OET Online Reading Part B

 
Part B : Multiple Choice Questions Time Limit: 20~25 Minutes

Task 3
Seasonal  Influenza  Vaccination  and  the  H1N1  Virus  
Authors: Cécile Viboud & Lone Simonsen
Source: Public Library of Science

As the novel pandemic influenza A (H1N1) virus spread around the world in
late spring 2009 with a well-matched pandemic vaccine not immediately
available, the question of partial protection afforded by seasonal influenza
vaccine arose. Coverage of the seasonal influenza vaccine had reached 30%–
40% in the general population in 2008–09 in the US and Canada, following
recent expansion of vaccine recommendations.

Unexpected Findings in a Sentinel Surveillance System

The spring 2009 pandemic wave was the perfect opportunity to address the
association between seasonal trivalent inactivated influenza vaccine (TIV)
and risk of pandemic illness. In an issue of PLoS Medicine, Danuta
Skowronski and colleagues report the unexpected results of a series of
Canadian epidemiological studies suggesting a counterproductive effect of
the vaccine. The findings are based on Canada's unique near-real-time
sentinel system for monitoring influenza vaccine effectiveness. Patients
with influenza-like illness who presented to a network of participating
physicians were tested for influenza virus by RT-PCR, and information on
demographics, clinical outcomes, and vaccine status was collected. In this
sentinel system, vaccine effectiveness may be measured by comparing
vaccination status among influenza-positive “case” patients with influenza-
negative “control” patients. This approach has produced accurate measures
of vaccine effectiveness for TIV in the past, with estimates of protection in
healthy adults higher when the vaccine is well-matched with circulating
influenza strains and lower for mismatched seasons. The sentinel system
was expanded to continue during April to July 2009, as the H1N1 virus
defied influenza seasonality and rapidly became dominant over seasonal
influenza viruses in Canada.

Additional Analyses and Proposed Biological Mechanisms

The Canadian sentinel study showed that receipt of TIV in the previous
season (autumn 2008) appeared to increase the risk of H1N1 illness by 1.03-
to 2.74-fold, even after adjustment for the comorbidities of age and
geography. The investigators were prudent and conducted multiple
sensitivity analyses to attempt to explain their perplexing findings.
Importantly, TIV remained protective against seasonal influenza viruses
circulating in April through May 2009, with an effectiveness estimated at
56%, suggesting that the system had not suddenly become flawed. TIV
appeared as a risk factor in people under 50, but not in seniors—although
senior estimates were imprecise due to lower rates of pandemic illness in
that age group. Interestingly, if vaccine were truly a risk factor in younger

This  resource  was  developed  by  OET  Online   1  

Website:  http://oetonline.com.au       Email:  oetonline@gmail.com  
 
OET Online Reading Part B
 
adults, seniors may have fared better because their immune response to
vaccination is less rigorous.

Potential Biases and Findings from Other Countries

The Canadian authors provided a full description of their study population

and carefully compared vaccine coverage and prevalence of comorbidities in
controls with national or province-level age-specific estimates—the best one
can do short of a randomized study. In parallel, profound bias in
observational studies of vaccine effectiveness does exist, as was amply
documented in several cohort studies overestimating the mortality benefits
of seasonal influenza vaccination in seniors.

Given the uncertainty associated with observational studies, we believe it

would be premature to conclude that TIV increased the risk of 2009
pandemic illness, especially in light of six other contemporaneous
observational studies in civilian populations that have produced highly
conflicting results. We note the large spread of vaccine effectiveness
estimates in those studies; indeed, four of the studies set in the US and
Australia did not show any association whereas two Mexican studies
suggested a protective effect of 35%–73%.

Policy Implications and a Way Forward

The alleged association between seasonal vaccination and 2009 H1N1 illness
remains an open question, given the conflicting evidence from available
research. Canadian health authorities debated whether to postpone
seasonal vaccination in the autumn of 2009 until after a second pandemic
wave had occurred, but decided to follow normal vaccine recommendations
instead because of concern about a resurgence of seasonal influenza viruses
during the 2009–10 season. This illustrates the difficulty of making policy
decisions in the midst of a public health crisis, when officials must rely on
limited and possibly biased evidence from observational data, even in the
best possible scenario of a well-established sentinel monitoring system
already in place.

What happens next? Given the timeliness of the Canadian sentinel system,
data on the association between seasonal TIV and risk of H1N1 illness during
the autumn 2009 pandemic wave will become available very soon, and will
be crucial in confirming or refuting the earlier Canadian results. In addition,
evidence may be gained from disease patterns during the autumn 2009
pandemic wave in other countries and from immunological studies
characterizing the baseline immunological status of vaccinated and
unvaccinated populations. Overall, this perplexing experience in Canada
teaches us how to best react to disparate and conflicting studies and can aid
in preparing for the next public health crisis.

