Ben Ihlow was a healthy, devoted young dad who was looking forward to spending his first Father’s Day with his 11-month-old son Andrew.
But earlier this month, the bright 30-year-old from Melbourne, Australia, died from flu within days of developing it.‘Everyone’s in shock, because it was so sudden,’ his uncle, Neil Adams, said.
Ben, a keen footballer and cricketer, had become ill on a Monday with ‘just a bit of a bug’. But by the Friday, his condition worsened so much that he was hospitalised. He suddenly passed away two days later from flu complications.
Sudden: Australian Ben Ihlow tragically died, this month, after a week-long battle with the flu
Ben was a tragic victim of one of the worst flu outbreaks on record in Australia, with the number of cases two-and-a-half times higher than last year.
Older people, especially those over 80, have been particularly affected, and care homes have been hit hard: at one in Victoria, eight residents died. There has also been a spike in cases among children aged five to nine.
As the flu season in Australia and the Southern hemisphere could be mirrored in the UK and the rest of the Northern hemisphere, the NHS is now bracing itself for a similar outbreak.
As Simon Stevens, the NHS chief executive, warned last week: ‘If that reproduces itself here over this coming winter, that is going to mean much more pressure on GP services and hospitals.’
But whether they will be able to cope is just one of the questions being asked. There are also concerns about whether the flu vaccine we’ll be using in the coming weeks will actually work against this rapidly mutating virus.
So why has Australia been hit so badly? And what might the implications be for the UK?
A BAD OUTBREAK HERE IS LIKELY
There are two main types of influenza virus that cause illness and seasonal epidemics: influenza A and B.
Flu viruses are shape-shifters, constantly changing the proteins on their surfaces — the parts of the virus that your immune system sees — so that they can escape detection.
When they change, the immune system no longer recognises them and then finds it harder to fight the virus.
Tragic: Ben, a keen footballer and cricketer, had become ill on a Monday but was hospitalised with complications by the Friday – shortly before his death
If the proteins change in a major way — what scientists call an ‘antigenic shift’ — it can cause a pandemic, which is what happened with swine flu in 2009 with the A (H1N1) strain. Thankfully, this happens only occasionally.
The situation in Australia is what’s described as an antigenic drift, rather than shift, which means the virus has mutated in a minor way; it’s still causing problems, because we have less immunity to it (immunity builds up from exposure to viruses from previous seasons), but nothing like the scale of a pandemic.
The spike in Australian cases has been caused by influenza A (H3N2) subtype, a strain that’s been circulating in humans since 1968.
It’s a virus to which the elderly are particularly susceptible (similar to one that circulated in the UK in the winter of 2014/15, causing a significant number of deaths).
The strain could dominate in the UK, too — and may be here already. ‘The Southern hemisphere is an important place to monitor as it will seed and transmit its flu virus to the Northern hemisphere,’ explains Professor Robert Booy, an expert on infectious diseases at the University of Sydney and head of the clinical research team at the National Centre for Immunisation Research and Surveillance in Australia.
Sadness: Ben – pictured with his baby son – was a tragic victim of one of the worst flu outbreaks on record in Australia, with the number of cases two-and-a-half times higher than last year
‘What we are seeing in Australia at the moment could easily transmit to the UK because of the ease of global travel and tourism,’ he adds.
The composition of this year’s vaccine, chosen by the World Health Organisation (WHO) in March, contains strains of A and B viruses, including H3N2. But it appears to have performed poorly in Australia, possibly because the virus has mutated.
‘In a good year we would expect a general effectiveness of 50 per cent, but we don’t know if we have reached that this year,’ says Professor Allen Cheng, director of the infection prevention unit at Alfred Health at Monash University in Melbourne.
What we are seeing in Australia at the moment could easily transmit to the UK because of the ease of global travel and tourism
Experts won’t know just how effective the vaccine was until the end of this month, when WHO experts meet in Melbourne.
But Professor Cheng admits: ‘The vaccine does not look completely effective in all age groups. Generally, the vaccine is less effective in the elderly.’ This is because as you age, your immune response to vaccines (which is what makes it effective) and infections gets weaker, a process called immunosenescence.
If 50 per cent effectiveness is regarded as good for the general population, for older people the figure is lower. In the UK last winter the vaccine did not work at all in those aged 65 and over, but the previous winter, effectiveness was 29 per cent.
‘The effectiveness in older people could be down to 20 per cent because their immune system is not so strong and they do not respond so well to a vaccine,’ says Professor Booy.
Whatever your age, but particularly if you’re over 65, ‘people should be vaccinated, as it will provide some protection, even if isn’t complete’, adds Professor Cheng.
‘The vaccine can still reduce your chance of getting flu by about 20 to 60 per cent — it varies: in some years it is higher, and in other years it is lower. But there is some benefit.’
And the elderly in care homes are particularly vulnerable to flu. ‘Deaths in care homes can be high both because of low vaccination rates and ease of spread in such communities,’ explains Professor John Oxford, an expert in virology at Queen Mary, University of London.
IS A BOOSTER JAB THE ANSWER?
Scientists have been looking at other ways to boost people’s immune response to the flu virus. One idea doing the rounds in Australia is to give a booster dose if you had the vaccine very early in the season.
That the effectiveness of the vaccine could wane is a possibility, acknowledges Professor Oxford.
Prevention better than cure: Last winter, vaccine uptake in England in those aged 65 and over was 70.5 per cent — the target is 75 per cent
The flu season extends over many months, from November to March, and peak vaccine immunity in the elderly is about five to six weeks after they have had their vaccine, he says. A booster dose would seem to make sense, says Professor Cheng: ‘We suggest waning immunity is taken into account when considering when people are vaccinated.’
That is, whether they should get jabbed when the vaccine first becomes available, or whether they can wait for three or four months until June or July during the Australian winter, he says.
Others think the focus should be on getting as many people as possible vaccinated with a first dose in the first instance.
Last winter, vaccine uptake in England in those aged 65 and over was 70.5 per cent — the target is 75 per cent. And uptake was only 49 per cent in those aged six months to 65 years in at-risk groups (see box).
AT GREATER RISK AS YOU AGE
Another way to boost an immune response in the elderly is by giving them a high-dose vaccine. Since 2009, patients in the U.S. aged 65 and over have had access to a vaccine called Fluzone High-Dose, which has four times the strength of a regular flu jab.
As you get older, your immune system weakens, so a higher dose should, in theory, help stimulate more antibodies.
A study published in the New England Journal of Medicine in 2014, involving more than 30,000 people in North America, showed that the high-dose vaccine was 24.2 per cent more effective in preventing flu in adults aged 65 and older compared to the normal vaccine. The most common side-effects of this high-dose vaccine include a sore injection site, muscle pain, malaise and headache.
However, its manufacturer (Sanofi Pasteur) has not made an application for it to be licensed in the European Union, according to the European Medicines Agency.
Another way to boost immunity includes adding a chemical known as an adjuvant to the vaccine. Some adjuvants, such as aluminium-based ones, have been used for a long time in non-flu vaccines. But they can potentially cause more side-effects, such as fever.
And the jury is still out on whether the adjuvant that was used in the pandemic vaccine in Europe in 2009 was associated with a rise in cases of narcolepsy, points out Professor Cheng.
An adjuvanted vaccine could soon be on its way to the UK, though. One such vaccine, for those aged 65 and over, is due to be licensed in the UK later this year, and could potentially be used in next year’s flu programme, according to draft minutes of the June meeting of the Joint Committee on Vaccination and Immunisation.
Ultimately, the holy grail would be a vaccine that tackled all types of flu virus by targeting the part of it that is universal to them all.