JAMA news releases are made available to the public after 3 pm US Central time on the first 4 Tuesdays of each month. The Archives Journals news releases are made available to the public after 3 pm Central time on Mondays. We also provide a list of previous news releases.
THIS WEEK'S CONTENT
JAMA NEWS RELEASES
(Embargoed for Release: 3:00 p.m. CT, Tuesday, December 6, 2005)
JAMA NEWS RELEASES
USE OF CHEMOTHERAPY AFTER SURGERY FOR COLON CANCER HAS RISEN, WITH INCREASE IN SURVIVAL RATE
PNEUMONIA HOSPITALIZATION RATES ON THE RISE FOR OLDER ADULTS
WIDE-SPREAD USE OF INTRANASAL FLU VACCINE DOES NOT SHOW UNEXPECTED SERIOUS RISKS
SERIOUS ADVERSE REACTIONS TO SMALLPOX VACCINE APPEAR TO BE LIMITED
JAMA REPORT (VIDEO NEWS RELEASE SCRIPT)
VIDEO: Windows Media | Quicktime
GOVERNMENT STUDY FINDS NASAL FLU VACCINE SAFE WHEN USED AS DIRECTED
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Embargoed for Release: 3:00 p.m. CT, Tuesday, December 6, 2005
Media Advisory: To contact J. Milburn Jessup, M.D., call Liz McDonald at 202-687-5100. To contact editorial co-author Eric Van Cutsem, M.D., Ph.D., email: eric.vancutsem{at}uz.kuleuven.ac.be.
USE OF CHEMOTHERAPY AFTER SURGERY FOR COLON CANCER HAS RISEN, WITH INCREASE IN SURVIVAL RATE
CHICAGO—More patients with stage III colon cancer are receiving chemotherapy after surgery, with an associated significant increase in 5-year survival, according to a study in the December 7 issue of JAMA. The study also found that women, blacks and the elderly were less likely to receive this treatment.
According to background information in the article, based on the results of two trials, the National Institutes of Health Consensus Conference recommended in 1990 that adjuvant chemotherapy (chemotherapy after the primary tumor has been removed by some other method, as in surgery or radiation therapy) be given to all patients with stage III colon cancer who were not enrolled in a clinical trial. However, as with most recommendations, it is not clear to what extent they are followed or contribute to outcome in the general population.
J. Milburn Jessup, M.D., of the National Cancer Institute, Rockville, Md., and colleagues assessed to what extent the 1990 Consensus Conference recommendation has been followed in the community and whether adjuvant chemotherapy has improved the 5-year survival of patients with stage III colon cancer. The study included data from 85,934 patients with stage III colon cancer from 560 hospital cancer registries who were entered into the National Cancer Data Base (NCDB) between 1990 and 2002. The data included standard clinical, pathological, and first course of treatment variables.
The researchers found an increase in the use of adjuvant chemotherapy for all patients with stage III colon cancers from 39 percent of patients in 1990 to 64 percent in 2002, but use was lower in black, female, and elderly patients. The difference in 5 year survival increased from an 8 percent improvement in the 1991 subgroup to 16 percent in the 1997 subgroup that received adjuvant chemotherapy compared with surgery alone. The researchers also found that adjuvant chemotherapy increases survival in elderly patients as much as it does in younger patients. However, the benefit of adjuvant chemotherapy in blacks and those with high-grade cancers is not as great.
“Future studies are needed to identify whether newer agents such as irinotecan and oxaliplatin may be more effective in patients with high-grade cancers or in blacks than the 5-fluorouracil and leucovorin regimens that were dominant during the time that the cohorts reported herein were followed up for survival,” the authors conclude.
(JAMA. 2005;294:2703-2711. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: This study was supported in part by the American College of Surgeons and the American Cancer Society.
EDITORIAL: PROGRESS IN THE ADJUVANT TREATMENT OF COLON CANCER — HAS IT INFLUENCED CLINICAL PRACTICE?
In an accompanying editorial, Eric Van Cutsem, M.D., Ph.D., of University Hospital Gasthuisberg, Leuven, Belgium, and Frederico Costa, M.D., of Hospital Sírio Libanês, São Paulo, Brazil, comment on the study by Jessup et al.
