xtcian

Thanks for the info. If Dr. C is taking questions, I'm wondering if you think the H1N1 is more dangerous than the seasonal flu. I have two kids under 4 and I'm wondering how neurotic to be this season.

Thanks, Dr. C, and Ian.

i never remember getting the flu as a kid or ever hearing the letters CDC until i was 22. what happened?

I've heard rumors that people 60+ may have immunity from this as there was a similar strain that went around the country (maybe world) in the 1940s and that's why that age group (unless in compromised health) are in the priority group. Is that true?

Thanks! Bigger question is: Is this just the usual hype, or do we have real reason to be concerned? I think we are so used to warnings that when something big hits, we downplay it. So is this really going to be as bad as they're making it sound? Will lots of people be dying?

oops meant to say "are NOT in the priority group."

Thank you Dr. C for the information you have passed on.

May I ask that you please comment on the safety of the vaccine. There are some people out there who say it is very dangerous and no one should get it. What are your thoughts with regard to this? What about squalene?

btw, I think it is safe and people should get it, but I value your opinion more than my own.

So am I just being bull-headed, as I have absolutely no intention of getting either of these shots? I never get a flu shot, but I also don't get the flu, at least not in 16-ish years, since I was about 13.

Kevin,
I kind of think your statement

"I never get a flu shot, but I also don't get the flu"

is like saying I am not wearing a seat belt because I never get in a car wreck....

Doc C. can only read browsers by day (and not post), so the good doctor is emailing me answers:

"Children are the group most likely to be infected with H1N1 and the most likely to be hospitalized, though fortunately not the most likely to die of H1N1. We are seeing lots of school outbreaks right now. I don't know how worried you should be, but what I do know is that unlike many epidemics, we have a lot of tools available: the vaccine, Tamiflu, and good 'ol soap and water for handwashing. There are things you can do to avoid getting sick, the most important being to get your children vaccinated for H1N1 -- especially if they have any chronic medical conditions that put them at increased risk for complications, such as asthma -- and of course the recommended hand washing and cough-covering. Even if if they do get it, most kids will be sick for a few days, have a high fever, feel rotten, and get over it. If they do get sick, see your pediatrician and keep them home until 24 hrs after the fever resolves. In short, be worried enough to take action, but don't worry yourself into a panic."

One of the greatest blog titles ever.

Thanks for the info.

Thanks for the info, Dr. C.

I skipped the flu shot last year because I was broke and couldn't afford to spend the $25 on it at the minute clinic at our local CVS.

Huge, stupid mistake - one I won't ever make again.

I not only got the flu, but I developed bronchitis and sinusitis and was on a variety of antibiotics for those infections. Oh, and all the violent coughing I was doing caused me to re-herniate a disc in my lower back that I'd previously injured at the end of last summer/early fall. I spent a week in bed, then a week on the floor (better for my back) before feeling better.

When our company offered flu shots this year to employees and their significant others, my name was first on the list.

That was a great summary for us, thanks!
I will put in my two cents as a doc and Mom.

My 8 year old just had H1N1. It was a pretty severe flu - came home from school Thursday with a fever and continued to be sick until Sunday night. Didn't go back to school until Tues and even then was very tired. Fever as high as 103.5 and pretty severe croup. Very uncomfortable and miserable for all involved. I was so concerned about her breathing I took her to the doctor (and I don't do this for nothing).

Worse than regular flu? Not so sure, but pretty damn bad..

But then... 3 days after getting well she woke up again with fever, shaking chills and 103 temp and turned out to have a post flu pneumonia. This is exactly the complication you should fear b/c this is how kids (and adults) die - a bacteria comes in and takes advantage of the low immune system and damaged lungs. Anyway - 5 hours in the ER and some antibiotics and she is doing great (although was sick for a total of 4 more days and missed 2 more days of school in the mean time). Scary stuff. That was my typical, healthy kid. I'm really scared of my developmentally disabled child getting it and so far, we've been lucky.

So, that's my experience as a Mom.
As a doctor, I've seen mostly bad flu symptoms that resolve and general misery and not much else but I do recommend the vaccine.
I worry a little, and maybe Dr. C can address this issue about getting the seasonal flu vaccine in such close proximity to the H1N1 vaccine. Given Guillian Barre is a known complication of flu shots are we increasing our risk of this by getting essentially two flu shots back to back? I imagine this scenario was not really tested.

