Dr. Michael Gardam in a lab at UHN in Toronto, August 29, 2007.Ryan Carter
The following discussion was originally published on Oct. 23, 2009 and was conducted live from 1-2 p.m. ET. It has been edited for clarity and to better help answer your questions on swine flu/H1N1. Read the transcript from the original discussion here.
Caroline Alphonso: Welcome everyone to our H1N1 discussion with Dr. Michael Gardam of the Ontario Agency of Health Protection and Promotion. Health Canada approved the vaccine on Wednesday, and local public health authorities are embarking on mass vaccination clinics starting the week of Oct. 25 across the country. This is the country's largest immunization campaign.
The following questions were posed to Dr. Gardam from readers.
Q: Do you as a doctor feel safe taking the H1N1 flu shot? I mean the Canadian studies aren't even done yet! I for one won't be taking the shot!
A: I actually had planned to get my shot this morning but our hospital hasn't received it yet--hopefully I can get it Monday. This vaccine is like any other vaccine or drug -- we don't need Canadian studies to say that they are safe and effective. The data for this vaccine come from Europe. The Canadian studies are more about fine tuning the vaccination process...
Q: My son is 3 1/2, recently had an asthma attack for first time, should he get the vaccine with or without the adjuvant?
A: I think your son should get the adjuvanted vaccine. Here is why: He is in the age group that is likely to get infected; he has asthma which is a risk factor for more severe flu; the adjuvanted vaccine gives a better immune response than the unadjuvanted vaccine (it works better); and it is available now, whereas the unadjuvanted vaccine won't be available for awhile.
Q: My son has epilepsy and everything that I read leads me to agree that he needs the vaccine. I am nervous, however, as you hear so many conflicting reports regarding the safety of the vaccine. I have always believed in vaccination, but this time I am very worried. What are your take on the safety of this vaccine?
A: The reality is that there really are not any credible reports about any safety issues with the vaccine. we have been giving flu shots for decades ... this is just another flu shot. The only difference is the adjuvant, which has been used in millions of people around the world. The adjuvant is made up of two natural fats: vitamin E and squalene which is a molecule your body makes (the squalene in the vaccine comes from fish oil). I'm giving it to my kids without any worries.
Q: I have just received innoculation for the seasonal flu. ... when should I receive the HiNI flu shot ? I am over 65 years of age?
A: There is no reason why you can't get the H1N1 vaccine as well. The good news is you are more likely than someone under-65 to already have protective immunity to H1N1 (so you are less likely to get infected), but if you do get infected, you have a higher risk than someone younger of ending up really sick. So bottom line, I would get it.
Q: I am over 65 and am a doctor. Should I get the H1N1 shot first, wait for a while and then get the regular flu shot? Or the other way round? or both together? Is it necessary to wait a specified period of time between the two flu shots?
A: You can get both shots at the same time, one in each arm.
Q: Myself and two of my children have already had the flu this season (we're in Vancouver and our school has been hit hard). We don't know for sure if it was H1N1, but it likely was. Do we still need to be vacinated?
A: Eventhough we had a peak of flu last spring going into the summer, the reality is that the majority of people who had symptoms during that time did not have H1N1 - there were other viruses circulating in the community at that time. Certainly if you had a positive test for H1N1 I don't think you need to run out and get vaccinated, but otherwise, the odds are you didn't have H1N1.
Q: There is so much controversy about the vaccine - in fact, several friends' doctors advised them not to get the vaccine for themselves or their young children. I am surprised at this but don't know why their doctors are advising that. It makes me even more nervous to hear that and even though my own doctor advised me to get the vaccine, I am confused. What are people afraid of?
A: As sad as it is for me to type this, not all doctors know what they are talking about. Much of our education has actually been aimed at doctors to make sure that they have the facts straight. There is almost no reason why somebody shouldn't get vaccinated ... it all comes down to whether you want to prevent yourself from getting the flu.
