Source:
H1N1 Flu Vaccination Clinics
City of Ottawa
(Accessed 1 March 2010, 18:00 EST)

Ottawa Public Flu Clinics ended Wednesday, 10 February 2010.

• Seasonal flu information
• Adjuvanted vaccine information
• Unadjuvanted vaccine information
• Questions About the H1N1 Vaccine
And See: Preventing the flu: Dosing Recommendations

Seasonal flu and H1N1 vaccines may be obtained through family physicians and area walk-in clinics. It is recommended that you phone to determine whether they have the vaccine(s) on hand.

For a list of walk-in clinics and health centres in the Ottawa area,
see City of Ottawa Ottawa Walk-in Clinics.

For questions regarding the H1N1 or the seasonal flu vaccine, please call a Public Health Nurse at extension 28020 (English), or extension 28030 (Français).

Source: Preventing and treating the flu
Messages from the Medical Officer of Health, City of Ottawa
(26 November 2009; revised 2 December 2009, concerning wristbands)
[Last Accessed 22 January 2010, 06:15 EST]

[...]
Preventing the flu
The H1N1 vaccine is the best way to protect yourself and your family against the pandemic virus. I encourage all Ottawa residents to get vaccinated, and ask you to kindly share the following recommendations with people in your network, with the understanding that these guidelines may be updated as new information becomes available.

Link added. NOTE: This table has been updated (no date shown) at H1N1 flu vaccine dosing recommendations, which see. The updates have been added below.
Category	Dosing Recommendation
Age 0-5 months	H1N1 flu vaccine not authorized for use
Age over 6 months and less than 3 years	2 half-doses of adjuvanted* vaccine, administered at least 21 days apart
Age 3 to 9 years Healthy children	1 half-dose of adjuvanted* vaccine, for now** For unadjuvanted (GSK): 2 doses (0.5 ml each) minimum 21 days apart. Although not recommended, it is not contraindicated for this age group. Panvax is contraindicated for this age group.
Age 3 to 9 years Children with chronic medical conditions***	2 half-doses of adjuvanted* vaccine, administered at least 21 days apart
Age 10 to 64 years Healthy people	1 dose of either adjuvanted* or unadjuvanted vaccine
Age 10 to 64 years People with chronic medical conditions***	1 dose of adjuvanted* vaccine
Age 65 years and over	1 dose of adjuvanted* vaccine
Pregnant women	1 dose of unadjuvanted vaccine
Pregnant women More than 20 weeks pregnant	If unadjuvanted vaccine is not available and rates of H1N1 flu are high or increasing in the community, women more than 20 weeks pregnant should be offered 1 dose of adjuvanted* vaccine.
Pregnant women With severe chronic disease(s)	If unadjuvanted vaccine is not available and rates of H1N1 flu are high or increasing in the community, pregnant women with severe chronic disease(s) should be offered 1 dose of adjuvanted* vaccine.
* An adjuvant is a substance that is added to a vaccine to boost the individual’s immune response. It includes naturally occurring oil (called squalene), water and vitamin E. ** These recommendations may be updated as more information becomes available. *** A chronic medical condition is any condition that impacts someone's ability to handle illness.
Co-administration recommendations H1N1 flu vaccine may be administered concurrently with seasonal flu vaccine and other vaccines. If co-administered, injections should be given in separate limbs. If not given concurrently, there is no minimum interval required between the H1N1 flu vaccine and other vaccines. This advice is consistent with the Canadian Immunization Guide.

The H1N1 vaccine is currently available through OPH vaccination clinics, as well as in a limited number of physicians’ offices. In addition to six fixed clinic sites, OPH will operate a number of roving clinics across the city well into December. In an effort to minimize line-ups, wristbands will start being given out at all clinics one hour before clinics open. Once residents receive one or more wristbands for themselves and their family, they are given an estimated time (if necessary) to return to the clinic – avoiding a long wait time. For clinic locations, schedules and wait times updated frequently throughout the day, visit ottawa.ca/health or call 3-1-1.

