Dr. Roberts on the Flu Shot and Coronavirus

Dr. Jordan Roberts is a Thrivous science advisor and an advocate of the flu shot. He recently sat down with a flu-shot-curious mom, Blaire Ostler. Together, they discussed her questions and concerns, such as:

• Should I get a flu shot? Does the flu shot work?
• What is in the flu shot? Is the flu shot a live virus?
• Can you get the flu from the flu shot? Can the flu shot make you sick?
• When to get flu shot? How long does the flu shot last?

At the end, Jordan and Blaire also discuss the possibility of coronavirus vaccinations. Here's a recording of their discussion, followed by an edited transcript:

Blaire: Welcome, everyone. I'm here today with Dr. Roberts. And I'm really glad that you've agreed to talk to me about the flu shot because, I plead guilty, I don't get the flu shot. I don't give my kids the flu shot. And, to be honest with you, I'm painfully ignorant on the topic. And I'm wondering if you can help answer some questions and clear things up to me, so that I can make a more informed decision about whether or not I want to get the flu shot.

Jordan: Absolutely. I'd be happy to.

Blaire: Awesome. Okay. So one of my first concerns about the flu shot is: I heard that getting the flu shot is actually giving you the flu.

Jordan: That's a really valid concern. I think that makes perfect sense for you as a person and as a mother. You wouldn't want to give yourself or your kids something that could be harmful. Right? And, as your doctor, I wouldn't want to do that either. In fact, I took an oath when I graduated from medical school that I would first do no harm.

That's a very common misconception. But I think I can answer your question quite simply. No. You cannot get the flu from the flu shot. It's theoretically impossible.

Blaire: And how is that the case?

Jordan: Because the flu shot is not a live vaccine. It's not even killed vaccine. It's what we're calling "recombinant" vaccine. So it relies on a newer technology that's DNA-based. And I can explain what those terms mean, if you'd like.

Blaire: Yeah. Please. So what's the difference between a live vaccine and a dead vaccine and what we use now?

Jordan: Sure. The very first flu vaccinations came about a hundred years ago, after the great Spanish Flu pandemic that killed scores of millions of people. They were very crude technologies but a major advance in public health.

They would actually grow live cultures of the whole flu virus particle in animals or other tissues, like mice or the eggs of chickens. And then they would insert a small needle into that live culture full of the virus particles, and push that under the skin of the person receiving the vaccine.

That person was literally being given the flu, but not in the traditional way that most of us catch the flu, which is through our respiratory system. So their symptoms were slightly different. They didn't have a lot of the cough and headache and runny nose that most of us experience when we get the flu.

But they did have the muscle aches and the fevers and those other symptoms, some of the gastrointestinal symptoms. But it was typically more of a mild case. And if that person was exposed to a person who actually had the respiratory flu later on, they were immune, which was the whole point of the exercise.

This was first done in the army and other places where you have a captive audience. But once it was demonstrated that this was safe, and that it was effective, it became widespread. It was routinely recommended.

A little bit later, people realized that was maybe not a great deal, to give people a living virus. And somebody had this insight: what if we destroyed the particle? What if we exposed it to some harmful chemicals or we boiled it, to make the little flu virus particle fall apart?

We showed that to the immune system in the form of a shot. And this was the birth of the true flu shot: a fluid in a syringe that goes into your body. This is what we call a "killed" vaccine. It's all the same parts. But they are destroyed either through being exposed to boiling water, formaldehyde, or ethanol.

Blaire: But they're still effective?

Jordan: Absolutely. And it's much safer. So the people wouldn't have the flu. They would have some of the same symptoms at the injection site: redness and swelling and pain, similar to what we'd get now. But not the true flu illness, unless a few of those viral particles managed to escape that destruction process.

Blaire: But even that isn't what we use today though?

Jordan: No. It's not. That was much safer and just as effective and was the standard of care for decades until the genomic revolution, when we started to understand that DNA is the common language that all life shares. And we decoded the DNA sequences of the flu genome.

The flu has just a short string of different genes that code for its various parts. A virus is a very simple, minimalist organism. It's essentially the perfect parasite. It has just enough genes to get into your body and hijack your body's own cells to make massive amounts of itself: new viral particles.