Q: I'm running the New York marathon on Nov. 1st. What, if any, are the possible down sides of getting the vaccine so close to race day? Should I just wait until I return to get my vaccination?
A: I love the marathon question, being crazy enough to do that kind of running myself. I definitely would get the vaccine. You don't want to be coughing up a lung on race day. You are going to be miserable enough as it is. Hope you get a PR.
Q: Have clinical studies showed any negative effects to getting the H1N1 vaccine?
A: There are studies and lots and lots of experience with components of this vaccine in millions of people that all say this vaccine is safe. There are no data saying it isn't safe.
Q: I'm concerned about the adjuvant squaline that is being added to the vaccine. This is the same substance that was added to the anthrax vaccine and was implicated in causing Gulf War Syndrome in American soldiers. I've heard people say this theory has been debunked, but I continue to hear evidence to the contrary.
A: I am glad you brought this up. If squalene is a problem, then we are all in trouble as we are all making it in our livers right now. It is a natural compound produced by your body. And the anthrax vaccine story is wrong. There was no squalene in that vaccine and it has never been scientifically linked to Gulf War syndrome. When people get sick they look for something to blame and vaccines seem to make a nice, easy target.
Q: Could you please talk about pregnant women? I understand the numbers in terms of risk of contracting the illness, but not in terms of getting seriously ill. Scary news stories have covered women dying/losing their babies who have underlying conditions/are smokers, etc. (mostly glossing over those facts), but what are the risks of getting really sick as a regular, healthy pregnant woman? And what are those risks vs the risks of getting the vaccine?
A: The risk of a pregnant woman contracting flu is the same as a non-pregnant woman. The risk of a pregnant woman getting really sick and potentially dying from flu is about 4-5 fold higher though. This has been shown consistently throughout this pandemic in multiple countries. The absolute risk of getting really sick though is still very small even if you are pregnant. I can't give you an exact numbers because that kind of data is not yet available.
Think of it this way: There is a small but documented risk of serious disease if you are pregnant, and serious disease is definitely a risk to your fetus. On the other hand, there is no evidence that any component of this vaccine is harmful to your fetus.
Q: My family has been sick but we were not tested. I realize testing everyone is time consuming and expensive but if I knew that I have already had, and survived, the swine flu I could then stop worrying for the rest of the winter (I worry about my kids as one has asthma and I have emphsyma) and my vaccine could go to some other person or country that may be short vaccines so in that sense why is testing not done on all people that show all the signs?
A: Lots of people want to know if they have had this already. The problem is there is no good routine lab test to figure that out. We can look for antibodies but this is only done in a small number of research labs and the test is not that good...and this is not unique to Canada; all labs are having the same issue.
Q: Dr. Gardam, I have a question that isn't related to vaccinations. I understand that complications from H1N1 is highest in certain vulnerable groups (e.g. immunocompromised) but there was recently a story about the young and healthy woman from B.C. who died from H1N1. Are you able to comment on this?
A: Yes a fair percentage of people who have died from H1N1 around the world have had no identifiable risk factors.
Q: Is it true the H1N1 flu vaccine is still being tested on the public? Is it true that tests do not mean the future side effect are known? Would it be better for a person over 65 to just have the regular flu shot than take a gamble on future problems from the H1N1 flu vaccine?? Lots of people do not trust this vaccine!
A: This vaccine is being treated like any other vaccine. One cannot do studies of millions of people before licensing so there is what we call post licensing surveillance where people report in very rare side effects.
Q: I am breastfeeding a three month old and considering getting the vaccine so that I don't get H1N1 and pass it to my baby and toddler (or be too sick to properly take care of them). However, I'm concerned that in the few days after I get the vaccine, my breastmilk will contain too much of the vaccine for my baby. I'm also concerned about the adjuvant. I know they have no clinical results for adjuvants in pregnant women but do they have clinical results to show it is safe in breastfeeding women? Should I dump my breastmilk for a few days after the vaccine or avoid getting the vaccine altogether since I will be breastfeeding?
