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This is a Second Opinion special edition. A town hall meeting on H1N1 influenza. Leading experts and doctors talk with citizens about the issues. Risk, spread of the flu, and vaccinations.
Here's your host, Dr. Peter Salgo.
(PETER)
Welcome to a special edition of Second Opinion, a town hall meeting on H1N1 flu. I'm Dr. Peter Salgo. Now, people all over the country are concerned about this virus. How much of their concern is based on hype, how much is based on real information, what should you be worried about? Well, we're going to help you sort through some of these issues. We are taking questions from citizens, and some of the states hard hit by H1N1, and we'll be hearing from member of our studio audience too. We've got a high-powered panel assembled to talk about H1N1. Dr. Janet Corson-Rikert, executive director of Gannett Health Center at Cornell University. Dr. Ann Schuchat, the assistant surgeon general and chief health officer of the H1N1 response group for the Centers for Disease Control and Prevention. Dr. Mark Shelly, epidemiologist and infectious disease specialist from the University of Rochester Medical Center. Dr. Barbara Ferrer, executive director of Boston Public Health Commission. And Dr. Lisa Harris, Second Opinion primary care physician. She specializes in adult and pediatric medicine. So, Dr. Harris, let's start with you. Let's some of the basics out of the way. What are basics of the H1N1 virus? How is it different, how is it the same?
(LISA)
Well, the H1N1 virus is really just a new or novel form of influenza A, and we know that there are two forms of influenza. A seasonal flu, influenza A and B. And H1N1 is just a newer version of influenza A.
(PETER)
Now, we've heard this in the beginning of this epidemic. This novel virus, if you will, called swine flu. Then suddenly in the middle of all of the uproar about this new virus, somebody changed the name to H1N1. Was that a PC change for some reason? Or is there real scientific basis for a name change.
(Mark)
Well, when it was first identified and culture from patients, the sequence was determined, and the sequence was similar to that to a virus that had been circulating in swine, in pigs. And so that, it got called swine flu. But most people, who have this viral infection, haven't been anywhere close to a pig. And so it's more correct to say this is a human virus that has jumped to us with some similarity to a virus that had been circulating in swine. So now it's called a human H1N1 virus.
(PETER)
So this wasn't an attempt to protect the poor innocent pigs fro discrimination. This really was a scientific, scientific move here. Dr. Ferrer, is this flu more dangerous, is H1N1, than seasonal flu, the ordinary flu?
(BARBARA)
You know, Peter, I think flu is, is, is basically something that can be dangerous for some people, whether it's H1N1 influenza, or it's season flu. Most people with flu feel lousy, but recover quickly, and, and go on without any adverse effects. But as with seasonal flu, with H1N1 influenza, we have some folks who are much more likely to have the possibility of having some serious complications. And so I think when you think about this, you have to think about people in target populations.
(PETER)
But you always have to think people in target populations. And, and I think the sense of this H1N1, that the people have been getting, from the newspapers, from the various media outlets, is that this is a novel virus. This is evil, bad, new. Dr. Schuchat, what's going on here?
(ANNE)
This is a virus that's causing a pandemic, and that's because it's a virus that's different from the strains that we've been having for the past many years. So most of us are susceptible to it. It may not cause disease in any one individual that's more severe than the disease they might get from a seasonal flu strain, but we think more people may get sick because fewer of us have ever seen this kind of virus.
(PETER)
So just to nail this point, even though people are urged to get a seasonal flu vaccine, because the virus changes year after year, you're saying that because this is even more novel, more people are susceptible?
(ANNE)
Yeah, we think, we think almost everybody is susceptible to this virus. And we might have more people ill this year than we would have in a typical seasonal flu year. But of course, seasonal flu does cause a lot of illness each year. So it's also causing disease in younger people. Not so much in the elderly, so that's a difference also, with the seasonal flu.
(PETER)
I want to get to that in a moment. In fact, very soon. But I think it's obvious from what you said, people just feel awful. Nobody wants to go out there and volunteer to get this H1N1 virus. So why don't we start the conversation by taking a question from Birmingham, Alabama, where we have a college student, Trent Madison.
(AUDIENCE)
I was wondering how swine flu spreads, and if I go to a party or to a friend's house and accidently drink from somebody else's cup, if I can get it. Or if I go and just make out with my girlfriend. I'm wondering if I can get it from that way, as well.
(PETER)
Okay. So he wonders, can you get it from making out with his girlfriend?
(ANNE)
Sure, yeah. Well, you know, first off we don't think that drinking from somebody else's cup is a good idea in general. There's a lot of germs that can spread that way. The main way that influenza is spread, whether it's the H1N1 or seasonal flu, is by coughing and sneezing on each other. It's spread through respiratory droplets. But sometimes those can get on our hands, they can get on other surfaces, and so if you touch something where the virus is, and then touch your eyes or nose, you can actually get an infection. So we think that's why hand washing is important, covering your cough or sneeze, staying home when you're sick, staying away from other people, so that you don't spread, you know, though the coughing and sneezing route.
(PETER)
You know, I noticed a lot of folks here were smiling. I mean, the question sounds humorous, can I get this from making out with my girlfriend. But it's an important question, isn't it. I mean, especially on college campuses.
(Janet)
Yes, it's actually a very important question, and a good one for college students to ask. The primary mechanism of transmission as Dr. Schuchat mentioned, is really transmission when you are ill. But one point to make here is that this virus, like some other viruses, actually can be transmitted before symptoms develop. So it's really important that these basic habits of hygiene, of not sharing cups and utensils, of not sharing other people's cigarettes, or lip balm, are really important, just general guidelines to follow for this illness and any other. And we'll certainly help in reducing transmission of this virus.
(PETER)
Can I just interject? It would be good if you didn't share your own cigarettes. I mean, cigarettes are just bad, flu or no flu, right. It's a very important question also, about his age. You alluded to this. This is a young man who's talking to us, and we've been taught that seasonal flu, that the young adult population is not particularly at risk. Not necessarily from the bug, but from the bad effects of this bug.
(ANNE)
Yeah, you know, seasonal flu kills about 36,000 people a year. But most of those people are the elderly. And what's different about this 2009 H1N1 virus is we've seen so much disease in young people. A disproportionate amount of children, young adults, have been getting sick. And that we really notice, especially the more severe illness that we've been seeing in kids, and some young adults.