“The central issue regarding adjuvant chemotherapy is the difficulty in assessing its real benefit for an individual patient. The recommendation is generally based on the proof of efficacy in a selected population at risk for disease recurrence. The decision-making process is always complex. On the one hand, the physician’s understanding of the potential benefit is influenced by his or her own prejudice; on the other hand, the patient’s confidence is influenced by beliefs and fear. Factors such as comorbidities, socioeconomic status, and low adherence to therapy are among the well-described causes for not using adjuvant chemotherapy. Ongoing studies of molecular markers for colorectal cancer should help determine which patients benefit most from adjuvant therapy.”
“Even though causes for recommending or not recommending adjuvant chemotherapy are multifactorial, Jessup et al observed an increase in the use of adjuvant chemotherapy over time. It is not clear why it took so many years for a majority of patients to receive adjuvant treatment despite the clear demonstration of a survival benefit. Hopefully, further progress in the knowledge of adjuvant therapy will have a more rapid influence on clinical practice in the near future,” the authors conclude.
(JAMA. 2005;294:2758-2760. Available pre-embargo to the media at www.jamamedia.org)
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, December 6, 2005
Media Advisory: To contact Alicia M. Fry, M.D., M.P.H., call Christine Pearson at 404-639-3286.To contact editorial co-author Thomas M. File, Jr., M.D., call Mike Bernstein at 330-375-7930.
PNEUMONIA HOSPITALIZATION RATES ON THE RISE FOR OLDER ADULTS
CHICAGO—Hospitalization rates for pneumonia have increased substantially for U.S. adults 65 to 84 years of age, according to a study in the December 7 issue of JAMA.
Pneumonia is among the top 10 causes of death in the United States and is a significant cause of outpatient visits and hospitalizations, according to background information in the article. Factors that increase the risk for pneumonia include the presence of underlying medical conditions, advanced age, functional disability, and residency in long-term care facilities.
Alicia M. Fry, M.D., M.P.H., of the Centers for Disease Control and Prevention, Atlanta, and colleagues conducted a study to determine if an increase in chronic underlying conditions might be contributing to greater hospitalization rates for pneumonia. The researchers used data from the National Hospital Discharge Survey (NHDS) to study trends according to age groups in hospitalization rates for pneumonia during a 15-year period (1988-2002) among U.S. residents aged 65 years or older. The characteristics, outcomes, and comorbid (co-existing illness) disease diagnoses of patients with a hospital discharge diagnosis of pneumonia were compared with those of patients with a hospital discharge diagnosis for other causes during the study period.
The researchers found that hospitalization rates for pneumonia increased by 20 percent from 1988-1990 to 2000-2002 for patients aged 65 to 74 years and for patients aged 75 to 84 years. Rates of hospitalization for pneumonia were 2-fold higher for patients aged 85 years or older (51 per 1,000 population for first-listed discharge code of pneumonia) than among patients aged 75 to 84 years but did not significantly increase from 1988-1990 to 2000-2002. The proportion of patients aged 65 years or older diagnosed with pneumonia and a chronic cardiac disease, chronic pulmonary disease, or diabetes mellitus increased from 66 percent in 1988-1990 to 77 percent in 2000-2002. During 2000-2002, approximately 1 in 83 patients aged 65 to 74 years and 1 in 38 patients aged 74 to 84 years were hospitalized each year with a first-listed diagnosis of pneumonia.
“The increasing proportion of patients with underlying comorbid conditions among those hospitalized for pneumonia supports our primary hypothesis that an increase in the prevalence of underlying conditions that predispose individuals to pneumonia might partially account for the increase in rates of pneumonia hospitalization among patients aged 65 to 84 years. Our findings suggest that efforts to prevent pneumonia among older adults should focus on those at the extremes of age and those with underlying medical conditions,” the authors write.
“… because the number of individuals at highest risk for pneumonia, those aged 85 years or older, will continue to increase in the United States and behavioral changes may be difficult to sustain, additional strategies, such as more effective vaccines for older individuals and new vaccines for common pathogens without a currently licensed vaccine … will likely be necessary,” they write.
