In a few weeks, every adult in Canada will decide if they (and their children) will get the flu vaccine to protect against H1N1. At the best of times, it seems the decision of whether or not to get the seasonal flu shot is tough to make. Only about one-third of Canadians do each year. Now, with the pandemic vaccine arriving in doctor’s offices in November, Canadians are being asked to get a second shot this fall.
But will they? Probably not. A recent poll shows that, as of the first week of October, only one in three Canadians plan on getting the H1N1 vaccine, according to Harris/Decima. That’s down from 45 per cent in late August. Experts say this reflects the public’s growing apathy toward the pandemic in light of seemingly contradictory information about H1N1 (which is commonly referred to as swine flu, even though it’s a combination of flu viruses from pigs, birds and humans). People are being bombarded by “on the one hand” and “on the other hand” studies and recommendations. “There is confusion,” says Dr. Sarah Kredentser, president of the College of Family Physicians of Canada. “And I think it’s warranted confusion, because the messages keep changing.”
Only last spring, the world was expecting the worst: thousands of cases of H1N1 in Mexico caused its capital city to shut down. Many countries, including Canada, issued travel advisories urging people to cancel their trips. There were calls to have international borders closed. News footage emerged of citizens wearing aseptic white masks, with only their fear-filled eyes visible. Terrifying stories cast back to the Spanish flu outbreak of 1918. And daily—sometimes twice a day—the World Health Organization issued updates, and elevated its phase of alert until finally, in June, came the most ominous declaration yet: H1N1 was a full-blown pandemic.
That sparked one of the most dramatic public health responses of our time. Health Canada began preparing our stockpile of top-notch antiviral drugs for distribution in case Canadians started getting severely sick. Companies installed hand sanitizer stations at every door. Minor hockey leagues directed coaches to make sure all players had their own water bottle. And then the biggie: the federal government ordered enough H1N1 flu vaccines for every man, woman and child across the country who would want or need one—more than $400 million worth—and notified the provinces that the shots would be ready for the fall and winter onslaught.
And yet, the majority of Canadians say they won’t bother being vaccinated—even though Health Canada is resolute, as are other medical bodies, that everyone should get the pandemic shot. Experts believe that “trust issues” are developing between Canadians and public health authorities. “People are feeling like there’s mixed messages coming out,” says Natalie Henrich, a bio-cultural anthropology researcher at the B.C. Centre for Disease Control, and that’s contributing to “a possible erosion of confidence in what health officials are saying.” Some Canadians are checking out of the debate altogether because they’ve had enough of trying to keep up. “People throw their hands up in the air and say, ‘I don’t know how to decide what I should do or not, so I’m not going to do any of it,’ ” says Henrich.
There are good reasons for the confusion. For starters, despite the pandemic alert, the H1N1 virus has been mostly mild. While any number of fatalities is a tragedy, in Canada, death has been the least common outcome of the H1N1 flu—79 people have died across the country as of the first week of October. In most cases, the pandemic flu causes minor symptoms such as coughing and fever, and the majority of infected people fully recover in a few days. “Right now,” says Henrich, “people don’t see the virus as particularly threatening.”
When the H1N1 flu does prove severe or lethal, it’s often a surprising group of Canadians who are the victims—young adults, especially women. Usually, the elderly and children with other medical problems are the most susceptible to the seasonal flu and its killer potential. The fact is, each flu attacks different groups. H1N1 also hits people who have underlying health problems such as diabetes, asthma and heart disease particularly hard. That’s bad news in a country where these conditions are common: “The growth of people living with chronic disease in most of the developed world has been tremendous over the past decade,” says Sandra Crouse Quinn, professor of behavioural and community health sciences at the University of Pittsburgh, adding, “They’re going to be at a higher risk” for H1N1 complications.
And there’s confusion about some rather serious logistical matters. An unpublished study has revealed that among a group of Canadians who had the seasonal flu vaccine first, their risk of contracting the H1N1 pandemic virus was 1 to two times higher. A vociferous debate erupted over when people should get each flu shot. That’s led some provinces and territories to change the order of the vaccines—giving the pandemic shot to most people before the seasonal one. Those different decisions, say experts, don’t alleviate public concerns. “You’ve got this variation in policy between the provinces,” says Dr. Donald Low, microbiologist-in-chief at Mount Sinai Hospital in Toronto, which “just adds fuel to the fire.”