(PETER)
All right, we've got a question from our studio audience. Go ahead, sir.
(AUDIENCE)
Hi. I'm Dr. John ((Rooter)), an internal medicine resident physician. I was one of the first confirmed cases of H1N1 in the northeast. Shortly after I became symptomatic, I was given the antiviral Tamiflu. Overall, my illness was fairly mild, and I was back to my baseline within 36 hours. Would you characterize my case as typical?
(PETER)
Is he typical? You're out in the community, Lisa.
(LISA)
Yeah. Yeah, I think for the most part, you are fairly typical for a young adult. It can be very difficult to determine if it's H1N1, if it's just a cold or if it's influenza A or B, seasonal influenza. But for young adults, people who don't have other medical problems that put them at risk for severity, this is pretty much what we expect. Stay home, don't talk to people, don't touch people, don't drink behind anybody else. And when your fever is gone, you can go back to work.
(PETER)
On a scale of 1-10, how crummy did you feel?
(AUDIENCE)
Maybe a 4.
(LISA)
That would not be so typical.
(PETER)
That would not be so typical.
(LISA)
Yeah, yeah, yeah. I think you were lucky.
(PETER)
Was it luck, but, or was it something else? I want to focus on another part of your story. Because, within how many hours, now, you're a doc. You're watching for signs and symptoms within yourself, although we know that lots of docs don't really take good care of themselves. You noticed something was wrong, and you took Tamiflu, which is an antiviral. Within how many hours was it?
(AUDIENCE)
Well, I had, I had developed a cough and runny nose and fatigue, and then a low-grade fever, and I, I received Tamiflu within 12 hours of my symptom onset.
(LISA)
Now see that's, that's pretty atypical, because most people are going to be at home for a day to three, four days, before they get in touch with their physician or with someone else to determine whether or not they're ill. And for you as a resident physician, what's more important is, not so much what would happen to you, given that you're young and healthy, or we're presuming that. But what would happen to the people that you could potentially expose at the hospital.
(AUDIENCE)
Absolutely.
(PETER)
So do you think the Tamiflu was wise, you only felt 4, likely, as opposed to a 10 if that.
(ANNE)
Well no, I think that Tamiflu can shorten the symptoms that a person has when they have a relatively mild illness like that. But we think Tamiflu can be lifesaving when you have a severe illness in the hospital. It's not going to save every life, but it's very important for severe illness, to seek care promptly and, and get medicine.
(JANET)
I should make the point that I think a lot of, a lot of people that we're seeing, certainly students on a college campus, really are having a very mild illness. Even without taking Tamiflu and recover without any kind of treatment.
(PETER)
Okay, which goes to the point we were making during the lead-in to this broadcast. We've got to know whether this is really Armageddon, or whether this is a mild case of flu, or if it lies somewhere in the middle. I know what you're going to tell me.
(ANNE)
Well, you know, every, everyone is different. And right now, we're really focusing on certain people who we think have a higher risk of having a really hard time with flu, pregnant women, people with chronic conditions like asthma, diabetes, the very young. Those are people who might have a much worse illness. Now, some people who are totally health and young, can have a pretty nasty bout of this. It's not really like a cold. Usually body aches, fatigue, hard to sit up. I mean, you can be pretty wiped out, with influenza, whether it's the H1N1 or the seasonal strains. But most people will just be fine after several days of taking care of themselves. Some people do need to seek care.
(PETER)
Now, when you see folks on the campus, the symptoms they complain of, that you can point to and say, ah, this is flu or H1N1 or season flu. Just, can you just list them?
(JANET)
Usually we see a fairly abrupt onset of symptoms, unlike a typical upper respiratory infection. So it could be a pretty sudden onset of sore throat, headache, fever, cough. Some of the cases we're seeing also have vomiting and diarrhea, although that's not as common as the others. So the muscle aches, is really a, a quite specific issue for flu.
(LISA)
And a temperature of 99 is not a fever. I get about 20 calls a day with, I have a fever, my temperature is 99, my temperature is 100. We're talking about high temperatures.
(JANET)
But I do, I do want to point out that we are seeing some influenza that really doesn't have high fevers. And we're even seeing some students, I think, who probably do have influenza based on the patterns of illness and what we're seeing, who really are not even febrile.
(PETER)
All right, we're going to take another question from a view. This is from Chris Lawrence in Alabama. Chris.
(AUDIENCE)
How contagious is H1N1 compared to the regular flu?
(ANNE)
You know, the regular flu is pretty contagious, and so is this. But what's different about this one is that nobody's really seen it before. So there's more people that can get it. So it's spreading in about the same way, but it's finding a person who has no immunity at all. It's just, it's just, there are more of us that could get it upon encountering it.
(PETER)
I want to bring this back again, because I keep coming back to the question of, everybody getting sick, versus everybody getting very sick. It's one thing if nobody's immune, so they all get the H1N1. But are more people getting really deathly ill from this than you would expect from seasonal flu.
(ANNE)
You know, let me give you an example. We have had 60 children die from this new strain, since April. From April through August. And usually we would have zero children die from flu in the summer. So this flu has been causing disease at a time when seasonal flu just doesn't. So we don't really know what's going to happen in the next few months. But the principle thing is, this flu is able to spread when other flus can't, because we haven't seen it before. But on an individual basis, the chances are, you'll have a relatively short illness, unless you're unlucky, or unless you have one of these underlying conditions.
(PETER)
I know we have a …Yeah, go ahead.
(LISA)
Because people haven't seen it before, because people don't stay home. They still go to work when they feel sick. They still go to work when they're coughing, they go to school when they're coughing, when they feel ill. And they'll wait 48 to 72 hours before they decide to stay home. And the caveat is, wash your hands and stay home.
(PETER)
I, before we move to a question here from our audience, who's been waiting patiently for a moment, I do want to focus on something you just said. This is not flu season. Or at least it wasn't over the summer. H1N1 doesn't seem to be following the playbook.
(ANNE)
Right.
(PETER)
It doesn't go away in the summer to come back in the winter months.
(ANNE)
And it's, exactly, so we've had outbreaks in summer camps, we've had continuing illness including some of these fatalities, that I mentioned, and really, that's just a sign that the strain hasn't gone through our population fully. So we don't, you know, we're getting into flu season now. It's getting colder, kids are back at school. We're seeing increases in disease. We don't know exactly how many waves of, of the flu season we'll have this year, but we know it's an unusual circumstance, and so we're taking it pretty seriously.
