News & Events

Oct 5 09 NYTimes Room for Debate: America Takes On Swine Flu

By The Editors

Nati Harnik/Associated Press Five doses of swine flu vaccine, part of the first shipment of vaccine sent to Methodist Hospital in Omaha, Neb., Oct. 5, 2009.

The roll-out of the swine flu vaccination program, one of the largest such drives in U.S. history, started Monday. The federal government has ordered 250 million doses of vaccine, which will be distributed by state health officials this fall.

Yet surveys have found that a large portion of the public is uncertain about getting the vaccine, either because of concerns about potential side effects or because they sense the health warnings about the H1N1 virus are overblown. At the same time, many doctors worry that they are ill-prepared to handle the nationwide drive to immunize everyone.

We asked some doctors and public health experts, will such an ambitious immunization program work? What worries you most?

Confusion and Misinformation

David Ozonoff, a doctor and chronic-disease epidemiologist, is a professor of environmental health at the Boston University School of Public Health.

The difference between this year’s pandemic swine flu and seasonal flu is not the clinical behavior of the virus or its biology – so far that seems fairly typical for flu viruses. Nor is the H1N1 vaccine is not any less tested or more hazardous than the seasonal flu vaccine used every year. It is just a strain change, so there is no reason to expect any more or any less in the way of side effects.

The most rational policy is vaccination for the general population, but people may not make optimal choices.

But because this swine flu is pandemic strain, its epidemiology is different. Pandemic strains typically target a much younger population. The shift in risk from older age groups to younger means that critical care beds and the limited number of sophisticated mechanical ventilators needed to help victims breathe are being disproportionately needed by previously healthy adults and school-aged children or younger.

The numbers, thankfully, are still not large, but even a modest increase could break an already brittle system. To avoid this, everything we know about influenza indicates the most rational policy is to provide vaccination for the general population, and that’s the direction of current federal policies and recommendations.

At the same time, competent adults should be allowed to make their own decisions, even if their choices are not optimal for avoiding the risk of serious disease. And while health care workers have an ethical obligation to be vaccinated because they come in contact with people who are at higher risk for serious disease and death from flu, mandatory policies, even for them, are probably counter-productive. My greatest worry is that controversy over flu vaccine policy will be used by a vocal minority opposed to vaccination in any form to create confusion about all vaccination and lead to deaths or unnecessary disability of infants and children.

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Despite ramped up production, there is still too little vaccine for the world’s population. If the U.S. does not end up using all the vaccine ordered, I would hope the supply be made available to the rest of the world. In my view there should be a date certain for being vaccinated (say, sometime in January) after which time, except for a small reserve, swine flu vaccine can be shipped to less wealthy countries who need it and where it will save lives.

The Backlash Against Vaccination

Gregory Dworkin is the chief of pediatric pulmonology and medical director of the Pediatric Inpatient Unit at Danbury Hospital in Danbury, Conn. He is the founding editor of Flu Wiki, a Web site about flu and other health issues.

The discussion among many doctors now is about who goes first in getting the vaccine. I worry that those who need the vaccine the most (pregnant women, children, those with high risk conditions, and health care workers) will be slow to accept and ask for the vaccine.

Public health officials need to respond forcefully against the resistance to vaccination that has been growing.

This may be for a variety of reasons, including fear of a “new rushed” shot (it’s similar to the standard flu shot with the new virus swapped in), fear of getting the flu from the vaccine (that can’t happen with the shot; unlike the nasal spray for healthy people between 2 and 49, the shot contains an inactive virus), a habit of getting flu vaccines (the baseline immunization rate in a typical year for some high risk groups is pretty low — 8 percent for pregnant women, less than 30 percent for children with asthma, less than 50 percent for health care workers). The rate of flu vaccination is much better for the elderly, but that’s not who we are targeting with the swine flu vaccine.

For many years there has been an under-addressed backlash against vaccination. Some of the reaction to swine flu vaccination is connected to that backlash, which shows that public health officials need to respond more forcefully against that kind of resistance.

