Dr. Melissa D. Young is a clinical pharmacist and Certified Diabetes Educator at the American Association of Diabetes Educators1 who holds a very personal interest in advocating for annual influenza (flu) vaccination. Twelve years ago, her mother passed away after an influenza infection was complicated by bacterial pneumonia. Young’s mother had a pre-existing chronic lung condition, but “she had refused to get a flu vaccine because she mistakenly thought it would give her the flu,” says Young.

It’s a sad, but all too common story.  According to data collected by the Centers for Disease Control and Prevention,2 of US adults who were hospitalized for influenza infection in 2018-2019 with additional information available, 93 percent had at least one underlying medical condition. Despite overwhelming evidence of the benefits of annual flu vaccination, vaccination rates remain well below the Healthy People 2020 targets3, leaving a significant portion of the population vulnerable.

Calling the medical community to action

In the US, nearly half of all adults age 45–64 years, and 80 percent of those age 65 years and older, have multiple chronic health conditions that put them at high risk for flu-related complications, including heart attack, stroke, hospitalization, and even death. To address this public health threat, the medical community is working collaboratively to protect the most vulnerable patients. 

Influenza viruses cause an inflammatory reaction that can last for several weeks following acute infection. This flu-related inflammation can exacerbate4 existing chronic conditions, including heart disease, lung disease, and diabetes. It can also increase the risk of myocardial infarction and stroke long after the acute phase passes. One study found the incidence of admissions for acute myocardial infarction was six times higher during the seven days following laboratory confirmation of influenza infection as during a control interval5.

Additionally, adults with diabetes6 were six times more likely to be hospitalized and three times more likely to die from flu-related complications than people without diabetes.

“Regardless of which influenza strains are prominent in a given year, the outcomes are always the same,” says National Foundation for Infectious Diseases (NFID) Medical Director William Schaffner, MD7. “Chronic health conditions predispose patients to serious outcomes from flu.” 

Yet there remains low awareness of the importance of annual flu vaccination for adults with chronic health conditions. Despite the abundance of public health guidance urging people to get vaccinated each year, increasing flu vaccination rates has proven extremely difficult. Vaccination coverage among adults has increased slightly over the past decade, but remains about 45 percent, leaving more than half of US adults vulnerable each year.

In 2018, Young and representatives from various specialty groups reviewed the dangers of flu in adults with certain chronic health conditions at a multi-disciplinary roundtable hosted by the NFID.

The roundtable discussions and conclusions were summarized in an NFID Call to Action,8 which urges all healthcare professionals to prioritize annual flu vaccination for adults with chronic health conditions.

U.S. Health and Human Services Secretary Alex Azar receives his flu shot at NFID News Conference. Credit: NFID

The roadblocks to vaccination

The science supporting the benefits of annual flu vaccination are clear. “On average, seasonal influenza vaccination can reduce the chances of getting flu by between 40-60 percent when circulating strains of the virus are well-matched to the vaccine,” says Schaffner. “But even if a vaccinated individual does contract flu, the vaccine still provides partial protection and can play a significant role in preventing serious outcomes, including pneumonia, hospitalization, and death. It can also help reduce transmission of the flu virus within communities, adding another layer of protection for chronic disease patients.”

These benefits are particularly strong in people with heart disease. “Data show that patients who are vaccinated reduce their risk of a cardiovascular event by one-third compared to those who do not get vaccinated,” says Allen J. Taylor, MD9, representative of the American College of Cardiology at the roundtable.

Despite the overwhelming evidence in favor of vaccination, an August 2019 NFID survey10 found one in four people, who are at higher risk for flu-related complications, said they did not plan to get vaccinated this season. Of the top reasons cited for not getting a flu vaccine, 51 percent did not think the flu vaccine worked, 34 percent were concerned about side effects, and 22 percent were concerned about contracting flu from the vaccine.

“Many people don’t understand the flu,” says Young. “They think it’s a bad cold. That’s talking point number one. The flu is not just a bad cold. Flu kills people.” CDC estimates11 that in the US, up to 61,000 people died from flu and related complications between October 2018 and May 2019.

Schaffner is also quick to point out that most of the commonly cited fears about side effects were unfounded. “Millions of doses of flu vaccines have been given safely for many years, and side-effects, other than soreness around the injection site, are rare. And of course, you cannot get flu from a flu vaccine.”

Debunking the myths about flu vaccines has been a challenge, but there is one source of information patients inherently trust to set the record straight— healthcare professionals.

Most trusted sources of medical information

“As one of the most trusted sources of medical information, healthcare professionals have a particularly powerful impact on the decision to vaccinate,” says Schaffner. “One study12 found that, even if patients have negative attitudes toward vaccines, a physician recommendation can boost immunization rates as high as 80 percent.”

Strategies for improving flu vaccination rates in adults with certain chronic health conditions including heart disease, diabetes, and lung disease were also addressed at the 2018 NFID roundtable.

The NFID Call to Action recommends that both primary care providers and specialists stock and insist upon annual flu vaccination, particularly for patients with chronic health conditions and for adult patients who might have an undiagnosed condition, or are likely to spread the flu to others.

