American College of Physicians: Internal Medicine — Doctors for Adults ®


Flu season brings news about supply, updates from CDC

From the October ACP-ASIM Observer, copyright 2002 by the American College of Physicians-American Society of Internal Medicine.

By Gina Rollins

Tips to vaccinate more skeptical patients

As flu season begins to get into full swing, there is good news about the vaccine supply—and some updated recommendations from the CDC.

First, the good news. While both the 2000 and 2001 flu seasons were plagued by delays, public health authorities predict few problems with vaccine supplies this year. The CDC projects that between 92 and 97 million doses will be produced, and that most of those doses will be available in October. More vaccine should be distributed by the beginning of November.

Vaccine supplies should not be an issue this year, but public health authorities are still urging physicians to target in October those individuals at the highest risk of flu-related complications. CDC officials are paying special attention to the chronically ill—particularly asthmatics—as well as infants and their families. Here are some strategies to keep your patients healthy, along with some updated immunization recommendations:

High-risk patients first. One recommendation hasn't changed: Start immunizing your high-risk patients now.

The CDC's Advisory Committee on Immunization Practices (ACIP) considers the following groups to be high-risk: patients 65 and older, as well as those between six months and age 64 who have chronic medical conditions like pulmonary or cardiovascular diseases, diabetes, kidney disorders or immunosupression from either medications or HIV. They should be vaccinated first.

Others who should start receiving the vaccine this month include health care workers, household members of patients at increased risk of complications, and children between six months and eight years of age who are receiving the vaccine for the first time. (They need a booster dose one month after the initial vaccination.)

Beginning in November, start vaccinating healthy people between ages 50 and 64, as well as anyone else who wants the vaccine. In 2000, the ACIP began recommending that healthy 50-to-64 year olds receive the vaccine as a better way to target the 10 million to 14 million people in that age group who have chronic conditions that put them at risk for flu complications.

"A lot of 50-to-64 year olds have high-risk conditions but don't get vaccinated," explained Carolyn B. Bridges, ACP-ASIM Member, a medical epidemiologist with the CDC's influenza branch. She said that physicians usually have better luck targeting patients who should be immunized by age instead of medical condition.

Subspecialists have a vital—but often unrecognized—role in reaching high-risk patients. "They expect the general internist or the public health department to do immunizations, but in many instances they're the only physician the patient sees," explained William Schaffner, FACP, chair of the preventive medicine department at Vanderbilt University Medical Center and a member of the ACP-ASIM Adult Immunization Initiative's advisory board. If you are in a subspecialty that has a high-risk flu population—cardiology, for example—you may want to consider offering the vaccine.

Target asthmatics. When it comes to reaching out to high-risk patients, public health officials say that physicians need to immunize more adults with chronic illnesses. Kathleen M. Neuzil, ACP-ASIM Member, assistant professor at the University of Washington and member of the ACP-ASIM.

Adult Immunization Initiative's advisory board, estimated that no more than 40% of these patients get immunized against the flu. "It's ridiculously low," she said.

One high-risk group receiving particular attention this year is asthmatics. In the past, both asthmatics and their physicians worried that flu vaccination could trigger an asthmatic reaction or hurt lung function. As a result, only about 10% of asthmatics get vaccinated each year.

A study published in the Nov. 22, 2001, New England Journal of Medicine, however, demonstrated that the vaccine doesn't worsen asthma symptoms or lung function. "We looked at children, severe asthmatics, people taking other medications," said pulmonlogist Mario Castro, MD, lead author of the study and assistant professor of medicine at Washington University in St. Louis. "They all had the same level of exacerbation" between vaccine and placebo.

Based on this new evidence, the American Lung Association is planning a news release this month urging physicians to vaccinate asthmatics. "We can now reassure asthmatics that their lung function and asthma symptoms will not be worsened by the flu vaccine," Dr. Castro said. No matter how severe patients' asthma is, he added, the vaccine does not appear to make it worse.

"We also need to tell patients that if they get the flu, they are at risk of being quite ill and even dying," he said. "They need to be vaccinated."

Immunize infants—and their families. The ACIP has identified a new at-risk group: healthy children between the ages of six and 23 months and their immediate family.

"We stopped short of a full recommendation, but we are encouraging these children and their household contacts to get vaccinated when feasible," explained Dr. Bridges. The committee made the change because of evidence that young, otherwise healthy children face an increased risk of flu-related hospitalization.

Better late than never. Although high-risk patients should be targeted in October, you should continue to vaccinate them—and all other groups—throughout the season, according to Pascale Wortley, MD, a medical officer for CDC's National Immunization Program. "We have to somehow overcome this artificial barrier where vaccinations stop at the end of November, the presumed end of the flu season," she said. "In reality, flu season often doesn't start until February."