The H1N1 vaccine schedule has also been complicated by an editorial in the Canadian Medical Association Journal, which warned that the federal government’s plan to deliver 50.4 million pandemic shots in November is too late for at-risk people. The editorial also raised the issue of using a pharmacological agent called an adjuvant in the H1N1 vaccine to boost people’s response to the vaccine. Until now, adjuvants have never been used in Canadian flu shots. “So when people hear you not only have a new vaccine,” says Low, “but you have a vaccine that has an adjuvant, that’s just a little bit more reason for concern.”
Add to all this the worry of some Canadians that the vaccine has been made in a rush, and the meddling of self-appointed health ambassadors such as political satirist Bill Maher— who twittered, “If u get a swine flu shot ur an idiot”—and it’s no wonder the public isn’t sure about whether they’ll get vaccinated, let alone when. Meantime, medical authorities are bracing for the much anticipated “second wave” of H1N1 in the months ahead. The chief public health officer, Dr. David Butler-Jones, estimates that one in three Canadians will get the pandemic flu. The vaccine could curb that. “This is the largest immunization campaign in history,” he told media recently. “We have to get it right.”
• Everyone should be vaccinated, especially young adults.
As far as medical experts such as Low are concerned, no one should skip the H1N1 shot. “We should all protect ourselves by getting vaccinated,” he says, especially amid growing consensus that the second wave of H1N1 may be worse than the first. But some groups are more vulnerable to the virus than others. People under age 65 who have medical problems, pregnant women and children between six months and five years are among the first priority groups, according to the Public Health Agency of Canada, because if they contract the pandemic flu it could be severe, and the complications could be life-threatening.
Because flu outbreaks are common in schools, it’s important to vaccinate children and youth ages five to 18. Adults between 19 and 64 are also at increased risk for getting severely sick with H1N1. In particular, the pandemic flu attacks young adults in their 30s. That has stunned medical observers because these groups are usually the least susceptible to the seasonal flu. A report in the latest Journal of the American Medical Association reveals that among 168 Canadian patients who were in ICU between April and August because of H1N1, the median age was 32, and most were females.
Meanwhile, older people, especially those born before 1957, are less vulnerable to H1N1 compared to the seasonal flu. They have some natural immunity to the pandemic flu because they have been exposed to strains of it in the past. Still, the Public Health Agency says seniors will benefit from the pandemic flu shot too.
Health care professionals, first responders, people who work with poultry and swine, Aboriginals and others living in isolated and remote areas are a high priority for pandemic flu vaccination as well. And Canadians who have been infected with H1N1 already this year and recovered should still get vaccinated. Even though they may have built up antibodies against the virus, this immunity may not be permanent. Plus, the Public Health Agency says the vaccine will give those people further protection.
• The H1N1 vaccine has not been made much differently or more hastily than other flu shots.
Many Canadians suspect that vaccines created during a health crisis have been “rushed to market,” shows research by Henrich, who conducted 11 focus groups a couple of years ago to understand how the public feels about new drugs developed in response to a pandemic. People wonder, “Are we taking short cuts?” acknowledges Low, and whether the vaccine is dangerous. That’s not the case. “It’s made the same as seasonal vaccines are made,” he says of the H1N1 vaccine, which is being manufactured by GlaxoSmithKline at its Ste. Foy, Que., plant, “and we’ve got decades of experience.”
According to a Health Canada document, seasonal flu vaccines are always made in a matter of months. Every February, the WHO identifies three flu viruses that will be incorporated into the shot, and prepares a vaccine strain. That goes to manufacturers, who then replicate it in eggs or animal cells. Next come clinical trials in humans to prove that the vaccine is safe and effective. Health Canada decides to approve the vaccine based on those findings and a detailed account of how the vaccine was made. Three batches of the vaccine are tested. Once the vaccine is authorized, the federal government buys enough for the provinces and territories, which distribute the vaccine to doctor’s offices and clinics. Usually by November, the seasonal flu shot is offered to Canadians. The Public Health Agency continues to monitor the flu vaccine for adverse effects.
In the case of the H1N1 pandemic shot, there is a difference: Health Canada is basing its approval of the vaccine on international clinical trials that started in early September. That’s because the Canadian clinical trials won’t begin until mid-October. Those findings will be used to evaluate the vaccine on an ongoing basis.
• Health officials say the vaccine is safe.
