How to communicate the risks of the H1N1 virus and vaccination
It’s important to state that Dr. Sandman did not write these suggestions for use by safety and health professionals. As you read the suggestions, you’ll see the language is intended for risk communications delivered by the Centers for Disease Control and Prevention (CDC) and other public officials to the public at large. His use of “we” refers to the public officials who are communicating to the general populace. Still, his suggestions include useful background information on the H1N1 virus and attitudes toward it and vaccinations.
For the full article, go to Dr. Sandman’s web site: www.psandman.com/or directly to www.psandman.com/col/swinecomm.htm
Says Dr. Sandman: “I have drafted these messages to be used once at least limited amounts of pandemic vaccine have become available. But of course communication shouldn’t wait till then. With minor changes in verb tense, the messages can be used immediately. They are written with the United States and other developed countries in mind. Vaccination messaging for countries with little or no vaccine will need to be very different.”
So far, the pandemic H1N1 virus causes mostly mild disease. We expect H1N1 to infect very large numbers of people – one-third or more of the population, based on our experience with the past few influenza pandemics. But nearly all the people it infects will experience mild symptoms. Some will experience no symptoms at all; they won’t even know they were infected. On the other extreme, some will get extremely sick, and some will die. But most will have respiratory symptoms for a few days, with or without aches and fever, and then they’ll be fine again. So far, if the CDC’s estimated case numbers and confirmed death counts are close to accurate, pandemic H1N1 is turning out milder and less deadly than the average year of the seasonal flu, although most of those dying are far younger than most seasonal flu victims.
The pandemic H1N1 vaccine is almost certainly a very safe vaccine. (I am assuming that nothing alarming emerges from vaccine safety trials that are ongoing as I write this.) All vaccines have side effects, but the flu vaccine has very few. Nonetheless, some people are understandably concerned because the pandemic H1N1 vaccine was developed and tested very quickly. Others are understandably concerned because some versions of the vaccine – approved for use in some countries – relied on new cell-based vaccine manufacturing techniques instead of the tried-and-true egg-based method, or on new chemicals (called adjuvants) to boost the effectiveness of the vaccine, or on the mercury-containing preservative thimerosal that continues to be controversial despite strong safety evidence. Still others are understandably concerned because of serious side effects that are thought to have resulted the last time there was a rushed project to develop a human vaccine against a novel swine flu virus – in 1976, against a different H1N1 virus that in the end didn’t even launch a pandemic.
It is impossible to say with certainty that nothing unexpected will happen, that the vaccine developed from this swine-bird-human hybrid H1N1 virus won’t end up different in some way from other influenza vaccines … some way that does damage subtle enough that the safety testing misses it. We will be watching carefully to discover any such surprises fast once the mass vaccination program begins.
We are not saying the pandemic vaccine is risk-free. We are saying it is considerably lower-risk than the pandemic virus itself.
Almost everybody is better off vaccinated than unvaccinated against the pandemic virus. But assuming no change in virulence, the decision doesn’t matter much for most people. This is a vaccine that is almost certainly safe, which will reduce your chances of catching a disease that will probably be mild. If you’re not pregnant, asthmatic, immunocompromised, or in some other high-risk group, the chances that the pandemic H1N1 virus will make you seriously ill are low. The chances that the pandemic H1N1 vaccine will make you seriously ill are far lower. On balance, everyone except people with known allergies to a vaccine ingredient is better off vaccinated than unvaccinated. We think the medical benefit of the vaccine is worth the hassle of two trips to the doctor.
But for some people getting vaccinated isn’t just a hassle. Some people are more anxious about the pandemic vaccine than they are about catching pandemic influenza – and anxiety is medically harmful too. If you don’t want to get vaccinated, or get your child vaccinated, we are not pressuring you to do so.
There are times when doctors strongly urge their patients to get past their anxiety and take some action that is medically important. So far, this is not one of those times.
The case for vaccination is stronger for people in high-risk groups. If you’re pregnant, asthmatic, immunocompromised, or in one of the other high-risk groups, your chances of getting very sick if you catch the pandemic flu are higher than for most people. Still, even for you the odds are good that the disease will be mild if you catch it. Because there is a stronger case for vaccinating people in these high-risk groups than for vaccinating other people, and because we don’t yet have enough vaccine for everyone, we are making it available to people in the high-risk groups first.
But we would rather vaccinate someone who wants to be vaccinated than someone – even someone in a high-risk group – who is reluctant to be vaccinated. So people in the high-risk groups get first dibs. But if you’re more worried about the vaccine than you are about the disease, feel free to decline and let the dose that is temporarily being held for you go to someone else instead. You may get a chance to rethink that decision if vaccine is still available later in the year.
This position is highly controversial among doctors and public health professionals. So it’s important to be really clear. Our medical advice to people in the high-risk groups is unequivocal: We advise you to get vaccinated against the pandemic flu. The vaccine could save your life. But getting you vaccinated is not so urgent that we are willing to pressure you into it – especially when there is not yet enough vaccine for everybody and there are people in lower-priority groups who really want that dose (and it could save their life too). So we hope you will understand our recommendation and make a well-informed choice.
