It's hard to ignore the concern in the wording of the latest weekly CDC flu update.
The influenza-like illness that we track with our ILInet sentinel provider system is showing higher levels of illness than we saw last week. Again, these are unprecedented levels of illness. The national average is about 6.1% of doctors visits, for purposes of influenza-like illness that's very high at any time particularly in October. We also track mortality around the country. Through something called the pneumonia and influenza mortality survey with 122 cities. And for the first week this fall, we're seeing that the amount of influenza and pneumonia mortality is above the epidemic threshold. All of these things may suggest it's a very busy and difficult flu season and we are seeing very high levels of activity around the country. We are also having updates on the pediatric deaths. Unfortunately those are going up as well. There are now a total of 86 children under 18 who died from this H1N1 influenza virus, the 2009 H1N1 influenza virus. We had 11 more influenza pediatric deaths reported in week 40, which is the week that ends October 10. Ten of those are confirmed to be due to the new strain, the 2009 H1N1 strain and the 11th is probably due to that but the typing hasn't been completed. About half of the deaths that we've seen in children since September 1st have been occurring in teens between the ages of 12 and 17. These are very sobering statistics, unfortunately, they are likely to increase...
We hope that the continuing deaths in children will be as few as possible but this is a very brisk number, usually in a whole season that lasts from going to September all the way to may, you would only have about 40 or 50 deaths so in just one month's time we've had that many.
Yet even as the data show increases in flu cases (widespread in most states) and increases in mortality, the public remains skeptical about vaccination. It isn't disinterest. The latest Pew poll clearly shows that folks are paying attention:
It may be under-appreciation of risk, but that will sort itself out over time. Here's why I say that (see red line):
Still, right now the public health officials and the public are not sharing exactly the same concerns (vaccine safety is a considerable public issue and perception of safely is what's on public health's radar.) As outlined by John Solomon on his blog via an anonymous public health expert (comments I've heard myself), public health officials are concerned about three things:
"My biggest concerns as of the moment:
1) Concerned that a substantial portion of country may be infected before vaccine arrives — will depend on speed with which epidemic moves in next month, as well as speed with which vaccine can be delivered to states, as well as how fast states are able to get vaccine into people.
2) Concerned that large numbers of persons who could get vaccine will choose not to vaccine because of concerns that it is experimental or untested — great deal of misinformation out there on the streets. The Paul Offit editorial in [Monday's] New York Times describes many of the widely circulating beliefs about the vaccine and the actual facts. Poll about 2 weeks ago showed that while 60% of American parents willing to get their kids vaccinated for seasonal flu, only 40% were planning on their kids vaccinated for H1N1 – even though almost all of the flu circulating now is H1N1.
3) Concerned that antiviral resistance could develop –so far there is no sustained neurominidase inhibitor resistant strain circulating, just single cases popping up and very rarely. If sustained resistance occurred, we would lose key tool for treating the sickest patients. It is good sign that no sustained resistance has developed so far, but it would be a non-linear event if it happened. No accepted view from the hard core flu virology community on the likelihood of this happening or not."
Luckily, there's no current evidence for other than occasional cases of antiviral resistance. And how's the vaccination plan going? Here are the basics: with current technology, flu vaccine takes six months to make. With the description of the new virus in print in mid-April, we are now six months in, vaccine is now being made, and it is just now rolling out for inoculation. Is it timely? Yes. Is it timely enough? No, because the virus didn't wait for us. We could have closed schools to slow spread, but that would have cost us between 10 and 47 billion dollars in a recession (reserved for a more virulent bug.)
In fact, the vaccine is slow to arrive, as many of us predicted (an easy prediction because nothing goes as planned on paper.) Here's how much we'll need, based on CDC projections:
But for right now we only have 11.8 million on hand and delivered, and 40 million doses scheduled for October arrival; the rest will be here in November. That means health care workers will get vaccine offered to them first, along with young children and pregnant women and kids with underlying conditions. Healthy children less than 24 will go next, followed by 25-64 year olds with underlying conditions. After that, healthy adults, and after that, healthy seniors. There's room in line for everyone, but the kids go first. That is the message we have been passing along since September: with pandemics there are always shortages of staff, space and stuff, and that should be the expectation and part of planning.