A: No significant amounts of the vaccine will get into breast milk. And again, the adjuvant is vitamin E and squalene - your child is already producing squalene naturally. It is definitely a good idea for you to do as you say - get vaccinated to protect your baby.
Q: What is the age cut off for needing 2 shots of H1N1 instead of just one in children?
A: Kids six months to nine years old should get two half dose shots. This dosing schedule may be modified as additional trial information becomes available.
Q: "There is almost no reason why somebody shouldn't get vaccinated, it all comes down to whether you want to prevent yourself from getting the flu." Don't mind getting the flu - what I'd like to avoid is two weeks in a heart/lung machine and/or death. I think that's the issue for many. Getting sick occasionally isn't a big deal. Dying or killing someone else IS.
A: Yes you are right, nobody wants to get really sick from this. It is important for people to be aware that the risk of serious illness if you are otherwise healthy is small, but not zero.
Q: Why does the Globe continue to call this the Swine Flu instead of H1N1... continuing to use this term. only further damages our pork industry.
A: The term swine flu is common parlance. It was originally called swine flu by the World Health Organization. We make sure we refer to it as H1N1 as well. It is important that are stories be readable and accessible to the public, not overloaded with jargon.
Q: If a 65+ person has been vaccinated as early as this month with the seasonal flu vaccine. Do they need to be re-vaccinated again in the spring as their immunity tends to wears out after a few months?
A: You will likely be OK if you got your shot recently, you shouldn't need to be revaccinated this spring. Keep tuned to the public health advice this spring in case something changes
Q: What's the preservative that they're using in the vaccine?
A: The preservative in the vaccine is thimerosol. This is another one of those molecules that people get worried about, because it contains mercury. The amount of mercury in a typical vaccine is the same as in less than in a can of tuna. Thimerosol has NEVER been credibly linked to any health problems, including autism, this is despite researchers trying very very hard to find a link.
Q: Is the nasal spray safer for children and is it available in Ontario?
A: The nasal spray is not available in Canada.
Q: Should I be concerned about GBS? Also why can children under 6 months not get the vaccine for H1N1?
A: Six month olds aren't vaccinated because it doesn't work, their immune system is too young to respond to the vaccine. That is why we recommend those around them get vaccinated.
GBS (Guillan Barre syndrome) was associated with the swine flu vaccine in 1976 and never since. An association does not mean that it was caused by the vaccine, only that they were associated (like saying that umbrellas are associated with rain, doesn't mean they cause rain). The association that year was a possible increase of 1 case per 100 000 people vaccinated. Please note:
- that is pretty small;
- the risk of getting GBS from having natural flu infection is greater than that;
- the risk of serious complications from the flu is much greater than that; and
- Most cases of GBS are actually caused by infections including food poisoning. So GBS, like the adjuvant and thimerosol, are red herrings.
Q: There is a lot of criticism that the media is scare-mongering and confusing the public about H1N1. As a senior public health offiicial what do you think about what you read in the paper and see on TV. Is it confusing?
A: In general, I don't think there has been scare-mongering. Most of the coverage I have seen has been just fine. I think the biggest problem we have all faced is that flu is very very confusing, shows up in different ways and different places, and we are always looking for more information to better understand what might happen. This uncertainty means that you will see some variation in reports and that can be confusing.
Q: My wife is pregnant, and we're confused about the H1N1 vaccine. Would you recommend she get the vaccine available in Toronto next week, or should she wait for the adjuvant-free version? (We were surprised when her midwife suggested she go ahead and get the version available next week.) Also, which one should our two-year-old son get?
A: I understand your confusion Re: which vaccine for your wife. The current recommendation is that if she is less than 20 weeks and otherwise healthy, she can probably wait if she wants to get the non-adjuvanted vaccine - this is because the first trimester of pregnancy is not at increased risk of severe disease - not because of safety concerns with the adjuvanted vaccine.
