H1N1 Immunization Campaign Targets College Students

RALEIGH — In response to continued cases of H1N1 on college campuses across the state, the N.C. Division of Public Health is sponsoring a college immunization campaign during the month of February to protect young people against the flu. “While flu cases are not at the level they were back in the fall, we are seeing clear evidence that H1N1 is still striking young people,” said Zack Moore, M.D., public health epidemiologist.

From late January through early February, student health centers outpaced other providers in cases of influenza-like illness. A similar trend was evident during the fall wave of H1N1, with student health centers consistently seeing higher-than-average rates of flu. However, statistics from the state’s Immunization Branch show college-age individuals remain the least immunized overall in the state. As of Jan. 30, only 5 percent of 19- to 24-year-olds had received vaccine distributed to colleges through the N.C. Division of Public Health.

“Students appear to be less interested now because H1N1 is not getting the publicity it did in the fall,” said Katrin Wesner, director of Abrons Student Health Center at the University of North Carolina at Wilmington. “This campaign will help us re-energize our efforts and remind people that it is not too late to be vaccinated.”

College mascots are joining the campaign to encourage students to get immunized. Mascots from eight colleges and universities will be sporting bandages with the message “The Flu Stops With Me” at selected basketball games during February. In addition to their campus efforts, student health services personnel will offer immunization clinics at games to reach students and others who have not yet been vaccinated.

“This is a great opportunity for us to reach one of our most at-risk populations,” said State Health Director Jeffrey Engel, M.D. “We appreciate the support of our colleges and universities in helping us get the message out about the importance of immunization.”

Colleges involved in the campaign include N.C. State University, Fayetteville State University, UNC-Chapel Hill, UNC-Charlotte, North Carolina A&T, UNC-Wilmington, East Carolina University and Winston-Salem State University.

For information about H1N1 and immunization clinics, see flu.nc.gov. Students may also check with the student health center at their college or university.

Last week the Guilford County Department of Public Health sponsored two open influenza vaccine clinics.

We had about 150 citizens come to get their “flu shields”.

Influenza is still circulating across the state and in Guilford County, but at levels that aren’t drawing much attention.

I encourage everyone who has not had both seasonal and H1N1 vaccines to get them both.  Public Health officials anticipate that there will be a second outbreak in the coming few months.

In the meantime, the Health Department will continue to keep our clinics open and appointments available to schedule immunizations.  But we intend to hold on further large open clinics for now and until the demand for vaccine increases.

Guilford County Department of Public Health will hold two more flu vaccination clinics for the general public on Wednesday, January 27, 2010 at Christ United Methodist Church, 1300 N. College Drive in High Point and Moses Cone MedCenter, 2630 Willard Dairy Road, also in High Point.  The time will be 4:00 p.m. to 7:00 p.m.

Each clinic will offer both the H1N1 and seasonal flu vaccines. The H1N1 flu vaccine will be available for persons 6 months of age and older.  Seasonal flu vaccine will be available for persons 4 years of age and older. 
The vaccines will be provided at no cost. No appointment is needed. Vaccines will be available first-come, first-served.   Spanish interpreters will be on site to assist.

For more information about these clinics, call Guilford County Department of Public Health at 641-7777.

Stephen R. Covey (of 7 Habits of Highly Effective People fame) speaks of the “emotional bank account”. The metaphor is a rather simple one to understand. In each encounter with other individuals we establish a “bank account”. Sometimes the bank account starts as neutral; sometimes it has some trust already built into it. Unfortunately in too many encounters we find ourselves starting a relationship already in debt; where mistrust is already present without our having said a single word or performed a single action.
Part of the challenge comes from the nature of the deposits we make versus the magnitude of the withdrawals. We can spend virtually all of our existence being compassionate, kind and courteous towards our friends, families, colleagues or patients. It is human nature to undervalue those positive deposits; indeed we take this behavior as our due and discount it. But should we lose our tempers or make an error in judgment, the withdrawal sends the bank account into a debt from which we may not recover. It can take years of positive actions to overcome one withdrawal, even if the withdrawal was a misunderstanding, unforeseeable or unavoidable.
I bring this up because the emotional bank account applies to influenza vaccination campaigns and public acceptance of vaccination. In the 20 January 2010 JAMA, there is an article entitled “Public health response to influenza A (H1N1) as an opportunity to build public trust” by HJ Larson and DL Heymann of the London School of Hygiene and Tropical Medicine and the Center on Global Health Security in England. In so many words, they are talking about the state of the public health emotional bank account. Despite best intentions, public health has been overdrawn for years.
We started our vaccination efforts in debt with the nation’s community.
The catalog of missteps is not necessarily long. But the withdrawals are huge:
1. The US Public Health didn’t treat syphilis patients in Tuskegee, Alabama in order to accumulate knowledge of its natural history. That knowledge was already available historically in the Oslo studies. This study now serves as the boogeyman to scare every investigator applying to an IRB for study approval. The Tuskegee study was started before I was born, but even now is in the collective memories of Guilford residents.
2. Concerns about preservatives in influenza vaccines were not alleviated by CDC/FDA assurances that thimerosal poses no risk. If there are no risks, then why would one purposefully remove it? How can you make a perfectly safe vaccine “safer” and why would you try?
3. Links of influenza vaccination to Guillain-Barre Syndrome have yet to be resolved. The advocacy of the first swine flu vaccine by public health was halted when cases of GBS surfaced abruptly. Although it was unlikely to be due to the vaccine, the CDC took it on the chin and many long and successful careers ended back then.
4. The use of the word “recall” in returning vaccine that was losing its potency led to many fears. Even when actions by public health are correct, the words used can carry meanings that are not intended.