(PETER)
All right. We do have a question from our audience. Go right ahead, please.
(AUDIENCE)
Hi, my name is Heather Gray, and I live in Rochester, New York. I recently moved here from Seattle, where the H1N1 virus is widespread. What do you recommend people do if they think they have they have the flu?
(BARBARA)
Stay home.
(PETER)
I think, Lisa, you say that, stay home. But isn't that counterintuitive, I mean…
(BARBARA)
I actually, well, you know, I think it's actually a good question. Because I think there are two parts to it. One is, you know, what should you do, and the other part, I think you might be also referring to is, when do you need to seek care. You know, definitely, when you're feeling sick, particularly when you have a fever, we know there's flu going around, you're coughing, you're sneezing, you have body aches. You need to stay home. And you need to stay home until your fever-free without medication for at least 24 hours. Now, everybody doesn't need to go to the doctor. But I think, you know, for, when you hear that it may, in fact, cause serious illness, you wonder, well, well who should go to the doctor, and if I don't feel well, should I be calling my doctor, should I be going to the emergency room? When should I be seeking care? And if you're a parent, when should I worry because my child is sick, and maybe this is mild illness, but maybe it's not. So I think it's really important to be well informed, to know if you're a person that has underlying health conditions that puts you at risk, to know, in fact, if you have children in your household who are very little, you need to pay particular attention. To know the signs when you're going from mild illness to serious illness, dehydration. You know, if you have young children and they're not urinating well, they're not able to cry with tears. If you have excessive vomiting. If your fever stays high over a long period of time. So, you know, I think we have, we have a responsibility, as well as health professionals, to make sure that people have good information, so that they're able to make the right decision about, not only what they need to do to take care of themselves and their family, but when they need to seek care, and see a health professional.
(PETER)
But I hear, I hear in my mind, the question that's bubbling up. If I don't bother my doctor, if I don't go to the doctor's office because I could be transmitting H1N1, how am I going to get this oral antiviral medicine, which the doctor would like to know is appropriate for what's ailing me, in enough time to be sure that it's worth taking?
(LISA)
So it's, it's worth calling your primary care physician to ask exactly that question. So if you haven't figured out that you're, you are at a high-risk population because you have asthma, cancer, diabetes, or you're very young or something like that, I mean, those are the populations that we're talking about. If you're young and otherwise healthy, then you don't need Tamiflu, and you don't need to be taking other people's Tamiflu, you don't need to be stopping by the emergency room or things like that. But you can always call. And we, we get at least 15-20 calls in the morning, in a small primary care office, for patients for exactly that reason. So it's easy for us to reinforce that over the telephone. There's no reason for you to come in and expose other people.
(PETER)
And before we leave this, this whole topic of oral antivirals, Tamiflu being one, we ought to mention that there has been some confusion out there, in children's doses. Because the prescription is often given in teaspoons or cc's. And the instructions with the medicine were coming in milligrams, and people had to do higher math for this. Has this been fixed?
(ANNE)
Yeah, we hope we've gotten the word out, both to pharmacists and to physicians about how to prescribe the formulations for children. We've also been able to release more of the liquid syrup. There was a little bit of a, not enough in some places, and so we've been able to release more syrup to the states, so that they'll have it for children who need it. And it is important for parents to sort of be watching their kids and make sure that if your child is getting better, and then gets worse, that's a warning sign. If your child is having trouble breathing, that's a warning sign. If you can't wake your child up, that's a warning sign. Those things are very important for people to know.
(PETER)
And what about in adults, before we leave this topic. What would prompt you, as an adult, monitoring yourself, to say, time to call the doc, or maybe even time to go see the doc.
(MARK)
Well, I think immune suppression, the knowing your own risk factors, and how you fit in. The one thing we haven't mentioned really is immune suppression. If you were HIV infected, for example, that would be someone who ought to seek treatment, earlier than somebody else, even if that treatment is called in over the phone. The other thing I think is, that shortness of breath is an important one. That shortness of breath is something that you, that we can correct in the hospital, but we can't correct at home until the point that you aren't able to get around and communicate something. So that would be another warning. So if you have…
(LISA)
If you have chest pain, I think I would add…
(PETER)
Chest pain.
(MARK)
So if you have, if you have the underlying risk factors, then you know you've got to call early. Or if you find yourself feeling so sick not that you're just so achy, but rather that you're getting short of breath, or chest pain, that's when you've got to have somebody help you get to the emergency room.
(PETER)
All right. Now, before we move on to talk about the hot topic of this H1N1 vaccine, I want to sum up, if we can. A bit of what we've discussed so far. The symptoms of H1N1 flu are similar to the symptoms of regular seasonal flu. H1N1 is spread through droplets, coughing or sneezing, for example. Not through the food supply necessarily, not through the water supply, though sharing food, water with someone who's sick is never a good idea. There are common sense precautions you can take to avoid catching H1N1, and if you feel sick, stay home. Call your doctor, follow precautions to prevent spreading this to folks who don't have the disease already. Everybody agree about all of that.
(LISA)
Absolutely.
(PETER)
This is a special edition of Second Opinion, a town hall meeting on H1N1 flu. I'm Dr. Peter Salgo and we're talking with people in some of the states hard hit by the H1N1 virus, and with members of our studio audience. Joining us for the discussion about vaccines, are Dr. Richard Barbano, who has joined us just for this section. He is chief of neurology at Rochester General Hospital. Dr. Ann Schuchat, assistant surgeon general and chief health officer of the H1N1 response group for the Centers for Disease Control and Prevention. Dr. Mark Shelly, epidemiologist and infectious disease specialist from the University of Rochester Medical Center. Dr. Barbara Ferrer, executive director of Boston Public Health Commission. And Dr. Lisa Harris, Second Opinion primary care physician, who specializes in adult and pediatric medicine. Dr. Barbano, thanks for joining us for this section, but I have to ask the obvious question. We're talking about an H1N1 vaccine. What's a neurologist got to do with all this? Why are you concerned with it?
(RICHARD)
Well, that's a great question. I think we have to sit back and look at this a little historically. As a lot of people are aware, after the vaccinations in 1976 for the swine flue at that point, there was a slight increase in a risk of a neurologic illness called Guillain-Barré syndrome. We just call it GBS for short. And because of that historical occurrence, people are concerned that there may be a similar problem after this vaccine.