(JAMA. 2005;294:2712-2719. Available pre-embargo to the media at www.jamamedia.org)
EDITORIAL: PNEUMONIA IN OLDER ADULTS — REVERSING THE TREND
In an accompanying editorial, Thomas M. File, Jr., M.D., and James S. Tan, M.D., of Northeastern Ohio Universities College of Medicine, Rootstown, Ohio, and Summa Health System, Akron, Ohio, comment on the study on pneumonia and older adults.
“As Fry et al point out, new strategies for preventive vaccines are necessary. The development of more potent vaccines could potentially further reduce complications in elderly persons. It will be important to determine whether new recommendations for influenza vaccination of children will have a similar effect of reducing the disease burden in older adults as it has with the use of the conjugate pneumococcal vaccine for invasive pneumococcal disease.”
“Chemoprophylaxis can be used as an adjunct to vaccination for prevention and control of influenza. Chemoprophylaxis may be useful for those who have household exposure to influenza, who live or work in institutions with an influenza outbreak, or who are at high risk for influenza complications in the setting of a community outbreak. Chemoprophylaxis also may be useful for persons with contraindications to influenza vaccine or as an adjunct to vaccination for those who may not respond well to influenza vaccine (e.g., persons with human immunodeficiency virus),” the authors write.
“Clinicians can intervene to modify some of the associated risk factors for pneumonia in older adults. Administration of preventive vaccines, counseling about smoking cessation, stabilization of underlying conditions, and promotion of appropriate nutrition may help to reduce the risk of community-acquired pneumonia and thereby promote longer and healthier lives for older adults,” the authors conclude.
(JAMA. 2005;294:2760-2763. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: For the financial disclosures of the authors, please see the JAMA editorial.
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, December 6, 2005
Media Advisory: To contact Hector S. Izurieta, M.D., M.P.H., call Julie Zawisza at 301-827-6242. To contact editorial co-author Kathleen M. Neuzil, M.D., M.P.H., call Clare Hagerty at 206-685-1323.
WIDE-SPREAD USE OF INTRANASAL FLU VACCINE DOES NOT SHOW UNEXPECTED SERIOUS RISKS
CHICAGO—Approximately 2.5 million people received the intranasal influenza vaccine the last 2 flu seasons, and a new study did not identify unexpected serious risks associated with use of this vaccine, according to an article in the December 7 issue of JAMA.
Annual influenza vaccination is the primary method for protection against influenza illness, according to background information in the article. Until the 2002-2003 influenza season, the only licensed influenza vaccine in the United States was the inactivated, trivalent (reacting immunologically with three different combining sites [as of antigens or antibodies]) injectable vaccine, with recommendations emphasizing use among individuals for whom influenza is of particular concern. In June 2003, the U.S. Food and Drug Administration (FDA) licensed a trivalent live, attenuated influenza vaccine (LAIV-T [FluMist]) for intranasal use among healthy persons 5 to 49 years of age. Each dose contains live attenuated influenza virus of the 3 strains recommended by the U.S. Public Health Service for the corresponding influenza season. Although the number of vaccinees studied during prelicensure LAIV-T clinical trials was relatively large (20,228), postlicensure administration of the vaccine to much larger populations could reveal new safety issues.
Hector S. Izurieta, M.D., M.P.H., of the Food and Drug Administration, Rockville, Md., and colleagues examined the adverse events reported to the U.S. Vaccine Adverse Event Reporting System (VAERS) during the first 2 influenza seasons (2003-2004, 2004-2005) following LAIV-T licensure to identify new or unexpected adverse events, including rare events.
Approximately 2,500,000 persons received LAIV-T during the first 2 postlicensure seasons. As of August 16, 2005, VAERS received 460 adverse event reports for vaccinations received from August 2003 through July 2005. No fatalities were reported. There were 7 reports of possible anaphylaxis (hypersensitivity reaction to the injection of a substance resulting from prior contact with a substance), 2 reports of Guillain-Barré syndrome (GBS - a temporary inflammation of the nerves, causing pain, weakness, and paralysis in the extremities), 1 report of Bell palsy (paralysis of the facial muscles), and 8 reports of asthma exacerbation among individuals with a prior asthma history. Events in individuals for whom the vaccine was not indicated accounted for 73 reports (16 percent).
