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Education plays key role in making flu shots routine

Expert says confusion about flu's danger and vaccine's effectiveness is preventing widespread immunization

From the September ACP Observer, copyright 2006 by the American College of Physicians.

By Paula S. Katz

As chair of ACP's Adult Immunization Initiative and liaison to the CDC's Advisory Committee on Immunization Practices (ACIP), Gregory A. Poland, FACP, has a first-hand view of new flu vaccine initiatives that could affect physicians and patients this flu season—and of plans for dealing with a possible pandemic.


Gregory A. Poland, FACP



And as an internist with the Mayo Clinic in Rochester, Minn., where he is also director of Mayo's vaccine research group, he is working hard not only to make sure that his very high-risk patients get vaccinated this year, but that all his patients learn the benefits of flu prevention. ACP Observer spoke with Dr. Poland about the new thinking on prevention and what internists should be doing this year.

Q: The CDC says that 100 million doses of vaccine should be available this year. Does that mean we won't have supply problems?

A: Every year it seems we deal with this. So far, one of the three strains had contamination problems at one manufacturer [Sanofi Pasteur], which was detected and eliminated. This is different than the situation two years ago with Chiron [where close to 50 million doses were contaminated and could not be used]. Sanofi Pasteur is saying that they found and corrected the problem and that it will not impact their total doses produced.

Q: So if there's enough vaccine, what holds patients back from getting it?

A: They have the same reservations that health care workers do who don't get vaccinated: They have misperceptions about the vaccine's safety and its efficacy, and about the seriousness of influenza.

Plus, the public is very fickle about flu vaccine. When they perceive that it's a bad flu year, they will stand in line and demand vaccine. But last year's light season may influence them not to get the vaccine unless they hear otherwise from the health care workers who care for them.

Q: What can physicians do to keep their immunization rates up?

A: Part of the approach is to educate people and address the three major misperceptions.

First, patients think that any illness they get between September and April is the flu, and that leads them to conclude that "I got the vaccine and got the flu anyway." They didn't; it most often was some other respiratory illness.

Second, people have the misperception that flu is a minor annoyance, when in reality “influenza” is a serious infection capable of causing significant morbidity and mortality. It might shock readers to understand that one in 10,000 people alive today will be dead in the coming months from a virus that we can prevent—which is shocking.

And this misconception: "The vaccine caused me to get the flu." It doesn’t. With the new live virus intranasal vaccine, the public and health care workers think, "Oh no, we're going to spread it and harm people." That's simply not true.

Q: What practical tips do you have for office-based practices?

A: At Mayo we have a standing order program that could easily be implemented in an office. The nurse screens every patient and looks for contraindications, then orders and gives the influenza or pneumococcal vaccine.

Physicians can run educational videos about the importance of influenza and pneumococcal vaccine in their waiting rooms. They can also identify and send reminders to high-risk patients--not just mention it when they come in. They can send a letter saying, "I recommend you get these two vaccines" [flu and pneumococcal]. It makes a big impact when a trusted authority figure does that.

And physicians should do spot audits to monitor how many of their patients are actually getting immunized. Studies show that physicians think they are giving the vaccine to high-risk patients at high rates, but you may well find a different story.

Q: Physicians say delivery continues to be a big problem. Rhode Island, for example, is moving toward a centralized distribution system. Is this the wave of the future?

A: Delivery is frustrating; some offices order the vaccine and can't get it. The concept of centralized distribution has merit and deserves to be seriously looked at. Maybe it could be done through the CDC or state health departments.

Q: Patients haven't created a big demand for Flumist, although there's plenty of it. What's holding them back?

A: The idea that it's a live virus bothers some people. Plus, some people don't like a spray in their nose, and some people do get a minor sore throat for 24 hours. But Flumist is a great vaccine, a better vaccine than the injectable form because it offers better cross protection when the influenza strains circulating are not in the vaccine. I've had it twice and I give it to my family. The vaccine is safe and effective.

Q: Is it still more expensive than the injectable?

A: The idea is to get the price to the same as the injectable, but it still has a slightly higher price and charge. Each office establishes what their charge is going to be and when you consider not having to inject, particularly in years with drift between the strains, is the price really higher?

Q: There were major concerns last season about growing resistance to antivirals. What's the best advice for physicians this year?