In 21 out of the last 25 years, according to the CDC, the flu season peaked in January. Nationwide, the season usually lasts an average of 10 weeks; in individual communities, the flu season is slightly shorter and lasts anywhere from six to eight weeks. The duration can vary widely in timing, Dr. Bridges said, with early outbreaks in some parts of the country and later ones in others.

"We'd prefer that people be protected during an entire outbreak, but it's better to get it late than not at all," said Dr. Neuzil, who is the College's representative to the ACIP. While it takes most patients about two weeks to develop antibodies after receiving the vaccine, she explained, the start and duration of flu season is unpredictable. As a result, the vaccine may protect patients even if you administer it after flu has been identified in your community.

Given the priority of high-risk patients and the call to continue vaccinating throughout the season, what should you do for healthy patients who want to be vaccinated earlier than the guidelines suggest? "We don't want to put physicians in an awkward position," Dr. Bridges said, "but in general, it's helpful to use the first available vaccine for high-risk people. We recommend that healthy people wait until November, but we leave it to the physician's discretion."

Protect yourself. One overlooked group is health care workers, with only about 40% getting immunized each year. Not only can health care professionals pass the flu to their families, but they can also infect high-risk patients.

"We have way too many outbreaks in facilities with high-risk patients such as nursing homes, bone marrow transplant units, neonatal ICUs and children's chronic care facilities," Dr. Bridges said. "We see the flu first in health care workers before it's in patients."

Because health care professionals forget how easily the flu is spread, they tend to assume that any sniffles they have are not the flu. As Dr. Bridges noted, however, "For healthy health care workers, the symptoms can run the gamut from sneezing and dry cough to feeling like you've been hit by a truck and having to be in bed for five days. You can even be infected but asymptomatic, so from the clinical symptoms alone, you can't tell whether it's the flu."

Optimize reimbursements. Translating the above recommendations into practice remains challenging. Because reimbursement rates for vaccinations sometimes don't even cover costs, some physicians no longer immunize their patients. The College is fighting for better reimbursement, in part through participation in the National Influenza Summit, an annual event cosponsored by the AMA and CDC. The summit convened a working group exploring payment issues for vaccine and its administration and sent a letter to CMS last month asking for improvements in Medicare reimbursements for immunization services.

While those efforts continue, you can make the most of limited reimbursement by using roster billing, which involves submitting one claim for all Medicare beneficiaries who receive either a pneumococcal polysaccharide vaccine or flu vaccine on the same day. Coupling roster billing with special vaccination hours, where patients come in just for flu shots, can help reduce your costs.

Managing vaccine inventory is another tricky issue that has been complicated by recent shortages. For the last few years, physicians have complained that everyone but doctors—in some instances, even health clubs—have received supplies of vaccine before they did.

While physicians have tried to guarantee their supply by ordering early, some manufacturers have implemented no-return policies, sticking physicians with unused vials. Some practices have gotten around this problem by collaborating with others in their communities, Dr. Neuzil said. Physicians with multiyear contracts may not yet be affected by this restriction.

You might also consider developing standing orders that all patients are to receive the vaccine unless it is contraindicated. Gregory A. Poland, FACP, professor of medicine and director of the Mayo Vaccine Research Group at the Mayo Clinic and chair of the ACP-ASIM Adult Immunization Initiative's advisory board, suggested making flu vaccination a stated priority of the practice. Designate one nurse "as the immunization champion," he said. "You can give her resources, authorization and standing orders that don't necessarily require your time."

Gina Rollins is a freelance writer in Silver Spring, Md.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP-ASIM.


Tips to vaccinate more skeptical patients

While public health authorities tout the benefits of flu immunizations, many patients still worry they'll catch the flu from the vaccine, or that it simply won't work.

Massive public awareness campaigns have raised coverage rates dramatically over the past 20 years. About 66% of all seniors now receive the vaccine each year, but rates are much lower among minorities. Only about half of African Americans get immunized, while only about 55% of Hispanics get vaccinated.

Physicians need to use their pivotal role in convincing patients to be vaccinated. Studies have shown that advice from a trusted medical advisor "trumps everything else," said William Schaffner, FACP, chair of the preventive medicine department at Vanderbilt University Medical Center and a member of the ACP-ASIM Adult Immunization Initiative's advisory board. "If a patient is skeptical, you need to take a minute and provide knowledge, reassurance and personal testimony."

What can you say to make your point? Here are some helpful facts:

  • The flu vaccine does not use a live virus, so patients won't get the flu.
  • The vaccine has been improved over the years and doesn't cause arm pain like it did in the past.
  • It significantly decreases the risk of complications and death from flu, something that both patients and providers tend to underestimate.

Finally, you can always resort to statistics. Each year, an estimated 300,000 people are hospitalized from flu or its complications, and 25,000 die. Even in years where there is a poor match between the vaccine and the predominate strain in the community (such as 1997-1998), the vaccine can still reduce flu-related hospitalizations or death by one-third.


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