(PETER)
I mean, it's, it's fair to say, that GBS, if you will, made a lot of news back in '76. I can tell you from personal experience, the guy behind me on line, we were all interns at the time, who got the vaccine, wound up in the neurologic institute with Guillain-Barré. So, if you get this, this is non-trivial. So is it reasonable to understand, at least why people are concerned, especially because this all started out with swine flu, swine flu before it was H1N1.
(RICHARD)
Sure. I mean, there is always reason for concern, but there are a couple things that we need to put in perspective. Firstly, I think it's always important to remember that GBS is a serious illness. But the majority of people make a full recovery. So we need to, to at least allay some fears there. Not to say that it's not a serious illness. And obviously can even cause death in severe cases. But we really don't know the similarity between the swine vaccine then and this current one. And in fact, we think it's, it's quite unlikely that there will be the increase in Guillain-Barré syndrome. It's also important to remember that even in that 1976 situation, the increase in GBS was only 1 per 100,000 people vaccinated. So it's still a quite small risk.
(PETER)
But is it worth, I know it's worth asking this question, because we talked about the name change, from swine flu to H1N1, anticipating the name change from swine flu vaccine, to H1N1 vaccine. And if you look at the web, and you read a lot of the, the blogs, their point is they changed the name so we wouldn't know it was swine flu vaccine, because that's a bad vaccine.
(ANNE)
You know, it's so important for us to learn from history, and vaccine safety is really important, more than ever now. But I think there's so many differences between 1976 and today. In 1976, there was a new virus that caused some disease, and a vaccine was produced, and given. But there was no pandemic. Today, we're having a pandemic. The new virus has emerged, has caused a lot of disease, including many deaths, and so a vaccine is being made, somewhat differently from back in 1976, and we're going forward with that. The vaccine that's being made today against H1N1, is being made exactly the same way as the seasonal influenza vaccines. 100 million people get the seasonal vaccines each year. They have a really good safety record.
(PETER)
Is it worth asking, I know we have a studio question coming up, but I want to slide this one in. Is it worth asking, because I was listening to you, whether we didn't have a pandemic in 1976 because people got the swine flue vaccine?
(ANNE)
No, actually the difference there, you know, the illness was in January and February. And they had all these months before they started vaccinating, because then and now, it takes many months to make a flu vaccine. What happened with us, is that we had new disease in April. Disease kept happening, through the summer, in the U.S., all through the southern hemisphere. We have a lot of disease that's occurred, so we know that this virus is capable of spreading through populations. So we think that a vaccine is likely to have benefit, in terms of reducing disease. Right now, based on everything I know, I'm not expecting risk, but we might find out that there is some risk, but we're certain that there will be benefit.
(LISA)
I think that one of the things, just very quickly, that you might want to, you might want to subtitle this show, Stop the Madness. Because there's just a lot of craziness that's out there. So, as to Dr. Schuchat's point, this is a pandemic now. So you, with everything else that we do in medicine, it's a risk-benefit ratio. So we're talking about the risk of allowing the pandemic to continue, with increased deaths, versus the very small risk of a potential for increased self-limited disease.
(RICHARD)
That's a great point. And, and if the risk, for GBS follows the seasonal vaccine risk, it is very small. Many studies have shown no association. At worst, maybe one in a million. So we are talking really small risk here.
(PETER)
Okay. Let's go to the audience. We've got a question.
(AUDIENCE)
Hi, I'm Dr. Marci Chodroff. I'm a primary care physician in Rochester, New York. My question is, many patients are concerned about the safety of the H1N1 vaccine, and how do we know that it is safe?
(PETER)
How do you know it's safe?
(ANNE)
Yeah, you know, we have a lot of different ways of, of figuring that out. And of course, no intervention is without any risk or any hypothetical risk. So it's really important for us to keep an eye on things. What we do know is that the seasonal flu vaccines have been used a lot. They've been used in seniors, they've been used in children, they've been used in pregnant women, and we don't have significant severe side effects from the, the seasonal flu vaccines. The H1N1 vaccine is being made exactly the same way. It has also been going through clinical trials, and we haven't had any red flags in those clinical trials. Things have looked actually really great so far. But we know the clinical trials are just in hundreds or thousands of people, not in millions and millions of people. But what we do have, is a, a safety system. When the vaccines are used in large numbers, we keep looking. We don't stop with the clinical trials. We keep monitoring safety. And because of this, H1N1 vaccination program that we're planning, or about to launch, we are enhancing the way that we monitor safety. If there's some unusual rare safety problem with the H1N1 vaccine, I want to know about it. We want to find it, we want to do something about it. So we're not just assuming that nothing bad is going to happen. We want to be ready if there is some kind of rare problem. So I think we know a lot from the past, of using seasonal flu vaccines, from the clinical trials, and we're not just going to assume everything will be fine. We'll keep a very close watch on things.
(PETER)
Let me ask you a question.
(AUDIENCE)
Yes.
(PETER)
You practice in New York State.
(AUDIENCE)
I do.
(PETER)
It's mandatory, in New York State, that health care providers get this vaccine.
(AUDIENCE)
That's what I've heard.
(PETER)
Were it not, would you?
(AUDIENCE)
Would I get it?
(PETER)
Yeah, would you get the vaccine?
(AUDIENCE)
I, I think I would, just because I'm in contact with so many patients all the time, and I've already had a few cases, so.
(PETER)
I'll ask an unfair question, which was based on your question. How do you know the vaccine is safe? Do you know for sure? And by the way, what does safe mean?
(ANNE)
Right. You know, you can never know for sure. I think it's really important that as a public health system, we take vaccine safety seriously. We know that we've had problems with medicines in the past, we've had problems with some vaccines, we've had to recall them. We have to have a strong monitoring system. Before vaccines are licensed, and after they're used. But what I can say is that hundreds of millions of people, have gotten seasonal flu vaccines. The same companies that make the seasonal flu vaccine for the U.S., are making the H1N1 vaccines for our use this year, and they're being overseen by the Food and Drug Administration, the FDA, a lot of oversight, a lot of contamination checking and safety checking and so forth. So I feel that we have a strong system. But everyone needs to get those facts and make the decisions themselves.