If she is more than 20 weeks or less than 20 weeks with underlying medical problems I think it makes the most sense to get the adjuvanted vaccine now so that she is protected as soon as possible as the country is just heading into its fall wave of flu right now.
Q: I would really like to know about masks -- why aren't Canadians wearing them on a daily basis in public?
A: Katie, surprisingly we have no data on how well masks work when worn by the general public. I think it makes sense if you are sick and coughing, and have to go out, that you wear a mask.....but nobody knows how much others wearing masks around you will protect them. We wear them (or respirators) in healthcare but also stress hand washing and may wear glowns, gloves and eye protection as well.
Bottom line, I have no problem with people doing that if they want, I just don't know how much it will help. I personally don't wear a mask on the subway but I definitely wash my hands a lot.
Q: With three family members who have died from three different autoimmune diseases, and many living with other autoimmune diseases, I'm concerned the adjuvant may trigger an underlying autoimmune disease. Can you comment on this?
A: This is a very tricky question that is currently being discussed and I suggest that people with serious autoimmune diseases such as lupus should talk to their immunologists about it. Again, one would have to weigh that theoretical risk versus the real risk that someone with severe autoimmune diseases is going to be at increased risk for getting bad disease from the flu.
Q: It was rather difficult to get the death rate attributed to influenza. Would you know it. This is for people worrying about neurological complication of 1 in a million. However hard to argue when you dont' t know the complication rate and death rate for influenza.
A: We don't know the actual risk of death per people infected because we don't have a good handle on the number of people infected. This is a problem all over the world because you just can't test everybody. Many people with flu won't even seek healthcare.
The estimates I have seen of the risk of serious disease, especially in people with underlying illnesses is certainly greater than the risk of serious adverse events from the flu shot.
Q: I'm a nurse and required to get a flu shot every year and I'm wondering what the cumulative effect that thimerosol will have if I'm taking one, or in this case, two flu shots per year.
A: There isn't a lot of thimerosol in the vaccine as I mentioned before, you are exposed to many many fold more mercury just by living in a industrialized country. Also, if your previous flu shots were given from single preloaded syringes, there was no thimerosol in the vaccine (it is only put in multidose vials). I've had at least 15 seasonal flu shots so I am right there with you.
Q: Can you clarify the situation with egg allergy as an absolute contraindication for the H1N1 vaccine? If you have a positive response to egg antigen with skin testing, but no symptoms at all when you eat eggs, can you have the vaccine?
A: The only time we worry about egg allergies is if someone has had true anaphylaxis to eggs (difficulty breathing, asthma, facial swelling etc.).
Q: How long does it take for the vaccine to provide immunity/to reach full effectiveness?
A: It takes about 10-14 days to develop immunity post vaccine. It may be a bit quicker with the adjuvanted vaccine because it works so well.
Q: I'm generally healthy and getting by the flu season fine without any flu shots in the past. But my boyfriend and I will go to Mexico for a week in mid November. Would that be an added motive for us to get the shot, or this virus has no particular correlation with Mexico any more? We are both in our early 30s.
A: There really isn't a link to Mexico anymore. I would just get it in the off chance you get flu while down there and it screws up your holiday. Nothing worse than sitting on the beach hacking up a lung.
Q: I have heard that in our Ontario hospitals, few people have died because of the vaccine, so everyone is pretty freaked out. Have you heard any of that?
A: Nobody has died because of the vaccine. But many people have died from H1N1 before the vaccine was available.
Q: Some people believe that taking the flu shot every year for the "run of the mill flu" defeats the purpose of building up the body's natural immunity. This year maybe people like that are thinking "I don't want to die from the big one, so I better get a shot this year". Is it fair to say this kind of thinking misses the fact that getting a shot every year has the same affect of building up immunity?
A: Yes you are correct. Getting a shot is the same thing as getting the flu in terms of developing immunity, only with the shot, you don't have to go through actually getting sick. which is one of the main reasons why I get it every year.