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Shortage Forces Revamping of Flu and Pneumococcal Vaccination Strategy

Patients line up at a Giant supermarket in Alexandria, Va., last October to get flu shots. Flu shots were given out at grocery stores after the stores received thousands of vaccine doses before manufacturers shipped them to many private doctors. (AP Photo/Ron Edmonds).

Typically during the final months of the year, U.S. public health officials and physicians do their utmost to persuade reluctant adults to be vaccinated against infection by soon-to-be circulating influenza viruses. But a shortfall in U.S. flu vaccine supplies, which was beginning to ease by mid-December, forced public health experts to revise that usual strategy and recommend something akin to vaccine triage. Even as they are asking the general populace to be patient and grant priority for obtaining the vaccine to those such as the elderly, chronically ill, and healthcare workers who need it most, a good deal of jostling is taking place in the private sector where much of the vaccinating takes place. Those actions threaten to disrupt the orderliness that seems needed to implement this delicate plan, which also entails reaching out to elderly and minority populations to make wider use of a vaccine to protect against pneumococcal infections.

In a separate development, one that holds promise for avoiding such scrambling in future years but not for addressing shortages for the 2000-2001 flu season, Aviron of Mountain View, Calif., and American Home Products Corp. of Madison, N.J., announced this fall that they are seeking approval from the Food and Drug Administration (FDA) for FluMist, an influenza vaccine that is administered intranasally. If licensed, this vaccine would add another useful and alternative vaccine for controlling annual influenza epidemics and, in this case, a product that is particularly suitable for use among children, who suffer high attack rates and thus help inadvertently in spreading infections throughout the population.

Meanwhile, efforts that rely on broad-based use of the conventional injectable vaccine to tame influenza continue to be a priority for public health officials, whose customary campaigns of public persuasion were subject to adjustment in the face of vaccine supply shortages. Even in the best of circumstances, the virus typically causes some 20,000 deaths per year, more than any other vaccine-preventable disease, according to Kristin Nichol of the Veterans Administration Medical Center in Minneapolis, Minn., and chair of the National Coalition for Adult Immunization.

This year, the public health advice about obtaining this vaccine is being modulated to suit rather different circumstances, Nichol and other public health experts said during a press briefing convened by the National Foundation for Infectious Diseases and held last fall in Washington, D.C. Thus, the revised strategy calls for vaccinating especially vulnerable groups first, including the elderly and the chronically ill, while asking others to wait until the lagging supply of vaccine catches up to fulfill the wider demand that comes with vaccinating the main part of the adult population.

"We're not denying the fact that we have a problem here," says Surgeon General David Satcher. "We would love to start [vaccinating] as soon as possible. But for 14 of the last 18 years the flu season peaked after January, so we don't expect this delay to have a major impact on the [expected, annual] epidemic." Ordinarily, because the flu season begins in December and peaks between January and March, officials urge adults to be vaccinated early in October to mid-November.

Although the recommendation that most adults delay being vaccinated seems straightforward, implementing this revised vaccination program was not proving so easy as 2000 drew to a close. A major reason for this difficulty is that the public health officials recommending these measures have little or no real say over how vaccine supplies are allocated and distributed. "Vaccine distribution is in the private sector," explains Keiji Fukuda of the Centers for Disease Control and Prevention in Atlanta, Ga. Thus, public health officials depend on "voluntary efforts," he says. "We do not control [vaccine distribution and use], and can't tell people what to do."

Indeed, reports in the news media indicate that the availability of influenza vaccine varies erratically. Moreover, secondary and tertiary markets for the vaccine have appeared in short order, offering immediate supplies but at greatly elevated prices to selected pharmacies and other purchasers. According to some reports, some vaccine lots are being resold several times over, with the price escalating as the product passes from one broker to another. Public health officials are providing information on vaccine availability on websites and in brochures as a way of addressing some of these vaccine distribution-related problems, according to Fukuda.

Such market maneuvering could help to thwart the determination of public health officials to implement an orderly, albeit somewhat unorthodox schedule for administering the influenza vaccine and, they hope, pneumococcal vaccinations as well. Officials admit to at least one auxiliary purpose to publicizing these alternative flu vaccine recommendations so aggressively. Because vaccination coverage to protect against pneumococcal infections remains low, particularly among elderly adults, public health experts are urging physicians and others who administer the flu vaccine to take advantage of their encounters with members of this population group to promote the use of other vaccines to them.

This challenge of reaching out to adult populations and providing them with access to vaccines—and, in some cases, convincing members of reluctant population segments to accept their use—remains largely unmet, particularly among certain minority group populations, according to Bonnie Word of the Washington, D.C.-based National Medical Association (NMA), an organization representing primarily African American physicians and other health professionals. "The concept of routine adult immunizations doesn't exist yet," she says. Moreover, unlike for children, who generally satisfy certain immunization requirements before being allowed to attend elementary school, "there are no statutory requirements for adult vaccinations." Although the NMA focuses mainly on adults in minority groups, a more general public health movement is afoot to reach out to and convince adults to review their vaccination status and participate in programs that could provide them with tangible health benefits.

Jeffrey L. Fox
Jeffrey L. Fox is the ASM News Current Topics and Features Editor.