(PETER)
All right, let's go down a few little bullet points, if we could. The CDC has a set of guidelines and recommendations for who should get the vaccine. So what are the recommendations right now?
(ANNE)
Well what we, we have bought enough vaccine, that anyone who wants to be vaccinated, can be vaccinated. But initially, when vaccines in relatively limited supply, we're recommending that five focus populations really come in and get the vaccine. These are groups that are either at higher risk for complications from flu, or that might be around others, and might be able to spread the flue to other vulnerable people. Pregnant women, health care workers, people who care for or live with a baby under 6 months of age, because the babies themselves can't be vaccinated. They can't be vaccinated, because the vaccine won't work in them, not because it's not safe, just because it won't work. Also for children and young adults, 6 months of age through the ages of 24, and then for adults 25 to 64 years of age, who have underlying health problems like asthma, diabetes.
(PETER)
All right. We have a question from the audience.
(AUDIENCE)
Hi, I'm Katie Conroy, and I'm pregnant. I'm not drinking alcohol, I'm not eating sushi, I'm taking all these precautions for the safety of my baby. Should I be worried about being injected with the virus so I don't get H1N1?
(ANNE)
You know, congratulations on your pregnancy.
(PETER)
That's a correct answer. Congratulations.
(ANNE)
Yeah, so it's such an important time. You know, you're taking really good care of yourself, and you're thinking about the baby, and I think that there are a couple key things for you. If you get fever and respiratory symptoms, it's really important you check with your health care provider. If you do come down with flu, whether it's the seasonal flu or the H1N1, we think those antiviral medicines are really important for you. But we also think it's a really good idea for you to vaccinated. I know that people who are pregnant really don't want to do anything different. You know, you want to do the tried and true. But what I can tell you is, that this flu is pretty scary in pregnancy. We've, we've had some women who have gotten really, really sick. And tragically, some women have actually died from the virus. So we're taking this really seriously. Based on everything that I know, the risk of influenza in pregnancy is much, much, much greater for you and your baby, than the theoretical potential side effects of a vaccine. You need to make that choice, but I would strongly recommend you to be vaccinated.
(LISA)
And I would add to that, are you taking prenatal vitamins?
(AUDIENCE)
Every day. And the DHA.
(LISA)
So, so point about that is that you're putting something in your body that helps your body to do what it's supposed to do, and that's really what the vaccine, all the vaccine does, is build up immunity, so that your body protects itself from the virus, and that's the issue. You really need to protect yourself and your unborn fetus from disease.
(PETER)
Now, there are two kinds of vaccine, that we're hearing about, right.
(BARBARA)
Right.
(PETER)
Live virus and killed virus.
(BARBARA)
Right.
(PETER)
And there's some that she should avoid and some that she should not avoid. How do we, how will you deal with that?
(BARBARA)
Right. I mean, you know, the most important thing is, you know, you need to work closely with your, with your physicians. But, you know, in general, the recommendation for, for pregnant women, is that they avoid the flu mist, and that they, in fact, are going to be looking for the injectable doses, which are, in fact, as you referred to, dead virus.
(PETER)
So the injectable is dead virus.
(BARBARA)
Right.
(PETER)
The inhaled, flu mist, is live virus.
(BARBARA)
Well, it…
(PETER)
Pregnant women don't want the live virus.
(BARBARA)
Sort of live. It's attenuated…
(PETER)
It's attenuated, but it's still something which generates a small (( ))
(LISA)
It's like the fly that you hit, that's just kind of laying there, not moving.
(PETER)
I don't even want to go there. Who shouldn't get this vaccine, by the way?
(ANNE)
The flu mist shouldn't be given to children younger than 2 years of age, or to adults 50 years or older, shouldn't be given to pregnant women, and it shouldn't be given to people with asthma or other underlying conditions.
(PETER)
And it's being given, the injectable vaccine is just one shot, two shots?
(ANNE)
For most people it will be one shot, or one spray of the nasal spray. For children under 10, we think two doses are going to be needed.
(PETER)
Okay, so kids, two.
(ANNE)
Children's influenza, just seasonal flu.
(PETER)
No, I'm talking about H1N1.
(ANNE)
The H1N1, yeah.
(PETER)
The H1N1, right. And another question is, can I take them both on the same day?
(ANNE)
Right. We think it's fine to get the two shots on the same day, or to get a shot and a spray on the same day. But we don't think it's okay to get two sprays on the same day. The, the weakened live viruses, we don't think you'll get a good take, if you take both of them together.
(PETER)
So it's not dangerous, it just doesn't work as well.
(ANNE)
Exactly, exactly.
(PETER)
All right, we've got another question. Go ahead.
(AUDIENCE)
I'm Heidi from New York and I'm also a mother of a 4-year-old. And I'm concerned about mercury levels in the vaccine. Is there a dangerous level of mercury in the vaccine, particularly for pregnant women and their unborn child. And the rest of the general public. And, can I request a vaccine with no mercury?
(ANNE)
So, the mercury that you're speaking about, a lot of people talk about thimerosal, which is a preservative that contains a type of mercury in it. We know that some people are concerned about that, and we've produced vaccine that doesn't have the thimerosal in it. There will be formulations, like the nasal spray, that doesn't have the, the thimerosal. And some single syringes that don't have it. And then there will be multidose vials that do have the thimerosal. We've procured a whole lot of that, so we do think you're likely to be able to get that, if that's your preference. As a scientist and a public health expert, I can say that, although there were some questions about thimerosal, there have been a lot of studies done, and there really isn't any scientific link between the thimerosal and problem, but we know that some people have concerns and we wanted to be able to address those. So that's why both formulations will be available.
(PETER)
Yeah, Mark.
(MARK)
And you mentioned you're from New York, and in New York state, they've basically, all though I agree with Dr. Schuchat that there is no risk from the thimerosal, pregnant women and children are not permitted to receive vaccines with thimerosal at the present time. So that's not a concern they would be using that. But it's also important to remember, that only about 20% of the entire stock of vaccine, will be thimerosal free. So if you are an otherwise healthy adult with no reason whatsoever to be concerned about this, if you are going after the limited amount of vaccine that is thimerosal free, that those people like the pregnant women, will have to compete, or you'll be competing with them, for a limited supply of vaccine.
(PETER)
Does that satisfy you, does that answer make you happy?