So, for example, the influenza virus has two major, what I call, "trojan horse" proteins, located on the outside of its shell. And then it has the shell. And then, on the inside is its genome, a piece of DNA or RNA in this case. It's a very simple thing.

We know some things about what happens if we can show the body those trojan horse proteins, what we call the "H" and "N" proteins. You've probably heard of things like the H1N1 virus. And those refer to specific proteins, found on the surface of the virus particle, that trick your body into thinking it's something interesting, to take it into itself, and then it's got you.

It inserts its DNA into your cell. And that cell is going to die. That cell is going to be hijacked and become nothing more than a virus-producing factory. And when your body's immune cells discover that the cell has been hijacked, they trigger it for apoptosis or programmed cell death, or suicide to stop this threat of infection.

What we do now, with our recombinant vaccine technology, is take the DNA for those viral particles, H and N. And we put that little piece of DNA inside a vector, usually a chicken egg embryo. And we co-opt that embryo to make massive amounts of those H and N proteins. Then we purify those proteins. And that's what goes in the shot.

Knowing this, that you're only seeing the H and N proteins, does that make sense why it's impossible to get the flu from a flu shot?

Blaire: It does. But what else goes into the vaccine? Is there any mercury involved, or anything like that?

Jordan: That's also another very good point. Certain doses of the flu vaccine come in what we call a "multi-dose" vial, where you draw multiple doses for dozens of people from the same vial. Those vials do require a preservative. And, as part of that preservative cocktail, there are some mercury-containing chemicals.

Mercury is a natural element, found in nature. There are certain forms of it that are toxic to us, certainly. And we know those forms. We'd never put harmful amounts of those forms of mercury in something that I give to a person.

So, yes, while there is mercury in those multi-dose vials, in the single-dose vials, there's not. Those don't require preservative.

Blaire: How often are the different vials used? Or how do you know if you're getting a multi-dose vial or a single-dose vial?

Jordan: It depends on the age of the patient who's receiving the vaccine, and the maker of the vaccine. There are only a handful of pharmaceutical companies that make the flu shot every year. And I can talk about how they choose which strains to go in.

Blaire: How do you even know how to make the flu shot? What are you injecting into me?

Jordan: That's a very good question. You've probably heard things like: "I've heard that the flu vaccine varies in its effectiveness from year to year." Right?

Blaire: Yeah. Exactly, because that's the point. If I'm going to inject myself with something, I want to have a good chance that it's actually going to do something. Right?

Jordan: Absolutely.

Blaire: So how does that work?

Jordan: We want it to be both safe and effective.

Blaire: Yes.

Jordan: The important thing to remember is that when it's summer, here, in the northern hemisphere, it's winter somewhere. It's flu season somewhere else. The CDC (Centers for Disease Control) in Atlanta has good partnerships with other similar organizations in places in the southern hemisphere, places like Australia, New Zealand, South Africa, Chile, and Argentina. And they share information.

When it's our summer, and it's the height of flu season in the southern hemisphere, those organizations are sharing data back and forth. They're telling us which strains of the flu they are seeing that are causing the majority of disease. The CDC graciously accepts that information and shares in turn, when it's our turn.

Then they put all that information into these complex mathematical algorithms that predict human migration, based on things like shipping lanes and cruise ships and air travel. All of these other things go into the formula. And it gets better and better with every year.

It's not a silver bullet. It's not a crystal ball. This is the cutting edge of science. But there's no way to know with 100% certainty which strains are going to come north when it's our turn. We have to rely on statistics.

Blaire: So, percentage-wise, what would it be like? How effective is this going to be? Do you have a percent?

Jordan: On average, the effectiveness, meaning the correlation between the strains that are chosen to go in the vaccine ahead of the flu season and the ones we actually end up seeing, is pretty close. I'd say, on average, it's about 75% effective, which means that some years are better and some years worse.

A few years ago, there was a pretty rough year, where the correlation between the ones we saw and the ones we were prepared for was only about 25%. 25% is better than zero. And zero is the percent chance you have of being immune if you don't get vaccinated.

Blaire: But if I do get vaccinated then what are some of the side effects that I can expect from being injected with this?

Jordan: Typically, the side effects are localized to where you get the injection: things like redness, soreness at the site of the injection, pain, and low-grade fever. Those are typically mild and temporary, two or three days at most. And they usually respond really well to things like ice, ibuprofen, and rest.

