REGION: North America
TOPIC: Health
PBS NewsHour
Originally Aired: Dec. 15, 2009
Insider Forum

Who Should Get Vaccinated, How Bad Will the H1N1 Pandemic Get, What's Ahead?

CDC flu head Dr. Anne Schuchat and flu expert Dr. Michael Osterholm answered your questions about the H1N1 pandemic.
Doctor with patient

BETTY ANN BOWSER: Welcome to the Online NewsHour's Insider Forum. I'm Betty Ann Bowser. The new WETA-NewsHour documentary, "Anatomy of a Pandemic," follows the course of the current H1N1 influenza outbreak, explains the science of the H1N1 vaccine and explores how this pandemic compares with pandemics of the past.

Today we have asked two experts to join us to answer your follow-up questions about the documentary. Rear Adm. Dr. Ann Schuchat is the director of the Centers for Disease Control's National Center for Immunization and Respiratory Diseases and has worked at the CDC since 1988 on immunization and infectious diseases.

And Mike Osterholm is the director of the University of Minnesota's Center for Infectious Disease Research and Policy and is a professor of environmental health sciences at the University of Minnesota.

Okay, the first question we got is from Jessica Meyers from Rockville, Maryland. She wants to know: "The documentary was pretty scary. What would be the first signs that the virus has recombined into a more dangerous strain?"

DR. ANN SCHUCHAT: We're testing the viruses that are identified in particular from severe patients. So we will have laboratory evidence of changes in the virus. But we also look for clusters of unusual disease patterns that will merit special investigation.

BETTY ANN BOWSER: And have you found anything so far?

DR. ANN SCHUCHAT: There has been recognition of a mutation that was found in Norway by some scientists and in Ukraine. And that mutation has been found in several other countries, including the U.S. But, so far, the additional studies we have done are reassuring that this isn't that long-awaited terrible mutation.

MIKE OSTERHOLM: One of the other areas that we're also looking at very carefully is the development of antiviral drug resistance which in itself is a mutation that would be of concern. And to date, while there have been clusters - and small ones, at that - of antiviral resistant strains, most of these emerging in hospital settings, among immune-compromised patients - and there have been some isolates from persons in the community where resistances has developed, we have not seen that be a serious public health problem.

This is one we're monitoring very closely because we believe today that antiviral drugs can play a very important role in reducing severe illness and preventing death. But if we were to lose that ability because of resistance, this would be a significant problem. The good news is, to date, we're still in pretty good shape.

BETTY ANN BOWSER: Mike, what does it take to have a mutation occur? I mean, how easy and/or difficult is this to make it happen?

MIKE OSTERHOLM: Well, one of the things that makes influenza a very challenging infectious disease among all the ones we deal with is the way that it basically reproduces itself. It's a very sloppy and promiscuous virus, unlike many other infectious agents. It doesn't, for example, have a good way to correct mistakes when its genetic material is reproduced and somehow there is an error in that reproduction.

The second thing is that the virus actually will swap out its genes with another influenza virus if two separate viruses should inhabit the same cell in a pig lung or a human lung or some other animal species. And so that between the two of those different situations, this virus is more likely to experience genetic change than most other infectious agents that we see.

So we have to be always vigilant about that. That's why, in fact, think of all the other vaccines that we have today and our repertoire of public health vaccines where we actually have to change out the vaccine on an almost annual basis to get the right seasonal strain match between the vaccine and the virus. Again, this is because of this rather unstable genetic picture. So this does present some very usual challenges with influenza and one that we're constantly following.

Now, the good news is - if there is any good news - is that in previous pandemics - and I say previous as in two: 1957 and 1968 - there was actually a substantial period of time from when those pandemics emerged and the strain of virus causing those pandemics and the actual occurrence of substantial change in those pandemic viruses. For example, in 1957, it was 7 years before we ended up having to change the strain of virus in the vaccine to actually accommodate any changes in the virus.

So hopefully, we will continue to see in this virus that we have now not change. And if that were to be the case we - this vaccine will remain highly effective that we have now and we won't have to worry about mutations or reassortments, these genetic changes resulting in a more severe strain in terms of causing disease.