(AUDIENCE)
Well, if it's, if it's not allowed for pregnant women and their unborn child, then why wouldn't it be a risk for the rest of the population?
(MARK)
That rule was made by politicians and lawyers. It wasn't made based on the best we could come out with. And so, to understand, that that really is the key, that the politicians said it was that way, and then we start to think that it has medical validity behind it. But it does, it really does not. An adult, the amount of thimerosal in an adult, is, is an unreasonable concern.
(PETER)
But let me pursue this, if I may. First of all, pregnant women are urged not to eat tuna right now, because there's a fair amount of, of mercury in tuna. Thimerosal is a mercury compound. Why are you restricting tuna, but you say that, the mercury in the thimerosal isn't a risk, it's just the politicians doing that?
(MARK)
Well, I, I don't know the relative quantity of mercury in the tuna, or the risk factors in tuna. I just know that, that we have made this a rule by extension, and basically, as we keep extending it out, become afraid of too many things.
(PETER)
But if people are worried about mercury, and if there's a way to make a vaccine mercury free, what's the harm?
(LISA)
Well, I think this gets, speaks again, to stop the madness. Okay. We're talking about thimerosal which is a mercury based preservative. So we're not actually giving large amounts of mercury into your system.
(PETER)
You're not eating a thermometer.
(LISA)
And you're not eating tuna that's laden with mercury, that's the difference. We, there's a lot of science. Years and years and years of science that show that there's no link between the thimerosal preservative in vaccine and disease, specifically autism, if you want to throw it out there. And we know that from just years and years and years and years of data. We know that from looking at population studies in other countries outside of the United States where there is no autism. So it's really, as Mark has said earlier, an unreasonable risk. So we really need to, to educate people, that you're not ingesting a thermometer and putting yourself at risk.
(PETER)
All right, I know that we are not going to settle the thimerosal…
(LISA)
Not today.
(PETER)
…autism question right here on this stage at this moment. I'm going to let it go. With the knowledge that there is some overripe fruit being thrown televisions right now around the country.
(LISA)
Right.
(PETER)
And I'm not disclosing your home phone number at the moment, either. So what I'd like to do is continue and go on to another question. This one is from Michael Pierce in Alabama. Michael.
(AUDIENCE)
In my adult life, I've got to be honest, I've never been vaccinated. Why should I be concerned about H1N1?
(PETER)
Good question. Never took a vaccine before. He looks like a healthy, and since not in the studio, I can call him a middle-aged man. Why now, if he never needed it before?
(LISA)
Because it's not about him. It's about who he can expose. So we need to stop being so insular and being so selfish, and really think about, who are you around and who could you potentially expose that could get very sick, and can potentially have a serious complication from influenza.
(PETER)
If you want to talk about selfish, can we talk about herd immunity. If, if he's saying, I'm healthy, everyone around me, and I'm, by the way, I'm not putting words in his mouth. I don't know, and I assume that's not what he said. But let's say somebody else says, I'm healthy. If everybody around me gets vaccinated, they won't get sick. So I'm safe. What's wrong with that argument?
(ANNE)
You know, actually for this particular vaccine, we did it a little bit differently. We had our advisory committee look at who was getting really, really sick, and who was spreading a lot. And if there wasn't initially, if there weren't initially enough vaccine for absolutely everyone, who should the vaccine really go for? And so we're not saying, on day 1, or day 20, that every single one of us needs to run in and try to get vaccinated. But we're saying, if you're pregnant, if you have an underlying health condition and you're, if you're young, younger than 25, and over 6 months, if you're health care worker, who could be making your patients sick. If you're taking care of a baby who's too young to be vaccinated, but who could, could have a very severe illness, then we really want you to think about getting vaccinated, because it could save your life, and it could protect those around you.
(PETER)
But you'll forgive me, as rational as that sounds, that's not, in my view, what people are hearing. Or how they're interpreting what they're hearing. What they're hearing is, pandemic, Armageddon, get this vaccine. The world is going to stop spinning on its axis unless you do.
(ANNE)
Yeah, no, I think we're really, it's so important to, to get that balance. I don't want people to be complacent. I don't want someone to feel that, well, nothing bad could possibly happen, so I'm not going to worry about this. But I also don't want people to go really out of proportion. I just want people to know the facts and be able to make good choices themselves.
(PETER)
All right, let's go to a question from our audience.
(AUDIENCE)
Hi. I'm Mary Bernstein. And I was vaccinated for this, if I were vaccinated for the swine flu, in the '70s, would I, would I still be immune? Or would I need to be revaccinated?
(PETER)
Good question.
(ANNE)
Right. We don't think that being vaccinated back in 1976 would protect you today. It turns out the influenza virus in 1976, although, you know, it had the swine roots of it, was actually pretty distantly related to what we're seeing right now. That was an H1N1. This is an H1N1. The 1918 so-called Spanish flu, was also an H1N1. But we don't think a vaccination in 1976 would protect you now. We think to be protected this, this year, one would either need to be vaccinated, or we, it looks like people who are older, you know, people particularly in their 60s, and 70s, and 80s, seem to have some kind of protection. But we don't think it's from any type of vaccination, because people have looked at specimens from people who were vaccinated and people who weren't.
(PETER)
So that's, basically if you're old enough, 60, 70, 80.
(LISA)
And you don't have underlying disease. So if you don't have asthma, you're not immunocompromised, you don't have diabetes. They you probably could wait to be vaccinated from H1N1.
(PETER)
Is it fair, is it fair, before we wrap up this segment. For the media, and I know we're going to get into more of this in a moment. To be showing those dramatic horrific pictures of the Spanish flu, telling the stories about the Spanish flu. When this H1N1 doesn't seem to be at all like the Spanish flu.
(LISA)
You know, that was something I wanted to comment on earlier. I think people have equated the term, pandemic, with the Black Plague, that everyone's going to die from this disease. The term, pandemic, just means that it's everywhere. And it's everywhere, again, because you won't stay home. Stay home when you're sick.
(PETER)
All right.
(LISA)
So, it's, it's just everywhere. So if people follow precautions, then, you know, it's not the Spanish flu where people, massive amounts of people were dying from disease.
(PETER)
Okay, thank you. Before we move on to the public policy and other public health issues, I want to sum up some of this vaccine discussion that we've been having.