This  resource  was  developed  by  OET  Online   2  

Website:  http://oetonline.com.au       Email:  oetonline@gmail.com  
 
OET Online Reading Part B
 
Part B : Multiple Choice Questions
 
1. The question of partial protection against H1N1 arose…
a. before spring 2009
b. during Spring 2009
c. after spring 2009
d. during 2008-09

2. According to Danuta Skowronski….

a. the inactivated influenza vaccine may not be having the desired effects.
b. Canada’s near-real-time sentinel system is unique.
c. the epidemiological studies were counterproductive
d. the inactivated influenza vaccine has proven to be ineffective.

3. The vaccine achieved higher rates of protection in healthy adults when….

a. it was supported by physicians.
b. the sentinel system was expanded.
c. used in the right season.
d. it was matched with other current influenza strains.

4. Which one of the following is closest in meaning to the word prudent?

a. anxious
b. cautious
c. busy
d. confused
 
5. The Canadian sentinel study demonstrated that…..
a. age and geography had no effect on the vaccine’s effectiveness.
b. vaccinations on senior citizens is less effective than on younger people.
c. the vaccination was no longer effective.
d. the risk of H1N1 seemed to be higher among people who received the
TIV vaccination.

6. Which of the following sentences best summarises the writers’ opinion

regarding the uncertainty associated with observational studies?
a. More studies are needed to determine whether TIV increased the risk
of the 2009 pandemic illness.
b. It is too early to tell whether the risk of catching the 2009 pandemic
illness increased due to TIV.
c. The Australian and Mexican studies prove that there is no association
between TIV and increased risk of catching the 2009 pandemic illness.
d. Civilian populations are less at risk of catching the 2009 pandemic
illness.

This  resource  was  developed  by  OET  Online   3  

Website:  http://oetonline.com.au       Email:  oetonline@gmail.com  
 
OET Online Reading Part B
 

7. Which one of the following is closest in meaning to the word alleged?

a. reported
b. likely
c. suspected
d. possible

8. Canadian health authorities did not postpone the Autumn 2009 seasonal
vaccination because…
a. of a fear seasonal influenza viruses would reappear in the 2009-10
season.
b. there was too much conflicting evidence regarding the effectiveness of
the vaccine.
c. the sentinel monitoring system was well established.
d. observational data may have been biased.

9. What would make the most suitable alternative title for the article?
a. Current research on H1N1 and other influenza strains
b. Errors in Canadian health policy
c. Possible link between influenza vaccination and increased risk of
H1N1 illness.
d. Unreliable H1N1 and influenza vaccination research

This  resource  was  developed  by  OET  Online   4  

Website:  http://oetonline.com.au       Email:  oetonline@gmail.com  
 
OET Online Reading Part B
 
Answer Key
1. b 2. a 3. d 4. b 5. d 6. b 7. c 8.a 9. c
Question 1
a) Incorrect
b) Correct: during is a synonym for as
c) Incorrect
d) Incorrect
Question 2
a) Correct: counterproductive can mean not achieving what you want
b) Incorrect: the system is unique but it has nothing to do with Danuta
Skowronski
c) Incorrect: it is not the studies that were counterproductive
d) Incorrect: This is a suggestion not a fact
Question 3
a) Incorrect: This is not stated
b) Incorrect: This is not stated
c) Incorrect: This is not stated
d) Correct: Refer highlighted text.
Question 4
a) Incorrect
b) Correct: The meaning can be deduced by the fact that they conducted
several tests so were therefore cautious
c) Incorrect
d) Incorrect
Question 5
a) Incorrect: no connection
b) Incorrect: not mentioned
c) Incorrect : it had a limited effect
d) Correct: Refer highlighted text
Question 6
a) Incorrect: More studies not mentioned
b) Correct: Premature to conclude means too early to tell
c) Incorrect: Nothing was proven
d) Incorrect
Question 7
a) Incorrect
b) Incorrect
c) Correct: The meaning can be deduced by the overall discussion in the
article
d) Incorrect
Question 8
a) Correct: See highlighted text
b) Incorrect: This is a true fact but not the answer to the question
c) Incorrect: This is also a true fact but not the answer to the question
d) Incorrect: This is also a true fact but not the answer to the question
Question 9
a) Incorrect: Too general
b) Incorrect: This opinionis not stated in the article
c) Correct: This issue is raised several times in the text including in
questions 2 & 5
d) Incorrect: The research results have been inconsistent bit not unreliable.