“Reports to VAERS in the first 2 seasons of LAIV-T use did not identify any unexpected serious risk with this vaccine when used according to approved indications. Like many vaccines and other medical products, LAIV-T may rarely cause anaphylaxis. As with other vaccines, LAIV-T could carry the risk of anaphylaxis or other allergic events. Continued monitoring of neurological events, such as GBS, appears warranted. Determination of the risk of secondary transmission of the vaccine virus would require a focused clinical study,” the authors write.
“The reports of asthma exacerbations in vaccinees with prior asthma history highlight the potential risks of not following the approved indications and support the need for continued close surveillance for asthma exacerbations following use of this vaccine. The finding of a high proportion of vaccine administration errors and the reports of use among persons for whom this vaccine was not indicated underscore the need for the clinician to follow the package insert indications regarding vaccine administration and patient eligibility,” the researchers conclude.
(JAMA. 2005;294:2720-2725. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: The study was implemented by FDA and CDC scientists and the only funds used were from CDC and FDA budgets. This study had no external sponsors.
EDITORIAL: VACCINE SAFETY — ACHIEVING THE PROPER BALANCE
In an accompanying editorial, Kathleen M. Neuzil, M.D., M.P.H., of the University of Washington, Seattle, and Marie R. Griffin, M.D., M.P.H., of Vanderbilt University School of Medicine, Nashville, Tenn., discuss the issue of vaccine safety.
“In an era in which influenza vaccine delays and shortages have become the norm, LAIV represents an important option to increase vaccination rates among healthy persons for their own protection and for the protection of those with whom they have close contact. Currently, LAIV is licensed for healthy persons 5 to 49 years of age, although expanded indications may be forthcoming (based on the intent of the company to file for broader licensure). As with any licensed product, continued monitoring of the safety of LAIV will be important. However, the cumulative evidence, including the VAERS experience, should reassure clinicians and patients of the safety of both licensed influenza vaccines. Decisions regarding which influenza vaccine to choose in the healthy 5- to 49-year-old age group should be based on availability, patient preference, and cost,” the authors write.
(JAMA. 2005;294:2763-2765. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Dr. Neuzil has received research funding from MedImmune for participation in a multicenter clinical trial of an LAIV in 2004-2005.
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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Embargoed for Release: 3:00 p.m. CT, Tuesday, December 6, 2005
Media Advisory: To contact Christine G. Casey, M.D., or the lead author of the second study, James J. Sejvar, M.D., call Von Roebuck at 404-639-3286.
SERIOUS ADVERSE REACTIONS TO SMALLPOX VACCINE APPEAR TO BE LIMITED
CHICAGO—There was a low rate of life-threatening adverse reactions to the smallpox vaccine administered to potential first responders to a bioterrorism incident, possibly attributable to rigorous vaccine safety screening and educational programs, according to a study in the December 7 issue of JAMA.
Routine childhood immunization against smallpox in the United States ceased in 1971, according to background information in the article. Although the World Health Organization declared in 1980 that smallpox had been eradicated worldwide, there is concern that smallpox virus may exist outside the World Health Organization-designated repository laboratories and may be used as a bioweapon. Detection of a smallpox case could represent an intentional bioterrorism event requiring an immediate, coordinated response by public health, medical, and law enforcement personnel to control the outbreak and protect the public.
In January 2003, the U.S. Department of Health and Human Services (DHHS) implemented a voluntary civilian smallpox vaccination program, in which vaccine was administered to federal, state, and local volunteers who might be first responders during a bioterrorism event.
Christine G. Casey, M.D., of the Centers for Disease Control and Prevention, Atlanta, and colleagues examined the vaccine safety profile among civilians who received smallpox vaccine between January 24 and October 31, 2003. The researchers evaluated adverse events reported via the Vaccine Adverse Event Reporting System (VAERS) and the Centers for Disease Control and Prevention.
