Effect Measure

In early September swine flu was just ramping up in the US and there was no vaccine. CDC envisaged adequate vaccine supplies by end of October but in reality this was too optimistic. For a period of weeks, the news was full of stories of long lines at vaccine clinics and the frustration of worried parents who were anxious about the health of their children in a pandemic where children seemed to be most at risk. The flu struck in North America first, but eventually made its way to over 200 countries on every continent, some of them desperately poor. They didn’t have to worry about too much optimism. They were burdened by too little resources and the rich countries, the US in the lead, were taking up the lion’s share of the world’s productive capacity for flu antigen, but the flu was getting to them later than the US.

Now it has arrived, just as the second wave of this pandemic is easing off in the US. The decline in flu in the US has also brought with it a decline in anxiety and that has prompted a decline in desire for vaccination. The result is that production and demand are out of phase and it is now likely a significant portion of swine flu vaccine originally intended for US citizens will go begging. CDC is saying this is a good time to get vaccinated for people who dodged the flu bullet this fall, but human nature being what it is many people are ignoring this prudent advice. If a third wave starts in January, which is quite plausible and would be a carbon copy of the 1957 pandemic, those with little foresight will again clamor for the vaccine. What I think we should say to them is this. We don’t have it any more. We did the right thing and gave it away to places that wanted it and needed it. Here’s the way we put it in early September:

I am opposed to mandatory vaccination, even though I believe vaccination is an important public health measure that will save millions of lives. But there isn’t enough vaccine for everyone in the world, so if people in the US don’t want it, then any unused stock (keeping a small reserve) should be released by a date certain (say January 15 for the sake of argument) and given to others. I believe this will doom many Americans to severe sickness and some to a fatal illness, but the compensation is that many others, children and adults, in poorer parts of the world will be saved. Their lives are worth no less than American lives. If someone in this country, for whatever reasons, doesn’t wish to receive the vaccine, someone who wants it and needs it will be waiting. (Effect Measure, September 8, 2009)

We aren’t the only ones saying this. To take just one recent example, three public health scholars and practitioners from Johns Hopkins (the School of Public Health and the Berman Institute of Bioethics), Ruth Karron (Center for Immunization Research), Orin Levine (the International Vaccine Access Center) and Ruth Faden (Berman Institute of Bioethics) weighed in two weeks ago in an Op Ed in the San Francisco Chronicle:

In June, the World Health Organization confirmed that a new influenza pandemic was upon us. The United States and other wealthy countries supported a nearly unprecedented effort to develop, test and license H1N1 influenza vaccines, and give their own citizens nearly exclusive access to these vaccines as quickly as possible. Delays in manufacture meant that in October and November, many in these countries had to wait their turn while limited supplies were given to those at greatest risk.

December is already very different.

In the United States, the number of new H1N1 cases is steadily decreasing, while the vaccine supply increases. In the first week of December, we saw an increase of 13 million doses over the previous week, and our supply has roughly doubled over the past month, with more than 76 million doses of vaccine shipped for distribution. Soon, everyone in the United States who wants the vaccine will have it, and there will be more on hand. (San Francisco Chronicle)

Their conclusion? The US should start to give our excess away. The Netherlands, France and Germany have already begun to do this. The US and other wealthy countries had pledged 10% of their vaccine supply to the poorer nations, although they have yet to deliver any of it. Now is the time, as in “immediately,” say Karron, Levine and Fadden. But 10% of our vaccine supply won’t go very far globally. So if our citizens don’t want it, we should give ours away, except for a small emergency reserve and whatever is produced after January 15. And if it turns out a third wave materializes and suddenly people in the US want the vaccine, that’s tough luck. They had their chance and didn’t take it. If we do this, people who aren’t as lucky will get their chance, too.

Comments

  1. #1 caia
    January 4, 2010

    I would agree, except that as of late December, I was still unable to even be considered for vaccination at my doctor’s office, since they they claimed they only had enough vaccine for the small children in their practice.

    If they suddenly got enough vaccine now, today, to vaccinate anyone in their practice who wanted it, the window of opportunity for getting it before January 15th would be eleven days. Not really much time at all. It’s not that easy to get an appointment in that amount of time, unless you have an urgent illness. And I bet if I called today, they still wouldn’t have it.