I could find other examples easily, but you get the idea. And of course all of these emotional bank withdrawals are played out in the current climate where distrust of any governmental agency seems to be equated with being a patriot.

But there are remedies. As Larson and Heymann espouse in their commentary, there are three key elements of building trust: knowledge and expertise, openness and honesty, and concern and care. There doesn’t seem to be a better way to build a positive emotional bank account.

The World Health Organization has been called to task for exaggerating the threat of H1N1 and, essentially, making up the H1N1 pandemic.

In the United States alone there have been 38,000 hospitalizations and 1779 deaths since 30 August!!!

You can judge for yourself, but locally influenza has been an ordeal!  It’s not a governmental conspiracy at any level: local, state, national or international.  Our family members have been sick.  Our Emergency Rooms and ICUs have been filled.  We’ve had deaths in Guilford County directly due to influenza.  No exaggeration.

So where do we stand at this date?

The CDC has a newsletter that they publish with supplemental updates.  Late last week they sent out an MMWR report, “Interim Results: Influenza A (H1N1) 2009 monovalent vaccination coverage”.   We’ve got a long way to go to protect our communities from the next wave of swine flu (more about that in a moment).

Using ongoing telephone surveys, the CDC has estimated that 61 million people have received the H1N1 vaccine.  That sounds pretty fair…until you calculate that 61 million is only 20% of the population.  AND of the people who need it the most, those with chronic medical conditions (such as diabetes, obesity, asthma)  only 12% have been vaccinated.  Clearly now that we have more than adequate vaccine supplies we need to continue our efforts in offering vaccination to everyone.

It is a relief that we are in a trough right now with actual cases of H1N1.  North Carolina is seeing “local” activity rather than “widespread”.  Influenza-like illness is at the baseline level, almost that level seen before schools opened this fall.  The lack of widespread activity removes a lot of the pressure on the medical community, but also reduces the anxiety levels that prompt people to seek vaccination.

No one knows what the future holds with influenza.   But the current pattern has similarities with the 1957-8 influenza season.  Namely, there may well be a third wave of infections in February/March that equals if not exceeds anything we’ve seen so far.

The 80% of us who have not taken advantage of vaccine availability should reconsider their choice.  We have vaccine and continue to make it available to those who want it.

The Center for Disease Control and Prevention has a new media campaign to encourage people to get the H1N1 vaccine.  A sample of the social media efforts can be viewed online.

I also saw a state sponsored public service announcement last night on television.  It showed a lineup of very pretty and happy people after they had supposedly received their influenza vaccine.  Each has a bandaid on their arm which they proudly show to camera.  There is only a small problem:  The bandaid is over their biceps…that’s not where you get the vaccine.  The deltoid muscle (upper arm) is where the injection is placed…so the bandaids are in the wrong spot.  Nice try though.

The national medical journals have been busy since Christmas.  Just looking at the major ones, JAMA and the New England Journal of Medicine, there are very important articles about the influenza disease and the vaccine.

From our CDC and England’s MRC, there is an article that describes the “household transmission of 2009 pandemic influenza A (H1N1) virus in the United States”.  So if one family member gets the flu, how many other family members get sick?  Well it appears that the transmission is lower than seen in past influenza seasons.  In three quarters of households, no one else got sick.  As we’ve seen here in Greensboro, the incubation time (from the sick family member to other sick family members) is about three days.  (Cauchemez and others, NEJM 2009;361:2619)

Remember back to April, there was that high school in New York City where students went to Mexico for spring break and came back with H1N1.  The same issue of the New England Journal describes some of the details about the spread of the virus at that point in time. (Lessler and others. NEJM 2009:361:2628)

Of equal interest are a report from Australia and an accompanying editorial by Tony Fiore and Kathleen Neuzil in JAMA, that explores the response of infants and children to the H1N1 vaccine.  The conclusions are that the vaccine is highly potent, even after one shot, and there are no unexpected side effects (it is safe).  Although we might be able to get by with only one shot for children, it is better to get two, as we currently provide.