Most people don’t have any adverse effects to influenza shots. “Flu vaccines, by and large, are generally pretty safe,” says Quinn. The WHO reports that when side effects do occur, they’re usually brief and mild: swelling or redness at the injection site, fever, headache, or sore muscles and joints. Basically, “we feel lousy for a day, or tender” where we got the shot, Quinn explains. That’s a sign the vaccine is jump-starting our body’s fight against the virus, she says: “That’s our immune system doing exactly what we want it to do.”
But she and other experts acknowledge that there are “infrequent” serious side effects. During the swine flu outbreak in the U.S. in 1976, there was an increased incidence of Guillain-Barré syndrome, which can cause paralysis, after some people were immunized, says Low. There is debate over whether that was directly caused by the shot. “There was never really any proven association with Guillain-Barré and the vaccine,” he points out, “but that hangs in the back of people’s minds.” What’s more, Low and Quinn insist that this virus is different and that the pandemic shot and our surveillance methods are more sophisticated. “We have more protection now than 40-plus years ago,” says Quinn.
• While adjuvants haven’t been used in Canadian flu shots, they are common in other vaccines.
The other big difference between the H1N1 and seasonal flu shots is the use of an adjuvant in the pandemic vaccine. “The adjuvant basically helps to stimulate the immune response,” says Quinn, who has studied public reaction to novel drugs in the U.S. In effect, scientists can use less of the viral material to protect each person. That’s important during a pandemic because it means more people can be vaccinated, she explains. It also helps boost the effects of the shot in people who have “a less robust immune response,” such as the elderly, says Low.
Adjuvants have been included in Canadian shots for decades, but never in influenza vaccines, says Low, largely because “it was never really felt to be needed.” Because of the widespread need for H1N1 vaccines around the world, the WHO has asked countries to use “dose-sparing” vaccines wherever possible. The United States, which historically hasn’t used adjuvants in flu shots, decided against using one for the H1N1 pandemic vaccine. The adjuvant would have designated the H1N1 shot an “emergency use authorization” by the U.S. Food and Drug Administration. Quinn’s research shows that less than 10 per cent of Americans would get the shot under that circumstance. In Europe, however, adjuvants are common in flu shots, and many countries have incorporated them into the H1N1 vaccine.
While Canada’s Public Health Agency says that “all evidence suggests that adjuvanted vaccines are just as safe as unadjuvanted vaccines,” there is no safety research on how adjuvanted shots affect pregnant women. The WHO has recommended that where possible, they receive non-adjuvanted H1N1 shots. The federal government has purchased 1.2 million doses of a non-adjuvanted H1N1 vaccine for pregnant women.
• In most places and for most people, H1N1 shots will be widely available before seasonal flu vaccines, either at the doctor’s office or at clinics.
The order in which you get the seasonal and H1N1 flu shots depends on where you live, your age and health status. But many provinces have revamped their timelines recently in this way: first, people in long-term care facilities and the elderly will receive the seasonal flu shot, since they are most at risk of catching it. Next, the H1N1 vaccine will be offered to the general public, given expectations that it will be the predominant influenza circulating this autumn and winter. Finally, the seasonal shot will be offered to everyone. In most cases, the vaccines will be administered at doctor’s offices or flu shot clinics. (For details of each province and territory’s vaccine schedules visit macleans.ca/flushot.)
• H1N1 is transmitted the same way as other influenzas.
H1N1, like every flu, is spread when the virus enters our nose, throat or eyes. That usually happens when we pick up a sick person’s germs either as they’re sprayed in the air we breathe via coughs or sneezes, or when they get left on hard surfaces such as desks or doorknobs. It can take between two days and a week for a person to feel sick after picking up the virus. Even the day before symptoms appear, an infected person can pass on the H1N1 virus to others, and that can continue for up to a week. Keep your distance from infected people, and if you’ll be within six feet, consider wearing a surgical mask and safety glasses to cut the risk of getting sick.
• The symptoms are similar too.
Every influenza, including the H1N1 flu, is a respiratory illness, so the virus affects our nose, throat and lungs. According to the Public Health Agency, H1N1 pandemic flu almost always includes a cough and fever. It’s also common to feel fatigue, muscle aches, sore throat, runny nose, headache and a decrease in appetite. Sometimes it causes nausea, vomiting or diarrhea.
It’s important to keep track of how the H1N1 flu is progressing, in case complications such as pneumonia or asthma occur. Watch out if fever, diarrhea or stomach pain goes away and then returns. If there are other symptoms such as purple or blue lips, dizziness, infrequent urination, chest pain, wheezing, trouble breathing, coughing up blood, strange behaviours or thoughts, and difficulty staying awake, it’s important to see a health care worker.