The City’s H1N1 strategy is designed to provide residents with easy access to vaccinations close to where they live. To ensure the greatest access and convenience for Ottawa residents, we continue to work with the community and our health care partners to identify alternate immunizer services to complement the City’s mass vaccination clinics.

Treating the flu
While the latest surge in flu activity is just behind us, we expect the virus to remain with us well into next year. OPH continues to monitor flu activity very closely.

OPH has worked with its local health care partners to manage the treatment of the flu and ensure that residents know what to do when they come down with flu-like symptoms.

The majority of H1N1 flu cases have been mild. Even though flu symptoms (such as fever, cough, muscle aches, a sore throat, fatigue, weakness and loss of appetite) can make people feel really sick and can last for several days, in most cases residents can care for themselves and their children at home. This is done with plenty of rest and fluids to avoid dehydration, as well as acetaminophen and ibuprofen, as needed, to reduce aches and fever. People who are ill can avoid spreading the flu by staying at least two metres away from other household members and friends, washing their hands often, covering their coughs and sneezes, and cleaning commonly touched surfaces with normal household disinfectants. In all cases, people should stay home until they are fever-free for 24 hours AND they are feeling better.

Medical attention is necessary in some cases.

Pregnant women, seniors, toddlers and people with chronic medical conditions should seek medical assessment from their family physician or primary health care provider within 48 hours of showing flu-like symptoms to reduce their risk of developing serious complications from the flu. Also, individuals whose symptoms are quickly worsening should see their doctor or primary care provider immediately.

People whose symptoms become severe – such as shortness of breath, difficulty breathing, lips turning blue and loss of consciousness – must go to their local hospital emergency department.

Knowing when to stay home or seek medical attention will enable our local medical professionals to treat those patients who most need medical attention. Residents who wish to speak to a public health nurse about when medical attention is warranted are invited to contact the Ottawa Public Health Information Line at 613-580-6744. A user-friendly tool can also help parents decide if their sick child requires urgent care at a local hospital, timely medical assessment with a primary care provider, or care at home.

As the flu season continues, we will inform you of major developments that may have an impact on our local organizations and residents. For ongoing information on treating and preventing the flu, visit ottawa.ca/health or call the Ottawa Public Health Information Line at 613-580-6744.

Source: NR: Flu Assessment Centres closing after providing care to thousands
Media Advisories, News Releases & Public Service Announcements,
City of Ottawa (19 November 2009)
Contact: Public Affairs (613-580-2450), medias@ottawa.ca
(Last Accessed 22 January 2010, 06:15 EST) Link added.

Ottawa – After serving nearly 3,000 people, most flu assessment centres (FACs) will deactivate their operations at the end of day Friday due to declining demand. One FAC at the Tungasuvvingat Inuit Community Centre will continue to operate.

[...] The community health centres and the Wabano Centre for Aboriginal Health where the FACs have been located will resume primary health care for their clients as well as their social services and community programs. The Orléans Urgent Care Clinic will maintain its usual range of health services.

The Tungasuvvingat Inuit Community Centre will continue providing flu assessment services to its clients, since flu activity continues to rise among the local Inuit population.

[...] While the majority of flu cases remain mild and can be cared for at home, people who are at greater risk of developing flu-related complications – such as seniors, toddlers, pregnant women and individuals with medical conditions – should see a physician or go to a walk-in clinic in the first 48 hours after onset of flu-like symptoms. As well, people seeing their symptoms quickly worsen should see a doctor or primary health care provider immediately.

People who are experiencing severe symptoms such as respiratory distress or passing out should go to the closest hospital for emergency care.

For more information on H1N1 and vaccination clinics, visit ottawa.ca/health or contact the Ottawa Public Health Information Line at 613-580-6744.

