New challenge for officials: Maximizing takers for increased flu shot supply

More influenza vaccine is expected for the 2006-07 season than ever before, but public health officials and medical society representatives are still worried. Their concern: How the legacy of recent years of supply disruptions may affect the willingness of those who have traditionally administered the flu shot to do so, according to discussions at the National Influenza Vaccine Summit in Chicago last month. This event, sponsored by the American Medical Association and the Centers for Disease Control and Prevention, occurs at least annually.

"The challenge we're faced with is a big one," said Glen Nowak, PhD, CDC's director of media relations.

For example, the proportion of flu shots provided by the Alabama Dept. of Public Health rose from 10% in 2004 to 20% in 2005, according to an annual survey carried out by state health officials. This jump did not, however, represent an increase in the actual number of vaccines given by the agency. The health department gave the same number of shots from year to year while the amount handed out in physicians' offices went down, either because some reduced their orders or got out of the business completely.

This scenario illustrates what many vaccine experts predict will be the biggest challenge of the upcoming flu season. As many as 120 million doses are expected to be manufactured, which is about 40 million more than last year and significantly more than has ever been made in a single season.

But public health departments have limited budgets and may not be able to afford the cost of handling more vaccine. And physicians may be less than eager to put energy into something that has such a rocky track record for being delivered in a timely manner -- if at all.

"How are we going to absorb 40 million extra doses? It's unlikely that public health is going to double its capacity," said Donald E. Williamson, MD, the Alabama state health officer who represented the Assn. of State and Territorial Health Officials at the summit.

"It's very, very unlikely physicians are going to purchase it. It's like we're having a party and nobody is coming," Dr. Williamson said.

To be fair, experts point out that even without the recent difficulties, ramping up demand on such a short timeline would be a significant test.

"We have to increase consumer demand in the next three months on a scale that, in the history of marketing, has been rarely accomplished," said Dr. Nowak.

And the stakes are high. Experts fear that if a significant portion of the vaccine is not used, the supply will shrink again, as it did in the wake of the 2002-03 season when 95 million doses were available but millions went to waste. (See correction)

Only 85 million doses were manufactured for the following season, when demand returned to a higher level.

"The worst problem we could face is having too much vaccine and having substantial vaccine left over," said Dr. Williamson. "At the end of the day, this would be a disincentive to the manufacturers."

Boosting confidence

Experts say the most immediate hurdle will be rebuilding faith in the vaccine delivery system.

A current lack of confidence has led many physicians to curtail or eliminate ordering vaccine because of fears that it would show up so late that it would be impossible to convince patients to take advantage of it. Physicians could then be stuck with unused vaccine that couldn't be returned for a refund.

"Until we rebuild the confidence of physicians in the supply, we're not going to get anywhere," said Robert Hopkins, MD, associate professor of internal medicine and pediatrics at the University of Arkansas for Medical Sciences, Little Rock, who represented the American College of Physicians.

Experts say they also need to overcome the belief among physicians that administering flu vaccine is a loss leader, even in the smoothest of years. Medicare rates for the shot itself as well as its administration have increased, and physicians who attended the summit say that it is very possible to at least break even or make a profit.

The summit intends to create a physician tool kit explaining how to promote vaccination and how to get paid. Physician advocates say economic viability is crucial because, while many doctors believe in administering the flu shot, it is not possible to continue at a loss.

"We need to be able to not lose money in giving influenza vaccine," said Herb Young, MD, scientific activities division director at the American Academy of Family Physicians.

Physicians also complain that the complicated prioritization schedule from the Advisory Committee on Immunization Practices, which includes about 73% of the population, interferes with achieving this viability.

Some would prefer being allowed to offer the shot to everyone. But last year's recommendations made it necessary to create reminder/recall systems to bring certain patients back in for flu shots while deferring others.

In response to such complaints, the summit, as it has in the past, came out in favor of encouraging vaccination for everyone, while also stating that some groups need more encouragement than others.

"It's not a money-making endeavor. We do it because it's the right thing to do, but we need to make the message as simple as possible and make my job easier," said Andrew Eisenberg, MD, a family physician from Madisonville, Texas, who represented the Texas Medical Assn.