    While traveling last weekend, I did see signs up at pharmacies advertising they had H1N1 vaccine. But aside from wondering about the cost (someone I know was billed recently for a chunk of change just for the administration of the seasonal vaccine, not the vaccine itself, and I don’t know if pharmacies take my insurance), I’d actually like to discuss this vaccination with my doctor, as it relates to my specific health concerns. (I am convinced of its worth to the generic person.)

    Guess if I don’t give up on that and drive a couple hundred miles back to the urban center where I saw it being offered, then I’m just another complacent American who snoozed and lost.

  2. #2 shotqueen
    January 4, 2010

    I work at a public health department doing H1N1 vaccinations. Very few people are coming in for their free vaccination. Some days I’m lucky if I’ve given 20 H1N1 shots.

    If our citizens don’t want the vaccination, by all means give the vaccine to other countries.

  3. #3 Martin
    January 4, 2010

    Fine. Give my vaccine away. But please stay the hell away from me and my family if you got that dangerous vaccine – you may give the Swine Flu to us.

    A third wave? Kidding me? The numbers of infected and deaths are so low that this is proof that the CDC is playing yet another little scare and hype game with the public and the public ain’t biting.

    How about using those 800 people working on Swine Flu for something more real – like a cancer-causing Retrovirus? That might be a good use of resources. The CDC is irrelevant and knows it. Stop crying wolf, idiots.

  4. #4 revere
    January 4, 2010

    caia: You are right. Jan. 15 may be too soon. But the principle is the same if it is Jan. 31 or Feb. 15.

    Martin: Yes, I’ll stay away from your family. They are potential vectors and also sources of ignorance. I got vaccinated with a vaccine that has no virus in it. As for a third wave, I hope you are right. But in 1957 that’s exactly what happened and so far this one is just like 1957. Neither you nor I nor CDC know if there will be a third wave, but it has happened in the past. You seem to have a secret source of information, though, about cancer causing retroviruses. Good for you. Stay away from my family. We don’t want to catch cancer from you.

  5. #5 Hank Roberts
    January 4, 2010

    Heck, they should’ve let the people allowed the vaccine who didn’t want it to sell their …. no, that wouldn’t be fair either, that’d just be a tax on stupidity. And we have those aplenty. Maybe they should have made a free lottery ticket available with each H1N1 shot — it wouldn’t have changed the odds significantly for the lottery, but sure would’ve pulled in the people who don’t understand what’s important.

    And herd immunity is important. Pity about the name though. Need to rename it with something catchy, so to speak.

    Nevertheless, I’m still waiting for people my age to be allowed the vaccine, in my area (California) I wish they had at least set up an “eagerly waiting” list for those of us who’ve been politely holding back.

  6. #6 mso
    January 4, 2010

    Yes, the other countries should receive much of the US excess vaccine. But CDC, the states, and local health departments and well as private health care providers need to sustain public information and outreach efforts to high risk people. If a third wave arises, it won’t be just the dumb clucks who didn’t take the vaccine who will suffer. Hospitals and health departments, and the economy will take another hit of some scale. All of which is secondary to the jeopary it would pose to vulnberable kids whose parent(s) were perhaps just too darn busy working two jobs to get the vaccine or chase the booster doses down. Plus the native folks whose risk is inordinantly high but whose barriers to services didn’t automatically recede because mainstream America waged a free vaccine campaign.

    That said, I am disappointed that the pharmacy box stores, at least in this state, have not taken extra effort (minor expense for them) to be able to administer this vaccine to youth – the most at risk — and are providing to adults only. This suggests they are more interested in trying to get business into the store than help the larger community. That model — which they use every year to greater extent with seasonal flu vaccine — really misses the mark for this pandemic year.

  7. #7 stoneymonster
    January 4, 2010

    Revere,

    That’s a wonderful sentiment, but there are still areas (where I live for example, Santa Clara county) where the vaccine cannot be had for love or money. It’s amazing reading these articles about oversupply and no demand when we STILL cannot get it. At this point it’s almost criminal incompetence on someone’s part.

  8. #8 Nico
    January 4, 2010

    In my city,( toronto) once the high risk groups got theirs, it was “really, we have doses, we want to use them all” come one, come all.

    Overall, while they’d told me my non at risk husband would have to wait till christmas, he got his mid november because the rollout was that efficient. Vials were shuttled to clinics running low, from clinics with over supply. The first week was a bit rough logistics wise, but after that it seemed to even out considerably.