Health agencies serving the First Nations, Inuit and Métis provide assessment and treatment services, but only for their target populations.
Name	Address	Details
Tungasuvvingat Inuit Community Centre	297 Savard Avenue, Vanier (613-749-4500) [MAP]	Tungasuvvingat Inuit has pandemic H1N1 triage and treatment services.
These services include antiviral medication (Tamiflu) and vaccines with a physician and a registered nurse on site at Savard. If you are experiencing flu like symptoms or would like to get the H1N1 vaccine (pending its release by the ministry of health) please call us to arrange an appointment time. Flu symptoms can include the following: fever cough headache tiredness sore throat runny or stuffy nose body aches diarrhea and vomiting If you would like more information please contact TI’s health services staff - Colleen, Julia , Mary or Connie 613-749-4500. A schedule for walk-in clinic times will be available shortly - please check our web site regularly for further information - www.tungasuvvingatinuit.ca Source: Activities & Announcements, Tungasuvvingat Inuit (Last Accessed: 22 January 2010; 06:15 EST).

Source: Swine flu: A researcher's perspective: Hype can make us all ill
CBC News (2 November 2009)

Image Credit: CBC News, courtesy Allan Cassels.

Alan Cassels is a drug policy researcher at the University of Victoria and co-author of the 2005 book Selling Sickness, about the role of the pharmaceutical industry in helping to create and market illness. These are his responses to questions he has been getting regularly these past weeks via email and from anxious parents in the schoolyard about the H1N1 virus and the vaccine that has been designed to deal with it.

Q: Should I get vaccinated or not? Young people are dying
from this flu, surely the vaccine might help?

A: It largely depends on your own situation. If you are the kind of person who routinely gets the flu every year, finds yourself missing work, has other chronic conditions or, even, is just plain worried, go ahead. It might help and probably won't hurt.

If you are, like me, relatively healthy, rarely get the flu and don't work in a situation where it might be hazardous to be sick (such as a hospital), then you can probably give it a miss.

Q: Are public health officials fear mongering?

A: Not really. If they didn't push a mass immunization campaign, they would not be doing their jobs.

Yet with the media focusing on deaths in the rare cases, such as otherwise healthy young children, clearly this isn't productive.

Q: Is this pandemic worth worrying about?

A: Probably not. If we can learn from the experience in the southern hemisphere, which just had its main flu season, mortality from the H1N1 virus is relatively low.

Most countries had flu-related mortality rates of less than one per 100,000 cases. That's tiny.

Q: But what about the Spanish flu of 1919? Couldn't the swine flu pandemic
be a repeat of this massively deadly pandemic?

A: Not likely. It's healthier to think in terms of probabilities, not possibilities.

The Spanish flu had such a high death count partly because it took place in a world without antibiotics and which was much less wealthy and less hygienic than today.

Do we need reminding that in 2005 the World Health Organization predicted that up to 150 million people might die from Avian flu? The eventual death toll was 262 people.

Q: But surely the H1N1 flu is severe and deadly?

A: Compared to what? The regular run-of-the-mill seasonal flu? Nope. There is substantial evidence that the mortality rate from H1N1 flu is actually much smaller than seasonal flu.

Q: Does the vaccine work?

A: It depends on your definition of work. It works in terms of helping people develop antibodies to that particular virus. But are those antibodies enough to keep you from getting sick?

Often people who get the flu shot still get the flu. And we know there are many other circulating viruses that could still make you sick.

When people tell you the flu vaccine "reduces mortality by 50 per cent" you need to know that these stats come from cohort studies, which compare death rates in vaccinated people versus non-vaccinated people.

The truth is, those two groups may be very fundamentally different to start with and the vaccine might have had nothing to do with the observed outcomes.

This "healthy-user bias," as it is called, is rampant in vaccine studies. Without randomization and a true control group to compare, we don't really know for sure if flu campaigns achieve their intended outcomes.

