The CDC's vaccination advice for the over-65 set has been misleading.
In the federal government's explanations of swine flu, through its Web site and public-service announcements, one message has come through loud and clear: seniors can rest easy. Children face a much greater risk from this disease, and they are dying from it in numbers never seen with regular, seasonal flu. Maybe seniors even have some special immunity to H1N1.
There's only one problem: according to a new analysis, the CDC's own numbers show clearly and unequivocally that H1N1 is more than twice as deadly to seniors as to children. As a result, "many older adults undoubtedly underestimate their own risk and the importance of getting vaccinated," says Peter Sandman, a longtime scholar of risk communication. "Older adults have been told they don't have to worry, and that's not true. If the virus comes back, people will die."
Sandman's analysis of the latest estimates of cases, hospitalizations, and deaths by the U.S. Centers for Disease Control and Prevention is here, but let me summarize the basics. Children 0 to 17 are likeliest to catch swine flu. But adults (18 to 64) and seniors (65 and older) are much more likely to die of the disease. Kids are least likely to die if they catch swine flu.
Specifically, an estimated 21.3 percent of children 0 to 17 (of whom there are 75 million) have contracted H1N1. Of those 16 million cases, there have been 71,000 hospitalizations and 1,090 deaths. That works out to a case-hospitalization rate (the chance of being hospitalized if you contract H1N1) of 0.44 percent, and a case-fatality rate (the risk of dying of the flu if you get it) of 0.007 percent.
Compare those numbers with those for America's 194 million 18-to-64s. Of them, 27 million have contracted H1N1, 121,000 have been hospitalized, and 7,450 have died. A little math shows that 13.9 percent of this age group has contracted the illness, but that the case-hospitalization rate is 0.45 percent and the case-fatality rate is 0.028 percent—quadruple that of children. Finally, among the nation's 39 million seniors, there have been 4 million cases, 21,000 hospitalizations, and 1,280 deaths. That yields a 10.3 percent risk of contracting H1N1, a case-hospitalization rate of 0.52 percent, and a case-fatality rate of 0.032 percent—the highest of any age group.
The CDC did not dispute these numbers when I e-mailed them to epidemiologist Beth Bell, an M.D. who is associate director for epidemiologic science at CDC's National Center for Immunization and Respiratory Diseases. "The basic calculation is right," she told me. "You have uncovered an important reality about H1N1: seniors are not immune to it, and we should encourage older people to get vaccinated."
Yet even leading physicians are still getting the risk calculus wrong. In a recent interview, Joseph Stubbs, president of the American College of Physicians, said, "So far the H1N1 virus has [caused] … 10,000 deaths. Most of these deaths have occurred among young people, which is particularly tragic." I won't dispute the "tragic" part, but the facts are otherwise: 1,090 deaths in people under 18, and 7,450 deaths among adults under 65. And the CDC still describes the swine-flu threat to people over 65 this way (I've annotated some of the statements, in parentheses):
"The new 2009 H1N1 virus does not seem to be affecting people 65 years and older in the same way that seasonal flu usually does." (True: with seasonal flu, some 90 percent of deaths are of people 65 and older, whereas with H1N1 13 percent of deaths have been in this age group.) "Most people who have gotten sick from this new virus have been younger." (True.) "People 65 and older are less likely to get infected with this new virus." (True: a risk of about 10 percent vs. 14 percent for younger adults and 21 percent for children.) "There have been relatively few infections and even fewer cases of serious illness and death with this new virus in people older than 65." (Seriously misleading: the risk of death for a senior who contracts H1N1 is more than four times that of a child who gets it.) "But while people 65 and older are less likely to be infected with 2009 H1N1 flu, those that do become infected are at greater risk of having serious complications from their illness." (Yes—which leads to the question, why have seniors had to wait at the end of the line, so to speak, to receive vaccinations?)
The answer to that last question seems to be twofold. The first is that children 0 to 17 are at higher risk from H1N1 than they are from seasonal flu. The second is that children are little Typhoid Marys: whatever they catch, they spread to more people than seniors do. CDC's decision to prioritize children—especially during the fall, when vaccine was in short supply—made sense from this perspective.
But that decision, and the widespread belief that seniors have little to fear from H1N1, could now prove deadly. As Sandman puts it, "I thought there was some sense of putting kids first, especially when vaccine was scarce, to control the spread. It wasn't crazy, even though it was false [to say that seniors face less risk from H1N1 than children do]. But we are paying a high price for that miscommunication: I know a lot of seniors who say they've pushed their grandchildren to get vaccinated, but won't do it themselves. They've been told they don't have to worry, and that is not true." The CDC's policy of putting children first for vaccines and downplaying the risk to older adults "went from being unwise, though understandable, to being a deadly piece of miscommunication," he says. "CDC and HHS continue to dig a deeper and deeper hole by exclusively saying that children are most at risk."
Indeed, during PSAs that aired during college-bowl games, the HHS continued to hammer home the message that "young Americans have been especially hard hit by the 2009 H1N1 flu," as a press release quotes HHS Secretary Kathleen Sebelius as saying. The ad, the department explains, is "aimed at encouraging young people and all Americans to get vaccinated against the H1N1 flu." Again, young people—who have only one quarter the risk of dying from H1N1 if they catch it—come first.
Dr. Beth Bell told me that CDC's vaccine recommendations are "flexible, and should change based on the availability of vaccine and epidemiology"—that is, which population groups are getting sick and dying. "We completely agree with you that at this juncture, when we have a window of opportunity, vaccinations should be expanded to those 65 and older."
That's a welcome about-face, but it remains to be seen if the CDC, or the media, can change the very prevalent mindset among Americans that older adults don't really need to get the H1N1 vaccine. (So far, the CDC estimates that 60 million Americans have received the H1N1 vaccine, with twice as many children as adults getting immunized. Sadly, it also appears that the government remains far from acknowledging the import of its own statistics. Jan. 10 kicks off National Influenza Vaccination Week. Monday targets health-care workers; Tuesday is for people with underlying health conditions; Wednesday is for children, pregnant women, and families. Thursday is for young adults. Bringing up the rear, on Friday, are seniors—the group at greatest risk of dying from H1N1.