Did Weight Bias Play A Role In Access To H1N1 Vaccinations?

Reader may recall that the H1N1 flu outbreak in 2009 was particularly deadly to obese individuals.

This increased severity and fatality of H1N1 infections in obese patients became apparent early during the spring outbreak of the epidemic and prompted the Public Health Agency of Canada to recommend that individuals with severe obesity should be included amongst those to be given first access to the H1N1 influenza vaccine.

A paper by Chris Kaposy from Memorial University of Newfoundland, published in VACCINE, suggests that this PHAC recommendation was largely ignored by the provinces, who bear the responsibility for health care delivery in Canada.

In fact, only one province (Manitoba) followed the PHAC recommendations and considered all people under 65 with severe obesity eligible for H1N1 influenza vaccination on October 26 2009 – early in the vaccination campaign.

Alberta, Nova Scotia, and Saskatchewan, did list individuals with severe obesity, but placed narrow age restrictions on those who were given early access.

New Brunswick and Ontario listed severe obesity as a sequencing category late in the vaccination campaign (as late as November 2009).

In British Columbia, Newfoundland and Labrador, Prince Edward Island, and Quebec, obesity (or ‘severe’ obesity) was never specifically listed as a chronic health condition that qualified one for early access to the H1N1 influenza vaccine. In fact, it appears that ‘obesity’ was specifically removed from the list of eligible chronic conditions that warranted early access.

The author provides at least two pieces of evidence that weight bias may have played a role in the provinces’ decisions:

“First of all, consider that in every single province the H1N1 influenza vaccine was available to pregnant women over 20 weeks gestation very early in the mass vaccination campaign. In most provinces, the vaccine was available to this group from late October 2009 onward. Clearly there was a pan-Canadian commitment during the H1N1 influenza pandemic to offer early vaccine access to pregnant women – who were also listed in the PHAC categories as a vulnerable group. Every Canadian province could have similarly chosen to vaccinate people with severe obesity early in the campaign, but they did not.”

Secondly, the delay in access cannot be explained by scarcity of vaccine – in fact, in each of the four provinces (British Columbia, Newfoundland and Labrador, Prince Edward Island, and Quebec) that never listed people with severe obesity as eligible for early vaccination, school children were vaccinated early – prior to the availability of the vaccine to the general public despite the fact that the PHAC guidelines did not list school children as a vulnerable group and computer modelling did not support the priority use of vaccination in school children ahead of high-risk individuals.

Thus, this commentary argues, Canadian provinces demonstrated an ambiguous commitment to the early vaccination of people who were severely obese, despite clear and strong early evidence that individuals with severe obesity presented an especially vulnerable group and despite clear and timely recommendations by the federal public health agency to consider severely obese individuals for priority access.

Given that H1N1 influenza ultimately did result in significant number of fatalities (especially amongst people with severe obesity), I wonder if public outrage would have been greater had any other group of ‘vulnerable’ individuals been as overtly ‘overlooked’.

Edmonton, Alberta

Kaposy C (2011). The influence of the stigma of obesity on H1N1 influenza vaccine sequencing in Canada in 2009. Vaccine PMID: 22041304