Flu summit addresses new challenges
■ Vaccine advocates urge universal immunization of children and teens and confront repercussions of last season's vaccine being less effective than hoped.
By Victoria Stagg Elliott — Posted June 2, 2008
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With more influenza vaccine than ever before likely available in the upcoming season, public health officials and physicians are faced with countering the aftershocks of last season's flu-strain mismatch and implementing new recommendations regarding who should receive the preventive.
These issues were among the topics addressed at the National Influenza Vaccine Summit in Atlanta last month. The summit is an annual event co-sponsored by the American Medical Association and the Centers for Disease Control and Prevention.
"There looks to be a plentiful supply. What we need to do now is determine how to most wisely and equitably distribute and use it so that it makes it into noses and arms," said Gina Mootrey, DO, MPH, the summit's co-chair and associate director for adult immunization at the CDC.
Approximately 143 million to 145 million doses are predicted for next season, and, with five vaccine manufacturers in the game, the supply chain is more stable than ever. Advocates want to close the growing gap between what is manufactured and what is used. Out of the 140 million doses produced last year, about 113 million were distributed. This amount is more than ever before, but approximately 27 million doses remained on the shelves.
"We have to keep chipping away until we get these numbers up," said Nancy Hughes, RN, director of the American Nurses Assn.'s Center for Occupational and Environmental Health. "We've got to overcome the myths and the barriers."
One of those barriers is the findings earlier this year about the vaccine's effectiveness. A paper in the April 18 Morbidity and Mortality Weekly Report reported that the strains selected for last season's vaccine were not a good match for the strains that actually circulated. The vaccine was 58% effective against the most common one, and overall effectiveness was 44%. Also, the preventive may have reduced the severity of illness for strains not included. Still, the message many patients heard was that the vaccine didn't work.
"The concern is that, because the so-called mismatch received so much attention, there will be difficulty in recruiting physicians and the general public to take advantage of the vaccine abundance. There may be some merit to that concern," said William Schaffner, MD, who represented the National Foundation for Infectious Diseases at the summit. He also is the chair of the Dept. of Preventive Medicine at Vanderbilt University School of Medicine in Nashville, Tenn.
For next season, a key test will involve how easily new recommendations from the Advisory Committee on Immunization Practices are adopted. In February, ACIP added all children 6 months to 18 years to the list of people designated to receive this vaccine. The panel wants full implementation by the 2009-10 season.
Physicians welcomed the simplification of the recommendations. But those who will be giving the shots also noted the difficulties involved in adding 30 million children to the list. This circumstance is especially acute, since those younger than 9 who are receiving it for the first time need two doses at least four weeks apart.
"It does make it less confusing, but some people feel that the increase in volume of vaccines given to children is an extra burden on the medical home," said Jennifer Shu, MD, an Atlanta-based pediatrician who represented the American Academy of Pediatrics at the meeting.
Flu vaccine, for the most part, also lacks a regulatory mandate linking it to school attendance. Only New Jersey currently requires it of children attending preschool and licensed day-care centers. That state legislation was enacted in December 2007 and takes effect in September. Supporters say the dictate should make vaccination more likely, although not necessarily a done deal.
"The challenge will be to make sure that the day care centers and preschools know of this requirement and that physicians, health care providers and clinics are aware that this is in fact a requirement," said Eddy Bresnitz, MD, state epidemiologist at the New Jersey Dept. of Health and Senior Services. "We're not expecting perfect implementation, but we think we'll get reasonable rates."
Also, while the supply has been fairly stable and growing for several years, the effect of previous unstable seasons continues to be felt among physicians providing vaccines to this age group. For example, surveys of members of the American Academy of Family Physicians have found that the number saying that they plan to order vaccine dropped from 94% in 2005 to nearly 90%in 2007.
"We know that the vast majority are giving immunizations for influenza. [It's] not a statistically significant decline but it got our attention," said Herbert Young, MD, director of the AAFP's scientific activities division.
The first supplies of the intranasal version are expected to arrive in physicians' offices as early as August. The injectable will be available in September. Meanwhile, the AMA continues efforts to communicate with those involved in vaccine distribution so that physicians who serve populations at high risk of complications receive supplies in a timely manner. The AMA also encourages physicians and other medical workers to be vaccinated themselves.