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.
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.
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: Is the flu vaccine free?
A: The H1N1 vaccine will be 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.
Q: This is a new, experimental vaccine. Has it been properly tested?
A: The H1N1 vaccine is similar to past flu vaccines – except with a different antigen, of course – 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; 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 inhaled steroids and other 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: 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: Again, 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: How much is the “largest immunization campaign in Canadian history” costing us, the taxpayers?
A: The vaccine costs about $8 a dose, so $400-million for the product plus the costs of administration, which are more difficult to calculate. 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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