Talking to healthy patients about flu shot alternatives
From the November ACP Observer, copyright © 2004 by the American College of Physicians.
By Janet Colwell
As an internist with the Mayo Clinic in Rochester, Minn., Gregory A. Poland, FACP, is spending many hours explaining to healthy patients why they need to pass on getting a flu shot this year.
And as Chair of ACP's Adult Immunization Initiative and director of Mayo's Vaccine Research Group, Dr. Poland has carefully followed the country's five-year trend in influenza vaccine shortages. ACP Observer spoke with Dr. Poland about this year's shortage and the alternatives he's offering healthy patients.
Q: Do you currently have a supply of vaccine?
A: We received about 50% of our ordered supply before the shortage was announced, and then ordered and got a large shipment of [nasal vaccine] FluMist. We'll still be short compared to what we normally use, but that's why we're following the recommendations from the CDC's ACIP [Advisory Committee on Immunization Practices] and directing it toward the high-risk people.
Q: Are you seeing any flu cases?
A: Yes, we've had cases in Rochester. Low level, but they're coming in. We've had only three or four cases so far.
Q: How do you screen patients to ensure that vaccine is going only to those at highest risk?
A: We do several things. We have signs and posters in the waiting rooms telling patients about the shortage and the criteria for getting shots. As they come in, we tell them why we have to turn them away if they don't meet the ACIP criteria. We tell them they can always check back later in the season, but that we don't expect any more vaccine to be available.
Q: What are you telling patients about antivirals?
A: We tell them if influenza starts circulating in your community and if you have symptoms, contact us within 48 hours because we can treat this. People seem to really understand that message.
Q: In the CDC's antiviral guidelines, why were older antivirals chosen for prophylaxis and newer ones for treatment?
A: The older ones, amantadine and rimantadine, are much cheaper. So when you don't know whether somebody is going to be exposed or not, you can prophylax a lot of people for a long time at much lower cost by using the older drugs.
There's also a scientific reason. Remember, with prophylaxis you're giving people these drugs for six weeks or sometimes longer. In that period, you can begin to see resistance to the medication.
The most effective treatments are the neuraminidase inhibitors—oseltamivir or zanamivir—so you don't want to start with those and start developing strains that are resistant. The newer drugs were chosen for treatment also because of their demonstrated efficacy and decreasing complications and mortality.
Q: Some states have issued emergency orders forbidding physicians from vaccinating healthy patients—but FluMist is approved only for healthy patients. Should doctors in those states feel comfortable giving FluMist to healthy patients?
A: Yes. FluMist is licensed only for people 5-49 years old who are healthy. The vaccine is safe, and it is effective.
The advantage of using FluMist is twofold. One, the more people who get an influenza vaccine—be it trivalent inactivated or FluMist—the greater "herd immunity" there is, and the less chance of transmission to people at high risk. Secondly, every time we use a FluMist dose, we free up a trivalent inactivated dose, which is the only vaccine that the people most at risk can get.
Q: In states that don't have emergency orders, are physicians, like yourself, able to hold the line with healthy patients who want vaccine? Should doctors worry about potential legal issues if they refuse to vaccinate healthy patients who later get ill?
A: I really think that's a red herring. I don't think physicians should be concerned about that at all and, if they are, I would simply tell them to document it. They are, in fact, following the standard of care in the United States based on these interim ACIP recommendations that have been filed.
The other thing they can do is tell patients that FluMist is available and, if they have these symptoms, to seek medical care.
Q: Internists are being urged to work with their local health departments to coordinate redistribution of local supplies. What has your clinic done?
A: We're a very big entity, so we've created a roundtable of communication among our local health department, Mayo Clinic and the other practices in town. That way everybody knows what everybody else is doing. We thought it would be a disaster if we didn't all follow the same policy.
Q: In its recent letter to the Department of Health and Human Services, the College pointed out the need for a permanent mechanism for distribution and a major government vaccine stockpile, among other recommendations. Do you think any new distribution or production mechanisms will result from this year's shortage?
A: I think the key thing that a bipartisan Congress will have to do is liability reform. New manufacturers are not interested in entering the market. The costs and the risks are too high, while the profit is too small. The government has to find a way to provide incentive to industry to stay in the market and to attract new industry into the market.
I think there will be enough political pressure, now that we've been through five years with three different manufacturers dropping out and causing shortages. So we've got the attention of the public and the legislators. I think the answer is to use the free market but provide incentives.
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