The most interesting article was actually a comment by Dr. Ofri in NEJM, entitled “The Emotional Epidemiology of H1N1 Influenza vaccine”.  Simply put, when we wanted the vaccine we didn’t have it.  Now that we have it in great supply, we don’t want it.

My take on Dr. Ofri’s comments is that… I agree.  There is this great science fiction movie, Serenity, I’ve enjoyed watching many times.  The premise is that there is a federation plot to eliminate violence on a distant planet.  But rather than making people peaceful, instead it makes 90% of people so peaceful they stop eating and they die… and it makes 10% of people so violent that they become monsters.  We all tend to react that way to issues…going to extremes.  Either we are frantic to get the vaccine or we’re totally indifferent.  A middle ground would definitely be nice….we recognize the potency of the vaccine, the safety of the vaccine, the availability of the vaccine.  AND we start thinking collectively.  Even if you don’t get influenza each year, even if you do only get a mild “flu” when you do, your loved ones aren’t so lucky.  The people most vulnerable to influenza are also the least likely to get protection from a vaccine.  So by providing ring immunity, by vaccinating the strong, you protect the weak.

That’s loving kindness.

Big Box Retailers Approved For Direct Shipments Of H1N1 Vaccine

RALEIGH — As part of a nationwide initiative to improve vaccination rates against 2009 H1N1 virus, retail pharmacy chains and retail-based medical clinics across North Carolina are now able to get H1N1 vaccine directly from the Centers for Disease Control and Prevention (CDC).

State Health Director Jeffrey Engel said he and health directors from across the country are supporting the supplementary 2009 Influenza (H1N1) vaccine initiative by the CDC as a way to get more vaccine out to the public at a critical time.

“The more people we can get immunized against this virus, the less likely it is to spread in the coming months,” said Engel. “This initiative helps us expand the pool of providers and venues where vaccine is available.”

According to the CDC, retail chains will be allowed to order vaccine directly from the CDC on a weekly basis through the end of January. To participate, chains must be capable of ordering an initial minimum of 100,000 doses of vaccine at one time and delivering all doses of vaccine received to vaccination administration sites within two days after receipt of vaccine.

The supplemental retail initiative will be in addition to the vaccine doses allocated to states based on their population size. North Carolina is expected to receive up to two million more doses of vaccine before the end of January.

Retail pharmacies may opt to continue receiving vaccine through the N.C. Division of Public Health, which is responsible for vaccine distribution to retail and independent pharmacies, local health departments, colleges and universities, private providers and hospitals.

Consumers are advised to check directly with their local pharmacies or health departments for vaccine availability or visit flu.nc.gov for a convenient flu vaccine locator.

The news went out last night that the vaccine manufacturer, MedImmune, was recalling millions of doses of their nasal live attenuated influenza vaccine, FluMist.  I just now received the information from the CDC that explains the purpose of the recall.

Imagine that the nasal vaccine is a carton of milk that you bought in October.  In October you poured the milk over your bowl of cereal and enjoyed it immensely. Then you put the milk back in the refrigerator.  Putting the orange juice in front of the milk carton, you forgot it was there…until yesterday.  Now on rediscovering the milk, you notice the carton is past it’s expiration date.  You could drink it and probably nothing will happen.  Or you can toss the milk and buy some that you know will be fresh and good.  Most of us would just toss the milk and go to the store for some fresh milk.

That is kind of what happened with the nasal vaccine.  The company has been monitoring the “potency” of the vaccine and it has been perfectly fine up until just recently.  They found that the potency of the vaccine had dropped below what they wanted it to be, so they asked everyone to return the vaccine (like tossing the carton of milk even when its probably still good) from the questionable lots.

So here’s the important part.  Even if we kept using the vaccine now, it would probably work.  But rather than take any chance that it will lose more of its strength and have to do a “do-over”, they are pulling the lots.

So no one has to fret…except we at the health department who need to find out if we have any of the lots on our shelf.  If we do, we’ll send them back.

No one has to get revaccinated.  No one has to know what lot they received because all the vaccines that were given were potent at the time they were given.