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Andre Picard (John Morstad)
Andre Picard (John Morstad)

Ask André Picard

Your H1N1 vaccine questions answered Add to ...

The Globe and Mail's public health reporter, André Picard, tries to clear up the "conflusion" on the H1N1 vaccine and who should get the shot. Mr. Picard has also answered your questions on the the virus itself and questions from parents.

Please note that this information is not medical advice. Rather, it is an attempt to synthesize and explain in plain language information from public health officials and medical experts.

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Q: Is there a vaccine for H1N1?

A: In Canada, there are actually two versions of H1N1 vaccine: an adjuvanted vaccine that has the brand name Arepanrix and a vaccine without adjuvants. The Public Health Agency of Canada has ordered 50.4 million doses, 1.8 million of them non-adjuvanted. Massive inoculation campaigns are now underway.

Q: There are 34 million Canadians, so why did we order 50 million doses?

A: Fifty million doses is the equivalent of two doses for 75 per cent of the population. Initially, it was believed two doses of the vaccine would be required to produce immunity, and it takes about six months to produce the vaccine. In the interim, research showed that one dose was sufficient to provide immunity. Excess stock will go to developing countries that cannot afford the H1N1 vaccine.

Q: Was the government only planning to immunize 75 per cent of the population?

A: While public health officials say repeatedly that everyone should be immunized, realistically, they know that many (if not most) Canadians will not get immunized. Only about one-third of people get the seasonal flu vaccine and a recent poll showed that approximately the same number plan to get the H1N1 vaccine. In the U.S., however, interest in the vaccine was tepid until a lot of people started getting sick. In and the U.S. were are seeing the same trend: A stampede to vaccine clinics.

Q: The government says six million doses of vaccine were delivered but there seem to be shortages everywhere. Who actually received the vaccine?

A: Here is the breakdown of the number of vaccines delivered to each jurisdiction as of Oct. 31. The distribution is roughly per capita, with the exception of employees of the federal government. The provinces and territories (and federal departments) are then responsible for redistributing the product.

Province, Territory or jurisdiction

# of vaccines distributed

Newfoundland and Labrador

86,000

Prince Edward Island

29,000

Nova Scotia

160,000

New Brunswick

129,000

Quebec

1,331,000

Ontario

2,249,500

Manitoba

206,000

Saskatchewan

173,000

Alberta

622,000

British Columbia

818,000

Nunavut

22,000

Northwest Territories

34,000

Yukon

24,000

Foreign Affairs

15,000

National Defence

75,500

RCMP

62,000

Q: In the end, how many Canadians actually received the H1N1 vaccine?

A: As of mid-December, almost 15 million doses of vaccine had been distributed, meaning about 40 per cent of the population was vaccinated. Canada has one of the highest H1N1 vaccination rates in the world.

Q: Is the flu vaccine free?

A: The H1N1 vaccine is offered to all Canadians free of charge. For seasonal flu, the rules vary from province-to-province. Virtually every province offers the vaccine gratis to members of high-risk groups like seniors, but charge a minimal fee to others. (Those fees are often covered by employers and insurers.)

Q: How does the vaccine work?

A: The vaccine contains antigens that trick the immune system into thinking it is being attacked by the H1N1 virus so it produces antibodies. It takes about a week for immunity to develop after vaccination.

Q: Does that mean I can get the flu from the flu shot?

A: No. The vaccine does not contain live virus so you cannot contract influenza from it.

Q: I really don't like needles. Is there any other way to get vaccinated?

A: In the U.S., some vaccination is done with a nasal spray called FluMist. The product is not (yet) available in Canada.

Q: What's an adjuvant?

A: An adjuvant is a substance used to bolster the antigens in the vaccine; an adjuvant was used in the H1N1 vaccine because of fears that manufacturers would not be able to harvest sufficient stocks from eggs to make antigen. The adjuvanted vaccine, Arepanrix, contains 3.75 micrograms of antigen; the non-adjuvanted version has 15 micrograms of antigen.

Q: What's in the adjuvant?

A: The product from GlaxoSmithKline, Canada's sole provider of H1N1 vaccine, called Arepanrix, uses an adjuvant called AS03, which consists of squalene (shark liver oil), DL-alpha-tocopherol (vitamin E) and polysorbate 80 (an emulsifier also used in ice cream). There are claims about the dangers of squalene but very little evidence to back them up. For example, it is claimed that the adjuvant used in the anthrax vaccine was to blame for Gulf War syndrome, but there was not adjuvant in that vaccine.



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Q: This is a new, experimental vaccine. Has it been properly tested?