This  resource  was  developed  by  OET  Online   5  

Website:  http://oetonline.com.au       Email:  oetonline@gmail.com  
 
OET Online Reading Part B
 
Answers Highlighted
 
Does  Seasonal  Influenza  Vaccination  Increase  the  Risk  of  Illness  with  the  
2009  A/H1N1  Pandemic  Virus?  by  Cécile  Viboud  &  Lone  Simonsen  

1 a) As the novel pandemic influenza A (H1N1) virus spread around the world
in late spring 2009 with a well-matched pandemic vaccine not immediately
available, the question of partial protection afforded by seasonal influenza
vaccine arose. Coverage of the seasonal influenza vaccine had reached 30%–
40% in the general population in 2008–09 in the US and Canada, following
recent expansion of vaccine recommendations.

Unexpected Findings in a Sentinel Surveillance System

The spring 2009 pandemic wave was the perfect opportunity to address the
association between seasonal trivalent inactivated influenza vaccine (TIV)
and risk of pandemic illness. In an issue of PLoS Medicine, Danuta
Skowronski and colleagues report the unexpected results of a series of
Canadian epidemiological studies 2 a) & 9 c)suggesting a counterproductive
effect of the vaccine. The findings are based on Canada's unique near-real-
time sentinel system for monitoring influenza vaccine effectiveness.
Patients with influenza-like illness who presented to a network of
participating physicians were tested for influenza virus by RT-PCR, and
information on demographics, clinical outcomes, and vaccine status was
collected. In this sentinel system, vaccine effectiveness may be measured
by comparing vaccination status among influenza-positive “case” patients
with influenza-negative “control” patients. This approach has produced
accurate measures of vaccine effectiveness for TIV in the past, 3 d)with
estimates of protection in healthy adults higher when the vaccine is well-
matched with circulating influenza strains and lower for mismatched
seasons. The sentinel system was expanded to continue during April to July
2009, as the pH1N1 virus defied influenza seasonality and rapidly became
dominant over seasonal influenza viruses in Canada.

Additional Analyses and Proposed Biological Mechanisms

5 d) & 9 c)The Canadian sentinel study showed that receipt of TIV in the
previous season (autumn 2008) appeared to increase the risk of H1N1 illness
by 1.03- to 2.74-fold, even after adjustment for the comorbidities of age
and geography. 4 a)The investigators were prudent and conducted multiple
sensitivity analyses to attempt to explain their perplexing findings.
Importantly, TIV remained protective against seasonal influenza viruses
circulating in April through May 2009, with an effectiveness estimated at
56%, suggesting that the system had not suddenly become flawed. TIV
appeared as a risk factor in people under 50, but not in seniors—although
senior estimates were imprecise due to lower rates of pandemic illness in
that age group. Interestingly, if vaccine were truly a risk factor in younger
adults, seniors may have fared better because their immune response to
vaccination is less rigorous.
This  resource  was  developed  by  OET  Online   6  
Website:  http://oetonline.com.au       Email:  oetonline@gmail.com  
 
OET Online Reading Part B
 

Potential Biases and Findings from Other Countries

The Canadian authors provided a full description of their study population

and carefully compared vaccine coverage and prevalence of comorbidities in
controls with national or province-level age-specific estimates—the best one
can do short of a randomized study. In parallel, profound bias in
observational studies of vaccine effectiveness does exist, as was amply
documented in several cohort studies overestimating the mortality benefits
of seasonal influenza vaccination in seniors.

Given the uncertainty associated with observational studies, 6 b) we believe

it would be premature to conclude that TIV increased the risk of 2009
pandemic illness, especially in light of six other contemporaneous
observational studies in civilian populations that have produced highly
conflicting results. We note the large spread of vaccine effectiveness
estimates in those studies; indeed, four of the studies set in the US and
Australia did not show any association whereas two Mexican studies
suggested a protective effect of 35%–73%.

Policy Implications and a Way Forward

The 7 c) alleged association between seasonal vaccination and 2009 H1N1

illness remains an open question, given the conflicting evidence from
available research. 8 a)Canadian health authorities debated whether to
postpone seasonal vaccination in the autumn of 2009 until after a second
pandemic wave had occurred, but decided to follow normal vaccine
recommendations instead because of concern about a resurgence of
seasonal influenza viruses during the 2009–10 season. This illustrates the
difficulty of making policy decisions in the midst of a public health crisis,
when officials must rely on limited and possibly biased evidence from
observational data, even in the best possible scenario of a well-established
sentinel monitoring system already in place.

What happens next? Given the timeliness of the Canadian sentinel system,
data on the association between seasonal TIV and risk of H1N1 illness during
the autumn 2009 pandemic wave will become available very soon, and will
be crucial in confirming or refuting the earlier Canadian results. In addition,
evidence may be gained from disease patterns during the autumn 2009
pandemic wave in other countries and from immunological studies
characterizing the baseline immunological status of vaccinated and
unvaccinated populations. Overall, this perplexing experience in Canada
teaches us how to best react to disparate and conflicting studies and can aid
in preparing for the next public health crisis.

This  resource  was  developed  by  OET  Online   7  

Website:  http://oetonline.com.au       Email:  oetonline@gmail.com