There are five groups that need to get vaccinated, if you follow the recommendations. The key differences in the risk groups between this and seasonal flu, is that one of the high-risk groups for H1N1 is people between the ages of 6 months and 24 years of age. And of course, if you are chronically ill or you have any questions, just talk to your doctor. A phone call. From home.
(PETER)
This is a special edition of Second Opinion, a town hall meeting on H1N1 flu. I'm Dr. Peter Salgo and we're talking with people in some of the states hard hit by H1N1, and with some members of our studio audience. Joining us for the discussion about public policy and public health, are Dr. Janet Corson-Rikert, executive director of Gannett Health Center at Cornell University. Dr. Anne Schuchat, assistant surgeon general and chief health officer of the H1N1 response group for the Centers for Disease Control and Prevention. Dr. Mark Shelly, epidemiologist and infectious disease specialist from the University of Rochester Medical Center. Dr. Barbara Ferrer, executive director of Boston Public Health Commission. And Dr. Lisa Harris, Second Opinion primary care physician, who specializes in adult and pediatric medicine. Welcome back Janet. Nice to see you again. Now, let's talk about public policy. Let's talk about the risk and the benefit. I may have mentioned that I live in New York City, and you know this. And I was in line, and I did get the swine flu vaccine, when it was propounded that we all do that. Because if we didn't, all heck was going to break loose. The guy behind me got GBS, Guillain-Barré syndrome. Now, in New York state, it is required that health care workers, by statute, if you will, by emergency degree, get both seasonal vaccine, and H1N1. In other parts of the country, health care workers as a prerequisite to keep their jobs, are required to get vaccinated. Does this sound rational to you? I can tell you, that where I work, there's tremendous pushback against this. Lots of people don't want to be vaccinated. They just don't want to be ordered to be vaccinated. Does that sound rational?
(LISA)
Well, you know, I do pediatrics, where it's mandated in New York State that students have the tetanus vaccine before entering sixth grade. And they're actually kicked out of school. So I don't understand why the adults are having an issue, when in pediatrics, we've had this mandate or degree for a long time. You don't have immunizations, you don't go to daycare, you don't go to school. So, this is a disease that can kill people. Get the vaccine.
(PETER)
But you, you've heard this on the radio. A lot of the talk shows are saying this is an invasion of your personal privacy, that the government is invading everything, and this is some large plot, god knows what the object of the plot may be. But, but there are people, I think, and not to, not to make light of this, who really do feel that constraining them by law to do this, in some way, invades what they should be able to do by choice.
(BARBARA)
Well, you know, we actually have a lot of workplace regulations. So let's just be honest about, sort of what happens in the workplace as being different from what happens in your private home. So there is, there have been no regulations regulating the private people, private citizens, in fact, have to get vaccinated. And I think we need to assure the public that there's no intent on that. The issue that's happening in hospitals and in health care facilities, is around patient safety. And just like there's a whole host of workplace regulations already in place at hospitals around patient safety, this has been an additional one. So I think we just have to separate the issues about what's appropriate in terms of regulating, things that go on in a workplace, and what's appropriate in terms of regulations that may affect us in our private lives.
(PETER)
Before you get symptomatic, that is to say, before you start with the aches, the pains, the fever, whatever, from H1N1, are you infectious to other people? Are you at risk?
(MARK)
Yes.
(BARBARA)
Yes.
(PETER)
You are.
(BARBARA)
Yes.
(PETER)
That's the critical answer, isn't it.
(BARBARA)
Yes.
(PETER)
You don't know you're a risk, you haven't been vaccinated, so you could have the, the disease, and you could be infecting scores of patients who trust you with their lives.
(BARBARA)
And think about, think about what's happening in the hospital. You are working with very sick patients. So a very sick patient who now is exposed to an influenza virus that they have no other immunity to, can, in fact, die. So I think we have to always be careful about how we portray an issue around the policy. And in this case, I think the reason that people are talking about regulations, is really because they're putting patient safety first.
(MARK)
Yeah, we've learned, we've learned a lot lessons from the standards, yearly flu vaccines, and that is that in nursing homes, for example, when the high risk population is elderly, in nursing homes with a higher percent of their staff vaccinated, there are less influenza like illnesses, and less deaths in those groups, by as much a 10% reduction in the absolute rate of death in those nursing homes. So that tells us that, that not getting vaccinated, is associated with more patient or resident death, and that's one of the reasons that people have been saying, it's time for us, as health care providers, to say, yes, we'll roll up our sleeve and get the shot, so that we provide that level of protection, which is what our patients expect.
(ANNE)
You know, in medicine, we take an oath, above all, do no harm. And I think it's sort of the least of it, as a health care worker, to protect yourself and those around you.
(PETER)
So, if I may paraphrase this, if you're a doctor, you're a nurse, you're a health care provider, suck it up. Get the vaccine.
(ANNE)
That's it.
(PETER)
You know, it goes with the territory. And what I've heard is, oh, it's okay. If I get sick, at the first sign of getting sick, I'll wear a mask. You're telling me that won't work either.
(LISA)
It's too late.
(PETER)
It's too late.
(BARBARA)
Too late.
(PETER)
So the folks out there in our audience who depend on the health care workers to guard their health, actually should expect us to be willing to take the vaccine.
(LISA)
And if you're a health care worker and you get sick, we want you to stay home. We don't want you to come in.
(PETER)
Why is this a common theme. Stay at home.
(MARK)
But there's one other thing about, we've talked about the fact that influenza has a range, that if you get influenza, it's a range from a small disease to a deadly disease, and everywhere in between. And that a number of people who are transmitted the virus, are having a very mild disease. So mild that, you know, it wouldn't even register. You wouldn't even think about staying home that day. Because it's that mild. And some of that is what we're preventing with the vaccine. Bringing, bringing that to be less common.
(PETER)
If I may, what you're, if I may, just rephrase that a bit. You may have a mild case of the disease. But the virus in someone else, specifically someone with a, with a diseased immune system, for example, that virus can do something entirely different to the person who catches it next.
(LISA)
Right, that's right.
(PETER)
So though you don't feel sick, it doesn't mean the next person won't die from it. Is that, is that fair?
(ANNE)
Yes.
(PETER)
All right, we have a question from the audience.
(AUDIENCE)
Hi, I'm Todd ((Grenair)), I live in Rochester, New York, father of a couple young boys. There's a lot of media hype, that's just scaring people, making them fearful they're going to catch something. It's changing the way we interact with each other. Is this flu really that bad?