A: The H1N1 vaccine is similar to past flu vaccines, which have a good safety record. New versions of the flu vaccine do not require new human trials each year. The controversial aspect of Arepanrix is the adjuvant. While adjuvants have been used in vaccines for some time, AS03 has undergone limited safety testing. Health Canada insists that there have been no shortcuts taken in the approval process for the vaccine.

Q: What do you mean by limited safety testing?

A: Approximately 45,000 people have received a flu vaccine containing AS03 but that was a vaccine designed to protect against H5N1 (avian influenza) not H1N1. A similar adjuvant, MF59, has been used in about 40 million vaccinations in Europe.

Q: Is H1N1 vaccine safe?

A: Like every drug, the H1N1 vaccine has benefits and risks. The benefit is that it can prevent infection with swine flu - though the protection is not 100 per cent. The risks for most people are minimal, some redness and maybe a slight fever but in rare cases, there can be serious complications like Guillain-Barré syndrome. But those risks are not unique to this vaccine. And bear in mind that vaccines are among the safest drugs on the market.

Q: Isn't there mercury in the vaccine?

A: Flu vaccine is packaged in vials that contain multiple doses; to avoid contamination, a mercury-based preservative called thimerosal is added. One dose of vaccine contains about 5 micrograms of mercury; a tuna sandwich contains about 25 micrograms of mercury. There are persistent claims that mercury in vaccines causes autism but this has been debunked.

Q: Should pregnant women get the H1N1 vaccine?

A: Pregnant women, whose immune systems are suppressed, are at high risk of complications from the flu. Therefore, it is recommended that they be the first in line to get the H1N1 vaccine. The H1N1 vaccine that is recommended for pregnant women does not contain adjuvants.

Q: If adjuvants are safe, then why the exception for pregnant women?

A: The short answer is that there is no safety data related to pregnant women, so officials are erring on the side of caution. The World Health Organization says pregnant women should get non-adjuvanted vaccine where possible, but that an adjuvanted vaccine could be used if necessary.

Q: Is it true there is no non-adjuvanted vaccine available? In that case what should a pregnant woman do?

A: The federal government has purchased some non-adjuvanted vaccine from Australia and it is waiting for a Canadian-made version to come out of production in a few weeks. But none is yet available. As the risks are greater for women who are further along in their pregnancy, those in the third trimester should get the adjuvanted vaccine, and as soon as possible. Women in their first and second trimester can choose to wait or get the vaccine that is available now. The risk of adjuvants is theoretical. The risk of the flu is real.

Q: Is there anyone who should not get the vaccine?

A : Anyone with a severe allergy to egg proteins (egg and egg-based products), chicken protein or any of the constituent parts should not get the vaccine. Those other ingredients include thimerosal, sodium chloride, disodium hydrogen phosphate, potassium dihydrogen phosphate, potassium chloride, and trace amounts of formaldehyde, sodium deoxycholate and sucrose. People with latex allergy should also tell clinic personnel, who often wear latex gloves. People who cannot get the vaccine can take antivirals like Tamiflu as a preventive measure.

Q: Is there an egg-free version of H1N1 available for those with allergies?

A: There is no egg-free version of the vaccine available in Canada.

Q: Does the vaccine offer the same protection to everyone?

A: No, people's immune systems are not all identical so the body can take varying amounts of time to produce an antibody response. But usually the vaccine will offer protection within a week or so. However, it should be noted that people whose immune system is weak or compromised may not produce as good a response (meaning they have less protection against the H1N1). These include people being treated with chemotherapy for cancer, people with HIV-AIDS, people treated with certain medications.

Q: There is an article in The Atlantic magazine that suggests the H1N1 vaccine doesn't work. Is that true?

A: The article in The Atlantic underscores an important paradox: Flu vaccines (including H1N1) offer the least protection to those who are most vulnerable to complications - those with chronic health conditions. And they work best in people who are already healthy. Another key question raised by the article is: Does vaccinating everyone actually reduce the death rate? Some research suggests that vaccinating widely reduces the death rate by half; other research suggests the impact on the death rate is virtually nil.

Q: You said earlier that people who take inhaled steroids should not get the vaccine?

A: That was an error and the information was removed promptly - though apparently not promptly enough. (This item is updated regularly because information changes.) To be clear: People who take large quantities of inhaled corticosteroids may see have a compromised immune system but they can receive the vaccine, which contains no live virus. People who are immunosuppressed should not take the inhaled version of the vaccine because it contains live virus.

Q: I am allergic to seafood and fish and I read that the vaccine contains shark liver oil. Am I safe?

A: It is recommended that anyone who has had an anaphylactic reaction consult a physician (preferably an allergist) before getting the shot. It would be inappropriate to offer up individual medical advice in an article of this sort, which is designed to provide general information.