• How we treat H1N1 flu depends on how serious the infection is.
In healthy people, treating H1N1 flu is similar to dealing with the seasonal flu. The key: stay home, rest and drink lots of fluids, recommends the Public Health Agency. A mild cough suppressant may be useful for sleeping at night, except for children under six. A cold compress, as well as acetaminophen or ibuprofen every four to six hours, can help treat a fever or body aches. Don’t give kids under age six aspirin because it has been associated with Reye’s syndrome, which can be a deadly disease. Pregnant women who have H1N1 flu symptoms or people who have other health problems should visit their doctor right away to figure out the best treatment.
Two antiviral drugs may be given to patients whose H1N1 flu appears more serious within 48 hours of getting sick. They are called oseltamivir and zanamivir (the brand names are Tamiflu and Relenza, respectively). They work by reducing the virus’s ability to reproduce in the body. Canada has 55 million doses of these drugs, and they can only be prescribed by doctors. In the most serious cases, people with H1N1 flu may need to be hospitalized. A special ventilator may be used, if necessary, to help these patients breathe.
• There are other measures besides vaccination to help prevent H1N1.
There’s no magic trick to avoiding the pandemic flu; health officials say common sense goes a long way. Infected people should cough and sneeze into their sleeves. Disinfect common surfaces and dispose of used tissues carefully and promptly. And despite a controversial report commissioned by the Public Health Agency showing that handwashing isn’t very effective in preventing the spread of flu, experts such as Kredentser insist it doesn’t hurt. “I don’t think there’s anybody in health who could deny that historically we know that handwashing is a significant strategy in infection control,” she says. “It would be a shame if people believe that, ‘Well, I don’t need to bother doing that anymore.’ ”
• “Pandemic” and “mild flu” aren’t contradictory.
“People think of pandemics as people dying left and right,” says Kredentser. That’s the stuff of science fiction. Pandemic alerts actually signal that a virus is highly communicable, not virulent. The WHO officially calls this a moderate pandemic, but “mild” has become the buzzword, referring to the symptoms experienced by most sick people. So, while the WHO’s pandemic alert is alarming in that it represents the highest level of transmissibility, it doesn’t mean H1N1 is always deadly.
Even though most Canadians aren’t planning to roll up their sleeve for the H1N1 shot, virtually all medical authorities around the world unilaterally endorse the vaccine as the best way to prevent the flu. One of the big reasons getting the shot is so widely promoted is because of its impact on entire communities, not just individuals. Experts say that every time someone refuses to get the flu shot, that jeopardizes the well-being of others.
This thinking is based on the concept of “herd immunity,” which is often overlooked by the public when considering the benefits of immunization. The basic premise is that if 70 per cent of a population gets vaccinated against H1N1, the virus will, effectively, be stopped in its tracks. “If people have been vaccinated it creates transmission barriers,” explains Henrich. “So basically, the disease can’t spread or spreads very inefficiently.” Family, friends and co-workers will have one less person to potentially infect them. It also protects people who can’t get the flu shot because of underlying conditions. “For those individuals,” says Henrich, herd immunity means that “it’s unlikely the virus is going to be able to find a route to them.”
If most people don’t get vaccinated against H1N1, experts worry that a large percentage of the population will get sick, says Low—and that the health care system won’t be able to manage. Intensive care units may be overloaded, beds and special ventilators may be scarce, and medical professionals may be run off their feet. In fact, hospitals could be short-staffed if a significant share of health care workers become infected too. “It’s really a numbers game,” says Low, “so the more people that you can protect, the more people you can take out of the equation of being susceptible, the better we’re able to handle [H1N1] as a society.”
Although the pandemic has been confusing, Quinn says that, to a large extent, that’s inherent in dealing with new viruses. “If there’s one watchword for influenza, it’s uncertainty,” she explains. Viruses mutate, and in the case of H1N1, scientists are just learning about how this strain behaves in people and responds to various treatments. Some reluctance to get vaccinated is understandable, adds Quinn, because it’s been decades since we’ve had to deal with a severe and pervasive outbreak of communicable disease, and its devastating effects. Many people don’t “fully grasp” that “vaccination is really not just an issue of personal good,” says Quinn, “but of the public’s health.” Or, depending what comes next with H1N1, widespread public illness.