Flu vaccine abundant, but doctors still report glitches

Physicians are frustrated by distribution challenges but plan to vaccinate until doses are exhausted.

By Victoria Stagg Elliott — Posted Jan. 1, 2007

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This season, Matthew Johnson, MD, a family physician in Park Forest, Ill., received his stock of flu vaccine. The 350 ordered doses arrived in early November 2006, a bit later than expected -- but at least they made it. He could not always say that.

"This year the start was slow, but we did get our supply," he said. "Last year I gave them an F. This year, they get a C-."

Manufacturers produced more flu vaccine in 2006 than ever before, though distribution has still not been seamless. Because the vaccine is made continuously throughout the season, not everyone who ordered it -- including some physicians -- had all of their supplies early on. According to the Centers for Disease Control and Prevention, more than 97 million doses were distributed by the end of November. Another 10 million to 15 million are expected before the season ends.

Despite some unevenness in the distribution, the abundant supply has meant that public health officials have been able to focus attention on using as much of the available supply as possible and extending the vaccination season. This effort has been the pursuit of those working on vaccination issues, because many feel that expanding the number of people who receive shots will require this extra calendar time. Officials decided early on that, unlike previous seasons, no prioritization of patients was necessary, and the CDC declared the week after Thanksgiving National Influenza Vaccination Week.

This push was endorsed by numerous medical organizations, including the American Medical Association. Many physicians support the concept of vaccinating into December and beyond -- when demand has traditionally been minimal -- if they have vaccine available.

"As long as I have a supply, we will simply continue to vaccinate longer," said Dr. Johnson.

Doctors said patients are receptive to the suggestion, especially when flu hits the community and makes the local newspaper headlines.

"Once there's a few stories about flu, they come in and get [vaccinated]," said Roger Baxter, MD, clinical leader of the flu outreach program and co-director of the Vaccine Study Center at Kaiser Permanente in California.

But while many agree extending the vaccination season is a good idea, physicians are still bruised from previous seasons, which were even bumpier with supplies more scarce.

"This is a pretty poor distribution system," said Michael Greene, MD, a family physician from Macon, Ga., and a past president of the Medical Assn. of Georgia.

Questions of timing

For physicians who did not receive vaccine until after large-scale, retail-venue vaccination clinics had started up, it still felt like a national shortage.

"Now, we can get all we need, but everybody gets it before we get it. That needs to be fixed," said Stuart Sanders, MD, an internist and sports medicine physician in Demorest, Ga. "It's frustrating that the drugstores and grocery stores get it, but doctors could not."

Data have not supported the belief that retail chains get preferential treatment over physician offices. AMA policy states that adequate doses of every manufacturer's supply should be sold directly to health care professionals who immunize high-priority patients.

According to data from a Gallup telephone survey presented at the National Influenza Vaccine Summit, an initiative co-sponsored by the AMA and the CDC, 10% of adults receive their shots in retail outlets, but 39% get them in physician offices.

At this point in the season, doses are still for sale, and supply gaps are being filled. Although many physicians agree with the late season concept, especially if they still have vaccine, there's some question about the economic viability of ordering more now so close to the end of the season.

Steven Malkin, MD, an internist in Arlington Heights, Ill., and immediate past president of the Chicago Medical Society, finished up the last of his 120 vials in early December 2006 but has no plans to order more. He skipped administering the vaccine in recent seasons because reimbursement made it economically difficult. This situation has improved, and he's back in the flu shot business. But with most of his patients already vaccinated and unused supplies nonreturnable, he's fearful of getting stuck with it.

"If I could return it, I wouldn't have a problem," said Dr. Malkin. "I just break even on flu vaccinations. I can't lose money on them."

But in order to fully utilize supplies, several municipalities are developing innovative ways to increase uptake outside the doctor's office. The Seattle-King County Dept. of Public Health vaccinated hundreds of people in early December as part of an emergency preparedness drill. The National Assn. of County and City Health Officials, through sponsorship from flu vaccine manufacturer GlaxoSmithKline Inc., also funded three projects aiming to extend the season. In Houston and Los Angeles, they will provide education and vaccination in Women, Infants and Children program sites. A project in rural Nebraska will provide flu immunizations in livestock barns on sale days.

"These exciting new services will point the way toward the goal of vaccinating everyone at risk, everywhere in America, every year," said NACCHO President Poki Stewart Namkung, MD, MPH.

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Zeroing in on the avian influenza virus

Researchers have identified some of the mutations required for the H5N1 avian influenza virus to make the jump from birds to humans, according to a research letter published in the Nov. 16, 2006, Nature.

Additional unknown changes are needed before this virus is easily transmissible and can become a pandemic strain, and the authors hope this work will lead to its early detection in order to give public health officials and vaccine manufacturers extra time to prepare for an outbreak.

"There are big differences between the virus first found in 1997 and the virus we see now," said Yoshihiro Kawaoka, DVM, PhD, senior author and a virologist at the University of Wisconsin School of Veterinary Medicine in Madison. "We are watching this virus turn itself into a human pathogen."

To better prepare physicians and public health officials for such an occurrence, the World Health Organization issued avian influenza investigation guidelines in October 2006. Details are available online (link).

According to this document, investigations of possible human cases should be initiated if the local bird population tests positive for the H5N1 virus, particularly if more than one patient in an area has acute respiratory illness with an unknown cause.

This paper also called for those suspected of having H5N1 infection and their families to be interviewed within the first two days of the start of the investigation. A local case definition should be developed including information about time and location of the possible outbreak. If many contacts need to be traced, investigators can prioritize to reach those most at risk.

The agency has recorded 258 confirmed human cases since 2003, including 154 deaths.

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External links

National Influenza Vaccine Summit, a partnership co-sponsored by the AMA and the Centers for Disease Control and Prevention (link)

Prevent Influenza Now! sponsored by the National Influenza Vaccine Summit to facilitate extending the vaccination season (link)

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