Q: Has anyone had an allergic reaction to the vaccine?

A: As of late November, the Public Health Agency of Canada reported 24 cases of severe allergic reaction in people who received the H1N1 vaccine. That is a rate of 0.32 cases of anaphylaxis per 100,000 doses. That is actually lower that the anticipated rate of one case per 100,000. Again, anyone with a severe allergy should notify clinic staff before getting the shot.

Q: I suffer from Crohn's and am taking Humira, which is a powerful immunosuppressant drug. No one wants to stand up and say whether a person with an autoimmune disease like myself should or could have the H1N1 shot.

A: It would be irresponsible to answer such a specific question on a general information site like this one. But to repeat earlier answers: The H1N1 vaccine does not contain live virus so it does not pose a risk of disease to those who are immunocompromised; however, people with suppressed immune systems do not always produce a strong response to vaccines, so it may not be as effective.

Q: Is it true that the non-adjuvanted vaccine given to pregnant women contains 10 times more mercury (thimerosal)?

A: Yes, the unadjuvanted vaccine does contain 50 micrograms of thimerosal while the adjuvanted vaccine has five micrograms

Q: Is H1N1 vaccine mandatory for anyone like doctors or nurses?

A: No, there is no mandatory influenza vaccination in Canada. However, health professionals are a priority group for getting the vaccine. it has been argued that health-care professionals in particular have a moral duty to get vaccinated (not to mention a practical reason) because they are in regular contact with both patients who have influenza and patients who are at greatest risk of severe complications. Vaccinations rates among health professionals vary wildly among institutions; some have a culture of vaccination and some do not.

Q: Should I get the vaccine if I've already had the flu?

A: If you had a laboratory-confirmed case of H1N1, there is no need to be vaccinated. However, bear in mind that only about one-third of people who say they have had the flu actually had influenza.

Q: What if you are positive you had the H1N1 flu, but it was not confirmed, and you get the shot, -- will there be any side effects.

A: If you have already had H1N1 and you get the vaccine the side effects will be exactly the same as if you never had the disease, meaning you will probably have a bit of soreness at the point of injection. But there is no danger in getting the vaccine if you have already had H1N1 influenza.

Q: If I get the H1N1 vaccine do I also need to get the seasonal flu vaccine?

A: The jury is still out on that question but the answer is probably. Right now H1N1 is the predominant strain of influenza circulating in Canada so seasonal flu may come along later, or not at all. However, frail seniors, particularly if they are living in an institutional setting, should get the seasonal flu vaccine. Some provinces are offering seasonal flu vaccine at the same time as H1N1; others are not.

Q: How is the seasonal vaccine different from the H1N1 vaccine?

A: The seasonal flu vaccine, brand name Fluviral, contains three strains each year. In 2009-10 those strains are A/Brisbane (H1N1), A/Brisbane (H3N2) and B/Brisbane. Please note that the A/Brisbane (H1N1) is not at all the same as the pandemic strain, which is A/California (H1N1).

Q: I've heard that the flu vaccine really hurts. Is that true?

A: It is well documented that vaccines that contain adjuvants hurt more than those that do not. So, yes, you can expect that the H1N1 vaccine will be more painful than seasonal flu vaccine. But remember, the flu itself is a lot more painful.

Q: I read that people who have had the seasonal flu shot are at greater risk of getting H1N1 so shouldn't I avoid the regular flu shot this year?

A: A study did indeed show that, among those infected with H1N1, more had been vaccinated against the seasonal flu in the past than had not. But the past vaccines did not cause them to be more at risk. Rather, it is an association. The reality is that people at highest risk of getting the flu - frail elderly, those with chronic illnesses - are most likely to get the flu shot each year. And they, particularly those with underlying illnesses like chronic obstructive pulmonary disorder and asthma, remain at very high risk.

Q: I'm worried about H1N1. Where can I get the vaccine?

A: The entire stock of H1N1 vaccine was purchased by the federal government and it is being distributed to the provinces. There are clinics around the country and but you need to check with your local health region or provincial telehealth line for details. As you will know from news reports, the lines can be frustratingly long.

Q: Can I avoid the lines by going to my doctor?

A: To date, vaccine has not been distributed to individual physicians in all provinces, though that will likely change. Even in normal circumstances, many doctors do not keep flu vaccine in their offices because it requires refrigeration and a pretty short shelf life. The H1N1 vaccine also needs to be mixed, which is a bother.

Q: You can't vaccinate all Canadians at the same time. So is there a priority list?

