1. Objectives

Teachers' Objectives
After completing this module, you should be able to simply yet effectively teach:
1.) The genetic and epidemiological basics of both the seasonal and novel H1N1 virus
2.) The ethical principles underlying pandemic planning and resource allocation
3.) The public health model that informs prioritization of vaccination

Curriculum Integration Ideas
This brief may be used in life science classes during units for topics including:
1.) Infectious diseases and prevention
2.) Health current events
3.) Public policy discussions on pandemic planning

2. H1N1 viruses and vaccines

Since humans began genetically analyzing the human influenza virus, there have been numerous H1N1 viruses recorded. There are two major subtypes of the influenza virus (the bug that causes the seasonal flu): A and B. H1N1 is a sub-type of type A influenza and is named such because of the kind of hemagglutinin and neuraminidase, two surface proteins that allow the virus to enter human cells, it carries. For example, other types include H5N1 and H3N3. Each year, normal assortment of genes between viruses leads to different viruses causing the majority of illnesses in the seasonal flu epidemic. Novel H1N1, however, is named such because the genes that reassembled came from humans, birds, and pigs. Swine flu, then, is a misnomer as the virus does not infect nor come from pigs; simply, a small amount of the genetic material inside the virus is the same as the flu virus that affects pigs.

Symptoms of the flu (either type) include fever, dry cough, sore throat, runny nose, headache, fatigue, muscle aches, nausea, vomiting, and diarrhea. The novel H1N1 virus is much more likely to cause stomach symptoms. The influenza virus, regardless of type, is spread through droplets. When a person coughs or sneezes, droplets containing the virus can be inhaled by a nearby person. These droplets can also land on surfaces that another person touches before touching their own nose or mouth. Hand-washing is the mainstay of prevention during influenza season.

Each year, a seasonal flu vaccine specific for that year is created. This is an incredibly arduous task for scientists and epidemiologists since they must predict in the spring what will be the three viruses causing a majority of illnesses the coming winter flu season. The effectiveness of the seasonal flu vaccine, then, depends on two factors: (1) the match of the vaccine viruses to the actual viruses in the environment, and (2) the immune system response of the person receiving the vaccine. The novel H1N1 vaccine is therefore an easier vaccine to make as scientists did not have to guess what virus would be causing disease since it was already known - the match was perfect. Only the immune system of the person receiving the vaccine impacts its effectiveness. Just like the seasonal flu vaccine, the novel H1N1 vaccine can be administered in two manners - a live, inhaled vaccine or an inactivated, injected vaccine.

3. A Closer Look - CDC Prioritization Policies

Another difference between the seasonal flu viruses and the novel H1N1 virus is the epidemiology, or who the disease infects and the natural progression of the disease. The seasonal flu virus tends to affect the elderly, those that are immunocompromised, and people that take care of these two groups. The seasonal influenza vaccination is recommended for those people over 50 years old, immunocompromised, with chronic health problems, pregnant women, healthcare and nursing home workers, and household contacts of infants and the groups listed above.

The novel H1N1 virus, however, tends to affect younger and healthier people. Its worst effects are seen in children, pregnant women, and people who take care of these two groups. While the mortality rate is similar to that of the seasonal flu virus, the difference is that healthier and younger people are affected by novel H1N1. Vaccination is recommended for pregnant women, children and adolescents, healthcare workers, and household contacts of infants. The CDC website lists information regarding prevention, symptoms, vaccination, and much more for both seasonal and novel H1N1 influenza.

To immunize the target groups identified by the CDC, the US government predicted that 250 million doses would be needed. Unfortunately, production has been lagging and around 10% of the doses required have been received by hospitals and clinics. There has been a great deal of media attention paid to this shortage - CBS News reports.

4. What Are Some Of The Ethical Issues?
There is a wide variety of ethical issues that have been raised by the novel H1N1 vaccine. Some of these are:

Pandemic Planning
Perhaps the biggest controversy surrounding the novel H1N1 vaccine is the shortage. Hospitals and clinics are receiving only a fraction of the doses they require and many weeks past the expected timeframe. When scarce resources have to be allocated, should the sickest or those most likely to become sick receive priority? Should those that are young and have the most years to live receive the vaccine or should it be reserved for those that are older and sicker? Should ability to pay be a factor? How do busy emergency rooms and doctors' offices handle the additional patients without exposing their other patients? Should schools stop having large group assemblies, churches be closed, and sporting games temporarily postponed so that the chance of transmission from one person to another is decreased? These are all difficult questions, some which have been answered by the government and others which await a conclusion.

Mandatory Vaccination
Some schools and hospitals are requiring students and employees to receive the novel H1N1 vaccination or face suspension. Their rationale is that by not receiving the vaccine, not only can that student/employee become sick and infected, but possibly transmit the infection to other students/coworkers or patients. On the other hand, most places only strongly encourage the seasonal flu vaccine, which has a similar mortality to novel H1N1, but do not require it. What do you think? Is it fair to require students or employees to get vaccinated to protect others? Should provisions for religious or moral objections to vaccinations be permitted?

Role of the Media
The media, whether newsprint, magazine, radio, television, or internet, is easily the entity that provides the most information to the public regarding symptoms, prevention, and vaccination for novel H1N1. However, media producers have several conflicts of interest. They have a journalistic ethical responsibility to report the truth, without hype or false alarms. However, the sheer number of sources that people get their information from means that each news source must compete with the other for viewers/readers. Each media company also has a fiduciary responsibility to its shareholders to produce a profit. While this is a constant conflict of interest for media companies, pandemics such as novel H1N1 vaccination can heighten this conflict of interest. If you were a media producer, how would you handle the reporting of novel H1N1 when so little is known and people are becoming sick and dying?

Watch this news broadcast.

What are the emotions and questions this news clip raises? Do you think both sides are presented equally? Would you receive the H1N1 vaccine after hearing this broadcast? Would it change your opinion if a CDC spokesperson was also featured explaining the dangers of H1N1, why the vaccine is safe, and how the vaccine can save lives? Would knowing the fact that thimerosal has been repeatedly shown to not cause autism influence your decision? Why do you think this media source chose to present their story with this angle?

Have you seen hype and false reporting by the media during the H1N1 pandemic and the vaccination drives? Do you think scaring people about false or exaggerated dangers will make people watch more news broadcasts (that is, earn money for the media source)? What are the dangers of reporting only one side of an issue? Are the consequences of biased reporting worse when viewers' health is concerned?

5. Review Questions
1. Why is swine flu a misnomer? How did the novel H1N1 virus come into existence?
2. What are the differences in prioritization groups between seasonal flu and the novel H1N1 flu?
3. Scare resources are an unfortunate component of modern healthcare. Can you name other everyday examples of how the government and doctors must decide how to allocate these resources?