Universal flu vaccination considered

Some health officials also propose mandating vaccination for all health care workers, but many have doubts about the feasibility of either proposal.

By Victoria Stagg Elliott — Posted May 17, 2004

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It's the time of year when public health officials begin planning for next year's flu season, and experts are debating whether flu vaccine recommendations should be expanded to include everyone, rather than following the ever-growing, specific and complex lists of targeted individuals.

Many say such a step could stabilize vaccine supplies and increase the number of people vaccinated, particularly those in high-risk groups who need it the most.

"It's something we have to seriously consider," said Walter A. Orenstein, MD, associate director of the Emory University Vaccine Center in Atlanta and former director of the Center for Disease Control and Prevention's National Immunization Program. "Our present policy has not resulted in optimal immunization coverage. Some of our recommendations, which are very scientifically based and very logical, can be very difficult to implement, and my hope is that if enough demand was created that supply would increase substantially."

Over the past few years, physicians struggled with ever-changing guidelines. Some seasons the shot's target groups have been narrowed because of supply shortages or delays. Other years, when the supply was more prevalent, recommendations were expanded to include as many as two-thirds of the population.

The result has been confusion for patients and either feast or famine in terms of vaccine supply. The 2001-2002 season was a time of plenty, but millions of doses were left over. The year after, manufacturers were less willing to produce as much, making it impossible to meet the unexpectedly high demand. Nearly all available doses were used.

Universal vaccination has its doubters, but the question is being carefully considered by both the National Influenza Vaccine Summit, co-sponsored by the AMA and the CDC, and the CDC's Advisory Committee on Immunization Practices. Experts are closely watching data coming from Ontario, Canada, the first area in North America to recommend the vaccine to everyone. Since this shift in July 2000, Ontario's population-wide vaccination rate increased from 16% to 44%. The increase for those older than 65 was from 60% to 77%.

"That's a pretty big improvement," said Ronald Bangasser, MD, a member of the summit and immediate president of the California Medical Assn. "I'd like to see that kind of improvement in our country."

Many experts question, though, how well something that works in Canada's nationalized health system would work in the United States.

"That's a huge number of people to vaccinate, and ... a lot of vaccine," said Roger Baxter, MD, infectious disease consultant with Kaiser Permanente in Oakland, Calif. "And there are so many issues related to payment."

Issues of supply and demand

Physicians say it could make their work simpler and might make those who are not aware that they are in a high-risk category come in and get the jab.

Manufacturers say they would be willing to make more vaccine but caution that changing recommendations might not automatically translate to increased consumer interest.

"Recommendation alone does not translate into increased immunization," said Len Lavenda, spokesman for Aventis-Pasteur, which expects to produce at least 43 million doses for next season. "We've seen recommendations expand over the past few years without necessarily a corresponding increase in the number of people who get immunized."

Public health advocates hope that universal vaccination could lead to herd immunity, which would, in turn, protect those who are at high risk of flu-related complications but unable to get the vaccine, such as infants younger than six months old. But the benefit is more a suspected than proven one.

There is also the hope that a universal recommendation would improve the vaccination rate among health care workers, which hovers around 38%. The Assn. for Professionals in Infection Control and Epidemiology launched a campaign last month to get health workers vaccinated. The CDC also announced an effort to target this group during the next vaccination season, an effort supported by numerous medical societies including the AMA.

"As the front line in the fight against communicable illnesses, health care professionals are very busy with many complex issues facing them, and it is easy to overlook the influenza vaccine," said AMA President Donald J. Palmisano, MD. "Strong efforts must be made to improve the low rate of influenza immunization among health care workers."

There are even those who believe that mandatory vaccinations for these professionals should be considered.

"This is a clear and obvious patient safety issue. Health care workers give [the flu] to vulnerable patients, and they die. We are killing people," said Greg Poland, MD, who spoke at the summit in favor of mandating vaccination for those in the health care industry and is a professor of medicine and infectious disease at the Mayo Clinic in Rochester, Minn.

Approximately 90 million to 100 million flu vaccine doses are expected for the 2004-05 season, including one million to two million doses of the nasal version. Manufacturers are still early in the process but say production is on schedule.

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SARS: Keeping a watchful eye

In addition to common respiratory pathogens, health officials are on the lookout for newer ones that could emerge or re-emerge here, such as severe acute respiratory syndrome.

In April, the Chinese Ministry of Health announced the presence of nine possible or confirmed SARS cases. The Centers for Disease Control and Prevention distributed alerts to state health departments that in turn distributed the information to local medical personnel and health facilities.

"What you hope is that when somebody who was in China eight or nine days ago walks into that emergency room and says, 'I've got a fever and cough,' that one of the first things they're asked about is travel," said Jon Rosenberg, MD, medical epidemiologist in the division of communicable disease control at the California Dept. of Health Services.

International health experts praised the Chinese government for releasing information about the cases to the international community much more quickly than last year.

"The government did indeed learn their lesson," said Daniel Bausch, MD, MPH, associate professor of tropical medicine at Tulane University, New Orleans.

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External links

2004 National Influenza Vaccine Summit (link)

SARS information from the World Health Organization (link)

"Influenza Immunization Among Health Care Workers," Call to Action from the National Foundation for Infectious Diseases, in pdf (link)

Flu information from the Centers for Disease Control and Prevention (link)

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