In addition, the Call to Action also recommends that specialists, such as cardiologists, pulmonologists, and endocrinologists, routinely incorporate flu vaccines into patient visits in the fall. If healthcare professionals are unable to provide flu vaccines in their practice, they should write a prescription for a flu vaccine that can be administered at a local pharmacy, to reinforce the importance and urgency of annual flu vaccination, and increase patient compliance.

The urgency of this public health issue and the need to increase awareness among specialty groups has energized supporters of the NFID Call to Action to work together to educate their stakeholders.

The American College of Cardiology is using its CardioSmart platform13 to reach cardiologists, nurses, and other members of the healthcare team. This platform supplies tools and resources to educate patients about the importance of annual flu vaccines. Among the resources are infographics14 for waiting and exam rooms, mobile apps with synthesized guideline recommendations and vaccination reminders.

NFID has also created a robust online toolkit15 with materials geared toward educating both patients and specialty physicians about the dangerous impact of flu on adults with chronic health conditions. The toolkit includes infographics and public service announcements to help spread awareness about the critical issue.

“Collaborative efforts with government agencies, industry, and other medical specialty societies are crucial for helping to reach the widest clinician and patient audiences possible,” explains Taylor.

Young also makes a point of individualizing her advice to patients during follow-up visits. “It’s just part of their healthcare. It’s simply what they do every year along with everything else,” she says. Young emphasizes the importance of clarifying the potential for chronic diseases to worsen if patients are not vaccinated against flu, as well as the risk they run of losing their independence.

“It’s our responsibility as healthcare professionals to care for our patients. Flu vaccination is part of it and it’s our responsibility to be educated about it,” says Young.

A unified stance against flu

Since publication in September 2018, more than 20 organizations have signed on to support the NFID Call to Action to improve awareness of both the dangers of flu among adults with chronic health conditions and the benefits of annual vaccination. This cooperation is vital to protecting high-risk adults.

“Although we saw a slight increase in flu vaccination rates among US adults compared to the 2017-2018 season, fewer than half of all US adults were vaccinated during the 2018-2019 flu season. Simply put, vaccination coverage needs to increase to ensure optimal protection against flu,” says Schaffner. “The responsibility to protect public health is shared amongst many entities, including the medical community, patient advocacy groups, government, and industry. Teamwork is critical in the fight against disease, and no single entity has complete responsibility. Many messengers with a unified message can create a chorus promoting flu prevention.”


  1. Melissa D. Young, PharmD, RPh, BC-ADM, CDE is a Clinical Pharmacy Specialist for the Department of Veterans Affairs and a diabetes care and education specialist at the American Association of Diabetes Educators.
  2. Centers for Disease Control and Prevention. Update: Influenza Activity in the United States During the 2018–19 Season and Composition of the 2019–20 Influenza Vaccine. https://www.cdc.gov/mmwr/volumes/68/wr/mm6824a3.htm. Accessed: November 7, 2019.
  3. HealthyPeople.gov 2020 targets: https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases
  4. NFID Clinical updates. The dangers of influenza and benefits of vaccination in adults with chronic health conditions. Infect. Dis. Clin. Pract. 26, 313–321 (2018).
  5. Kwong, J. C. et al. Acute myocardial infarction after laboratory-confirmed influenza infection. N. Engl. J. Med. 378, 345–353 (2018).
  6. NFID. Flu diabetes fact sheet. Available: https://www.nfid.org/wp-content/uploads/2019/11/Diabetes-Fact-Sheet-Final.pdf. Accessed November 7, 2019.
  7. William Schaffner, MD, professor of Preventive Medicine and Infectious Diseases at Vanderbilt University Medical Center, is the Medical Director at NFID.
  8. National Foundation for Infectious Diseases. Call to Action: The dangers of influenza and benefits of vaccination in adults with chronic health conditions. Available https://www.nfid.org/wp-content/uploads/2019/08/cta-dangers-of-influenza-in-adults-with-chronic-health-c.pdf. Accessed November 7, 2019.
  9. Allen J. Taylor, MD is the chair of cardiology at MedStar Heart and Vascular Institute in Washington DC and a representative of the American College of Cardiology
  10. NFID Survey: Attitudes about influenza and pneumococcal disease prevention. Available: https://www.nfid.org/about-nfid/newsroom/news-conferences/2019-nfid-influenza-pneumococcal-disease-news-conference/national-poll-attitudes-about-flu-and-pneumococcal-disease-prevention Accessed November 7, 2019.
  11. Centers for Disease Control and Prevention. 2018-2019 U.S. Flu Season: Preliminary Burden Estimates.  https://www.cdc.gov/flu/about/burden/preliminary-in-season-estimates.htm. Accessed November 7, 2019.
  12. Nichol, K. L. et al. Factors associated with influenza and pneumococcal vaccination behavior among high-risk adults. J. Gen. Intern. Med. 11, 673–677 (1996).
  13. https://www.cardiosmart.org/. Accessed November 7, 2019.
  14. NFID. Flu and chronic health conditions toolkit. Available: https://www.nfid.org/toolkits/flu-and-chronic-health-conditions/. Accessed November 7, 2019.