Swine flu
The vaccination debate
To be jabbed or not
Last Updated: Wednesday, October 28, 2009 | 3:01 PM ET
By Naheed Mustafa, special to CBC News
Dr. Sohail Gandhi runs a fairly typical medical practice in rural Stayner, Ont., near Georgian Bay.
He sees kids, seniors, expectant mothers — "cradle-to-grave care," as he puts it.
He and his fellow doctors are gearing up for the H1N1 vaccine, which they expect to get their hands on sometime this week.
In Ottawa, Mika Hoffer, 4½, is not eager to get his H1N1 flu shot. (Fred Chartrand/Canadian Press) He says he has found the experience an "extraordinary challenge" because the whole flu campaign has come together so quickly.
The information about who should get the swine flu vaccine, when, and which type (with adjuvant or without) changes often and quickly.
(Adults should get one dose while children between six months and nine are to get two half-doses, 21 days apart, says Health Canada.)
Dr. Gandhi says he's spending much of his time these days educating his patients about what their options are because there is a dearth of good, accessible information out there and that has left many people confused and ambivalent.
He has already seen one teenager with the virus end up on a respirator.
Bottom line for him: "This strain of virus is fairly dangerous, especially to younger folks. We need to do something rather than nothing."
The great debate
To vaccinate or not? The question is turning into Canada's great debate, particularly in the wake of some recent, tragic flu deaths and polls that show just over a third of Canadians are planning to get a swine flu shot.
On the one hand, many experts say that the risk for those not getting vaccinated is pretty low.
Experts point out the death rate from the initial bout of swine flu in the spring was not nearly as high as many had expected, even in southern hemisphere countries such as Australia where the main flu season has just passed and where the H1N1 vaccine wasn't approved until nearly the end.
On the other hand, H1N1 has spread very quickly, to 177 countries so far, and is proving to be particularly dangerous to unusual (for the flu) groups such as children and young, apparently healthy adults in their 20s, as well as those with compromised immune systems such as pregnant women and adults with conditions like asthma.
In both Canada and the U.S., health authorities are reporting that influenza-like illnesses are running higher than normal these past four weeks, though they have largely given up tracking how much of this is H1N1 related.
Faced with these concerns — a new strain that hasn't been seen for years with a different victim profile — a jab with a needle would certainly seem like the best option, particularly if the alternative is a very high fever and visit to a jammed and bug-infested emergency room.
Or as Canada's chief public health officer, Dr. David Butler-Jones puts it: "It's actually more about the people around me because I don't want to be the source of an infection that might send one of my kids, or grandkids or friends to a hospital or ultimately kill them."
Is it safe?
Some people have expressed concerns about the safety of the vaccine, concerns which may be magnified because of the speed with which the swine flu campaign's been rolled out.
For his part, Dr. Gandhi allows that there is some legitimacy to the argument that there hasn't been enough testing of this particular swine flu vaccine.
But he says it is very similar to the type of flu shot that is given in past years and which has generally proven safe.
However, the difference between the swine flu vaccine and the seasonal flu vaccine is the addition of an adjuvant, a compound that boosts the body's immune response on its own.
It's been added at the request of the World Health Organization to help make more of the specific H1N1 ingredients go around.
Adjuvants have been widely used in other vaccines, notably the bird flu vaccine in much of Asia where it was tested on at least 45,000 people without serious incident, WHO says.
Because the adjuvanted vaccine has not been tested on pregnant women, a non-adjuvanted vaccine will be made available for them but it won't arrive until at least next week.
In the meantime, public health officials say that women with a history of illnesses or who are well along in their pregnancy might not want to wait.
The vaccine does not contain a live virus, so it can't give you the flu.
But people with asthma or even minor egg allergies should consult their doctors first before getting the shot. People with serious egg allergies should not be vaccinated.
Is it effective?
Despite the general sense that Canadians should go out and get vaccinated especially if they fall into one of the high risk groups, there has been little discussion about whether the vaccine is even effective.
Health researchers argue that the only way to know about a vaccine's true effectiveness is to carry out randomized trials. In other words, give the vaccine to one random group, a placebo to the other, and track the results.
But that kind of random testing hasn't been done for the H1N1 vaccine. It makes it impossible to know whether vaccinated individuals remained healthy because they had the shot or were just lucky enough to avoid the bug.
Dr. Jim Wright at the University of British Columbia says he would be willing to take the vaccine — but only if it was part of a trial.
We haven't seen the last of the swine flu, he says, and if we don't test the effectiveness of this vaccine, we'll be mired in the same vaccination debate each year.
"If we don't do a trial, then next year in September or October everyone will be wondering again if they should take the vaccine. My criticism of this vaccine is the same as my criticism of other flu vaccines.
"There are no (randomized) trials done so we don't know if it worked or not and every year we hear that it doesn't look like it worked," he says.
Worst case
The theory of vaccines is that they are like a firebreak to a forest fire: If enough people are immunized, a virus doesn't get to pick up the head of steam it needs to do its worst.
Proponents say that we need mass vaccination now because, even though this particular strain might not be so terrible, if it mutates into something more potent then at least large numbers of Canadians will have acquired some protection.
But Dr. Wright says that even considering a worst-case scenario, using that as the rationale for vaccination now makes no sense since this current vaccine probably wouldn't work against a future strain in any event.
He says the world's seen H1N1 play out in Australia, Argentina, and New Zealand and that it's clear the swine flu isn't that bad.
"We're giving the vaccine for something that isn't that severe and we don't know if it is effective. That's the story."
Dr. Alison McGeer, the head of infection control at Mount Sinai Hospital in Toronto, agrees about the flu not being that bad.
As a frontline health worker who expects to be regularly exposed to the virus, she's getting vaccinated. But she's not overly concerned if most Canadians decide not to go for it.
"In a worst-case scenario," she says, "if we didn't have the (H1N1) vaccine our ICUs would be stressed, we'd have to cancel surgeries because our systems would be overloaded, there'd be stress on family doctors but we'd get through it.
"Australia got through its first wave and there's no reason to think it would be much different here."