And so once we have vaccine will everyone ask for it? Not even close, according to Pew, although for context remember that only 20-30% of the public gets vaccinated every year against flu, and that includes seniors (75% vaccination rate), who get vaccinated more than any other group (8% for pregnant women, less than 30% for asthmatic kids younger than 17.)
Overall, fewer than half of Americans (47%) say that they would get the swine flu vaccine if it was available to them; an identical percentage says they would not get the vaccine. A clear majority of Democrats (60%) say they would get the swine flu vaccine if it was available, compared with 41% of Republicans and the same percentage of independents.
It might seem like Democrats are more inclined to trust this government, and that the anti-Administration bent of right wing nutters is taking a toll. After all, there's a partisan edge to this:
More than half of Republicans (54%) say news reports are overstating the swine flu's danger, compared with 42% of independents and just 35% of Democrats.
But given that this is a political blog, think of this as if it were an election. The main issue is not the hard core opposition (they are always there, fixed in their thinking, and not subject to rational discussion), it's the reasonable and persuadable public that needs convincing that this vaccine is safe, and they won't be reached by yelling at the nutters. To put this another way, there are legitimate concerns about wanting to see safety data that should be addressed rather than ignored. For example, whenever something gets studied, it ought to get published asap and made available. Here's a good start:
By day 21 after vaccination, antibody titers of 1:40 or more were observed in 116 of 120 subjects (96.7%) who received the 15-µg dose and in 112 of 120 subjects (93.3%) who received the 30-µg dose. No deaths, serious adverse events, or adverse events of special interest were reported. Local discomfort (e.g., injection-site tenderness or pain) was reported by 46.3% of subjects, and systemic symptoms (e.g., headache) by 45.0% of subjects. Nearly all events were mild to moderate in intensity.
Do rare adverse events happen? Sure. But the rare real event doesn't mean everyone else should, for example, abandon flying.
Sullenberger Flies Fateful Route Again, to Cheers
And if you were on that plane and won't fly the route again, bless you, I understand.
Absent more data like that above, safety is the number 1 issue (Pew again):
Note that only 16% "don't believe in vaccination" (even that small number includes those who think flu shots make them ill, which can happen for the egg allergic or those who have had previous reactions) and that as many (9%) "want to give their slot to someone who needs it more" as those (10%) who think "the swine flu risk is exaggerated". The big chunks of concern are safety (35%) or those who simply think they are too healthy to worry (23%).
The betting is that local deaths will increase demand, while stories about side effects will do the opposite. But if those flu numbers keep spiking, demand will start to grow.
So what's the best way to proceed? Follow the advice in this Nature editorial:
Public-health authorities, who are keen to contain the pandemic's spread, need to realize that their best hope of dealing with such public reluctance is to patiently address the concerns that underlie it.
Sometimes, it's true, those concerns go beyond any appeal to reason. They grow out of a visceral mistrust of authority in general - and of government, regulatory agencies, medical researchers and multinational pharmaceutical companies, in particular. A sophisticated anti-vaccine movement has emerged that plays on this wariness, and helps to feed the conspiracy theories about the H1N1 vaccine that are circulating on the Internet and in viral e-mails.
But far more often, say researchers who have studied this subject, people are assessing vaccination through a perfectly rational cost-benefit analysis.
[snip]
More generally, for officials and researchers at all levels, the scepticism over the pandemic vaccine should serve as a timely reminder of the imperative to work to gain greater public trust in science-based advice and in those who give it.
Most vaccine skeptics have legitimate reasons for concern and are indeed making their own decisions for this voluntary program. Think of them as the independents. I completely agree with the thrust of the editorial, and think it's worth time to discuss the pros and cons of vaccination with them. It'll save lives to do so.
Oh, yeah, and there's this:
Skepticism is healthy. And as I noted here, I think a persuasive voluntary program is the best way to get as many people as possible to accept vaccination. In the meantime, I reserve the right to give the nutters a hard time.
See Rimjob's recommended diary on vaccine fact and fiction. There's more to skepticism than just the nutters, but they're no help at all.