The chances of having a more severe reaction, like an anaphylactic reaction, severe pain, or a more rare complication, like Guillain-Barré ascending paralysis or death, from the flu shot is incredibly small. I mean, your chances of winning the lottery or being struck by lightning are better.

Blaire: Okay. Let's say I forego the flu shot. I don't want to worry about any side effects. I'm really healthy. And I don't really get sick that often anyway. Why do I need to get flu shot?

Jordan: I hear that a lot. That's probably the most common response that I get from my healthy young patients, who just don't understand why I'm recommending it. And you're right. If you got the flu, it would be a couple weeks of misery. Have you been sick recently? Have you had the flu recently?

Blaire: Yeah. I actually did get the flu this season. And I did not get the flu shot. So I'm very curious.

Jordan: So you probably remember. It was two weeks when you felt like you were going to die.

Blaire: Yeah. It was brutal.

Jordan: Yeah. High fevers, muscle aches. You know, it's pretty rough. But you're young and healthy. So you probably will bounce back pretty quickly. Right?

The tricky thing about the flu and the important thing to remember is that it's a highly evolved thing. And it is evolved to continue to spread. If every person who got flu, on the day they got sick and started to have symptoms, would go to isolate themselves then they would prevent other people from coming in contact with them. In some sense, the virus knows this.

It doesn't have a brain. It can't really know it. But it has evolved a mechanism to get around that. That mechanism is that when you are exposed then there's actually a lapse in time between when you are contagious and when you start to develop symptoms. And it's during that time that you are shedding or spreading the virus.

Blaire: So, for a couple days, I could be spreading the virus without even knowing I have the virus in the first place. And I can be giving it to someone far more vulnerable than myself.

Jordan: Exactly. Someone who is younger, older, whose immune system is not really up to snuff, on chemotherapy or on some sort of medication for a problem like arthritis or Crohn's disease, where their immune system is being suppressed: those are the people who get very sick from the flu, people who end up in the hospital, people who die from the flu.

And God forbid if that should happen and you were the one who gave them that. In a way, you are indirectly responsible for their illness and death.

Blaire: So what I'm hearing is it's not just about vaccinating myself. It's about creating this kind of vaccinated environment in which to protect the vulnerable members of your tribe.

Jordan: Exactly. It's about being a good steward of the public health. In epidemiology, we have a term for that. And that's "herd immunity." When we have a very healthy immune herd, they create a sort of shield or protective barrier around those few in our midst who are vulnerable or unvaccinated. And they protect from and prevent these large-scale outbreaks of things that are very contagious, like the flu virus.

To get that real immunity benefit, we have to have high levels of immunity and vaccinations, levels above 75% to 80%. Unfortunately, we don't typically reach that in America. Most years, we succeed in vaccinating about 50% of the adult population against the flu.

But that's pretty good in a country of 350 million people. That's literally more than a hundred million people who get the flu shot every year. And how many of them have a major serious reaction or die from the flu on a given year? It's maybe one or two.

Blaire: How many people die of the flu?

Jordan: Tens of thousands.

Blaire: Okay. So the chances of dying of the flu shot are significantly less than dying of the flu?

Jordan: Not even in the same ballpark.

Blaire: Not even in the same ballpark. So I'm a mom. I have three kids. And, while I am concerned with herd immunity, I'm more concerned about my individual children. So could you explain to me, then, are there any differences in giving the flu shot to healthy adults, someone like myself, and then my younger children? I have a twelve-year-old, a nine-year-old, and a six-year-old. And then, how young is too young to get the flu shot?

Jordan: That's a great question. And it's changing. With new vaccines coming on the market, the youngest age possible that we can give them is going down. And we have now different strengths available for different people at different ages.

The typical flu shot, what we call "quadrivalent" shot, protects you from four strains of the virus that the CDC has identified. These are the big four that we really want to make sure that most people get immunized against.

For people who are 65 and above, we have what we call our "high-dose" flu shot, which can be for twelve to fifteen strains. Those are people who are much more likely to be acutely ill and die from the flu. So we give them a broader range of protection.

And now there's even one in the middle that's approved for people who are 50 and older. It covers about ten strains.