But, again, with influenza, expect the unexpected. We are constantly looking for this, but we hope that we won't see these changes that would really make us worry even more about this particular strain.

Dr Ann Schuchat
Dr Ann Schuchat
Centers For Disease Control
The universal flu vaccine will be the ultimate, but there is a lot of promising - other approaches that might even bear fruit sooner.

Search for a universal vaccine

BETTY ANN BOWSER: The next question comes from Teresa Arbott and she wants to know: "What is it going to take for a universal flu virus vaccine to be created for all different types of flu?"

DR. ANN SCHUCHAT: You know that, of course, was featured in the documentary and is a very exciting aspect of current vaccine science. You know, there is some promising work that was highlighted and this is the Holy Grail of influenza vaccines. But it has taken - you know, I think that it will take time and work to see whether the hypotheses and leads that are being followed pan out.

Again, with vaccines for influenza, there have been years of research into a lot of different approaches and we haven't really gotten that next-generation jump that we'd like to see. The universal flu vaccine will be the ultimate, but there is a lot of promising - other approaches that might even bear fruit sooner.

Dr. Mike Osterholm
Dr. Mike Osterholm
Center for Infectious Disease
And one other thing that we're wrestling with today in the area of public health and science in general is almost what some of us have come to label an anti-science movement in our society.

Public suspicion of science

BETTY ANN BOWSER: The next question is from L. Lange in Canton, Ohio, and she wants to know - her mother developed ALS after getting a swine flu shot in 1976. And she is now age 62 and she wonders if she is genetically predisposed to a neurological problem because of this and, because of it, should she get the H1N1 vaccine?

MIKE OSTERHOLM: Well, let me address this head on because it was our group, actually, in Minnesota that first documented that occurrence of Guillain-Barré syndrome, a type of neurologic disease, with the 1976 vaccine. And I was very involved with subsequent studies that looked at the risk of these neurologic diseases - specifically Guillain-Barré syndrome associated with the vaccine.

The important message to get across is that there was no other condition other than Guillain-Barré syndrome that was associated with that 1976 vaccine, including ALS. So while on any one given day there will be lots of people around the world that will develop any number of different health conditions, some of those will coincidentally occur - of course, occur immediately after a person has been vaccinated with this vaccine. But there is no cause and effect.

We see that - there are over 2,000 women a day in this country that have spontaneous abortions. I could go through a whole laundry list of conditions - including the onset of neurologic diseases - and the very, very good news with this vaccine, with data now on millions of people is that there has been no evidence of any adverse event of any serious health nature - meaning beyond local inflammation at the site of the injection and so forth - there has been nothing that would suggest that there is any risk here.

So I would strongly urge that the individual whose mother developed ALS after the 1976 vaccine look at that as a coincidental event, not as a cause and effect, and that there is absolutely no reason why they should defer themselves from receiving this vaccine because of that event.

BETTY ANN BOWSER: Why do you think the public is so suspicious these days of vaccines causing all sorts of things?

DR. ANN SCHUCHAT: You know, we have a tremendous success story in the United States with high immunization coverage and very low rates of most vaccine-preventable diseases. So a lot of parents - and even a lot of doctors - have never seen some of the fatal forms of vaccine-preventable diseases like measles and Haemophilus influenza b, meningitis. Even with influenza, there is less awareness of the severe toll that it can take on some unfortunate people.

So I think that, as recognition of the diseases that vaccines are preventing has decreased and parents have started to ask questions about what the vaccines are for - and I think that we have had some scares really about unsubstantiated linkages between chronic neurologic problems and vaccines, things like fears about autism and vaccines that did not pan out when the scientists explored this in detail.

So I think that parents have lost track sometimes of the benefits that vaccines have continued to cause and may have concerns about possible risks.

MIKE OSTERHOLM: And one other thing that we're wrestling with today in the area of public health and science in general is almost what some of us have come to label an anti-science movement in our society. And this may be in part a response to the complexities of our, quote, unquote, "scientific" world today.

But whether it's around vaccines, whether it's around certain aspects of food safety and the use of irradiation, whether it's the issues around global climate change, we can see a whole number of topics today where we are seeing people pull back from objective scientific data, where they are willing to believe someone who post anything on an Internet site that, no matter how far-fetched it is. We see people taking their advice from comedians as opposed to doctors today and doing that with great seriousness.