A total of 37,901 volunteers in 55 jurisdictions received at least 1 dose of smallpox vaccine. VAERS received 822 reports of adverse events following smallpox vaccination (overall reporting rate, 217 per 10,000 vaccinees). A total of 590 adverse events (72 percent) were reported within 14 days of vaccination. Nonserious adverse events (n = 722) included multiple signs and symptoms of mild and self-limited local reactions. One hundred adverse events (12 percent) were designated as serious, resulting in 85 hospitalizations, 2 permanent disabilities, 10 life-threatening illnesses, and 3 deaths. Among the serious adverse events, 21 cases were classified as myocarditis (inflammation of the muscular tissue of the heart) and/or pericarditis (inflammation of a membrane that surrounds the heart) and 10 as ischemic cardiac events that were not anticipated based on historical data. Two cases of generalized vaccinia (a skin eruption in reaction to vaccination) and 1 case of postvaccinial encephalitis (inflammation of the brain) were detected. No preventable life-threatening adverse reactions, contact transmissions, or adverse reactions that required treatment with vaccinia immune globulin were identified. Serious adverse events were more common among older revaccinees than younger first-time vaccinees.
“The absence of preventable serious adverse reactions provides indirect evidence of effective vaccination screening and education, as well as attentive vaccination site care and monitoring,” the authors write.
“This comprehensive smallpox vaccine safety monitoring and response system can serve as an effective model for vaccine campaigns that may occur in response to public health emergencies. Unique aspects included rapid detection, investigation, and response to rare and potentially serious adverse events. Our report highlights the success of education, screening, and clinical investigations and reviews in augmenting a robust safety monitoring system to minimize preventable adverse events. Additional reduction of overall vaccinia adverse events might be achievable through study of cardiac and dermatological risk factors, a better understanding of vaccinia host-pathogen interaction, and development of a less reactogenic vaccinia vaccine,” the researchers conclude.
(JAMA. 2005;294:2734-2743. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: All financial and material support for the surveillance efforts was conducted as part of the CDC and state health department public health response. No additional funding was sought to support these activities.
NEUROLOGIC ADVERSE EVENTS FROM SMALLPOX VACCINE GENERALLY MILD
In a related study in this issue of JAMA, adverse neurologic reactions from smallpox vaccination were generally mild and the rate of specific syndromes did not exceed baseline estimates.
Rare adverse events causally associated with smallpox vaccination include neurologic syndromes such as central nervous system (CNS) and peripheral nervous system (PNS) complications, according to background information in the article. The most common CNS complication after smallpox vaccination is encephalitis (postvaccinial encephalomyelitis - inflammation of the brain and spinal cord). Other infrequent events can include headache, Guillain-Barré syndrome (a temporary inflammation of the nerves, causing pain, weakness, and paralysis in the extremities), Bell palsy (paralysis of the facial muscles), and myelitis (inflammation of the spinal cord).
James J. Sejvar, M.D., of the Centers for Disease Control and Prevention, Atlanta, and colleagues assessed reports of postvaccinial encephalomyelitis and other neurologic adverse events between December 16, 2002, and March 11, 2004, among DHHS and DoD smallpox vaccinees, to clinically characterize them and assess their frequency. Information on the events was obtained through active case reporting and review of data submitted to the Vaccine Adverse Event Reporting System among 665,000 persons vaccinated against smallpox by the Departments of Defense (n = 590,400) and Health and Human Services (n = 64,600) during the 2002-2004 U.S. Smallpox Vaccination Program.
The researchers found that there were 214 neurologic adverse events temporally associated with smallpox vaccination; 111 reports involved DHHS and 103 involved DoD vaccinees. Fifty-four percent of these events occurred within 1 week of vaccination, and 53 percent were among primary vaccinees. The most common neurologic adverse event was headache (95 cases), followed by nonserious limb paresthesias (n = 17) or pain (n = 13) and dizziness or vertigo (n = 13). Serious neurologic adverse events included 13 cases of suspected meningitis, 3 cases of suspected encephalitis or myelitis, 11 cases of Bell palsy, 8 seizures (including 1 death), and 3 cases of Guillain-Barré syndrome. Among these 39 events, 27 (69 percent) occurred in primary vaccinees and all but 2 occurred within 12 days of vaccination.