Now, I haven't mentioned at all the flu mist, the nasal spray. That is truly a live vaccine, what we call a "live attenuated" vaccine. It's been weakened a little bit to produce a less vigorous kind of response. But it is truly a whole particle that we give to children to avoid a shot.

It's not available every year because it's very difficult to grow in culture. So some years it just doesn't make it to market in time. In those years, we do use the shot for kids. But some years, it is available. It's not a good idea if your child suffers from respiratory problems or asthma, though. You should still give them the shot.

In general, we recommend the flu vaccination for children as young as six months old. And if a mother is breastfeeding then to continue breastfeeding through that season is really important.

Blaire: When do you recommend I give my kids and myself the flu shot? If we're going to go get the flu shot, I want it to be effective. When do I do this?

Jordan: That's a great question. Here we are, kind of late in the flu season. It's not too late. We continue to see flu cases pop up through April. But the ideal time to get your flu shot is early in the fall: September, October. That's typically when we get the flu shot in stock. So I'd say, this year, if you decide to go ahead and take the plunge and get it yourself and for your kids, go to your doctor's office or pharmacy, come late September, early October.

Blaire: What about for people who say, I already had the flu this season, so I'm going to be good the rest of season.

Jordan: I wish it were so. But it's not. We are locked in an arms race with the flu. The flu virus is constantly mutating, which is why we have to create a new flu vaccine every year to kind of play catch-up, cat-and-mouse, with this flu virus.

Now, there is real hope that, at some point in the future, we will have what we call the universal flu vaccine: one flu vaccine that you can get, either a single injection or a series, as a child and develop lifelong immunity against all strains of influenza forever, that ever could be.

Blaire: It's like super children, immune to the flu.

Jordan: And when we have that, we'll see the flu go the way of the dinosaur, the way of smallpox. It will be eradicated in humans. I'd say that vaccine, while we're making important progress towards that, it's not ready for the limelight. It's still probably ten maybe even fifteen years away. But it definitely is something that we are working on and, I think, something that we will see in our lifetime: a true universal flu shot, which is really exciting.

Until then, though, the annual flu shot is still our best defense against pandemic influenza.

Blaire: My final question, then, I have to ask. While I trust the data, and I'm trusting everything you're saying, but at the end of the day, I'm making these decisions based upon emotions. And what I need to know from you is: do you give your kids the flu vaccine?

Jordan: Absolutely. I go in with them, actually. We all get it together. Yeah. Solidarity.

Blaire: Okay.

Jordan: Yeah. Every year, they cry and they complain. But it's the right thing to do. As a father, I want them to be safe. And I want to show a good example. So we do it together.

Blaire: Thanks so much for helping me understand the flu shot better. I was totally ignorant on the topic.

Jordan: I think these are all really important questions. And I never want my patients to feel judged or condescended to when they have legitimate questions about the safety and effectiveness of a treatment I recommend.

Now, I've gotten a lot of questions recently about emerging threats, things like coronavirus, which is a hot topic right now.

Blaire: Oh, sure.

Jordan: I think influenza still presents a much greater imminent danger to most of us than coronavirus. But a lot of the same preventive strategies apply.

So, during this respiratory season, it's really important to practice good hand hygiene. If you're in public and you come home, you should wash your hands before eating anything, before touching your face. You should try to avoid concerts and sporting events, if at all possible, the airport, places where germs are likely to be spread and come in from different parts of the world.

If you feel that you are sick, you should avoid going to work that day. You should keep your children home, if they're sick. You should seek urgent medical attention for fevers that don't respond to typical antipyretics, or if you or your child can't keep down enough fluid. These are all really important reasons to go seek medical attention.

And if we get to the point where there is a vaccine against coronavirus, or any pandemic for that matter, that is available and recommended, you should get that. You should get that too.

Blaire: I assume it has to go through rigorous testing, right?

Jordan: Absolutely. In fact, there are already some initial phase one studies that are being done on coronavirus vaccination, in particular. And these phases are intended to make sure that the drug is effective, that it is safe, that it is dosed appropriately before it ever reaches the mass market, where we would give it routinely to people.

Blaire: Okay.

Jordan: These are are people who have our best interest at heart right. They want us all to be healthy. There's no conspiracy to make us all stick or dumb by giving vaccines.

Blaire: Right. Well, thank you so much for your time. I already feel better about the flu shot.

Jordan: Good. It's my pleasure.