And so, I think that one of the areas that we all need to study, not just around the areas of vaccine - although this is the key area that we want to address today - is why is society beginning to shun almost a science-based approach? And this is going to be important for us as we move forward with a whole lot of public health activities and other science-based programs.

DR. ANN SCHUCHAT: You know, and just to add to the discussion, I think it's important for people to know that with childhood immunizations, the vast majority of parents vaccinate their children with the recommended vaccines. So while we hear about outbreaks that occur among people who are refusing vaccines or about some vocal people who really do question a lot about the value of vaccines, you know, most people are doing what health professionals recommend.

And I think that's a very important feature. That's not the case in some other countries. And so, I think we are fortunate to have as strong an immunization system as we have. It's just one of those things that we would like it to be able to sustain threats in the future.

Dr. Ann Schuchat
Dr. Ann Schuchat
Centers for Disease Control
Now that we have ample supplies of vaccine, we really hope more people will take advantage of it, both those in the groups that we targeted early on and then additional healthy adults and seniors.

Who should get vaccinated?

BETTY ANN BOWSER: Okay, the next question comes from Julie in Madison, Wisconsin. And she wants to know, "if somebody has already had the swine flu, should they get the vaccine?"

DR. ANN SCHUCHAT: This is a common question. Most people who have had an illness that they think is the H1N1 infection haven't actually gotten the confirmatory laboratory test that could prove it, so our recommendation is to get the vaccine. We don't know of any harm in getting the vaccine if you've already had the H1N1 infection. And yet, many of the people who think they've had this may have had another respiratory illness that would not protect them.

There are anecdotally a number of people who tell us, I've had this thing multiple times. And that just tells you that most of those circumstances, one of the times, it wasn't actually the H1N1 influenza virus. So we do think it's reasonable to get the vaccine even if you think you've already had this infection.

BETTY ANN BOWSER: The next question is from Tshimanga Tsamandu from South Bend, Indiana, who wants to know: "Why is the vaccination necessary for everybody to have who meets the standards" - in other words, the high-risk groups?

DR. ANN SCHUCHAT: Well, those groups are people who have a higher chance of suffering hospitalization or dying from influenza or who are at greater risk of spreading the infection to vulnerable people like newborn babies or the patients that they care for if they're a healthcare worker. At this point, most states have opened vaccination to additional groups, to really the general population as the supply has improved. But the general goal is for those who could disproportionately suffer from this virus to have a chance to protect themselves and their loved ones in terms of who are the early target populations?

And it sounds like Mike may want to add to that.

MIKE OSTERHOLM: And I just want to emphasize - yeah, I just want to emphasize this point. I think Ann's done a very good job of laying out - the criteria was really based on the likelihood of severity of illness. But we want to make sure everyone understands that we believe everyone is actually vulnerable to this virus. And therefore, there's not somehow that you are at risk and need to get vaccinated and you are not at risk.

Everyone is at risk of becoming infected. And either they need to be protected through having had disease - but in many instances, it was pointed out, we won't know that. So we would rather err on the side of safety and say get vaccinated if you weren't absolutely confirmed to have been an H1N1 infection. And either that or being vaccinated - and in some instances, there may be individuals well over the age of 65 who may have experienced this virus or a cousin to it 40 or more years ago. But even that is unclear as to how many people over age 65 are protected.

So our bottom line message is everyone should be vaccinated.

DR. ANN SCHUCHAT: I think there's also a key point right now that we have this incredible window of opportunity right now with a lot more vaccine available in the states and communities and a little bit of a window in terms of the disease. You know, it's starting to get better in a lot of places. But that doesn't mean it's over.

And so we think this is a critical time for people to go out and be vaccinated, ideally before the holidays, before they're gathering with other family members, but the weeks and months ahead could lead to a lot more H1N1 infection. And now that we have ample supplies of vaccine, we really hope more people will take advantage of it, both those in the groups that we targeted early on and then additional healthy adults and seniors who have been hoping to be vaccinated but didn't yet have a chance to.