Q: Isn't it public spirited to get vaccinated, so you won't spread the virus to others?

A: That sounds plausible, but is that recommendation evidence-based? Researchers who have combed through hundreds of flu-vaccine studies find very little evidence that suggests a vaccine will prevent the spread of the virus in the general population.

Of the hundreds of studies on flu immunization campaigns, only about four are of sufficient rigour to say anything definitive. And two of those studies show the vaccine in question to be useless.

Basing public health policy on only two quality studies doesn't seem sound to me.

Q: Is the vaccine safe?

A: Again, depends on what you mean by safe. Within the bounds in which it was studied, the H1N1 vaccine appears not to have much of a tendency to produce adverse effects.

The truth, however, is that we don't know of any rare but potentially serious effects of the vaccine campaign until we've inoculated many thousands of people.

Repeating the refrain that the vaccine is "safe and effective" is fine for reassurance but it is starting to sound strained because no one can say with 100 per cent confidence that the new flu vaccine won't cause adverse effects in some people.

Q: What's your bottom line? What needs to be done to eliminate all this
uncertainty of the vaccine?

A: More research. Better research in the form of large, randomized, placebo-controlled trials on the annual flu shot would undoubtedly erase some of these concerns and establish where the benefits and harms lie.

Following patients over the long term will give us a much clearer picture of a vaccine's safety and effectiveness and the effects of natural immunity.

To those who say that studying the sacred flu shot with randomized, placebo-controlled trials is unethical, I say that if such a trial were planned, I'd be first in line to roll up my sleeve.

To me, it is unethical to carry on large-scale, hype-inducing public health programs without collecting the kind of good quality data that is needed to prove the vaccines are doing what we hope they are.

Q: Any last words?

A: Here's my sound bite: "If they randomize, I'll immunize." In the interim, government policies of calmness, coupled with accurate information for both professionals and public is my prescription. Hype can make us all ill.

Source: Resistant swine flu found
Pulse (18 November 2009)
Ulaval - À double tranchant, Jean Hamann,
Le journal de la communauté universitaire, Volume 45, numéro 12 (19.11.09)
Emergence of Oseltamivir-Resistant Pandemic H1N1 Virus during Prophylaxis
Baz M, Abed Y, Papenburg J, Bouhy X, Hamelin Marie-Eve, Boivin G,
Centre Hospitalier Universitaire de Québec
Correspondence, New England Journal of Medicine
Published at www.nejm.org on 11 November 2009 (10.1056/NEJMc0910060).

The first case of Tamiflu-resistant swine flu developing in someone given the drug prophylacticly has been reported by Canadian doctors.

Tamiflu was given to all family members of a young boy who had developed swine flu. But a day later his father developed flu-like symptoms and he tested positive for H1N1.

His virus had a single amino acid change (H275Y mutation) of its neuraminidase protein.

The resistant strain of the virus was 400 times less sensitive to the neuraminidase inhibitor than the wild type virus, according to doctors in Quebec writing in the New England Journal of Medicine. It remained sensitive to zanamivir (Relenza).

The researchers believe resistance developed because the patient had sub-therapeutic blood levels of Tamiflu at the time of being infected – allowing the virus to mutate. [...]

Recent Reports

• WHO | Pandemic (H1N1) 2009 - update 77
  (4.12.09)
  
  [...] From the start of H1N1 pandemic (19 April) till 28th November 2009, cumulatively 150 countries shared a total of 19284 specimens (14879 clinical samples and 4405 virus isolates) with WHO CCs for confirmatory diagnosis and further characterization.
  
  A mutation of D222G in the amino acid sequence of the haemagglutinin protein of the pandemic virus is being monitored by GISN. In addition to Norway, the mutation has also been observed in Brazil, China, Chinese Taipei, Finland, France, Italy, Japan, Mexico, Spain, ,[sic] Ukraine, and USA, in both severe and mild cases.
  