Also - to address asd's question - I did look up squalene. Here was the best info I found, from the WHO, http://www.who.int/vaccine_safety/topics/adjuvants/squalene/questions_and_answers/en/
The negative stuff about squalene seems to be mostly from fringe groups that have an overall antivaccine agenda so I wouldn't trust anything from them. Seems most of the real evidence on squalene indicates no harm.

My boys have already gotten the regular shot. I'm going back and forth on the H1N1. Too much info from conflicting sources...gah.

Question, does the H1N1 have thimerosal? Hmm, I guess this is my answer:

http://www.cdc.gov/h1n1flu/vaccination/thimerosal_qa.htm

My 3yr old (almost)daughter is considered high risk with asthma/repiratory issues. I would rather take the perceived risks associated with the vaccine than get the flu and possible resulting complications. However, she is allergic to eggs and can't get the vaccine. So, it will be a little nerve-racking for us to wait this one out.

Hey, I apologize in advance for worrying about the more trivial aspects of cold care, but I read in this months Wine Spectator, that ZiCam nasal spray was being recalled and reformulated because some people were losing their sense of smell! If you like your food, wine, scotch, to taste good, smell is kinda important.

I can't read the blog from work so am just seeing all these questions now (saw the first one 'how worried should we be') before I left. Will answer your great questions tonight after kid bedtime.

In the "how worried should I be" line of questioning...I volunteer 8-10 hours per month at the local childrens hospital doing art with the patients and their siblings in their rooms. Of course I follow all the precautions, including handwashing, using the hand sanitizer dispensers, wiping down supplies between room visits, and avoiding touching my face. And I do not go into rooms where contact precautions are posted (they have told us that if the census lists fever, we're not to go in). I don't worry so much about myself, but I do worry about bringing something home to my little ones. Is this a valid concern, or am I doing enough to protect them? Oh and I also change clothes as soon as I get home.

And thanks for sharing your professional opinion with us! :-)

OK, Q&A time.

1) Is H1N1 more dangerous than the regular seasonal flu?

It depends on what you mean by dangerous. Right now in terms of disease severity, H1N1 looks like it has a similar spectrum of illness to regular seasonal flu -- which kills thousands of people a year so is not itself harmless. However the vulnerable population is different. It is quite clear that children and young adults are most likely to get H1N1 and that is quite different from seasonal flu. Since they tend to be together in schools and colleges, it's easy for them to get exposed. Their lack of immunity means that many who get exposed will get sick. Most who get sick will recover but a percentage will have to go to the hospital, the ICU, and a very few will die. If enough people get sick, even if only a few % are severely ill there will be a large absolute number of severely ill. So on an individual level there is not too much worry, but on the population level we are concerned.

The worst case scenario that everyone is worried about is a 1918 type flu (which caused a more severe clinical illness), with a more virulent flu causing more deaths in a population lacking immunity. It is unlikely that even if the flu strain became more virulent we would see a situation like 1918, because we have antibiotics to treat the secondary bacterial pneumonia (as Neva eloquently described above) that killed many then. Also we have more ventilators and ICU level care, though there is concern about what we'd do if there were more people needing ICU beds than we have available.

I want to stress that so far the 1918 scenario doesn't seem to be happening. Flu is unpredictable though, since it can mutate and recombine with other flu strains, so we are preparing for the worst and hoping for the best. More answers to follow.

2) What about the H1N1 vaccine? Is it safe? Does it contain squalene, is that safe? Does it contain thimerosal?

The H1N1 vaccine is very similar to the seasonal flu vaccine (which this year is H3N2). It's made the same way, only the antigens (components of the outer coat of the virus, that your immune system learns to recognize) are different. Seasonal flu vaccine has an excellent safety profile and has been given annually for over 30 years.

Injected H1N1 vaccine in the US will be available both with and without thimerosal. Live weakened vaccines, such as the H1N1 nasal spray, never contain thimerosal. Thimerosal is a preservative that is used to keep multiuse vials from being contaminated when different needles are used to draw up the vaccine dose. Multiple large studies have shown no association between thimerosal and autism, but because some people would prefer no to receive thimerosal-containing vaccines, thimerosal-free single-use H1N1 vaccine doses will be available.

Squalene is a naturally occurring substance that is found in the body. When emulsified with oil, it serves as an adjuvant, a substance added to vaccines that increases the body's immune response to the vaccine. Squalene-containing flu vaccines are approved in Europe and has been used millions of times without problems. There is some alternative medicine internet info about squalene out there, however I agree it is coming from sources that are antivaccine in general. The US H1N1 vaccine will not contain squalene.