A: It is recommended that the following groups get the vaccine first because they are at higher risk of complications if they get sick:

  • People under 65 with chronic health conditions;
  • Pregnant women
  • Children aged six months to five years of age;
  • People living in remote and isolated communities, particularly First Nations;
  • Front-line health workers;
  • Care providers to those at high-risk.

Next in line should be:

  • Children/youth aged 5-18;
  • First responders like firefighters and police;
  • Poultry and swine workers;
  • Adults aged 19-64;
  • Adults 65 and older.

To date, public health officials have politely asked that people respect these priority lists but, with shortages growing worse, the priority lists will likely be enforced more strictly in coming weeks.

Q: If I get the vaccine can I still get the flu?

A: Influenza vaccines are not 100 per cent effective so, yes, it is possible. However, chances are the symptoms will be more mild. Getting the H1N1 vaccine does not mean you will not get sick this winter; there are other strains of flu and numerous other viruses and bacteria that circulate.

Q: I'm pretty sure my daughter has the flu. Can I give her cough syrup?

A: There is very little evidence that over-the-counter cough syrups, cough drops and cold and flu medicines are of any benefit. In children, these products can actually be dangerous. The best treatment for a cough is hydration, so if you are sick sip water and chicken soup.

Q: My child is complaining about achiness - can I give my child Tylenol or baby Aspirin for the pain?

A: Children under the age of 18 should never be given ASA (Aspirin and similar products) because it can cause a rare but deadly condition called Reye's syndrome. So-called baby Aspirin is not a product for children, it is a low-dose product for adults. Tylenol (acetaminophen), Advil (ibuprofen) and similar products can be used to treat pain. But recent research has suggested that Tylenol can pose risks to children with asthma and allergies. In all instances, it wise to consult a pediatrician before giving medication - especially a new medication - to a child.

Q: I read that the 13-year-old child who died of H1N1 had taken fever reducers. Are they dangerous?

A: Products like Tylenol, Advil and concoctions that contain these drugs can be used to treat pain and reduce fever. The danger is not necessarily the product per se but that they can mask symptoms and create a false sense of security. Fever, in itself, is not dangerous unless a child's temperate is extremely high. However, some research suggests that artificially lowering fever can reduce the immune response, prolong illness and actually endanger children. As a result, some countries like Japan, say that fever reducers should never be used in children.

Q: What about babies?

A: Babies under the age of six months should not get the H1N1 vaccine. Some public health officials believe that children under age of three should get non-adjuvanted vaccine. But parents, siblings and caregivers of very young children should get the vaccine to minimize the risk of infecting the baby.

Q: My three-year-old daughter got the flu two weeks ago. The doctor said it was H1N1 but it was not confirmed because the region doesn't do routine testing. My husband and I did not get sick. How can this be? We took no special precautions. Now we're wondering: Should we get the vaccine or are we immune to this flu?

A: You have raised several interesting issues related to H1N1 and vaccination. First, about 90 per cent of all the flu cases in Canada today are caused H1N1. There is very little seasonal flu so far. That's why doctors assume that cases of the flu are H1N1. Testing everyone is not considered a good use of resources.

Second, there is a common assumption that everyone exposed to the H1N1 virus will get the flu. In fact, the large majority of people exposed to the virus will not get sick.

Even though you were in close contact with someone sick with swine flu, healthy young adults like yourselves have powerful immune systems that fight off a constant barrage of pathogens. When you are exposed to a virus, your body will produce antigens and develop immune resistance. In some people, this happens with very few disease symptoms; others will get quite sick. A vaccine does the same thing by tricking the body into thinking it is being exposed the virus.

Many people argue that there is no need to be vaccinated, that we should depend on our immune systems and bolster them with good nutrition. That is a bit of a gamble.

With H1N1, a new strain, it is anticipated that about one-third of the population will get sick. To date, it is estimated that about five per cent of Canadians have fallen ill with H1N1, so a lot more sick people are expected in the coming months.

While it is true that most cases of the flu are "self-limiting" - meaning you get better with rest and fluids, in rare instances people can get gravely ill and die. Again, the risk of complications is greatest in those with weaker immune systems - babies, children, people with chronic health conditions - but some healthy people will get severe illness.

So far in Canada, 1,779 people have been hospitalized with H1N1, including 351 who ended up in intensive care and required ventilators. There have been 92 confirmed deaths.

That is why public health officials recommend that everyone by vaccinated unless they had a laboratory-confirmed case of H1N1. That would include you and your daughter. Even if you have immunity to H1N1, the vaccine will do no harm.

Q: In the online posts, many comments suggest that journalists like yourself are queue-jumpers who use their insider knowledge to get the vaccine. Are you brave enough to answer honestly?