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At the same time, we need to be cautious about mandating vaccination, even for health care workers (the New York State Health Department is requiring that all hospital, home health and hospice workers get seasonal and swine flu vaccinations). Even in institutions like hospitals, resentment from the medical staff can spill over to patients and the community at large. That’s why I think a persuasive voluntary program is the best way to get as many people as possible to accept vaccination.

A Serious Persuasion Problem

Robert Blendon is a professor of health policy and political analysis at the Harvard University John F. Kennedy Kennedy School of Government and the School of Public Health.

At this stage it is too early to assess the effectiveness of the national campaign to get Americans vaccinated for H1N1. The larger communications effort just began a few weeks ago, and the vaccine is just starting to arrive in communities this week.

But in a survey conducted by the Harvard School of Public Health, we found reasons to worry about how many people would get the vaccine: only 40 percent of adults and 51 percent of parents said they were absolutely certain they would get the vaccine for themselves or their children.

Getting people to accept vaccination may be a challenge when there is general distrust of government and the media.


The extent of the public’s willingness to be vaccinated will be affected to some degree by how serious and widespread the initial outbreak is. We found six out of ten of those who said they did not intend to receive the vaccine would change their mind and get it if there were people in their community who were sick or dying from H1N1.

From my perspective, public health officials have some serious challenges. We found about a third of the public considered the H1N1 vaccine to be very safe vs. 57 percent for the seasonal flu vaccine. Public health officials need to focus their educational efforts on narrowing the gap in perceptions of safety for H1N1 and the seasonal flu vaccine by emphasizing the scientific evidence for the safety of the H1N1 vaccine and marshalling the support of trusted health/science experts and organizations representing doctors and nurses.

In addition, a share of the public is resistant to taking the vaccine because they do not see themselves at serious risk or because they believe they could be treated with anti-virals if they were to get infected. These beliefs may cause problems for people in a widespread outbreak, and public health officials need to address them with the support of trusted groups.

I believe these tasks will not be easy for public health officials. We are in an era of general distrust of government and the media. It is too soon to know what effect this environment will have on the success of the H1N1 vaccination campaign.

Infections from Doctors and Nurses

Kevin Pho, a primary care doctor in Nashua, N.H., blogs at

Not only are patients asking me whether they should receive the H1N1 influenza vaccine, but it’s a question doctors are asking themselves.

Recent polls say doctors and nurses may be more resistant to getting vaccinated than most Americans. The British Medical Journal published a survey showing that less than half of health care professionals are willing to receive the vaccine, while a poll from the Nursing Times found that only 37 percent of front-line nurses plan to be vaccinated against H1N1 influenza.

Unimmunized health care workers infected with the flu may have only mild symptoms, but can infect others.


This is consistent with data from the Centers for Disease Control and Prevention indicating that 60 percent of American health care workers traditionally don’t get vaccinated even against the seasonal flu.

Reasons for refusal include a fear of side effects, including the perception that the dead virus contained in the injectable form of the vaccine can cause disease. This is false, as is the belief that physicians and nurses are “too healthy” to become infected.

Indeed, unimmunized health care workers infected with the flu can show only mild symptoms, yet still have to potential to infect others. Also, a recent study showed that those infected with the H1N1 virus can be contagious for up to eight days after the onset of symptoms, significantly longer than strains of seasonal flu.

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Some also fear the manufacturing process, saying that the vaccine was “rushed” to production. This is another myth, as the CDC reports that the H1N1 vaccine is expected to have a safety profile comparable to the seasonal flu vaccine. This makes sense, as both vaccines are produced in a similar fashion.

There are over 11 million health care providers working in our hospitals, nursing homes and medical clinics. And with studies suggesting that 70 percent of doctors plan to continue working despite being sick with flu-like symptoms, tens of thousands of contagious workers can potentially infect patients who are already sick, or predisposed to flu complications. We owe it to our patients to receive the H1N1 influenza vaccine.