    Not all the provinces were as efficient, but I see a big issue in the US where the system was even more patchwork, with some clinics free, some people had to pay, if you could find it at all.

  9. #9 Paula
    January 4, 2010

    My doctor’s office has yet to phone me back to say they’ve the vaccine available for us older persons. As it happens, I went ahead and got vaccinated through our local public health department once Oregon announced vaccine was available generally, but there seems, out here in the sticks, no effort whatsoever being made, since sometime in November, to remind anyone that this flu may return.

  10. #10 Trish Gannon
    January 4, 2010

    I just received a press release today that a clinic will be available for the shots Jan. 16. This is only the second clinic in my area (North Idaho) where the shots have been available to everyone… I missed the first clinic by 15 minutes due to a previous appt running late.

    According to the last press release I received from CDC (Jan 2) visits to doctors for ILI have increased slightly, reversing an 8-week trend.

    We have many ignorant here similar to Martin. I think we should be able to sue them (or shoot them on sight, which is usually a stance they seem to prefer here) if they refuse the shot, catch the flu and spread it. But that’s because if I were god, I’d be a vengeful one. Good thing I’m just a regular Joe. (Okay, slight sarcasm there.)

  11. #11 M. Randolph Kruger
    January 4, 2010

    So far I havent seen anything that indicated that the vax even worked, but I am like Revere and that is that if you are going to do it then do so. But do it as part of an informed decision. It is an EUA vaccination and there have been about the same number of reactions/problems as 76. Slightly less GBS though, but it is happening.

    By definition its not necessarily unsafe, just untested. Now let me put it to you this way Martin, if this had been H5N1 even young Randolph, knowing what he knows about all the crap about retroviruses, mercury, squalene and the other stuff… I would be taking it.

    The ONLY reason I dont take flu shots is that I dont get it as a rule. Cant remember since the 60′s having it except when some jackass in the military gave me a shot of it. Each and every time it gave me pneumonia, made me sick for a month and finally after spending a lot of money to vax me and then take care of my ass… I held one of the few waivers in the military for flu shots. It wasnt an egg allergy either Martin. 12 hours after each one I got for 9 years I was cold sweating, lungs filling with funk and generally about a 102, even made it to 103 once.

    Its all about the protection. Is the protection any good on a rapidly evolving bug? Yes, but at best on ly temporary. Scientists like Revere base their decisions on information. If the information is crap they make a crap decision. So far there isn’t any indication that the new vax is worse than anything thats already been out there. But thats if you take the vax seasonally. I don’t. Nor does anyone in my family because of the reactions. But bunkie, if the third wave is the big potato then we are getting ready to do it. Pretty well running amok in Ukraine, China and other places. So its likely the third starting now with both pathogenics and virulence unknown. If its the same strain then the vax might keep you alive if its matched. If not…….. If this is the prelude to H5N1 or a reassort/recombination then with our fearless leader in charge… You dont have a thing to worry about, neither you or I will make it. Bumbling bureaucrats, crappy quality control and that one would be dropping people like fleas after a dog dipping. Not to mention the shutdowns of all types of services.

    Lotsa people are on the fence post on this stuff. My kids got H1N1 and I may have had a headache with no fever or gunk from one of them for a day. I was fine but tired. OTOH-My son did what I told him from the second it started… he was about the weekend with it. My daughter? Two weeks with the kiss my butt Daddy attitude ending after day 3. She had it hard and once we got her hydrated and loaded with vitamins it was a steady rise out of it. No vax.

    So.. its the informed decision and you are reading a lot of hype on the counter-culture network about the vax. I wouldnt take it because of squalene or mercury automatically but the flumist doesnt have either in it bubba… My point is that you shouldnt dissuade others from taking it though. I am special, just ask me. But for the other folks, give them the info (pro and con) and let them decide. I recommend this one below and you should read it about flu vax over all.

    One thing is SURE though and that is that if a bug from Hell comes and you have no resistance to it then will sicken and perhaps die. AT RISKS GO AT MUCH HIGHER RATES than published numbers. You have asthma or cystic fibrosis you are walking corpse if you got H1N1 this year or an insurance company nightmare as it has killed and infected in high numbers already. Shit, being fat was a large factor as was pregnant…They needed the vax even in my moderately biased mind on this. Risks outweighing the possibilities of personal disaster. Remember, they can treat you for a reaction post vax. But so far I havent seen anyone successfully treat dead…

    Revere might want to elaborate on the treatments for this…modern science and all.

