To boost or not to boost, or how our H1N1 vaccines will leave millions naked

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My latest piece for Slate examines the unsettling consequences of the United States' choice of swine flu vaccines.

The good news about these vaccines is that, to judge by the first vaccine trial results, published last week, they appear to work fast, safely â and at about a half to a quarter of the doses that the CDC expected. This means we effectively have about two to four times as many vaccines as we had figured we would. Since we ordered 195 million doses, we could vaccinate damn near the whole country.

If the fast-tracking efforts continue to work and the flu peaks closer to Christmas than Columbus Day, this robust and effective vaccine supply stands to sharply check swine flu in the United States, saving anywhere from a few thousand to 50,000 lives.

That's the good news. The bad news?

But what if we could save two to four times that many lives by vaccinating another 200 million to 300 million people worldwide?

Well, we could haveâbut the United States effectively decided not to do so when it ordered its vaccine supply. Back in May, many other countries ordered swine flu vaccines that include boosters, called adjuvants, that reduce by half or more the amount of antigen (the imposter or inactivated infectious agent) a vaccine requires to be effective. The United States, however, ordered almost all of its doses in the nonadjuvant, or unboosted, formâan older model of vaccine, considered the U.S. standard, that uses more antigen but creates vaccines that are (at least theoretically) safer. That safety, however, comes at the cost of exhausting the precious antigen supplies much faster â and leaving hundreds of millions elsewhere unvaccinated.

Altogether, I conclude,

if the virus retains its present, relatively "mild" courseâkilling about as many as the seasonal flu but more heavily concentrated on adults under 60, especially the sick and the pregnantâthis could mean some 20,000 to 50,000 deaths.

It's not pretty, and it's not simple. For the full range of complications (well, as full as I can make it in about 1000 words), check out the whole story.

You'll also want to check out some of the posts that drew this problem and some of its many wrinkles to my attention. Foremost is a great post from Revere at Effect Measure, who serves as a peerless â and peerlessly passionate and informed â guide to things infectious, especially flu. Close behind is Columbia University virologist Vincent Racaniello, who keeps a blog, and some great links and podcasts, at his Virology Blog.

Cheers.

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It will definitely leave me naked since I don't take vaccinations at all. in the first place. I surely will not be taking this monster of a vaccination. Any visrus that was created or altered by human hands is one thing. A government mandated vaccinaton for that same virus is a little suspicious to me.

www.newscientist.com/.../is-swine-flu-a-bioterrorist-vi.html

www.examiner.com/x-6495-National-Intelligence-Examiner~y2009m5d14-Tamif…

By Put that thing… (not verified) on 17 Sep 2009 #permalink

David,

Your latest piece in Slate was nicely done and informative. It's always refreshing to see pieces that put local/national health issues in a global context. One issue that was not mentioned in your piece was the fact that influenza vaccines using adjuvants would require additional testing prior to FDA approval, thus potentially delaying the distribution of the novel H1N1 vaccine beyond November. Given that speed is of the essence in this situation, I'm sure this factored into the decision-making process.

By Bryan Rock (not verified) on 18 Sep 2009 #permalink

David: First, thanks for the excellent piece; and second for the kind words and link. Always appreciated.

Regarding your commenter who doesn't want the vaccine, that's fine. I hope he/she doesn't get flu and make some innocent person sick but there willl be more vaccine antigen for someone else who otherwise couldn't get it. It's a zero sum game and this player doesn't want to play. That doesn't mean they still can't lose, but I wish them luck.

Regarding Bryan's point, yes, there would have to be clinical trials for an adjuvanted vaccine (even though the rare events of concern are invisible in those trials). But they can be/could have been done simultaneously with the unadjuvante vaccines and we can use the regulatory information of most of the rest of the world that does use adjuvanted vacine (like Canada and Europe). So we could have had both: data on adjuvanted and unadjuvanted vaccines.

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Adding adjuvant(s) doubles the amount of vaccine available?

Well, yes. But adding ersatz to oatmeal makes double the amount of that available, to feed to prisoners. That doesn't make it a good idea.

By P. Jennings (not verified) on 18 Sep 2009 #permalink

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