  Systematic surveillance conducted by GISN laboratories continues to detect incidents of H1N1 pandemic viruses that show resistance to the antiviral oseltamivir. Antiviral susceptibility testing has been carried out on pandemic H1N1 specimens and isolates from at least 31 countries. 96 cases of oseltamivir resistant pandemic H1N1 have been reported from GISN so far. All of these viruses show the same H275Y mutation, but remain sensitive to zanamivir.
   Virology data update: Northern and Southern hemispheres (week 17‐47) -- Number of specimens positive for influenza by subtypes (from 19 April to 21 November)
  
• Oseltamivir resistance in immunocompromised hospital patients
  Pandemic (H1N1) 2009 briefing note 18, WHO (2.12.09)
  
  [...] Vigilant monitoring needed
  WHO recommends vigilant monitoring for the development of oseltamivir-resistant viruses and for any changes in the transmissibility or pathogenicity of these viruses. Experience with seasonal influenza viruses shows that resistant viruses can quickly spread within the general population and become established, rendering one or more antiviral drugs ineffective.
  
  Experience acquired since the initial characterization of the H1N1 pandemic virus in March shows that the neuraminidase inhibitors, oseltamivir and zanamivir, when administered early, reduce the risk of complications and may also improve the clinical outcome in patients with severe disease. This experience underscores the need to protect the effectiveness of these drugs by minimizing the occurrence and impact of drug resistance.
  
  WHO received the first report of an oseltamivir-resistant pandemic virus in July. In general, cases of oseltamivir resistance have been geographically dispersed, sporadic and not linked to one another. The number of these events has been steadily increasing, in line with recent increases in influenza activity in many parts of the world and a corresponding increase in the administration of antiviral drugs.
  
  Within the past two weeks, the number of documented cases of oseltamivir resistance in H1N1 viruses has risen from 57 to 96. Around one third of these cases occurred in patients whose immune systems were severely suppressed by haematological malignancy, aggressive chemotherapy for cancer, or post-transplant treatment. The clusters in the two hospital wards should be viewed in the context of these overall trends. Although all incidents of oseltamivir resistance merit investigation, no evidence suggests that events to date constitute a public health threat.

Source: What’s in your H1N1 flu vaccine?
Alex Roslin, Straight.com, Vancouver (19 November 2009)

Chris Shaw wasn’t always skeptical about vaccines. The neuroscientist at the University of British Columbia had his teenage son vaccinated with most of the recommended shots. But then he started studying some of the ingredients commonly found in vaccines.

Image Credit: Matthew Burrows, Straight.com Researcher Chris Shaw says GlaxoSmithKline’s product-information leaflet for its H1N1 vaccine doesn’t carry nearly enough safety data.

What he discovered caused him to go cold turkey on all shots for his six-year-old daughter. And that includes the vaccine for the H1N1 flu.

“I am not convinced H1N1 is sufficiently hazardous to most people to risk the potential downside of the vaccine,” Shaw said over the phone from his office in the research pavilion at the Vancouver Coastal Health Authority.

Shaw isn’t an easily dismissed vaccine conspiracy theorist. He is a leading expert on amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease) and Parkinson’s disease. While investigating unusually high rates of ALS and other neurological disorders among veterans who have Gulf War syndrome, he found evidence that the cause may have been aluminum salt, an ingredient in the cocktail of vaccines given to soldiers before deployment.

Although aluminum salt isn’t present in the H1N1 vaccine, Shaw’s discovery made him concerned about other vaccines, including the swine-flu shot. He isn’t alone in his thoughts.

Despite a full frontal assault of news about the dangers of the flu and the importance of vaccination, a survey in late October revealed that only 36 percent of Canadians said they would get the shot. Lack of trust in the vaccine was cited as the main reason for vaccine opposition. Another poll in November found that 65 percent of Canadians believe the media has overreacted to the threat of swine flu.