A: I am in the risk category healthy adults aged 18-65. I live in Montreal. I am eligible to receive the H1N1 vaccine after Dec. 7, and so I will get my shot some time after that date. Then I will get my seasonal flu vaccine.

Q: Why aren't teachers and daycare workers considered "high-priority" for the H1N1 vaccine? Teachers are in daily contact with children (and sick children). Also, many teachers are in their childbearing years and lots of them get pregnant. I don't understand why teachers aren't at the front of the line for vaccination.

A: When outbreaks of infectious disease occur, schools and daycare centres are invariably among the places hit first and hardest. Children are virtual microbe-spreading machines and teachers know this well - they tend to get every bug out there. By virtue of being in contact with large groups of children, teachers at relatively high risk of contracting H1N1.

However, the priority groups for vaccination are not those at highest risk of contracting the disease, but those at highest risk of suffering complications and dying if they are infected. This in an important distinction.

The priority groups are:

  • People under 65 with chronic health conditions;
  • Pregnant women;
  • Children aged six months to five years of age;
  • People living in remote and isolated communities, particularly First Nations;
  • Front-line health workers;
  • Care providers to those at high-risk.

As you can see, pregnant women (including teachers) are a high priority for the vaccine. Some jurisdictions, like Quebec, are also urging all pregnant teachers, daycare workers and health professionals to take "preventive early maternity leave" to lessen their risk of contracting H1N1 influenza.

Daycare workers who care for children under the age of six months are a high-priority group and should be vaccinated. Daycare workers and teachers of children aged six months to five years, as well as those care for or teach children with chronic health conditions like cystic fibrosis are also considered a high-priority group in most jurisdictions though there are varying interpretations of what the term "care provider to those at high-risk" means.

So, while not all teachers and daycare workers are at the front of the line for vaccination, some of them should be.

Many have wondered why front-line health-care workers are considered high priority and teachers are not. After all, nurses and doctors are not at higher risk of complications and dying if they are infected. There are two reasons: 1) Front-line health-care workers treat a lot of high-risk patients and could put those patients at grave risk if they passed on the flu bug; 2) They are needed to treat people who are sick with the flu (and other conditions), particularly if there is a pandemic that causes widespread illness. Put crudely, a sick nurse would cause a lot more sickness and social disruption than a sick teacher.

Q: There is a lot of talk of the risk of H1N1 to children. Can you tell me how many children have actually died? And were they all healthy? Also, how does that compare to a regular flu season?

A: As of Oct. 24, there have been 100 deaths from H1N1 in Canada, including six deaths in children 15 and under (that is seven per cent of the total). Only one of the children who died had an underlying health condition. By comparison, among adults, 63 per cent of the fatalities have occurred in people with an underlying condition.

In a 'normal' flu season, there are roughly 5,000 deaths, most of them seniors. Between three and five children die of seasonal influenza annually (less than 0.1 per cent), and they are usually babies with underdeveloped immune system. Deaths in the six months to 15 age category are very rare.

While every death of a child is tragic, it is also important to keep them in context. The greatest risk to children, by far, is unintentional injuries - motor vehicle crashes, falls, accidental poisoning - which result in almost 400 deaths a year. Another 170 children each year die of cancer. So one of the best ways to keep your child safe is to drive carefully when you head to the vaccination clinic.

Q: There are six priority groups for vaccination, including people under 65 with chronic medical conditions. My wife and I are both over 65; she suffers from COPD and requires oxygen. She gets the flu shot every year because she is considered high-risk. Can you tell my why she is being sent to the back of the line this time? This seems, at best, arbitrary and bureaucratic and, at worst, flagrant discrimination against seniors.

A: In regular flu seasons, seniors (particularly those with lung diseases like COPD) are the high-risk group. However, there is strong evidence that older people (meaning over 50) have full or partial immunity to swine flu. That is because, between 1918 and 1957, H1N1 viruses circulated commonly so most people developed antibodies that seem to protect them against the current strain of H1N1. In other words, seniors are well down the priority list because they stand to get a lot less benefit from the shot than younger people. It should be noted though that some physicians and public health officials believe that all people with respiratory conditions like COPD and asthma should be vaccinated in priority fashion, regardless of age. This is an area of some controversy. While seniors have a lower risk of contracting H1N1, if they do get infected, disease can be very severe. In fact, despite all the attention paid to the deaths of young people, the over-65 group has the highest mortality rate from H1N1 and virtually all seniors who died had underlying health conditions. Finally, don't forget that, even if they are being told to wait for the H1N1 vaccine, it is recommended that seniors get the seasonal flu vaccine.

Globe readers have a number of questions related to blood donation and transfusion.

