sábado, 7 de noviembre de 2009

Physicians Are Talking About: Is It Worth Getting the H1N1 Vaccine?

As the H1N1 vaccine arrives in local healthcare centers, the public debate still rages whether to risk the vaccine or the flu. Not even physicians are immune to the controversy.

An internist posting on Medscape's Physician Connect (MPC), an all-physician discussion board, asked his colleagues whether they plan to get vaccinated against H1N1. Some have responded with a decided "yes."

"I will take the swine flu vaccine as soon as it's available," says a clinical immunologist. "Ditto for wife and son."

"I am anxiously awaiting the vaccine," says a pregnant family medicine physician. "Pregnant women especially are having serious complications from H1N1, and I will take any and all immunity I can get."

"I have an acquaintance whose otherwise healthy 13-year-old died from H1N1 this summer," says a pediatrician, "so that'd be a great big yes."

"Immunizations have saved millions of lives, and counting," says a family medicine physician. "Why wouldn't I get the vaccine?"

However, other physicians are equally adamant about not getting the H1N1 vaccine.

"I don't want to be a lab rat," says an internist.

"No way I or my family will receive the vaccine. Not a chance!" comments another internist.

"Emphatically no to both vaccines," says a family medicine physician. "I agree with Dr. Joseph Mercola's take on the swine flu and this and the prior round of vaccinations for it. I believe, based on all I've read to date, that vaccinations cause a body more harm than good."
"I remember the last vaccine rushed to production. People died and some developed paralysis," says another family medicine physician. "I prefer to take my chances."
Several physicians wonder about the advisability of vaccinating segments of the population already exposed to influenza. An emergency medicine physician, who saw H1N1 cases throughout September, comments, "If the epidemiology here mirrors the Southern Hemisphere flu season, by the time H1N1 vaccine is available the virus probably will be done circulating through my community."
An anesthesiologist in the Dallas/Fort Worth, Texas, area commented that his community experienced a flu outbreak in September: "I'm not very enthused about giving my son the swine flu shot considering [that] he's likely had the disease already."

MPC contributors who have been treating H1N1 in their communities say that the illness, in the majority of cases, is mild. However, data on the spread and severity of the H1N1 virus are only now emerging. Two studies recently published in JAMA reported that the outbreaks in Mexico and Canada lasted about 3 months, but the peak lasted just a few weeks.[1] The Mexican cohort incurred a mortality of 27%,[2] twice as high as the Canadian cohort (14%).[3] The studies reported that the H1N1 influenza can produce a rapidly progressive respiratory failure that is refractory to conventional mechanical ventilation and that frequently targets young and healthy patients.

"This ain't your grandma's seasonal flu virus," says a pediatrician. "It's a quadruple-reassortant swine/avian hybrid that's never been seen before, significantly different from its predecessors, even if relatively wimpy." For this reason, he suggests that caution is warranted with regard to the infection and the vaccine. He adds, "It's not inconceivable that this vaccine could cause side effects not seen with seasonal vaccine, although it seems safe in trials, so far." A family medicine physician agrees: "Any vaccine made at the last minute and made only by a few manufacturers with huge government contracts at stake cannot help but be higher risk for untoward side effects."
Some of the reluctance to take the vaccine revolves around the accounts of increased risk for Guillain-Barré syndrome (GBS) associated with the 1976 H1N1 vaccine. The US Centers for Disease Control and Prevention (CDC) maintains that in 1976 there was a small risk for GBS after H1N1 vaccination (approximately 1 additional case per 100,000 people receiving vaccine),[4] which was slightly higher than the risk found in the general population. The potential risks for GBS associated with the current vaccine are unknown.
"GBS isn't directly attributable to the vaccine," says a pediatrician, "and the risk is miniscule. Definitely less than the risk of getting the flu and possibly having secondary problems develop." An internist concurs, "It doesn't make sense to risk getting an illness that is a known cause of GBS because of fear that the vaccine for the disease might carry a risk for it."
One family medicine physician considers the greatest benefit of the vaccine may be the immunity that it yields to future, more deadly influenza strains: "If H1N1 recombines with H5N1 picking up a gene or mutating so it binds deeper in the respiratory tract and hence becomes more likely to cause more serious illness, more pneumonia, we're in for a world of hurt. If the current vaccine develops even scant partial immunity to developing lethal forms, then it's worth the risk. For me and my children."
The scant amount of data available on the H1N1 vaccine leaves the risk-benefit ratio unclear for some physicians and their patients. A 60-year-old pediatrician who takes steroids and hydroxychloroquine (Plaquenil®) comments, "I am still not sure if I will take the shots." He adds that he does not know what to do about his patients who have autoimmune diseases, noting that there is no consensus among their rheumatologists. A family medicine physician comments, "I'm not sure I can justify recommending this vaccine to all children until safety is better ascertained when, so far, cases on the whole seem to be mild."
A pulmonologist says, "If you are in a high-risk group of flu complication, you should receive the vaccine. If you are in a high-exposure profession, you roll the dice and take your chances -- the chances of bad happening to you without the vaccine are likely to be higher than bad happening to you with the vaccine."
An internist considers the vaccine especially indicated in healthcare providers: "Influenza is highly contagious. Healthcare workers get exposed to it even more than members of the general population, and people infected with it can shed virus before they are symptomatic. Given these facts, the only ethical course for most healthcare workers is to be vaccinated."
One advocate for the vaccine speaks to the irony of the situation: "Those of us who take the risk and get the vaccine protect those who are unwilling to take the risk themselves."

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