    Whether vaccinations year on year cause bigger and better bugs is a big question… to be answered later. I doubt if anyone knows but the vax makers and I can tell you with a certainty if it does they wouldn’t tell you.

    http://www.bmj.com/cgi/content/short/333/7574/912?ehom=

  12. #12 Curious
    January 4, 2010

    Like Caia, H1N1 vaccines here are still only available to high-risk groups. I think that the Health Dept. opened it up to everyone, today, actually, and I just saw a sign go up at Walgreen’s that they have H1N1 shots. Our Kroger is only giving the shot to high-risk groups, too.

    So yes, give them away. But give those who followed the rules and waited their turn a chance to get their shots first.

  13. #13 Rowan
    January 4, 2010

    A few weeks ago I was driving past a grocery store in Washington state with a pharmacy that had a sign out stating they had the H1N1 vaccine available. I immediately pulled into their parking lot, went in, signed up for and received the shot. I gladly paid the $15 for it.

  14. #14 Paula
    January 5, 2010

    Looking at the posts from caia, stoneymonster, Trish Gannon, Curious, Rowan, and myself, I’d say that public health policymakers in certain Eastern Seaboard cities might do well to look at the rest of the nation, inc. but hardly only the Northwest, before selflessly giving away these other citizens’ vaccine supply. And for that matter, perhaps ask why there should even at this date be such variation in availability. Pats on the back are good, but so is renewed self-critiquing sometimes.

  15. #15 GeorgetT
    January 5, 2010

    caia: Texas has mandated the H1N1 Vaccine price is $15 – nobody can charge more. If I remember right, that’s the service fee for the shot and the state is actually picking up the cost of the vaccine itself.

  16. #16 GeorgetT
    January 5, 2010

    Additionally, I should mention the supply in Texas has been excellent. I got mine in early Nov without any effort from a doctor’s office and even saw it at Walgreen’s prior to that.

    Definitely, there is a distribution problem.

  17. #17 MoM
    January 5, 2010

    As of 12-29, several state DoH websites ran the story that CDC was releasing H1N1 vaccine to the so-called “Big Box” stores. CVS, for one, has a list of cities and states where they are offering the shots to all comers. For those in California, CVS says it is available in 220 stores across the state. Google “H1N1 vaccine at CVS” (no quotes). Other major pharmacies (Walgreens et. al.) will get you similar results. Walgreens’website says that all of their stores nationwide have it for an $18 administration fee.

  18. #18 redrabbitslife
    January 5, 2010

    Wow, Kruger, misinformed much? Are you a chiropractor by any chance?

    Let’s just address one of those ducks right now:

    Whether vaccinations year on year cause bigger and better bugs is a big question… to be answered later. I doubt if anyone knows but the vax makers and I can tell you with a certainty if it does they wouldn’t tell you.

    There’s no plausible mechanism for vaccination increasing the virulence of any virus. It’s an entirely different issue than infectivity (or resistance). The resistance one sees from one year to the next is based on something called antigen drift, which is based on point mutation of an H or N antigen already circulating in the population. Pandemic flu is based on a new-to-humans H and N antigen coming from genetic reassortment of human influenza virus with an animal version of the virus, or antigen shift.

    Both of these have happened as long as there has been influenza, and will continue to happen. It’s just what the virus does. Thus the ability to catch flu year in and year out (drift). Thus the pandemic flu every sixty or so years (shift). This is not changing, and is indeed the reasoning behind the annual flu shot.

    Virulence – the severity of the disease caused once you get infection – is dependent on other factors, in particular the machinery within the virus for propogation. I may be wrong, but I don’t think we have a way to detect how virulent a particular influenza virus will be.

    We notice tendencies, for example, that H5N1 has had an extraordinarily high virulence to date. This has little to do with the H or the N, which are like the clothing the virus wears. The clothing does not make the killer, but if you hear there’s a killer on the loose and you see a guy in an orange jumpsuit, you’d do well to be suspicious.

  19. #19 mk
    January 6, 2010

    Got my N1H1 yesterday at Giant Foods store. 15 bucks. Short line.

    Go for it people.