Q: I'm a long-time blood donor. Yesterday, I got the flu shot. Can I still give blood?

Q: I'm getting heart surgery next week. I'm wondering if can get swine flu from a transfusion?

Q: If you get the flu, does it stay in your blood? If you give blood will it endanger others?

Q: If I get blood from someone who had the vaccine, will I get the antibodies? I mean, can avoid getting the vaccine myself that way?

A: Yes, you can donate blood after getting flu shot, but Canadian Blood Services recommends that you wait 48 hours before doing so. This is simply an extension of normal policy, where blood donors are asked to flag if they feel unwell after a donation - an indication they may have been infected by a bacterium or a virus. That blood is discarded. Because minor reactions like fever are common after the flu shot, the wait period is a way of ensuring that blood donations are not wasted.

There is no wait period for getting a flu shot after a blood donation and no impact on the efficacy of the vaccine.

You cannot get the flu (H1N1 or seasonal) by giving or receiving blood or blood products. Influenza is a virus spread through the respiratory route; it is not blood-borne.

If you get a blood transfusion from someone who has had the H1N1 vaccine or who has had the flu, you will get some antibodies but it is very unlikely you will get enough to protect you. Besides, getting a vaccine is a lot less trouble than getting a transfusion.

So far, pandemic influenza has not had an appreciable effect on blood donation. But, with the flu becoming more widespread, the plan is to "ramp up" collection and bolster inventory to seven days' worth from the normal five days' supply. To do so, CBS needs 120,000 blood donations over the next six weeks.

Getting a needle in your arm is in vogue these days so consider getting a second needle and giving the Gift of Life.

Q: There's a lot of talk about queue-jumping so I would like to know if the Prime Minister and other senior officials received priority access to the H1N1 shot?

A: Stephen Harper has said he will get the shot. The PM has asthma and was eligible to get the vaccine on a priority basis but he has opted to wait and get it at the same time as others in his lower-priority age group.

Federal Health Minister Leona Aglukkaq said her one-year-old baby, who is in a high-risk group, has been vaccinated but she is waiting her turn.

Dr. David Butler-Jones, the man who, in a $3.5-million ad campaign, has been relentlessly urging Canadians to get vaccinated and wash their hands, has not yet been vaccinated either. The chief public health officer of Canada, who suffers from both asthma and an immune condition, was going to get his H1N1 vaccine early on to set an example but, because of media reports of shortages, long waits and queue-jumping, he too opted to wait.

Q: My husband and I are heading to Florida in a couple of days, where we plan to spend the winter. I'm wondering if Snowbirds can get vaccinated before going south?

Q: I'm a frequent flyer. It seems that every day I'm on a plane with someone who is hacking and coughing. I really don't want to get the flu and spread it to others. Public health says I can't get the vaccine for a couple of more weeks. Doesn't it make sense to vaccinate people like me sooner?

A: Being trapped on a plane for several hours with the modern-day version of Typhoid Mary is certainly no fun. But there are no special provisions to provide early vaccination to Snowbirds and frequent flyers. Remember, those given high priority are those most likely to suffer serious complications if they are infected with H1N1 influenza, not those who are most likely to actually catch the bug.

Public health officials are urging those who are sick to avoid mass transit, and calling on carriers to be flexible (read: no punitive charges) in allowing them to delay their travel.

The good news is that some jurisdictions - particularly those outside large urban centres - are vaccinating priority groups more quickly than they had anticipated so the shot will soon be available to everyone. So check with your local public health authorities before heading south.

Today, we have several questions related to pregnancy and babies:

Q: I am eight months pregnant and I have been vaccinated against H1N1. What I want to know is: Will my baby have antibodies when she is born?

A: Flu studies done in the past show that when pregnant women get flu shots before giving birth, they pass on immunity to their child. The baby may not have 100 per cent immunity but even partial protection can be helpful during the infants first few months of life.

Q: My baby is two months old and can't be vaccinated. But I'm breastfeeding - will that protect him? (I got the adjuvanted vaccine myself because my doctor said it was safe to get while breastfeeding.)

A: Breastfeeding has many advantages. Breastfed children are generally healthier, which offers some protection against infection with pathogens like the H1N1 virus. Moms can also pass on some immunity to the baby in their breast milk. Finally, breastfeeding mothers themselves tend to have stronger immune systems; this reduces the chance of a contracting the flu and passing it on to her infant. And, you are correct, the vaccine is recommended for breastfeeding Moms, and if they have very young babies they are at the top of the priority list.

Q: We have a newborn. My husband, my other children and myself have all been vaccinated. But lots of people aren't vaccinated so should we keep the baby out of public places just to be safe?