A: Neuraminidase inhibitors are useful for both treatment and prevention of influenza. In some very high risk groups--for example, persons with chronic lung disease, I use them as a “belt and suspenders” approach, along with vaccine, to preventing influenza. In nursing homes for example, I would recommend that the first step is to immunize all the staff; the second is to immunize the patients; the third, if influenza is in the community, to use antivirals for prophylaxis.

Q: What's the downside?

A: While antivirals do reduce the number of days ill and decrease rates of hospitalization and complications, it's expensive to treat rather than prevent disease. Remember, the patient is transmitting the virus a day or two before symptoms appear. Also, as there is more overuse of neuraminidase inhibitors, we will start seeing resistance.

Q: What do you suggest physicians do to keep resistance in check?

A: The best way to prevent resistance is to prevent disease with vaccine. When that is not possible—for example, with a hypersensitivity reaction to a vaccine component--then it is logical to use antivirals as prophylaxis.

Q: What is the most important national initiative taking place now in regard to influenza prevention?

A: I think it is the move toward requiring influenza vaccine for health care workers (HCW) with direct patient contact unless it is actively declined. The ACIP—an independent body that advises the CDC on immunization recommendations—along with the Joint Commission on Accreditation of Healthcare Organizations [JCAHO], recently published recommendations to that effect. It goes into effect once institutions get their vaccine in September or October. This has now been recognized as a patient safety and quality of care issue. The CDC and virtually every professional organization that has examined the issue agree.

Q: What is JCAHO doing to enforce this?

A: While it's not a mandate from JCAHO to get vaccinated, there is a new standard effective Jan. 1, 2007, requiring hospitals to offer influenza vaccinations to staff, and collecting information on rates and causes for declination. Plus, institutions will need to demonstrate improvement in influenza rates in health care workers each year.

Q: What prompted these steps?

A: The recognition that as HCWs we have a duty to protect our patients. We don’t make wearing masks or gloves in an operating room optional for HCWs, we standardize and require those interventions with proven benefit and safety. The CDC has recommended the vaccine for health care workers for 25 years, but immunization rates are only at 36%. HCWs don't realize that the reason to get the vaccine is less about protecting themselves and more about protecting patients.

Sick patients infect health care workers who aren't vaccinated. So when an 80-year-old woman comes in with congestive heart failure, we pass it on to her. It should be clear to everyone that this is a patient safety and quality of care issue and that we have an ethical and legal duty to protect patients from transmittable diseases.

Q: Is there any talk of moving to immunize the entire U.S. population?

A: The ACIP has signaled its intent to move toward universal immunization. The proposal says it would begin in 2013, but virtually everybody on the ACIP committee thought that was too long a timeline. The plan is to study the issue and come up with a plan for implementation. I think we will see major benefits in terms of reduction of doctor visits, hospitalizations, deaths, disability days, and days missed from work and school. This initiative needs to be implemented as soon as possible, and even has beneficial overlap with pandemic influenza preparedness.

Q: Does a move toward universal immunization raise issues about supply?

A: Yes. In fact, that has been used as an argument to implement the proposal more slowly. Manufacturers—who are for-profit and whose product has a six-month shelf life—aren't going to make 200 million doses and hope we use them.

But I don't see any reason we couldn't make a universal recommendation today knowing it would only increase supply somewhat. It would send a very powerful message about the importance of vaccine and concerns about influenza infection. I also believe that the best way to increase the availability of influenza vaccine is to increase the demand for it.

Q: How would that recommendation play into pandemic preparedness?

A: If we use more influenza vaccine, existing manufacturers will make more, and other manufacturers will be encouraged to enter the market. Preventing co-infection with seasonal and a novel influenza viral strain decreases the probability of a pandemic influenza strain developing. It also prevents confusion between seasonal and pandemic influenza.

Paula S. Katz is a freelance writer based in Vernon Hills, Ill., who specializes in health care.

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

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For more information

For more information about flu vaccine, visit the following Web sites:

  • Infection Control Guidance for the Prevention and Control of Influenza in Acute-Care Facilities.

  • Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP).

  • Questions & Answers: Influenza Vaccine Production, Supply & Distribution in the United States.

  • Key Facts about Influenza and the Influenza Vaccine.

  • Vaccination Resources for Health Care Professionals.

  • Joint Commission Establishes Infection Control Standard to Address Influenza Vaccines for Staff.

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