Even many health workers aren’t convinced. In two separate surveys, in the U.K. (Pulse) and Hong Kong (British Medical Journal), published in August, half of health-care professionals said they didn’t intend to get the vaccine.

Canadian health officials and some newspaper columnists have reacted by accusing vaccine opponents of being conspiracy mongers or just plain irresponsible.

Who is right? Is the cure really worse than the disease? Let’s look at some numbers.

First, the disease. Swine flu had killed 161 Canadians as of November 12. That works out to one death per 200,000 Canadians in the past six-and-a-half months. Over the same period of time, major cardiovascular diseases typically claim 240 times more Canadian lives (about 39,000), cancer claims 230 times more (37,000 deaths), pneumonia kills 18 times more (2,800), and accidental falls claim eight times more (1,260), according to calculations based on 2005 Statistics Canada figures.

H1N1 has about the same death rate as hernias. But we don’t see scary front-page headlines for months on end about hernias, pneumonia, or falling down.

“It’s really not causing—and is not going to cause and nowhere has caused—significant levels of illness or death,” Dr. Richard Schabas, Ontario’s former chief medical officer of health, told the CBC on November 12.

Schabas said H1N1 “has ultimately turned out to be, from a pandemic perspective, a dud”.

What about the vaccine? Is it safe? Despite the onslaught of confident pronouncements from health officials and doctors, Shaw says he hasn’t seen enough information on the safety of the vaccine. “If the science were there, we could make a rational decision. But it’s a coin toss.”

Looking for answers, Shaw turned to the 24-page product-information leaflet on the vaccine released by drug giant GlaxoSmithKline. Health Canada used this document in approving the shot.

The leaflet leaves Shaw cold. “You couldn’t turn this in as a master’s thesis anywhere I know of and get a passing grade,” he said, calling the leaflet a “shocking document”.

Shaw said the material lacks basic information. For example, there is no safety data at all for several groups of people—pregnant women, people aged over 60, kids aged 10 to 17, and children under three. For kids three to nine years old, there is only “very limited” data. [...]
[Continue Reading — adverse effects, thimerosal, squalene, polysorbate 80...] [Single Page]

Source: Safety of pandemic vaccines
WHO (19.11.09)

Pandemic (H1N1) 2009 briefing note 16

19 NOVEMBER 2009 | GENEVA -- To date, WHO has received vaccination information from 16 of around 40 countries conducting national H1N1 pandemic vaccine campaigns. Based on information in these 16 countries, WHO estimates that around 80 million doses of pandemic vaccine have been distributed and around 65 million people have been vaccinated. National immunization campaigns began in Australia and the People’s Republic of China in late September.

Vaccination campaigns currently under way to protect populations from pandemic influenza are among the largest in the history of several countries, and numbers are growing daily. Given this scale of vaccine administration, at least some rare adverse reactions, not detectable during even large clinical trials, could occur, underscoring the need for rigorous monitoring of safety. Results to date are encouraging.

Common side effects

As anticipated, side effects commonly reported include swelling, redness, or pain at the injection site, which usually resolves spontaneously a short time after vaccination.

Fever, headache, fatigue, and muscle aches, occurring shortly after vaccine administration, have also been reported, though with less frequency. These symptoms also resolve spontaneously, usually within 48 hours. In addition, a variety of allergic reactions has been observed. The frequency of these reactions is well within the expected range.

Guillain-Barre syndrome

To date, fewer than ten suspected cases of Guillain-Barre syndrome have been reported in people who have received vaccine. These numbers are in line with normal background rates of this illness, as reported in a recent study. Nonetheless, all such cases are being investigated to determine whether these are randomly occurring events or if they might be associated with vaccination.

WHO has received no reports of fatal outcomes among suspected or confirmed cases of Guillain-Barre syndrome detected since vaccination campaigns began. All cases have recovered. WHO recommends continued active monitoring for Guillain-Barre syndrome. [...]