A: A key message that public health officials have tried to convey is that while H1N1 poses a risk, that risk should be kept in context and life must go on. The large majority of people - including babies - will not get sick from the flu and only a tiny minority will get gravely ill or die. While you should not deliberately put your baby in harm's way, trying to hide away (or quarantine) the baby will not substantially reduce risk and will probably be a huge inconvenience to the family.

Q: I am not pregnant, but I'm trying to get pregnant. Should I get the non-adjuvanted vaccine just to be safe?

A: The recommendation is that pregnant women receive the non-adjuvanted vaccine. Currently, there are no provisions to provide the non-adjuvanted vaccine to others. However, by week's end, more than one million doses of non-adjuvanted vaccine will be available - far more than there are pregnant women, so there may be some latitude. (After the queue-jumping scandals though, don't expect clinics to stray at all from the rules. Try and raise your specific situation with an individual physician.) Public health officials, for their part, say that it is vaccination that it is important, regardless of whether you receive the adjuvanted or non-adjuvanted version. This is particularly true for pregnant women - and those trying to get pregnant - because flu symptoms (especially fever) can trigger miscarriages and injure the fetus.

Q: Why is the vaccine not considered safe for children under 6 months and what magically happens at 6 months to make it safe?

A: The issue is not safety, it is efficiency. Children under the age of six months do not have fully developed immune systems so they do not produce a good immune response to the vaccine. That is why it is recommended that caregivers and close contacts of young babies - parents, siblings, daycare workers - be vaccinated.

Today, we a number of questions related to legal liability and vaccination:

Q: Is it true that I can't sue if the swine flu vaccine makes me sick or kills me?

Q: I've read some pretty frightening things about vaccines on the Internet. How many people do they actually kill?

Q: I read that in the U.S. vaccine makers can't be sued. Is that true in Canada too?

Q: Why have the vaccine producers been given blanket immunity shielding them from any adverse reaction lawsuits?

Q: When I got the H1N1 vaccine, I had to sign a waiver that said I couldn't sue. Is that valid?

A: In the U.S., federal legislation has, since the 1980s, protected vaccine makers against lawsuits related to childhood vaccines. In July, that protection was extended to makers of H1N1 vaccine. This was done because, in the litigious U.S., drug companies had essentially threatened to stop producing childhood vaccines, which are not particularly profitable and there were fears that production of the flu vaccine would be delayed by legal concerns.

The inability to sue manufacturers does not mean those who are vaccine-damaged cannot receive compensation. The U.S. has a "vaccine court" that hears cases and awards compensation.

In Canada, vaccine manufacturers do not have blanket protection from lawsuits and suits related to harm caused by vaccine are usually settled out-of-court. One province, Quebec, has a no-fault insurance program that operates in a manner similar to the U.S. vaccine court. Over two decades, there have been about 100 claims and a couple of dozen substantial awards.

The Canadian Paediatric Society estimates that about five children a year will potentially suffer a serious adverse event from vaccination. Bear in mind that there are almost 400,000 children born a year and they get approximately two dozen shots by the time they hit kindergarten.

Health officials describe the number of severe adverse reactions to influenza vaccines as "very rare." The biggest danger is a life-threatening allergic reaction to a component of the vaccine such as egg proteins. In rare instances - again, numbers are hard to come by - a person can suffer from Guillain-Barré syndrome after vaccination. The autoimmune condition, which is characterized by paralysis that can be reversed, is related to fever. The disastrous 1976 swine flu vaccination campaign was derailed by reports of numerous cases of Guillain-Barré. But infectious disease experts note that the flu itself triggers far more cases of Guillain-Barré than the vaccine.

On the question of "immunity" from H1N1 vaccine lawsuits (a clever play on words), the reality is a bit more complex. In the contract between the government of Canada and GlaxoSmithKline, Ottawa promises to "indemnify" anyone harmed by the vaccine. Practically, what this means is that, if you suffer harm from the vaccine, you can sue and the government, not GSK, will be responsible for paying the settlement.

Many have argued that this is an unnecessary gift to a big, wealthy pharmaceutical company. But the underlying philosophy - as articulated in a landmark 1985 Supreme Court judgment - is that people exposed to a potential harm while undergoing an intervention that is in the greater public good, particularly at the urging of the state, should be compensated by the state if they are harmed in the process.

Finally, when you get a H1N1 vaccine you will be asked to sign a waiver. The wording of these waivers varies a lot across the country but most say that you waive the right to sue those administering the vaccine - principally nurses. Lawyers consulted said that these waivers would in no way limit your ability to sue the vaccine maker of the government.