“Our findings identified many milder neurologic adverse events temporally but not necessarily causally associated with smallpox vaccination. They suggest that such events are generally self-limited, nonserious, and not associated with severe morbidity or mortality when screening defers persons with high-risk conditions,” the authors write.
“Smallpox vaccine was given to healthy people, which creates a low tolerance for associated risk. Risks associated with vaccines are best identified through population-based assessments. New, possibly less reactogenic smallpox vaccines are currently under development. Continued monitoring for neurologic events is needed to assess the safety of smallpox vaccines and to better characterize the spectrum of neurologic illness associated with them,” the researchers conclude.
(JAMA. 2005;294:2744-2750. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: This study was supported by the CDC and the U.S. Department of Defense.
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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JAMA REPORTS
VIDEO: Windows Media | Quicktime
GOVERNMENT STUDY FINDS NASAL FLU VACCINE SAFE WHEN USED AS DIRECTED
VIDEO:
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William listening to Dr. Mattey
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WATCH 8-YEAR OLD WILLIAM’S FACE WHEN HE LEARNS HE’S NOT GETTING HIS USUAL FLU SHOT.
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Dr. Mattey showing William nasal flu vaccine dispenser, William’s face lights up
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“It looks like a shot, but there’s no needle, it’s just a squirt gun, it goes up your nose.”
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C/u of Nasal flu vaccine in Dr. Mattey’s hand
William getting vaccinated Dr. Izurieta in meeting with colleagues
Young woman getting nasal flu vaccine
GFX/JAMA COVER
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THIS NASAL FLU VACCINE CAME OUT IN 2003. A SQUIRT IN EACH NOSTRIL PROTECTS AGAINST THE FLU. RESEARCHERS, LIKE DR. HECTOR IZURIETA (iz-ree-EH-ta) AND HIS COLLEAGES AT THE FOOD AND DRUG ADMINISTRATION, TRACK REPORTS OF BAD REACTIONS OR OTHER HEALTH PROBLEMS ASSOCIATED WITH ALL VACCINES. THEIR NEW FINDINGS ABOUT THIS NASAL FLU VACCINE APPEAR IN JAMA, THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
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Super: Hector Izurieta, M.D., M.P.H.
Food and Drug Administration
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“Among 2 ½ million people who received the vaccine, we received only 460, approximately, reports of illness or problems with the vaccination – that’s not a large number.”
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More of same young woman getting nasal vaccine
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NOT COMPARED TO OTHER VACCINES – WHICH ARE STILL OVERWHELMINGLY SAFE. BUT WHAT KIND OF PROBLEMS WERE REPORTED WITH THE NASAL FLU VACCINE?
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Hector Izurieta, M.D., M.P.H.
Food and Drug Administration
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“A few of them were serious allergic reaction. A few of them were asthma attacks among people who had a prior asthma history. Those people who had the prior asthma history should not have received the vaccine anyway.”
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Different girl getting nasal flu vaccine
Backtime Dr. Mattey
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THAT’S BECAUSE THE VACCINE IS ONLY RECOMMENDED FOR PEOPLE AGES FIVE TO FORTY-NINE WHO DON’T HAVE ASTHMA OR ANY OTHER CHRONIC CONDITIONS. IN THOSE PEOPLE, THE STUDY SHOWS THE VACCINE IS SAFE. NO SURPRISE TO THIS PEDIATRICIAN.
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Super: James Mattey, M.D.
Pediatrician
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“We encourage our patients to consider it, we offer it as an option and will continue to do so.”
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More of William getting vaccine
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HE SAYS PEOPLE MAY GET SOME MILD COLD OR FLU SYMPTOMS AFTER GETTING THE NASAL VACCINE, BUT HE RARELY SEES THAT IN HIS PATIENTS. HE DOES SEE LESS FLU, AND LESS STRESS.
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Dr. Mattey talking with William after vaccination
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“Did it bother you at all?
No.
Is a squirt gun better than a shot?
Nods yes.”
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Close up William
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THIS IS MAVIS PRALL WITH THE JAMA REPORT.
