything. Trials are done for the use of vaccines and look for immunity; They are immunological studies in which the response of the antibodies is seen and you see if the vaccine really responds or not and safety aspects of the vaccine. However, we must leave these studies behind and look for others, not just immunological ones. It is necessary to go towards studies where other variables are seen and that show the entire scenario that includes the flu, which is still unknown. These studies that analyze the effectiveness of the flu vaccine in real situations are where we have to go to provide more evidence and convince both society and health professionals of vaccination. On the other hand, we are increasingly calculating the risk: now we know the risk of having an acute myocardial infarction after suffering a flu-like illness, suffering a stroke or a diabetogenic complication. Figures are already starting to come up.
Q. Is the population aware of the seriousness of the flu?
R. We have socialized the burden of disease caused by the flu. It’s strong, but it’s true. We know the mortality he has and he is socialized. In the pre-pandemic season in Spain, it is estimated that there were around 4,000 or 6,000 deaths from influenza and more than half a million cases. We are talking about a really important disease and, therefore, we must be aware of its seriousness and not use the terms that have been used in COVID-19, for example, “flu” COVID-19, as if the flu were a picture banal. In addition, the flu vaccine, within the health community, is still something that not everyone is convinced of. In fact, the vaccination results of health professionals are far from optimal.
“The vaccination results of health professionals are far from optimal”
Q. Precisely, health workers play an important role in conveying that vaccination is the most effective prevention tool. How to increase awareness?
R. If the health professional himself does not get vaccinated, it is because he has some doubt about the vaccination. And if he has any doubts about the vaccine, he is hardly going to be able to convey the need for vaccination to his patients. In this sense, it is necessary to shed more light with more studies and more evidence, trying to demonstrate what the World Health Organization already said a few years ago: the most cost-effective tool to prevent flu is vaccination. And, as of today, we have no other. This vaccine will have its virtues and its defects. The ideal would be a universal vaccine, but we have the vaccine we have and it prevents many cases. We have to influence that.
Q. Vaccination coverage in children is higher than in adults. How to change that trend?
A. Coverage is higher in children due to the childhood vaccination schedule. Now they are trying to forget and abandon the idea of the childhood immunization calendar for one of vaccinations throughout life, because there are more and more vaccinations in adults. Vaccines are not something only from childhood, but they have to accompany us throughout life. And now a new concept is being introduced: that of immunizations. Because there is already active immunization and passive immunization that can be introduced. In Spain there are very good results from childhood vaccination – where pediatricians have an undoubted role – but in adults they have never been as expected and that is where we have to influence. The greatest exponent in adult vaccination has always been the flu, but there are other equally important vaccines. Convincing the healthcare provider of the importance of this and other vaccines in adults is essential.
Q. What future challenges are presented in influenza vaccination?
R. The problem is that it is an annual vaccination and everything that is annual is complicated. It is not like childhood vaccinations, which are usually one and then there are booster doses, but they protect. Here the virus has a very high mutation capacity and what circulates one year does not circulate the following year. Predicting the future is complicated and that is the main problem. One makes predictions of what is going to circulate the following year and with that selects the strain that is believed to be most similar to what is going to circulate in the future. That is why there are years of very good effectiveness, because the strain that has been chosen corresponds to the one that has circulated, and other years of less effectiveness. It is true that much progress has been made in vaccines and now there are no longer only those produced in eggs, which have a longer production period, with problems in egg production, growth, etc. There are new vaccine production processes that have been incorporated in recent years: recombinant and mRNA vaccines, which will possibly reduce production times. And this in the face of a possible flu pandemic is very important. But there will always be doubt about the strain that can circulate, until we find a universal vaccine.
“There are new vaccine production processes that production times will possibly decrease and this is very important in the face of a flu pandemic“
Q. And regarding COVID-19, should you also go towards a seasonal vaccination like the flu?
A. COVID-19 is still taking hold. It is not clear what the paths it will take will be, but everything indicates that it will become one more coronavirus, one more respiratory infection, within the framework of respiratory infections that may occur in each season. It will increasingly have a seasonal component, as respiratory viruses usually have, and, in this sense, we will see if we are going towards an annual vaccination or not. That is not yet known. But the most viable scenario is a double vaccination: against COVID-19 and against the flu.