Q: Is the non-adjuvanted vaccine available now for pregnant women? And can we get non-adjuvanted vaccine for our kids too?

A: By week's end (Nov. 10) one million doses of non-adjuvanted vaccine have been distributed to the provinces and territories. However, the vaccine, called Panvax, has not yet been approved by Health Canada. Approval is imminent so the vaccine should be available to any pregnant woman who asks by week's end.

The formal recommendation is that only pregnant women get the non-adjuvanted form of the vaccine. But some parents have safety concerns because there has been limited testing of the adjuvant, particularly in younger children.

So the question becomes: Should you demand the non-adjuvanted vaccine?

The vast majority of pediatricians and public health officials will tell you that the adjuvanted vaccine is safe and that it actually works better than the non-adjuvanted vaccine - meaning it generates a better immune response, including in children and pregnant women.

But if you insist, will you be able to get non-adjuvanted vaccine for your child? Currently, the answer is: Probably not. Most vaccinations are being done in clinics and, after a series of queue-jumping scandals, the recommendations are being followed to the letter. Individual physicians have more freedom to provide non-adjuvanted vaccine to patients but they have been supplied with very little of that product.

Q: Our three girls (ages 2, 2, and 4) have been vaccinated. We were told at the clinic a half-dose was provided and to return in three weeks for the other half-dose. But then I heard on that radio that a second shot was no longer required. Can you help clear up this confusion?

A: The current recommendation is that children aged six months to nine years should receive the adjuvanted vaccine in two half-doses, administered 21 days apart. But the World Health Organization said last week that one half-dose provides a sufficient immune response to protect children from H1N1. The Canadian policy is currently being reviewed. Practically, the focus now is getting all children vaccinated once and, within the next couple of weeks, it will likely be announced that young children don't need a second shot - a rare bit of good flu news for parents. For the seasonal flu, it is still recommended that children aged six months to nine years get the vaccine in two shots, at least 28 days apart.

Everyone 10 and over requires only one shot of H1N1 vaccine and one shot of seasonal flu vaccine.

Q: How will we know when the pandemic is over?

A: Influenza spreads in a well-established and predictable manner: The number of cases increases in an accelerating manner until it reaches a peak, and then the number of new cases gradually falls off. Public health officials will know that peak has been reached when they start to see a decrease in the number of new cases. In Canada, the peak of H1N1 influenza was reached the week of Nov. 24.

Q: There have been two waves of H1N1. Will there be a third wave?

A: The "third wave" theory is a point of much debate among public health officials. While it is possible that there could be a resurgence of H1N1 flu in the New Year - after all the flu usually peaks in January - it is unlikely. Why? Because, to date, about 40 per cent of Canadians have been vaccinated and another 10-15 per cent of the population has likely been infected. That means only about one-third of the population is at risk of contracting H1N1, so large outbreaks are not likely. However, one can expect to see a fair bit of seasonal flu early in 2010.

Q: In the end, how many people actually died of H1N1?

A: As of Dec. 19, there were 401 confirmed deaths from H1N1. A total of 1,404 Canadian were admitted to intensive care units for treatment of the swine flu; some of them will have life-long disabilities as a result. There were also 8,436 people whose flu symptoms were so severe that they required hospitalization. The most noteworthy characteristic of H1N1 was how it disproportionately affected younger people. For example, while influenza usually affects seniors, the median age of those hospitalized with H1N1 was only 28 and the median age of those who died was 53.

Q: When you look back were the people in the priority groups for vaccination more at risk?

A: According to the latest data - mid-December - those with underlying medical conditions like asthma and cystic fibrosis suffered the brunt of the H1N1 epidemic. More than half of people who were hospitalized and three-quarters of the deaths occurred among those with underlying conditions that placed them at high-risk. Similarly, one in five hospitalizations and one in 12 deaths occurred among pregnant women. Finally, about seven per cent of hospitalizations and deaths were in aboriginal people while they make up only about one per cent of the population.

Q: How much is the "largest immunization campaign in Canadian history" costing us, the taxpayers?

A: The vaccine costs about $8 a dose, so the total cost is about $400-million. Far more costly though is the cost of administering and publicizing the vaccine in the hundreds of clinic sites around the country; as of mid-November, that cost had reached about $1.5-billion. So, when all is said and done, the H1N1 campaign will cost well in excess of $2-billion. The federal government is picking up 60 per cent of the tab and the provinces are on the hook for the other 40 per cent.

Q: Who can I call if I have more questions?

A: The Public Health Agency of Canada has a H1N1 hotline 1-800454-8302. Most provinces and health regions also have telehealth lines that you can call for information, including where to get a flu shot.

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