(PETER)
Who wants this one? I mean, I've been alluding to it, why don't we just tackle it head on.
(BARBARA)
I don't, you know, I think there's, there's two questions there. One is, is it that bad, and the other is, are we changing some practices. So (( )), let's talk about changing some practices. The fact that people are being asked to wash their hands frequently. That's a good idea. And that's a practice that we should be promoting, we should have always been promoting it, and if this is an opportunity for us to sort of put out to the general public, that it's really important to, to do some things on a regular basis, like wash your hands, and cover your cough appropriately, and stay home, I, I don't think that's a bad idea. I also don't think it's a bad idea for us, when there is a lot of flu in your community. That could be your school or your business, to change some practices that may happen routinely. So I work a lot with the schools in my city, and I've suggested that we are going into what we predict will be a pretty significant flu season. And they should avoid unnecessary mixing of students. So if you don't need to cram all the students into the gym, for an activity, please don't. Not during the flu season. Now I don't think that's alarmist, I think that's saying, when there's a lot of flu in your community, change some practices that will help reduce transmission. You know, the same thing about putting hand sanitizer in lots of places. It's a good idea. It makes it easy for people to, in fact, frequently put some hand sanitizer on your hands, so that if you happen to touch or shake hands with a person who is infectious, you reduce the likelihood, you know, if you are using the hand sanitizer afterwards, of, of, you know, contaminating yourself of getting sick. So, you know, I know sometimes it does feel like we're alarming people, but some of this is really common sense. And practices that help us not just with flu, but with lots of other infectious diseases.
(PETER)
Are you alarmed, sir? Are you alarmed?
(AUDIENCE)
I'm not sure. That's, that's why I'm here, that's why I'm asking.
(PETER)
People around you alarmed?
(AUDIENCE)
There are people around me that are alarmed. There are also people that think it's hype.
(PETER)
But I guess the sense that I'm getting from you, is that this alarm, makes you uneasy.
(AUDIENCE)
Yes.
(PETER)
That the hype makes you uneasy. But if everybody got the answer you just got, you'd be a lot happier.
(AUDIENCE)
Absolutely.
(PETER)
Is that fair?
(AUDIENCE)
Yes.
(PETER)
What can we do, other than doing what we're doing right now, to put a damper on some of this, because I think he's right. I think people out there are pouring gasoline on this fire, and it may not be the right thing to do.
(LISA)
There's a really difficult balance, because a lot of what we need to do during a pandemic is about behavior change. Whether it's about staying home when we're sick, or about being interested in getting vaccinated if it's recommended for us. And motivation for behavior change actually needs accurate risk assessment. You kind of need to know, what's going to happen to me, what's going to happen to the people that I love. So we actually do have to talk about this, and ideally we can talk about it in a way that is balanced, that gives people the kind of information that helps them make good choices. But we can't sort of not talk about it, and have people ready to take the types of actions that will protect us as a community.
v (LISA)
Yeah, I think we need to operate, not in fear mode, but in awareness mode, and we just need to start utilizing some, some common sense. So now that all of you have been educated about what to do, you can pass that on to all your neighbors and friends. And you know, a lot of this is common sense. You know that you shouldn't text when you drive, but a lot of people do it. It's a common sense awareness thing.
(PETER)
Let's not even go there. But what I want to do is I want to go to, I want to go to college campuses, I mean, because, to some degree, there's enforced propinquity, in college campuses, and that, combined with the fact that we've already said that that's an age group which is susceptible to this virus, that's a recipe, I think, for viral spread.
(JANET)
That's right, and I think it's a reason why most college campuses around the country, I think, have really been working on this issue, and preparing for quite a while, with the expectation that there would probably be a fair amount of, of any kind of pandemic flu in a college campus setting. And because this virus is mild enough that universities really should be continuing to operate, we've wanted to put into place some of the things that we've been thinking about. And one of the nice things about most colleges is that they have college health services, so they can really operate, as a small village, with an extension of the public health system, that is in other areas. So the health services work both to deliver care and to help think about some of the public health messages.
(PETER)
You know, in terms of not just colleges, but lower schools. In New York, I know there are some schools where the principal or the headmistress greets every child on the way in with a handshake. That looks like it's stopped. They're doing the, what, the elbow rub. Does that make sense?
(LISA)
That makes a lot of sense.
(PETER)
It does, does it. What about employers? People are going to be home with this disease, and people are going to be home helping people who are disabled with this disease. Have we seen around the country, employers being sympathetic to this, or not.
(BARBARA)
You know, I think, you know, our mayor actually brought together all the businesses in the city of Boston, and he asked them to do two things. One is, to think about their HR policies, and think about making sure that their policies allowed people who were sick to stay home without penalty, and with pay, and to allow people who needed to care for children who were sick, to stay home without penalty and with pay. He also said, you know, businesses need to make it easy for people to get vaccinated. You know, so he instituted for all city workers, a two-hour leave policy, paid leave policy, so that people would go and get vaccinated, or get their family members vaccinated. So I think there's a huge role that employers can play, and supporting all our efforts to really limit transmission.
(PETER)
Okay, I'm going to leave, we've got almost no time left. But I can't leave without one question that somebody asked me. Knowing that I was coming here, which was, we know the flu virus mutates. We know that seasonal flu mutates. Swine flu. H1N1. When's it going to mutate, will this vaccine we're getting work forever, or are we going to need another one. And you've got about, oh, 30 seconds. Who wants this.
(MARK)
That fact that it's been a vaccine that's been, the virus is circulating and it's based on a virus that was present just a short while ago, means it should be a better match. But we also know that the influenza virus changes a little bit every year, and so we are likely to have to have to address the slight changes on a regular basis.
(PETER)
Slight changes, coming up, coming soon to a theater near you, and we don't have time for any more comments. But thank you all so, so much for being here. That is all the time we have. This has been just a great conversation. Let's sum up a few things. H1N1 is a new strain of flu, and everybody is working on this problem to try to find a path to the right answer, and you have a role to play as well. You need to consider what is right for you, what is right for your family. You need to discuss this with your doctor. One takeaway message, Lisa, you gave it right is, stay home. Many thanks to all of our panel members, our audience members who asked the questions. I'm Dr. Peter Salgo. Thanks for watching to you all. Thanks for listening. We'll see you.
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