Flu vaccine: Too much of a good thing?
Faced with a possible surplus, physicians and public health experts
now wonder how to boost lagging demand.
By
Victoria Stagg Elliott, AMNews staff. Oct. 28, 2002.
Additional information
Ronald Bangasser, MD's phone has been ringing off the hook. Would he
like to buy more flu vaccine, the callers ask. But the family physician
has already got plenty.
Dr. Bangasser, director of external affairs at Beaver Medical Group in
Redlands, Calif., has been vaccinating his high-risk patients for several
weeks, and he's well stocked to vaccinate his staff and his lower-risk
patients over the next month.
That's a far cry from the situation during the past two years. Flu
vaccine was late, if it arrived at all, and his high-risk patients went
without, while those at lower risk received their vaccinations at the
chain drug store or grocery elsewhere in town.
"It's perfect. We're giving it out like crazy to everybody who's
high-risk," said Dr. Bangasser, who is also president-elect of the
California Medical Assn.
After two years of shortages and delays caused by manufacturing
difficulties and uneven distribution, the United States will have more
vaccine this year than ever before.
According to the Centers for Disease Control and Prevention, 92.7
million doses will be available this season, and more than 80% of them
will be delivered by Nov. 1. Last year, 87 million doses were produced,
and there were a few delays. In 2000, there were only 75 million doses and
significant delays.
92.7 million doses of flu vaccine will be available this season,
5.7 million more than in 2001.
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"Now, let's use it and vaccinate as many people as we can," said Dennis
J. O'Mara, associate director for adult immunization at the CDC National
Immunization Program.
Physicians and public health officials say the questions are no longer:
Who gets the vaccine first, who gets deferred and who doesn't get it all?
Instead, they are asking: How do we use up most of this vaccine, and what
are the implications if we don't? How do we increase vaccination rates
among those who are high-risk, as well as get the word out to new groups
of people targeted for vaccination?
"It's not an absolute, but it's highly likely we will have less vaccine
next year if we have lots left this year," said Arnold Monto, MD,
professor of epidemiology at the University of Michigan School of Public
Health in Ann Arbor. "It's a 'Catch-22.' You have shortages because of all
sorts of things that you can't control. There's pent-up demand, and then
you have a situation like this."
Public health officials say they are worried that lots of leftover
vaccine could dampen commercial interest in the product. Last season,
nearly every link in the supply chain -- from manufacturers to doctors --
got stuck with some surplus vaccine. Many complained that this negatively
impacted their bottom lines and made them more hesitant to deal with the
vaccine.
"If you've got those doses left over, you're paying for them at the
front end, and is that going to be disincentive for people ordering?" said
Robert Hopkins, MD, associate professor of internal medicine and
pediatrics at the University of Arkansas for Medical Sciences in Little
Rock.
Some doctors and vaccine providers are no longer offering flu shots
because of previous hassles. The fact that only three companies
manufacture the vaccine has long been considered a factor in supply
instability. Also, there hasn't been a bad flu season in recent memory,
which may reduce patient interest.
80% of flu vaccine doses should be delivered by Nov. 1.
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For their part, manufacturers say they are committed, at least in the
short term, to making the vaccine. The long term is more of an open
question.
Physicians, meanwhile, say they are redoubling their efforts to get
their patients vaccinated.
"We may not be able to do as well this year as we might had we not had
the downtimes last year and the year before, but I don't think it's going
to be that far off from as good as we can do," said Dr. Bangasser.
"Patients will come back."
Physicians say they're not worried about the high-risk patients. They
know that they need it, despite the hassles of the past two years,
although they might have fallen out of the habit of getting vaccinated so
early. Doctors are more worried about how to convince their lower-risk
patients that it is now a good idea.
"The high-risk folks are easy," said Dr. Hopkins. "The lower-risk
folks, it's a little more of a sell. You have to talk them into it. If
we're having a bad season, it'll be easy. If it's not a bad season, it'll
vary a lot."
Doctors are also concerned about convincing parents that the vaccine is
appropriate for infants. The CDC Advisory Committee on Immunization
Practices recommends that children ages 6 to 24 months be vaccinated
against the flu. But some parents complain that at those ages their
children are turned into pincushions, and they question whether flu shots
are necessary on top of other immunizations.
"Parents are used to thinking about vaccines," said Dr. Hopkins. "But I
have had some parents say, 'Oh, no, not another shot.' "
Need remains
Although many physicians feel as if flu vaccine is raining down on
them, public health officials warn that the supply is not really a surplus
this year. It may be more than sufficient to meet the demand, but it is
not sufficient to meet the need.
Ways must be found to deliver more vaccine to more people in order to
meet public health goals. The supply must not only be made more stable but
expanded to more than 150 million doses in order to meet Healthy People
2010 goals.
150 million doses of flu vaccine would be needed to meet Healthy
People 2010 goals.
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"We don't have a glut," said O'Mara. "We need to ramp up demand, but
exactly how we do that isn't clear."
Experts say that price increases over the past two years have helped
make the supply situation more stable. The fiscal pain of unsold doses
will be more than offset by the higher profit on the ones that do sell.
Physicians say, however, that the price increases remain their No. 1
complaint.
"I'm hopeful lots of people want to come get the vaccine, and I hope we
run out," said Howard Weinblatt, MD, medical director of Integrated Health
Associates in Ann Arbor, Mich. "And I hope we have 10 different vaccine
distributors begging us to take vaccine off their hands at ridiculously
low prices."
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ADDITIONAL INFORMATION:
Building an adult immunization infrastructure
The flu vaccine supply problems of 2000 and 2001 have fostered the
beginnings of an adult immunization infrastructure, much like the one
currently in place for children.
"That's a cause that's growing," said Howard Weinblatt, MD, medical
director of Integrated Health Associates in Ann Arbor, Mich.
The movement is an outgrowth of the numerous meetings convened about
the influenza vaccine supply, which brought together various public health
agencies, medical societies, manufacturers, distributors, physicians and
other immunization providers.
Adult immunization rates are increasingly being considered as possible
measurements of quality. And, most recently, the Advisory Committee on
Immunization Practices at the Centers for Disease Control and Prevention
released its first adult immunization schedule in conjunction with the
American Academy of Family Physicians and the American College of
Obstetricians and Gynecologists.
The committee has issued various recommendations for adults over the
years, but this is the first formal schedule issued in conjunction with
major medical societies.
"It will make it a little easier for physicians to think about adult
immunizations," said Robert Hopkins, MD, associate professor of internal
medicine and pediatrics at the University of Arkansas for Medical Sciences
in Little Rock. "I think a lot of times adult immunizations is one of the
things that gets lost in the shuffle. As visits get shorter, some things
fall by the wayside."
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Weblink
Notice
to readers, "Recommended Adult Immunization Schedule, United States,
2002-2003," Morbidity and Mortality Weekly Report, Oct. 11
(http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5140a5.htm)
Article,
"Prevention and Control of Influenza: Recommendations of the Advisory
Committee on Immunization Practices," Morbidity and Mortality Weekly
Report, April 12 (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5103a1.htm)
AMA on
adult vaccination (http://www.ama-assn.org/ama/pub/category/1826.html)
Healthy People 2010
immunization goals (http://www.health.gov/healthypeople/document/html/uih/uih_4.htm#immuniz)
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Copyright 2002 American Medical Association. All
rights reserved.