There is a special case to be made for vaccinating children and healthcare workers. In the U.S., children 0 to 4 years of age have the highest rate of hospitalization for pandemic H1N1; the 5- to 24-year-old age group has the second highest rate. In addition, both children and healthcare workers are significant transmitters of influenza. Experience so far shows that pandemic H1N1 can spread very quickly through schools, and that children who catch the disease at school can pass it along to family members.
Healthcare workers come into close contact with pandemic flu patients, and also come into close contact with other patients in high-risk groups. They can all too easily catch the disease from the former and give it to the latter – often before they have any symptoms of their own, or when they have come to work feeling ill (which many healthcare workers tend to do, despite our strong advice to the contrary).
In short, children and healthcare workers should be vaccinated both for their own good and also for the good of others.
Nonetheless, the pandemic disease is mostly mild so far. Some parents will prefer not to get their children vaccinated, and some healthcare workers will prefer not to get themselves vaccinated. While we believe that vaccination is medically advisable for both children and healthcare workers, we have no intention of pressuring people to change their personal health decisions in order to protect other people from a disease that is usually mild. Parents and healthcare workers who have decided against pandemic flu vaccination should know that the public health profession recommends in favor of pandemic vaccination, for the good of both the person vaccinated and the people that person has contact with. And then they should make their own decisions without any pressure from us.
All this could change. Back in the spring, we judged it to be an urgent priority to order a lot of novel H1N1 vaccine, chiefly because it was not yet clear how virulent or mild the new virus was turning out to be. We were also concerned (and still are) that the novel (now pandemic) H1N1 virus might become more virulent at any time. We hoped then – as we hope now – that a vaccine against an early strain of pandemic H1N1 would be at least partly effective against a more lethal mutation of pandemic H1N1. Such a mutation has not happened so far, but it is still a possibility.
If the pandemic H1N1 virus does become more virulent, and if the vaccine still works against that new, more virulent strain, we will implement an emergency mass vaccination program. Such a program has already been developed in case it is needed. So far, there are no signs of increasing virulence, and there is no expert knowledge bearing on whether such a change in the virus is likely or unlikely. We are watching for it. If it happens we will push much harder for mass vaccination, and will try to persuade even those who are anxious about the vaccine to change their minds.
Other developments that would affect our advice would be: (a) If evidence emerges that the H1N1 virus is becoming more resistant to antiviral medications, making the vaccine our only effective pharmaceutical intervention; (b) If evidence emerges that a particular group of people is more vulnerable to serious H1N1 complications than has so far been evident; or (c) If evidence emerges that the vaccine has unexpected complications or is less effective than we anticipate.
Eventually we hope most people will be vaccinated against H1N1. The novel H1N1 virus is here to stay. Odds are it will remain pandemic for a year or two, and will then become one of the influenza strains that circulate seasonally. If that happens, the pandemic H1N1 vaccine will become part of the seasonal flu vaccine. Eventually we want as many people as possible to have been vaccinated against this new strain of influenza. The sooner lots of people have antibodies against this disease, the safer we will all be. (Of course people who have had the pandemic flu already have these antibodies now, and therefore do not need to be vaccinated. Unfortunately, we have no reliable, cost-effective test that would enable us to screen these people out of a mass vaccination program.)
The best time to get vaccinated against pandemic H1N1 would have been last April, when the novel H1N1 virus first appeared. But we have all had to wait – involuntarily – until initial batches of pandemic H1N1 vaccine could be produced, tested, approved, and distributed. We don’t yet have enough vaccine for everyone in the country who wants it, so some people in non-prioritized groups will have to wait a few months more – once again, involuntarily. People in the developing world, where there is very little vaccine, will have to wait a lot longer than that – also involuntarily. If some people in prioritized groups also want to wait – voluntarily – to see how the virus develops and make sure nothing goes wrong with the vaccine, they should feel free to do so.
Don’t forget the seasonal flu vaccine. The case for getting vaccinated against the seasonal flu is a little weaker this year than it is most years (at this point in the season), for two reasons. First, the pandemic strain may out-compete some of the seasonal flu strains – as happened in some countries in the Southern Hemisphere during their flu season this year – which means this year’s seasonal flu strains may cause less disease than usual. Second, one of the seasonal flu strains, H3N2, may be drifting from the one that’s in the 2009-2010 vaccine, which means this year’s seasonal vaccine may be less effective than usual. Despite these two possible (but not yet established) factors, getting vaccinated against the seasonal flu remains a good idea, especially for healthcare workers, people over 60, and people in other high-risk groups.
If you’re willing to do one or the other but not both, which one do we recommend? Of course we think ideally everyone would choose to get both vaccines, once they are available – and we don’t expect a shortage of the seasonal flu vaccine this year. Still, if you have decided to pick only one or the other, here’s our recommendation, with reference to your specific risk characteristics….