However, some squalene is being stockpiled for an emergency situation, in case we need to immunize many more people (if 1918 flu scenario starts unfolding and we decide to try to immunize everyone as soon as possible). Then we would need to stretch the vaccine supply as much as possible. By boosting the immune response to the vaccine, squalene would allow lower doses of vaccine to be given and thus allow many more people to be immunized.

3) What about Guillain-Barre syndrome (GBS)? Will GBS be more likely if people get both H1N1 and seasonal flu vaccine?

GBS is a rare autoimmune disorder in which the body starts making antibodies that attack its own peripheral nerves, causing acute paralysis. It is serious and can be life-threatening if the breathing muscles are involved. Most people make a full recovery. There are many infections that can trigger GBS, though 60% of GBS cases have no obvious trigger. It is thought that when an infectious agent contains antigens that are similar to proteins on the surface of nerves, they get attacked by the antibodies generated against the infection. The nerves are sort of innocent bystanders that happen to have surface proteins that partly resemble the antigens of the infection. Infections that can cause GBS include campylobacter (causes food poisoning), influenza itself, herpesviruses, and many others. Very rarely vaccines can also cause GBS.

So why are people worried about GBS and H1N1 vaccine specifically? Because 1976, the last time there was a swine flu outbreak, there was an increase in GBS cases reported after H1N1 vaccine. GBS increased from 1 case per 100,000 people in the population to 2 cases per 100,000 people. It was never quite clear whether it was the vaccine or influenza infection its. But out of an abundance of caution, and because the flu season was winding down and not as bad as feared, the vaccine program was halted. Since then there have been many studies of the seasonal flu vaccine and most have shown no association with GBS. Two studies have suggested that there could be up to 1 additional GBS case per million people vaccinated fir seasonal flu.

The initial FDA safety studies have shown no problem with this year's H1N1 vaccine, but GBS is a rare event. So we are going to be monitoring the GBS situation very carefully as we go into the vaccination program. If there is any problem it will detected early and decisions made from there. We also have to keep in mind that flu vaccine will prevent many infections and thus prevent hospitalizations and in some cases severe illness and death from flu.

We don't know if receiving both seasonal flu vaccine and H1N1 vaccine in close proximity will increase the risk of GBS, though there is no a priori reason to think so. This is another reason for close monitoring of all GBS cases this year.

4) Why aren't people over 60 getting H1N1?

They are getting it, but at much lower rates than young adults. This probably has something to do with previous exposure to a similar strain of flu many years ago providing some residual immunity. At least that is the explanation currently being offered. I think this explanation has some weaknesses, but don't know how else to explain what we are definitely seeing. It's weird. There is hardly ever a disease where it's protective to be old!

5) For jje with questions about volunteering in the hospital:

First of all, what great work! Thanks for doing it. Should you be worried about bringing H1N1 home to your family?

I think this is an individual risk/benefit situation. For the mother of the 3 yo child who can't be immunized because of an egg allergy, and who is at high risk for severe flu because of asthma, I might advise sitting out volunteering this flu season. However, if your children get vaccinated for H1N1 and you take all the precautions, use the hand sanitizer, avoid kids with fever and cough, you'll do all you can to protect them -- and honestly, they are at risk for H1N1 exposure in daycare/preschool/elementary school anyway.

As for things other than H1N1, I struggle with that too. I worry a lot about tuberculosis. In the end I take these risks as part of my job and so far nothing bad has happened. It sounds like you get a lot out of volunteering and I'm sure the kids you work with love it.

Any other flu questions?

Thanks for taking the time to respond to the questions, Dr. C. You have given us an incredible amount of information and I'm grateful for it. I am definitely feeling better about getting the shot for my boys.

And thanks for the compliment. :-) This is my third year doing Arts for Life ( http://www.aflnc.org/ ) and I truly love it.

I worked last weekend and I was surprised to see how the contact precautions were VERY visible on the doors. Last year, you'd have to be super focused on the doors to catch them before you walked in and sometimes they'd be missing supplies. Now you can't miss the giant, bright yellow bags filled with gloves, masks and gowns.

And today I had a note from my chair saying that she didn't work with ANYONE this morning - every single door had contact precautions. That amazes and scares me, given that the census is usually about four pages long with about 15 names per page. She suspects our program director might suspend the program (at least for the JL volunteers) until flu season has passed.

I agree with jje, THANKS for taking the time to do this. Your accurate information and thoughtful answers are appreciated.