  20. #20 Sahara
    January 7, 2010

    @Redrabbitslife
    That was a very informative comment, it helped me to (I hope) understand more the difference between flu wax and wane numbers each year, and virulence of any given strain of flu.

    In Utah where I live, my doctor told me that the vaccine has been officially allowed to anyone, but many hospitals/clinics do not have a large supply and so are still limiting it to at-risk population. I am pregnant, and they offered me one of the two shots left in the building – and one was from the Family Practice down the hall who offered it to the other departments. (Although personally, I decline flu shots each year for my own reasons, and would be happy to give mine to a person eager for it)

    Overall it doesn’t sound like this extra supply is getting distributed very well.

  21. #21 Sahara
    January 7, 2010

    Oh, and I would like to note that France, Netherlands, and Germany aren’t actually GIVING away their vaccine, they are SELLING their vaccine to countries negotiating a price with them.

    (I understand, after all they did have to buy it in the first place, and probably want to get some of their money’s worth, but I just think that should be clarified)

  22. #22 John Thacker
    January 8, 2010

    “If a third wave starts in January, which is quite plausible and would be a carbon copy of the 1957 pandemic, those with little foresight will again clamor for the vaccine.”

    It is plausible. It wouldn’t be quite a “carbon copy,” because thankfully the death numbers for variant H1N1 are still far below the H2N2 “Asian flu” of 1957. According to the CDC, deaths are still below the December 2007-February 2008 epidemic, though it is always worse when the deaths are concentrated among the young and healthy as now, unlike then when the elderly were at severe risk.

    Deaths so far have been similar to that of a normal flu season, just several months earlier and, horrifyingly, concentrated in the young instead of in the 65+. Of course, people radically underestimate how deadly normal seasonal flu is too. We’ll see the true test over the next few months whether there will be a second wave.

    While it’s plausible, I’m hoping that the experiences of Australia and New Zealand are a good guide for the Northern Hemisphere. They too experienced an early flu season with variant H1N1, and did not experience a second wave around normal flu season time, as we’re fearing.

  23. #23 Paula
    January 8, 2010

    I’m wondering if you’ve seen today’s Newsweek online article by Sharon Begley, “Why seniors really should fear swine flu,” which points out that some CDC recommendations on this have been, to use the headline writers term, “misleading.” Maybe we should wait a bit before giving away the vaccine people were told they cohort didn’t need. (Oh, and, re the shot, I-got-mine.) Here’s the URL–http://www.newsweek.com/id/229947

  24. #24 Josef Hlasny
    January 18, 2010

    However, the swine flu outbreak was a ‘false pandemic’; said Wolfgang Wodarg, head of health at the Council of Europe (January 8, 2010). He has branded the H1N1 outbreak as ‘one of the greatest medical scandals of the century’. However, swine flu is not the first time we have suffered this nonsense. See predictions about BSE/ vCJD by Roy M. Anderson. He has mathematically modelled the spread of new variant Creutzfeld- Jakob disease (v CJD), published in Nature (406, 583-584; 10 August 2000). There his team showed that the current mortality data are consistent with between 63 and 136,000 cases among the population known to have a susceptible genotype (about 40% of the total population), with on average less than two cases of vCJD arising from the consumption of one infected bovine. However, far fewer people are carrying the human form of mad cow disease than previously feared. There have been 168 definite or probable cases of vCJD since 1995, suggesting that the risk had been „overestimated“. WHY? Because in Britain, much of the alarmism about Mad Cow disease was never justified scientifically. It was pure, math-model-driven science fiction. But it was pushed very vigorously by the British science establishment, which has never confessed to its errors!. This led to an obscene £5 billion campaign of British cattle destruction and compensation. So this could be “more greatest medical scandal”… WHY? According to my opinion BSE (popularly called ‘mad cow disease’) is not an infectious disease ( http://www.bse-expert.cz ). See these relationships, according to my recent presentation at 29th World Veterinary Congress in Vancouver; Neurodegenerative Diseases and Schizophrenia as a Hyper or Hypofunction of the NMDA Receptors (www.bse-expert.cz/pdf/Veter_kongres.pdf).

  25. #25 Paula
    January 18, 2010

    It’s still pretty disorganized, conflicting, apparently. And in Washington State, where according to news headlines there’s a glut of the vaccine, a Seattle friend whose physician is with one UW clinic was told there were only a dozen doses available and she’d have to wait.