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.

"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.

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.

"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."

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."

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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