Dr. Ann Schuchat
Dr. Ann Schuchat
Centers for Disease Control
We can't neglect how influenza happens everywhere and that we're all interconnected, and that investments in global capacity-strengthening on the laboratory and epidemiologic side are really critical.

Lessons for the next pandemic

BETTY ANN BOWSER: The next question is from Charlie Meeker of Fletcher, North Carolina. And he wants to know: "What do we know about Tamiflu resistance?"

DR. ANN SCHUCHAT: There's just a couple dozen resistant influenza viruses here in the U.S. and around the world, two or three times that. So these are rare circumstances. We've had a couple clusters in health care facilities or one on a train in Asia, but so far, the vast majority of people who have influenza caused by the 2009 H1N1 virus have disease that's easily treated with the oseltamivir, or Tamiflu, medicine.

That doesn't mean that resistance couldn't become more common in the future. With seasonal flu virus, we had, within just a 1-year timespan virtually all of the seasonal flue strains in one of the types became resistant. So we need to keep tracking this and we really want to make sure that the medicines are used for people who have severe disease or who have risks of complications of infection. And the medicines that we have right now ought to work well.

BETTY ANN BOWSER: And then the final question comes from David Merz from Little Mountain, South Carolina. And I guess, really, this is one for you, Ann. He wants to know, "what are the major lessons the CDC has learned about the response?"

DR. ANN SCHUCHAT: You know, there's so many lessons. I'll just try to pick a couple. I think that one important lesson is to be extremely careful in our communication. I think we've been criticized for over-promising the amount of vaccine that would become available. And I think it's important, going forward, that we always pay attention to managing expectations and preparing the public to cope with the challenges that we face. So I think that this was something that we probably could have done better in our communication.

Another key lesson for me is how important global investments are. We have been working hard to strengthen influenza laboratory detection around the world, based on the H5N1 bird flu problem and we've really strengthened capacity in many places in Asia and some places in Africa so that if they developed clusters of severe respiratory disease, they would be able to identify the flu strain and sort out whether something unusual was going on.

I think it's unfortunate that the Mexico laboratory capacity was not strengthened as part of that effort, because if we had, a couple weeks ahead of time, recognized the strain that was causing severe disease in Mexico, we might have really been able to accelerate the vaccine production. If we could have just found it two or three weeks earlier, the availability of vaccine two or three weeks earlier would have made a big difference this fall.

So I think we can't neglect how influenza happens everywhere and that we're all interconnected, and that investments in global capacity-strengthening on the laboratory and epidemiologic side are really critical. So those are just two lessons. I think Mike probably has a couple lessons he'd like to -

MIKE OSTERHOLM: Yeah, well, if I could add kind of an outside perspective, not being part of the federal response here, let me just say that I think that Ann's point about the messaging and expectations on vaccine is on the mark, and I give the CDC and HHS in general credit for having learned that lesson and, I think, responded appropriately.

But I think another very important message is that on the whole, all the investment that was made in pandemic preparedness has paid off in very large dividends. I think that the overall response from the Centers for Disease Control and Prevention in particular and state and local health departments has been nothing short of stellar. Communications have been frequent. There has been a very clear messaging on many aspects of this pandemic that, had this occurred 10 years ago, would not have happened.

I think there has been a recognition that there are many aspects to a pandemic that are far beyond that of just a patient getting sick. It involves the areas of health-care delivery, business preparedness, public communications and risk management in general. And so I think that on a whole, you know, we have to give credit where credit's due, and I think that some have suggested that our federal agencies may have originally hyped this situation based on what they now perceive to be the risk, which I would very strongly disagree with.

I think that every honest and reasonable means of portraying what this pandemic would be like, what it is going to be like and, frankly, what it still may be like in a potential third wave later this winter, I think they've done a great job. And we don't hear that enough. You know, we usually think of governments as being somebody who responds, and never quite good enough. And I think in this case, I think they've done an exceptional job.

BETTY ANN BOWSER: Well, thank you very much, both of you, for being with us today.

DR. ANN SCHUCHAT: Thank you, Betty.



Dec. 14, 2009
Anatomy of a Pandemic Documentary


Dec. 14, 2009
What Young People Should Know About H1N1

CDC Flu Site
Center for Infectious Disease